The Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures (2024)

Routine use of a systemic prophylactic antibiotic prior to a dental procedure in patients with a hip or knee replacement may not reduce the risk of a subsequent periprosthetic joint infection.

Four low quality studies were included (Kao, 2017; Berbari, 2010; Thornhill, 2023; Sax, 2023) as the best available evidence. In 255,568 patients, Kao et al. reported no difference in risk of periprosthetic joint infection (PJI) between total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients who had a dental procedure within 2 years after arthroplasty and those that did not. Of those who had a dental procedure, there was no difference in PJI risk between those that received antibiotics and those that did not. Berbari et al. found no association with low-risk and high-risk dental procedures with TKA and THA PJI in 339 matched patients. In addition, they found that antibiotic prophylaxis prior to dental procedures did not decrease the risk of PJI. In a database analysis of over 1,952,917, Sax et al. similarly found no association between a dental procedure, defined as any procedure involving gingival manipulation, and risk of PJI. In addition, comparing patients who undergo a dental procedure, the rates of PJI and revision were not different between patients who received antibiotic prophylaxis and those who did not.

Benefits/Harms of Implementation
Periprosthetic joint infection is a devastating complication after TJA associated with increased morbidity and mortality. While the data reviewed does not support this, it is possible that rates of PJI after dental procedures may increase without antibiotic prophylaxis. Importantly, however, rates of PJI are reported as low as 1%. The direct societal cost of providing antibiotic prophylaxis prior to dental procedures in patients with TJA is significant, and it is expected that wider adoption of the recommendation will decrease these societal costs. In addition, antibiotic prophylaxis may promote the selection of antibiotic-resistant bacteria and increase the risk of Clostridioides difficile infection. Thus, limiting the use of dental antibiotic prophylaxis in TJA may lead to significant cost savings, reduce the risk of developing antibiotic resistance, and incidence of Clostridioides difficile infection.

Outcome Importance
Antibiotic prophylaxis prior to dental procedures after THA and TKA is a widely utilized practice. For many, this recommendation will be a shift in practice, which may limit wide acceptability. Some stakeholders may have concerns regarding the risks of not providing antibiotic prophylaxis in higher risk patients such as revision TJA patients, patients with prior PJI, or patients with certain medical comorbidities. Importantly, the evidence in this recommendation is mostly derived from patients with primary arthroplasty, particularly THA and TKA. The number of patients with revision arthroplasty and other high-risk populations was too small in the studies included to draw meaningful conclusions. However, it could be argued that the predominance of staphylococci and relative infrequency of viridans group streptococci and other mouth bacterial flora as a causative microbiologic etiology of PJI makes antibiotic prophylaxis prior to dental procedures less intuitive as a prevention strategy even in high-risk populations.

Cost Effectiveness/Resource Utilization
It is estimated that the annual cost of dental antibiotic prophylaxis for patients undergoing TJA in the United States is $59 million, which will only continue to increase as the rates of arthroplasty increase (Thornhill, 2022). Implementing this recommendation could result in significant cost savings for the healthcare system. Moreover, it would reduce antibiotic usage and support antibiotic stewardship, along with its associated benefits.

Acceptability
Periprosthetic joint infections are among the most common causes of failure after TJA. As the number of patients undergoing THA and TKA increases annually, the number of PJIs will increase as well as the costs and secondary adverse effects of antibiotic prophylaxis prior to dental procedures. With increased emphasis on value-based care, this recommendation will reduce costs to the healthcare system without impacting the risk of PJI. In addition, antimicrobial stewardship will prevent the selection of antibiotic-resistant bacteria and protect patients from adverse events associated with unnecessary antibiotic use. A recent large case-control study demonstrated that clindamycin and amoxicillin-clavulanate, commonly used antibiotics for dental prophylaxis, are associated with some of the highest risks of C. difficile infection among all the examined oral antibiotics (Miller, 2023).

Feasibility
Fortunately, adopting the guidelines is not resource-intensive or reliant on special needs. Therefore, it would be highly feasible to implement the guidelines with greater clinician acceptance.

