At Issue: Antibiotic prophylaxis may be unnecessary for dental procedures after TJA
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Key takeaways:
- Many orthopedic surgeons and dentists use antibiotic prophylaxis in patients with prosthetic joints.
- However, dental procedures may not be a risk factor for periprosthetic joint infection.
Initially recommended for use prior to dental procedures for patients with cardiac conditions to prevent infective endocarditis, the use of antibiotic prophylaxis has also increased to include a variety of patient populations.
Because dental-related bacteremia may cause periprosthetic joint infections, clinicians began prescribing antibiotic prophylaxis prior to dental procedures to patients with prosthetic joints. However, recent literature has not shown an association between dental procedures and PJI, and the use of antibiotic prophylaxis has been found to be associated with adverse events.
Healio spoke with experts on whether orthopedic surgeons and dentists should practice evidence-based medicine for the use of antibiotic prophylaxis in dental procedures in patients who have had total joint arthroplasty.
Larry M. Baddour, MD, FIDSA, FAHA; Thomas M. Paumier, DDS; and Bryan D. Springer, MD
Each year, more than 1 million hip and knee replacements take place in the United States, with approximately 7 million people living with total joint replacements. Projections indicate a fourfold increase in annual replacement procedures by 2030. The historical reliance on antibiotic prophylaxis for routine and invasive dental procedures traces its roots back to the 1950s, drawing from guidelines aimed at preventing infective endocarditis set by the American Heart Association. However, both the American Dental Association (ADA) and American Association of Orthopaedic Surgeons both together and separately have put out no fewer than six recommendations in the last 30 years, often with conflicting opinions.
Decisions regarding antibiotic prophylaxis before invasive dental procedures often diverge, leaving patients to grapple with conflicting advice from their orthopedic surgeons and dentists. Practice patterns suggest that greater than 90% of orthopedic surgeons recommend antibiotic prophylaxis for dental procedures. The need for a fresh evaluation of this practice becomes apparent in light of more recent and robust clinical evidence that shows no association between invasive dental procedures and prosthetic joint infections. While patients are traditionally instructed by orthopedic surgeons to adopt antibiotic prophylaxis, some dentists argue against its necessity, creating a dilemma for patients in choosing the most prudent course of action.
In a 2017 case-control propensity-matched study in Taiwan involving more than 250,000 patients with knee or hip arthroplasties, researchers identified 57,000 matched patients who underwent dental procedures vs. those who served as controls. The findings revealed no associated risk of PJI following such dental procedures. In addition, a subgroup analysis of 6,500 dental patients who had used antibiotic prophylaxis vs. a matched group who did not use antibiotic prophylaxis showed no protective effects of antibiotics.
A 2022 case-crossover study in the Journal of the American Medical Association encompassing nearly 10,000 patients in the United Kingdom with late PJI compared the number of dental procedures in the 3 months prior to development of PJI vs. the preceding 12-month control period. Antibiotic prophylaxis was not utilized, and the results showed no association between invasive dental procedures and development of late PJI.
Similar outcomes were also shown in a January 2023 case-crossover study published in The Journal of the American Dental Association, involving nearly 2,500 U.S. patients with late PJI. This study found no association between invasive dental procedures, the development of late PJI or protective benefits of antibiotic prophylaxis. Notably, these studies, designed with greater statistical power, confirm the most recent guidelines based on studies that were substantially underpowered.
Given that most PJI cases are attributed to staphylococci rather than oral viridans group streptococci, the emphasis on antibiotic prophylaxis for dental procedures comes into question. With viridans group streptococci causing less than 5% of PJI cases, a focus on improving oral hygiene, particularly in people with prosthetic joints and poor oral health, appears more effective than routine antibiotic prophylaxis for dental procedures. Given the frequency of bloodstream infection due to viridans group streptococci is higher from routine oral hygiene activities, like toothbrushing, than from invasive dental procedures, particularly in those with poor oral hygiene, it is more likely that bacteremia caused by daily living activities account for the small number of late PJI cases due to these organisms. Thus, it is reasonable to advocate for improving oral hygiene to reduce the limited number of late PJI due to oral bacteria.
Most community-acquired C. difficile infections are associated with antibiotic use and are more likely to occur in individuals older than 65 years. This observation is important as we consider the population that most requires prosthetic joint placement. Contrary to popular belief, a single dose of antibiotic prophylaxis for an invasive dental procedure can be associated with this potentially deadly infection. A recent investigation by Martin H. Thornhill, MBBS, BDS, PhD, and colleagues reported 13 deaths per million single doses of 600 mg clindamycin used for antibiotic prophylaxis, all due to C. difficile infection or antibiotic-associated colitis. In contrast, amoxicillin, the antibiotic most administered as prophylaxis for invasive dental procedures, had the least adverse drug reactions and resulted in no deaths. These findings with clindamycin use prompted the American Heart Association to exclude clindamycin as an option to amoxicillin in the 2021 scientific statement addressing infective endocarditis prevention, antibiotic prophylaxis and invasive dental procedures. Moreover, this perspective has been embraced by many in updating practice guidelines and recommendations.
