Streptococcus

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A referring dentist called me to discuss a patient that had been referred to him by an orthopedic surgeon. The patient has persistent strep infection in his prosthetic hip. He wanted to rule out the mouth as a potential source of the problem. The patient apparently has incipient periodontal problems. Has anyone come across this? Ideas on how to manage this situation?

David

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David

I had a case last month that was somewhat similar. I was consulted by an orthopedic surgeon at my hospital to see a patient with an infected total knee. She reported recent toothaches, so they wanted to rule out odontogenic infection. Turns out her pain was pulpitis… No infection. You need to carefully explain this stuff to physicians, especially orthopedic surgeons, because frankly, many of them don’t understand this stuff.

In your case since strep is a known pathogen it would be advisable to get the patient in for scaling & root planing as indicated by your exam. Also check for periapical pathology. Even if the patient is hospitalized on IV abx, they can usually leave for an office visit. Ask the MDs involved (which will likely include an infectious disease doc) how they want to handle prophylactic abx. You may want to recommend evidence based options such as IV Pen G plus Flagyll, or IV Unasyn (which is like IV Augmentin), or IV clindamycin. If they have cultured Strep from the joint, they may know which antibiotics it is susceptible to.

In my experience, ortho-surgeons are quick to blame teeth… But the evidence (cultures of infected total joints, along with the AHA investigations into bacteremias caused by normal eating, tooth brushing, etc) do not support their position.

Andy

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When I had my hip replaced last summer, my Orthopod told me the biggest risk of the procedure was infection from the mouth. He told me he removes 3 hips / month and cultures are positive most times for oral pathogens. Patients are then w/o a joint for 6 months until a re do.
I would do FMX and rule out any possibility of perio, residual endo, caries. Any tooth with a large restoration, crown, past endo may not exhibit residual pathology as seen by periapicals but may be apparent with CBCT. Then what to do?
I see a lot of undiagnosed radiolucencies with CBCT.
I would request a copy of the culture and talk with infectious Dx doc since one is likely to be involved.

Mark

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Interesting with the AAP being so (not) proactive on the changes in thought by the AMA/AHA on the other systemic interrelations with periodontitis, Maybe there is a way to get this out there. Does anyone know if there are any orthopedic articles on this? Mark – please ask your orthopedist. I will peek into medline to see what I can find out.

Bob

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