Do I need to take antibiotics before dental work?

Antibiotic Prophylaxis for Dental Procedures

Antibiotic prophylaxis before dental procedures is only recommended for patients with specific high-risk cardiac conditions and is not necessary for most people. 1

Who Needs Antibiotic Prophylaxis

Antibiotic prophylaxis is recommended only for patients with:

• Prosthetic cardiac valves or prosthetic material used for valve repair 1, 2
• Previous history of infective endocarditis 1, 2
• Specific congenital heart diseases:
  • Unrepaired cyanotic congenital heart disease 2
  • Completely repaired congenital heart defect with prosthetic material during the first 6 months after procedure 2
  • Repaired congenital heart disease with residual defects at or adjacent to the site of a prosthetic patch or device 2
• Cardiac transplant recipients who develop cardiac valvulopathy 1, 2

Who Does NOT Need Antibiotic Prophylaxis

• Patients with mitral valve prolapse (MVP) 3
• Most patients with prosthetic joints (except in specific circumstances like previous prosthetic joint infection or immunocompromised conditions) 1
• Healthy individuals without cardiac risk factors 3, 1

Dental Procedures Requiring Prophylaxis (for High-Risk Patients Only)

Prophylaxis is recommended for procedures that:

• Involve manipulation of gingival tissue 3, 2
• Involve manipulation of the periapical region of teeth 3, 2
• Involve perforation of the oral mucosa 3, 2

Prophylaxis is NOT needed for:

• Routine anesthetic injections through noninfected tissue 3
• Taking dental radiographs 3
• Placement of removable prosthodontic or orthodontic appliances 3
• Adjustment of orthodontic appliances 3
• Placement of orthodontic brackets 3
• Shedding of deciduous teeth 3
• Bleeding from trauma to the lips or oral mucosa 3

Recommended Antibiotic Regimens

For patients who can take oral medications:

• Standard regimen: Amoxicillin 2g orally 30-60 minutes before the procedure 1, 2
• For penicillin-allergic patients: Clindamycin 600mg orally 30-60 minutes before the procedure 1, 2
• Alternative for penicillin-allergic patients: Azithromycin or clarithromycin 500mg orally 2

For patients unable to take oral medications:

• Ampicillin 2.0g IM or IV within 30 minutes before the procedure 1
• For penicillin-allergic patients: Clindamycin 600mg IV 2

Special Considerations

• For patients already receiving long-term antibiotic therapy, select an antibiotic from a different class rather than increasing the dosage of the current antibiotic 3
• For patients on anticoagulants, oral administration is preferred over intramuscular injections 3, 1
• For patients on hemodialysis, the standard 2g amoxicillin dose is still recommended if not allergic to penicillin 1, 4
• A single pre-procedure dose is sufficient; post-procedure antibiotics are not recommended for prophylaxis 1

Common Pitfalls to Avoid

• Prescribing antibiotics for all dental procedures without appropriate risk stratification 1
• Prescribing prolonged courses of antibiotics when only a single pre-procedure dose is indicated 1
• Using cephalosporins in patients with history of anaphylaxis, angioedema, or urticaria with penicillins due to cross-sensitivity 2
• Neglecting the importance of maintaining good oral hygiene, which is more important for preventing infective endocarditis than antibiotic prophylaxis 1

Evidence Limitations

The evidence supporting antibiotic prophylaxis for dental procedures is limited. A Cochrane review found no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people undergoing invasive dental procedures 5. However, given the high mortality rate associated with infective endocarditis, prophylaxis is still recommended for high-risk patients based on expert consensus.