Prophylactic antibiotic coverage in patients with total arthroplasty: current practice

The need for prophylactic antibiotic coverage before dental treatment to prevent late prosthetic joint infection has not been established. Most orthopedic surgeons who responded to the survey thought that no relationship existed between dentally induced transient bacteremias and prosthetic joint infections, but a majority of these respondents recommended antibiotic prophylaxis anyway. The current literature discloses few late prosthetic joint infections that can be attributed to the transient bacteremia expected to occur after dental treatment. Most of the respondents who recommended prophylactic antibiotics, preferred a cephalosporin. The use of this antibiotic may not be indicated because transient bacteremias that occur after dental treatment primarily are streptococcal and are of oral origin. The preferred drug for the control of oral organisms remains penicillin. Penicillin also remains the antibiotic recommended by the American Heart Association as the preferred prophylaxis against infective endocarditis secondary to dental treatment. Before any definitive statement concerning the prevention of prosthetic joint infections occurring after dentally induced transient bacteremias can be made, additional research needs to be conducted to determine the extent of the relationship and to determine the antibiotic most effective in controlling the specific bacteria involved. Currently, we recommend that dental practitioners who provide treatment to patients with arthroplasty consult with and follow the recommendations of the patient's orthopedic surgeon regarding antibiotic prophylaxis. However, we believe that the orthopedic and dental professions need to form a joint committee to examine and evaluate the current data. After this evaluation, a joint statement that concerns the relationship of and recommendations for the prevention of dentally induced bacteremias and joint infections should be issued.     

Concentrations of cephalexin in mandibular alveolar bone, blood, and oral fluids.

Results from this study of 16 patients who underwent extractions and alveoloplasty indicate that cephalexin effectively penetrates alveolar bone. After cephalexin had been administered, 500 mg four times a day for 48 hours, the average concentration in bone exceeded the average minimal inhibitory concentration of six organisms commonly encountered in infections and bacteremias of dental origin. These data and the current knowledge of cephalexin suggest that cephalosporins may have a unique use in dental infections or potentially harmful bacteremias caused by susceptible organisms.     

Patients with prosthetic joints: Are they at risk when receiving invasive dental procedures?

Most prosthetic joint infections (PJI) are due to wound contamination at the time of surgery. Some infections occur due to the hematogenous spread of bacteria from distant sites of infection. A review of the literature fails to associate PJI with transient bacteremias from invasive dental procedures. Several authors have described conditions which, they believe, render patients with prosthetic joints more at risk for infection. Prosthetic joint patients with these "high risk" conditions have the same types of infecting organisms as other patients with PJI. This indicates that the infecting bacteria are from wound contamination or distant sites of infection and not related to dental procedure bacteremias. Based on this review, antibiotic prophylaxis is not indicated for patients with prosthetic joints when receiving invasive dental procedures, since there is no proven benefit and there are known risks involved with the use of antibiotics. However, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS), in an advisory statement, suggest prophylaxis for "high risk" patients. The ADA and AAOS recommend a single dose of amoxicillin, cephradine, or clindamycin when prophylaxis is selected. The dentist is ultimately responsible for making treatment recommendations for his or her patients.     

Infected total hip replacement after dental procedures.

Three cases are reported in which there was a worrisome association between dental work and an infected total hip replacement. The patients had long asymptomatic intervals subsequent to implantation of prosthetic hip joints. After dental procedures, infections became apparent in these hips. Such infections carry an enormous and crippling morbidity. The potential complications of transient bacteremia in the patient with a cardiac valvular prosthesis are appreciated and the importance of prophylactic antibodies for dental work in such patients is well known. Although we emphasize that there is no proof that the infections in our patients were metastatic from the mouth, the sequence of events is suggestive. We recommend prophylactic antibiotics for dental work in the patient with a total hip replacement.     

Antibiotic prophylaxis for selected implants and devices

Certain implants or devices are widely believed to put patients at risk from oral bacteremia. They include but are not limited to intravascular access devices, solid organ transplants, vascular grafts, coronary artery stents, breast implants, and penile prostheses. The purpose of this article is to review the risk of implant or device infection from transient bacteremia of oral origin and to provide recommendations for appropriate dental management. Since dental treatment bacteremias are a very rare cause of metastatic infections, attributing causality to dental treatment procedures can be viewed as unfounded in almost all cases.     

