Nothing but the Tooth: Considering antibiotics for dental care after joint replacements

Q: Twelve years ago I had two knee replacements. I had to take antibiotics for several days before my dental appointments for a few years. I had a reverse shoulder implant two months ago and now need some dental work done. Should I be taking antibiotics? Thanks for your advice.

J. M.

A: You ask a most important question. Unfortunately, there is no absolute right or wrong answer. There are varying opinions.

Years ago (as much as 20 or more), prophylactic antibiotic coverage for routine dental procedures was the accepted standard for those undergoing or having had joint replacement. Early on, we dentists in consult with the orthopedic surgeon, would prescribe antibiotics, the day before, the day of and two days after a dental procedure if you the patient had a joint replacement and we would usually do this for a two-year post joint replacement period. I believe, the thinking was that it was better “to be safe rather than sorry.”

As more and more scientific studies were done, the norm evolved to become prescribing one dose of antibiotic an hour before the dental procedure and an hour after. This protocol and many others in between were being thought of as right and proper.

That mode of thought has now been questioned and this questioning has been going on for a number of years. The major concern is the overuse and overprescribing of oral antibiotics, which has led to more and more resistant strains of bacteria developing. The obvious problem is that with more and more resistant strains growing out, if an infection occurs, the common antibiotics may be of no use and in the case of severe aggressive strains of bacteria like CDiff, the inability to treat could result in loss of a prosthetic joint or even worse, death.

So that you can understand better, when medication is given to kill bacteria or even slow the growth of bacteria, the bacterium itself tries to survive this insult by developing strains of itself that are resistant and can indeed survive that aggressive onslaught.

In addition, the past 20 or more years have shown the prescribing behavior of health professionals to have increased significantly to the point where we are now addressing more carefully and more scientifically whether that protocol is the proper one.

The only absolutely correct answer to your question is to consult with your orthopedist as well as your dental professional. In respect to that I believe you should be prepared for some difference of opinion. Suffice it to say that the most up-to-date and prevailing thought seems to be that in only certain circumstances should antibiotics be needed. Most of these pertain to your past medical history. If you are an insulin dependent diabetic, if you suffer from rheumatoid arthritis, if your immune system is compromised or if you have a history of prior joint replacement infection, then antibiotic coverage is needed. If these or certain others are not the case and most importantly, your oral health is very good then I believe they will not feel that antibiotic coverage is indicated.

As a dental health professional, I would say to you and all my readers, that if you have a joint replacement or are considering one, you should strive to achieve excellent oral health on a day-to-day basis. By this I mean specifically, that your gum tissue does not bleed when contacted as a result of routine brushing, flossing or performing any other gentle treatment that comes in contact with your soft tissue. Even when you have routine professional dental cleanings or restorative treatment there should be no bleeding. All oral soft tissue when not irritated or inflamed will not bleed on light touch nor will be painful to touch. If this is not the case then you should be seeing a dental professional for treatment to achieve that status. The usual and common cause of this bleeding (if evident) is the buildup of biologic debris that has been left in place thereby causing inflammation of the tissue it is in contact with. Removal of this irritant will return all people with a good medical history, to the state of healthy and firm soft gum tissue. For some, there are other causes for this irritation such as poor dental restorative treatment but I am sure your dentist can discuss any specific causative issue and work to reverse it.

Again, I very much appreciate your question because as our population ages past the expected lifespan of various joints and organs, issues and treatment such as you have undergone are becoming much more the norm rather than the exception. Surgical procedures will most always allow introduction of bacteria to the bloodstream which in most cases causes no harm unless a pre-existing or pre-disposing condition is present.

Wishing you all the best and hoping you are happy with my explanation.

Dr. Richard Greenberg of Ipswich practiced dentistry for 45 years after having attended dental school at Columbia University, where he was later an associate clinical professor of restorative dentistry and facilitator of the course of ethics. Do you have a dental question or comment about the column? Email him at dr.richard@nothingbutthetooth.org.