Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons¹ with joint replacement.

Joint replacement

Terminology used in this Advisory

Resources consulted

• How long does a hip replacement last?: The Lancet (article)
• Total Hip Replacement: American Academy of Orthopaedic Surgeons
• Total Hip Replacement: Cleveland Clinic 
• Total Joint Replacement: American Academy of Orthopaedic Surgeons
• Total Knee Replacement: American Academy of Orthopaedic Surgeons

1. Arthroplasty, alternative term for joint replacement. 
2. Bacteremia, the transient presence of bacteria in the blood that
   1. is the principal means by which local or superficial infections spread to the body’s internal organs and structures
   2. often results from simple cuts or scratches
   3. may occur after oral healthcare procedures, minor surgery or other invasive procedures 
   4. normally elicits a vigorous immune response to prevent the bacteria from spreading
   5. in the presence of an impaired immune system may be dangerous.
3. Hematogenous seeding of artificial joints when, in bacteremia, bacteria pass from the blood stream into artificial joints, which
   1. may
      1. occur as early infections
      2. occur as late infections
      3. be associated with acute infection in the oral cavity
      4. arise during
         1. normal daily life 
         2. dental, urological and other surgical and medical procedures
   2. does not parallel infective endocarditis (CDHO Advisory) because, in the development of infective endocarditis the anatomy, blood supply, microorganisms and mechanisms of infection differ fundamentally.
4. Infection phases in joint replacement comprise
   1. early infections, which
      1. occur in the days or weeks following joint replacement
      2. are generally easier to treat than late infections
   2. late infections, which 
      1. occur months or years following joint replacement
      2. almost always require 
         1. removal of the implant and subsequent revision surgery 
         2. intensive antibiotic treatment.
5. Joint replacement, total joint replacement, in which a biological joint is surgically replaced by an artificial joint.
6. Megaprostheses, which 
   1. are used to reconstruct bones as well as joints affected by disease, such as cancer, or major injury
   2. are subject to infection, a common complication.
7. Prosthesis, in the context of orthopaedics, is a device used to replace
   1. a diseased joint or bone
   2. a damaged joint or bone.
8. Revision surgery, chiefly 
   1. replacement of an existing artificial joint with a new one because it is infected, worn out, loosened, or associated with bone fracture
   2. needed after expiry of the service life-time of an artificial joint, which
      1. typically ranges from ten to twenty or more years, depending on a variety of factors, including the location of the involved joint and type of prosthetic involved as well as individual patient/client factors
      2. may be shortened by mechanical stress related to obesity or excessive physical activity. 
9. Synovial joint, a type of joint that in most instances permits substantial movement, in which 
   1. the articulating bones are separated by cavity containing synovial fluid 
   2. the ends of the bone are covered with articular cartilage.

Overview of joint replacement

Resources consulted

• College of Dental Hygienists of Ontario: Joint Replacement Fact Sheet
• Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England |  JAMA Netw Open
• Antibiotics for Prevention of Periprosthetic Joint Infection Following Dentistry: Time to Focus on Data | Clinical Infectious Diseases
• Canadian Dental Association
• Canadian Dental Association: Comment on the 2009 American Academy of Orthopaedic Surgeons’ Information Statement on Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements
• Canadian Orthopaedic Association
• American Dental Association: Antibiotic Prophylaxis Prior to Dental Procedures
• American Dental Association: Management of patients with prosthetic joints undergoing dental procedures
• American Academy of Orthopaedic Surgeons
• American Association of Orthopaedic Surgeons and American Dental Association
• Arthritis Society
  • https://www.arthritis.ca/treatment/surgery/knee-replacement-surgery
  • https://www.arthritis.ca/treatment/surgery/hip-replacement-surgery

Overview of interpretations of infection risk in joint replacement and the role of antibiotic prophylaxis

See also Chronology

The American Academy of Orthopaedic Surgeons and the American Dental Association Evidence-Based Guideline (2012)

In December 2012, the American Academy of Orthopaedic Surgeons in conjunction with the American Dental Association conducted a systematic review and released a joint evidence-based clinical practice guideline. 

