Antibiotic Prophylaxis Before Dental Procedures for Prevention of Infective Endocarditis
Antibiotics are prescribed before dental procedures in high-risk patients to prevent bacteremia-induced infective endocarditis, which carries significant morbidity and mortality risk. The practice is based on the understanding that dental procedures can cause transient bacteremia that may lead to endocarditis in susceptible individuals.
Patient Selection for Antibiotic Prophylaxis
Prophylaxis is indicated only for patients at highest risk of adverse outcomes from infective endocarditis 1:
- Patients with prosthetic cardiac valves or prosthetic material used for valve repair
- Patients with previous infective endocarditis
- Patients with specific congenital heart disease:
- Unrepaired cyanotic congenital heart disease
- Completely repaired congenital heart defects with prosthetic material during first 6 months after procedure
- Repaired congenital heart disease with residual defects adjacent to prosthetic patches or devices
- Cardiac transplant recipients who develop cardiac valvulopathy
Recommended Antibiotic Regimens
Standard Regimen
- Adults: Amoxicillin 2g orally as a single dose 30-60 minutes before procedure 2, 1
- Children: Amoxicillin 50 mg/kg orally as a single dose 30-60 minutes before procedure 2
For Patients Allergic to Penicillin
- Adults: Clindamycin 600mg, or Azithromycin/Clarithromycin 500mg orally 30-60 minutes before procedure 2, 1
- Children: Clindamycin 20mg/kg, or Azithromycin/Clarithromycin 15mg/kg orally 2
For Patients Unable to Take Oral Medications
- Adults: Ampicillin 2g IM or IV, or Cefazolin/Ceftriaxone 1g IM or IV 2
- Children: Ampicillin 50mg/kg IM or IV, or Cefazolin/Ceftriaxone 50mg/kg IM or IV 2
Dental Procedures Requiring Prophylaxis
Prophylaxis is recommended for procedures involving:
- Manipulation of gingival tissue
- Manipulation of the periapical region of teeth
- Perforation of oral mucosa 1
These include:
- Dental extractions
- Periodontal procedures
- Dental implant placement
- Endodontic (root canal) procedures
- Subgingival placement of antibiotic fibers/strips
- Initial placement of orthodontic bands (not brackets)
- Local anesthetic injections through infected tissues 2
Procedures NOT Requiring Prophylaxis
- Routine anesthetic injections through non-infected tissue
- Taking dental radiographs
- Placement of removable prosthodontic/orthodontic appliances
- Adjustment of orthodontic appliances
- Placement of orthodontic brackets
- Shedding of deciduous teeth
- Bleeding from trauma to lips or oral mucosa 1
Special Considerations
If antibiotic dose is not administered before the procedure, it may be given up to 2 hours afterward 1
For patients already on antibiotics for other reasons, select an antibiotic from a different class rather than increasing the dose of the current antibiotic 2
Cephalosporins should be avoided in patients with history of anaphylaxis, angioedema, or urticaria with penicillins due to potential cross-reactivity 2
Maintaining optimal oral hygiene is more important than antibiotic prophylaxis for preventing infective endocarditis 2, 1
Rationale and Evidence
The rationale for antibiotic prophylaxis has evolved significantly over time. Current guidelines represent a significant narrowing of indications compared to historical recommendations 2. This change reflects:
Recognition that bacteremia from daily activities (brushing teeth, flossing) may pose a greater cumulative risk than occasional dental procedures 2
Limited evidence supporting the efficacy of antibiotic prophylaxis in preventing infective endocarditis 3
Concerns about antibiotic resistance and adverse drug reactions 1
Focus on patients at highest risk of adverse outcomes rather than those at highest risk of acquiring endocarditis 2
The current approach balances the potential benefits of prophylaxis against the risks of unnecessary antibiotic use, focusing protection on those patients who would suffer the most severe consequences from infective endocarditis.