Future Research
There is a need for higher-quality evidence, investigations into specific patient subgroups, and economic analyses. Future studies should aim to address the existing gaps in evidence, particularly regarding the efficacy of prophylaxis in high-risk groups (e.g. immunosuppressed and revision TJA) and the cost-benefit analysis of such practices. In particular, future research should focus on patients with revision or megaprostheses as well as patients with medical comorbidities that already place them at a heightened risk of infection (e.g. immunocompromised). Additionally, exploring patient-centered outcomes and preferences could enrich the evidence base and inform more nuanced recommendations.

Implementation of a dental screening in patients before a hip or knee replacement may not reduce the risk of subsequent periprosthetic joint infection.

The literature regarding oral health maintenance prior to elective total joint arthroplasty (TJA) included 4 low quality studies presented in 3 groups (dental clearance, dental evaluation, and dental screening) based on study design.

Two studies have evaluated the effect of mandating formal preoperative dental clearance (performed by a dentist) prior to TJA (Kwan, 2023; Lampley, 2014). Kwan et al. propensity score matched 8,654 patients who had been referred for preoperative dental clearance to 8,654 patients who were not referred based on age, gender, and body mass index (Kwan, 2023). The authors identified no difference between groups in the rate of postoperative prosthetic joint infection (PJI) nor in the bacteriological makeup of infectious organisms in patients undergoing TJA. Furthermore, Lampley et al. compared postoperative infection rates of 365 TJA patients who had received dental clearance to a retrospective cohort of 218 hip fracture patients treated with hip arthroplasty who did not have clearance (Lampley, 2014). Although 8.8% of patients who underwent dental clearance had periodontal disease that required treatment preoperatively, the authors found no significant difference in the rate of early postoperative PJI between the cleared versus uncleared groups (1.7% versus 2.5%, p=0.512). Based on the published data the four patients in the hip fracture cohort reported as having a PJI do not appear to meet the 2011 Musculoskeletal Infection Society Criteria as detailed in the methods. However, eliminating these four reported PJIs in the hip fracture cohort would continue to show no benefit for dental clearance.

Fenske et al. performed a retrospective analysis on 777 elective arthroplasty patients comparing early (< 4 weeks from TJA) PJI rates in patients who were not screened, screened by their orthopedic surgeon, or were screened by a dentist (Fenske, 2023). Although the authors found no significant difference in postoperative PJI rates among non-screened versus screened (1.6% versus 1%), infection rates were significantly lower in those patients screened by a dentist compared to an orthopedic surgeon (0% versus 2.3%, p=0.021) with all infections occurring in patients screened by the orthopaedic surgeon. A significantly higher rate of patients screened by dentists underwent a dental procedure prior to their TJA compared to patients screened by orthopaedic surgeons (23.6% vs. 0%, p=0.001).
Finally, a single study looked at the prevalence of PJI in patients with and without a documented dental evaluation prior to undergoing primary TJA. Over four-years, Sonn et al. retrospectively analyzed a consecutive cohort of patients undergoing 2457 elective arthroplasty procedures, finding that 79.1% had a documented dental evaluation, 15.0% had no documented dental evaluation, and 5.9% were edentulous (Sonn, 2019). An extraction of at least one tooth prior to surgery was identified as necessary in 11.5% of dental evaluations. While the authors do not document the time between dental evaluation and surgery, the median time between extraction and surgery was 52 days (IQR, 25-99; range 1-853). Overall, dental evaluation was not associated with a decreased risk of PJI. While the authors found that patients who required a dental extraction trended towards having a higher rate of postoperative complications (adjusted hazard ratio 1.24, p=0.57), they also noted these patients were more likely to exhibit features of immune suppression and diabetes.

Benefits/Harms of Implementation
Clinicians should encourage patients to maintain good dental health and can recommend a formal preoperative assessment by a trained dental practitioner when 1) a history of poor dental hygiene is disclosed, 2) patients exhibit comorbidities such as poorly controlled diabetes, malnutrition, smoking, or immunosuppression that could put them at risk of dental pathology, and 3) when both the cost and feasibility of a dental consultation are appropriate to the patient. The final decision to require formal dental consultation should be a shared decision between the provider and the patient.

Outcome Importance
Periprosthetic joint infection is a devastating complication after TJA associated with increased morbidity and mortality. Fortunately, rates of PJI are reported as low as 1%. It is unclear whether implementation of dental screening may identify patients at high risk and further mitigate the risk of PJI.

