CONSENSUS RECOMMENDATION Non-invasive dental procedures which induce bacteremia do so transiently, with pathogen clearance occurring within hours, or at the longest, within a day following the procedure (Lockhart, 2008). Therefore, noninvasive dental procedures and minimally invasive dental care procedures can be performed safely up until the day before elective total joint arthroplasty (TJA) surgery. Conversely, oral surgical procedures and dental extractions involve prolonged healing stages, which can last for up to three weeks. Therefore, when feasible, oral surgical and extraction procedures should be completed at least 3 weeks in advance of elective TJA surgery. Table 3 lists specific recommendations on how long to wait after the different types of dental procedures before proceeding with a TJA.
The mouth has a high cellular turnover rate, with gingival healing (as from scaling and root planing) being completed within 3 days. However, oral surgical procedures often produce wounds which heal by primary or secondary intent. Typical epithelialization from a dental extraction takes 2 weeks, with the healing process consisting of 3 phases: inflammatory (days 3-5), proliferation (up to 14 days), and remodeling (6 weeks) (Haj Yahya, 2021). In diabetics, epithelialization can be delayed up to 3 weeks, especially in the context of a dental extraction (Ruggiero, 2024). Although there is no universally accepted scale for oral mucosal wound healing, the most reassuring feature of oral wound healing is the presence of wound epithelialization (Rodriquez, 2024). Upon completion of epithelialization, bacteremia levels from routine chewing return to baseline levels. Thus, it is recommended that elective TJA be delayed 3 weeks, the average time of epithelization, after oral surgical and extraction procedures.
When active dental infections are present, management can be lengthy and involve oral or intravenous antibiotics. Furthermore, extraction of an infected tooth or treatment by endodontic therapy (root canal therapy) in conjunction with antibiotic therapy is often needed to resolve severe oral infections. Due to the possibility of infection persistence, elective TJA surgery should be postponed until dental and antibiotic treatment has concluded with subsequent verification that the oral infection has been eradicated.
Benefits/Harms of Implementation
The dental and orthopedic team needs to weigh the benefits/harms individually for each patient, considering the patient’s values and preferences. In general, there is limited harm in delaying elective arthroplasty for the maximum noted 3-week period.
Outcome Importance
Periprosthetic joint infection is recognized as a devastating complication after TJA associated with increased morbidity and mortality. This consensus opinion tries to weigh concerns for balancing transient bacteremia from dental procedures and infection risk potential for the planned joint replacement.
Cost Effectiveness/Resource Utilization
There is limited evidence to support cost-effectiveness. However, this opinion does not accelerate resource utilization but rather considers delay and timing of delay in resource utilization.
Acceptability
This consensus opinion aims to give guidance that can be considered by healthcare team members to maximize access to dental healthcare while minimizing any potential risk of transient bacteremia seeding a planned TJA in the perioperative period.
Feasibility
After the dissemination of the clinical practice guideline, there should be limited obstacles to widespread adoption. Communication between dentists and orthopedic surgeons is essential for care coordination.
Future Research
As limited research was available, investigations documenting dental treatment and type (grouped by hematogenous bacteremia potential) undertaken at specific time points prior to TJA surgery, then correlated with PJI outcomes, would be of benefit.