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Medically Compromised Patient Care

Course Number: 628

Total Joint Replacement Patients

In general, no premedication is required for total joint replacement (TJR) patients without additional risk factors that will be discussed in this section. However, it is recommended to send a medical consult for high-risk TJR patients for possible pre-medication prior to dental treatment if they present with the following risk factors: 1) immunocompromised/immunosuppressed, 2) patients with co-morbidities. For example, patients in the first group may have a condition such as rheumatoid arthritis or systemic lupus, or they may be experiencing drug- or radiation-induced immunosuppression. Patients in the second group would be those with the following co-morbidities: history of joint infection/failure, insulin dependent diabetes, hemophilia, malnourishment, HIV, or malignancy (PME). The decision should always be based on a consult between the dentist, physician, and patient. In essence, there will be three options to move forward with a TJR patient: 1) no pre-med necessary if there are no risk factors present, 2) medical consult required if one of the risk factors is present, or 3) current medical consult exists in the medical history that states pre-med guidelines from the orthopedic surgeon.

For assistance with antibiotic recommendations, dental practitioners can refer to the American Academy of Orthopedic Surgeons Appropriate Use Criteria document. Table 5 outlines specific clinical circumstances that suggest the patient may be at increased risk of joint infection, while Table 6 lists recommendations for when to send a consultation for a dental patient with a prosthetic joint.

Table 5. Clinical circumstances that suggest the presence of increased risk of joint infection (11)
Circumstances related to the artificial joint:
  • Patients with previous late prosthetic joint infection
Severely immunocompromised patients
  • Diabetic patient with poor glycemic control (>8.5 A1c within last 3 months or current blood glucose reading >200)
  • Patient with Stage 3 AIDS with CD4T lymphocyte count < 200
  • Cancer patient
  • Patient with autoimmune disorders (i.e., rheumatoid arthritis and lupus erythematosus) MAY be at increased risk
  • Patient taking biologic disease modifying agents or other immunosuppressive medications:
    • Patient taking >10 mg of prednisone (or equivalent) per day
    • Patient with organ or bone marrow transplant on immunosuppressives
  • Patient with inherited diseases of immunodeficiency
* Adapted from: Appropriate Use Criteria for Management of Patients with Orthopedic Implants Undergoing Dental Procedures. 2016.
Table 6. Recommendations for consultations for dental patients with prosthetic joints (11)
  • In cases where there are no circumstances (see Table 5) present that suggest the patient has an increased risk of late prosthetic joint infection, NO consultation with the orthopedic surgeon is necessary.
    • In these cases, if the patient states that their orthopedic surgeon has recommended antibiotic prophylaxis in the past, a consultation should be sent to the surgeon with a copy of the current guidelines.
    • A statement should be included that if antibiotics are still recommended, the prescription should be provided by the orthopedic surgeon.
  • When clinical circumstances are present that suggest the patient is at higher risk of a late prosthetic joint infection, it is appropriate for the dentist to make the final judgment to use antibiotic prophylaxis.
  • In cases where the patient’s current status is in question, it may be helpful to consult the patient’s treating physician (for diabetes, AIDS, cancer, etc.) for additional information.

Once the dentist and patient with a prosthetic joint have discussed the current health status and any previous need for antibiotics, the dentist can ascertain whether there are any clinical circumstances that suggest increased risk for the patient and take the appropriate action (Figure 3). If the patient does not have clinical circumstances that suggest increased risk (green), the dentist must determine whether the orthopedic surgeon has or has not recommended antibiotic prophylaxis in the past. If they have not, then it is ok to proceed with dental treatment. However, if the surgeon has recommended antibiotics, then the dentist should send a consultation to the surgeon first. The dentist can follow the appropriate steps if the patient may have increased risk (yellow) or if they definitely do have clinical circumstances that suggest increased risk (red).

ce628 - Figure 3

Figure 3. Decision Tree for Joint Replacement Patients.11

However, even with these guidelines, there are numerous conditions that either the patient, physician, or dentist may feel warrant providing antibiotic prophylaxis before dental treatment in order to prevent infections at remote locations due to oral bacteria.8 Using the questions in Table 7, the dental practitioner can gather helpful information that will ensure dental treatment is completed at the proper time.

Table 7. Follow-Up Questions for Patients with Total Joint Replacements (1)
  • When was the prosthetic joint surgery?
  • Have you been told to take antibiotics prior to having dental work?
  • If so, who advised antibiotic prophylaxis? (Please provide name and contact number)
  • Are you allergic to any antibiotics?