1. The AAOS and ADA joint evidence-based clinical practice guideline at December 7, 2012,
   1. explains that a systematic review was conducted between October 2010 and July 2011 that demonstrated where there was good evidence, where evidence was lacking, and what topics future research should target to improve the prevention of orthopaedic implant infection in patients undergoing dental procedures
   2. notes that a clinical practice guideline was created and based on a systematic review of published studies related to the prevention of orthopaedic implant infection in patients undergoing dental procedures
   3. encourages readers to consider the information presented in the guidelines
   4. advises that
      1. the statement represents AAOS’ and the ADA’s current recommendations on antibiotic prophylaxis
      2. AAOS regularly reviews and updates all informational statements as new technology, evidence, or policy is developed
      3. the guidelines are not intended to be a fixed protocol as some patients may require more or less treatment or different means of diagnosis and is not intended as the standard of care nor as a substitute for clinical judgment as it is impossible to make recommendations for all conceivable clinical situations in which bacteremias may occur
      4. the guidelines are not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners
   5. recommends that 
      1. the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures (Limited recommendation)²
      2. they are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures
      3. in the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Patients who may be at potentially higher risk for joint infection were not specifically examined in this systematic review, therefore, clinicians should use their professional judgment and clinical decision-making skills to identify those patients who may be at a greater risk (e.g., immunocompromised) and consult with the most appropriate healthcare provider(s).

In 2014, a panel of experts convened by the ADA Council on Scientific Affairs developed an evidence-based clinical practice guideline (CPG), released in January 2015, on the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures. However, this advice lacked AAOS support.

1.      The ADA clinical practice guideline at January 2015,
   1. was intended to clarify the “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report,” which was developed and published by the American Academy of Orthopaedic Surgeons and the American Dental Association (the 2012 Panel);
   2. noted that evidence failed to demonstrate an association between dental procedures and prosthetic joint infection or any effectiveness for antibiotic prophylaxis;
   3. advised that the above information, in conjunction with the potential harm from antibiotic use, led the panel to conclude that, in general, using antibiotics before dental procedures is not recommended to prevent prosthetic joint infection; and further advised that the dental 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; and
   4. also concluded that additional case-control studies were needed to increase the level of certainty in the evidence to a level higher than moderate.

The Canadian Dental Association Position (2013)

The Canadian Dental Association (Position Statement – June 2013)

1. concurred with the systematic review of the AAOS and ADA evidence-based 2015 guideline which determined that there was no direct evidence that dental procedures cause orthopaedic implant infections.
2. suggested that 
   1. patients should not be exposed to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit
   2. routine antibiotic prophylaxis is not indicated for dental patients with total joint replacements, nor for patients with orthopaedic pins, plates and screws
   3. patients should be in optimal oral health prior to having total joint replacement and should maintain good oral hygiene and oral health following surgery. Orofacial infections in all patients, including those with total joint prostheses, should be treated to eliminate the source of infection and prevent its spread.

The Canadian Orthopaedic Association/Canadian Dental Association/Association of Medical Microbiology and Infectious Disease Canada — Consensus Statement: Dental Patients with Total Joint Replacement (2016)

The COA, CDA, and AMMI

1. reviewed the current best available evidence on the effectiveness of dental antibiotic prophylaxis in the reduction of orthopaedic prosthetic joint infections, in the context of the issue of emerging antimicrobial resistance and the critical role of all healthcare providers to steward appropriate use of antimicrobial drugs.
2. concluded that
   1. most transient bacteremia or oral origin occurs outside of dental procedures
   2. the significant majority of prosthetic joint infections are not due to organisms found in the mouth
   3. few prosthetic joint infections have an observable and clearly defined relationship with dental procedures
   4. there is no reliable evidence that antibiotic prophylaxis prior to dental procedures prevents prosthetic joint infections.
3. recommended the following with regard to management of dental patients/clients with orthopaedic devices
   1. patients/clients should not be exposed to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit
   2. routine antibiotic prophylaxis is not indicated for dental patients/clients with total joint replacements, nor for patients/clients with orthopaedic pins, plates, and screws
   3. patients/clients should be in optimal oral health prior to having total joint replacement and should maintain good oral hygiene and oral health following surgery
   4. orofacial infections in all patients/clients, including those with total joint prostheses, should be treated to eliminate the source of infection and prevent its spread.

The American Academy of Orthopaedic Surgeons and the American Dental Association — Appropriate Use Criteria for the Management of Patients With Orthopaedic Implants Undergoing Dental Procedures (9/23/2016 and 10/24/2016)

The AAOS Board of Directors and the ADA Council on Scientific Affairs adopted conjoint appropriate use criteria for antibiotic prophylaxis in 2016. In contradistinction to the 2016 COA/CDA/AMMI Consensus Statement, the AAOS/ADA criteria allowed for antibiotic prophylaxis in a limited subset of patients/clients with joint replacements who have certain co-morbidities and/or past history of peri-prosthetic or deep prosthetic joint infections.  Included in the AAOS/ADA document was adjustment of the 2007 statement of the American Heart Association on prevention of infective endocarditis (https://www.ahajournals.org/doi/full/10.1161/circulationaha.106.183095) to reflect removal of clindamycin and cefazolin as antibiotic prophylaxis options for joint replacement, based on more recently published literature.