Temporomandibular joint replacement periprosthetic joint infections: a review of early diagnostic testing options

The incidence of a periprosthetic joint infection is uncommon after total joint replacement. Since the clinical, psychological, and economic consequences of this complication are substantial, the development of management algorithms based on early diagnostic testing has been the subject of continued exploration in the orthopaedic literature. While there has been discussion of this topic in the total temporomandibular joint replacement literature and preliminary management algorithms have been established, no diagnostic testing protocols have been proposed or studied for the management of early and/or late periprosthetic joint infections. This paper will review the classification of periprosthetic joint infections, the associated risk factors, the clinical sensitivity and specificity of laboratory and imaging diagnostic studies and their utility in the management of early and late onset orthopaedic periprosthetic joint infections. This review may provide an initial framework for the use of early diagnostic testing for the management of total temporomandibular joint replacement periprosthetic joint infections and stimulate further investigation into this topic.     

Dental flossing and its relationship to transient bacteremia

This study was designed to determine the role of dental flossing in producing transient bacteremias. An improved protocol that provides for repeated samplings of blood was developed. Four patients had 32 blood cultures taken (16 before flossing and 16 after). Two of the patients had no periodontal disease and two had only marginal gingivitis. The results showed that the patients who flossed daily developed no bacteremias but that patients who delayed flossing from 1 to 4 days developed bacteremias 86% of the time. It is important that patients who have a history of rheumatic fever and those who have internal prosthetic devices be cautioned regarding sporadic flossing. While gingival bleeding was not significantly related to bacteremias in this study, further investigation is needed to ascertain how flossing in various types of periodontal disease relates to bacteremias.     

The patient with chronic renal failure who is undergoing dialysis or renal transplantation: another consideration for antimicrobial prophylaxis

A patient with chronic renal failure who is undergoing dialysis or renal transplantation is susceptible to a number of infections. Transient, usually asymptomatic bacteremias occur in a wide variety of dental manipulations, particularly those involving the mucous membranes. Certain bacteremias may cause serious complications in these already compromised patients. Therefore, antimicrobial prophylaxis is essential when these patients undergo bacteremia-causing dental procedures.     

Microbiological diagnostics in oral diseases

Most infections of the oral cavity, including the major dental diseases caries and periodontitis, are opportunistic in nature. They are caused or maintained by microorganisms of the resident or transient flora normally present in low numbers and not pathogenic, but in certain circumstances develop infections. Mucosal infections have some degree of specificity [e.g. Candida spp., Staphylococcus aureus, and enterics] and a microbiological test can be interpreted accurately for clinical diagnosis and choice of treatment. Subepithelial or deep infections, however, include a number of species from the resident flora, mainly anaerobes whose role in the infections is difficult to interpret. However, microbiological tests and the presence of certain bacterial species could be used for treatment control, risk-evaluation and even for patient motivation in the prevention of these diseases. Microbiological diagnosis can be used in general practice for several purposes and in various situations that can be of great value for the dental patient.     

Prevention and detection of prosthetic temporomandibular joint infections—update

Prosthetic joint infections are not only distressing complications for patients and surgeons, but also have an enormous financial impact on healthcare systems. The reported incidence of prosthetic joint infection is likely underestimated due to difficulties in their diagnosis. This unfortunate complication has challenged joint replacement surgeons for years, despite all the advances made in this surgical discipline. Since eradication of these infections can be very difficult, prevention remains the primary objective. Identifying recipient risk factors, adopting a proper surgical technique, appropriate wound care, optimizing the operating room environment, and appropriate postoperative care have become some of the core elements that can help to minimize the overall incidence of this complication. The purpose of this article is to provide the temporomandibular joint replacement surgeon with an update on the prevention and detection of prosthetic joint infections based on a review of the most recent information published in the orthopedic and surgical literature.     

The role of total joint replacement surgery in the orthognathic patient

Alloplastic reconstruction of the temporomandibular joint, commonly referred to as total joint replacement, is used to treat end stage joint disease in a cohort of patients who present with a range of condylar pathology. In considering its role in the management of the orthognathic patient, it is helpful to categorize patients into those with primary pathology of the mandibular condyle or those with primary dentofacial deformity. The success of total joint replacement is predicated by the predictably stable results that are achieved when used in carefully selected clinical scenarios. In this article, we will discuss the role of total joint replacement surgery in the orthognathic patient and highlight its clinical impact by inclusion of a case study.     

Reprint of the role of total joint replacement surgery in the orthognathic patient

Alloplastic reconstruction of the temporomandibular joint, commonly referred to as total joint replacement, is used to treat end stage joint disease in a cohort of patients who present with a range of condylar pathology. In considering its role in the management of the orthognathic patient, it is helpful to categorize patients into those with primary pathology of the mandibular condyle or those with primary dentofacial deformity. The success of total joint replacement is predicated by the predictably stable results that are achieved when used in carefully selected clinical scenarios. In this article, we will discuss the role of total joint replacement surgery in the orthognathic patient and highlight its clinical impact by inclusion of a case study.     

