Antibiotic Prophylaxis Prior to Dental Procedures

Recommendations for antibiotic prophylaxis prior to certain dental procedures have existed historically for two groups of patients:

• those with heart conditions that may predispose them to infective endocarditis; and
• those who have a prosthetic joint(s) and may be at risk for developing hematogenous infections at the site of the prosthetic.

However, compared with prior recommendation statements, there are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures.

In 2014, the ADA Council on Scientific Affairs assembled an expert panel to update and clarify the clinical recommendations found in the 2012 evidence report and 2013 guideline, Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.^{1, 2}

As was found in 2012, the updated systematic review undertaken in 2014 and published in 2015 found no association between dental procedures and prosthetic joint infections.³ Based on this evidence review, the 2015 ADA clinical practice guideline states,³ "In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”

A co-published editorial by Meyer⁴ also states:

"The new CSA guideline clearly states that for most patients, prophylactic antibiotics are not indicated before dental procedures to prevent [prosthetic joint infections]. The new guideline also takes into consideration that patients who have previous medical conditions or complications associated with their joint replacement surgery may have specific needs calling for premedication. In medically compromised patients who are undergoing dental procedures that include gingival manipulation or mucosal inclusion, prophylactic antibiotics should be considered only after consultation with the patient and orthopedic surgeon. For patients with serious health conditions, such as immunocompromising diseases, it may be appropriate for the orthopedic surgeon to recommend an antibiotic regimen when medically indicated, as footnoted in the new chair-side guide."

A 2017 commentary⁵ published in the February 2017 issue of JADA written by ADA-appointed experts, offers guidance for using appropriate use criteria published by the American Academy of Orthopaedic Surgeons in January 2017⁶ that address managing care for patients with orthopedic implants undergoing dental procedures. The JADA editorial calls the appropriate use criteria "a decision-support tool to supplement clinicians in their judgment" and it emphasizes discussion of available treatment options between the patient, dentist and orthopedic surgeon, weighing the potential risks and benefits. The commentary encourages dentists to continue to use the 2015 guideline,³ consult the appropriate use criteria as needed, and respect the patient's specific needs and preferences when considering antibiotic prophylaxis before dental treatment. According to the ADA Chairside Guide, in cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.

With input from the ADA, the American Heart Association (AHA) released guidelines for the prevention of infective endocarditis in 2007,⁷ which were approved by the CSA as they relate to dentistry in 2008.⁸  In 2017, the AHA and American College of Cardiology (ACC) published a focused update⁹ to their 2014 guidelines on the management of valvular heart disease that reinforce the previous recommendations.

These current guidelines support infective endocarditis premedication for a relatively small subset of patients. This is based on a review of scientific evidence, which showed that the risk of adverse reactions to antibiotics generally outweigh the benefits of prophylaxis for many patients who would have been considered eligible for prophylaxis in previous versions of the guidelines. Concern about the development of drug-resistant bacteria also was a factor.

In addition, the data are mixed as to whether prophylactic antibiotics taken before a dental procedure prevent infective endocarditis. The guidelines note that people who are at risk for infective endocarditis are regularly exposed to oral bacteria during basic daily activities such as brushing or flossing.  The valvular disease management guidelines⁹ recommend that persons at risk of developing bacterial infective endocarditis (see “Patient Selection”) establish and maintain the best possible oral health to reduce potential sources of bacterial seeding.  They state, “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.”

Patient Selection
The current infective endocarditis/valvular heart disease guidelines state that use of preventive antibiotics before certain dental procedures is reasonable for patients with:

• prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts;
• prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords;
• a history of infective endocarditis;
• a cardiac transplant^a with valve regurgitation due to a structurally abnormal valve;
• the following congenital (present from birth) heart disease:^b
• unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
• any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device

^a According to limited data, infective endocarditis appears to be more common in heart transplant recipients than in the general population; the risk of infective endocarditis is highest in the first 6 months after transplant because of endothelial disruption, high-intensity immunosuppressive therapy, frequent central venous catheter access, and frequent endomyocardial biopsies.^9
b Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease.

Pediatric Patients
Congenital heart disease can indicate that prescription of prophylactic antibiotics may be appropriate for children. It is important to note, however, that when antibiotic prophylaxis is called for due to congenital heart concerns, they should only be considered when the patient has:

• Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had a surgical shunts and conduits.
• A congenital heart defect that's been completely repaired with prosthetic material or a device for the first six months after the repair procedure.
• Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.

Antibiotic prophylaxis is not recommended for any other form of congenital heart disease.

Beyond identifying the specific patient population for whom antibiotic prophylaxis is appropriate, special consideration should be given to the antibiotic dose prescribed to children, as it will vary according to the child’s weight. Weight-based regimens for children are outlined in Table 2 of the 2007 American Heart Association guidelines.⁸ As with any medication, check with the primary caregiver to determine whether the child has an allergy to antibiotics or other antibiotic related concerns before prescribing.

