Oral Bacteria May Affect a Joint Replacement

When gums bleed, either from tooth brushing, flossing, dental procedures, and/or the association with gum disease, bacteria from the mouth can enter the circulatory system.  Once in the bloodstream, these bacteria can settle in and around an artificial joint.  Occasionally, the outcome is an infection around the orthopedic implant, which may result in implant failure.

Awareness and Good Oral Health is Essential

Awareness of the risks associated with arthroplasty infection is very important.  Since there is a potential risk of contracting an oral induced blood-borne infection around the artificial joint, obtaining and maintaining good oral hygiene is essential.  Good home care, in conjunction with regularly scheduled maintenance visits with a dentist or periodontist, is the best proactive approach.

Patients need to discuss their medical history with their dentist/periodontist.  Although most dental procedures do not require a preventive antibiotic, there are situations where it may be advised.  The oral healthcare professional and the orthopedic surgeon, working together, will determine the appropriate course of treatment.

Considering a Joint Replacement?

For a patient considering an orthopedic implant, including a hip replacement or knee replacement, a Periodontal Risk Evaluation and exam prior to surgery is strongly recommended. In fact, many orthopedic surgeons require a dental clearance before they will proceed with surgery.  In this way, any necessary treatment can be rendered well in advance of the orthopedic procedure, which may lessen the chances of complications due to bacteria originating in the mouth.

Researchers are looking into the possible relationship between periodontal disease and osteoporosis/ osteopenia.  Although some have found no relationship, other research suggests a plausible association.  The exact nature of the relationship is unknown.  Both diseases are bone-resorptive and involve multiple common risk factors. The bone loss in periodontal disease and osteoporosis is magnified, either locally or systemically, by the activity of cytokines (proteins and glycoproteins involved in cellular communication). In periodontal disease, bone loss around the teeth leads to loose teeth and subsequent tooth loss.  In osteoporosis, the bone loss can affect the skeletal structure throughout the body, leading to fractures and other complications.

Many patients at risk for osteoporosis have been prescribed a category of drugs called bisphosphonates.  It is the injectable form of these drugs, used to prevent bone metastasis in cancer patients, that is associated with a serious side effect, called osteonecrosis. However, patients on an oral bisphosphonate should be made aware of a slight chance of osteonectrosis following oral surgery (tooth extractions or any other periodontal surgery).

For patients who are experiencing loose or shifting teeth, who have a family history of periodontal disease, who have chronic bad breath, or who have been diagnosed with osteoporosis or osteopenia, a comprehensive Periodontal Risk Evaluation is recommended.  This exam should be performed by a periodontist or dentist trained in the diagnosis and treatment of periodontal disease.  This examination should include the review of current, full mouth x-rays to determine the degree of possible periodontal bone loss.

The Dental Management of Patients on Bisphosphonate Therapy

The management of osteonecrosis of the jaw is complex, and in many cases the prognosis is not good.  It is therefore critical to prevent the development of bisphosphonate-related osteonecrosis of the jaw (BRONJ).  The administration of intravenous bisphosphonates such as Zometa, Aredia and Bonefos presents a significant risk of BRONJ.  The reported incidence of BRONJ after intravenous bisphosphonates ranges between 0.8% to 12%. It is imperative that the physician and the dental professional co-manage patient care.  

Prior to the patient beginning intravenous bisphosphonate therapy, a comprehensive Periodontal Risk Evaluation is essential.  The dental professional should inform the patient of the risk of osteonecrosis, address decayed teeth, identify and eliminate existing dental infections, eliminate compromised or questionable teeth, evaluate and perhaps remove the third molars, and eliminate or modify ill-fitting removable prostheses.

The risk of developing osteonecrosis when taking oral bisphosphonates such as Fosomax, Fosomax Plus D, Actonel and Boniva is very low.  Regardless of the low risk, it is important to be aware of a potential risk, particularly if the patient is on the medication for more than three years.   

Patients on oral bisphosphonate therapy for more than three years are generally considered at a modest risk for developing osteonecrosis.  Any oral infection should be treated aggressively and non-surgical options should be reviewed.  For example, retaining a root with endodontic treatment should be considered an option, rather than the total extraction of the tooth.  If surgical treatment or implant placement is necessary, a sextant or one tooth at a time should be treated, allowing approximately two months before the next surgical intervention.  There is some discussion about the possible benefits of taking a three month drug holiday prior to treatment; however, there is no supporting data to indicate a benefit.

A blood test to determine the bone turnover measuring C-terminal Telopeptide has also been discussed.  Such a test would not, however, discriminate between bone turnover in the jaw versus the total body.  Furthermore, there is no data indicating that the results would have any bearing on a patient developing osteonecrosis.

Medical History and the Dental Professional

As demonstrated above, the relationship between the mouth, the overall health of the body, and the effects of medication are intertwined. It is essential, therefore, for patients to make their dental professional aware of their medical history and any changes to medications.

With the newly emerging scientific literature regarding the Oral Systemic Connection, the importance of physicians and dental professionals working to co-manage patient care is becoming more evident. Having a dental clearance prior to joint replacement or prior to beginning bisphosphonate therapy could prove extremely beneficial.

Anyone you may know having periodontal disease should have a Periodontal Risk Evaluation performed by a periodontist or dentist who specializes in the diagnosis and treatment of periodontal disease.

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