Temporomandibular joint reconstruction with total alloplastic joint replacement

This paper is a preliminary paper which presents the early findings of an ongoing prospective trial on the use of the TMJ Concepts and Biomet Lorenz total joint replacement systems for the reconstruction of the temporomandibular joint (TMJ). Total alloplastic replacement of the TMJ has become a viable option for many people who suffer from TMJ disease where surgical reconstruction is indicated. Degenerative joint diseases such as osteoarthritis, rheumatoid arthritis, psoriatic arthritis, TMJ ankylosis, malunited condylar fractures and tumours can be successfully treated using this technique. There are a number of TMJ prostheses available. Two of the joint replacement products, which have been found to be most reliable and have FDA approval in the United States, are the TMJ Concepts system and the Biomet Lorenz system, and for this reason they are being investigated in this study. This study presents the findings of seven patients with a total of 12 joint replacements using either the TMJ Concepts system or the Biomet Lorenz joint system. Two patients (3 joints) had the TMJ Concepts system and five patients (9 joints) had the Biomet Lorenz system. Although still early, the results were generally pleasing, with the longest replacement having been in position for three years and the most recent six months. The average postoperative mouth opening was 29.7 mm (range 25-35 mm) with an average pain score of 1.7 (range 0-3, minimum score of 0 and maximum 10). Complications were minimal and related to sensory disturbance to the lip in one patient and joint dislocation in two patients.     

Osteoarthritis of the ankle

Ankle arthritis is a debilitating condition. Primary ankle joint osteoarthritis is much rarer than hip or knee arthritis. The majority of cases are post-traumatic secondary to previous articular trauma or ligamentous instability. Treatment methods available are guided by disease severity and the patient's functional demands. Weight loss, activity modification, the wearing of an ankle brace or high-topped lace-up boots and orthoses should be the first line of treatment. Joint-sparing procedures such as arthroscopic debridement, supramalleolar osteotomy and distraction arthroplasty have been trialled with low levels of supporting evidence. The demand for joint preservation has led to the development of total ankle allografting procedures, but these have fallen out of favour. Despite advancements, the gold standard for end-stage arthritis remains arthrodesis, although evidence for total ankle arthroplasty in certain groups of patients is increasing. The current third-generation implants have improved survivorship although their results remain inferior to arthroplasty of the hip and knee. There is currently a UK randomized control trial of ankle replacement versus arthrodesis under way as well as several national joint registries, which will hopefully better define those patients who will gain most benefit from replacement as opposed to fusion.     

Total temporomandibular joint replacement. Who? What? When? Where?

The temporomandibular joint, like other joints such as the hip and knee, can be affected by a number of conditions that may lead to joint failure, necessitating total joint replacement. The TMJ Implants, Inc., or Christensen alloplastic reconstruction prostheses, play an important role in the treatment of these conditions. Patients with severely degenerated and/or nonfunctioning joints who undergo reconstruction with the Christensen total joint replacement prosthesis experience an increase in quality of life similar to that experienced by orthopedic patients with total joint replacement of the knee or hip.     

Dental treatment and late prosthetic joint infections

Hospital and dental charts of 2,693 patients in whom total prosthetic joints had been placed at the Veterans Administration Hospitals of Ann Arbor and Allen Park, Michigan, as well as at The University of Michigan Hospital, were analyzed. Of the thirty (1.1%) late prosthetic joint infections (greater than 6 months after placement), only one (0.04%) could be temporally associated with dental treatment. A Fisher's exact test of the data reflected that dental treatment in this population did not increase the incidence of late prosthetic joint infections (p value is 0.0005). Nine of the thirty late infections occurred in insulin-dependent diabetic patients and patients on long-term immunosuppressive therapy. An analysis of the organisms isolated from the late infections shows that 54% where Staphylococcus epidermidis and Staphylococcus aureus. These data do not support the practice of prescribing prophylactic antibiotic coverage of prosthetic hip and knee joints prior to all dental therapy. Rather, use of antibiotics during dental treatment appears warranted only if a chronic bacteremia is anticipated or where a predisposing systemic condition may exist.     

Historical development of alloplastic temporomandibular joint replacement after 1945 and state of the art

The variety of temporomandibular joint (TMJ) prostheses and condylar reconstruction plates available is in contradiction to their rare application. This emphasizes that alloplastic TMJ reconstruction is still evolving. This article reviews the history of TMJ reconstruction. Medline as well as public and private libraries have been searched. Current systems are reviewed. Prosthetic devices can be differentiated into fossa-eminence prostheses, ramus prostheses and condylar reconstruction plates, and total joint prostheses. Fossa and total joint prostheses are recommended when the glenoid fossa is exposed due to excessive stress (degenerative disorders, arthritis, ankylosis, multiply operated pain patients). Singular replacement of the condyle is preferred as a temporary solution in ablative surgery. The use of prosthetic devices for long-term replacement should be restricted to selected cases, taking care to retain the disk, in order to prevent penetration into the middle cranial fossa. The term ‘condylar reconstruction plate’ reflects this more clearly than ‘ramus prosthesis’ which suggests permanent reconstruction. Long-term studies comparing the functional and aesthetic results of the various prostheses and condylar reconstruction plates are not available, which leaves the choice to personal experience.     

