Is there scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections? A systematic review

Familial Renal Glucosuria and Potential Pharmacogenetic Impact on Sodium-Glucose Cotransporter-2 Inhibitors

Key Points

A significant knowledge gap exists in SLC5A2 's role in familial renal glycosuria and sodium-glucose cotransporter-2 inhibitors' efficacy. Two percent of individuals in the All-of-Us cohort harbor rare genetic variants in SLC5A2 , potentially increasing the risk of familial renal glycosuria. Our trial suggests differential responses to sodium-glucose cotransporter-2 inhibitors in individuals with rare SLC5A2 alleles compared with wild types.

Background

Renal glucosuria is a rare inheritable trait caused by loss-of-function variants in the gene that encodes sodium-glucose cotransporter-2 (SGLT2) (i.e ., SLC5A2 ). The genetics of renal glucosuria is poorly understood, and even less is known on how loss-of-function variants in SLC5A2 may affect response to SGLT2 inhibitors, a new class of medication gaining popularity to treat diabetes by artificially inducing glucosuria.

Methods

We used two biobanks that link genomic with electronic health record data to study the genetics of renal glucosuria. This included 245,394 participants enrolled in the All of Us Research Program and 11,011 enrolled in Marshfield Clinic's Personalized Research Project (PMRP). Association studies in All of Us and PMRP identified ten variants that reached an experiment-wise Bonferroni threshold in either cohort, of which nine were novel. PMRP was further used as a recruitment source for a prospective SGLT2 pharmacogenetic trial. During a glucose tolerance test, the trial measured urine glucose concentrations in 15 SLC5A2 variant–positive individuals and 15 matched wild types with and without an SGLT2 inhibitor.

Results

This trial demonstrated that carriers of SLC5A2 risk variants may be more sensitive to SGLT2 inhibitors compared with wild types (P = 0.075). On the basis of population data, 2% of an ethnically diverse population carried rare variants in SLC5A2 and are at risk of renal glucosuria.

Conclusions

As a result, 2% of individuals being treated with SGLT2 inhibitors may respond differently to this new class of medication compared with the general population, suggesting that a larger investigation into SLC5A2 variants and SGLT2 inhibitors is needed.

Emerging Concepts in Periprosthetic Joint Infection Research: The Human Microbiome

Microorganisms, including bacteria, fungi, and viruses, that reside on and within the human body are collectively known as the human microbiome. Dysbiosis, or disruption in the microbiome, has been implicated in several disease processes, including asthma, obesity, autoimmune diseases, and numerous other conditions. While the Human Microbiome Project and the generation of descriptive studies it inspired established correlations between characteristic patterns in the composition of the microbiome and specific disease phenotypes, current research has begun to focus on elucidating the causal role of the microbiome in disease pathogenesis. Within the field of orthopaedic surgery, researchers have proposed the concept of a "gut-joint axis," whereby the intestinal microbiome influences joint health and the development of diseases, such as osteoarthritis and periprosthetic joint infection (PJI). It is theorized that intestinal dysbiosis increases gut permeability, leading to the translocation of bacteria and their metabolic products into the systemic circulation and the stimulation of proinflammatory response cascades throughout the body, including within the joints. While correlative studies have identified patterns of dysbiotic derangement associated with osteoarthritis and PJI, translational research is needed to clarify the precise mechanisms by which these changes influence disease processes. Additionally, an emerging body of literature has challenged the previously held belief that certain body sites are sterile and do not possess a microbiome, with studies identifying distinct microbial genomic signatures and a core microbiome that varies between anatomic sites. A more thorough characterization of the joint microbiome may have profound implications for our understanding of PJI pathogenesis and our ability to stratify patients based on risk. The purpose of this review was to outline our current understanding of the human microbiome to describe the gut-joint axis and its role in specific pathologies, including PJI, and to highlight the potential of microbiome-based therapeutic interventions in the field of orthopaedics.

The Microbial Revolution in the World of Joint Replacement Surgery

Background

The prevalence of revision surgery due to aseptic loosening and periprosthetic joint infection (PJI) following total hip and knee arthroplasty is growing. Strategies to prevent the need for revision surgery and its associated health-care costs and patient morbidity are needed. Therapies that modulate the gut microbiota to influence bone health and systemic inflammation are a novel area of research.

