What are the recommended prophylactic antibiotics prior to a dental procedure in a patient with a history of knee replacement (Total Knee Arthroplasty, TKA)?

From the Guidelines

Antibiotic prophylaxis is not recommended for most patients with prosthetic joint implants, including those with knee replacements, prior to dental procedures, as the risk of prosthetic joint infection is low and the potential harms of antibiotic use outweigh the benefits. The American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) have updated their guidelines to reflect this recommendation, citing a lack of evidence to support the use of antibiotic prophylaxis in this setting 1.

The guidelines suggest that antibiotic prophylaxis may be considered for high-risk patients, such as those with immunocompromised conditions, diabetes, rheumatoid arthritis, or previous prosthetic joint infections 1. However, even in these cases, the decision to use antibiotic prophylaxis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

Some studies have suggested that the risk of prosthetic joint infection from dental procedures is low, and that the use of antibiotic prophylaxis may not significantly reduce this risk 1. For example, a population-based cohort study of 255,568 Taiwanese residents found no significant association between invasive dental treatment and the incidence of prosthetic joint infection during the first 2 postoperative years 1.

Key points to consider:

• The risk of prosthetic joint infection from dental procedures is low
• The potential harms of antibiotic use, such as antibiotic resistance and adverse reactions, outweigh the benefits for most patients
• High-risk patients may require individualized consideration for antibiotic prophylaxis
• Patients should inform their dentist about their knee replacement and consult with their orthopedic surgeon regarding their specific needs for antibiotic prophylaxis.

It is essential to weigh the potential benefits and harms of antibiotic prophylaxis for each patient, considering their unique medical history and risk factors, rather than relying on a blanket recommendation 1.

From the Research

Recommended Prophylactic Antibiotics

• The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints is a topic of debate 2, 3, 4.
• Studies have shown that routine antibiotics prior to dental procedures do not affect the risk of late-presenting periprosthetic joint infection (PJI) 2.
• The American Dental Association Council on Scientific Affairs developed an evidence-based clinical practice guideline that recommends against the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures, except in cases where there is a significant medical risk 3.
• A systematic review of the literature found no direct evidence to support the use of prophylactic antibiotics prior to dental procedures in patients with total joint arthroplasty (TJA) 4.

Specific Studies

• A retrospective cohort study found that routine antibiotics prior to dental procedures were not shown to affect the risk of late-presenting PJI, and that all dental-associated PJIs occurred in patients who were prescribed antibiotics 2.
• A study on the effect of preoperative oral antibiotic use on the risk of PJI after primary knee or hip replacement found that preoperative antibiotic use was associated with a reduced risk of PJI, but cautioned against indiscriminate use of antibiotics 5.
• A study on extended oral antibiotic prophylaxis in high-risk patients found that it substantially reduced the primary total hip and knee arthroplasty 90-day infection rate, but encouraged further study and deliberation before adopting such a protocol 6.

Key Findings

• The current evidence suggests that prophylactic antibiotics are not necessary prior to dental procedures in patients with prosthetic joints, except in cases where there is a significant medical risk 2, 3, 4.
• The use of antibiotics prior to dental procedures does not appear to reduce the risk of PJI, and may even contribute to the development of antimicrobial resistance 2, 5.
• Further study is needed to determine the optimal approach to preventing PJI in patients with prosthetic joints who are undergoing dental procedures 4, 6.