Since 2016, an increasing body of evidence and preponderance of reputable authorities refute prior recommendations to give antibiotic prophylaxis to patients/clients with prosthetic joints prior to invasive dental/dental hygiene procedures (particularly on a routine basis).

Purposes of joint replacement

Joint replacement 

1. is performed 
   1. chiefly on the knee, hip, and shoulder joints
   2. less commonly on the elbow, wrist, and ankle joints
   3. when osteoarthritis or rheumatoid arthritis
      1. is painful enough to undermine the quality of life 
      2. impairs the ability to work or undertake important activities of a normal life
   4. to restore function after severe trauma
   5. when other forms of treatment, such as physiotherapy, are no longer sufficient
   6. as revision surgery
   7. when comorbid conditions such as obesity require it 
2. involves surgery that 
   1. removes the impaired cartilage and bone from the joint
   2. implants the artificial joint, which is cemented into bone or installed with a special coating to promote adherence to the bone through growth of new bone.

Occurrence of joint infection associated with joint replacement

Joint replacement infection is a devastating complication, which

1. may not be adequately combated by the body’s immune system because
   1. the immune system’s normal function of defending tissues against bacteria is impaired by the material implanted into the joint
   2. bacteria are difficult to eliminate from the implanted joint
2. is uncommon though
   1. its occurrence is the subject of uncertainty
   2. the 2010 study, Antibiotics for Prevention of Periprosthetic Joint Infection Following Dentistry: Time to Focus on Data, reports that
      1. the infection 
         1. occurs after
            1. total hip replacement in 0.3 to 1 percent of patients 
            2. total knee replacement in 1 to 2 percent of patients 
         2. is associated with the hematogenous route in 35 to 40 percent of instances
         3. is chiefly a sequel to
            1. skin infection
            2. urinary-tract sepsis
   3. the 2019 editorial,  Prosthetic Joint Infection notes that incidence of prosthetic joint infections (PJI) ranges from 1% to 2% in primary procedures for total knee (TKA) and total hip arthroplasty (THA), with international registry data showing that risk of revision due to PJI is rising for primary and revision THA.

Risk factors of joint infection

Joint replacement risk factors include infection of the synovial space enclosing the implanted joint, which

1. requires particular attention to infection control including antibiotic prophylaxis 
   1. during the orthopaedic surgery
   2. in the immediate post-operative phase of the orthopaedic surgery
   3. in conjunction potentially with some surgery (but not routinely dental/dental hygiene procedures) indefinitely after the joint replacement because of the risk of hematogenous seeding.
2. in the context of antibiotic prophylaxis
   1. is considered the greatest risk for a synovial joint because with this type of joint hematogenous seeding is most likely to occur
   2. is considered the least risk with pins, plates and screws, and other orthopaedic hardware because with these hematogenous seeding is unlikely to occur 
   3. the potential benefit of antibiotic prophylaxis requires
      1. weighing against the known risks of antibiotics, including toxicity, allergy, and bacterial antibiotic resistance
      2. clinical judgment which in determining the appropriateness of antibiotic  prophylaxis for individual patients/clients which may require consultation with the orthopaedic surgeon or primary care provider. To reiterate, as per the 2016 COA/CDA/AMMI Consensus Statement, routine antibiotic prophylaxis is not indicated for dental/dental hygiene patients/clients with total joint replacements, nor for patients/clients with orthopaedic pins, plates, and screws. Thus, the vast majority of patients/clients with joint replacements should not be receiving antibiotic prophylaxis. However, certain medical conditions³ may warrant consideration of antibiotic prophylaxis according to some American authorities.

Signs and symptoms of joint infection

following Joint replacement include

1. chills
2. drainage from the wound
3. increasing redness, tenderness, or swelling of the wound
4. warmth to the touch of the skin over the replaced joint 
5. pain, which increases with activity and rest
6. persistent fever 
7. swelling.

Medical investigation and treatment of joint infection

Joint replacement investigation and treatment 

1. involves a high index of suspicion for any change or unusual signs and symptoms in persons with a history of joint replacement
2. embraces
   1. early infections
   2. late infections
3. requires for any person with signs and symptoms of joint infection prompt and vigorous investigation and treatment, including
   1. elimination of the source of the infection
   2. appropriate therapeutic antibiotics.

