Total Ankle Arthroplasty Patients: Is Antibiotic Prophylaxis Necessary Before Dental Procedures?

By Jason Miller, DPM, FACFAS, Benjamin Marder, DPM, AACFAS and Sokieu Mach, DPM 

Is there a need for antibiotic prophylaxis prior to a dental procedure for patients with a history of ankle arthroplasty? It is debatable as most studies and recommendations focus on total knee and hip prosthetic joints. The presumptive reason for a lack of clear guidelines following total ankle arthroplasty (TAA) is likely traceable to its relative infrequency in the general population in comparison to total hip and knee replacement procedures. However, there is no reason to exclude total ankle prosthetic joints from these recommendations. 

In 2003, the American Dental Association (ADA) issued a report that addressed antibiotic prophylaxis for dental patients who have total joint replacements. This report included a recommendation to provide antibiotic prophylaxis to all patients during the first two years following joint replacement.¹ However, as of December 2008, the American Academy of Orthopaedic Surgeons (AAOS) no longer supported these recommendations due to insufficient supporting evidence. 

In 2013, the ADA and the AAOS co-developed an evidenced-based Clinical Practice Guideline (CPG). They recommended against antibiotic prophylaxis to prevent prosthetic joint infections before routine dental procedures but recommended the practitioner exercise professional judgement.² These recommendations are based on an absence of reliable evidence linking prosthetic joint infections to poor oral health. In 2017, the ADA and the AAOS collaborated again and issued an Appropriate Use Criteria (AUC), which determined that antibiotic prophylaxis was rarely appropriate for 61 percent of distinct patient scenarios assessed and voted on by a panel of experts.³ Scenarios included type of dental procedure, immunocompromised status, degree of glycemic control, history of prosthetic joint infection and time since hip or knee joint replacement. 

In the literature, there is one identified case report of a total ankle joint infection after a routine dental procedure.⁴ The patient was an immunocompetent 58-year-old male with a history of multiple joint arthroplasties. Three and a half years after his right total ankle arthroplasty, the patient went for a routine dental cleaning and took two grams of amoxicillin for prophylaxis. Approximately 12 hours after the dental procedure with no prior symptoms, the patient had new onset pain and swelling in his right ankle. Aspiration of ankle fluid revealed frank purulence and cultures identified Streptococcus mitis. Streptococcus mitis is a species of Streptococcus viridans, which commonly occurs in the oral cavity and is a known source of hematogenous prosthetic joint infections.⁵ This patient went on to a staged surgical intervention with an antibiotic spacer and a revisional total ankle arthroplasty. 

This case begs the question of how bacteria from his mouth seeded his ankle implant in such a short time frame, even with appropriate antibiotic prophylaxis. It is a possibility that daily activities such as tooth brushing or flossing contributed to the bacteremia prior to his dental procedure. 

Oral bacteria, however transient and small, enter the bloodstream while one is chewing, clenching and brushing teeth. A study found that more study participants in the control group had multiple dental hygiene visits (63 percent) in comparison to patients who had prosthetic joint infections (54 percent) and that there is a trend for a lower risk of developing a prosthetic joint infection if a patient had at least one dental hygiene visit.⁶ 

Good dental hygiene may be much more important than antibiotic prophylaxis before dental procedures and dental manipulation. Potential total joint replacement candidates should undergo full oral examination and diagnostic radiographs to be cleared for the procedure. Organ transplant and major cardiac surgery candidates in South Australia are routinely referred for an oral examination prior to surgical intervention.⁷

There are risks for overutilizing antibiotics as prophylaxis for dental procedures in patients with prosthetic joints. There are concerns about increased bacterial resistance and the development of multi-resistant strains with repeated exposure, increased costs, and adverse events. 

Let’s talk numbers. One study calculated that 1,250 total joint replacement patients must be treated with antibiotic prophylaxis in order to prevent a single occurrence of prosthetic joint infection.⁶ That is a sizeable amount of antibiotics to prescribe without direct evidence of the merits, especially with the existence of known side effects. These side effects, such as allergies, nausea and diarrhea, are higher than the actual number of prevented prosthetic joint infections per 1,000 prescriptions for antibiotic prophylaxis.⁸ In addition to potential side effects, the annual cost for antibiotic prophylaxis during dental procedures in patients with prosthetic joints averages 50 million dollars in the United States.⁸ 

Evidence continues to fail to demonstrate an association between dental procedures and prosthetic joint infections, or any effectiveness of antibiotic prophylaxis. However, complications associated with prosthetic joints and dental examinations may be under-reported. With this information in conjunction with the potential harm from antibiotic use, using antibiotics before dental procedures is not the official recommendation from the ADA and AAOS to prevent prosthetic joint infections.⁹ 

However, a dental examination prior to total joint arthroplasty and clearance from a dentist are wise. The focus of preventing prosthetic joint infections during dental examinations should be less on the medicolegal aspect but more on the individual patient’s risk factors. How is the patient’s oral health? How long will the dental procedure take? What are the patient’s comorbidities and age? Does this patient have a history of an infected total joint? One should assess each the patient’s individual risk factors prior to prescribing antibiotic prophylaxis when there is a history of total joint replacement. For instance, using 0.2 percent chlorhexidine prophylactically to reduce bacteremia after tooth extraction may improve outcomes.⁸  Further studies should look into other ways to prophylactically address these scenarios.

Dr. Miller is the Director of the Pennsylvania Intensive Lower Extremity Fellowship at Premier Orthopaedics in Malvern, Pa.

Dr. Marder is a Fellow with the Pennsylvania Intensive Lower Extremity Fellowship in Malvern, Pa.

Dr. Mach is a second-year resident with the Phoenixville Hospital/Tower Health podiatric residency program.

References

1. American Dental Association. Antibiotic prophylaxis for dental patients with total joint replacements. Available at:  https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/07/antibioticprophylaxisfordentalpatientswithtotaljointreplacements.pdf . Accessed March 12, 2020.
2. Rethman M, Watters W, Abt E, et al. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg Am. 2013;95(8):745-747. 
3. Quinn R, Murray J, Pezold R, et al. Management of patients with orthopaedic implants undergoing dental procedures. J Am Acad Orthop Surg. 2017;25(7):138-141. 
4. Young JL, May MM, Haddad SL, et al. Infected total ankle arthroplasty following routine dental procedure. Foot Ankle Int. 2009;30(3):252-257. 
5. Noori N, Myerson C, Charlton T, Thordarson D. Is antibiotic prophylaxis necessary before dental procedures in patients post total ankle arthroplasty? Foot Ankle Int. 2018;40(2):237–241.
6. Zimmerli W, Sendhi P. Antibiotics for prevention of peri-prosthetic joint infection following dentistry: time to focus on data. Clin Infect Dis. 2010;50(1):17-19.
7. Scott J, Morgan D, Avent M, et al. Patients with artificial joints: do they need antibiotic cover for dental treatment? Aust Dent J. 2005;50(4):45-53. 
8. Sendi P, Uckay I, Suva D, et al. Antibiotic prophylaxis during dental procedures in patients with prosthetic joints. J Bone Jt Infect. 2016;1:42-49. 
9. 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. J Am Dent Assoc. 2015:146(1):11-16, e1-e8.