Planning Joint Replacement Surgery? Check-In With Your Dentist First
Joint replacement surgery is one of the most frequently performed surgical procedures globally, with over one million total joint replacements conducted annually in the United States alone (American Academy of Orthopaedic Surgeons, 2023). While these surgeries generally have high success rates, approximately 7% of all joint replacement surgeries are revision procedures, often necessitated by post-surgical complications, including infections (Huotari & Agthe, 2022). One emerging concern is the role of periodontal disease as a contributing factor to joint infections, which underscores the critical need for pre-surgical dental evaluations.
The Link Between Periodontal Disease and Joint Infections
Periodontal disease, characterized by chronic bacterial infection and inflammation of the gums, has been implicated in various systemic health issues, including cardiovascular disease, diabetes, and respiratory infections (Sanz et al., 2020). The bacteria responsible for periodontal disease can enter the bloodstream, leading to bacteremia, and potentially seed remote sites, such as prosthetic joints (Fowler et al., 2021). This systemic spread of bacteria, particularly in immunocompromised or elderly patients, can result in prosthetic joint infections (PJIs), among the most devastating complications of joint replacement surgery.
Research has consistently demonstrated that poor oral health is a significant risk factor for PJIs. For instance, a study by Berbari et al. (2010) found that patients with periodontal disease were at a higher risk of developing PJIs compared to those with good oral health. This association highlights the necessity for a thorough dental examination and clearance before joint replacement surgery.
The Role of Dentists in Pre-Surgical Evaluation
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) both recommend that patients undergoing joint replacement surgery should receive a dental clearance before their procedure (American Academy of Orthopaedic Surgeons & American Dental Association, 2016). This clearance involves a comprehensive dental examination to identify and treat any existing oral infections, particularly periodontal disease, which could pose a risk for postoperative complications.
A pre-surgical dental clearance is not merely a formality but a critical step in the preoperative planning process. Periodontal infections, even without apparent symptoms, can be insidious and may remain undetected without a thorough examination. Advanced periodontal disease often presents with inflamed, bleeding gums, but it can also be asymptomatic, making it difficult for patients to recognize the severity of their condition (Pihlstrom et al., 2005). Therefore, dental professionals play a crucial role in diagnosing and managing these infections before they can compromise surgical outcomes.
The Consequences of Ignoring Periodontal Health
Neglecting to address periodontal disease before joint replacement surgery can lead to severe complications. Once bacteria from an oral infection reach the prosthetic joint, they can cause a deep joint infection, which is challenging to treat and often necessitates surgical revision. These infections lead to prolonged recovery times and increased healthcare costs and significantly impact the patient’s quality of life (Sendi & Zimmerli, 2012).
A landmark study published in the British Medical Journal in 1994 highlighted that the mouth is a principal source of bacterial infection in patients with prosthetic joints (Wilson et al., 1994). Numerous studies have since supported this early recognition of the link between oral health and PJIs, reinforcing the importance of dental health in the context of joint replacement surgery.
The Growing Burden of Joint Diseases and the Need for Interdisciplinary Care
Joint diseases, including osteoarthritis, affect over 20 million people in the United States, and the demand for joint replacement surgeries is expected to rise significantly in the coming decades (Losina et al., 2012). The Kaiser Permanente National Joint Replacement Registry estimates that by 2030, the total number of hip and knee replacements will exceed 4 million annually (Kaiser Permanente, 2015). Given this projected increase, it is more important than ever to identify and mitigate all potential risk factors for surgical complications, including those related to oral health.
Collaboration between orthopedic surgeons and dental professionals is essential for optimizing patient outcomes. Orthopedic surgeons should be informed of any significant periodontal issues in their patients, as this may warrant postponing surgery until the infection is fully managed. In emergencies where surgery cannot be delayed, stringent antibiotic prophylaxis and close postoperative monitoring are crucial to prevent infection (Skaar et al., 2016).
The Role of Antibiotic Prophylaxis Post-Joint Replacement
Maintaining good oral health remains paramount for patients who have undergone joint replacement surgery. The AAOS recommends that these patients take prophylactic antibiotics before future dental procedures to reduce the risk of bacteremia and subsequent PJIs (American Academy of Orthopaedic Surgeons, 2023). However, the decision to use antibiotic prophylaxis should be made on a case-by-case basis, in consultation with the patient’s dentist and orthopedic surgeon, to balance the benefits against potential risks such as antibiotic resistance.
Conclusion
The relationship between oral health and the success of joint replacement surgery is increasingly recognized in both the medical and dental fields. By ensuring that patients receive a comprehensive dental examination and necessary treatments before joint replacement surgery, healthcare providers can significantly reduce the risk of PJIs and improve surgical outcomes. The collaboration between dentists and orthopedic surgeons is vital in providing holistic care that addresses all potential sources of infection, thereby enhancing patient safety and recovery.
AAOSH Resources
Download our free eBook to share with your patients. It explains how the mouth is connected to the body and the importance of maintaining a healthy mouth for the overall success of any surgical procedure.
Watch this free video, "Periodontal Pathogens Associated with Osteoarthritis and Periprosthetic Joint Infections of the Knee" by Garth Ehrlich, PhD. (This is a free video. CE Credit is not available for this course unless it is viewed through the members.aaosh.org Learning Platform.)
Sign Up for one of our upcoming AAOSH day-long virtual learning events, where you can earn up to 6 CE/CME from the comfort of your home or office! Use the code LEARN30 at checkout to save 30% on any of our LIVE Virtual events!
References
American Academy of Orthopaedic Surgeons. (2023). AAOS clinical practice guideline on the diagnosis and prevention of periprosthetic joint infections. Retrieved from AAOS website.
American Academy of Orthopaedic Surgeons, & American Dental Association. (2016). Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-Based Guideline and Evidence Report. The Journal of Bone and Joint Surgery, 98(10), 825-826.
Berbari, E. F., et al. (2010). Risk factors for periprosthetic joint infection: Case-control study. Clinical Infectious Diseases, 50(4), 438-443.
Fowler, T. J., et al. (2021). The oral microbiome and its role in systemic health: A focus on the link between periodontal disease and cardiovascular disease. Frontiers in Oral Health, 2, 657327.
Huotari, K., & Agthe, N. (2022). Revision total knee arthroplasty: Current indications and clinical outcomes. EFORT Open Reviews, 7(8), 550-560.
Kaiser Permanente National Joint Replacement Registry. (2015). Annual Report. Retrieved from Kaiser Permanente website.
Losina, E., et al. (2012). Lifetime risk and age at diagnosis of symptomatic knee osteoarthritis in the US. Arthritis Care & Research, 64(4), 487-492.
Pihlstrom, B. L., et al. (2005). Periodontal diseases. The Lancet, 366(9499), 1809-1820.
Sanz, M., et al. (2020). Periodontitis and cardiovascular diseases: Consensus report. Journal of Clinical Periodontology, 47(3), 268-288.
Sendi, P., & Zimmerli, W. (2012). Antimicrobial treatment concepts for orthopaedic device-related infection. Clinical Microbiology and Infection, 18(12), 1176-1184.
Skaar, D. D., et al. (2016). Dental procedures and prosthetic joint infections: A narrative review. Infection Control & Hospital Epidemiology, 37(12), 1399-1406.
Wilson, N. V., et al. (1994). The role of oral health in prosthetic joint infections. British Medical Journal, 309(6953), 506-508.