ANESTHESIA/FACIAL PAIN

J Oral Maxillofac Surg

69:2106-2111, 2011

Perioperative, Postoperative, and

Prophylactic Use of Antibiotics in
Alloplastic Total Temporomandibular
Joint Replacement Surgery: A Survey and
Preliminary Guidelines
Louis G. Mercuri, DDS, MS,* and
David Psutka, DDS, FRCD(C)†

Purpose: In 2009, the American Academy Of Orthopedic Surgeons recommended lifelong prophylaxis
after orthopedic total joint replacement (TJR) before these patients undergo dental, aerodigestive,
genitourinary (GU), and gastrointestinal (GI) procedures. Because oral and maxillofacial surgeons world-
wide are implanting alloplastic total temporomandibular joint replacements (TMJ TJRs), it appeared
reasonable to survey these surgeons to obtain data that might shed some light, not only on this issue, but
also to obtain some data to begin to develop preliminary guidelines for the peri- and postoperative use
of antibiotics for TMJ TJR using these results and the orthopedic data.
Materials and Methods: A total of 35 surgeons worldwide, members of either the TMJ Concepts
or Biomet Microfixation online networks were e-mailed a standard questionnaire surveying their
perioperative, postoperative, and prophylactic use of antibiotics for their TMJ TJR cases.
Results: Of the 35 surgeons, 26 (74.2%) from 8 different countries responded. A total of 2,476
cases (3,368 joints) were retrospectively surveyed. Of the responding surgeons, 96.2% used, in order
of frequency, cefazolin, clindamycin, cephalosporin, or penicillin-based antibiotics in the perioper-
ative period and continued their use for a mean of 7 days (range 5 to 14) postoperatively. Also, 46.2%
soaked the TJR components either in the perioperative antibiotic or in vancomycin, poviodine,
gentamycin, or peroxide before implantation. In addition, 61.5% irrigated the wounds after device
implantation with bacitracin, vancomycin, poviodine, peroxide, or the perioperative antibiotic.
These surgeons reported that 51 joints (1.51%) had become infected within a mean of 6 months
(range 2 weeks to 12 years) postoperatively. A total of 32 devices (0.95%) required removal and/or
replacement. In cases in which the organisms were isolated, the organisms commonly associated
with biofilm infection of TJR devices, Staphylococcus aureus, S epidermidis, Peptostreptococcus,
and Pseudamonas aeruginosa, were cultured. In only 1 joint (0.003%) was there a suggestion of an
association with an invasive dental/aerodigestive, GU/GI procedure. Regarding prophylaxis after
TMJ TJRs and before dental/aerodigestive, GU, or GI procedures, 53.8% of the respondents reported
that they provided prophylaxis. Of these, 1 recommended doing this for 6 months and 4 for 2 years,
such as has been the American Dental Association/American Academy of Orthopedic Surgeons
recommendation since 2003; and 9 reported they believe these TMJ TJR patients should have
lifetime antibiotic prophylaxis before invasive dental/aerodigestive, GU, or GI procedures.

*Clinical Consultant, TMJ Concepts, Ventura, CA. © 2011 American Association of Oral and Maxillofacial Surgeons
†Senior Attending Surgeon, Mount Sinai Hospital, Center for 0278-2391/11/6908-0012$36.00/0
Excellence in TMJ Reconstructive Surgery, University of Toronto, doi:10.1016/j.joms.2011.01.006
Private Practice, Mississauga, ON, Canada; and Consultant, Biomet
Microfixation, Jacksonville, FL.
Address correspondence and reprint requests to Dr Mercuri:
TMJ Concepts, 1793 Eastman Ave, Ventura, CA 93003; e-mail:
lgm@tmjconcepts.com