Prevention of joint infection risk 

Joint replacement joint infection risks of 

1. early infections are prevented by 
   1. antibiotics
      1. given within one hour of the start of joint replacement surgery
      2. continued for a short period following the joint replacement surgery
   2. strict adherence to sterile procedure
   3. oral healthcare inspection, including dental hygiene, and necessary treatment some weeks prior to the orthopaedic surgery 
2. late infections are not necessarily prevented by antibiotic prophylaxis for dental/dental hygiene procedures⁴, although antibiotic prophylaxis is sometimes prescribed for dental/dental hygiene procedures
   1. as a non-evidence-based precaution for some patients/clients with a history of joint replacement
   2. in accordance to certain prevailing recommendations (such as those of the American Academy of Orthopaedic Surgeons [2016], which are at odds with those of the Canadian Orthopaedic Association, the Canadian Dental Association, and the Association of Medical Microbiology and Infectious Disease Canada [2016]).

Prognosis for joint infection 

Joint replacement infection is associated with a prognosis that includes 

1. serious disability
2. revision surgery that is premature relative to the expected service life-time of the replacement joint.

Multimedia and images

Hip joint replacement – series
Knee joint replacement prosthesis

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with joint replacement but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions for joint replacement that, at various times and by various authorities, were thought to require special consideration because they were thought to potentially place patients/clients at elevated risk for adverse outcomes (particularly prosthetic joint infections, although not necessarily related to invasive dental/dental hygiene procedures) were (but not limited to)

1. immunocompromise/immunosuppression
2. inflammatory arthropathies, such as
   1. rheumatoid arthritis (CDHO Advisory)
   2. systemic lupus erythematosus (CDHO Advisory)
3. drug-induced immunosuppression (CDHO Advisory)
4. radiation-induced immunosuppression (CDHO Advisory)
5. patients with comorbidities, including
   1. diabetes (CDHO Advisory)
   2. obesity
   3. HIV (CDHO Advisory)
   4. smoking
6. previous prosthetic joint infections
7. malnourishment (CDHO Advisory)
8. hemophilia (CDHO Advisory)
9. HIV infection (CDHO Advisory)
10. insulin-dependent (Type 1) diabetes (CDHO Advisory)
11. malignancy
12. megaprostheses

However, according to the American Dental Association (ADA 2017, reiterated in an online “Key Points” update by the ADA Scientific & Research Institute’s Department of Scientific Information, Evidence Synthesis & Research Translation on January 5, 2022), compared with previous recommendations, there are relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to invasive dental/dental hygiene procedures. Similarly, the American Academy of Orthopaedic Surgeons (AAOS 2016) now does not recommend prophylactic antibiotic premedication, regardless of the oral procedure, for most patients/clients with prosthetic joint implants. The 2016 Consensus Statement of the Canadian Orthopaedic Association, the Canadian Dental Association, and the Association of Medical Microbiology and Infectious Disease Canada is even more definitive: there is no reliable evidence that antibiotic prophylaxis prior to dental/dental hygiene procedures prevents prosthetic joint infections, and therefore patients/clients should not be unnecessarily exposed to the adverse effects of antibiotics, and thus routine antibiotic prophylaxis is not indicated for dental/dental hygiene patients/clients with total joint replacements, nor for patients/clients with orthopaedic pins, plates, and screws.

Oral health considerations

Chronology

In 1997, the American Academy of Orthopaedic Surgeons together with the American Dental Association developed an information statement on antibiotic prophylaxis for patients who have undergone joint replacement. It was collaboratively revised and republished in 2003. 

The 2003 statement’s recommendations limited the use of antibiotic prophylaxis to the first two years following joint replacement surgery, with certain important exceptions such as a weakened immune system. For the exceptions, antibiotic prophylaxis was stipulated regardless of the length of time after the joint replacement surgery. 

In 2007, the Canadian Dental Association reaffirmed its support for the 2003 statement.

In 2009, the American Academy of Orthopaedic Surgeons released a new Information Statement, which was developed independently of the American Dental Association. The statement was offered as an educational tool based on the opinion of the authors. 

The Educational tool’s recommendations differed from the 2003 statement by recommending antibiotic prophylaxis prior to any invasive procedure that may produce bacteremia, regardless of the length of time after the joint replacement surgery. The removal of the time limitation for antibiotic prophylaxis led to debate among dental authorities.

In 2009, the Canadian Dental Association⁵ confirmed that it stood by its 2007 position and therefore, that of the American Academy of Orthopaedic Surgeons, developed jointly with the American Dental Association in 2003.

In 2010, the American Academy of Orthopaedic Surgeons released a revised Information Statement. This was developed as an educational tool based on the opinion of the authors, and its readers “are encouraged to consider the information presented and reach their own conclusions.”

