Do I Need Antibiotics for Dental Work After a Joint Replacement?

Antibiotics have long been used before dental procedures for people who have undergone joint replacement surgery due to the risk of joint implant infection. These guidelines are no longer in place, and antibiotics are generally not used prior to dental work in those who have had a total knee or hip replacement.

With that said, people with a history of joint implant infection may very well benefit from preventive antibiotics. Your orthopedic surgeon should work with your dentist to determine the best antibiotics to use.

This article explains the risk of infection in people who have undergone hip or knee replacement and the current recommendations for preventing infections during invasive oral procedures.

Risk of Infection After a Joint Replacement

One of the biggest concerns following joint replacement surgery is an infection of the implant. Also known as a prosthetic joint infection (PJI), this can occur soon after the joint replacement surgery or many years later.

The bacteria most commonly associated with PJI are Staphylococcus aureus or strains of Streptococcus or Enterococcus.

There are three ways that bacteria can reach the implant and establish an infection:

• Intraoperative infection: The direct introduction of bacteria into the joint during surgery
  
• Soft-tissue transmission; The spread of bacteria from a nearby organ, such as a kidney infection that spreads to a hip joint
• Bloodborne infection: The spread of bacteria through the bloodstream to a joint, such as caused skin wounds, skin ulcers, IV drug use, or surgical and dental procedures

Dental procedures are of concern because they can cause breaks in the gums that allow bacteria to enter the bloodstream, eventually reaching the artificial joint. Dental procedures can not only cause PJIs but also lead to a serious infection of the heart, called endocarditis.

Dental treatments can also introduce new, more invasive bacteria into the mouth that the immune system has a harder time controlling.

Recommendations for Antibiotics for Routine Dental Work

Antibiotics are often given before surgery to prevent postoperative infection, a strategy known as preoperative prophylaxis. This was supported by research in 2008 which showed that doing so reduced the risk of infection following a total hip and knee replacement by over 80%.

The same rationale was applied to dentistry in which preoperative prophylaxis was commonly used before dental work to prevent PJI. In 2009, the American Academy of Orthopedic Surgeons (AAOS) and the American Dental Association (ADA) both endorsed the approach for anyone who had undergone a total hip or knee arthroscopy (replacement surgery).

Just seven years later, in 2016, the decision was reversed when the AAOS and ADA advised against the practice. This was based on evidence that the practice not only didn't help but only served to increase the risk of antibiotic resistance by exposing patients to antibiotics they didn't need.

A 2017 analysis in Infectious Control and Hospital Epidemiology supported the recommendation. According to the study, which involved 13,026 people with total knee or hip replacements, preoperative antibiotics did not lower the risk of PJI following dental procedures compared to people who were given no antibiotics.

Antibiotics for Special Circumstances

The revised AAOS/ADA recommendation does not entirely exclude the need for preoperative antibiotics for all people with total hip or knee replacements.

According to the AAOS/ADA guidelines, antibiotic prophylaxis may be used before invasive dental work for the following groups:

• People who have experienced a PJI in the past
• People with autoimmune diseases like rheumatoid arthritis or lupus in whom an infection can trigger severe symptoms
• People with hemophilia or type 1 diabetes who are at increased risk of bloodborne infections
• Immunocompromised people who are at risk of complications from bacterial infections, including organ transplant recipients, people with untreated HIV, and those undergoing cancer treatment

The AAOS/ADA recommends that you discuss the risks and benefits of prophylactic antibiotics with your healthcare provider to make a fully informed, shared decision.

Types of Antibiotics Use for Oral Procedures

When antibiotics are indicated for the prevention of PJI, the AAOS/ADA recommends that the following antibiotics be taken no less than one hour before the dental procedure:

• First-line preferred: Amoxil (amoxicillin)
• Alternative: Second-generation cephalosporins like Ancef (cefazolin)
• Alternative: Principin (ampicillin)
• Alternative: Macrolide antibiotics like Cleocin (clindamycin)

Summary

In the past, antibiotics were given before dental work to prevent prosthetic joint infection (PJI) in people with a total hip or knee replacement. Evidence has shown that the practice does not help and may only increase the risk of antibiotic resistance. Since 2016, the practice was no longer endorsed.

The only people who should be prescribed antibiotics before dental work are those who have had a PJI in the past. If prescribed, the antibiotic is taken no less than one hour before the dental procedure.