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Hello, everyone! I’m Dr. Trish Murray – physician, best-selling author, and the Health Catalyst Speaker. Today I’m going to spend a few minutes talking about something that a lot of patients ask me about. Patients that have had joint replacements always are asking, “Do I need to always take antibiotics before I get my teeth cleaned? Or before I have a dental procedure?” Actually, not being a dentist, a lot of times I wasn’t quite sure. I was like, “I really need to review this.” Let’s go over it because actually the bottom line is, the answer is – no! Let’s make sure you understand. This discussion is about antibiotic prophylaxis for dental procedures. It’s the American Dental Association’s Clinical Guidelines. The dental association of the United States has researched this and reviewed it, and a panel of experts has come up with the guidelines.

Now, what is prophylaxis? Prophylaxis means that you would take antibiotics prior to a dental procedure in order to avoid any type of infection in a prosthetic joint like a joint replacement.

Now, what are the historical reasons why we would even consider taking antibiotics before you have a dental procedure? The reason is bacteremia. You see, folks, the plaque that you go to the dental hygienist for, when they use all these horrible tools and they’re scraping and scratching and scratching and scraping and we’re all clenching our hands to the arms of the chair the whole time because we hate…can you sense how much I hate going to the dentist for this? I do go twice a year because I know I need it. Why? Because the plaques that build up on our teeth and along the gumline of our teeth are actually biofilms.

Biofilm is when bacteria and other microorganisms create a colony, a little colony. They get together, they hang out together. They create a little pack or a colony and then they form a certain material or chemical or gel-like substance or plaque-like substance that encases them in their own little pack and their own little colony and their own little environment. Your immune system can’t get to them. That’s what the dental hygienist is scraping away and breaking up is the plaques and the biofilms that have formed along the gumline of your teeth. When they do that they release, of course, all of the bacteria into your mouth and into your bloodstream. Some goes down into your gut and you pass it, but some gets absorbed into your bloodstream. That’s what bacteremia means. If bacteria are floating around in your bloodstream then they could possibly then get to the joints and seed the prosthetic joint that you have, whether that be your knee, your hip, your shoulder, whatever.

That’s the second reason here, historical reasons for using prophylactic antibiotics is the concern that bacteremia caused by someone scraping all the bacteria off your teeth all at once as a big load would possibly be a risk for seeding a joint replacement and causing an infection of the joint replacement.

The other concern is that, of course, all the blood goes to the heart and so a heart infection called endocarditis is possible due to bacteremia. For many years it was thought that, again, dental procedures put people at an increased risk of infective endocarditis and joint replacement. That’s why prophylactic antibiotics were given, or many times are still given, by dentists prior to dental procedures.

But the January 2015 Journal of the American Dental Association Guidelines were created based on a panel that they put together, the American Dental Association put together, in 2014. An expert panel looked at the current best evidence and they felt that the current best evidence, when they all looked at it, failed to demonstrate an association between dental procedures and prosthetic joint infection.

They also realized that using antibiotics over and over and over throughout a year, maybe three times, again may increase antibiotic resistance. Antibiotic resistances means that if you take antibiotics it kills bugs – yes, but it also exposes those bugs to those antibiotics, and the bugs are smart! They know how to change possibly their genetics or the way they interact with them chemical, and maybe they develop a resistance against the antibiotic. Then when you need the antibiotics because you really are definitively sick, they won’t work. This is why a negative effect of using prophylactic antibiotics may increase antibiotic resistance is another reason to give evidence why we should not. If the incidence of joint replacement infection is not very high, then the weight would not be in favor of using antibiotics prophylactically.

Another reason is it may increase incidence of reverse drug reactions. Antibiotics are not benign. Some people will have an anaphylactic reaction because they are allergic, and they didn’t know it. Or, they’ll have some other adverse allergic reaction to an antibiotic. Or, if you’ve heard of Clostridium difficile, C. diff, that is caused by us taking an antibiotic and killing off certain bugs and allowing Clostridium difficile to become more prominent and then cause a horrible diarrhea that can become chronic and could kill someone eventually if it’s bad enough.

Another reason that they’re not recommending prophylactic antibiotics is cost. In 2013, the estimated annual cost of amoxicillin, which is one of the most common antibiotics used in prophylactic dental work given to patients with hip and knee joint replacements, before dental procedures in the United States only (not worldwide, just the United States) exceeded $50 million.

