When a family member recently had a full knee replacement she was surprised when Dr. Boyd asked her if the doctor had mentioned that she would need to have antibiotics when having dental work for the next two years at least. Apparently the orthopedic surgeon had not mentioned that. Thinking about it later it seemed like a good time to talk to our patients about this. Afterall, over a million (!) joint replacement surgeries are done every year.
To provide the most current information on the need for pretreatment antibiotics before dental treatment we checked with the American Academy on Orthopedic Surgeons (AAOS) and the American Dental Association (ADA). What we found when we check with these sources was that there was currently no consensus in their recommendations! How could that be? So we dug a little further and learned a little more about the lack of consensus.
In 2003, the ADA and the AAOS issued a report stating that antibiotics should be administered one hour prior to dental procedures for patients with “high risk” conditions and patients with prostheses less than two years old. Pretreatment antibiotics were not recommended for otherwise healthy patients with joint replacements. This recommendation stated that “the risk/benefit and cost/effectiveness ratios fail to justify the administration of routine antibiotic prophylaxis.” For five years this was the consensus in the thinking when it came to prescribing prophylactic antibiotics to patients who had undergone joint replacement surgery. Then in 2008, without input from any other organizations and without any studies to back it up, these recommendations were discarded by the AAOS.
In 2009, the AAOS issued an information statement that said, “Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.” In other words, if you have had joint replacement surgery you should be treated with antibiotics before having dental work for the rest of your life.
The American Dental Association, the Canadian Dental Association and the American Academy of Oral Medicine have taken issue with this recommendation. They state there was no clear explanation or scientific basis for this change in position. In fact, studies have shown that joint infections rarely are caused by bacterial species common to the mouth. Bushing teeth and other routine dental procedures cause the same bacteremia as invasive procedures, though on a lesser scale, and no one is suggesting daily antibiotic prophylaxis. That would be ridiculous!
So what do you do if you have had joint replacement therapy? Well, if it has been less than two years since the surgery or you are a high risk patient the ADA and the AAOS both agree that you should take antibiotics one hour prior to dental treatment. If you do not have high risk conditions and it has been longer than 2 years you should talk to your orthopedic surgeon to find out what they recommend for you. If the orthopedic surgeon wants you to continue to take antibiotics before dental treatment it is a good idea to get the surgeon to write out the orders so that it can be put in your dental record.
We understand that the AAOS is continuing to look at the relationship between joint prostheses, infections, and dental treatment. We hope that in the near future there is a guideline that is acceptable to both the AAOS and the ADA. Even though both organizations may not be in full agreement regarding pretreatment with antibiotics before dental treatment it is important to your health to be sure to let your dentist know if you have had joint replacement surgery – especially if it has been within two years.