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Concerns

Which joint(s) have been replaced?

When was the last joint replaced?

Have you had any complications associated with the joint replacement?

Do you have any conditions ("special circumstances") that would put you at a higher risk for hematogenous infections?

Do you have any drug allergies?

Antibiotic prophylaxis for dental patients with joint replacement, according to the American Dental Association

Prescription for antibiotic prophylaxis for a patient at risk for infection due to a total joint replacement. 4 visits

American Academy of Orthopedic Surgeons (AAOS) February 2009 recommendations for antibiotic prophylaxis for patients with prosthetic joints

Suggested AAOS antibiotic regimens

Which joint(s) have been replaced?

Total joint replacements of concern to dentistry are the major joints, such as the shoulder, elbow, hip, and knee.

Present guidelines do not require antibiotic prophylaxis for pins, plates, or screws.

When was the last joint replaced?

Within the first 2 years after a total joint replacement, antibiotic prophylaxis should be considered.

Beyond 2 years, antibiotic prophylaxis is considered only under special circumstances (see below).

Have you had any complications associated with the joint replacement?

A history of prosthetic joint infections is a consideration for antibiotic prophylaxis before dental procedures, even beyond 2 years after the joint replacement.

Do you have any conditions (“special circumstances”) that would put you at a higher risk for hematogenous infections?

Several comorbid diseases and conditions and special circumstances increase the risk for experiencing a hematogenous total joint infection. When these conditions are present, antibiotics should be considered.

Patients at increased risk of developing hematogenous joint infection:
  • All patients during the first two years after joint replacement.
  • Immunocompromised/Immunosuppressed Patients: Inflammatory arthropathies, such as rheumatoid arthritis and systemic lupus erythematosus.
  • Patients with Comorbidities: Previous prosthetic joint infections, malnourishment, hemophilia, HIV infection, insulin dependent (type 1) diabetes, malignancy.

Do you have any drug allergies?

Drug allergies may affect the choice of antibiotic used for prophylaxis.

Antibiotic prophylaxis for dental patients with total joint replacement, according to the American Dental Association:

Situation Agent Adult Regimen
Standard general prophylaxis Cephalexin, cephadrine, or amoxicillin 2 g orally
1 h before procedure
Unable to take oral medication Cephazolin or ampicillin Cephazollin 1 g or ampicillin 2g IM or IV
1 h before procedure
Allergic to penicillin Clindamycin 600 mg orally
1 h before procedure
Allergic to penicillin and unable to take oral medication Clindamycin 600 mg IV
within 30 min of procedure

Prescription for antibiotic prophylaxis for a patient at risk for infection due to a total joint replacement. 4 visits:

Patients with no penicillin or amoxicillin allergies
Name: John Doe    DOB: 1/1/50
Address:123 Main Street, Pleasantville, PA
Amoxicillin 500 mg tab.
Disp. 16 tabs.
Sig. 4 tabs. po, 1 hr. prior to dental appointment

 

Patients with cephalosporin or amoxicillin allergies
Name: John Doe    DOB: 1/1/50
Address:123 Main Street, Pleasantville, PA
Clindamycin 300 mg tab.
Disp. 8 tabs.
Sig. 2 tabs. po, 30-60 min. prior to dental appointment

American Academy of Orthopedic Surgeons (AAOS) February 2009 recommendations for antibiotic prophylaxis for patients with prosthetic joints

The American Academy of Orthopedic Surgeons recommendations in February 2009 stated:

“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.”

The guideline goes on to note:

Antibiotic prophylaxis is particularly important for those patients with one or more of the following risk factors.

All patients with prosthetic joint replacement
Immunocompromised/immunosuppressed patients
Inflammatory arthropathies (eg, rheumatoid arthritis, systemic lupus erythematosus)
Drug-induced immunosuppression
Radiation-induced immunosuppression
Patients with comorbidities (eg, diabetes, obesity, HIV, smoking)
Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (Type 1) diabetes
Malignancy
Megaprostheses

It is important to note that AAOS and ADA are currently working on new evidence-based guidelines as the February 2009 AAOS guidelines were not based on any new or evidence-based data.

Suggested AAOS antibiotic regimens

Select one of the following antibiotics:

Rx: amoxicillin 500 mg
In case of penicillin allergy: cephalexin 500 mg, or cephradine 500 mg
Disp. 4 tablets
Sig. Take 4 tablets (2 g) 1 hour before procedure

OK