Endocarditis prophylaxis at the dentist:
who should take antibiotics and when

Article written and reviewed by Dr Luca Moretti

Antibiotics before dental treatment are not needed by all patients with heart disease. According to ESC guidelines, endocarditis prophylaxis is recommended mainly for people at high cardiac risk when they undergo dental procedures capable of causing significant bacteremia, such as extractions, oral surgery, scaling with gingival manipulation and treatments involving the periapical region.
The main high-risk categories include people who have already had endocarditis, those with certain prosthetic valves or prosthetic material used for valve repair, and some people with congenital heart disease. Having common valvular heart disease, a pacemaker or a defibrillator does not automatically mean that antibiotics are required before dental treatment.

In practice, two things should be checked before a dental procedure:

• whether the cardiac condition belongs to a category for which prophylaxis is recommended or should be considered;
• whether the planned dental procedure manipulates the gingiva, periapical region or oral mucosa in a way considered to carry risk.

Prophylaxis aims to reduce the risk of a form of infective endocarditis related mainly to oral streptococci. It does not replace good dental hygiene and does not protect against every possible cause of endocarditis. The decision should be agreed with the physician and dentist on the basis of the actual heart condition, rather than being made independently every time dental treatment is scheduled.

Who should receive antibiotic prophylaxis before dental treatment

European recommendations indicate prophylaxis for patients with previous infective endocarditis. People who have already had the disease have a greater risk of a new episode and of complications, so invasive dental procedures require particular attention.
Prophylaxis is also recommended in the presence of surgically implanted prosthetic valves and material used for surgical valve repair. Transcatheter aortic and pulmonary prosthetic valves are also included in the ESC indications. Prosthetic valve endocarditis is particularly relevant because of its diagnostic difficulty and risk of complications.

Another category includes certain congenital heart diseases, particularly unrepaired cyanotic forms and situations treated with palliative shunts, conduits or other prosthetic material. After surgical repair, if no residual defects or prosthetic valve remain, the ESC limits the indication for prophylaxis to the first six months after the procedure.
Prophylaxis is also recommended in patients with ventricular assist devices. For transcatheter mitral or tricuspid repair, the ESC states that prophylaxis should be considered, whereas in heart transplant recipients it may be considered. In these situations, the indication should ideally be specified by the cardiologist who knows the exact type of procedure and device.

An important practical point concerns pacemakers and defibrillators: their presence alone is not an indication for dental antibiotic prophylaxis. The ESC specifies that antibiotics before dental procedures are not justified to prevent infection of an implantable cardiac device. Any cardiac device-related endocarditis has different mechanisms and preventive strategies.

Which dental procedures require prophylaxis and which do not

In patients for whom prophylaxis is indicated, the ESC recommends it when the procedure involves manipulation of gingival tissue, the periapical region of the tooth or perforation of the oral mucosa. Procedures considered at risk include dental extractions, oral surgery, periodontal surgery, implant surgery, oral biopsies, scaling and root canal treatments when they involve the area specified by the guidelines.
It is therefore not the generic fact of visiting the dentist that determines the need for antibiotics: what matters is what will actually be done. Two dental appointments can carry very different risks.

AHA recommendations, which are broadly consistent with the same general principle, do not consider injection of anesthetic through noninfected tissue, dental radiographs, placement or adjustment of removable orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth or bleeding caused by trauma to the lips or oral mucosa to be procedures at risk.
If a restorative or orthodontic procedure does not involve the gingiva and does not perforate the mucosa, it generally does not meet the definition of an invasive dental procedure requiring prophylaxis. If gingival manipulation or bleeding is expected, however, the actual procedure should be assessed.

Which antibiotic is used and when it should be taken

For an adult without allergy to penicillin or ampicillin, the standard ESC regimen for a high-risk dental procedure is amoxicillin 2 g orally as a single dose, 30-60 minutes before the procedure. Alternative regimens are available when oral administration is not possible and different options are available in cases of allergy.
The pediatric dose is calculated according to weight. In patients with penicillin allergy, the choice must take the type of allergic reaction into account, because some cephalosporins should not be used in people who have had anaphylaxis, angioedema or urticaria caused by penicillin or ampicillin.

ESC and AHA guidelines no longer recommend clindamycin as a routine drug for endocarditis prophylaxis, mainly because of its adverse-event profile and the risk of Clostridioides difficile infection. Alternatives listed by the ESC include, depending on the clinical situation, cephalexin, azithromycin or clarithromycin, doxycycline, cefazolin or ceftriaxone.
These regimens should not be interpreted as prescriptions for self-management. Allergies, age, pregnancy, renal function, antibiotics already being taken and clinical history can modify the choice. Prophylaxis should be prescribed by the professional who has verified the indication.

If the indicated dose has been forgotten, AHA recommendations allow administration up to two hours after the procedure in specific circumstances. This is not, however, a reason to routinely plan the antibiotic after treatment: the goal remains to achieve adequate blood concentrations before the bacteremia caused by the procedure.

Why antibiotics are not given to everyone with heart disease

Universal prophylaxis has progressively been abandoned because endocarditis is rare, bacteremia can also occur during normal everyday activities, and antibiotics can cause adverse reactions and promote resistance. In addition, there are no large randomized studies able to demonstrate directly, for every patient category, how much prophylaxis reduces risk.
More recent observational evidence has nevertheless strengthened the strategy of concentrating prophylaxis on high-risk patients. A U.S. study of nearly eight million people found, among high-risk individuals, a temporal association between invasive dental procedures and endocarditis and an association between prophylaxis and reduced risk. A subsequent 2024 systematic review and meta-analysis found a significant reduction in endocarditis after invasive dental procedures among high-risk individuals who had received prophylaxis.

This does not mean that antibiotics can eliminate the risk. The most important prevention is continuous: good oral health, treatment of dental infections and regular check-ups. The ESC recommends brushing twice daily in patients at high and intermediate risk; for high-risk patients it also recommends professional follow-up and hygiene at least twice a year.
A mouth with chronically inflamed gums exposes a person to repeated bacteremia during everyday activities. For this reason, postponing dental treatment for a long time out of fear of endocarditis can be counterproductive.

Frequently asked questions about dental endocarditis prophylaxis

Should people with a prosthetic valve take antibiotics before dental treatment?
For the prosthetic valve categories specified in ESC guidelines, yes, when the dental procedure is at risk, for example an extraction or a procedure that manipulates the gingiva or periapical region. The type of prosthesis and procedure should nevertheless be verified by the physician and dentist.

Should people with a pacemaker or defibrillator receive prophylaxis?
No, not simply because the device is present. Prophylaxis before dental treatment is not indicated to prevent CIED-related endocarditis.

Does scaling require antibiotics?
Scaling that manipulates gingival tissue is included among procedures at risk by the ESC, but antibiotics are necessary only if the patient also belongs to a category for which prophylaxis is indicated.

How long before the procedure should the antibiotic be taken?
The standard ESC regimen provides for a single dose 30-60 minutes before the procedure. The drug and dose must, however, be prescribed according to the individual situation.

Are antibiotics needed for every dental visit?
No. A visit, radiograph or procedure that does not involve the gingiva, periapical region or mucosa does not automatically require prophylaxis, even in many high-risk patients.