Do patients with a history of joint replacement require antibiotics before tooth extractions?

Antibiotic Prophylaxis Before Tooth Extractions in Joint Replacement Patients

Most patients with joint replacements do NOT need antibiotics before tooth extractions. The 2017 joint guidelines from the American Academy of Orthopedic Surgeons (AAOS) and American Dental Association (ADA) found that antibiotic prophylaxis is appropriate in only 12% of scenarios, may be appropriate in 27%, and is rarely appropriate in 61% of cases 1.

General Recommendation for Standard-Risk Patients

• Do not prescribe prophylactic antibiotics for healthy patients with prosthetic joints undergoing tooth extractions 1
• The ADA explicitly states that "prophylactic antibiotic should not be given" for most patients with prosthetic joint implants 2
• Multiple high-quality studies have failed to demonstrate any association between dental procedures and prosthetic joint infections, even without antibiotic prophylaxis 2, 1

Supporting Evidence

The evidence against routine prophylaxis is compelling:

• Case-control studies of 339 patients with prosthetic hip or knee infections found no statistical association between high-risk dental procedures (including extractions) without antibiotics and prosthetic joint infection 2
• A Taiwanese population-based study of 255,568 residents showed prosthetic joint infection occurred in 0.57% of those receiving dental treatment versus 0.61% in those without dental treatment—actually slightly lower in the dental group 2
• Among patients who received dental treatment, infection rates were nearly identical whether they received antibiotics (0.2%) or not (0.18%) 2

High-Risk Patients Who SHOULD Receive Prophylaxis

Reserve antibiotic prophylaxis exclusively for immunocompromised patients with the following conditions 1:

• HIV/AIDS 1
• Active malignancy 1
• Rheumatoid arthritis 1
• Solid organ transplant recipients on immunosuppression 1
• Previous prosthetic joint infection 1
• Inherited immune deficiency diseases 3
• Drug-induced or radiation-induced immunosuppression 3

Recommended Antibiotic Regimen for High-Risk Patients

When prophylaxis is indicated 1:

• Amoxicillin 2 grams orally, given 1 hour before the dental procedure (single dose only) 1
• For penicillin-allergic patients: Azithromycin (single dose) 1
• Never prescribe multiple days of antibiotics—only a single pre-procedure dose 1

Critical Pitfalls to Avoid

• Do not provide prophylaxis for all joint replacement patients without risk stratification 1
• Do not prescribe prolonged antibiotic courses when only a single pre-procedure dose is indicated 1
• Do not confuse patients with pins, plates, and screws (who never need prophylaxis) with those who have total joint replacements 1
• Recognize that the risk of adverse effects from antibiotics must be weighed against the extremely low risk of prosthetic joint infection from dental procedures 1

Evolution of Guidelines and Current Consensus

The guidelines have shifted dramatically away from routine prophylaxis:

• In 2009, AAOS initially recommended prophylaxis for all joint replacement patients before invasive procedures 2
• By 2013, AAOS reversed itself, recommending that "clinicians should consider discontinuing the long-standing practice of routinely prescribing antibiotic prophylaxis" 2
• The 2015 ADA statement was even more definitive: "prophylactic antibiotic should not be given" for general patients with prosthetic joints 2
• The 2017 Dutch Orthopedic and Dental Society concluded that antibiotic prophylaxis "is not appropriate" 2

More Effective Prevention Strategy

Good oral hygiene and regular dental care are more important for preventing hematogenous seeding of joint prostheses than antibiotic prophylaxis 1. Encourage patients to maintain excellent oral health and address dental infections promptly rather than relying on prophylactic antibiotics 2.