Cost Effectiveness/Resource Utilization
Implementing a mandatory dental screening could add significant costs for the patient beyond the screening, as patients who undergo a dental screening are more likely to need a dental procedure before proceeding to TJA. As such, this recommendation reduces cost and limits resource utilization. However, the decision should be made with the patient after discussing the potential risks and benefits of a dental screening due to the potential cost associated with the dental screening.

Acceptability
Given the individual biases based on clinician experience and training, it might be difficult to accomplish widespread acceptance of the current recommendation.

Feasibility
While the encouragement of good oral hygiene should always be supported, the decision to implement a dental screening program prior to TJA in the setting of the United States should be not taken lightly. Recent data reveals that approximately 68.5 million American adults (27% of the population) lack dental insurance (Carequest, 2023), a number that is nearly three times the percentage of those without health insurance. This discrepancy highlights the considerable challenge in ensuring equitable access to dental care, a challenge that continues to afflict specific minority populations over others (Fellows, 2022). Due to the lack of ample evidence to support mandatory clearance, screening, or evaluation by a dental professional prior to TJA, we do not recommend this practice. Mandating dental clearance may inadvertently decrease access to TJA care for certain patient populations. Consensus opinion supports optimization of dental hygiene prior to elective TJA.

Future Research
Four studies have attempted to identify approaches to dental clearance, screening, and evaluation that can improve oral health and decrease potentially infectious foci prior to TJA in patients with teeth with mixed findings. The retrospective nature of the study designs, lack of adequate cohort matching, and minimal details in the dental clearance evaluation and subsequent treatment needs/recommendations are limitations of the literature on this topic. Future studies on this topic should consider taking these limitations into account.

In the absence of reliable evidence, it is the opinion of the workgroup that the use of an oral topical antiseptic wash is not necessary before a dental procedure in patients with a hip or knee replacement.

The literature review did not identify any studies meeting inclusion criteria that evaluated topical antiseptic wash prior to a dental procedure for patients with a hip or knee replacement. The consensus recommendation stems from low quality data that has evaluated the impact of chlorhexidine mouthwash prophylaxis on bacteremia following dental procedures (Brown, 1998; Duvall, 2013; Lockhart, 1996; Maharaj, 2012; Tuna, 2012). The results of these studies indicate that chlorhexidine wash prophylaxis does not significantly reduce the level of bacteriemia following dental procedures. As a result, oral topical antiseptic wash is not recommended before a dental procedure in patients with a hip or knee replacement for the purpose of reducing the risk of periprosthetic joint infection (PJI).

Benefits/Harms of Implementation
Given that the data does not support the use of chlorhexidine washes, there is limited harm of implementing this recommendation. Potential benefits are the reduced patient and societal costs by not utilizing this practice.

Outcome Importance
Periprosthetic joint infection is a devastating complication after total joint arthroplasty associated with increased morbidity and mortality. Fortunately, rates of PJI are reported as low as 1%. The prevention of PJI is important but interventions should be implemented when evidence exists to guide the clinician.

Cost Effectiveness/Resource Utilization
This recommendation does not support the use of chlorhexidine wash, which will improve cost-effectiveness and resource utilization.

Acceptability
Because of the lack of demonstrated harm and historical practices of oral, topical antiseptic washes, clinicians might be less willing to accept the guidelines and change practice.

Feasibility
Fortunately, adopting the guidelines is not resource-intensive or reliant on special needs. Therefore, it would be highly feasible to implement the guidelines with greater clinician acceptance.

Future Research
Continued research with larger studies to examine the effectiveness of oral topical antiseptic wash prior to dental procedures on PJI risk for patient with a hip or knee arthroplasty are necessary to provide better understanding regarding the use of an oral topical antiseptic wash.

In the absence of reliable evidence, it is the opinion of the workgroup that the decision to delay a hip or knee replacement surgery is based on the risk of transient bacteremia, the occurrence of an invasive surgical procedure, or treatment of an active dental infection. Please see Table 3.

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.

 

In the absence of reliable evidence, it is the opinion of the workgroup that the decision to delay a dental procedure after hip or knee replacement surgery is based on the risk of transient bacteremia, the occurrence of an invasive surgical procedure, or treatment of an active dental infection (see table 3).

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.