Patient Criteria for Pre-Dental Procedure Antibiotics
Antibiotic prophylaxis before dental procedures is only recommended for specific high-risk patients with cardiac conditions at risk for infective endocarditis, not for routine use in patients with prosthetic joints or other conditions. 1, 2
Cardiac Conditions Requiring Prophylaxis
High-Risk Cardiac Conditions (Class I recommendation) 1
- Prosthetic cardiac valves
- Previous infective endocarditis
- Congenital heart disease (CHD):
- Unrepaired cyanotic CHD, including palliative shunts and conduits
- Completely repaired congenital heart defect with prosthetic material during the first 6 months after the procedure
- Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or device
- Cardiac transplantation recipients who develop cardiac valvulopathy
Dental Procedures Requiring Prophylaxis in High-Risk Patients
- Procedures involving manipulation of gingival tissue
- Procedures involving the periapical region of teeth
- Procedures involving perforation of oral mucosa
- Dental extractions
- Periodontal procedures
- Endodontic procedures beyond the apex
Dental Procedures NOT Requiring Prophylaxis (Even in High-Risk Patients)
- Local anesthetic injections in non-infected tissues
- 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
Recommended Antibiotic Regimens
Standard Prophylactic Regimen 1
- Adults: Amoxicillin 2g orally 1 hour before procedure
- Children: Amoxicillin 50 mg/kg orally 1 hour before procedure
For Penicillin-Allergic Patients 1, 2
- Adults: Clindamycin 600mg orally 1 hour before procedure
- Children: Clindamycin 20mg/kg orally 1 hour before procedure
- Alternative for adults: Azithromycin/Clarithromycin 500mg orally 1 hour before procedure
- Alternative for children: Azithromycin/Clarithromycin 15mg/kg orally 1 hour before procedure
Prosthetic Joint Patients
The American Academy of Orthopedic Surgeons (AAOS) and American Dental Association (ADA) do not recommend routine antibiotic prophylaxis for patients with prosthetic joints undergoing dental procedures 2, 3. Prophylaxis should be considered only for specific high-risk patients:
- Immunocompromised patients
- History of previous prosthetic joint infection
- Solid organ transplant recipients on immunosuppression
- Inherited immune deficiency diseases
- Severely immunocompromised patients
Important Clinical Considerations
Single dose is sufficient: A single preoperative dose provides adequate protection; additional postoperative doses are not necessary and may increase risk of adverse events 4.
Timing is critical: Administer antibiotics 30-60 minutes before the procedure to ensure adequate tissue concentration 2.
Antibiotic resistance concerns: The risk of antibiotic resistance and adverse reactions (approximately 20% chance of adverse events requiring medical attention) must be weighed against the limited benefit of prophylaxis in low-risk patients 2, 5.
Oral hygiene importance: Maintaining good oral hygiene is more effective than antibiotic prophylaxis for preventing infections in most patients 2.
No evidence for routine use: Current evidence does not support routine antibiotic prophylaxis for patients with prosthetic joints, as multiple studies show no statistical association between dental procedures without antibiotic prophylaxis and prosthetic joint infections 2, 6, 3.
Avoid anticoagulation changes: Anticoagulation and antiplatelet therapies typically should not be suspended for common dental treatments 7.
Post-cardiac event timing: Elective dental care should be avoided for six weeks after myocardial infarction or bare-metal stent placement, or for six months after drug-eluting stent placement 7.
The guidelines for antibiotic prophylaxis have been significantly narrowed over time as evidence has accumulated showing limited benefit and potential harm from unnecessary antibiotic use 5.