Periprosthetic Joint Infections due to bacteria from the oral cavity What do we know? Eva Vacha Dentist Technische Universität München, Germany

Transcription

1 Periprosthetic Joint Infections due to bacteria from the oral cavity What do we know? Eva Vacha Dentist Technische Universität München, Germany

2 Background The risk of haematogenic prosthetic joint infection (PJI) after dental procedures is discussed controversially. Orthopaedic surgeons and dentists are often uncertain how to deal with wearers of endoprosthesis concerning the prevention of PJI due to oral bacteria or even completely unaware of the problem. Few studies have evaluated PJI regarding the human mouth as the origin of the infection. 2

3 What bacteria are common in the human mouth? Streptococcus spp. (salivarius, vestibularis, anginosus, intermedius, constellatus, mitis, oralis, sanguinis, gordonii, parasanguinis, mutans, sobrinus, cristatus, pyogenes) Peptostreptococcus spp. (micros) Actinomyces spp. (naeslundii, Israeli, odontolyticus, georgiae, gerencseriae, pyogenes, meyeri) Lactobacillus spp. (paracasei, rhamnosus, fermentum, plantarum, acidophilus) Porphyromonas spp. (gingivalis, endodontalis) 3

4 What bacteria are common in the human mouth? Tannerella spp. (forsythensis) Prevotella spp. (intermedia, nigrescens, pallens, loescheii) Fusobacterium spp. (nucleatum) Campylobacter spp. (rectus, showae, gracilis) Haemophilus spp. (parainfluenzae) Actinobacillus spp. (actinomycetemcomitans) 4

5 What bacteria are common in the human mouth? Capnocytophaga spp. (ochracea, gingivalis, sputigena) Veillonella spp. (parvula, dispar, atypica, cricetti, caviae) Neisseria spp. (flavescens, subflava) Gemella spp. (haemolysans) Granulicatella spp. (elegans) 5

6 What bacteria are frequently causing PJI? Coagulasenegative staphylococci Staphylococcus aureus Gram-negative bacilli Tande & Patel 2014 Peel et al Stéfansdottir et al Trampuz & Zimmerli 2005 Geipel & Herrmann % 24% 28% 30-43% 25-30% 27% 26% 31% 12-23% 25% 9% 10% 6% 3-6% 20% Streptococci 8% 8% 8% 9-10% 10-15% Anaerobes 4% 2% 3% 2-4% 7-10% Enterococci 3% 3% 8% 3-7% / Other 15% 4% 1% / 2% 6

7 What bacteria are frequently causing PJI? Summary: 25% coagulase-negative staphylococci 25% Staphyloccous aureus 10% gram-negative bacilli 10% streptococci 30% other bacteria, polymicrobial infections, culture false-negative etc. 7

8 Are there bacteria typical for PJI that can origin from the human mouth? Streptococci - most common bacterial species in the human mouth - cause three times more often late PJI than early PJI (haematogenic nature?!) - are known for causing haematogenic infections such as infective endocarditis - most common aerobe bacterium in dental bacteraemia 8

9 Are there bacteria typical for PJI that can origin from the human mouth? Staphylococcus aureus - most common cause of acute haematogenic PJI - often from ulcerations of the skin - staphylocci - bacteraemia can have their origin in the mouth - cases are described, where PJI with staphylocci occured after dental treatment 9

10 Are there bacteria typical for PJI that can origin from the human mouth? Other bacteria Propionibacteria/Cutibacteria or Enteroccus faecalis can also cause bacteraemia after dental treatment (especially after endodontic treatment) the most common anaerobe bacteria in dental bacteraemia are Prevotella spp., Fusobacterium spp., Actinomyces spp., Lactobacillus spp., Enterococcus spp., Veillonellus spp. 10

11 Can dental procedures cause bacteraemia? Tooth extraction % Surgery of oral mucosa 13% Periodontal probing 10 43% Scaling and root planning 10 94% Professional teeth cleaning 15 39% Suture removal 11% Orthodontic procedures 26 57% Endodontic procedures 3 24% 11

