Limited effect of preoperative dental clearance on infection prevention in primary or revision hip arthroplasty for high- and low-risk groups

Kazuyoshi Baba; Hidetatsu Tanaka; Ryuichi Kanabuchi; Yasuaki Kuriyama; Daisuke Chiba; Yu Mori; Toshimi Aizawa

doi:10.1016/j.jorep.2025.100565

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Research Article

2025

:4;

100565

doi:

10.1016/j.jorep.2025.100565

Limited effect of preoperative dental clearance on infection prevention in primary or revision hip arthroplasty for high- and low-risk groups

Kazuyoshi Baba^a,, Hidetatsu Tanaka^a, Ryuichi Kanabuchi^a, Yasuaki Kuriyama^a, Daisuke Chiba^b, Yu Mori^a, Toshimi Aizawa^a

a Department of Orthopedic Surgery, Tohoku University School of Medicine, Japan

b Department of Orthopedic Surgery, Tohoku Rosai Hospital, Japan

⁎Corresponding author: Kazuyoshi Baba. kazuyoshi.baba.e3@tohoku.ac.jp

Received: 2024-12-30, Accepted: 2025-1-19, Published: 2025-1-27

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

This study aimed to evaluate the effectiveness of dental clearance (DC) in reducing the incidence of periprosthetic joint infection (PJI) and surgical site infection (SSI) in patients undergoing primary or revision total hip arthroplasty (THA).

456 primary and revision THA cases from January 2014 to December 2022 were analyzed. Bilateral THA cases were counted as two joints. From January 2018 onward, all THA patients underwent preoperative DC. PJI risk was assessed using Tan's risk scoring system, where higher scores indicated an increased risk. Patients were classified into high- and low-risk groups based on median risk scores and further divided based on whether they received DC. Incidence of PJI and SSI was recorded at 30 and 90 days post-surgery. Microorganisms identified in PJI cases were documented. Group risk scores were compared using the Wilcoxon rank-sum test, and PJI and SSI incidence rates were compared using Fisher's exact test, with significance at p < 0.05.

Among the joints analyzed, 235 underwent DC, while 221 did not. The median risk scores for high-risk groups were 77.1 with DC and 87.6 without DC, showing a significant difference. The low-risk groups had median scores of 23.9 and 23.3 with and without DC, respectively, showing no significant difference. One PJI case occurred in the high-risk without DC group at 30 days post-surgery. Two SSI cases occurred at 30 days and seven at 90 days post-surgery. There was no significant difference in PJI incidence between groups with or without DC at 30 days (P = 0.48). The overall incidence of PJI and SSI at 30 and 90 days showed no significant difference between high- and low-risk groups, regardless of whether DC was performed preoperatively.

DC before primary or revision THA did not significantly reduce PJI or SSI incidence in high-risk patients.

Keywords

Total hip arthroplasty

Periprosthetic joint infection

Surgical site infection

Dental clearance

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1 Introduction

Periprosthetic joint infection (PJI) and Surgical site infection (SSI) were the complications of total hip arthroplasty (THA) and should be prevented. The treatment of SSI burdens medical costs and elongates hospital stays.¹ Revision THA for PJI within one year is associated with an increased mortality risk.²^,³ Orthopedic surgeons should optimize patients before THA to reduce their risk of developing PJI or SSI. Screening for active infection at remote sites linked to PJI and SSI is recommended, such as oral, skin, and urogenital.⁴

The incidence of PJI attributed to oral organisms ranges from 6 % to 13 %.⁵ PJI could occur via a hematogenous spread of these organisms. Poor oral hygiene or dental caries might be the risk factors for PJI or SSI management before elective THA. The second International Consensus Meeting on Musculoskeletal Infections recommended dental clearance (DC) before total joint arthroplasty. There was a consensus that patients with active oral infections are at a higher risk of developing PJI and SSI. However, routine DC before arthroplasty was not mandated.⁴ Other studies have also indicated that undergoing DC does not significantly reduce the incidence of infectious complications following arthroplasty.^6–8

The DC or tooth extraction before total joint arthroplasty was unnecessary for all patients.⁴ To date, many studies have been conducted to investigate the effectiveness of DC before arthroplasty. However, no studies have evaluated the efficiency of preoperative DC in preventing infectious complications in patients at high risk for PJI. This study aims to investigate the efficacy of DC before primary or revision THA in PJI high-risk patients. We hypothesize that the DC before primary or revision THA in high-risk patients is effective in PJI high-risk patients.

