Bridging Mouth and Metal: Dental Hygiene and the Risk of Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) is one of the most serious complications of total joint arthroplasty (TJA), carrying both severe functional consequences and substantial economic costs. PJIs most commonly result from microbial contamination at the time of surgery or during the early postoperative period, while haematogenous seeding from distant infection sources accounts for a smaller proportion of cases. Patient-related factors, including diabetes mellitus, immunosuppression, obesity, malnutrition and smoking, as well as procedure-related factors such as prolonged operative time and wound complications, further increase risk. Among potential sources of haematogenous spread, the oral cavity has long been considered a possible source of infection, leading to routine dental clearance and prophylactic antibiotic use before dental procedures in patients with joint prostheses. However, contemporary epidemiological evidence challenges the causal role of dental-procedure-related bacteraemia in PJI. This review synthesises contemporary literature on the burden of PJI, the prevalence of dental pathology among arthroplasty patients, the microbiology of oral-associated infections and shifts in guideline recommendations. Across systemic reviews, cohort studies and registry data - dental associated PJIs are exceedingly rare. Prophylactic antibiotics provide no measurable protection and nearly half of the implicated organisms are resistant to amoxicillin. The evidence supports prioritising lifelong oral hygiene and targeted management of systemic comorbidities as more effective strategies for risk reduction. Selective dental intervention in high-risk patients, rather than universal clearance or prophylaxis, aligns with antibiotic stewardship and equitable access to surgery. Historical literature has not demonstrated a consistent causal relationship between dental pathology and PJI, highlighting the need for well-designed prospective studies. Accordingly, practice has shifted away from blanket antibiotic prophylaxis towards individualised, risk-based decision making.