12 What dental procedures are at a low or high risk to cause bacteraemia? No risk Low risk High risk Applying of ointments Fluoride treatments, Taking of oral impressions Taking of oral radiographs Placement of orthodontic brackets Postoperative suture removal Restorative dentistry, dental filling Intracanal endodontic treatment Placement of rubber dam Local aneasthetic injections (not intraligamentary or intraosseus) Dental extractions, mouth surgery, therapy for dental abscess Periodontal procedures; Prophylactic cleaning of teeth or implants where bleeding is expected Endodontic instrumentation beyond the apex Initial placements of orthodontic bands Intraligamentary and intraosseus local anaesthetic injections 12

13 Can daily routine dental procedures cause bacteraemia? Tooth brushing % Flossing, use of interdental sticks 0 86% Oral irrigation devices 7 50% Chewing food 0 17% CAVE: The higher the numbers of bacteria present in the mouth, the higher the chance of getting bacteraemia!!! 13

14 Is it possible for oral bacteria to cause PJI? The same bacterial DNS could be found in the synovial fluid and the dental plaque of patients (Témoin et al. 2012). The same patterns of bacterial polypeptides could be found in the joint and in the mouth of patients (Bartzokas et al. 1994). From the mouth to the joint is a possible route for bacteria to take! 14

15 Cases of PJI after dental treatment Mougari et al PJI of a 10 year old knee endoprosthesis due to Granulicatella adiacens after tooth extraction because of a dental abscess (without antibiotic prophylaxis). Skiest & Coykendall 1995 PJI of a hip endoprosthesis due to Streptococcus oralis after a series of dental procedures with antibiotic prophylaxis but the found bacterium was highly resistant to erythromycin, the antibiotic taken for prophylaxis. 15

16 Cases of PJI after dental treatment Brown & Drinkwater 2012 Haematogenic PJI of 1 year old hip prosthesis due to Actinomyces spp. after a prophylactic teeth cleaning (without prophylaxis). Strazzeri & Anzel 1986 Late PJI of a 10 year old hip endoprosthesis due to Actinomyces israelii after extraction of 3 teeth and filling of 7 cavities (without prophylaxis). Bartz et al Late PJI of a 9 year old hip endoprosthesis due to Peptostrepococcus micros after several dental visits due to acute pain (without prophylaxis). 16

17 Cases of PJI after dental treatment Rubin et al PJI of 5 year old hip prosthesis due to Staphylococcus aureus after dental scaling (without prophylaxis). PJI of 5 year old hip prosthesis due to Staphylococcus aureus after multiple tooth extractions (without prophylaxis). PJI of 3 year old hip prosthesis due to beta haemolytic Streptococcus group G after six dental sessions, one of which was covered with an antibiotic. Linqvist & Slätis 1985 PJI of a 3 year old hip endoprosthesis due to Streptococcus viridans after tooth extractions and treatment of severe periodontal disease (without prophylaxis). PJI of a 5 year old hip endoprosthesis due to Streptococcus viridans after tooth extractions because of severe periodontitis (without prophylaxis). 17

18 Cases of PJI after dental treatment Important: The first symptoms mostly occured a few days up to 4 weeks after the dental treatment Prostheses often have been functional and pain free for years before the infection Prophylaxis is not necessarily working because bacteria can be resistant 18

19 What is the risk of developping PJI due to dental teatment? 6 13% of the late PJI are caused by dental treatments 0,1 0,2% of the wearers of endoprostheses will suffer a PJI caused by dental treatment (LaPorte et al. 1999; Waldman et al. 1976; Maderazo et al. 1988) Some studies state that wearers of endoprostheses don`t have a higher risk for joint infections after dental treatment (Kao et al. 2016, Berbari et al. 2010) 19

20 What do the orthopaedic surgeons advise? 3% of the orthopaedic clinics advise their patients to get a clinical dental examination before the insertion of an endoprosthesis 0% of the orthopaedic clinics contact their patients dentists before the insertion of a prosthesis 55% of the orthopaedic clinics advise their patients to take antibiotic prophylaxis prior to dental treatment after the insertion of an endoprosthesis (Nusime et al. 2011: Survey among the german orthopaedic clinics with the highest insertion rates for endoprostheses) 20

