Updated CPG Addresses PJI Prevention in Patients Undergoing Total Joint Arthroplasty and Dental Procedures

In November 2024, the AAOS Board of Directors approved the updated Clinical Practice Guideline (CPG) for the Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection (PJI) in Patients Undergoing Dental Procedures, which replaces the previous guideline from 2012. The CPG supports patients who are scheduled for or have undergone total knee arthroplasty (TKA) or total hip arthroplasty (THA) and may need dental procedures by addressing antibiotic use and the timing of dental procedures before or after these total joint arthroplasty (TJA) procedures to help prevent infection.

“Dental procedures are believed to possibly allow bacteria to enter the bloodstream and attach themselves to hip or knee implants, potentially causing PJI in a patient,” said Yale Fillingham, MD, FAAOS, co-chair of AAOS’ guideline development group. “PJI is one of the most devastating complications for patients following TJA, and we must do everything possible that is supported by evidence to prevent these infections. Given the large number of annual TJA procedures and that most of these patients undergo a dental cleaning at least twice a year, this CPG is relevant to nearly every TJA patient.”

THA and TKA are two of the most common surgical procedures performed worldwide. In the United States, more than 1 million THAs and TKAs are performed each year, and these cases are estimated to increase by 659 percent and 469 percent, respectively, by 2060. Unfortunately, PJI is associated with increased mortality (up to 250 percent greater than patients who do not have PJI), along with the risk of a higher incidence of mental health disorders.

The work group studied the latest data to provide clinically backed evidence for orthopaedic surgeons and dentists aimed at prevention but also weighed it against potential patient harm. The updated guideline includes two limited-strength options and three consensus options. Options are developed when little or no evidence exists on a particular topic.

The group issued a limited-strength option stating that routine use of a systemic prophylactic antibiotic before a dental procedure in patients with a hip or knee replacement may not reduce the risk of a subsequent PJI.

“The committee took a close look at the data on the administration of antibiotics before a dental procedure after both hip and knee replacement to see if it mitigated the potential risk of a PJI associated with that dental procedure,” said Charles Hannon, MD, MBA, FAAOS, co-chair of AAOS’ guideline development group. “Based on the best available data, no study found that administering antibiotics before a dental procedure changed a patient’s risk of getting a periprosthetic joint infection. With that said, it is important to recognize there may be other considerations that may lead a provider to prescribe antibiotics for an individual patient. This decision should be made with the patient, and the unique risks and benefits for the patient should be considered.”

The second limited-strength option states that screening patients who have received certain dental procedures before hip or knee replacement may not reduce the risk of subsequent PJI. However, the workgroup recognizes that patients should be aware of theÊpotential risks of poor oral hygiene.

The workgroup also developed a new resource with suggested time intervals between dental procedures and TJA that supports two consensus statements. These statements address whether to delay arthroplasty after a dental procedure or delay a dental procedure after TKA or THA.

“It was important to create an at-a-glance tool for orthopaedic surgeons, dentists, and their healthcare teams that provides guidance on the timing of dental procedures before and after TKA and THA. The tool outlines suggested timing based on the risk of transient bacteremia, the occurrence of an invasive surgical procedure that can lead to higher bacterial loads/increased infection risk, or the treatment of an active dental infection,” Dr. Hannon said.

Highlights from the chart include:

• Noninvasive dental procedures and minimally invasive dental care procedures such as dental examinations (without probing), oral hygiene procedures, and orthodontic procedures can be performed safely until the day before elective TJA surgery.
• Oral surgery procedures and dental extractions, which can take up to 3 weeks to heal, should be completed at least 3 weeks before elective TJA.
• Most dental procedures should be delayed for up to 3 months after TJA based on the type of procedure performed.

The updated CPG was jointly developed by AAOS and the American Association of Hip and Knee Surgeons, with contributions from the Infectious Diseases Society of America, the Musculoskeletal Infection Society, and the American Dental Association.

The full CPG and accompanying documentation are available through AAOS’ OrthoGuidelines website and free mobile app.