Dental Treatment for Patients with Artificial Joints

Posted by Dr. Edward Magida | Filed under , , , , ,

Today's dentists are presented with a myriad of patients who have prosthetic joints, pins, screws and/or plates of some type. These patients need to have special consideration as far as how to keep these devices infection free. For many years there were conflicting ideas about the need to premedicate these people. The prevailing thoughts ranged from condemning the use of all prophylactic antibiotics for all dental procedures, to the complete opposite, which was to use antibiotics for all types of treatment on all patients, all the time for life.

In 1997, The American Dental Association, in conjunction with the American Academy of Orthopaedic Surgeons issued an advisory regarding antibiotic prophylaxis guidelines. This advisory stated that antibiotic premedication is not needed for patients who have pins, screws or plates, and it is also not indicated for the majority of dental patients who have total joint replacements. The advisory stated that only for those patients who would be at increased risk for blood borne total joint infection, should antibiotics be considered.

The following conditions or diseases would place a patient with a prosthetic joint at risk of infection following dental treatment:

  • Immunocompromised patients- either because of disease, drug or radiation induced suppression
  • Patients who have rheumatoid arthritis or systemic lupus erythematosus
  • Insulin dependent diabetics
  • Hemophiliacs
  • Malnourished patients
  • Joint replacement patients-up until the first 2 years after joint surgery
  • Joint replacement patients-if there has been a previous prosthetic joint infection

The advisory also stratified the incidence of bacterial infections developing based upon the severity of the dental treatment. The following are the types of treatments that would require antibiotic premedication. Extractions, periodontal treatments, implant placement, certain types of root canal procedures, initial placement of orthodontic bands, and a dental cleaning in a patient where much bleeding is expected to occur. Treatment that would not indicate antibiotics would include simple restorative or prosthetic dentistry, local injections, conventional root canal procedures, suture removal, orthodontic appliance removal, impressions and x-rays.

As stated before, some physicians and dentists advocate the use of antibiotic premedication for all procedures on patients with prosthetic joints. This can present a potential problem though, for the unrestrained use of antibiotics has been shown to have certain hazards. These include overgrowth of pathogenic organisms (disease causing bacteria ), secondary infections, bacterial resistance in the patient, bacterial resistance to the drug being used and allergic reactions, including potentially fatal anaphylactic reactions.

All patients preparing to undergo joint replacement should receive a complete dental examination including the taking of new x-rays to look for any infections present in the oral cavity. Even if the patient is not complaining of any problems or discomfort, a full mouth x-ray series is definitely needed, since many dormant or non-painful abscesses are found this way. The treating of any oral infection before the joint surgery is absolutely imperative to help prevent problems in the future with the prosthesis.

Every case is different, and if the treating dentist or physician has reason to think premedication is needed for a dental procedure, than after careful consideration of the guidelines, the patients health is of paramount importance.

Geriatric Dental Patients

Posted by Dr. Edward Magida | Filed under , , , ,

Since 1988 I have been the staff dentist at numerous nursing, convalescent and adult care facilities. While at times, most people would find it a difficult, if not eye opening experience, I personally find it very rewarding to be able to help these patients with their dental needs and help with their problems. While most patients do not pose too much of a problem, there are some, due to their mental and/or physical ailments, that can be a true challenge to treat.

Dentists, at least most of us, are perfectionists. While in my office I strive for this all the time, I have had to learn that for some elderly patients, due to the limitations they present to dental treatment, this is not always possible. Sometimes I can only offer the best I can do given the circumstances. I know that there is no one else many times who would even attempt to help so I feel that at least I am trying my best.

Nursing home patients' needs are somewhat different than the rest of us. Many of them wear full or partial dentures. These are many times in need of repair or replacement. Teeth that have been removed should be added to the person's dentures to maintain a full compliment of teeth. I can't tell you how many people are wearing partial dentures that were made for them years ago. In the interim, someone took out one or more teeth but never bothered to replace the now missing teeth on the person’s denture. I don’t know how some people eat. Not being able to eat properly and nourish yourself, is a major downfall of patients in these types of settings. You wouldn’t think of buying one set of tires for your car and expecting to have them last your lifetime. You shouldn’t expect Uncle Bob’s denture to be a perfect fit forever either. The denture teeth wear down over the years and this makes it hard to chew, as well as causing the person’s face to "sink in" so to speak. Properly sized teeth give a person a more youthful look as well as increased chewing ability.

Sometimes the denture is fine but the patient has lost a lot of weight so the denture now "kind of swims" in the person’s mouth. In this case a reline of the teeth will allow it to fit properly to the shrunken gums. The biggest complaint I come across is the pain related to sore spots caused by pressure of the dentures on the gums. Sometimes all that is needed is some minor adjustment to the denture to make it a winner. Sometimes the reline procedure is needed to make a more intimate fit with the gums.

The biggest problem I see is the lack of basic oral hygiene. Either the person does not brush their teeth, or has it done for them on a daily basis, or it is done but is not very effective. This can easily lead to major cavity formation as well as periodontal disease. Both of these will ultimately lead to tooth loss. Many medications the elderly take will tend to adversely affect the teeth and gums. Many meds will dry out the person’s mouth which makes it easy for cavities to form. Someone with a dry mouth needs to pay extra attention to their oral hygiene.

If you know of someone in a nursing or convalescent type facility, please insist that the staff pay good attention to the oral hygiene of the person. This advice even goes to someone homebound or bedridden at home. I have on many occasions attended to people in these situations. The relative or personal aid must make sure the patient keeps his or her teeth as clean as possible. I know it sounds like common sense, but many times it just doesn't happen.

Getting back to why I do this. It is a great thrill to have the ability to help someone in need, and to help them in a way that no one else can or will. Just seeing a person’s new smile when all is said and done, goes a long way.