21 What do the dentists advise? most dentists don t know if their patients have an endoprosthesis (it s not in their anamnesis questionnaire) only slowly are they getting aware of the potential (?) problems 21

22 Do patients with endoprosthesis need antibiotic prophylaxis prior to dental treatment? No consens! - individually evaluate antibiotic prophylaxis for each patient, not generally (Sendi et al. 2016, Sollecito et al. 2015, Rossi et al. 2005, LaPorte et al. 1999, Thyne & Ferguson 1991, ) but evaluate according to what standards?!? - only patients with a high risk of getting PJI or patients who get a high risk dental procedure i.e. (ADA und AAOS 2003) high risk patients: immunocompromised, first two years after implantation, comorbidities like malignancy, diabetes etc. high risk dental procedures: tooth extraction, periodontal procedures, surgery etc. - only in the first few years after the prosthesis insertion before dental treatment where bleeding is expected (AE 2016) - prophylaxis for every patient with an endoprosthesis (AAOS 2009) 22

23 Antibiotic prophylaxis prior to dental treatment for patients with endoprosthesis? Pro lowers the bacteraemia rate after dental treatment usually very compatible described cases of PJI after dental treatment have all occured without antibiotic prophylaxis or when bacteria where resistant against chosen antibiotics Antibiotic prophylaxis against infective endocarditis seems to work (UK!) PJI is a devastating complication with a high morbidity and mortality rate (and very expensive to treat) 23

24 Antibiotic prophylaxis prior to dental treatment for patients with endoprosthesis? Contra severe side effects possible higher costs eventually no effect (for example due to resistancy of bacteria against the antibiotics) 24

25 Are local antibiotics and/or desinfectants reasonable? Promising! Chlorhexidine Mouthwash can reduce bacteraemia after dental procedures Local antibiotics can reduce bacteraemia after dental procedures 25

26 How important is a good oral hygiene? Obtaining and maintaining an optimal oral hygiene is recommended by many research teams (Gomez et al. 2011, Assael 2009, Uckay et al. 2008, Rossi et al. 2005, Bartzokas et al. 1994) Lampley et al found no benefit of a good oral hygiene Berbari et al found a clear benefit of a good oral hygiene Young et al states that many people who canꞌt afford dental treatment would have a delayed operative date and therefore a longer period of poor orthopaedic function resulting in weight gain, hypertension, diabetes, pain killer addiction 26

27 How important is a good oral hygiene? Fact is: Poor oral hygiene often results in decayed teeth, periodontal disease and an increased load of bacteria in the mouth and therefore increases the chance of being in need of a high risk dental treatment getting bacteraemia during dental procedures or daily dental routines 27

28 How important is a good oral hygiene? Most people don t have the money for dental treatment. But they do for a good oral hygiene!!! Tooth Brush: 0,75 Euro Tooth Paste: 0,45 Euro Dental floss: 0,85 Euro 10 minutes per day: 0,00 Euro 1 functioning hand: 0,00 Euro 2,05 Euro Is money really an excuse?! 28

29 How important are frequent dental visits? Important! The earlier dental diseases are detected the lower the chance of beeing in need of a high risk dental treatment! Dental filling Endodontic treatment Tooth extraction Also: The earlier dental diseases are detected the less the treatment hurts 29

30 Clinical relevance for orthopaedic surgeons Always refer patients with PJI due to oral cavity bacteria to a dentist to cure the cause of the infection Oral cavity bacteria that have infected a prosthetic joint may also infect the heart valves a blood culture and a heart echo are recommended Refer patients to a dentist before the implantation of a prosthetic joint Put emphasis on the importance of an excellent oral hygiene to reduce the microbial load in the mouth (but advise against the use of oral irrigators) as bacteremia can also occur spontaneously without dental treatment 30

31 The author declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest. Thank you for your attention! 31