Methods

A literature review of preclinical and clinical peer-reviewed articles relating to the role of the gut microbiota in bone health and PJI was performed.

Results

There is evidence that the gut microbiota plays a role in maintaining bone mineral density, which can contribute to osseointegration, osteolysis, aseptic loosening, and periprosthetic fractures. Similarly, the gut microbiota influences gut permeability and the potential for bacterial translocation to the bloodstream, increasing susceptibility to PJI.

Conclusions

Emerging evidence supports the role of the gut microbiota in the development of complications such as aseptic loosening and PJI after total hip or knee arthroplasty. There is a potential for microbial therapies such as probiotics or fecal microbial transplantation to moderate the risk of developing these complications. However, further investigation is required.

Clinical Relevance

Modulation of the gut microbiota may influence patient outcomes following total joint arthroplasty.

Exploring the link between poor oral hygiene and mesh infection after hernia repair: a systematic review and proposed best practices

BACKGROUND

There is a reasonable body of evidence around oral/dental health and implant infection in orthopaedic and cardiovascular surgery. Another large area of surgical practice associated with a permanent implant is mesh hernia repair. This study aimed to review the evidence around oral/dental health and mesh infection.

METHODS

The research protocol was registered in PROSPERO (CRD42022334530). A systematic review of the literature was undertaken according to the PRISMA 2020 statement. The initial search identified 582 publications. A further four papers were identified from references. After a review by title and abstract, 40 papers were read in full text. Fourteen publications were included in the final review, and a total of 47,486 patients were included.

RESULTS

There is no published evidence investigating the state of oral hygiene/health and the risk of mesh infection or other infections in hernia surgery. Improvement in oral hygiene/health can reduce surgical site infection and implant infection in colorectal, gastric, liver, orthopaedic and cardiovascular surgery. Poor oral hygiene/health is associated with a large increase in oral bacteria and bacteraemia in everyday activities such as when chewing or brushing teeth. Antibiotic prophylaxis does not appear to be necessary before invasive dental care in patients with an implant.

CONCLUSION

Good oral hygiene and oral health is a strong public health message. The effect of poor oral hygiene on mesh infection and other complications of mesh hernia repair is unknown. While research is clearly needed in this area, extrapolating from evidence in other areas of surgery where implants are used, good oral hygiene/health should be encouraged amongst hernia patients both prior to and after their surgery.

Lack of oral health awareness and interdisciplinary dental care: a survey in patients prior to endoprosthesis and orthopaedic centres in Germany

OBJECTIVES

This cross-sectional survey aimed to evaluate the oral health behaviour of patients prior to endoprosthesis (EP), as well as the handling of oral health topics by German orthopaedic surgeons.

MATERIALS AND METHODS

Consecutive patients prior to EP answered a questionnaire regarding oral health behaviour, oral hygiene, oral complaints and information on the relationship between EP and oral health. Another questionnaire was digitally mailed to orthopaedic centres throughout Germany. This questionnaire included the importance of oral health for EP and issues on dental referrals/consultations prior to EP.

RESULTS

A total of 172 patients were included in the study, of whom 35.5% of patients reported that they were informed about oral health and EP. Half of the individuals reported regular professional tooth cleaning, and less than one-third (29.1%) reported of the performance of interdental cleaning. Information on oral health and EP was associated with regular professional tooth cleaning (yes: 59.8% vs. no: 35.6%, p = 0.01). A total of 221 orthopaedic clinics were included in the study, of which only a few had dental contact (14%), although the majority (92.8%) of the clinics were familiar with causal relationships between oral health and EP infections. Less than half of the centres reported of either verbal (48%) or written (43.9%) referrals for their patients to the dentist. University Medical Centres reported of more frequent dental contacts (p < 0.01).

CONCLUSION

Prior to EP, patients exhibited deficits in oral health behaviour, and orthopaedic clinics exhibited a lack of dental collaboration. Improvements in interdisciplinary care, especially regarding practical concepts for patient referral and education on oral health, appear to be necessary.

Characterization of the oral microbiome of children with type 1 diabetes in the acute and chronic phases

Background and Aim

The relationship between the oral microbiota and type 1 diabetes (T1D) remains unclear. We aimed to evaluate the variations in the oral microbiome in T1D and identify potentially associated bacterial factors.

