Approach to endocarditis prophylaxis for dental procedures

Bacteraemia associated with dental procedures usually involves viridans group streptococci, which are known to cause infective endocarditis. Traditionally, the presence of ‘significant bleeding’ associated with a dental procedure was assumed to be an indication of bacteraemia and hence a need for prophylaxis; however, studies show that bleeding is a poor indicator of bacteraemia from dental procedures.

Self-performed oral hygiene (eg toothbrushing, flossing, use of oral irrigators) can produce a similar incidence of bacteraemia to that caused by most dental procedures (excluding extractions). As these activities are performed more frequently than dental procedures, they have the potential to produce regular episodes of bacteraemia. Bacteraemia from self-performed oral hygiene is strongly associated with poor oral hygiene and gingival disease; therefore, the maintenance of good oral health and hygiene is likely to be more important than the use of antibiotic prophylaxis—see General measures to prevent infective endocarditis. Dental procedures are generally of longer duration than self-performed oral hygiene, so expose patients to a longer duration of bacteraemia. Antibiotic prophylaxis is therefore warranted for some dental procedures for high-risk patients.

Endocarditis prophylaxis is recommended only for patients with a cardiac condition listed here who are undergoing procedures involving manipulation of the gingival or periapical tissue or perforation of the oral mucosa (eg extraction, implant placement, biopsy, removal of soft tissue or bone, subgingival scaling and root planing, replanting avulsed teeth).

Other dental procedures do not require endocarditis prophylaxis. Surgical antibiotic prophylaxis may be indicated even if endocarditis prophylaxis is not—see Surgical prophylaxis for oral maxillofacial surgery.