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FACT SHEET: Joint Replacement (also known as “prosthetic joint”, “arthroplasty”, and “artificial joint”)

Date of Publication: June 20, 2019
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Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No.

Is medical consult advised? 

  • No, in most circumstances. 
  • Yes, if prosthetic joint infection (PJI) is suspected. 
  • Yes, if there is concern regarding the functioning of the prosthetic joint.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • No, for a patient/client with a joint replacement for which antibiotic prophylaxis is not recommended or required. This will be the vast majority of patients/clients with prosthetic joints based on the 2016 Consensus Statement on Patients with Total Joint Replacements having Dental Procedures issued by the Canadian Orthopaedic Association [COA], Canadian Dental Association [CDA], and Association of Medical Microbiology and Infectious Disease [AMMI] Canada.

Is medical consult advised? 

  • Yes, if the dental hygienist is unsure whether the patient/client requires antibiotic prophylaxis. This may be particularly relevant if the patient/client has: previously received antibiotic prophylaxis in connection with oral healthcare procedures or minor surgery; a past history of peri-prosthetic or deep prosthetic joint infection; severe immunosuppression1; poorly controlled diabetes; or, undergone revision total joint arthroplasty (TJA). Given evolving guidelines for antibiotic prophylaxis, consultation with the patient/client’s orthopaedic surgeon or another appropriate medical professional may be warranted. See footnote 2 below for more information.
  • Yes, if prosthetic joint infection is suspected.
  • Yes, if there is concern regarding the functioning of the prosthetic joint.

Is medical clearance required? 

  • No, for most patients/clients with joint replacements. (See above and below.)

Is antibiotic prophylaxis required? 

  • No, for the vast majority of patients/clients with prosthetic joints. According to 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. However, certain medical conditions2 may warrant consideration of antibiotic prophylaxis according to some American authorities.3 

Is postponing treatment advised?

  • Yes, if, in the absence of antibiotic prophylaxis, the dental hygienist is unsure whether the patient/client has comorbid conditions, complications, or associated conditions that may place the patient/client with a joint replacement at elevated risk for joint infection from invasive dental hygiene procedures. Medical consultation should be sought whether antibiotic prophylaxis is warranted.
  • Yes, if the patient/client has not received or complied with pre-medication (including antibiotic prophylaxis) as directed by the prescribing clinician (possibly the patient/client’s orthopaedic surgeon) or dentist. Most antibiotic prophylaxis regimens entail taking a single dose of antibiotic 30 to 60 minutes before invasive procedures (so that there will be high blood levels of antibiotic at the time bacteremia occurs).
  • Yes, nearly all routine office-based dental/oral hygiene procedures, including particularly invasive procedures, should be delayed for several weeks to 3 months after joint replacement or revision surgery unless clearance is given by the orthopaedic surgeon. Practice patterns vary among orthopaedic surgeons, with some surgeons adopting 6 weeks post-joint replacement as reasonable for dental/oral hygiene procedures, and others adopting 3 to 6 months. The American Academy of Orthopaedic Surgeons (2024 “Evidence-Based Clinical Practice Guideline” [CPG] in conjunction with the American Association of Hip and Knee Surgeons [AAHKS], and as endorsed by the American Dental Association)4 suggests that the minimum time needed after TJA until most dental/oral hygiene procedures is 3 months. An exception to this is dental examination without probing5, for which same day is the suggested minimum time after TJA.
  • Yes, if the patient/client is scheduled for total joint arthroplasty less than one week before proposed scaling and/or root planing (SRP) with manual (hand instruments) or ultrasonic scaler.
  • Yes, if the patient/client is scheduled for TJA less than one day before proposed oral hygiene procedures such as dental cleaning, dental prophylaxis using a rubber cup and handpiece (without scaling), and periodontal probing (without SRP).

