Understanding Clinical Practice Variation in Dental Prophylaxis After Total Shoulder Arthroplasty in ASES Surgeons: A Call for Shoulder-Specific Guidelines.

BACKGROUND: Periprosthetic joint infection (PJI) after total shoulder arthroplasty (TSA) is a severe complication with substantial patient and system burden. Although current total hip and knee arthroplasty guidelines generally discourage routine antibiotic prophylaxis for dental procedures, no shoulder-specific guidelines exist. In the absence of TSA-specific evidence, practice patterns may vary by surgeon experience. We hypothesized that the American Shoulder and Elbow Surgeons (ASES) members demonstrate heterogeneity in postoperative dental antibiotic prophylaxis practices after TSA and that experience managing a suspected dental-related shoulder PJI is associated with higher rates of prescribing postoperative dental antibiotic prophylaxis.

METHODS: An anonymous 21-item electronic survey was distributed to ASES members from August through September 2025, assessing demographics, postoperative dental antibiotic prophylaxis practices, attitudes toward applying hip and knee literature to TSA, and support for TSA-specific guidance. Categorical variables were compared using chi-square or Fisher's exact tests. Paired analyses compared preoperative and postoperative practices. Analysis of variance assessed Likert-scale responses. Significance was set at p < 0.05.

RESULTS: A total of 224 ASES members (15.0%) responded, with 99.1% complete surveys. Overall, 69.6% reported performing 60 or more TSAs annually. Two hundred of 224 respondents (89.3%) recommended postoperative dental antibiotic prophylaxis after TSA: 177 (79.0%) recommended prophylaxis routinely for varying postoperative durations and 23 (10.3%) reserved it for high-risk patients. Twenty-four respondents (10.7%) recommended no postoperative dental prophylaxis. Surgeons were significantly more likely to recommend postoperative than preoperative prophylaxis (p < 0.001). The most common regimen was a single dose (78.1%) of amoxicillin (82.3%). Fifty-two respondents (23.2%) reported having managed a suspected dental-related shoulder PJI and 27 respondents (12.1%) reported being unsure if they had a dental-related shoulder PJI. A total of 78/79 respondents reporting yes or unsure to a dental-related PJI recommended postoperative prophylaxis (98.7%), compared to respondents reporting no such experience (Fisher exact p<0.001). Mean comfort applying hip and knee arthroplasty literature to TSA was 3.83 ± 0.93 (5-point scale), while support for TSA-specific guidelines was higher at 4.35 ± 0.85.

DISCUSSION AND CONCLUSIONS: Most ASES respondents recommend antibiotic prophylaxis for dental procedures after TSA despite lower extremity guidance questioning routine use. Prior reported or unsure dental-related shoulder PJI experience was associated with more frequent prophylaxis use compared to those who did not have a dental-related shoulder PJI. Strong support for TSA-specific guidelines underscores the need for shoulder-focused studies to reduce practice variation while supporting antibiotic stewardship.