Oral Health Topics
Antibiotic Prophylaxis
Before some dental treatments, patients who have certain heart conditions and those with artificial joints take antibiotics. These people may be at risk of developing an infection in the heart or at the site of the artificial joint, respectively. Antibiotics reduce this risk. This is called antibiotic prophylaxis (pronounced pro-fuh-lax-iss).
When treating patients with heart conditions, dentists follow recommendations developed by the American Heart Association (AHA), with input from the ADA. For patients who have total joint replacements, they refer to recommendations developed by the American Academy of Orthopedic Surgeons (AAOS).
Recommendations for People with Heart Conditions
The AHA recommendations are meant to reduce the risk of infective endocarditis (pronounced end-o-car-die-tiss). Infective endocarditis (IE) is an infection of the lining inside the heart or the heart valves.
In the past, a number of heart conditions were thought to put patients at risk for IE. When writing the new recommendations, the AHA looked at published research and other scientific articles. They found that fewer conditions were associated with IE. As a result, a smaller group of patients needs to premedicate before dental treatments.
Why did the recommendations change?
After looking at the published scientific reports and articles, the AHA concluded that:
- the risks of adverse reactions to antibiotics outweigh the benefits of prophylaxis for most patients. Adverse reactions can range from mild (rashes) to severe (breathing problems that could result in death).
- when all the study results were looked at together, it wasn’t clear that premedication prevented IE.
- bacteria from the mouth can enter the bloodstream during daily activities like brushing or cleaning between the teeth. Once in the bloodstream, it can travel to the heart. People at risk of infection might be more likely to develop IE from these activities than after a dental treatment.
Also, bacteria that cause infections can become resistant to antibiotics if those drugs are used too often. Because of this, doctors try to limit the use of antibiotics.
Patient selection
The current recommendations recommend use of preventive antibiotics before certain dental procedures for people with:
- artificial heart valves
- a history of infective endocarditis
- a cardiac transplant that develops a heart valve problem
- the following congenital (present from birth) heart conditions:*
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device.
People who took prophylactic antibiotics in the past but no longer need them include those with:
- mitral valve prolapse
- rheumatic heart disease
- bicuspid valve disease
- calcified aortic stenosis
- congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.
Talk to your dentist about how these recommendations might apply to you.
Additional resources
- American Heart Association downloadable wallet card (available in English and Spanish)
- For the Dental Patient: Antibiotics and Your Heart
Recommendations for People with Total Joint Replacements
Recommendations from the AAOS are meant to reduce the risk of infections at the site of an artificial joint. They apply to people who have total joint replacements. Patients who have pins, plates or other orthopedic hardware are not affected.
AAOS recommends that dentists and physicians should consider whether patients who have total joint replacements should take antibiotics before certain types of dental procedures.Talk to your dentist about how these recommendations might apply to you.
Return to TopAdditional Resources
Antibiotic prophylaxis recommendations exist for two groups of patients:
- those with heart conditions that may predispose them to infective endocarditis; and
- those who have a total joint replacement and may be at risk for developing hematogenous infections at the site of the prosthetic.
Prophylaxis Recommendations: Infective Endocarditis (IE)
With input from the ADA, the American Heart Association (AHA) released the current recommendations for the prevention of infective endocarditis in 2008.
The complete recommendations, including the recommended regimen, can be found in:
The current recommendations recommend premedication for a smaller group of patients than previous versions. This change was based on a review of scientific evidence, which showed that the risk of adverse reactions to antibiotics outweigh the benefits of prophylaxis for most patients. Concern about the development of drug-resistant bacteria also was a factor.
Also, the data are mixed as to whether prophylactic antibiotics taken prior to a dental procedure prevent IE. The recommendations note that people who are at risk for IE are regularly exposed to oral flora during basic daily activities such as brushing or flossing, suggesting that IE is more likely to occur as a result of these everyday activities than from a dental procedure.
Patient selection
The current recommendations recommend use of preventive antibiotics prior to certain dental procedures for patients with:
- artificial heart valves
- a history of infective endocarditis
- a cardiac transplant that develops a heart valve problem
- the following congenital (present from birth) heart conditions:*
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
* Patients should check with their cardiologist if there is any question as to whether they fall into one of these categories.
Patients who took prophylactic antibiotics in the past but no longer need them include those with:
- mitral valve prolapse
- rheumatic heart disease
- bicuspid valve disease
- calcified aortic stenosis
- congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy
Dental procedures
Prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.
Additional considerations about antibiotic prophylaxis
Sometimes patients forget to premedicate prior to their appointments. The recommendation is that the antibiotic be given before the procedure. This is important because it allows the antibiotic to reach adequate blood levels. However, the recommendations to prevent infective endocarditis state:
"If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to two hours after the procedure."
Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the recommendations for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.
Additional resources
- Infective Endocarditis: Legal sidebar (PDF)
- Infective Endocarditis: FAQ (PDF)
- American Heart Association downloadable wallet card (available in English and Spanish)
- IE guideline tables (PDF) ADA Members only content
- For the Dental Patient*: Antibiotics and Your Heart
*For the Dental Patient is a JADA column that is geared toward patient education and intended to facilitate discussion between dentists and patients.
Total Joint Replacement
The American Dental Association and the American Academy of Orthopedic Surgeons (AAOS) are currently in the process of developing evidence-based clinical guidelines on the topic of antibiotic prophylaxis for patients with orthopedic implants undergoing dental procedures. The ADA and AAOS do not have a joint recommendation at this time. There are differing opinions on the need for antibiotic prophylaxis. These opinions/statements are presented below to assist the dentist in making informed decisions about the prescription of antibiotics. The ADA believes that the professional goal should be consensus among the dentist and physician, which is the expressed goal being pursued in the ongoing ADA/AAOS project.
- The American Academy of Oral Medicine 2010 position paper – The dental treatment of patients with joint replacements
- Debate & Opinion 2009 – Journal of the Canadian Dental Association
- The American Academy of Orthopedic Surgeons 2009 information statement – Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements
- The American Dental Association summary tables based on the 2003 report* – Antibiotic prophylaxis for dental patients with total joint replacements
*This report was retired by the American Academy of Orthopedic Surgeons (AAOS), effective December 5, 2008. As a result of this action, the report has been removed from the AAOS website and is no longer supported, endorsed, or distributed by the Academy.
Additional Resources
If you have any questions about these recommendations, please contact the ADA Division of Science via e-mail. ADA members may also use the Association’s toll-free number and ask for x2878.
