AAOS Clinical Practice Guideline for the Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures

Introduction 

Overview

This clinical practice guideline is based on a systematic review of published studies examining the influence of dental care and procedures on outcomes after total joint arthroplasty (TJA) as well as strategies to mitigate potential risks associated with dental care and procedures in patients with a TJA. It provides recommendations that will help practitioners to integrate the current evidence and clinical practice, and it highlights gaps in the literature in need of future research. This guideline is intended to be used by appropriately trained physicians and dentists considering prevention of total hip and knee arthroplasty periprosthetic joint infection in patients undergoing dental procedures. The recommendations are a guide for physicians and dentists that should not be interpreted as a standard of care. It also serves as an information resource for developers and applied users of clinical practice guidelines.

Goals and Rationale

The purpose of this clinical practice guideline is to evaluate the current best evidence associated with treatment. Evidence-based medicine (EBM) standards advocate for use of empirical evidence by physicians in their clinical decision making. To assist with access to the large resources of information, a systematic review of the literature in publication was conducted between January 1980 and October 2023. It highlights where there is good evidence, where evidence is lacking, and what topics future research will need to target in order to help facilitate evidence-based decision making in the prevention of total hip and knee arthroplasty periprosthetic joint infection in patients undergoing dental procedures. AAOS staff methodologists assisted the physician/clinician work group in evaluating the existing literature so that they could formulate the following recommendations based on a rigorous systematic process. Musculoskeletal care is provided in many different settings and by a variety of providers. We created this guideline as an educational tool to guide qualified physicians and clinicians in making treatment decisions that improve the quality and efficacy of care. This guideline should not be construed as including all possible methods of care or excluding acceptable interventions similarly directed at obtaining favorable outcomes. The final decision to use a specific procedure must be made after assessing all concerns presented by the patient and consideration of locality-specific resources.

Intented Users

This guideline is intended for use by all qualified clinicians, including orthopedic surgeons as well as dental providers, considering prevention of total hip and knee arthroplasty periprosthetic joint infection in patients undergoing dental procedures. It serves as an information resource for medical practitioners. In general, individual practicing physicians and clinicians do not have the resources required to complete a project of comparable scope and duration involving the evaluation of an extensive literature base. In April 2019, the AAOS adopted the use of the GRADE Evidence-to-Decision Framework into its clinical practice guideline development methodology. This Framework enables work group members to incorporate additional factors into the strength of each recommendation and move away from the rigidity of previous AAOS recommendation language stems. The AAOS intends for this guideline to assist treatment providers not only in making shared clinical decisions with their patients, but also in describing to patients and their loved ones why a selected intervention represents the best available course of treatment. This guideline is not intended for use as a benefits determination document. It does not cover allocation of resources, business and ethical considerations, and other factors needed to determine the material value of orthopaedic care. Users of this guideline may also want to consider the appropriate use criteria (AUC) related prevention of orthopaedic implant infection in patients undergoing dental procedures.

Patient Population

This guideline is intended for use with patients who are scheduled to undergo TJA as well as those who have a TJA and are seeking dental care.

Scope

The scope of this guideline includes the role of dental screening, antibiotic prophylaxis, prevention, and timing of dental procedures before and after TJA. The population was limited to patients with total hip (THA) or total knee arthroplasty (TKA) implants due to a paucity of data on the scope topics in patients with other orthopaedic implants. 

Etiology

PJI affects 1-2% of primary THA and TKA. There are several causes of PJI including hematogenous spread, contiguous spread from a local source, or surgical site infection from the index procedure. 

Incidence and Prevalence

TKA and THA are two of the most common surgical procedures performed worldwide. In the United States, over 1 million TKAs and THAs are performed each year. It is estimated that by 2060 the number of THA and TKA procedures performed will increase by 659% and 469%, respectively (Shichman, 2023).

Burden of Disease

As the number of patients who undergo THA and TKA continue to rise, so too will the number of patients presenting for dental care and procedures with a THA and TKA. 

Emotional and Physical Impact

Patients who have a PJI have increased pain and physical limitations. PJI is also associated with increased mortality, up to 250% greater than patients who do not have PJI (Villa, 2024). There are also significant emotional impacts of PJI including a higher incidence of mental health disorders, including anxiety, depression, and psychotic disorders (Das, 2024).

Potential Benefits, Harm, and Contraindications

There are several benefits and harms when considering dental screening prior to surgery, timing of dental procedures prior to surgery, as well as antibiotic prophylaxis in patients who have a THA or TKA who undergo a dental procedure. The ultimate goal is to limit and prevent PJI after THA or TKA. However, interventions aimed at prevention must be weighed against potential harms including patient inconvenience, patient and societal costs, as well as other adverse clinical events such as the development of Clostridioides difficile infection or antibiotic-resistant bacteria with widespread antibiotic use. The ultimate decision on whether a patient should delay a dental procedure before or after TJA, undergo dental screening before TJA, or receive antibiotic prophylaxis should be made through a shared decision-making process understanding the unique risks and benefits for that particular patient. 

Differences Between the Present and Previous Guidelines

This updated clinical practice guideline replaces the edition that was completed in 2012, “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.” This update considered the literature that we previously examined as well as the empirical evidence published since the 2012 guideline. In April 2019, the AAOS adopted the use of the GRADE Evidence-to-Decision Framework into its clinical practice guideline development methodology. This Framework enables work group members to incorporate additional factors into the strength of each recommendation and move away from the rigidity of previous AAOS recommendation language stems. The complete listing of inclusion criteria for this guideline is detailed in the section, “Study Selection Criteria,” (eAppendix 1).

For more information on the recommendations of this guideline, please visit AAOS OrthoGuidelines.