Methods

We performed high-throughput sequencing of the V3-V4 area of the 16S rRNA gene to profile the oral bacterial composition of 47 healthy children (CON group), 46 children with new-onset T1D in the acute phase (NT1D group), and 10 children with T1D in the chronic phase receiving insulin treatment (CT1D group). Multivariate statistical analysis of sequencing data was performed.

Results

Compared to the CON group, the NT1D group was characterized by decreased diversity and increased abundance of genera harboring opportunistic pathogens, while this trend was partially reversed in the CT1D group. Differential genera between groups could distinguish the NT1D group from the CON group (AUC = 0.933) and CT1D group (AUC = 0.846), respectively. Moreover, T1D-enriched genera were closely correlated with HbA1c, FBG and WBCs levels.

Conclusion

Our results showed that the acute phase of T1D was characterized by oral microbiota dysbiosis, which could be partially ameliorated via glycemic control. The possible role of oral microbiota dysbiosis on oral health and systemic metabolic status in T1D warrants further mechanistic investigation.

Association between oral health and oral health-related quality of life in patients before hip and knee endoprosthesis surgery: a cross-sectional study

Objectives

Aim of this cross-sectional study was the assessment of oral health-related quality of life (OHRQoL) health-related quality of life (HRQoL), oral health behaviour and oral health status in patients before hip and knee endoprosthesis (EP) surgery. Moreover, associations between OHRQoL, HRQoL and oral health should be examined.

Methods

Consecutive patients before hip and/or knee EP implantation were recruited and referred to the dental clinic for oral examination including: number of remaining teeth, dental findings (DMF-T-Index), periodontal condition (periodontal treatment need, Staging/Grading) and temporomandibular joint screening. OHRQoL was assessed by the German short form of oral health impact profile (OHIP G14), HRQoL by short-form 36 survey.

Results

Hundred and sixty two patients with a mean age of 66.80 ± 11.10 years were included, which had on average 18.22 ± 8.57 remaining teeth and a periodontal treatment need of 84.5%. The OHIP G14 sum score revealed a median of 1 (mean: 2.7 ± 4.4, 25–75th percentile: 0–4) and its dimension oral function of 0 (mean: 0.8 ± 1.8, 25–75th percentile: 0–1), what was also found for psychosocial impact (median: 0, mean: 1.4 ± 2.6, 25–75th percentile: 0–2). The OHIP G14 sum score and both dimensions were significantly associated with mental component summary (p < 0.01). A higher number of remaining teeth as well as remaining molars/premolars were associated with lower OHIP G14 sum score (p = 0.02). This was also found for the dimension oral function (p < 0.01).

Conclusion

Patients prior to hip and knee EP had an unaffected OHRQoL, although they had an insufficient oral health. Individuals before EP implantation need increased attention in dental care, fostering information, sensibilization and motivation of the patients.

One Third of Patients before Endoprosthesis Implantation Show an Oral Focus as Potential Source of Infectious Complication—The Value of Pre-Operative Dental Risk Stratification in a German Cohort

Objective: The aim of this cross-sectional cohort study was to evaluate a comprehensive dental examination and referral concept for patients prior to endoprosthesis (EP) implantation in an interdisciplinary setting. Methods: Patients, who were prepared for EP surgery in the clinic for orthopaedics, were referred to the dental clinic for a dental examination. Thereby, dental and periodontal treatment need, radiographic and temporomandibular joint findings were assessed. Based on oral and radiographic investigation, a risk classification for potential source of prosthetic infection was performed. If potential oral foci of EP infection were present (e.g., apically radiolucent teeth, severe periodontitis or additional inflammatory findings), patients were classified as at high risk for EP infection with oral origin. Those individuals were allocated to their family dentist or special clinic for dental treatment prior to EP surgery. Results: A total of 311 patients were included (mean age: 67.84 ± 10.96 years, 51% male). A dental treatment need of 33% was found, while the periodontal treatment need was 83%. Thirty-one percent of patients showed at least one apical radiolucency (a sign of chronic infection/inflammation). Furthermore, additional findings such as radiographic signs of sinusitis maxillaris were found in 24% of patients. Temporomandibular disease was probable in 17% of individuals. One-third (34%) were assigned to the high risk group for an EP infection with oral origin. Conclusion: German patients before EP have a high periodontal treatment need and show frequently (34%) a potential oral focus of infection, underlining the necessity of including dental examination and risk stratification as part of the pre-operative assessment prior to EP implantation. Therefore, an approach as applied in this study appears reasonable for those individuals.

