What prophylactic antibiotic is recommended for patients with valvular heart disease (VHD) undergoing dental surgery?

Prophylactic Antibiotic for Dental Surgery in Valvular Heart Disease

Not all patients with valvular heart disease require antibiotic prophylaxis before dental procedures—only those at highest risk for adverse outcomes from infective endocarditis should receive prophylaxis, and the first-line agent is amoxicillin 2 g orally given 30-60 minutes before the procedure. 1

Who Requires Prophylaxis

Antibiotic prophylaxis is reasonable only for patients with valvular heart disease who fall into the highest-risk categories 1:

• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair (including TAVR) 1, 2
• Previous infective endocarditis 1
• Cardiac transplant recipients who develop cardiac valvulopathy 1

Important: Most patients with native valvular heart disease do NOT require prophylaxis, including those with mitral valve prolapse, bicuspid aortic valve, or other common valvular lesions. 1 The 2008 ACC/AHA guidelines represent a major departure from previous recommendations, focusing on risk of adverse outcomes rather than lifetime risk of acquiring endocarditis. 1

Which Dental Procedures Require Prophylaxis

Prophylaxis is indicated for dental procedures that involve 1, 3, 2:

• Manipulation of gingival tissue
• Manipulation of the periapical region of teeth
• Perforation of the oral mucosa

Prophylaxis is NOT needed for 1:

• Routine anesthetic injections through noninfected tissue
• Dental radiographs
• Placement or adjustment of orthodontic appliances
• Shedding of deciduous teeth

Antibiotic Regimens

Standard Regimen (No Penicillin Allergy)

Amoxicillin 2 g orally, given 30-60 minutes before the procedure 1, 2

Unable to Take Oral Medication (No Penicillin Allergy)

• Ampicillin 2 g IM or IV 1
• OR Cefazolin or ceftriaxone 1 g IM or IV 1

Penicillin Allergy—Oral Options

First choice: Clindamycin 600 mg orally 3

Alternative options 1, 3:

• Cephalexin 2 g orally (or other first- or second-generation cephalosporin)
• Azithromycin 500 mg orally
• Clarithromycin 500 mg orally

Critical caveat: Cephalosporins should NEVER be used in patients with a history of anaphylaxis, angioedema, or urticaria with penicillins due to cross-sensitivity. 1, 3

Penicillin Allergy—Unable to Take Oral Medication

• Cefazolin or ceftriaxone 1 g IM or IV (only if no history of anaphylaxis/angioedema/urticaria with penicillins) 1
• OR Clindamycin 600 mg IM or IV 1

Rationale for Restrictive Approach

The ACC/AHA guidelines emphasize several key points 1:

• Infective endocarditis is more likely from daily bacteremia (tooth brushing, chewing) than from dental procedures 1
• Prophylaxis may prevent an exceedingly small number of cases, if any 1
• The risk of antibiotic adverse effects exceeds the benefit in most patients 1
• Optimal oral hygiene is more important than prophylactic antibiotics for reducing endocarditis risk 1, 3

A 2022 Cochrane review found no definitive evidence that antibiotic prophylaxis is effective or ineffective, but consensus remains that prophylaxis is reasonable for highest-risk patients given the catastrophic outcomes of endocarditis in prosthetic valve patients. 2, 4

Procedures NOT Requiring Prophylaxis

Antibiotic prophylaxis is NOT recommended for 1, 2:

• Gastrointestinal endoscopy (colonoscopy, esophagogastroduodenoscopy)
• Genitourinary procedures (cystoscopy)
• Transesophageal echocardiography
• Respiratory tract procedures (unless involving incision of mucosa in high-risk patients)

Special Considerations

For patients scheduled for prosthetic valve implantation or TAVR: Potential sources of dental sepsis should be eliminated at least 2 weeks before the procedure whenever possible. 3, 2 This proactive approach is more important than relying solely on prophylaxis. 2

For TAVR patients specifically: All transcatheter-implanted prostheses are considered high-risk cardiac conditions requiring prophylaxis, as infective endocarditis after TAVR occurs at rates equal to or exceeding surgical valve replacement, with a devastating 75% one-year mortality rate. 2

Patient communication: Because these guidelines represent a major change from decades of previous recommendations, clinicians should discuss the rationale with patients who may expect prophylaxis based on older guidance. 1 In select circumstances where both clinician and patient prefer continuing prophylaxis (e.g., severe mitral valve prolapse), ensure the risks of antibiotics are low before proceeding. 1