Antibiotic prophylaxis for patients with joint prostheses - still a dilemma for dental practitioners

OBJECTIVES: To provide a critical review of the current evidence that implicates dental-induced bacteraemia as a risk for joint infections in patients fitted with joint prostheses and appraise the need for antibiotic prophylaxis. DESIGN: Retrospective analysis. SETTING: Mainly hospital-based patients or subjects. OUTCOME MEASURES: The relationship between joint infections and dental treatment is equivocal at the best and there is no evidence that antibiotic prophylaxis provides such patients with any protection. RESULTS: Microbiological evidence linking dental treatment-induced bacteraemia to joint infections is weak and if an oral commensal is implicated, it is more likely to have arisen either from a spontaneous bacteraemia or from a dental infection. As a consequence of the latter, we recommended the institution of good dental health prior to joint replacement. There may be a case for providing prophylaxis to the immuno-compromised patient, but only if the immuno-suppression is associated with a neutropenia. In such circumstances, only emergency treatment should be considered until the neutropenia is resolved. Antibiotic regimens that are recommended by orthopaedic surgeons have not been evaluated in a randomised placebo-controlled study and many of the drugs are not licensed for this purpose. The evidence on cost-risk benefit seems to demonstrate that antibiotic prophylaxis with either amoxicillin or penicillin is not cost effective when compared with no prophylaxis. CONCLUSION: The case for providing antibiotic prophylaxis prior to dental treatment in patients fitted with a joint prosthesis is weak or virtually non-existent. Furthermore, the risk from providing prophylaxis is greater than the risk of a joint infection.     

Dental procedures and subsequent prosthetic joint infections: findings from the Medicare Current Beneficiary Survey

BackgroundThe publication of the 2009 American Academy of Orthopedic Surgeons’ (AAOS’) guidelines for antibiotic prophylaxis after joint replacement (arthroplasty) has renewed debate concerning appropriate prophylaxis for dental patients. The authors examined an administrative data set to assess whether dental procedures were associated with prosthetic joint infections (PJIs).MethodsUsing data for the years 1997 through 2006 from the Medicare Current Beneficiary Survey (MCBS), the authors identified participants who had undergone total joint arthroplasty and those who had experienced a PJI. They explored associations between dental procedures and subsequent PJIs by using time-to-event analyses (N = 1,000). A nested case-control study included case participants who had had PJIs (n = 42) and matched control participants who had had total arthroplasty but had no PJIs (n = 126). The authors calculated hazard ratios (HRs) and odds ratios (ORs).ResultsControl participants (people without PJIs) were more likely than were case participants (those with PJIs) to have undergone an invasive dental procedure, though this trend was not statistically significant in either the time-to-event analysis (HR = 0.78; 95 percent confidence interval [CI], 0.18–3.39) or the case-control analysis (OR = 0.56; 95 percent CI, 0.18–1.74). Only four of 42 case participants had undergone an invasive dental procedure in the 90 days before the infection occurred. Consideration of all dental procedures yielded similar results.ConclusionsDental procedures were not associated significantly with subsequent risk for PJIs, although this study's power was somewhat low. The clinical importance of prophylactic antibiotics in dentistry for patients who have undergone joint arthroplasty, therefore, may be questioned.Clinical ImplicationsThese results support the view that the 2009 AAOS Information Statement on antibiotic prophylaxis for people with prosthetic joints should be reconsidered for patients in that population who are receiving oral health care.     

Staphylococcus aureus-induced inflammation and bone destruction in experimental models of septic arthritis

Staphylococcus aureus is the most common cause of septic arthritis. This disease often leads to severe joint destruction and high mortality. An experimental model of S. aureus arthritis has been developed to study the course of inflammation and joint destruction, to elucidate the role of bacterial and host factors for joint pathology and mortality, and to develop therapeutical and preventive devices against septic arthritis and sepsis. Results show that the innate immune system is crucial in defending the host against staphylococcal infection while components of the specific immune system, T and B lymphocytes and their products, are detrimental to the host, mediating joint destruction and increasing mortality rates. Staphylococcal capsule polysaccharides, toxins, cell wall-attached adhesins and possibly also the chromosomal DNA are virulence determinants in S. aureus arthritis. Several vaccine candidates have recently been described which protects against staphylococcal infections, e.g. staphylococcal surface polysaccharides, enterotoxins devoid of their superantigenic properties and collagen adhesin. There are also new approaches suggested for treatment of ongoing infections, such as the combined use of antibiotics and corticosteroids.