When to administer antibiotic prophylaxis for dental extractions?

From the Guidelines

Antibiotic prophylaxis for dental extractions is recommended for patients at high risk of infective endocarditis, specifically those with prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease, repaired congenital heart defects with residual defects, cardiac transplant recipients with valve regurgitation, and prosthetic joint replacements within the first two years or in immunocompromised patients. The standard regimen is amoxicillin 2g orally 30-60 minutes before the procedure 1. For patients allergic to penicillin, alternatives include clindamycin 600mg, azithromycin 500mg, or clarithromycin 500mg orally. For patients unable to take oral medications, ampicillin 2g IM/IV or clindamycin 600mg IV can be administered. Some key points to consider when deciding on antibiotic prophylaxis include:

• The risk of adverse effects from antibiotics outweighs the benefit for most patients undergoing routine dental procedures, including those with mitral valve prolapse or fully healed prosthetic joints 1
• The estimated risk of infective endocarditis following dental procedures is very low, and antibiotic prophylaxis may only prevent a small number of cases 1
• The use of antibiotic prophylaxis should be limited to the highest-risk patients, as defined by the European Society of Cardiology guidelines 1
• Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of infective endocarditis 1

From the Research

Administration of Antibiotic Prophylaxis for Dental Extractions

• The American Heart Association recommends antibiotic prophylaxis for patients at high risk of developing infective endocarditis (IE) before certain dental procedures, including extractions 2.
• A study published in 2021 found that prophylactic antibiotics may reduce the risk of postsurgical infectious complications and dry socket in patients undergoing third molar extractions, but the evidence is of low certainty 3.
• The European Society of Cardiology guidelines recommend antibiotic prophylaxis for patients with the highest risk of developing IE, and reserve its use for specific dental procedures with interruption of consistency of the oral mucosa, such as extractions 4.
• A literature review published in 2014 discussed the controversial aspects related to antibiotic administration for prevention of IE, and suggested performing a risk-benefit evaluation in light of available guidelines before making a decision about administration 5.
• A 2024 study found that antibiotic prophylaxis significantly reduced endocarditis incidence following invasive dental procedures, including extractions, in high-risk individuals 6.

Timing of Antibiotic Administration

• The 2021 study found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important 3.
• A single administration of a penicillin derivative 30 to 60 minutes pre-operatively is still considered the main prophylactic strategy to prevent bacteraemia 5.

Patient-Specific Considerations

• The management of patients for infective endocarditis prophylaxis undergoing dental extractions is suboptimal, with antibiotic therapy being overused in some clinical scenarios and underutilized in those recommended by current guidelines 4.
• Immunocompromised patients need an individualized approach in consultation with their treating medical specialist 3.
• A risk-benefit evaluation should be performed in light of available guidelines before making a decision about antibiotic administration 5.