2106
MERCURI AND PSUTKA
Conclusion: The evidence provided from the present small study survey and a review of the orthopedic
data could provide the opportunity to develop guidelines for the preoperative, intraoperative, and
postoperative antibiotic management for TMJ TJRs and spur additional research into this important area
of patient management.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:2106-2111, 2011
The editorial in the September 2009 Journal of Oral
and Maxillofacial Surgery1 discussed a controversy
raised by the American Academy of Orthopedic Sur-
geons’ (AAOS) information statement recommending
lifelong prophylaxis after orthopedic total joint re-
placement (TJR) before these patients undergo den-
tal, aerodigestive, genitourinary (GU), or gastrointes-
tinal (GI) procedures.2
The AAOS statement cited studies describing bac-
teremias causing hematogenous seeding of joint im-
plants, in both the early postoperative period and
many years after implantation3 from dental, urologic,
and other medical procedures4 and daily life activi-
ties.3-6
However, 3 of the studies4-6 relate to bacteremias
causing endocarditis. McGowen7 reported “The anal-
ogy of late prosthetic joint infections with infective
endocarditis is invalid as the anatomy, blood supply,
microorganisms and mechanisms of infection are all
different.”
The AAOS statement cited data that “likely” provide
evidence of the association of oral cavity, skin, respi-
ratory, and gastrointestinal and genitourinary system
involvement with late orthopedic implant infec-
tion.8,9
“Given the potential adverse outcomes and cost of
treating an infected joint replacement, the AAOS rec-
ommends that clinicians consider antibiotic pro-
phylaxis for all total joint replacement patients
prior to any invasive procedure that may cause
bacteremia. This is particularly important for those
patients with one or more of the following risk
factors” (Table 1).3,9-18
The AAOS statement has provided “the current”
prophylactic antibiotic recommendations for differ-
ent invasive procedures based on the activity against
the endogenous organisms likely encountered, the
drug’s toxicity, and cost taken from the 2006 Medical
Letter (Table 2).19
The AAOS guidelines continue, “this statement pro-
vides recommendations to supplement practitioners
in their clinical judgment regarding antibiotic prophy-
laxis for patients with joint replacements . . .” and
that “. . . it is not intended as the standard of care nor
a substitute for clinical judgment . . .” Furthermore,
“any perceived potential benefit of antibiotic prophy-
laxis must be weighed against the known risks of
toxicity, allergy, and development, selection and
2107
Table 1. PATIENTS AT POTENTIAL INCREASED RISK
OF HEMATOGENOUS TOTAL JOINT INFECTION3,9-18
All patients with prosthetic joint replacement
Immunocompromised/immunosuppressed patients
Inflammatory arthropathies (eg, rheumatoid arthritis,
systemic lupus erythematosus)
Drug-induced immunosuppression
Radiation-induced immunosuppression
Patients with comorbidities (eg, diabetes, obesity, human
immunodeficiency virus, smoking)
Previous prosthetic joint infections
Malnourishment
Hemophilia
Human immunodeficiency virus infection
Insulin-dependent (type 1) diabetes
Malignancy
Megaprostheses
Modified from the American Academy of Orthopedic
Surgeons.2
Mercuri and Psutka. Antibiotics Use in TMJ TJR. J Oral Maxillofac
Surg 2011.
transmission of microbial resistance. Practitioners
must exercise their own clinical judgment in deter-
mining whether or not antibiotic prophylaxis is ap-
propriate.”
With the AAOS statement, the potential clinical
consequences, the controversy that has arisen over its
recommendation, and the fact that oral and maxillo-
facial surgeons worldwide are implanting temporo-
mandibular joint (TMJ) TJRs, we thought it reasonable
to survey these TMJ reconstructive surgeons to obtain
perioperative and postoperative antibiotic usage data
for these cases. These data might begin not only to
shed some light on this issue, but also could lead to
the development of guidelines for antibiotic use with
TMJ TJRs and spur additional investigation into this
important subject. Thus, as practitioners decide
whether to use perioperative antibiotics and/or pro-
vide prophylaxis before invasive dental, aerodiges-
tive, GU, or GI procedures, they might have some
evidence on which to base their decision.
Materials and Methods
A total of 35 surgeons worldwide, members of
either the TMJ Concepts (Ventura, CA) or Biomet
Microfixation (Jacksonville, FL) online networks were
e-mailed a standard questionnaire surveying their peri-
2108 ANTIBIOTICS USE IN TMJ TJR