Amid increasing rates of antibiotic resistance among bacteria, evidence suggests that the risks associated with routine antibiotic prophylaxis for patients with prosthetic joints outweigh any potential benefits. Several countries, including Australia, Brazil, Canada, Denmark, France, Netherlands, Norway, Portugal and the United Kingdom, do not recommend antibiotic prophylaxis for patients undergoing invasive dental procedures and have not observed an increase in late PJI incidence.
In conclusion, the findings addressed herein support the notion that a paradigm shift is needed in our approach to using antibiotic prophylaxis in patients with prosthetic joints who are undergoing invasive dental procedures. The call to cease the use of antibiotic prophylaxis for invasive dental procedures among the prosthetic joint patients is critically important and supports harm reduction among our patients.
References:
- Antibiotic resistance threats in the United States, 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Published December 2019. Accessed Oct. 19, 2023.
- Berbari EF, et al. Clin Infect Dis. 2010;doi:10.1086/648676.
- Costelloe C, et al. BMJ. 2010;doi:10.1136/bmj.c2096.
- Hays MR, et al. J Arthroplasty. 2023;doi:10.1016/j.arth.2023.02.025.
- Hensgens MPM, et al. J Antimicrob Chemother. 2012;doi:10.1093/jac/dkr508.
- Kao FC, et al. Infect Control Hosp Epidemiol. 2017;doi:10.1017/ice.2016.248.
- Kurtz S, et al. J Bone Joint Surg Am. 2007;doi:10.2106/JBJS.F.00222.
- Lockhart PB, et al. J Am Dent Assoc. 2009;doi:10.14219/jada.archive.2009.0046.
- Lockhart PB, et al. J Am Dent Assoc. 2020;doi:10.1016/j.adaj.2020.04.027.
- Lockhart PB, et al. J Am Dent Assoc. 2022;doi:10.1016/j.adaj.2022.02.010.
- Lockhart PB, et al. Oral Surg Oral Med Oral Pathol Oral Radiol. 2023;doi:10.1016/j.oooo.2023.02.020.
- Maradit Kremers H, et al. J Bont Joint Surg Am. 2015;doi:10.2106/JBJS.N.01141.
- Rees HW, et al. J Am Acad Orthop Surg. 2017;doi:10.5435/JAAOS-D-17-00004.
- Sollecito TP, et al. J Am Dent Assoc. 2015;doi:10.1016/j.adaj.2014.11.012.
- Thornhill MH, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2021.42987.
- Thornhill MH, et al. J Am Coll Cardiol. 2022;doi:10.1016/j.jacc.2022.06.030.
- Thornhill MH, et al. J Am Dent Assoc. 2023;doi:10.1016/j.adaj.2022.10.001.
- Thornhill MH, et al. J Antimicrob Chemother. 2015;doi:10.1093/jac/dkv115.
- Thornhill MH, et al. J Dent Res. 2019;doi:10.1177/0022034519863645.
- Wilson WR, et al. Circulation. 2021;doi:10.1161/CIR.0000000000000969.
- Zhang J, et al. Antimicrob Agents Chemother. 2022;doi:10.1128/aac.01129-22.
Baddour is professor emeritus of medicine in the division of public health, infectious disease and occupational medicine in the departments of medicine and cardiovascular medicine at the Mayo Clinic College of Medicine and Science and the Mayo Clinic. Paumier is a clinical instructor and of the general practice residency at Cleveland Clinic Mercy Hospital . Springer is from the OrthoCarolina Hip and Knee Center and a professor in the department of orthopedic surgery at Atrium Musculoskeletal Institute.
Laura Certain, MD, PhD
PJI is a dreaded complication of arthroplasty. Surgeons, infectious disease physicians and patients all want to do whatever is in our power to prevent PJI. However, our fear leads us to make irrational decisions, which can cause harm. Prescribing antibiotic prophylaxis for dental procedures in patients with prosthetic joints is one of these irrational behaviors, which persists despite decades of evidence that dental procedures are not a risk of PJI.