Oral management implications

  • Patients/clients with prosthetic joint replacements are commonly encountered in dental hygiene practice.
  • There is evidence that dental/dental hygiene procedures are not associated with prosthetic joint infection (PJI). Furthermore, most transient bacteremia of oral origin occurs outside of dental/dental hygiene procedures, and the significant majority of prosthetic joint infections are not due to microbes found in the mouth.
  • There is evidence that antibiotics provided prior to dental/dental hygiene procedures do  not prevent prosthetic joint infection.
  • Patients/clients should not be unnecessarily exposed to the adverse effects of antibiotics.6 Therefore, possible benefit of antibiotic prophylaxis, if any, should be weighed carefully against risks to the patient/client.
  • Guidelines from reputable Canadian (and American) authorities have evolved in recent years to, in general, advise against routinely using antibiotics before dental/dental hygiene procedures for the purpose of preventing hematogenous seeding (i.e., bacteremia) causation of prosthetic joint infections. However, practice patterns (for both orthopaedic surgeons and oral health professionals) vary within North America and globally.
  • There is no evidence that oral topical antiseptic mouthwash (e.g., chlorhexidine) significantly reduces the level of bacteremia following dental/dental hygiene procedures. Consequently, the AAOS/AAHKS (2024 “Evidence-Based Clinical Practice Guideline”) does not recommend oral topical antiseptic wash before a dental procedure in patients/clients with a hip or knee replacement for the purpose of reducing the risk of periprosthetic joint infection.
  • Patients/clients should be in optimal oral health prior to undergoing total joint replacement, and they should maintain good oral hygiene and oral health following surgery.
  • While some orthopaedic surgeons historically requested that their patients/clients not undergo dental procedures within 6 to 8 weeks prior to their joint replacement surgery, this lengthy time frame is not supported by emerging evidence. According to the AAOS/AAHKS (2024 “Evidence-Based Clinical Practice Guideline”)7, the suggested minimum time interval needed between dental procedures and TJA surgery is:
    • same day for dental examination without probing
    • 1 day for oral hygiene procedures, orthodontic procedures, and other non-invasive procedures
    • 1 week for scaling and/or root planing (SRP) with manual (hand instruments) or ultrasonic scaler
    • 3 weeks for dental extractions, oral surgery, and resolution of active dental infection.
  • Orofacial infections should be promptly treated in patients/clients with total joint prostheses, and in persons about to undergo arthroplasty, to eliminate the source of infection and prevent its spread.

Oral manifestations

  •  None.

Related signs and symptoms

  • More than 75,000 knee replacements and more than 63,000 hip replacements were performed annually in Canada in fiscal 2019-2020 before and just as the COVID-19 pandemic began. This made them the second and third most commonly performed surgeries. Of these, more than 10,300 were knee and hip revision (repeat) surgeries. However, the pandemic resulted in reduced surgical volumes. In fiscal 2021-2022, the corresponding figures were 58,443 knee and 58,635 hip replacements, with 8,942 being revisions.
  • Prosthetic joint replacement is an option for some patients/clients with joint destruction resulting from long-standing osteoarthritis (the most common reason, by far, for primary hip and knee replacements) or rheumatoid arthritis, as well as for some persons with non-healing fractures or avascular necrosis. The goals are reduction in pain and improvement in functioning.
  • The most common prosthetic joints are knee and hip replacements, followed by shoulder, elbow, wrist, and ankle.
  • Signs/symptoms of prosthetic joint infection8 include: pain and stiffness in a previously well-functioning prosthetic joint; swelling; erythema and warmth around the surgical wound; wound drainage; sinus tract communicating with the arthroplasty; fever, chills, and night sweats; and fatigue.  
  • While PJI has a much lower mortality rate than infective endocarditis, surgical removal of the artificial joint and prolonged treatment with antibiotics are usually required.

References and sources of more detailed information


Date: December 31, 2018
Revised: July 25, 2019; August 23, 2023; January 19, 2026


