Is antibiotic prophylaxis recommended for dental procedures in patients with joint hardware (artificial joint replacement) implanted 1 month prior?

From the Guidelines

Antibiotic prophylaxis is not recommended for dental procedures in patients with joint hardware implanted 1 month prior, unless the patient has a high-risk condition such as immunocompromised status, AIDS, cancer, RA, SOT on IS, or inherited immune deficiency diseases. The current evidence suggests that the risk of prosthetic joint infection (PJI) is low, and the risk of adverse events from antibiotic prophylaxis is higher 1. A study published in 2020 found that the risk of developing an antibiotic adverse event is 1 in 5, while the risk of PJI is less than 1% 1. The American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) have also updated their guidelines to recommend against routine antibiotic prophylaxis for patients with prosthetic joint implants, unless they have a high-risk condition 1.

Some key points to consider include:

• The risk of PJI is highest in the first few months after implantation, but the overall risk is still low 1
• Antibiotic prophylaxis can disrupt the gut microbiome, contribute to antibiotic resistance, and cause adverse events such as Clostridioides difficile infection 1
• The ADA and AAOS recommend against routine antibiotic prophylaxis for patients with prosthetic joint implants, unless they have a high-risk condition 1
• Patients who are immunocompromised, have AIDS, cancer, RA, SOT on IS, or inherited immune deficiency diseases may still require antibiotic prophylaxis before dental procedures 1

In general, 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. However, for patients with joint hardware implanted 1 month prior, without high-risk conditions, antibiotic prophylaxis is not recommended 1.

From the Research

Antibiotic Prophylaxis for Dental Procedures in Patients with Joint Hardware

• The American Dental Association Council on Scientific Affairs developed an evidence-based clinical practice guideline on the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures 2.
• The guideline states that, in general, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection, considering the risks of frequent or widespread antibiotic use, such as antibiotic resistance and adverse drug reactions.
• A study published in 2020 found that dentists' recommendations for the use of antibiotic prophylaxis varied depending on different factors, including health status of the patient, dental procedure, and time elapsed since joint surgery, suggesting that adherence to the guideline is still challenging 3.
• Another study published in 2022 found no significant positive association between invasive dental procedures and late periprosthetic joint infections, and therefore, no rationale to administer antibiotic prophylaxis before invasive dental procedures in patients with prosthetic joints 4.

Considerations for Patients with Joint Hardware Implanted 1 Month Prior

• The studies do not provide specific recommendations for patients with joint hardware implanted 1 month prior to the dental procedure.
• However, the American Dental Association guideline suggests that the practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis 2.
• The decision to use antibiotic prophylaxis should be based on the individual patient's needs and circumstances, taking into account the potential benefits and risks of antibiotic use.

Risks and Benefits of Antibiotic Prophylaxis

• The use of antibiotic prophylaxis is associated with risks, such as antibiotic resistance and adverse drug reactions 2, 4.
• However, in certain high-risk patients, extended oral antibiotic prophylaxis may substantially reduce the 90-day infection rate after primary total hip and knee arthroplasty 5.
• The benefits and risks of antibiotic prophylaxis should be carefully weighed and considered on a case-by-case basis, taking into account the individual patient's needs and circumstances.