What premedications are recommended for dental procedures?

Antibiotic Prophylaxis for Dental Procedures

Antibiotic prophylaxis for dental procedures should only be given to patients at highest risk for infective endocarditis undergoing invasive dental procedures that manipulate gingival tissue, the periapical region of teeth, or perforate the oral mucosa—the standard regimen is amoxicillin 2 grams orally given 30-60 minutes before the procedure. 1, 2

High-Risk Cardiac Conditions Requiring Prophylaxis

Antibiotic prophylaxis is only indicated for patients with the following cardiac conditions 1, 2:

• Prosthetic cardiac valves (including transcatheter-implanted prostheses and homografts) or prosthetic material used for cardiac valve repair 1, 3
• Previous history of infective endocarditis 1, 2
• Specific congenital heart diseases: unrepaired cyanotic CHD, completely repaired CHD with prosthetic material during first 6 months after procedure, or repaired CHD with residual defects at or adjacent to prosthetic patch/device 1, 3
• Cardiac transplant recipients who develop cardiac valvulopathy 1, 3

Important caveat: Patients with mitral valve prolapse, rheumatic heart disease without prosthetic valves, and other moderate-risk conditions do not require prophylaxis. 2, 4

Dental Procedures Requiring Prophylaxis

Prophylaxis is indicated only for procedures involving 1, 2:

• Manipulation of gingival tissue (including scaling and root planing) 1, 4
• Manipulation of the periapical region of teeth (including endodontic treatment beyond the apex) 1, 2
• Perforation of the oral mucosa 1, 3
• Dental extractions 2, 5
• Dental implant placement 2
• Initial placement of orthodontic bands 2

Prophylaxis is NOT required for 1, 2:

• Local anesthetic injections in non-infected tissues 1
• Treatment of superficial caries 1
• Removal of sutures 1
• Dental X-rays 1, 4
• Placement or adjustment of removable prosthodontic or orthodontic appliances 1
• Shedding of deciduous teeth or trauma to lips and oral mucosa 1

Standard Antibiotic Regimens

For Patients Without Penicillin Allergy

Amoxicillin 2 grams orally as a single dose 30-60 minutes before the procedure is the standard first-line regimen. 1, 2, 3

For Patients Unable to Take Oral Medications

Ampicillin 2 grams IM or IV within 30 minutes before the procedure is recommended. 1, 4

Alternatively, cefazolin or ceftriaxone 1 gram IM or IV can be used. 1

For Patients With Penicillin Allergy (Oral Administration)

The following alternatives are recommended 1, 2:

• Clindamycin 600 mg orally 1 hour before the procedure 1, 2, 3
• Azithromycin or clarithromycin 500 mg orally 1, 2
• Cephalexin 2 grams orally (or other first- or second-generation oral cephalosporin) 1, 2

Critical warning: Cephalosporins should not be used in patients with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin due to cross-sensitivity. 1

For Patients With Penicillin Allergy Unable to Take Oral Medications

• Cefazolin or ceftriaxone 1 gram IM or IV (if no history of anaphylaxis, angioedema, or urticaria with penicillin) 1, 3
• Clindamycin 600 mg IM or IV 1

Critical Special Considerations

Patients Already on Chronic Antibiotic Therapy

Select an antibiotic from a different class rather than increasing the dosage of the current antibiotic. 2, 4

Patients on Anticoagulants

Avoid intramuscular injections and use oral regimens whenever possible. 2, 4 This is essential to prevent hematoma formation at injection sites.

Patients on Hemodialysis

The standard 2 grams amoxicillin dose remains appropriate if not allergic to penicillin. 2, 4

Timing of Dental Care Before Cardiac Surgery

Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, unless the procedure is urgent. 1

Dental Implants in High-Risk Patients

The indication should be discussed on a case-by-case basis, with patients informed of uncertainties and the need for close follow-up. 1

Evidence Supporting These Recommendations

Recent high-quality research demonstrates a significant temporal association between invasive dental procedures (particularly extractions and oral surgical procedures) and subsequent infective endocarditis in high-risk individuals, with antibiotic prophylaxis associated with a 51% reduction in IE incidence (OR: 0.49; 95% CI: 0.29-0.85). 5 The association was strongest for dental extractions (OR: 11.08) and oral-surgical procedures (OR: 50.77). 5

Meta-analysis confirms that antibiotics significantly reduce bacteremia incidence after dental procedures, though effectiveness is moderate (risk ratio: 0.50). 6 IV amoxicillin-clavulanic acid showed considerable reduction in bacteremia, while clindamycin and cephalosporin had lower efficacy in penicillin-allergic patients. 6

Common Pitfalls to Avoid

• Do not prescribe prophylaxis for all dental patients—restrict to the highest-risk cardiac conditions only. 2, 3
• Do not prescribe prolonged courses—a single preoperative dose is sufficient; postoperative antibiotics are not recommended and only increase adverse event risk. 2, 4
• Do not use cephalosporins in patients with immediate-type penicillin hypersensitivity (anaphylaxis, angioedema, urticaria). 1
• Do not use IM injections in anticoagulated patients. 2, 4
• Do not prescribe prophylaxis for gastrointestinal or genitourinary procedures solely to prevent endocarditis—this is no longer recommended. 1, 3
• Do not use fluoroquinolones or glycopeptides due to unclear efficacy and potential induction of resistance. 1

The Bigger Picture

Maintaining good oral hygiene and regular dental care is more important for preventing infective endocarditis than antibiotic prophylaxis for dental procedures. 1, 4, 3 The rationale for current restrictive recommendations is that infective endocarditis is more likely to result from frequent exposure to random bacteremias associated with daily activities (such as tooth brushing and chewing) than from bacteremia caused by dental procedures. 1, 3 Even if prophylaxis were 100% effective, only an extremely small number of IE cases would be prevented. 1, 3