Table 2. ANTIBIOTIC PROPHYLAXIS RECOMMENDATIONS

Procedure Antimicrobial Agent Dose Timing

Dental Cephalexin 2 g PO 1 h before procedure

Cephradine
Amoxicillin
Ophthalmic Gentamycin Multiple topical drops Consult ophthalmologist or
Tobramycin for 2-24 h pharmacist for dosing regimen
Ciprofloxin OR
Gatifloxin 100 mg subconjuctivally
Levofloxin
Moxifloxin
Ofloxin or meomycin-
gramicidin-polymyxin B
Cefazolin
Orthopedic Cefazolin 1-2 g IV Begin dose 60 min before procedure
Cefluroxime 1.5 g IV
Vancomycin 1 g IV
Vascular Cefazolin 1-2 g IV Begin dose 60 min before procedure
Vancomycin 1 g IV
Gastrointestinal
Esophageal, gastroduodenal Cefazolin 1-2 g IV Begin dose 60 min before procedure
Biliary tract Cefazolin 1-2 g IV Begin dose 60 min before procedure
Colorectal Neomycin plus erythromycin 1g Dependent on time of procedure;
base PO or metronidazole 1g consult with GI physician and/or
PO pharmacist
Head and neck Clindamycin plus 600-900 mg IV Begin dose 60 min before procedure
gentamycin or cefazolin 1.5 mg/kg IV
1-2 g IV
Obstetric and gynecologic Cefoxitin, cefazolin 1-2 g IV Begin dose 60 min before procedure
Ampicillin/sulbactam 3 g IV
Genitourinary Ciprofloxin 500 mg PO or 1 h before procedure
400 mg IV Begin dose 60 min before procedure
Abbreviations: PO, orally; IV, intravenously.
Discontinue within 24 h of procedure; for most outpatient/office-based procedures, a single preprocedure dose will be
sufficient.
Modified from American Academy of Orthopedic Surgeons.19
Mercuri and Psutka. Antibiotics Use in TMJ TJR. J Oral Maxillofac Surg 2011.

