Prophylactic Antibiotics for Dental Procedures in Patients at High Risk of Bacterial Endocarditis
Antibiotic prophylaxis should only be considered for dental procedures requiring manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa in patients at highest risk for infective endocarditis. 1, 2
High-Risk Patient Groups Requiring Prophylaxis
Antibiotic prophylaxis is indicated for patients with:
- Prosthetic cardiac valves
- Previous history of infective endocarditis
- Congenital heart disease (CHD):
- Unrepaired cyanotic CHD
- Completely repaired CHD with prosthetic material during first 6 months after procedure
- Repaired CHD with residual defects at or adjacent to site of prosthetic patch/device
- Cardiac transplant recipients with cardiac valvulopathy 2
Dental Procedures Requiring Prophylaxis
Procedures requiring prophylaxis:
- Dental extractions
- Periodontal procedures (including scaling and root canal)
- Dental implant placement
- Endodontic procedures beyond the apex
- Subgingival placement of antibiotic fibers/strips
- Initial placement of orthodontic bands
- Any procedure involving manipulation of gingival tissue or periapical region of teeth 1, 2
Procedures NOT requiring prophylaxis:
- Local anesthetic injections in non-infected tissues
- Taking dental radiographs
- Placement/adjustment of removable prosthodontic/orthodontic appliances
- Treatment of superficial caries
- Removal of sutures
- Loss of deciduous teeth
- Trauma to lips and oral mucosa 1, 2
Recommended Antibiotic Regimens
Standard regimen (not allergic to penicillin):
- Adults: Amoxicillin 2g orally as single dose 30-60 minutes before procedure
- Children: Amoxicillin 50mg/kg orally as single dose 30-60 minutes before procedure 2
Alternative regimens (allergic to penicillin):
- Adults: Clindamycin 600mg OR Azithromycin/Clarithromycin 500mg orally 30-60 minutes before procedure
- Children: Clindamycin 20mg/kg OR Azithromycin/Clarithromycin 15mg/kg orally 30-60 minutes before procedure 2
Special considerations:
- If antibiotic dose is not administered before procedure, it may be given up to 2 hours after procedure 2
- For patients already on long-term antibiotic therapy, select an antibiotic from a different class rather than increasing dose 1, 2
- Cephalosporins should not be used in patients with history of anaphylaxis, angioedema, or urticaria after taking penicillin due to cross-sensitivity 1, 2
Important Clinical Considerations
Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of prosthetic valves or other intracardiac/intravascular foreign material (unless urgent) 1
Despite recommendations for prophylaxis, evidence from randomized controlled trials is lacking. A Cochrane review found no clear evidence whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis 3, 4
Recent studies suggest concerning levels of underprescribing of antibiotic prophylaxis for invasive dental procedures in high-risk patients 5
Current guidelines represent a significant narrowing of indications compared to historical recommendations, reflecting:
- Recognition that bacteremia from daily activities may pose greater cumulative risk than occasional dental procedures
- Limited evidence supporting efficacy of antibiotic prophylaxis
- Concerns about antibiotic resistance and adverse drug reactions 2
Maintaining optimal oral hygiene is critically important for preventing infective endocarditis, potentially more so than antibiotic prophylaxis 2