When is antibiotic prophylaxis indicated for patients undergoing dental procedures?

From the Guidelines

Antibiotic prophylaxis for dental procedures is primarily indicated for patients at highest risk of adverse outcomes from infective endocarditis, including those with prosthetic cardiac valves, previous infective endocarditis, certain congenital heart defects, and cardiac transplant recipients who develop cardiac valvulopathy, as recommended by the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1. The recommended regimen for most adults is amoxicillin 2g orally taken as a single dose 30-60 minutes before the procedure. For patients allergic to penicillin, alternatives include clindamycin 600mg, azithromycin or clarithromycin 500mg, or cephalexin 2g (if not severely allergic). Children should receive weight-adjusted doses: amoxicillin 50mg/kg, clindamycin 20mg/kg, or azithromycin/clarithromycin 15mg/kg. Prophylaxis is specifically recommended for procedures involving:

• Manipulation of gingival tissue
• The periapical region of teeth
• Perforation of oral mucosa The rationale behind this recommendation is that these high-risk cardiac patients may develop life-threatening endocarditis if transient bacteremia from dental procedures leads to bacterial colonization of damaged or abnormal heart valves. Notably, prophylaxis is no longer routinely recommended for patients with mitral valve prolapse, rheumatic heart disease, bicuspid aortic valves, calcified aortic stenosis, or implanted pacemakers and defibrillators, as the risk of adverse effects from antibiotics may outweigh the benefits in these lower-risk groups, as stated in the 2008 ACC/AHA guidelines for the management of adults with congenital heart disease 1 and the 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease 1. Additionally, the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1 emphasizes that prophylaxis is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. It is also important to note that the risk of antibiotic-associated adverse effects exceeds the benefit (if any) from prophylactic antibiotic therapy, as mentioned in the 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease 1. Therefore, antibiotic prophylaxis should be limited to high-risk patients undergoing dental procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of oral mucosa, as recommended by the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1.

From the Research

Indications for Antibiotic Prophylaxis

• Antibiotic prophylaxis is recommended for patients with certain underlying cardiac conditions, including:
  • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair 2
  • Previous infective endocarditis 2
  • Congenital Heart Disease (CHD) including unrepaired cyanotic as well as palliative shunts and conduits, completely repaired congenital heart defect with prosthetic material or device during the first six months after the procedure, repaired CHD with residual defects 2
  • Cardiac transplantation recipients who develop cardiac valvulopathy 2
• Antibiotic prophylaxis is also recommended for patients undergoing dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa 2, 3

Dental Procedures Requiring Antibiotic Prophylaxis

• Dental procedures that require antibiotic prophylaxis include:
  • Those that involve manipulation of gingival tissue or the periapical region of teeth 2
  • Those that involve perforation of the oral mucosa 2
  • Invasive dental procedures, such as those that involve incision or biopsy of the respiratory mucosa 2

Choice of Antibiotic

• The first line therapy recommended for antibiotic prophylaxis includes amoxicillin or ampicillin 2
• For patients allergic to penicillin, clindamycin 600 mg or azithromycin 500 mg may be used 2
• However, it is noted that an estimated 46% of organisms that cause prosthetic joint infection may be resistant to amoxicillin 4

Timing of Antibiotic Administration

• Antibiotics should be administered in a single dose before the procedure, but the dosage may be administered up to two hours after the procedure 2

Prevalence of Unnecessary Antibiotic Prophylaxis

• Studies have shown that a high percentage of antibiotic prophylaxis prescriptions before dental visits are unnecessary, ranging from 77.0% to 80.9% 5, 6
• Factors associated with unnecessary antibiotic prophylaxis include younger age, female sex, geographic region, rurality, type of antibiotic, and certain dental procedures 6