When are antibiotics indicated for dental procedures?

Antibiotic Prophylaxis for Dental Procedures

Antibiotic prophylaxis for dental procedures is only indicated for patients at highest risk of infective endocarditis undergoing procedures that manipulate the gingival or periapical region of teeth or perforate the oral mucosa. 1, 2

High-Risk Cardiac Patients Requiring Prophylaxis

• Patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair 1, 2
• Patients with previous infective endocarditis 1, 2
• Patients with congenital heart disease (CHD) including:
  • Unrepaired cyanotic CHD 1, 2
  • Completely repaired CHD with prosthetic material during first 6 months after procedure 1, 2
  • Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or device 1, 2
• Cardiac transplant recipients with cardiac valvulopathy 2

Dental Procedures Requiring Prophylaxis

• Procedures requiring manipulation of gingival tissue 1
• Procedures involving the periapical region of teeth 1
• Procedures involving perforation of the oral mucosa 1

Dental Procedures NOT Requiring Prophylaxis

• Local anesthetic injections in non-infected tissues 1
• Treatment of superficial caries 1
• Removal of sutures 1
• Dental X-rays 1
• Placement or adjustment of removable prosthodontic/orthodontic appliances 1
• Following shedding of deciduous teeth 1
• Trauma to lips or oral mucosa 1

Recommended Antibiotic Regimens

Standard Regimen:

• Amoxicillin 2g orally 1 hour before procedure 1, 2

For Penicillin-Allergic Patients:

• Clindamycin 600mg orally 1 hour before procedure 1, 2
• Alternative: Cephalexin 2g IV (if no history of anaphylaxis, angioedema, or urticaria with penicillin) 1
• Alternative: Azithromycin (for penicillin-allergic patients with prosthetic joints) 3

Special Considerations for Prosthetic Joint Patients

The American Academy of Orthopedic Surgeons (AAOS) and American Dental Association (ADA) no longer recommend routine antibiotic prophylaxis for most patients with prosthetic joints 4, 3. However, prophylaxis may be appropriate in specific high-risk patients:

• Immunocompromised/immunosuppressed patients (e.g., HIV/AIDS, active malignancy) 4, 3
• Patients with inflammatory arthropathies (e.g., rheumatoid arthritis) 4, 3
• Patients with previous prosthetic joint infection 4, 3
• Patients with recent joint replacement plus other risk factors 4

Important Clinical Considerations

• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac/intravascular foreign material 1, 2
• Good oral hygiene and regular dental care are more important for preventing infective endocarditis than antibiotic prophylaxis 2, 5
• Prophylaxis should consist of a single pre-procedure dose only, not multiple days of antibiotics 4, 3
• The risk of adverse events from antibiotics must be weighed against the risk of infection 2, 6
• Fluoroquinolones and glycopeptides are not recommended due to unclear efficacy and potential induction of resistance 1

Common Pitfalls to Avoid

• Prescribing prophylaxis for all dental procedures without considering the specific procedure type 1, 6
• Prescribing prophylaxis for patients without high-risk cardiac conditions 2, 6
• Using prolonged courses of antibiotics when only a single pre-procedure dose is indicated 3, 7
• Using antibiotics for local infections where drainage would be sufficient 7, 8
• Prescribing antibiotics for symptomatic irreversible pulpitis, necrotic pulps, and localized acute apical abscesses without systemic involvement 8

Non-Dental Procedures

• Systematic antibiotic prophylaxis is not recommended for non-dental procedures 1
• For respiratory, gastrointestinal, genitourinary, dermatological, or musculoskeletal procedures, antibiotic therapy is only needed when invasive procedures are performed in the context of established infection 1

By following these evidence-based guidelines, clinicians can help reduce unnecessary antibiotic use while still protecting high-risk patients from serious infections.