Dysbiotic relationship between arthritis and the oral-gut microbiome. A critical review

Arthritis and prosthetic joint infections (PJIs) overall are associated with reduced quality of life and limited work capacity. Multiple, overlapping factors contribute to these conditions. Some investigations have suggested a dysbiotic association between the oral-gut microbiome and pathogenesis of arthritis and PJIs. A better understanding of the role of the oral-gut microbiota in arthritis and PJI pathophysiology can shed light into how its disequilibrium can discharge a pro-inflammatory response, and impact the health of patients susceptible to arthritis or with established joint disease. A review of published in vivo and clinical data suggested that alterations in oral and gut microbiota can lead to a disturbance of immunoregulatory properties, and may be associated with joint infections and arthritis. This review brings new insights into the current status of the evidence on the potential molecules and inflammatory biomarkers disrupted by an oral-gut microbial dysbiosis. Normal commensals and pathogenic oral and gut microflora homeostasis are important not only to prevent infections per se but also its potential progression. Further experiments, especially controlled clinical trials, are needed to ascertain how microbiome manipulation and other microbiota-directed approaches can help control inflammation and effectively prevent and treat arthritic diseases. Additionally, studies on the effects of the long-term oral diseases, such as chronic periodontitis, on arthritis and PJIs need to be conducted.

PRISM (Pictorial Representation of Illness and Self-Measure) as Visual Tool to Support Oral Health Education Prior to Endoprosthetic Joint Replacement-A Novel Approach in Dentistry

Objective: This study aims to evaluate the application of Pictorial Representation of Illness and Self-Measure (PRISM) in educating patients regarding oral health before endoprosthesis (EP). Methods: The study consisted of two parts: (I) a cross-sectional study, where patients received a PRISM interview, oral health briefing and oral examinations (treatment need, oral focus). (II) In an observational part, patients were randomly assigned to either PRISM task (Test) or flyer-based verbal briefing (Control). Before and after the interviews, patients answered a questionnaire regarding importance of oral health for EP. Results: (I) 122 patients were included. The distance between subject (“myself”) and objects (oral health issues or EP) in the PRISM task were mainly not associated with age, gender, and oral conditions. In part (II), 80 patients (PRISM: n = 40, Control: n = 40) were included. After the interview, the values for perceived relationship between EP and teeth (p < 0.01), EP and gums (p < 0.01), and EP and dental consultations (p < 0.01) significantly increased in both groups. Both groups perceived a high benefit of the interview and felt well educated. Conclusions: PRISM has comparable positive effects like a flyer-based verbal briefing. PRISM as a novel visual tool can support the patient education regarding oral health before EP.

Is Antibiotic Prophylaxis Necessary before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review

As the population ages, more and more patients with orthopaedic prostheses (OPs) require dental implant treatment. Surveys of dentists and orthopaedic surgeons show that prophylactic antibiotics (PAs) are routinely prescribed with a very high frequency in patients with OPs who are about to undergo dental procedures. The present study aims to determine the need to prescribe prophylactic antibiotic therapy in patients with OPs treated with dental implants to promote their responsible use and reduce the risk of antimicrobial resistance. An electronic search of the MEDLINE database (via PubMed), Web of Science, LILACS, Google Scholar, and OpenGrey was carried out. The criteria used were those described by the PRISMA® Statement. No study investigated the need to prescribe PAs in patients with OPs, so four studies were included on the risk of infections of OPs after dental treatments with varying degrees of invasiveness. There is no evidence to suggest a relationship between dental implant surgeries and an increased risk of OP infection; therefore, PAs in these patients are not justified. However, the recommended doses of PAs in dental implant procedures in healthy patients are the same as those recommended to avoid infections of OPs.

