FACT SHEET: Joint Replacement (also known as “prosthetic joint”, “arthroplasty”, and “artificial joint”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
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, if the patient/client has a past history of peri-prosthetic or deep prosthetic joint infection, or if the patient/client has severe immunosuppression and/or poorly controlled diabetes. Given evolving guidelines for antibiotic prophylaxis, consultation with the patient/client’s orthopaedic surgeon or another appropriate medical professional may be warranted. See footnote 1 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 conditions1 may warrant consideration of antibiotic prophylaxis according to some American authorities.2
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, all routine office-based dental hygiene, including invasive procedures, should be delayed for several weeks 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/dental hygiene procedures, and others adopting 3 to 6 months.
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.3 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.
- 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. Some orthopaedic surgeons request that their patients/clients not undergo dental procedures within 6 to 8 weeks prior to their joint replacement surgery.
- 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.
Related signs and symptoms
- More than 75,000 knee replacements are more than 63,000 hip replacements are performed annually in Canada, making them the second and third most commonly performed surgeries.
- Prosthetic joint replacement is an option for some patients/clients with joint destruction resulting from long-standing osteoarthritis 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 infection4 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
- College of Dental Hygienists of Ontario
https://www.cdho.org/docs/default-source/pdfs/milestones/milestones_201802.pdf (Anastasopoulos R. Joint Replacement ― Should I Premedicate? Milestones. 2018;2:10-11.)
(Guideline: Recommended Antibiotic Prophylaxis Regimens for the Prevention of Infective Endocarditis and Hematogenous Joint Infection)
- Royal College of Dental Surgeons of Ontario https://www.rcdso.org/en-ca/standards-guidelines-resources/rcdso-news/frequently-asked-questions/information-on-antibiotic-prophylaxis-
- Thornhill MH, Crum A, Rex S, Stone T, Campbell R, Bradburn M, Fibisan V, Lockhart PB, Springer B, Baddour LM, Nicholl J. Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England. JAMA Netw Open. 2022 Jan 4;5(1):e2142987. doi: 10.1001/jamanetworkopen.2021.42987. PMID: 35044470; PMCID: PMC8771300. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788219
- Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners ― a report of the American Dental Association Council on Scientific Affairs. JADA 2015;146(1):11-16.
- Tande AJ, Patel R. Prosthetic joint infection. Clin Microbiol Rev. 2014;27(2):302-45.
- McNally CM, Visvanathan R, Liberali S, Adams RJ. Antibiotic prophylaxis for dental treatment after prosthetic joint replacement: exploring the orthopaedic surgeon’s opinion. Arthroplast Today. 2016;2(3):123-126. Published 2016 Mar 3. doi:10.1016/j.artd.2015.12.003
- Hollingshead CM, Brizuela M. Antibiotic Prophylaxis in Dental and Oral Surgery Practice. [Updated 2023 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK587360/
- Canadian Dental Association
- Canadian Orthopaedic Association
- Canadian Institute of Health Information
- Sunnybrook Health Sciences Centre
- Arthritis Society
- American Dental Association
https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_prosthetics.pdf?rev=848d32fce4d1484299d05bbb50f060b9&hash=2ECD50BD260BDC98EDCAF9569B969747 (Management of patients with prosthetic joints undergoing dental procedures)
- American Academy of Orthopaedic Surgeons
- American Association of Hip and Knee Surgeons
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
1 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 (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) now does not recommend prophylactic antibiotic premedication, regardless of the oral procedure, for most patients/clients with prosthetic joint implants. The AAOS does allow, however, for antibiotic prophylaxis in a limited subset of patients/clients with joint replacements who have certain co-morbidities (e.g., severe immunosupression and/or poorly controlled diabetes) and/or past history of peri-prosthetic or deep prosthetic joint infections.
2 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).
3 Potential harms of antibiotics include anaphylaxis, antibiotic resistance, and opportunistic infections.
4 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.