operative, postoperative, and prophylactic use of an-
tibiotics for their TMJ TJR cases.
Results
A total of 26 surgeons (74.2%) from 8 different
countries (Australia [2], Canada [4], Denmark [1],
England [2], Germany [1], New Zealand [1], Sweden
[1], and United States [14]) responded. A total of
2,476 cases (3,368 joints) were retrospectively sur-
veyed. One surgeon reported never using periopera-
tive antibiotics; the remainder (96.2%) used, in the
order of frequency, cefazolin, clindamycin, cephalo-
sporin, or penicillin-based antibiotics in the perioper-
ative period and continued their use for a mean of 7
days (range 5 to 14) postoperatively. Also, 12 sur-
geons (46.2%) soaked the TJR components in either
the perioperative antibiotic or vancomycin, povio-
dine, gentamycin, or peroxide before implantation. In
addition, 16 surgeons (61.5%) irrigated the wounds
after implantation of the device components with
bacitracin, vancomycin, poviodine, peroxide, or the
perioperative antibiotic.
A total of 51 infected joints (1.51%) were reported
to have occurred within a mean of 6 months postop-
eratively (range 2 weeks to 12 years). The surgeon
who did not provide perioperative antibiotics re-
ported 2 infections (2.2%) in the 92 TMJ TJRs he had
implanted. The infections had developed 3 and 9
months postoperatively. Both TJRs were removed and
replaced. The surgeon reported no organisms were
isolated in either case.
Of the 51 infected joints, 32 (62.7%; 0.95% of all
joints) required removal and/or replacement. When
organisms were isolated, the bacteria commonly as-
sociated with biofilm infection20 of TJR devices,
Staphylococcus aureus, S epidermidis, Peptostrepto-
coccus, and Pseudamonas aeruginosa, were cul-
tured. In only 1 joint (1.96%; 0.003% of all joints) was
even a suggestion present of an association with an
MERCURI AND PSUTKA
invasive dental/aerodigestive, GU/GI procedure. An
ipsilateral root-filled tooth treated by apicoectomy
and antibiotics resulted in facial swelling. The oral
infection resolved with antibiotic therapy, as had the
associated facial swelling over the alloplastic joint.
The device was not removed. The organism was not
identified because the patient never developed puru-
lence. This surgeon had reported the routine use of a
penicillin-based antibiotic during the perioperative
period and for 5 to 7 days postoperatively and did not
soak the TJR components before implantation. How-
ever, the surgeon did report spraying them with pov-
iodine before implantation. The surgeon recom-
mended antibiotic prophylaxis for invasive dental/
aerodigestive, GU, and GI procedures for the patient’s
lifetime after implantation.
Regarding prophylaxis before invasive dental/
aerodigestive, GU, and GI procedures, 14 surgeons
(53.8%) reported that they provided prophylaxis. Of
these 14 surgeons, 1 (7.1%) recommended doing this
for 6 months; 4 (16%) for 2 years, which had previ-
ously been the American Dental Association/AAOS
recommendation21; and 9 (76.9%) reported they be-
lieve these TMJ TJR patients should have lifetime
antibiotic prophylaxis before such invasive proce-
dures. Their common rationale was that the one dose
of prophylactic antibiotic presently recommended
was a small price, considering the clinical and finan-
cial consequences of such infections.
Discussion
Surgical site infection (SSI) after alloplastic joint
replacement is a serious and costly event for both the
patient and the health care system. Despite preoper-
ative, intraoperative, and postoperative precautions,
such events can and do occur. In the published or-
thopedic studies, it has been reported to be as low as
0.39% to as high as 4.29%.22 In the present small
sample-size study, SSI for TMJ TJR was reported to be
1.51%.
The SSI risk should be examined from a number of
perspectives, including the preoperative patient eval-
uation, preoperative skin preparation and antibiotic
prophylaxis protocols; surgical environment, tech-
nique, and duration; postoperative antibiotic regi-
men; and, finally, future prophylaxis for prosthetic
joint patients undergoing invasive dental, urologic,
GI, or aerodigestive procedures.
Peersman et al23 reported an SSI rate after primary
alloplastic total knee arthroplasty (TKA) of 0.39% but
0.97% after revision TKA in 6,489 replacements. Of
these, 86% were deep periprosthetic infections, one
third of which occurred within the first 3 months of
surgery and the remaining two thirds after 3 months.
The predominant organisms isolated were S aureus, S
2109
epidermidis, and Group B Streptococcus, organisms
commonly associated with biofilm20 infections. These
investigators concluded that patients undergoing re-
vision joint replacement surgery had a significantly
greater risk of infection than did patients undergoing
primary joint replacement. Also, if the surgery took
longer than 2.5 hours, the risk of infection was sig-
nificantly increased. They found that no change oc-
curred in the infection rate when the perioperative
antibiotic prophylaxis was decreased from 48 to 24
