AAOS Updates Clinical Practice Guideline to Prevent Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures

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Published 12/17/2024

AAOS Updates Clinical Practice Guideline to Prevent Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures

Updated guideline establishes guidance based on latest in evidence-based recommendations

ROSEMONT, Ill. (December 17, 2024)-The American Academy of Orthopaedic Surgeons (AAOS) issued an updated Clinical Practice Guideline (CPG) for the Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection (PJI) in Patients Undergoing Dental Procedures, which replaces the previous guideline from 2012. The CPG supports patients who are scheduled for or have undergone total joint arthroplasty (TJA) and may need dental procedures by addressing antibiotic use and the timing of dental procedures before or after joint replacements, such as total knee arthroplasty (TKA) or total hip arthroplasty (THA) to help prevent infection.

To view the full guideline, click here.

"Dental procedures are believed to possibly allow bacteria to enter the bloodstream and attach themselves to hip or knee implants, potentially causing PJI in a patient," said Yale Fillingham, MD, FAAOS, co-chair of the AAOS' guideline development group. "PJI is one of the most devastating complications for patients following TJA, and we must do everything possible that is supported by evidence to prevent these infections. Given the large number of annual TJA procedures and that most of these patients undergo a dental cleaning at least twice a year, this CPG is relevant to nearly every TJA patient."

THA and TKA are two of the most common surgical procedures performed worldwide. In the United States, over 1 million THAs and TKAs are performed each year, and these cases are estimated to increase by 659% and 469%, respectively, by 2060. Unfortunately, PJI is associated with increased mortality (up to 250% greater than patients who do not have PJI, along with the risk of a higher incidence of mental health disorders).

The workgroup studied the latest data to provide clinically backed evidence for orthopaedists and dentists aimed at prevention but also weighed it against potential patient harm. The updated guideline includes two limited-strength options and three consensus options. Options are developed when little or no evidence exists on a particular topic.

The group issued a limited-strength option stating that routine use of a systemic prophylactic antibiotic before a dental procedure in patients with a hip or knee replacement may not reduce the risk of a subsequent PJI.

"The committee took a close look at the data on the administration of antibiotics before a dental procedure after both hip and knee replacement to see if it mitigated the potential risk of a PJI associated with that dental procedure," said Charles Hannon, MD, FAAOS, co-chair of the AAOS' guideline development group. "Based on the best available data, no study found that administering antibiotics before a dental procedure changed a patient's risk of getting a parasitic joint infection. With that said, it is important to recognize there may be other considerations that may lead a provider to prescribe antibiotics for an individual patient. This decision should be made with the patient, and the unique risks and benefits for the patient should be considered."

The second limited-strength option states that screening patients who have received certain dental procedures before their hip or knee replacement may not reduce the risk of subsequent PJI. However, the workgroup recognizes that patients should be aware of the potential risks of poor oral hygiene.

Guidelines At-A-Glance Desk Reference
The workgroup also developed a new resource with suggested time intervals between dental procedures and TJA that supports two consensus statements. These statements address whether to delay an arthroplasty after a dental procedure or delay a dental procedure after TKA or THA.

"It was important to create an at-a-glance tool for orthopaedic surgeons, dentists and their healthcare teams that provides guidance on the timing of dental procedures before and after TKA and THA. The tool outlines suggested timing based on the risk of transient bacteremia, the occurrence of an invasive surgical procedure that can lead to higher bacterial loads/increased infection risk, or the treatment of an active dental infection," said Dr. Hannon.

Highlights from the chart include:

• Noninvasive dental procedures and minimally invasive dental care procedures such as dental examinations (without probing), oral hygiene procedures, and orthodontic procedures can be performed safely until the day before elective TJA surgery.
• Oral surgery procedures and dental extractions, which can take up to three weeks to heal, should be completed at least three weeks before elective TJA.
• The majority of dental procedures should be delayed for up to three months after TJA based on the type of procedure performed.

The updated CPG was jointly developed by the AAOS and the American Association of Hip and Knee Surgeons, with contributions from the Infectious Disease Society of America, the Musculoskeletal Infection Society, and the American Dental Association.

Intended CPG Use
CPGs are not meant to be stand-alone documents but rather serve as a point of reference and educational tool for orthopaedic surgeons and healthcare professionals managing patients presenting with PJI that may be related to TKA and THA. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician's independent medical judgment and the individual patient's specific clinical circumstances. The guideline is not intended for use as a benefits determination document.

The full Clinical Practice Guideline for the Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures is intended for reference by orthopaedic surgeons and dentists and is available through AAOS' OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.

About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world's largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal healthcare issues; and it leads the healthcare discussion on advancing quality.

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