What are the indications for antibiotic prophylaxis (Antibiotic Prophylaxis) for dental procedures in patients with certain medical conditions, such as Infective Endocarditis or Artificial Joint Replacement?

From the Guidelines

Antibiotic prophylaxis for dental procedures is now recommended only for patients at highest risk of adverse outcomes from infective endocarditis, as stated in the 2017 AHA/ACC guidelines 1. These high-risk patients include individuals with:

• Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
• Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
• Previous infective endocarditis
• Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device
• Cardiac transplant with valve regurgitation due to a structurally abnormal valve For these high-risk patients, prophylaxis is indicated for all dental procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa. The standard regimen is amoxicillin 2g orally 30-60 minutes before the procedure, as recommended by the American Heart Association 1. Some key points to consider:
• The risk of developing infective endocarditis is higher in patients with underlying valvular heart disease, but evidence for the efficacy of antibiotic prophylaxis is lacking 1
• The lack of supporting evidence, along with the risk of anaphylaxis and increasing bacterial resistance to antimicrobials, led to a revision in the 2007 AHA recommendations for prophylaxis limited to those patients at highest risk of adverse outcomes with infective endocarditis 1
• Optimal oral health is maintained through regular professional dental care and the use of appropriate dental products, such as manual, powered, and ultrasonic toothbrushes; dental floss; and other plaque-removal devices, which can help reduce potential sources of bacterial seeding 1

From the Research

Indications for Antibiotic Prophylaxis

The indications for antibiotic prophylaxis for dental procedures are primarily focused on preventing infective endocarditis in individuals at high risk. According to the studies, the following points are relevant:

• Invasive dental procedures, such as extractions and oral surgery, are associated with an increased risk of endocarditis in high-risk individuals 2, 3.
• Antibiotic prophylaxis is recommended before invasive dental procedures to prevent endocarditis in those at high risk 2, 3.
• The use of antibiotic prophylaxis has been shown to significantly reduce the incidence of endocarditis following invasive dental procedures 2, 3.

High-Risk Individuals

High-risk individuals for endocarditis include those with:

• Prosthetic heart valves 4, 5
• Congenital heart disease 4
• History of infective endocarditis 5
• Intravascular and intracardiac devices 5
• Complex congenital heart diseases, intravenous drug abusers, and patients with chronic renal failure under hemodialysis 5

Dental Procedures

The dental procedures that are associated with an increased risk of endocarditis include:

• Extractions 2, 3
• Oral surgery 2, 3
• Other invasive dental procedures 6

Antibiotic Prophylaxis

The use of antibiotic prophylaxis before invasive dental procedures is recommended to prevent endocarditis in high-risk individuals. The benefits and harms of antibiotic prophylaxis should be discussed with patients before a decision is made about administration 6.