hours postoperatively. Furthermore, they reported
that in their study, the comorbidities that were statis-
tically significant in increasing the risk of infection
were immunosuppressive therapy, poor nutrition, hy-
pokalemia, diabetes, obesity, and a history of smok-
ing.
Levent et al22 hypothesized that adherence to in-
fection risk prevention measures would reduce the
incidence of SSI after TKA. They developed a prospec-
tive study of 364 consecutive TKA patients to exam-
ine the significance of 5 variables commonly associ-
ated with the potential for SSI after alloplastic joint
replacement: 1) classic risk-factors (eg, diabetes, rheu-
matoid disease); 2) incomplete preoperative skin
preparation; 3) methicillin-resistant S aureus-positivi-
ty; 4) perioperative antibiotic use; and 5) duration of
surgery. After a median follow-up of 1 year, they
reported a 1.4% SSI rate. Of the 5 variables, only
perioperative antibiotic use and the duration of sur-
gery demonstrated significance.
Rosenberg et al24 reported that the delivery of an-
tibiotic prophylaxis within 1 hour before the surgical
incision is important in helping to decrease the inci-
dence of SSI in alloplastic total joint arthroplasty
cases. Thus, they recommended verification of antibi-
otic administration in such cases into the time-out
protocol to ensure compliance with appropriate tim-
ing of prophylactic antibiotics in these cases.
AlBuhairan et al25 systematically reviewed the
published evidence using the Cochrane Library,
MEDLINE, EMBASE, and CINAHL databases for the
effectiveness of perioperative antibiotic prophylaxis
for the reduction of wound infection in patients un-
dergoing total hip and knee replacements. After re-
viewing 26 studies (11,343 participants) that met
their inclusion criteria, a meta-analysis of 7 studies
(3,065 participants) revealed that perioperative anti-
biotic prophylaxis reduced the absolute risk of
wound infection by 8% and the relative risk by 81%
compared with no prophylaxis (P ⬍ .00001). The
comparisons of no other variable showed a significant
difference. Therefore, they concluded that perioper-
ative antibiotic prophylaxis should be routinely used
but that the choice of the agent should be determined
by the cost and local availability.
2110
In 1997, an expert panel representing both the
American Dental Association and the AAOS issued a
joint advisory statement regarding antibiotic prophy-
laxis for dental patients with TJRs.26 The panel con-
cluded that antibiotic prophylaxis was not indicated
for dental patients with pins, plates, and screws nor
routinely indicated for most dental patients with TJRs.
However, they believed it was advisable to consider
premedication in a small number of patients who
might have the potential for an increased risk of
hematogenous total joint infection. The panel recon-
vened in 2003 and modified the advisory. Because the
risk of hematogenous bacterial infection of a total
joint prosthesis was considered greatest within 2
years after arthroplasty or when the patient was
chronically ill or immunocompromised,27 they rec-
ommended that at-risk prosthetic joint patients under-
going dental procedures in which the mucosa would
be breeched be provided antibiotic prophylaxis for 2
years after prosthetic joint implantation.28
In 2002, Kingston et al29 polled orthopedic surgeons,
urologists, and dentists on whether reports of prosthetic
joint infections after urologic and dental procedures
might suggest antibiotic prophylaxis should be used
before these procedures. Orthopedic surgeons and urol-
ogists agreed that infection of a prosthetic joint could
result from urologic procedures. However, dentists did
not know whether dental procedures could result in
infection of a prosthetic joint. These investigators con-
cluded that a consensus should be developed owing to
the potential consequences in such cases. Also, in 2002,
Curry and Phillips30 reviewed the relevant published
data and reported that despite the joint American Dental
Association/ASOS advisory, consensus on this subject
was lacking and concluded that antibiotic prophylaxis
should not be routinely given to all patients undergoing
dental treatment but should be reserved for those pa-
tients deemed at high risk.
Seymour et al31 in 2003 concluded that the evi-
dence on the cost-risk benefit seemed to demonstrate
that antibiotic prophylaxis with either amoxicillin or
penicillin was not cost-effective compared with no
prophylaxis and that the case for prophylaxis after
alloplastic TJR and before dental treatment was weak
or virtually nonexistent. They reported that after re-
viewing the published data to that date, the risk of
antibiotic prophylaxis was greater than the risk of
prosthetic joint infection.
Berbari et al32 presented a prospective, single-center,
case-control study of patients hospitalized with alloplas-
tic total hip and knee infections. The control subjects
were patients who had undergone alloplastic total hip
and knee replacement and who had been hospitalized
