Antibiotic Prophylaxis for Hip Prosthesis Before Dental Procedures
Routine antibiotic prophylaxis is NOT recommended for patients with hip prostheses undergoing dental procedures. 1, 2, 3
Primary Recommendation
The American Academy of Orthopaedic Surgeons (AAOS) and American Dental Association (ADA) jointly recommend discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip prosthetic joint implants undergoing dental procedures. 1 This represents a reversal from earlier guidance and is based on direct evidence showing no association between dental procedures and prosthetic joint infections, regardless of antibiotic use. 1
Evidence Supporting No Prophylaxis
A well-conducted case-control study of 339 patients with prosthetic hip infections matched with 339 controls found no statistically significant association between dental procedures (high-risk or low-risk) and prosthetic hip infections, with or without antibiotic prophylaxis. 1
Daily activities like chewing and tooth brushing cause far more bacteremia episodes than dental procedures, yet these do not result in prosthetic joint infections. 1, 3
While antibiotics reduce dental procedure-associated bacteremia, there is no evidence linking this bacteremia to actual prosthetic joint infections—bacteremia is merely a surrogate outcome that may not translate to clinical benefit. 1
A Taiwanese population-based study of 255,568 residents showed prosthetic joint infection occurred in 0.57% of the dental treatment cohort versus 0.61% in the non-dental cohort, with no difference between those receiving prophylaxis versus not (P=0.8). 2
Exception: High-Risk Immunocompromised Patients
For select high-risk patients only, prophylaxis may be considered after shared decision-making: 1, 2
- Patients with HIV/AIDS
- Active cancer or malignancy
- Solid organ transplant recipients on immunosuppression
- Rheumatoid arthritis on immunosuppressive therapy
- Inherited immune deficiency diseases
Even in these populations, the evidence remains limited, and patient preference should guide the decision. 1
Critical Harms of Unnecessary Prophylaxis
Clindamycin carries a 12 per million risk of death from C. difficile infection from a single 600mg dose. 2
One in five hospitalized patients receiving antibiotics develops an adverse drug reaction requiring prolonged hospitalization, readmission, or emergency room visit. 2
Antibiotics disrupt the gut microbiome for extended periods and contribute to antibiotic resistance. 2
A systematic review found that 46% of organisms causing dental-associated prosthetic joint infections may be resistant to amoxicillin, questioning the efficacy even when prophylaxis is given. 4
If Prophylaxis Is Chosen (High-Risk Patients Only)
- Amoxicillin 2g orally as a single dose, 30-60 minutes before the dental procedure
- Azithromycin (NOT clindamycin due to C. difficile risk)
- Clindamycin 600mg orally 1 hour before procedure is an alternative but carries higher risk 3
Procedures requiring consideration: 3
- Only for procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa
- NOT required for routine anesthetic injections through noninfected tissue or dental radiographs
Best Practice: Oral Hygiene
The most effective strategy is maintaining appropriate oral hygiene rather than relying on antibiotic prophylaxis, as good oral health reduces baseline bacteremia risk from daily activities. 1, 3
Common Pitfalls to Avoid
Do not confuse this guidance with cardiac prophylaxis—patients with prosthetic cardiac valves or previous infective endocarditis DO require amoxicillin 2g before dental procedures, as the risk-benefit calculation is entirely different. 3
Do not prescribe prophylaxis based on time since surgery—the outdated "2-year rule" is no longer supported by evidence. 1
Do not use erythromycin for prophylaxis, as case reports document prosthetic hip infections despite erythromycin prophylaxis due to organism resistance. 5