Health
July 7, 2020
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Prosthetic joints and dentistry

By: George Malkemus
October 4, 2019

Antibiotics are not needed before dental treatment for patients with prosthetics.

Joint replacement

 A joint replacement involves the removal of a damaged joint that is replaced with an artificial joint, called prosthesis. Seventy percent of joint replacements are performed because arthritis has caused the joint to stiffen and become painful to the point that normal daily activities are no longer possible. If the joint does not respond to conservative treatment like medication, weight loss, activity restriction and use of walking aids such as a cane, joint replacement is considered appropriate and necessary.

The most common joints that are replaced are hips and knees. Over one million Americans have successful hip or knee replacement surgery each year.  There is ongoing work on elbow, shoulder and ankle replacement.  Joint replacement has a long history.  Total hip replacements date back to the 1700s. Today hip and knee replacements are highly successful due to improved and less invasive surgery techniques and the improvement in material components, in particular the metal titanium that replaced stainless steel.  Titanium has an amazing biocompatible feature; bone actually grows into the metal and fuses to the titanium implant.  Dental implants are also made out of titanium. The jawbone fuses to the dental implant root replacement.  

Infections in joint replacements 

Infections have always been a problem with joint replacement surgery.  During the 1950s, the infection rate after hip joint replacement surgery was close to 12 percent.  By the 1970s, the rate of infection after hip surgery had been reduced to less than two percent.  The reduction was due to two important changes: 1) treatment with antibiotics just before the hip joint replacement surgery and 2) the use of laminar airflow systems in the operating room. This reduced the most common post-operative infections in the prosthetic joints, which occur during the first three months after surgery and are caused by wound contamination in the operating room.   Infections that occur after three months are less common and thought to be caused by either wound contamination or the spread of bacteria through the blood circulatory system from an infected site in another part other body. One possible source of infection comes from the mouth through the gums. 

Periodontal disease and joint infections

Gum disease, called periodontal disease, plays a role in numerous disease conditions throughout the body including heart disease, strokes, ulcers and adverse pregnancy outcomes such as low birth weight and preterm births. Diabetes is also affected and increased by periodontal disease, which alters blood sugar control in diabetics.  Bacteria that build up between the tooth and gum can enter into the bloodstream when gums bleed. These bacteria can travel throughout the body and cause serious health problems. Also, periodontal disease is an inflammatory disease and affects other diseases that are affected by inflammation such as diabetes.

Since the 1970s, there has been concern that the source of the late infection in prosthetic joints was coming from periodontal disease. To prevent this possibility, antibiotics were given to prosthetic joint patients before dental treatment. Taking antibiotics before any medical or dental treatment is called antibiotic prophylaxis.  The theory was that bacteria found in bleeding, infected gums traveled from the mouth, through the blood stream to the prosthetic joint, where circulation is reduced and then eddied out in the joint area and started an infection. It was thought that taking antibiotics would prevent this from happening. Though there was no scientific basis for this theory, giving antibiotics before dental treatment to patients who had prosthetic joints became the norm during the 1980s and 1990s. During this time antibiotics were given routinely even for dental patients with metal pins, plates, and screws, and also even for prosthesis without metal, including breast implants. 

Subsequent studies have shown that antibiotic prophylaxis is not usually needed for most dental patients.  Prosthetic infections are almost exclusively caused by staphylococci.  These bacteria are not found in the mouth.  Also, individuals with periodontal disease are at a continual risk for infection spread, not just when they see the dentist. What is important is for all individuals to keep their gums in good health.   

Extensive evaluation of evidence-based studies has concluded that even high-risk dental procedures performed within six months to two years of prosthetic hip or knee procedure were not associated with increased risk of prosthetic infection compared to no dental procedures.   They also show that antibiotic prophylaxis did not decrease the risk of infection. 

Statistical research has shown that there is a much greater risk of allergic anaphylactic shock from antibiotic use than there is risk of prosthetic infection during a dental procedure.  Finally, bacteria resistance has become a concern with antibiotic over use. 

2003 guideline changes

In 2003, new guidelines were designed by a collaboration of the Infectious Diseases Society of America [IDSA], the America Dental Association [ADA] and the American Academy of Orthopedic Surgeons [AAOS]. 2003 guidelines state, “The risk/benefit and cost/effectiveness ratios fail to justify the administration of routine antibiotic prophylaxis.” 

According to the guidelines, “antibiotic prophylaxis was not recommended for patients with pins, plates or screws, or for otherwise healthy patients with total joint replacements.  Patients at greater risk due to specific medical conditions should be considered candidates for prophylaxis.  These included patients whose prostheses were less than two years old or those who had ‘high-risk’ conditions such as inflammatory arthropathies [rheumatoid arthritis, systemic lupus erythematosus], drug-induced or radiation-induced immunosuppression, previous joint infection, malnourishment, hemophilia, human immunodeficiency virus infection, insulin-dependent diabetes or malignancy.”

Present ADA Guidelines and Conclusions from 2015 

There is evidence that dental procedures are not associated with prosthetic joint implant infections.

There is evidence that antibiotics provided before oral care do not prevent prosthetic join implant infections.

There are potential harm of antibiotics including anaphylaxis, antibiotic resistance and opportunistic infection like C difficile.

The benefits of antibiotic prophylaxis may not exceed the harms for most patients.

Given this information in conjunction with the potential harm from antibiotic use, using antibiotics before dental procedures is not recommended to prevent prosthetic joint implant infection.

The individual patient’s circumstances and preferences should be considered when deciding whether to prescribe antibiotics prior to dental procedures.

Basically the 2015 guidelines say that there is no evidence showing dental treatment causing prosthetic implant infection, and antibiotic use is not recommended.

Most prosthetic patients do not need to take antibiotics before dental treatment.

 The most important recommendation is to keep one’s gums in good health.  Periodontal disease can be prevented with good oral health habits, such as brushing and flossing, and regular professional cleanings.

 

Enjoy Life and Keep Smiling!

 

George Malkemus has a Family and Cosmetic Dental Practice in Rohnert Park at 2 Padre Parkway, Suite 200. Call 585-8595, or email info@ malkemusdds.com.  Visit Dr. Malkemus’ Web site at http://www.malkemusdds.com