during the same period and were on the same orthope-
dic floor. These investigators concluded that dental pro-
cedures were not risk factors for subsequent total hip or
ANTIBIOTICS USE IN TMJ TJR
knee infection and that antibiotic prophylaxis before
high- or low-risk dental procedures was not associated
with a statistically significant reduction in the risk of hip
or knee infection. They concluded that current opinion-
based policies for the administration of antibiotic pro-
phylaxis to patients with prosthetic hip and knee re-
placements who undergo subsequent dental treatment
should be reconsidered.
However, this question might never be able to be
answered definitively because it appears impossible
to design a randomized clinical trial with large-enough
cohorts. This is because prosthetic joint infections are
rare23 and are more often caused by bacteria other
than members of the oral flora.33 Moreover, prescrib-
ing antibiotics needlessly can result in hypersensitiv-
ity reactions or even death from anaphylaxis. Also, the
increasing problem of antibiotic resistance must be
given serious consideration.
Perhaps the conclusions of Marculescu and Osmon34
on the subject summarize where medicine and dentistry
presently stand with this issue best: “The problem of
prophylaxis in orthopedic implant surgery will become
increasingly important and complex as the population
ages and requires more arthroplasty procedures, and the
prevalence of antimicrobial-resistant bacteria mean-
while continues to rise. Energy spent preventing pros-
thetic joint infection is more effective than that ex-
pended in treating the infection of a prosthetic joint,
once established. Prevention measures encompass a
wide array of variables related to host response, wound
environment, and microorganisms. Prophylaxis should
address these areas in the preoperative, intraoperative,
and postoperative periods. Antibiotic prophylaxis re-
mains the single most effective method of reducing the
prevalence of infection after total joint arthroplasty. In
the postoperative period, prophylaxis aims to protect
the prosthetic joint against hematogenous seeding from
oral, urologic, skin, or gastrointestinal sources. Current
dental and urologic advisory statements provide recom-
mendations for antibiotic prophylaxis for high-risk pro-
cedures. Close collaboration among the orthopedic sur-
geon, urologist, dentist, and infectious disease specialist
is crucial for providing recommendations regarding pro-
phylaxis in special circumstances. In these particular
circumstances, individual decisions should be made
based on clinical judgement.”
From the information available in published studies
and from our preliminary small study, we draw the
following conclusions:
Patients undergoing alloplastic TMJ replacement preop-
eratively should receive prophylactic antibiotic cover-
age within 1 hour before the surgical incision and
verification of antibiotic administration should be-
come an integral part of the time-out protocol to
ensure compliance with appropriate timing of admin-
MERCURI AND PSUTKA
istration. An antibiotic that covers the spectrum of
potential skin, ear, and saliva contaminants is recom-
mended. This practice will also protect high-risk pa-
tients (Table 1). A postoperative antibiotic regimen
also appears important for high-risk patients.
Intraoperative draping and operative techniques de-
signed to prevent cross-contamination between the
preauricular and retromandibular surgical sites and
oral cavity are essential.
The intraoperative soaking of components and/or ir-
rigation of the implant components with antibiotic
or antibacterial solution should be investigated fur-
ther with larger sample size studies; however, until
such data are available, from the findings of our
small survey, it appears to be a prudent protocol
until proved otherwise.
The time required to implant a TMJ TJR device, ac-
cording to the published data, is an extremely im-
portant determinant of SSI.
Postoperative prophylaxis after orthopedic TJR and be-
fore invasive dental, urologic, gastrointestinal, and
aerodigestive procedures, although questioned in
published studies, might be important in TMJ TJR,
because the tips of the condylar component ramus
fixation screws lie in the pterygomandibular space
and can be contaminated during inferior alveolar
nerve anesthesia administration techniques. This is
another area that should be investigated (Table 2).
We realize that our small survey study cannot pos-
sibly answer all the questions we have posed and that
we have raised many others yet to be answered.
However, we hope that the information and the pre-
liminary guidelines we have presented will stimulate
reconstructive TMJ surgeons to examine their preop-
erative protocols, intraoperative techniques, and post-
operative antibiotic regimens for their TMJ TJR pa-
tients and will stimulate and encourage additional
investigation in this important area of our specialty.
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