Antibiotics for Dental Work Following Joint Replacement

Updated guidelines limit antibiotics to at-risk individuals only

dentist replacement antibiotics
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Persons who have undergone joint replacement surgery are at risk for developing infections of their implanted joints. In severe cases of infection, a person may experience the loss of bone support to the implant and require surgery to repair it.

It is for this reason that doctors make every effort to counsel their patients on ways to avoid infection. Deep infection is a serious problem affecting between 4% of primary and 15% of revision knee replacements.

There have been changing recommendations as to whether antibiotics should be mandatory for joint replacement recipients when undergoing dental work. Starting in 2012, the recommendations were modified to say that most people would not require antibiotics for routine dental work but that treatment may be given to people at the highest risk of infection.

How Implant Infection Occurs

The most common route of a bacterial infection into the body is through broken skin. While normal tissue can typically defend itself against the invading bacteria, the inorganic materials of a prosthesis cannot. It is there that an infection can seed and cause damage to surrounding bone and tissue.

Another possible route involves oral infections and certain types of dental work. During a dental procedure (or any invasive medical procedure, for that matter), bacteria can often enter the bloodstream if the tissue is broken. With little immune protection, any infection of a knee replacement and hip replacement can quickly turn serious, increasing the risk of complications and disability.

To avoid this, doctors will often recommend a course of antibiotics before any invasive procedure. In this way, the natural bacteria on the skin or in the mouth will be dramatically suppressed. While this would certainly be recommended in advance of major surgery, persons undergoing certain dental procedures may also be reasonable candidates.

Current Dental Recommendations

There is often confusion (and not only among patients but doctors, as well) as to who should receive antibiotics before dental work. In the past, antibiotics were commonly administered for all dental procedures for the first two years following implant surgery. That recommendation was then extended in 2009 from two years to a lifetime. However, there was a complete turnaround in policy only three years later.

In its updated 2016 guidelines, the American Academy of Orthopedic Surgeons (AAOS) in association with the American Dental Association (ADA) stated that antibiotics are not recommended for persons undergoing routine dental work.

In defending the decision, both the AAOS and ADA stated that there was no evidence to suggest that the routine administration of antibiotics reduced the risk of joint implant infection. Similarly, the governing bodies were unable to endorse the use of oral antimicrobials prior to dental work and only reached consensus in recommending "healthy oral hygiene" as a means of ample protection.

Special Circumstances

This is not to suggest that antibiotics should be avoided or that there aren’t circumstances (such as major extractions) for which antibiotics may be appropriate.

There are also certain individuals who are inherently at higher risk of infection due to either a severely weakened or abnormal immune response. In many cases, these individuals are not only less able to fight infection but to control it once it occurs.

According to the AAOS/ADA guidelines, antibiotics may need to be administered prior to dental work for persons with the following conditions:

  • Rheumatoid arthritis, lupus, and other autoimmune disorders for which infection can trigger sometimes severe inflammation of the joints
  • Insulin-dependent diabetics and hemophiliacs who are at increased risk of blood-borne infections
  • Immune compromised individuals. including organ transplant recipients, persons undergoing cancer radiation therapy, and people with advanced HIV infection
  • Persons who have had a past infection of a joint implant

Recommended Antibiotics

When antibiotics are recommended, doctors will typically prescribe oral amoxicillin to be taken one hour before the dental work.

If you cannot tolerate oral antibiotics, your doctor may recommend cefazolin or ampicillin which are injected within an hour of the procedure. If you are allergic to these drugs, clindamycin (either oral or injected) may be used.

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Article Sources

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  1. Lenguerrand E, Whitehouse MR, Beswick AD, et al. Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales. Lancet Infect Dis. 2019 Apr;19(6):589-600. doi:10.1016/S1473-3099(18)30755-2

  2. Hamedani S. A clinical practice update on the Latest AAOS/ADA guideline (December 2012) on prevention of orthopaedic implant infection in dental patients. J Dentistry. 2013;14(1):49-52.

  3. American Academy of Orthopaedic Surgeons. Appropriate use criteria for the management of patients with orthopaedic implants undergoing dental procedures. October 24, 2016.