What are the recommended antibiotics for dental prophylaxis?

Dental Antibiotic Prophylaxis

For patients at highest cardiac risk undergoing invasive dental procedures, administer amoxicillin 2 g orally as a single dose 30-60 minutes before the procedure; if penicillin-allergic, use clindamycin 600 mg orally instead. 1

Who Requires Prophylaxis

Antibiotic prophylaxis should only be considered for patients with the following highest-risk cardiac conditions 1, 2:

• Prosthetic cardiac valves or prosthetic material used for cardiac valve repair (including transcatheter valves and annuloplasty rings) 1, 2
• Previous history of infective endocarditis 1, 2
• Congenital heart disease (CHD) in specific situations 1:
  • Unrepaired cyanotic CHD 1, 2
  • Completely repaired CHD with prosthetic material during the first 6 months only after the procedure 1
  • Repaired CHD with residual defects at or adjacent to the prosthetic patch site 1, 2

Prophylaxis is NOT recommended for 1:

• Bicuspid aortic valve 1
• Mitral valve prolapse 1, 3
• Calcific aortic stenosis 1
• Most other native valve diseases 1
• Cardiac transplant recipients (European guidelines differ from American on this point) 1

Which Dental Procedures Require Prophylaxis

Prophylaxis is indicated only for procedures involving 1, 2:

• Manipulation of gingival tissue 1, 2
• Manipulation of the periapical region of teeth 1, 2
• Perforation of the oral mucosa 1, 2
• Scaling and root canal procedures 1, 3

Prophylaxis is NOT needed for 1, 3:

• Local anesthetic injections in non-infected tissue 1
• Treatment of superficial caries 1
• Dental radiographs 1, 3
• Removal of sutures 1
• Placement or adjustment of removable prosthodontic or orthodontic appliances 1
• Shedding of deciduous teeth 1

Recommended Antibiotic Regimens

Standard Regimen (No Penicillin Allergy)

• Amoxicillin 2 g orally, single dose 30-60 minutes (or 1 hour) before procedure 1, 2
• Pediatric dose: 50 mg/kg orally (maximum 2 g) 1, 2

Penicillin Allergy

• Clindamycin 600 mg orally, single dose 30-60 minutes before procedure 1, 2
• Pediatric dose: 20 mg/kg orally 1

Alternative for Penicillin Allergy (if no anaphylaxis/angioedema/urticaria history)

• Cephalexin 2 g IV for adults or 50 mg/kg IV for children 1
• Cefazolin or ceftriaxone 1 g IV for adults or 50 mg/kg IV for children 1
• Critical caveat: Cephalosporins are contraindicated in patients with history of anaphylaxis, angioedema, or urticaria to penicillin due to cross-sensitivity 1

Unable to Take Oral Medications

• Ampicillin 2 g IM or IV within 30 minutes before procedure 1, 3
• Pediatric dose: 50 mg/kg IM or IV 1

Critical Clinical Considerations

Only a single pre-procedure dose is indicated—post-procedure antibiotics are not recommended and represent inappropriate prescribing 2, 3. Research demonstrates that over 80% of dental antibiotic prophylaxis prescriptions are unnecessary, highlighting the importance of strict adherence to guidelines 4.

For patients already on long-term antibiotic therapy, select an antibiotic from a different class rather than increasing the dosage of their current antibiotic 2, 3.

For patients on anticoagulants, oral administration is strongly preferred over intramuscular injections to avoid hematoma formation 3.

Eliminate potential sources of dental sepsis at least 2 weeks before implantation of prosthetic valves or intracardiac/intravascular foreign material, unless the cardiac procedure is urgent 1.

Evidence Quality and Nuances

The European Society of Cardiology guidelines (2015) provide the most comprehensive and recent framework 1. A critical evidence gap exists: no randomized controlled trials demonstrate that antibiotic prophylaxis actually prevents infective endocarditis 5. The Cochrane review found only one case-control study showing no significant effect of penicillin prophylaxis 5. Despite this, guidelines continue to recommend prophylaxis based on the severe consequences of infective endocarditis when it occurs in high-risk patients 1.

Research shows that maintaining good oral hygiene and regular dental care is more important for preventing infective endocarditis than antibiotic prophylaxis for individual procedures 1, 2. Daily activities causing bacteremia pose greater cumulative risk than isolated dental procedures 1.

Regarding antibiotic efficacy, pooled analysis demonstrates that antibiotics reduce bacteremia incidence moderately (risk ratio 0.50), with oral amoxicillin remaining the drug of choice 6. However, clindamycin shows lower efficacy in penicillin-allergic patients, and azithromycin may be superior in this population, though it is not included in current European guidelines 6.

Prosthetic Joint Considerations

Routine antibiotic prophylaxis is NOT recommended for most patients with prosthetic joints undergoing dental procedures 1, 7. The American Academy of Orthopedic Surgeons and American Dental Association reversed their 2009 recommendations in 2013 1.

Consider prophylaxis only in highly selected cases 7:

• Immunocompromised/immunosuppressed patients (inflammatory arthropathies, disease/drug/radiation-induced immunosuppression) 7
• Previous prosthetic joint infection 7

If prophylaxis is deemed necessary: Amoxicillin 2 g orally as a single dose 1 hour before the procedure 7. For penicillin allergy: azithromycin, clindamycin, or vancomycin 7.

Important: Patients with both prosthetic cardiac valves and joint replacements should follow the cardiac guidelines, which take precedence 7.