The rationale for antibiotic prophylaxis prior to dental work stems from the pathophysiological model that late PJI (occurring at least 3 months after arthroplasty, and often much later) are usually caused by hematogenous seeding of the joint. Bacteremia is clearly associated with PJI. Dental procedures that involve manipulation of the gingival mucosa can cause transient bacteremia, and, therefore, theoretically could cause PJI. This argument has led orthopedic surgeons to recommend a dose of antibiotics at the time of dental work.
Despite the logic of the above rationale, available data argue against dental procedures being a risk factor of PJI. Just considering the microbiology, it is rare for oral flora to cause PJI. Most PJI are caused by skin flora, mainly staphylococci. Moreover, while dental procedures can cause transient bacteremia, so can toothbrushing and flossing. The worse a patient’s dental health, the greater the likelihood that brushing and flossing will cause bacteremia. Therefore, any perceived association of PJI with dental work may simply reflect that patients who require significant dental work often have poor dental health, and, therefore, are more at risk for bacteremia every day, not just on days they visit the dentist. Poor dental health can also be associated with other conditions that increase risk of PJI, such as immune compromise or illicit drug use.
Several large studies have demonstrated no association between PJI and recent dental work. The first of these was a case-control study comparing 339 patients admitted to the hospital with a PJI to 339 patients with a history of total joint arthroplasty who were admitted to the hospital for a different reason. There was no difference in the incidence of recent dental procedures between the two groups. Importantly, about half of the patients in this cohort had some degree of immune compromise; the findings held within this subgroup.
More recently, a large cohort study of more than 9,000 patients in the United Kingdom, where routine antibiotic prophylaxis with dental work has never been recommended for arthroplasty patients, likewise found no association between late PJI and recent dental work. No well-done study has found any link between dental procedures and subsequent PJI. In the absence of this link, there is no reason to think that antibiotics given at the time of dental procedures will reduce the risk of PJI. Far more important is to ensure that patients have healthy dentition prior to getting a joint replacement and to encourage them to keep up with routine dental care.
It is worth noting that the studies looking for an association between PJI and dental work have focused on late PJI, because these are the ones more likely to be caused by hematogenous seeding. The available evidence indicates no association between dental work and late PJI, and, therefore, no role for antibiotic prophylaxis with dental procedures to prevent late PJI. Early PJIs are usually caused by organisms gaining access to the joint either during or shortly following surgery, when physical defenses against infection are compromised. Usually these are skin bacteria but can also come from a hematogenous route. My personal approach is to advise against medical procedures of any kind in the first few months after arthroplasty (eg, endoscopies, prostate biopsies, dental surgeries), due to the heightened risk of PJI in this period. If these procedures do happen shortly after arthroplasty, whether antibiotic prophylaxis is indicated is debatable. Most likely it is not necessary, but we do not have the same level of evidence as we do for late PJI. For prevention of late PJI, the evidence argues that antibiotics at the time of dental procedures are unlikely to have any beneficial effect.
Some of you may counter with an anecdote of a patient whose PJI seemed to be related to a dental procedure. My own anecdote: Early in my career as an infectious disease physician, I cared for a patient with recurrent Clostridium difficile colitis. He had been prescribed clindamycin as prophylaxis before a dental procedure because he had a prosthetic joint. He had been given clindamycin instead of amoxicillin due to a reported childhood penicillin allergy. His recurrent C. difficile colitis was a direct result of two incorrect choices, based on ignorance of current best practices in antibiotic prescribing. The risk of prescribing antibiotics with dental procedures may seem small, but it is not zero. The estimated risk of C. difficile colitis from peri-procedural antibiotic prophylaxis is about one in 2,000. In the absence of data indicating a benefit of antibiotic prophylaxis with dental work, there is no reason to expose patients to this risk.
References:
- Berbari EF, et al. Clin Infect Dis. 2010;doi:10.1086/648676.
- Carignan A, et al. Clin Infect Dis. 2008;doi:10.1086/588291.
- Crasta K, et al. J Clin Periodontol. 2009;doi:10.1111/j.1600-051X.2008.01372.x.
- Honkanen M, et al. Open Forum Infect Dis. 2019;doi:10.1093/ofid/ofz218.
- Lockhart PB, et al. Circulation. 2008;doi:10.1161/CIRCULATIONAHA.107.758524.
- Silver JG, et al. J Clin Periodontol. 1977;doi:10.1111/j.1600-051X.1977.tb01888.x.
- Thornhill MH, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2021.42987.
Certain is a clinical associate professor in the department of medicine in the division of infectious diseases and an adjunct associate professor in orthopedics at the University of Utah.
References:
- Katz JN, et al. Osteoarthr Cartil Open. 2021;doi:10.1016/j.ocarto.2021.100217.
- Lockhart PB, et al. J Am Dent Assoc. 2021;doi:10.1016/j.adaj.2020.04.027.
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