2 Method

The study is a retrospective case-control study. The study was conducted by the Declaration of Helsinki in 2013. The study was approved by our Institutional Review Board and informed consent was taken from all patients.

2.1

2.1 Study population

497 consequence hip surgeries performed From January 1, 2014, to December 31, 2022, were reviewed. The inclusion criteria were primary or revision THA. The bilateral THA was counted as two joints. The exclusion criteria were implant removal, femoral neck fracture, periprosthetic fracture, PJI, osteotomy, and incomplete medical records. 41 joints were excluded. Before January 1, 2018, the primary or revision had no DC. We recorded the patients' data, such as age, sex, body mass index, the number of previous surgeries performed on the same side of THA, and the past medical history. The joints were divided into two groups according to whether they underwent DC (Fig. 1).

Flowchart of the patient selection. We screened 497 patients who underwent primary or revision THA from January 1, 2014, to December 31, 2022. We excluded the following patients: 1 underwent implant removal, 6 with femoral neck fractures or periprosthetic fractures, 4 with PJI patients, 4 underwent osteotomy, and 26 had incomplete medical records. A total of 456 patients were included in this study and divided into four groups based on whether they had undergone DC and their PJI risk level. THA: total hip arthroplasty. PJI: periprosthetic joint infection. DC: dental clearance.

2.2

2.2 The preoperative assessment of PJI risk

The risk of PJI was assessed by a scoring system reported previously.⁹ The risk score for predicting PJI was calculated using a multivariate analysis of 42 potential risk factors, including patient characteristics and surgical variables. Of these, 17 significant risk factors were assigned weights based on their relative influence, such as insurance, previous surgeries, drug abuse, and comorbidities like HIV/AIDS. The scores were derived by scaling the regression coefficients to integer values. Internal and external validation was performed to validate the model's accuracy, showing areas under the curve ranging from 0.73 to 0.86, indicating good predictive accuracy.⁹ In Japan, all patients join the same insurance and perceive the same medical procedures. The patients considered the no risk of PJI according to their insurance. According to the score, the upper half of the scores was defined as the PJI high-risk group, while the lower half was defined as the PJI low-risk group. The high-risk or low-risk patients with DC were 117 and 118, respectively. In contrast, the high-risk or low-risk patients without DC were 110 and 111, respectively. (Fig. 1).

2.3

2.3 Dental clearance

From January 1, 2018, all patients who underwent elective primary or revision THA in our department received DC in the department of dentistry in our hospital before surgery. Patients with poor oral hygiene underwent preoperative cleaning, and those with periodontal disease or carious tooth with infectious focus had tooth extraction in that department of dentistry or nearby dental clinic. After DC, the patients were regularly checked for hygiene or teeth to keep them healthy until surgery.

2.4

2.4 Outcome measurement

Medical records were reviewed retrospectively, and the incidence of PJI or SSI at 30 and 90 days postoperatively were recorded. CDC criteria defined SSI, and PJI was defined by Musculoskeletal Infection Society criteria.¹⁰^,¹¹ The organisms isolated from samples collected due to suspected SSI or PJI were documented. First, the incidence of PJI or a combination of PJI and SSI was compared between the groups with or without DC. Subsequently, a subgroup analysis was performed to compare outcomes between high-risk patients with and without DC and between low-risk patients.

2.5

2.5 Statistical analysis

The distribution of the continuous variables was analyzed using the Shapiro-Wilk test. The continuous variable non-normally distributed was compared by using the Wilcoxon rank-sum test. The results were described as average ± standard deviation and interquartile range: median (25–75 percentile) for normally and non-normally distributed, respectively. PJI risk scores across four groups, the high-risk or the low-risk groups with or without DC, were analyzed using the Kruskal-Wallis test, followed by post-hoc comparisons using the Steel-Dwass method to identify specific intergroup differences. The incidence of PJI or SSI and PJI with or without DC were compared using Fisher's exact test. Statistical significance was set at P < 0.05, and analyses were performed using JMP Software Version 17.2.0 (SAS Institute Japan, Tokyo, Japan)

3 Result

The patients' characteristics are shown in Table 1. Only the age of the high-risk group with DC was normally distributed (Table 1). There were no significant differences in age, sex, BMI, and PJI risk score between the two groups with or without DC. PJI risk scores between the two groups with or without DC were 43.1 (23.8, 77.1) and 50.2 (23.3, 87.6), respectively, and there was no difference (p = 0.18). According to the PJI risk score, the patients were divided into four groups. The PJI risk scores of the high-risk groups were 77.1 (55.1, 107.8) and 87.6 (67.0, 128.6) with or without DC, respectively. The PJI risk scores of low-risk groups were 23.9 (20.0, 37.0) and 23.3 (19.7, 38.3) with or without DC, respectively (Table 1). Significant differences existed between the high-risk and low-risk groups, regardless of whether DC was performed (P < 0.0001). Among the high-risk patients, a significant difference was observed between those who received DC and those who did not (p = 0.007) (Fig. 2).