Again, to repeat the definitive guidelines, the January 2015 (and it hasn’t changed since then) Journal of the American Dental Association Guideline states that in general for patients with a prosthetic joint implant prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.

Now, for patients with a history of complications associated with their joint replacement surgery, meaning you had your joint replacement surgery, and you got an infection in the acute phase after the surgery, that would put you at maybe an increase risk for complications of dental procedures. So, again, for patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation and mucosal incision. So, gingiva is your gums. If you’re manipulating the gums and again, they’re scraping and all that stuff with the dental hygienist, that’s what they mean. Gingiva manipulation or mucosal incision. If the dentist is going to be cutting into your gums and the mucosa of your mouth that’s obviously going to put you at increased risk of bacteremia.

Listen to this – prophylactic antibiotics should only be considered after consultation with the patient and the orthopedic surgeon, the surgeon that did the joint replacement in the first place. What you want to do is you want to make sure you assess the patient’s medical status as a complete health history is always recommended when making final decisions regarding the need of antibiotic prophylaxis.

Even if a person did have a complication related to their joint replacement surgery in the acute phase right after, it still not 100% slam dunk reason to be using prophylactic antibiotics prior to dental procedures. Instead, you want to consider every single situation, every single individual case individually and make the right decision. The dentist, the patient, and they might want to consider the orthopedic surgeon as well to make the final decision as to whether that person should take prophylactic antibiotics prior to dental procedures.

Now, again, the clinical reasoning for this recommendation is there is evidence that dental procedures are NOT associated with prosthetic joint implant infections. There is evidence that antibiotics provided before oral care do not prevent prosthetic joint implant infections. Also, there are potential harms of antibiotics. There’s risk of anaphylaxis as I said before, antibiotic resistance may develop, and opportunistic infections like Clostridium difficile could occur. The benefits may not exceed the harm for most patients. In medicine, folks, everything really should be risk-benefit weighing. Is this procedure or this treatment or this clinical recommendation going to benefit me more than and in a way that is weighted heavier or higher than the amount of harm this treatment or therapy might cause? What they found was that the benefit may not exceed the harm for most patients in prescribing prophylactic antibiotics prior to a basic regular dental procedure.

Finally, individual patient’s circumstances and, of course, preferences should be considered when deciding whether to prescribe prophylactic antibiotics prior to dental procedures. Again, it’s not 100% – don’t ever prescribe them. You have to take every situation into an individual analysis. But, again, for the most part there is evidence that dental procedures are not associated with prosthetic joint implant infections.

Now, what are some situations to consider prophylactic antibiotics prior to dental procedures? Who are the people that might be at increased risk that bacteremia would cause a problem even though their joint replacement of their hip or their knee was three years ago? Those are the people that should be individually considered and evaluated for possible – yes – using prophylactic antibiotics before dental procedures. What conditions would put you at an increased risk that you should talk to your dentist more thoroughly and possibly, if you had a joint replacement, with your orthopedic surgeon?

Well, people with diabetes have immune system dysfunction and the sugar that is high in their bloodstream puts them at increased risk of any type of infection. If you have diabetes, you would fit into the category of someone who may want to consider still possibly taking antibiotics prophylactically before a dental procedure.

The other group is anyone who is also considered immunocompromised. Immunocompromised means your immune system is compromised and you may be at increased risk of infection in many different areas of the body because your immune system can’t quite keep up. Things like rheumatoid arthritis; again diabetes; chronic kidney disease; current use of chronic steroids, meaning for a long period of time (months at a time) or immunosuppressive drugs, like people with an autoimmune condition such as rheumatoid arthritis that are on immunosuppressing drugs and they have a joint replacement should consider possibly using or taking antibiotics prophylactically before dental procedures; if someone has a malignancy, again they are at an increased risk of an infection; and if someone, again, has had a previous joint infection then they too should consider being evaluated for the use of antibiotics.

I hope this has helped. The bottom line is for the majority of the population, you no longer have to wonder. The American Dental Association does not recommend prophylactic antibiotics before you get your teeth cleaned. It is a basic concept where there is evidence that there is not an increased incident of joint infection related to the bacteremia from dental procedures. I hope this helps, and we’ll see you on the next podcast!

 

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