Dental Procedures
Prophylaxis is recommended for the patients identified in the previous section 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 Infective Endocarditis Antibiotic Prophylaxis (When Indicated)
Sometimes, patients forget to premedicate before their appointments. The recommendation is that for patients with an indication for antibiotic prophylaxis, the antibiotic be given before the procedure. This is important because it allows the antibiotic to reach adequate blood levels. However, the guidelines to prevent infective endocarditis^{7, 8} state, “If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure.” If a patient with an indication for prophylaxis who appropriately received antibiotic premedication prior to a dental procedure one day and who is then scheduled the following day for a dental procedure also warranting premedication (e.g., dental prophylaxis), the antibiotic prophylaxis regimen should be repeated prior to the second appointment. Because of the nature of the pharmacokinetics of an antibiotic prophylaxis regimen, a single loading dose is given in order to cover the period of potential bacteremia produced by a single procedure.^10-12

Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the guidelines for infective endocarditis^{7, 8} 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.

Other patient groups also may merit special consideration, which is discussed more fully in the guidelines.

In 2015, The Lancet published a study out of the United Kingdom that reported a correlation between institution of more limited antibiotic prophylaxis guidelines by the National Institute for Health and Clinical Evidence (NICE) in 2008 and an increase in cases of infective endocarditis.¹³ Because of the retrospective and observational nature of the study, the authors acknowledged that their “data do not establish a causal association.” At this time, the ADA recommends that dentists continue to use the AHA/ACC guidelines discussed above. Dental professionals should periodically visit the ADA website for updates on this issue.

With the exception of the AHA/ACC guidelines regarding prevention of infective endocarditis,^7-9 there is no general guidance or recommendation to provide antibiotics as a prophylactic measure prior to dental procedures except for specific individuals with extenuating circumstances, where the determination and prescription is made by the patient’s surgeon or other treating physician. However, there are a myriad of other conditions that either patients, physicians, or dentists may think that antibiotic prophylaxis prior to dental treatment might be warranted to prevention development of infections at remote locations by bacteria normally associated with the oral flora.

The ADA has received queries from members for guidance concerning the evidence for antibiotic prophylaxis in patients who have undergone a variety of surgical interventions. In the following examples, the guidance has been that antibiotic prophylaxis is unwarranted unless the person is predisposed, for some reason, to infection, in which case, it may be appropriate for the treating physician to prescribe the antibiotic. ADA member inquiries have included questions regarding indications such as artificial joint replacement,^{2, 5} breast augmentation with implants,¹⁴ or penile implant.^{15, 16}

1. American Academy of Orthopaedic Surgeons/American Dental Association. Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report. American Academy of Orthopaedic Surgeons 2012. http://www.aaos.org/Research/guidelines/PUDP/PUDP_guideline.pdf. Accessed February 3, 2016.
2. Rethman MP, Watters W, 3rd, Abt E, et al. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg Am 2013;95(8):745-7.
3. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(1):11-16 e8.
4. Meyer DM. Providing clarity on evidence-based prophylactic guidelines for prosthetic joint infections. J Am Dent Assoc 2015;146(1):3-5.
5. American Dental Association-Appointed Members of the Expert Writing and Voting Panels Contributing to the Development of American Academy of Orthopedic Surgeons Appropriate Use Criteria. American Dental Association guidance for utilizing appropriate use criteria in the management of the care of patients with orthopedic implants undergoing dental procedures. J Am Dent Assoc 2017;148(2):57-59.
6. Quinn RH, Murray JN, Pezold R, Sevarino KS. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. J Bone Joint Surg Am 2017;99(2):161-63.
7. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):1736-54.
8. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
9. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.  Circulation 2017; 135: e1159-e1195.  Accessed June 19, 2017.
10. Dajani AS, Bisno AL, Chung KJ, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA 1990;264(22):2919-22.
11. Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000 1996;10:107-38.
12. Hussein H, Brown RS. Risk-benefit assessment for antibiotic prophylaxis in asplenic dental patients. Gen Dent 2016;64(4):62-5.
13. Dayer MJ, Jones S, Prendergast B, et al. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. Lancet 2015;385(9974):1219-28.
14. Stoopler ET, Sia YW, Kuperstein AS. Do patients with solid organ transplants or breast implants require antibiotic prophylaxis before dental treatment? J Can Dent Assoc 2012;78:c5.
15. Holland B, Kohler T. Minimizing Penile Implant Infection: A Literature Review of Patient and Surgical Factors. Curr Urol Rep 2015;16(12):81.
16. Kohler T. Personal communication: Antibiotic prophylaxis prior to dental work for men who have penile implants; 2017.

Professional Resources

• ADA Council on Scientific Affairs, Combating Antibiotic Resistance
• ADA Council on Scientific Affairs, Antibiotic Interference with Oral Contraceptives
• ADA Oral Health Topics: Antibiotic Stewardship
• Infective Endocarditis: Legal sidebar (PDF)
• IE guideline tables (PDF)
• JADA Editorial, Antibiotics: The good, the bad, the ugly
• Search the ADA Catalog for products related to antibiotic prophylaxis
• ADA Library Services

Patient Resources

JADA "For the Patient" page: What is antibiotic prophylaxis?

American Heart Association downloadable wallet card for patients

Centers for Disease Control and Prevention:

• Get Smart: Know When Antibiotics Work
• Antibiotic Use in the United States, 2017: Progress and Opportunities
• CDC Checklist for Antibiotic Prescribing in Dentistry