Table 1 The demographics of patients in this study.

Variables	High-risk group		P value	Low-risk group		P value
Variables	Dental clearance (+)	Dental clearance (−)	P value	Dental clearance (+)	Dental clearance (−)	P value
Numbers of joints, n	117	110		118	111
Age (years)	63 ± 13	67 (55, 73)	p = 0.76	66 (58, 74)	64 (57, 74)	p = 0.85
Sex, n	M 36 F 81	M25 F 85	p = 0.18	M 17 F 101	M 9 F 102	p = 0.15
BMI (kg/m2)	24.0 (20.3, 27.0)	23.1 (20.1, 26.3)	p = 0.23	24.0 (21.2, 27.0)	24.2 (22.1, 27.4)	p = 0.65
PJI risk score	77.1 (55.1, 107.8)	87.6 (67.0, 128.6)	p = 0.007∗	23.9 (20.0, 37.0)	23.3 (19.7, 38.3)	p = 0.98

Surgical procedure
Primary THA, n (%)	108 (92)	79 (72)		118 (100)	111 (100)
Revision THA, n (%)	9 (8)	31 (28)		0 (0)	0 (0)

Preoperative diagnosis, n
Osteoarthritis, n (%)	66 (56)	49 (45)		108 (92)	99 (89)
Osteonecrosis of femoral head, n (%)	42 (36)	31 (28)		10 (8)	12 (11)
Loosening of implants, n (%)	5 (4)	28 (25)		0 (0)	0 (0)
Instability after THA, n (%)	4 (3)	2 (2)		0 (0)	0 (0)

Incidence of SSI or PJI 30 days after surgery
PJI and SSI, n (%)	0 (0)	2 (1.8)	p = 0.23	0 (0)	1(1)	p = 0.48
PJI, n (%)	0 (0)	1 (0.9)	p = 0.48	0 (0)	0 (0)
Incidence of SSI and PJI 90 days after surgery
PJI and SSI, n (%)	1 (0.9)	2 (1.8)	p = 0.61	2 (1.7)	2 (1.8)	p = 1.0
PJI, n (%)	0 (0)	0 (0)		0 (0)	0 (0)

The PJI risk scores of each group. The PJI risk scores were calculated using the method previously reported. There were significant differences between high-risk and low-risk groups with or without DC. There was a significant difference between patients with and without DC in the high-risk group. PJI, periprosthetic joint infection; ∗, p < 0.05; ∗∗, p < 0.001.

After 30 days post-surgery, only one case of PJI occurred in the high-risk group without DC. The PJI risk score of the PJI case was 67, and it was predicted that the rate of PJI after surgery was 1.7–2.2 %.⁹ The causative organism of the PJI was Propionibacterium avidum. There was no significant difference in PJI incidence between the groups with and without DC 30 days post-surgery (p = 0.48). Two SSIs occurred 30 days after surgery: one case in the high-risk group without DC and one case in the low-risk group without DC. The seven SSI cases had occurred 90 days after surgery: one case in the high-risk group with DC, two cases in the high-risk group without DC, and two cases in the high-risk group with and without DC. The six causative Pathogens of PJI and SSI were isolated (Table 2). The incidence of PJI and SSI at both 30 and 90 days post-surgery showed no significant difference between the high-risk and low-risk groups, regardless of whether patients had received DC (Table 1).

Table 2 The organisms isolated from the PJI and SSI patients.

Organisms	N
MRSA	3
MSSA	1
Propionibacterium avidum	1
Corynebacterium striatum	1
Coagulase-negative staphylococcus	2
Staphylococcus epidermis	1
Not assessed or negative culture	4

4 Discussion

In this study, the incidence of PJI and SSI was not reduced by performing DC before elective primary or revision THA, even in the patients at high risk of PJI. The PJI risk score of the patient who acquired PJI was not so high. These results suggested that DC was not effective in preventing PJI and SSI, even among patients at high risk of PJI. To our knowledge, this is the first study to investigate the efficacy of DC according to preoperative predicting PJI risk.

