GP4d - Antibiotic Stewardship in Temporomandibular Joint Replacement: Does Duration Matter?

Abstract: Background/Problem: Prosthetic Joint Infections (PJIs) are a complication of total joint replacement (TJR) in both oral and maxillofacial and orthopedic literature. PJIs present a concerning source of morbidity in total joint replacement (TJR) patients, often requiring device removal, prolonged antimicrobial therapy, and management of complications such as pain, fistula formation, drainage, and cellulitis of the operative site. There is highly variable practice for antimicrobial implementation and duration of prophylactic antibiotic use peri- and postoperatively in TMJ TJR. This study examined the incidence of acute PJIs relative to the accepted rates in primary TMJ TJRs with only 24 hours of perioperative antibiotics, benchmarking TMJ TJR practices against established orthopedic literature standards for wound classification, antibiotic selection, and timing.

Materials and Methods: A prospective analysis of 107 primary TMJ TJRs was conducted to evaluate rates of acute PJI relative to the accepted rates among TMJ TJR. The rates of PJI among orthopedic TJR are often cited at about 1.4% and for TMJ TJR have been determined to be about 1.6% in FDA studies. Patients received perioperative antibiotics according to standard protocols. Patients were followed to determine the incidence of acute PJIs and continue to be assessed to determine any indication of delayed or late PJI.

Data Analysis: Over a 1-year period from January through December 2025, 107 primary TMJ TJRs were performed at the authors' home institution. These patients followed a standardized ERAS postoperative management protocol that included only 24 hours of perioperative antibiotics, most often cefazolin and metronidazole. The incidence of acute PJI was tracked based on clinical presentation to determine the rate of incidence and confidence interval. Attempts at further analysis including noninferiority testing were attempted, however due to the size of this preliminary data set and low rate of PJI at baseline, true noninferiority could not be ascertained with appropriate power.

Results: The overall acute TMJ PJI rate was 0.935% (1/107; 95% CI: 0.17% to 5.1%).

Outcomes and Conclusions: From this data set, the observed TMJ PJI rate of 0.935% with only perioperative antibiotics rivals that of the accepted incidence of 1.6% in TMJ TJRs when longer periods of antibiotics were utilized. Both rates are consistent with orthopedic literature for other joint replacements where the standard is only perioperative antibiotic use. Increased duration of antibiotics postoperatively is not likely to influence delayed and late TMJ TJR infections and would not likely prevent the majority of PJIs, occurring beyond the period of acute PJI. These preliminary findings support the adequacy of perioperative antibiotic protocols for primary TMJ TJRs and could continue to influence reduced duration of antibiotics which has the potential to significantly reduce adverse effects incurred from longer periods of antibiotic use.

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