Oral Infections in Orthopedic Surgical Procedures - Research Paper Example

Oral Infections in Orthopedic Surgical Procedures Preventing infections after any surgical procedure is the main goal ofpost operative care. This is to ensure safety of clients to be free from any harm of complications that could arise from invasive procedures such as surgeries. Any surgical procedure is done to prevent further damage to a person’s body and the least thing healthcare providers would want is to add any probable complication. Included in the most common complications that occur after surgery are surgical site infections, sepsis, cardiovascular complications, and respiratory complications, including postoperative pneumonia and thromboembolic complications. Patients who experience postoperative complications have dramatically increased hospital length of stay, hospital costs, and mortality and morbidity rates (Brazler & Hunt). Particularly in this paper, complications after orthopedic surgical procedures, such as hip, knee or shoulder joint repair, arising from oral infections will be discussed in terms of its incidence, management, prevention and cure. Post surgical infection: The dental and orthopedic relation According to Callan et al., the total population of the oral microflora of the human mouth has been estimated at 6 billion microbes that includes approximately 140 taxonomic groups and 700 plus different species. Although it is unlikely that any one individual harbors more than 200 species, according to studies at least 30 species participate in the inflammatory periodontal diseases. The 30 known species are mostly gram-negative and anaerobic, and produce endotoxins and other antigens capable of eliciting a profound host immune response (Callan et al.). Since a person’s oral cavity is naturally populated with dense and diverse population of oral microbes, it is said that dental patients suffer from periodic episodes of transient bacterial infections of oral origins. Dental procedures have long been considered a potential cause of implant infections even after the initial orthopedic postoperative period. This is because dental procedures can introduce bacteria from the mouth into the bloodstream (Jevsevar 1). Numerous reports have identified bacteremia in patients after dental treatment procedures such as extractions, scaling, periodontal probing, suture removal, orthodontic treatment, restorative dentistry, and nonsurgical endodontic therapy. Surprisingly it is also considered that even normal everyday oral activities such as mastication, tooth brushing and dental flossing can contribute to bacterial penetration in the blood stream. In fact several authors say that everyday oral event is more significant than dental procedures as a probable cause of systemic infection that leads to orthopedic surgery complications (Callan et al.). In the United States, it is estimated that more than 500,000 total joint arthroplasties are performed annually. Infection rate of such surgery are secondary to bacteremia. However, in spite of the potential for infection, case studies suggest that the risk of a joint prosthesis infection from bacteremia of oral origin is exceedingly low (Callan et al.). According to some studies, most joint infections appear to be caused by Staphylococcus aureus, Staphylococcus epidermidis, or other coagulase-negative staphylococci which are, on the contrary, not oral in origin. The predominant oral microbes implicated in both endocarditis and septic prosthetic joints belong to the viridians streptococci family such as Streptococcus mitis, Streptococcus oralis, Streptococcus gordonii, Streptococcus sanguis, and Streptococcus mutans. In addition to being ?-hemolytic, all of the viridans streptococci are aerobic, gram-positive microbes. Analyzed data from 6 studies determined that roughly 66% of 281 bacteria isolated from prosthetic joint infections were staphylococci, but only a small percentage of 5% were classified as viridans streptococci (Callan et al.). Such study suggest that orthopedic infections resulting from bacteremia of oral origin are rare but still it should not be a factor not to give the needed medical attention considering the cost and pain a person would have to go through if such complication arises. Callan et al. have posted 3 questions regarding oral infections and orthopedic surgeries that the author of this article finds significant because it covers the importance of collaborative care of dentists and orthopedic surgeons which are as follows: 1) what are the responsibilities of the dentist and orthopedic surgeon regarding prevention of infection before and during surgery? 2) What are the conditions for prescribing antibiotics for prophylaxis and treatment of patients with existing joint prostheses? 3) What are the responsibilities of the dentist and orthopedic surgeon regarding collaborative treatment of patients prior to and after joint replacement (Callan et al.)? Management of Oral infections in Orthopedic Surgical procedures The mutual responsibility of the both dentist and orthopedic surgeon is to reduce the incidence of dental bacteremia-related joint sepsis by providing collaborative antibiotic prophylaxis and treatment for patients who are candidate for joint replacement. In the presence of oral infections prior to orthopedic surgical procedure, close collaboration regarding the treatment of existing oral infection and the use of antibiotic prophylaxis after placement of a joint prosthesis is important for providing optimal care for the patient and ensuring that complications are least to arise post operatively (Callan et al.). Dental Evaluation: the need for in orthopedic surgeries Although it has been stated that complications after orthopedic surgeries from oral infection have small prevalence still the need for prevention is necessary to maintain the rate at the minimum. Thus, all patients who are candidate for orthopedic surgeries especially joint replacement procedures should be advised to have dental evaluation and clearance with an ample amount of time before the contemplated procedure. This is to allow treatment if possible if oral infection is present. Physicians highly recommend that major dental procedures such as tooth extractions and periodontal work completed before joint replacement surgery and likewise routine cleaning of teeth should be delayed for several weeks after to prevent possible entry of bacteria of oral origin that can cause damage to the replaced joint (American Academy of Orthopedic Surgeons). Preventing Infection Common causes of infection following hip replacement surgery are from bacteria that could be from dental procedures, urinary tract infections, or skin infections. For many people with joint replacements, the American Academy of Orthopedic Surgeons (AAOS) recommends taking preventative antibiotics before dental procedure even though the degree of evidence is controversial in the use of antibiotic prophylaxis (American Academy of Orthopedic Surgeons). Furthermore, advising