The risk factors for PJI and SSI were divided into patient-related and procedural factors. For example, patient-related factors included obesity, smoking, cardiovascular disorders, anemia, and diabetes mellitus, while procedural factors involved prior surgeries, longer operation times, and blood loss.^12–15 Patients frequently present with multiple concurrent risk factors. And the surgical factors often were not able to predict before surgery. In this study, the risk of PJI was defined using only preoperative factors. The PJI risk score was calculated using the cumulative total score method, and the predictive rate of postoperative PJI was increased exponentially.⁹ In this study, one patient had PJI. The risk score of the patient was 67. The score was lower than the median of the high-risk group. The rate of infectious complications, SSI and PJI, was not different between the high-risk groups with DC and without DC. These results suggested that the DC before primary or revision THA was not necessary for PJI high-risk patients.

In this study, patients with PJI risk scores higher than that of the patients who developed PJI did not develop either PJI or SSI. These findings suggest that the PJI risk does not necessarily correlate with poor oral hygiene, thus suggesting that the risk factors for PJI and periodontal disease do not always coexist. In 2018, at the second international consensus meeting on orthopedic infection, routine DC was not recommended before joint arthroplasty. However, it was recommended that patients who had active oral disease or infection might be at high risk of consequent PJI or SSI. These patients should be treated for oral disease or infection before surgeries.⁴ The methods for selecting patients with poor hygiene were investigated. The identified risk factors for poor hygiene included smoking, not visiting a dentist within the past 12 months, and narcotic abuse.⁷ It might be efficient that the risk for poor hygiene rather than PJI risk was the rationale for performing DC before THA.

Oral activities such as toothbrushing, flossing, and chewing led to bacteremia from the oral cavity.¹⁶ The prevalence of oral bacteremia in patients with healthy dentition might reach as high as 44 % after toothbrushing, 41 % after flossing, and 17 % after chewing.¹⁷^,¹⁸ Most of the oral flora consists of anaerobic bacteria with low virulence, leading to mild or asymptomatic infections.¹⁹ The level of bacteremia from daily activities has been reported to range from 1 to 32 colony-forming units per milliliter.^20–22 The bacterial load needed to induce PJI in humans remains unclear. However, animal models might provide some insights. Zimmerli et al. conducted animal studies using pigs to examine the amount of Staphylococcus aureus required to cause infection in foreign material, reporting that 46–210 colony-forming units per milliliter were necessary.²³ These results suggested that the bacteremia induced by daily activities did not deliver a high enough bacterial load to induce PJI, even in high-risk patients for PJI.

This study had several limitations. First, the sample size was small, and the patients were not randomly assigned. The occurrence of PJI after THA was rare. The previous studies reported the rate of PJI after THA 90 days after surgery was 1.3–1.7 %.²⁴ A large sample size is needed to determine whether DC is effective in preventing postoperative PJI and SSI in high-risk PJI patients. Second, the follow-up period was short. The present study evaluated the occurrence of PJI and SSI within 90 days. The previous review investigated the efficacy of DC and demonstrated that the PJI-related oral organisms were hematogenous. It took 32 months for the sign of infection.²⁵ The short follow-up period might have influenced the incidence of PJI and SSI. A long follow-up period was needed. Third, in this study, microbiologic analysis was not conducted to determine whether the bacteria isolated from patients with PJI or SSI were identical to those detected in their oral cavity. It remained unclear whether the bacteria detected in PJI or SSI patients in this study originated from hematogenous spread from the oral cavity.

5 Conclusion

The rates of PJI and SSI at 30 and 90 days following primary or revision THA did not decrease regardless of DC. These findings remained consistent even when the analysis was restricted to high-risk PJI patients. These results suggested that DC was necessarily not required for all patients before elective primary or revision THA.

CRediT authorship contribution statement

Kazuyoshi Baba: Conceptualization, Methodology, Investigation, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Hidetatsu Tanaka: Investigation, iting-Review & Editing. Ryuichi Kanabuchi: Investigation, Data curation. Yasuaki Kuriyama: Investigation, Data curation. Daisuke Chiba: Investigation, Data curation, riting-Review & Editing. Yu Mori: Writing – review & editing, Visualization, Supervision. Toshimi Aizawa: Writing – review & editing, Visualization, Supervision.

Ethics approval

This study was approved by the Institutional Review Board of our institute.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki in 2013. The study was approved by our Institutional Review Board (No 2021-1-1059) and informed consent was taken from all patients.

Guardian/Patient's cosent

The informed consent was taken from all patients.

Formatting of funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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