CONSENSUS RECOMMENDATION Orthopedic surgeons consider delaying dental care following total joint arthroplasty (TJA) surgery due to three concerns: 1) dental procedures produce transient bacteremia that could potentially seed the newly placed highly perfused joint replacement, 2) more invasive dental procedures lead to higher bacterial loads and potentially increased infection risk, and 3) joint replacements and the surrounding tissues are more susceptible to hematogenous infection acutely after surgery. There is no reliable clinical evidence to confirm the first two concerns. For the third concern, indirect clinical evidence and animal studies suggest that the surgical site may have increased hematogenous seeding risk for up to three months postoperatively (Honkanen, 2019). As a result, a consensus recommendation was made that consideration should be given to delaying a dental procedure for up to 3 months after a TJA based on the type of dental procedure performed. Table 3 lists specific recommendations on how long to wait after TJA before proceeding with the different types of dental procedures.
Is there a link between dental-related transient bacteremia and joint replacement infection in the early postoperative period?
Thornhill et al. (2022) linked medical and dental datasets of the National Health Service in the United Kingdom to evaluate the incidence of invasive dental procedures (IDPs) in a 3-month period prior to 9427 late periprosthetic joint infection (PJI) hospital admissions and the prior 12-month period for IDPs of extractions, scaling and endodontic care. The incidence of IDPs was significantly lower in the three months prior to PJI admission. Causal organisms were identified in 4338 (46%); among those, the majority were staphylococcus, and only 9% were oral streptococci, which authors believe to have been an overestimation due to lack of ICD-10 code specificity. Subsequently, Thornhill et al. (2023) using U.S. commercial and publicly funded health insurance claims data and a similar case-crossover study design of IDPs in the three months immediately before a PJI referred to as the case period compared with the preceding 12-month period (control) for 2,344 PJI hospital admissions attempted to answer the question of an association between IDPs and PJIs. They found no significant positive association between IDPs (1,821, of which 18.3% had antibiotic coverage) and subsequent PJI. These analyses suggest a lack of causal association between IDPs and PJIs. However, neither of these studies examined the association of IDPs and the incidence of PJI within the first few months following joint replacement surgery – a period that may present elevated risk due to increased joint perfusion. Regardless of whether a dental procedure is performed, the first three months after a joint replacement carry the highest risk for developing a PJI. Consequently, it is prudent to avoid any procedures, including dental procedures, that could theoretically or actually further elevate the risk of PIJ during this already critical time.
Is it known which dental procedures are more likely to lead to bacteremia?
In a recent systematic review including 25 randomized controlled trials and 64 nonrandomized controlled trials, Martins et al. (2023) in evaluating bacteremia before and after IDPs, defined as involving manipulation of dental or mucosal tissues around the teeth, found that the highest incidence was from dental extractions (62%-66%), periodontal scaling and root planing (SRP; 44%-36%), and oral health procedures (27%-28%) defined as dental prophylaxis (cleaning) and dental probing without SRP. They confirmed peak bacteremia occurred within 5 minutes of the end of the IDP and decreased over time with all but scaling and surgical procedures resolving by the 2-hour time point assessment. Methods are insufficient to reliably determine bacterial load magnitude in circulation; however, one quantitative real-time PCR and anaerobic/aerobic blood culture-based study suggests the magnitude of bacteremia is higher after dental extractions than supra gingival scaling procedures (Reis, 2018). Martins et al. (2023), in this systematic review, also noted that activities of daily living result in transient bacteremia, particularly in individuals with poor oral hygiene, with a frequency of 16% for dental flossing and chewing and 8%-26% for toothbrushing. Duration may be impacted by the patient’s immune system and ability to clear transient bacteremia.
Is a joint replacement site at increased risk for hematogenous seeding early after surgery?
The supposition that human arthroplasty surgical sites are more at risk for hematogenous seeding arises indirectly from evidence confirming that there is increased blood flow to the joint and its surrounding tissues within the first three months following surgery. Gavish et al (2023) published a systematic review and meta-analysis quantifying the skin temperature (ST) following total knee arthroplasty. Of the 318 patients included in the review encompassing ten studies, the authors found that ST was greatest during the first 2-weeks post-surgery (an average increase of 2.8°C), remained above preoperative temperature at 3-months (increase of 1.4°C) and then eventually decreased to 0.9 °C and 0.6 °C at six and 12-months respectively. Increased blood flow has also been described using advanced imaging in radiology. Hofmann et al. (1990) demonstrated in 59 knee replacements that periprosthetic tissues had significantly increased signal uptake on bone scans both within the immediate postoperative period and in the subsequent three months, regardless of fixation type. These signals take up to 2 years to normalize following hip replacement and five years following knee replacement (Glaudemans, 2013), reflecting the extended duration of soft tissue and bone healing that occurs following surgery.
Although direct evidence for increased hematogenous seeding risk immediately following human arthroplasty surgery is lacking, in-vivo animal modeling does appear to confirm this clinical concern. Both Blomgren et al. (1980) and Southwood et al. (1985) independently observed that rabbits that received arthroplasty implants were specifically susceptible to surgical site infections from low-dose bloodstream bacterial inoculations only within the first three to four weeks following surgery. Although more contemporary animal investigations have also been able to establish hematogenous infections with postoperative bacterial inoculations (Shiels, 2015; Wang, 2017), these have been at singular intervals, and a temporal relationship has not been studied.
Benefits/Harms of Implementation
Benefits/harms need to be weighed individually for each patient by the dental and orthopedic team, considering the patient’s values and preferences. More acute dental infections arising early in the TJA surgery period require management, while elective procedures might best be delayed for 3 months, during which the patient is engaged in rehabilitation of the joint with more limited mobility and pain. In general, there are limited harms from delay of elective dental procedures for the maximum noted 3-month period.
Outcome Importance
Periprosthetic joint infection is recognized as a devastating complication after total joint arthroplasty associated with increased morbidity and mortality. This consensus opinion tries to weigh concerns for balancing infection in the mouth and infection risk potential for the new joint during the early phase post-arthroplasty.
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 the health care team members to maximize access to dental healthcare while minimizing any potential risk of transient bacteremia seeding a new joint replacement in the early prosthetic joint healing phase.
Feasibility
After dissemination of the clinical practice guideline, there should be limited obstacles to wider spread adoption. Communication between dentists and orthopedic surgeons is essential for care coordination. For dental management of acute dental infection immediately after TJA while the patient is still in the hospital, this may assume the hospital or surgical facility has access to a dentist/oral and maxillofacial surgeon who will provide care in the hospital setting. If dental care is to be provided by a community dentist/oral and maxillofacial surgeon after hospital discharge, this may warrant additional time delay in scheduling definitive dental invasive intervention to resolve dental infection while the patient is maintained on intravenous antibiotics.
Future Research
As limited research was available, investigations documenting dental treatment and type (grouped by hematogenous bacteremia potential) undertaken at specific time points after TJA in the early healing phase, then correlated with PJI outcomes, would be of benefit.