Prosthetic joint infection, dental treatment and antibiotic prophylaxis

Dysbiotic relationship between arthritis and the oral-gut microbiome. A critical review

Arthritis and prosthetic joint infections (PJIs) overall are associated with reduced quality of life and limited work capacity. Multiple, overlapping factors contribute to these conditions. Some investigations have suggested a dysbiotic association between the oral-gut microbiome and pathogenesis of arthritis and PJIs. A better understanding of the role of the oral-gut microbiota in arthritis and PJI pathophysiology can shed light into how its disequilibrium can discharge a pro-inflammatory response, and impact the health of patients susceptible to arthritis or with established joint disease. A review of published in vivo and clinical data suggested that alterations in oral and gut microbiota can lead to a disturbance of immunoregulatory properties, and may be associated with joint infections and arthritis. This review brings new insights into the current status of the evidence on the potential molecules and inflammatory biomarkers disrupted by an oral-gut microbial dysbiosis. Normal commensals and pathogenic oral and gut microflora homeostasis are important not only to prevent infections per se but also its potential progression. Further experiments, especially controlled clinical trials, are needed to ascertain how microbiome manipulation and other microbiota-directed approaches can help control inflammation and effectively prevent and treat arthritic diseases. Additionally, studies on the effects of the long-term oral diseases, such as chronic periodontitis, on arthritis and PJIs need to be conducted.

Is there scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections? A systematic review

PURPOSE

To re-assess the scientific literature to ascertain if there is scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections.

INTRODUCTION

Prosthetic joint infections occur in approximately 0.3-2% of patients and, of these, around 6-13% are thought to be caused by oral bacteria. Antibiotic prophylaxis prior to dental procedures as a means to prevent a prosthetic joint infection has been controversial throughout the years. However, it remains unclear to what extent it has a beneficial effect. We do know that bacteraemia of oral origin is directly proportional to any ongoing inflammation or infection, and that a diseased periodontium may act as an entry for bacteria to spread to distant locations, through the bloodstream, and potentially be the cause of distant site infections.

MATERIALS AND METHODS

Updated literature search using the PubMed (Medline), and the Clarivate Analytics databases, to identify eligible articles since the previous searches up to April 2019 (last 5 years).

RESULTS

No studies that relate periodontal disease to the development of a prosthetic joint infection were found.

CONCLUSION

Currently, there is no evidence to support or exclude the need of antibiotic prophylaxis as a means to decrease the risk of prosthetic joint infections in patients with periodontal disease.

The role of poor oral health in surgical site infection following elective spinal surgery

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To describe oral health and hygiene as a risk factor for surgical site infection (SSI).

METHODS

This cross-sectional study was conducted on patients over 18 years of age who were candidates for elective spinal surgery. The exclusion criteria were immunodeficiency, history of cancer, history of previous infection at the surgical site, cutaneous diseases and long-term use of corticosteroids. Questionnaires were filled out for patients via an interview in order to collect the demographic data of patients. Oral and dental examinations were performed using DMFT (D: decayed, M: missing, F: filled, T: total) and PUFA (P: pulp, U: ulcer, F: fistula, A: abscess) indices. Data were analyzed using Fisher's exact test and Mann-Whitney test.

RESULTS

A total of 78 patients were evaluated. There were 59 females (75.6%) and 19 males (24.6%). Eight patients were positive for SSI. Teeth caries (P = 0.016) and periodontal disease (P = 0.049) were significantly correlated with SSI. No significant association was noted between PUFA and SSI (P > 0.05). Sixty-five patients (83.3%) had a history of dental infection before surgery. Fifty% of patients being positive for SSI had a history of dental abscess (P = 0.023).

CONCLUSIONS

A significant association exists between SSI and caries, gingivitis/periodontitis and history of dental abscess.

Antibiotic prophylaxis is not indicated prior to dental procedures for prevention of periprosthetic joint infections

Background and purpose - To minimize the risk of hematogenous periprosthetic joint infection (HPJI), international and Dutch guidelines recommended antibiotic prophylaxis prior to dental procedures. Unclear definitions and contradictory recommendations in these guidelines have led to unnecessary antibiotic prescriptions. To formulate new guidelines, a joint committee of the Dutch Orthopaedic and Dental Societies conducted a systematic literature review to answer the following question: can antibiotic prophylaxis be recommended for patients (with joint prostheses) undergoing dental procedures in order to prevent dental HPJI? Methods - The Medline, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs), reviews, and observational studies up to July 2015. Studies were included if they involved patients with joint implants undergoing dental procedures, and either considered HPJI as an outcome measure or described a correlation between HPJI and prophylactic antibiotics. A guideline was formulated using the GRADE method and AGREE II guidelines. Results - 9 studies were included in this systematic review. All were rated "very low quality of evidence". Additional literature was therefore consulted to address clinical questions that provide further insight into pathophysiology and risk factors. The 9 studies did not provide evidence that use of antibiotic prophylaxis reduces the incidence of dental HPJI, and the additional literature supported the conclusion that antibiotic prophylaxis should be discouraged in dental procedures. Interpretation - Prophylactic antibiotics in order to prevent dental HPJI should not be prescribed to patients with a normal or an impaired immune system function. Patients are recommended to maintain good oral hygiene and visit the dentist regularly.

Antibiotic prophylaxis for dental treatment after prosthetic joint replacement: exploring the orthopaedic surgeon's opinion

Background

Antibiotic prophylaxis before dental treatment is routinely recommended by orthopaedic surgeons to prevent prosthetic joint infection (PJI). This recommendation is at odds with current guidelines.

Methods

A postal survey of 9 checkbox or short-answer questions was completed by 633 orthopaedic surgeons.

Results

The majority of respondents (n = 186 of 260, 72%) believe that antibiotic prophylaxis is required indefinitely for dental treatment. A small number (n = 43, 15%) seek a dentist's opinion before elective joint replacement. The surgeons reported low numbers of PJIs, although 24% (n = 68 of 280) believed that they were associated with dental treatment.

Conclusions

Australian orthopaedic surgeons continue to recommend antibiotic prophylaxis for dental treatment. The recording of PJI in relation to dental procedures into clinical registries would enable the development of consistent guidelines between professional groups responsible for the care of this patient group.