“The joint replacement itself has no means of fighting infection,” Dr. Jevsevar says. He likens the situation to bacteria arriving at a vacation spot, with no white blood cells to spoil the good time.

But what may be the key difference between a mechanical heart valve and an artificial joint is that the former, because of its location, is constantly exposed to whatever bacteria may enter the bloodstream from dental work.

Pre-emptive use of antibiotics may seem like a small step to prevent a bigger problem down the road, but Dr. Jevsevar says there are several good reasons to avoid what may be unnecessary antibiotic use. “The first is an increase in bacterial resistance, which is a huge issue. Second, there are risks associated with taking antibiotics,” he says, noting those risks include common side effects like diarrhea, severe allergic reactions and potentially serious gastrointestinal complications. The third reason is cost.

So, should joint replacement patients now stop being prescribed antibiotics before dental procedures?

Well – not so fast. “What I would suggest is risk-stratifying,” Dr. Jevsevar says. That is, considering antibiotics only for those truly at increased risk of infection.

Other experts agree. “I think the dentist should be up front with the patients about the lack of scientific evidence to support antibiotic prophylaxis for joint prostheses, so patients can make sound decisions for themselves,” says Kanchan Ganda, MD, professor and head of the Division of Medicine, Department of Public Health and Community Services at the Tufts University School of Dental Medicine, Boston. But she says if the patient also has other health problems, “the dentist should confidently indicate the need to support and proceed with [antibiotics].”

Dr. Ganda says she would support continued use of antibiotics before dental work in joint replacement patients with:

  • Significant periodontal disease and/or presence of odontogenic (teeth) abscess
  • Autoimmune inflammatory joint diseases such as RA or systemic lupus erythematosus (SLE)
  • A past history of joint replacement infection
  • Multiple joint replacements
  • A recent (within 6 months) joint replacement
  • Insulin-dependent diabetes and/or uncontrolled diabetes
  • Immune deficiencies
  • Bleeding disorders, such as Hemophilia A/B or von Willebrand Disease
  • Malnourishment
  • A peripheral infection, such as a chronic, open-sore lesion.

Dr. Ganda says there are steps an otherwise healthy patient can take to minimize the risk of infection, aside from taking antibiotics. “The patient should maintain daily optimal flossing, brushing, mouthwash use, along with regular hygiene visits. The dentists should have the patient use a mouth rinse prior to every appointment, to de-germ the oral cavity and aggressively treat any source of oral infection immediately,” she says.