When are antibiotics indicated before dental procedures in patients with certain underlying medical conditions, such as a history of infective endocarditis, prosthetic heart valves, or prosthetic joints, or compromised immune systems, including Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) or those undergoing chemotherapy?

Antibiotic Prophylaxis Before Dental Procedures

Antibiotic prophylaxis before dental procedures is indicated only for patients with the highest-risk cardiac conditions undergoing invasive dental procedures that manipulate gingival tissue, the periapical region of teeth, or perforate the oral mucosa. 1, 2

High-Risk Cardiac Conditions Requiring Prophylaxis

Prophylaxis is recommended exclusively for patients with:

• Prosthetic cardiac valves (mechanical, bioprosthetic, or transcatheter-implanted such as TAVR) 1, 2, 3
• Previous infective endocarditis 1, 2
• Prosthetic material used for cardiac valve repair 1, 2, 3
• Specific congenital heart disease:
  • Unrepaired cyanotic congenital heart disease 1, 2
  • Completely repaired congenital heart defects with prosthetic material during the first 6 months after repair (until endothelialization occurs) 1
  • Repaired congenital heart disease with residual defects at or adjacent to the site of prosthetic material 1, 2, 3
• Cardiac transplant recipients who develop cardiac valvulopathy (per American Heart Association, though European Society of Cardiology does not support this) 1, 2

Conditions NOT Requiring Prophylaxis

Prophylaxis is NOT recommended for:

• Prosthetic joints (hip, knee, shoulder replacements) 4
• Coronary artery bypass grafting (CABG) alone without other high-risk conditions 5
• Native valve disease including bicuspid aortic valve, mitral valve prolapse, or calcific aortic stenosis 1
• Pacemakers or implantable defibrillators 1
• Immunocompromised patients (HIV/AIDS, chemotherapy) unless they have one of the high-risk cardiac conditions listed above 1
• Renal dialysis shunts, cerebrospinal fluid shunts, or vascular grafts 1

Dental Procedures Requiring Prophylaxis

Prophylaxis is indicated only for procedures involving:

• Manipulation of gingival tissue 1, 2, 3
• Manipulation of the periapical region of teeth 1, 2, 3
• Perforation of the oral mucosa 1, 2, 3
• Scaling and root canal procedures 1, 2
• Dental extractions and oral surgical procedures (highest risk) 6

Prophylaxis is NOT needed for:

• Local anesthetic injections in non-infected tissue 3
• Treatment of superficial caries 3
• Removal of sutures 3
• Dental X-rays 3
• Placement or adjustment of removable prosthodontic or orthodontic appliances 3
• Shedding of deciduous teeth or trauma to lips/oral mucosa 3

Recommended Antibiotic Regimens

Standard regimen (no penicillin allergy):

• Amoxicillin 2 g orally, 30-60 minutes before the procedure 1, 2, 3

Penicillin allergy:

• Clindamycin 600 mg orally or IV, 30-60 minutes before the procedure 1, 2, 3
• Alternative: Cephalexin 2 g orally or cefazolin 1 g IV (but cephalosporins should NOT be used in patients with history of anaphylaxis, angioedema, or urticaria to penicillin) 1, 2, 3
• Alternative: Azithromycin or clarithromycin 1

Non-Dental Procedures: No Prophylaxis Required

Antibiotic prophylaxis is NOT recommended for:

• Gastrointestinal procedures (colonoscopy, esophagogastroduodenoscopy) 1, 2
• Genitourinary procedures (cystoscopy) 1, 2
• Respiratory tract procedures 1
• Transesophageal echocardiography 1, 2
• Dermatological or musculoskeletal procedures 1

There is no compelling evidence that bacteremia from these procedures causes infective endocarditis 1, 5.

Evidence Supporting Current Recommendations

Recent high-quality evidence demonstrates:

• A 2022 study of nearly 8 million patients showed a significant temporal association between invasive dental procedures and subsequent infective endocarditis in high-risk patients (OR: 2.00), with the strongest association for dental extractions (OR: 11.08) and oral surgical procedures (OR: 50.77) 6
• Antibiotic prophylaxis was associated with a 51% reduction in infective endocarditis incidence following invasive dental procedures (OR: 0.49) in high-risk patients 6
• The mortality rate for infective endocarditis in prosthetic valve patients can reach 75% at one year, emphasizing the critical importance of prophylaxis in truly high-risk patients 2

However, no randomized controlled trials have been performed to evaluate prophylaxis efficacy, and current recommendations are based on expert consensus and observational data 2, 7.

Critical Considerations and Common Pitfalls

Patients already receiving antibiotics:

• If a patient is on long-term antibiotic therapy (e.g., for rheumatic fever prevention), select an antibiotic from a different class for prophylaxis rather than increasing the current antibiotic dose 1
• Avoid cephalosporins due to possible cross-resistance with oral flora already exposed to penicillin 1
• Preferably delay the dental procedure until at least 10 days after completion of antibiotic therapy to allow normal oral flora to reestablish 1

Patients on anticoagulants:

• Avoid intramuscular injections; use oral regimens whenever possible 1
• Use intravenous antibiotics only if the patient cannot tolerate or absorb oral medications 1

Most important prevention strategy:

• Maintenance of optimal oral health through regular professional dental care and good oral hygiene is more important than antibiotic prophylaxis for reducing infective endocarditis risk 2, 5, 3, 8
• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of prosthetic valves or intracardiac/intravascular foreign material 1, 5, 3

Common errors to avoid:

• Do not prescribe prophylaxis for prosthetic joint patients—the evidence does not support this practice 4
• Do not provide prophylaxis for low-risk cardiac conditions or non-invasive dental procedures 1
• Do not use fluoroquinolones or glycopeptides for prophylaxis due to unclear efficacy and potential for inducing resistance 3