Also in 2010, the American Academy of Orthopaedic Surgeons / American Dental Association Collaboration on antibiotic prophylaxis in bacteremia in patients with joint replacements was launched at their Introductory Meeting of November 20 and 21. The Collaboration was reported in 2012.

On December 7, 2012, the systematic review from the American Academy of Orthopaedic Surgeons / American Dental Association Collaboration on antibiotic prophylaxis in bacteremia in patients with joint replacements was released. The systematic review found no direct evidence that dental procedures cause orthopaedic implant infections. The review also yielded joint evidence-based guidelines which recommended (with a limited grade) that the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

In June 2013, the Canadian Dental Association’s Position paper on Dental Patients with Total Joint Replacement agreed with the 2012 American Academy of Orthopaedic Surgeons / American Dental Association systemic review on antibiotic prophylaxis in bacteremia in patients with joint replacements – that there was no direct evidence that dental procedures cause orthopaedic implant infections. The Canadian Dental Association took the position that routine antibiotic prophylaxis is not indicated for dental patients with total joint replacements, nor for patients with orthopaedic pins, plates and screws. This differed slightly from the ADA/AAOS clinical practice guideline which advised dentists to consider discontinuing the practice of routinely prescribing prophylactic antibiotics for dental patients with total joint replacements.

In 2014, a panel of experts convened by the ADA Council on Scientific Affairs was assembled which developed an evidence-based clinical practice guideline for dental practitioners titled The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. This was intended to clarify the “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report,” which was developed and published by the American Academy of Orthopaedic Surgeons and the American Dental Association (the 2012 Panel). The clinical practice guideline was released in January 2015 in the Journal of the American Dental Association. This guideline concluded that evidence failed to demonstrate an association between dental procedures and prosthetic joint infection or any effectiveness for antibiotic prophylaxis. This information, in conjunction with the potential harm from antibiotic use, led to the conclusion that, in general, using antibiotics before dental procedures is not recommended to prevent prosthetic joint infection (with the caveat that the dental 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). The guideline also concluded that additional case-control studies were needed to increase the level of certainty in the evidence to a level higher than moderate.

In June/July 2016, the Canadian Orthopaedic Association, the Canadian Dental Association, and the Association of Medical Microbiology and Infectious Disease released an evidence-based Consensus Statement that concluded that routine antibiotic prophylaxis is not indicated for dental patients/clients with total joint replacements, nor for patients/clients with orthopaedic pins, plates, and screws.  

In September/October 2016, the American Association of Orthopaedic Surgeons and the American Dental Association adopted appropriate antibiotic prophylaxis use criteria that allowed for prophylaxis in a limited subset of patients/clients with joint replacements who have certain co-morbidities and/or past history of peri-prosthetic or deep prosthetic joint infections. Included in the AAOS/ADA document was adjustment of the 2007 statement of the American Heart Association on prevention of infective endocarditis to reflect removal of clindamycin and cefazolin as antibiotic prophylaxis options for joint replacement, based on more recently published literature.

As stated previously, since 2016, an increasing body of evidence and preponderance of reputable authorities refute prior recommendations to give antibiotic prophylaxis to patients/clients with prosthetic joints prior to invasive dental/dental hygiene procedures (particularly on a routine basis).

Considerations for dental hygienists

Relative to the Procedures, the dental hygienist should take account of the following considerations. 

1. Good oral health and hygiene status
   1. prevents disease in the mouth and other parts of the body 
   2. decreases bacteremia of oral origin 
   3. should be advocated to persons who 
      1. have a history of joint replacement
      2. are likely to undergo joint replacement.
2. All routine dental hygiene, including the Procedures, should be delayed for several weeks after joint replacement or revision surgery or, if doubt exists, until clearance is given by the surgeon.
3. For a patient/client with a history of one or more of the comorbidities, complications or associated conditions listed above, the dental hygienist, prior to performing any of the Procedures, may need to seek the advice of the orthopaedic surgeon or another appropriate medical professional, whether directly or through the family physician (and not necessarily confined or focused on antibiotic prophylaxis).

1. Promoting health through oral hygiene for persons who have joint replacement.
2. Reducing the risk of hematogenous seeding of bacteria onto artificial joints resulting from bacteremia arising from the Procedures by
   1. seeking advice from the appropriate specialist or primary care provider about the need for antibiotic prophylaxis when warranted
   2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
   3. using appropriate techniques of communication
   4. providing advice on scheduling and duration of appointments.
3. Reducing the risk that oral health needs are unmet.

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III