Micromonas micros Infection of a Prosthetic Hip Joint: A Case Report and Review of the Literature

Micromonas micros is an oral anaerobic Gram-positive coccus and is a commensal of the mouth, and it is rarely isolated in prosthetic joint infections (PJIs) and even less frequently related to a preceding dental procedure with eventual hematogenous seeding of the prosthetic joint. Here, we present a case of a 56-year-old male with a prosthetic hip joint who developed Micromonas micros prosthetic hip joint infection with symptoms starting a few days after a dental procedure and not having received periprocedural antibiotic prophylaxis. He recovered well with surgical intervention and antimicrobial therapy. We conducted a literature review of prosthetic hip joint infections caused by Micromonas micros as well as briefly discuss current guidelines on antibiotic prophylaxis in patients with prosthetic joints undergoing dental procedures and some knowledge gaps.

Association between the Number of Prosthetic Crowns and Periodontitis: The Korea National Health and Nutrition Examination Survey (KNANES VII) from 2016-2018

Although the presence of prosthetic restorations has been associated with plaque accumulation, gingivitis, and periodontitis, there is a lack of large epidemiological investigations providing evidence on the association of prosthetic crowns with periodontitis. This study aimed to analyze the association between the number of prosthetic crowns and the presence of periodontitis. This study was based on the Seventh Korea National Health and Nutrition Examination Survey (2016-2018). A total of 12,689 participants over the age of 19 years were surveyed. Multivariate logistic regression analyses were used to identify the association between the number of prosthetic crowns and periodontitis after adjusting for potential confounders, including demographic variables, socio-economic characteristics, oral health-related variables, and oral and systemic clinical variables. The odds ratio of periodontitis showed statistically significant differences in the anterior and posterior regions, and the prevalence of periodontal disease increased as the number of crown prostheses increased. Participants with 6-10 and 11 prosthetic crowns had 1.24 and 1.28 times higher prevalence of periodontitis, respectively, than patients with no prosthetic crown. The results of this study show that the number of prosthetic crowns present in adults is related to the prevalence of periodontitis.

Evaluation and interpretation of prosthetic joint infection diagnostic investigations

BACKGROUND

Total joint arthroplasty (TJA) is considered one of the most successful surgical procedures ever developed. It can successfully provide pain relief, restore joint function, and improve mobility and quality of life. Prosthetic joint infection (PJI) presents with a wide variety and severity of signs and symptoms. It remains a major threat to the outcome of TJA procedures and usually necessitates surgical intervention and prolonged courses of antibiotics. Inappropriate treatment of an unrecognized PJI usually ends with unacceptable and sometimes catastrophic results.

THE AIM

The understanding and evaluation of diagnostic investigations are extremely important to properly diagnose PJI, including frequently unrecognized low-grade infections, and to provide healthcare professionals with needed information for the care of patients affected by this condition. This article aims to review most of the methods available in PJI diagnostics, to emphasize the strengths and the weaknesses of each of them, and to provide a guideline on how to select the surgical treatment strategy based on the level of diagnostic certainty during the evaluation period. To safely accomplish this, it is crucial to be aware of the limitations of each diagnostic modality.

THE FOCUS

The emphasis will be on the use and interpretation of the core criteria for PJI diagnosis, including the pathognomonic sinus tract communicating with the implant, purulent synovial fluid, inflammation in the periprosthetic tissue, cell count with differential, microbial growth in the synovial fluid culture, tissue sample cultures, and sonication samples.

Rare Occurrence of Acute Hematogenous Periprosthetic Joint Infection Due to Fusobacterium Nucleatum in the Background of a Dental Procedure: A Case Report

Objective

Fusobacterium nucleatum is an anaerobic gram‐negative bacilli that is one of the oral and other mucosal surface microbiota. It involves a wide range of human diseases and was first found in periodontal diseases, but reports of bone‐related infections caused by F. nucleatum are rare, especially periprosthetic joint infections (PJI).

Methods

Here, we present the first case of acute hematogenous PJI of the hip joint caused by F. nucleatum, and debridement, antibiotics, and implant retention (DAIR) was performed.

Results

The patient was successfully treated with DAIR, identification of isolates by metagenomics next‐generation sequencing was confirmed by polymerase chain reaction.

Conclusions

For stable acute hematogenous PJI after hip replacement, quick and accurate diagnosis, the identification of pathogenic microorganisms, and the use of DAIR combined with sufficient sensitive antibiotics have a certain clinical effect and can achieve the purpose of both preserving the prosthesis and infection control.