FOOTNOTES

1 The American Academy of Orthopaedic Surgeons (“Appropriate Use Criteria” 2025) lists several “severely immunocompromised” definitions. These include patients/clients with: Stage 3 AIDS (as per Centers for Disease Control and Prevention guidelines); cancer undergoing immunosuppressive chemotherapy with criteria for febrile or severe neutropenia; rheumatoid arthritis using certain biologic disease modifying agents; solid organ transplant on immunosuppressants; inherited diseases of immunodeficiency; and bone marrow transplant in various phases of treatment. More detailed information can be found at https://www.orthoguidelines.org/management-of-patients-with-orthopaedic-implants-undergoing-dental-procedures.
2 Patients/clients considered by various authorities at various times to be at potentially elevated risk of prosthetic joint infections ― not necessarily related to dental/dental hygiene procedures ― include those with: history of complications with their joint replacement surgery; previous prosthetic joint infections; recent joint replacement surgery (first 2 years); disease-, drug-, or radiation-induced immunosuppression; inflammatory arthropathies (such as rheumatoid arthritis or systemic lupus erythematosus); type 1 diabetes; malnutrition; and hemophilia. According to the American Dental Association (ADA; 2017), 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 and 2024/2025) does not recommend prophylactic antibiotic premedication, regardless of the oral procedure, for most patients/clients with prosthetic joint implants. The AAOS in 2016 (“Appropriate Use Criteria”, in conjunction with the ADA) did allow, however, for antibiotic prophylaxis in a limited subset of patients/clients with joint replacements who have certain co-morbidities (e.g., severe immunosuppression and/or poorly controlled diabetes) and/or past history of peri-prosthetic or deep prosthetic joint infections. In 2024, the AAOS (“Evidence-Based Clinical Practice Guideline” [CPG] in conjunction with the American Association of Hip and Knee Surgeons [AAHKS], and as endorsed by the ADA) stated that “routine use of a systemic prophylactic antibiotic prior to a dental procedure in patients with a hip or knee replacement may not reduce risk of a subsequent periprosthetic joint infection.” This CPG further noted that “evidence in this recommendation is mostly derived from patients with primary arthroplasty, particularly THA [total hip arthroplasty] and THK [total knee arthroplasty],” and not in potentially higher risk patients such as revision TJA patients. The subsequent 2025 AAOS “Appropriate Use Criteria” (which overlaid evidence-based information with collective expert clinical opinion), largely reflected the 2024 AAOS/AAHKS CPG with respect to antibiotic prophylaxis, with, however, allowance again being made for consideration of antibiotic prophylaxis in immunocompromised patients/clients with joint replacement who are about to undergo invasive dental procedures.
3 Suggested antibiotic prophylaxis regimens, when warranted, should be administered 30 to 60 minutes before invasive dental/dental hygiene procedures, and include (for adults):
– patients/clients not allergic to penicillins: amoxicillin 2 g orally;
– patients/clients unable to take oral medications: ampicillin 2 g intramuscularly (IM)** or intravenously (IV) [and not allergic to penicillins]; or, ceftriaxone*** 1 g IM or IV
– patients/clients allergic to penicillins: cephalexin*** 2 g orally; or, azithromycin 500 mg orally or clarithromycin 500 mg orally
– patients/clients allergic to penicillins and unable to take oral medications: ceftriaxone*** 1 g IM or IV; or, azithromycin equivalent dose 500 mg IV or clarithromycin equivalent dose 500 mg IV
* based on AAOS Appropriate Use Criteria For the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures (2016)
** intramuscular injections should be avoided in persons receiving anticoagulants
*** Cephalosporins should not be used in persons with a history of immediate type hypersensitivity reaction (anaphylaxis, angioedema, or urticaria) to penicillins (including ampicillin).
4 More detailed information related to suggested time intervals needed between dental procedures and TJA surgery can be found in Table 3 (page 27) of the 2024 AAOS/AAHKS CPG at https://www.aaos.org/globalassets/quality-and-practice-resources/dental/dental-2024/prevention-of-total-hip-and-knee-arthroplasty-pji-in-patients-undergoing-dental-procedures-cpg.pdf.
5 The AAOS/AAHKS “dental examination without probing” includes: dental radiograph or cone beam CT imaging; denture adjustment procedures; clear orthodontic aligner [invisible braces] adjustment procedures; and occlusal guard or bite splint adjustment.
6 Potential harms of antibiotics include anaphylaxis, antibiotic resistance, and opportunistic infections.
7 More detailed information related to suggested time intervals needed between specific dental procedures and TJA surgery can be found in Table 3 (page 27) of the 2024 AAOS/AAHKS CPG at https://www.aaos.org/globalassets/quality-and-practice-resources/dental/dental-2024/prevention-of-total-hip-and-knee-arthroplasty-pji-in-patients-undergoing-dental-procedures-cpg.pdf. Most transient bacteremia in a healthy mouth resolves in several hours, but longest times occur for extractions and scaling procedures.
8 Patients/clients at highest risk of developing PJI (non-dentally related) are those with wound drainage, contiguous infection at an adjacent site, or both after undergoing arthroplasty. Pre-operative risk factors, independent of dental/dental hygiene procedures, are prior operation/arthroplasty on the index joint, diabetes mellitus, and/or being immunocompromised (defined as rheumatoid arthritis or current use of systemic corticosteroids/immunosuppressive drugs or presence of a malignancy or history of chronic kidney disease). The majority of PJIs occurring within 1 year of surgery result from the introduction of microorganisms at the time of surgery; PJI resulting from hematogenous spread from a remote site of infection is rare. PJIs are sometimes classified according to time of occurrence relative to surgery; for example, early onset (< 3 months after last surgery), delayed onset (> 3 months but < 12 or 24 months after last surgery), and late onset (> 12 or 24 months after last surgery).


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.