Antibiotic Prophylaxis Guidelines

Guidelines prior to April 2007 

Many of you take an antibiotic prior to dental treatment. The purpose is to use an antibiotic prior to an infection to prevent an infection. It may be because of a mitral valve prolapse, certain types of implants, a joint replacement, or a heart murmur cause by a roughened heart valve. Antibiotic prophylaxis began initially to prevent bacterial endocarditis. Endocarditis is the collection and colonization of bacteria in the heart muscle. This leads to inflammation and deformation of the heart and is a life-threatening condition. 

The American Heart Association published its first guidelines in 1955. Since then the guidelines have been modified several times. Each revision has tried to make the antibiotic regime simpler to increase patient compliance. The revisions also attempt to consider the fact that many bacteria present can eventually become resistant to the antibiotic therapy. 

The guidelines for antibiotic prophylaxis was updated in 1990 and most recently in 1997. Before we review the most recent guidelines, as they relate to dentistry, please remember this. The original decision to use antibiotics to prevent infection was based on the assumption that if antibiotics are effective in treating an infection, they should be able to prevent them. Any studies to support this premise were done strictly in the laboratory and the primary mechanism for the prevention of endocarditis is not known. 

The AHA guidelines are followed by most practitioners, but it is not unusual to find certain changes in dosages or medications made by particular doctors. 

Antibiotic prophylaxis is recommended for the following:

High-risk category 

    • Prosthetic cardiac valves, including bioprosthetic and homograft valves 
    • Previous bacterial endocarditis 
    • Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot) 
    • Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category 
    • Most other congenital cardiac malformations (other than above and below) 
    • Acquired valvar dysfunction (eg, rheumatic heart disease) 
    • Hypertrophic cardiomyopathy 
    • Mitral valve prolapse with valvar regurgitation and/or thickened leaflets
Endocarditis prophylaxis is not recommended for the following:

Negligible-risk category (no greater risk than the general population) 

    • Isolated secundum atrial septal defect 
    • Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus 
    • Previous coronary artery bypass graft surgery 
    • Mitral valve prolapse without valvar regurgitation 
    • Physiologic, functional, or innocent heart murmurs 
    • Previous Kawasaki disease without valvar dysfunction 
    • Previous rheumatic fever without valvar dysfunction
    • Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
If you identify with a condition in the high or moderate risk groups, then antibiotic prophylaxis is recommended for the following dental procedures: 
    • Dental extractions 
    • Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance 
    • Dental implant placement and reimplantation of avulsed teeth 
    • Endodontic (root canal) instrumentation or surgery only beyond the apex 
    • Subgingival placement of antibiotic fibers or strips 
    • Initial placement of orthodontic bands but not brackets 
    • Intraligamentary local anesthetic injections 
    • Prophylactic cleaning of teeth or implants where bleeding is anticipated
Antibiotic prophylaxis is not recommended for the following dental procedures: 
    • Restorative dentistry (operative and prosthodontic) with or without retraction cord 
    • Local anesthetic injections (nonintraligamentary) 
    • Intracanal endodontic treatment; post placement and buildup 
    • Placement of rubber dams, postoperative suture removal, taking of oral impressions, and fluoride treatments 
    • Placement of removable prosthodontic or orthodontic appliances and orthodontic appliance adjustment 
    • Taking of oral radiographs 
    • Shedding of primary teeth
If antibiotic prophylaxis is necessary, the following medications and dosages are recommended by the AHA:
Standard prophylaxis Amoxicillin Adults: 2.0 g; children: 50 mg/kg orally 1 h before procedure
Unable to take oral medication Ampicillin Adults: 2.0 g IM or IV; children: 50 mg/kg IM or IV within 30 min before procedure
Allergic to Penicillin Clindamycin or Adults: 600 mg; children: 20 mg/kg orally 1 h before procedure
Cephalexin or cefadroxil or Adults: 2.0 g; children; 50 mg/kg orally 1 h before procedure
Azithromycin or clarithromycin Adults: 500 mg; children: 15 mg/kg orally 1 h before procedure
Allergic to penicillin and unable to take oral medications Clindamycin or Cefazolin Adults: 600 mg; children: 20 mg/kg IV within 30 min before procedure Adults: 1.0 g; children: 25 mg/kg IM or IV within 30 min before procedure

A complete listing of recommended procedures can be found at the American Heart Association websitewhich was the source for the infomation on this page.

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Stuart A. Greene, DDS-FAGD
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©2004 Stuart A. Greene, DDS-FAGD | Online since 1996 | Updated Continuously