Antibiotic Prophylaxis of Infective Endocarditis for Dental Procedures

Comments from Expert Advisory Group

• Endocarditis prophylaxis is only recommended in certain situations, as antibiotic prophylaxis may only be effective at preventing a very small number of endocarditis cases. 
• There is evidence demonstrating effectiveness of antibiotic prophylaxis in reducing the incidence of infective endocarditis in specific high-risk patients, which are listed below.
• Bacteraemia may be caused by daily activities such as tooth brushing, flossing, and chewing, and although these constitute low-level bacteraemia, they occur repetitively and may therefore outweigh the risk of bacteraemia associated with dental procedures.
• Maintenance of optimal oral health and hygiene and regular dental review are important in reducing the risk of endocarditis from both daily activities and dental procedures.
• The 2023 European Society of Cardiology (ESC) Guidelines for the management of endocarditis was a key reference source used for the development of these guidelines.

Procedures where endocarditis prophylaxis is not recommended

• Routine anaesthetic injections through non-infected tissue.
• Taking dental radiographs.
• Placement of removable prosthodontic or orthodontic appliances.
• Adjustment of orthodontic appliances.
• Placement of orthodontic brackets.
• Shedding of deciduous teeth.
• Bleeding from trauma to the lips or oral mucosa.
• Treatment of caries not involving the gingival margin or pulp.
• Removal of sutures.

Procedures where endocarditis prophylaxis is recommended

Endocarditis prophylaxis is recommended in patients with any cardiac condition listed below for at-risk dental procedures including:

• Dental extractions.
• Oral surgery procedures (including periodontal surgery, implant surgery and oral biopsies).
• Procedures involving manipulation of the gingival or periapical region of the teeth (including scaling and root canal procedures).
• Invasive dental procedures on established implants.

If any of the above occur inadvertently during a dental procedure, antibiotic prophylaxis may be administered up to 2 hours afterwards.

Cardiac conditions requiring endocarditis prophylaxis for at-risk dental procedures (listed above):

• Antibiotic prophylaxis is recommended in:
  • Patients with previous infective endocarditis.
  • Patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair.
  • Patients with transcatheter implanted aortic and pulmonary valvular prostheses.
  • Patients with venticular assist devices.
  • Patients with untreated cyanotic Congenital Heart Disease (CHD), and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure.

• Antibiotic prophylaxis should be considered in patients with transcatheter mitral and tricuspid valve repair.
• Antibiotic prophylaxis may be considered in recipients of heart transplant.

If the patient’s cardiac condition is unclear to the treating dentist, advice should be sought from the patient’s GP or Cardiologist.

Treatment

Safe Prescribing