patients about reporting at once early signs of infection is the best way to treat and prevent further replacement surgery complications. Patients should be aware of signs and symptoms of infection such as: persistent fever, shaking chills, increasing redness, tenderness, or swelling of the wound, drainage from the surgical wound, and increasing pain on replacement site with both activity and rest (American Academy of Orthopaedic Surgeons). Pharmacologically, antibiotic drug of choice includes amoxicillin given an hour before and 1.5 gm 6 hours after the initial dose. But if the patient is penicillin allergic, erythromycin may be given, 1 gram an hour before dental treatment and 500 mg 6 hours after the first dose. Also clindamycin is used as an alternative (Wheeless). Prevalence and management guidelines The prevalence of the significance of oral infections in orthopedic surgery complications is still at a very low rate. An example stated in a study regarding total hip replacement arthroplasty (THA) reported that dental procedures have only been involved infrequently from the review of records of 2,973 patients. Of the infections identified in 52 patients, only three were strongly associated with a dental procedure that only comprises a low rate of 6%. This was diagnosed by culture from the affected joint that reveals Streptococcus viridians in two cases and Peptostreptococcus in one. Of the three patients, one has diabetes mellitus and the other has rheumatoid arthritis, both conditions predisposing to infection. This only tells that other medical conditions could have much higher contribution to developing bacteremia after an orthopedic replacement surgery other than oral infections (LaPorte et al. 56). In a cohort study made by Berbari et al. regarding the use of antibiotic prophylaxis for dental procedures for post orthopedic surgery patient entitled “Dental Procedures as Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study.” A total of 339 case patients and 339 control subjects were studied. According to the study, there was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or even low-risk dental procedure who were not administered antibiotic prophylaxis, compared with the risk for patients not undergoing a dental procedure respectively. The study has concluded that dental procedures were not risk factors for subsequent total hip or knee infection. The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection (Berbari et al.8). This is in contrary to the practice that patients with systemic disease, or who are undergoing extensive procedures, should be considered for prophylactic antibiotic treatment (LaPorte et al. 56) which been of controversy even until the latest guidelines released by the American Association of Orthopedic Surgeons and the American Dental Association which is discussed below. The American Association of Orthopedic Surgeons and the American Dental Association have conceptualized a guideline to once and for all have a consensus on the practice of giving antibiotic prophylaxis for patients who will undergo dental procedure who have had or will be going for an orthopedic joint replacement surgery. And for this matter the direct relationship of oral infection causing orthopedic replacement surgery complications is also given emphasis. According to the guideline there is a multitude of indirect evidence but it does not totally prove the direct role of oral infection to bacteremia that causes orthopedic replacement surgery complication. Multiple studies of varied strengths also suggest that prophylaxis decreases the incidence of post dental procedure bacteremia. But still no studies have explained the true microbiological relationship between bacteremia and orthopedic implant infection (Rethman et al. 3). Moreover, the guidelines states that rates of bacteremia after dental procedures varied significantly depending on the procedure and the health status of a patient which is a very good point because oral activities and procedures are being done routinely and there has to be a point of whether what procedure can be done in any given case. As expected, this states that the more invasive oral procedures produced the highest median incidence of bacteremia, but common daily habits such as flossing, tooth brushing, and even chewing resulted in bacteremia in some cases. Having this is mind can bring into a conclusion that although the rate is relatively low in developing bacteremia of oral origin, still the need for oral hygiene is important and should be emphasized for patients who will undergo or have been through orthopedic replacement surgeries (Rethman et al. 3). Although there is no direct evidence that would suffice the claim of bacteremia following dental procedures, the need for preventive measures needs to be established to prevent complications that may arise. Even though this study suggest that the strength of the evidence is low, still the little prevalence rate as proved by culture finding organisms of oral origin in replacement sites opens the possibility that it can happen in varied instances. The author of this study believes that even the smallest possibility should not risk a person for complications and thus should be addressed the same way all other risk factors should be handled so that the slightest possibility of having complications from orthopedic surgical procedures is always avoided. Work Cited: American Academy of Orthopedic Surgeons. “Infections”. (2011) Web. July 2007 American Academy of Orthopedic Surgeons. “Total Hip Replacement” (2011) Web July 2007 Berbari E., Osmon D., Carr A., Hanssen A., Baddour L., Greene D., Kupp L., Baughan L., Harmsen S., Mandrekar J., Therneau T., Steckelberg J., Virk A. & Wilson W. Dental Procedures as Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study. Clin Infect Dis. (2010) 50 (1): 8-16. doi: 10.1086/648676. Print Brazler D. & Hunt D. The Surgical Infection Prevention and Surgical Care Improvement Projects: National Initiatives to Improve Outcomes for Patients Having Surgery. Clin Infect Dis. (20.06) 43 (3): 322-330. doi: 10.1086/505220I. Print Callan D., Evans R. & Cobb C. Periodontal Disease, Bacteremia, and Orthopedic Surgery. Dentistry iQ Network. N.d. Web 2012 Jevsevar D. Shared Decision Making Tool. American Dental Association. N.d. Web Laporte D., Waldman B., Mont M. & Hungerford D. Infections associated with dental procedures in total hip arthroplasty. J Bone Joint Surg Br January (1999) vol. 81-B no. 1 56-59. Print Rethman M., Watters W., Abt E., Anderson P., Boyer K., Carroll K., Evans R., Futrell H., Garvin K., Glenn S., Goldberg M., Hanson N., Hellstein J., Hewlett A., Kolessar D., Moucha C., O’Donnell R., Osmon D., O’Toole J., Rinella A., Steinberg M. Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures Executive Summary on the AAOS/ADA Clinical Practice Guideline. (2009). Web Wheeless C. Prevention and management of Infections from dental procedures. Wheeless’ textbook of Orthopedics. 2011. 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