What are the guidelines for dental prophylaxis after total hip arthroplasty (THA)?

From the Guidelines

Dental prophylaxis after hip replacement is not routinely recommended for most patients, and antibiotic prophylaxis is only considered for high-risk patients with specific conditions such as immunocompromise, previous prosthetic joint infection, or inflammatory arthropathy. The current guidelines, as outlined in the 2017 AAOS/ADA recommendations 1, suggest that antibiotic prophylaxis is not necessary for routine dental work after hip replacement unless the patient has specific risk factors.

Key Considerations

• The risk of prosthetic joint infection from dental procedures is extremely low, with studies showing no statistical association between high-risk dental procedures and PJI 1.
• The potential harms of routine antibiotic use, including antibiotic resistance, allergic reactions, and side effects, outweigh the benefits for most patients 1.
• Maintaining excellent oral hygiene through regular dental check-ups, brushing, and flossing is important for overall health and may reduce the risk of bacteria entering the bloodstream that could potentially affect the prosthetic joint.

Recommendations

• Patients with prosthetic joints should maintain good oral health following surgery, but routine antibiotic prophylaxis is not recommended unless specific risk factors are present 1.
• If prophylaxis is deemed necessary, amoxicillin 2g orally 1 hour before the dental procedure is typically recommended, with azithromycin as an alternative for patients with penicillin allergy, replacing clindamycin due to its higher risk of Clostridioides difficile infection (CDI) 1.
• The decision to use antibiotic prophylaxis should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history, as outlined in the 2017 AAOS/ADA recommendations 1.

Important Findings

• Studies have consistently shown that the risk of PJI from dental procedures is low, and that routine antibiotic prophylaxis does not significantly reduce this risk 1.
• The use of antibiotic prophylaxis can have significant harms, including the disruption of the gut microbiome, contribution to antibiotic resistance, and increased risk of adverse drug reactions (ADRs) 1.
• A recent study found that 1 in 5 patients develop an ADR that results in a prolonged length of stay, readmission, or a visit to an emergency room after receiving antibiotics 1.

From the Research

Dental Prophylaxis After Hip Replacement

• The use of antibiotic prophylaxis prior to dental procedures after total hip and knee arthroplasty has been a topic of debate, with some studies suggesting that it may not be necessary 2, 3.
• A retrospective cohort study found that routine antibiotics prior to dental procedures did not affect the risk of late-presenting periprosthetic joint infection (PJI) 2.
• Another study found that there was no significant positive association between invasive dental procedures and late periprosthetic joint infections, suggesting that antibiotic prophylaxis may not be necessary for patients with prosthetic joints undergoing dental procedures 3.
• However, some studies have found that extended oral antibiotic prophylaxis can reduce the risk of PJI in high-risk patients 4.
• The use of prophylactic antibiotics is most responsible for reducing infection, and the goal is to have adequate antibiotic tissue levels at the time of skin incision 5.
• Guidelines for antibiotics prior to dental procedures for patients with specific cardiac conditions and prosthetic joints have changed, reducing indications for antibiotic prophylaxis 6.

Key Findings

• Routine antibiotic prophylaxis before dental procedures is not necessary after total hip and knee arthroplasty 2, 3.
• Extended oral antibiotic prophylaxis can reduce the risk of PJI in high-risk patients 4.
• Prophylactic antibiotics should be used to reduce early periprosthetic joint replacement, with the goal of having adequate antibiotic tissue levels at the time of skin incision 5.
• Guidelines for antibiotics prior to dental procedures have changed, reducing indications for antibiotic prophylaxis 6.

Implications

• Dental care for patients with prosthetic joints should focus on maintaining good oral hygiene rather than recommending antibiotic prophylaxis for invasive dental procedures 3.
• Orthopedic surgeons and their patients should be reassured that dental care can be performed without the need for antibiotic prophylaxis, reducing the risk of adverse drug reactions and promoting antibiotic stewardship 3.