Dental health is checked before joint replacement, and the antibiotic question after it has a clearer answer than it used to.

Dental work is scheduled before surgery, not after

AAOS patient guidance advises scheduling any planned dental work, such as an extraction or periodontal treatment, well in advance of joint replacement ¹. The reason is a risk of infection for several weeks after the operation ¹. Many surgeons go further and ask for a dental screening before an elective replacement. In one series of 511 patients sent for routine screening, 18.5% needed a dental procedure before surgery, most often extractions, root canals, abscess drainage, or fillings ². The authors noted that universal screening adds cost and time ².

Whether screening prevents infection is less settled. A German cohort of 2,560 patients compared a period of referral to the family dentist with an earlier period without it ³. Infection within the first month after surgery fell from 1.8% to 0.8% ³. That is one study from one clinic. The AAOS appropriate use criteria describe dental screening before joint replacement as a shared decision, weighing the risks and benefits for that patient ⁴. Your surgeon decides whether to ask for a dental visit before your operation.

What the evidence says about oral bacteria and joint infection

Periprosthetic joint infection affects about 1% to 2% of primary hip and knee replacements ⁴. It can arise from bacteria introduced at the operation, from a nearby source, or from bacteria carried in the bloodstream from elsewhere in the body ⁴. The idea that dental procedures seed joint infections has been around for decades. The evidence has not supported it.

Bacteria enter the bloodstream during everyday activities, not only during dental procedures. A randomized study of 290 people cultured bacteria of the kinds that cause heart-valve infection from 23% after toothbrushing and 60% after an extraction without antibiotics ⁵. The AAOS criteria note that oral bacteremia frequently occurs with tooth brushing and eating ⁴. They also state that the chance of oral bacteremia being related to joint infection is extremely low, with no evidence for an association ⁴.

Direct studies of joint infection agree. A Mayo Clinic study compared 339 patients with infected hip or knee replacements against 339 controls ⁶. Dental procedures did not raise the risk of infection, and antibiotics before those procedures did not lower it ⁶. A study of 9,427 admissions for late prosthetic joint infection in England found no temporal association between invasive dental procedures and infection ⁷. Antibiotics before dental work have never been recommended there ⁷.

What the AAOS and ADA guidance now says about antibiotics

The American Dental Association's 2015 clinical practice guideline states that, in general, prophylactic antibiotics are not recommended before dental procedures for patients with prosthetic joint implants ⁸. The panel judged that the available evidence failed to show an association between dental procedures and joint infection ⁸. It weighed antibiotic resistance, adverse drug reactions, and cost, and it left room for clinical judgment where a patient's circumstances suggest a significant medical risk ⁸.

The AAOS issued updated appropriate use criteria in 2025, and they now align closely with that position. For a patient whose immune system is not compromised, the panel rated not prescribing antibiotics as appropriate, and prescribing them as rarely appropriate ⁴. That rating covers both non-invasive and invasive dental procedures ⁴. For a severely immunocompromised patient having an invasive procedure, such as an extraction, oral surgery, or scaling and root planing, both options were rated may be appropriate ⁴.

The document defines severely immunocompromised narrowly ⁴. Examples are advanced HIV, chemotherapy with very low white cell counts, and an organ or bone marrow transplant on immunosuppressants ⁴. Rheumatoid arthritis treated with biologic agents or high-dose prednisone is also listed ⁴. It states that routine, proper dental care and hygiene is an equal or more important infection-prevention measure ⁴. It also says its scope is average-risk patients, with no data to guide decisions for higher-risk groups such as revision implants or a prior joint infection ⁴. Whether any exception applies to you is a decision for your surgeon and your dentist together.

What to tell your dentist

Tell your dentist:

• That you have a hip or knee replacement, which joint, and the date of the surgery.
• Any condition or medication that affects your immune system, and any previous joint infection, since those are the situations the AAOS criteria single out ⁴.
• Whether your surgeon has given you a specific instruction about antibiotics, and what it says.
• Whether the visit is for a check-up or cleaning, or for an extraction, deep cleaning, or oral surgery. The criteria treat those groups differently ⁴.

What to ask your surgeon

• Do you want a dental screening before my operation, and by when should it be done?
• When can routine dental care resume after surgery?
• Do any of my conditions put me in the group where antibiotics before dental work may be appropriate?
• If antibiotics are ever needed before a dental visit, who prescribes them?