Antibiotic Prophylaxis Against Infective Endocarditis Before Dental Procedures

Quick Takes

  • Using large administrative databases, a case-crossover analysis demonstrated a significant temporal association between infective endocarditis (IE) and invasive dental procedures (IDPs) in the preceding 4 weeks, with the strongest associations for dental extractions and oral-surgical procedures.
  • In the same analysis, antibiotic prophylaxis (AP) was associated with a significant reduction in the incidence of IE following IDPs.
  • A cohort study confirmed the associations between IE and extractions or oral-surgical procedures in those at high IE risk, and the effect of AP in reducing those associations.

Study Questions:

Is there an association between invasive dental procedures (IDPs) and infective endocarditis (IE), and is antibiotic prophylaxis (AP) effective in reducing that risk?


Using data extracted from the Commercial/Medicare-Supplemental prescription benefits database and the IBM MarketScan Dental database, a case-crossover analysis and cohort study were performed for the association between IDPs and IE, and of AP efficacy in reducing IE risk among 7,951,972 US subjects (≥18 years of age with >16 months of linked data from January 2000–August 2015) with employer-provided Commercial/Medicare-Supplemental coverage. IE-related hospital admissions were identified using primary or secondary International Classification of Diseases, Ninth Edition (ICD-9) discharge diagnostic codes. IDPs were defined as those dental procedures that involve the manipulation of gingival tissue or the periapical region of the teeth, perforation of the oral mucosa, and endodontic procedures. Prescription benefits data were used to identify if AP was prescribed for each dental visit.


Time course studies showed that IE was most likely to occur within 4 weeks of an IDP. For those at high IE risk, case-crossover analysis demonstrated a significant temporal association between IE and IDPs in the preceding 4 weeks (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.59-2.52; p = 0.002). This relationship was strongest for dental extractions (OR, 11.08; 95% CI, 7.34-16.74; p < 0.0001) and oral-surgical procedures (OR, 50.77; 95% CI, 20.79-123.98; p < 0.0001). AP was associated with a significant reduction in IE incidence following IDP (OR, 0.49; 95% CI, 0.29-0.85; p = 0.01). The cohort study confirmed the associations between IE and extractions or oral-surgical procedures in those at high IE risk, and the effect of AP in reducing these associations (extractions: OR, 0.13; 95% CI, 0.03-0.34; p < 0.0001; oral-surgical procedures: OR, 0.09; 95% CI, 0.01-0.35; p = 0.002).


There was a significant temporal association between IDPs (particularly extractions and oral-surgical procedures) and subsequent IE in high-risk individuals, and a significant association between AP use and reduced IE incidence following these procedures. The authors concluded that these data support the American Heart Association (AHA) and other guideline recommendations that those at high IE risk should receive AP before IDPs.


Since 1955, the AHA has issued guidelines on AP to reduce the risk of IE among people undergoing IDPs. However, in the absence of clinical trials documenting the efficacy of AP in reducing IE risk, and with stated concern for adverse drug reactions and the promotion of antibiotic resistance, AHA and European Society of Cardiology recommendations currently limit AP use to those at the highest risk, and current United Kingdom recommendations support the complete cessation of AP. Although previous IE case-crossover studies have been small and lacked statistical power, this study, relying on large administrative databases, demonstrated that AP use prior to IDPs (especially extractions or other oral-surgical procedures) was associated with a significant reduction in the incidence of IE in high-risk individuals. Study limitations include the reliance on administrative databases with their inherent limitations and that probably are not representative of the whole US population, and the inability of using those databases to discern the microbiological causes of IE.

This study refers to patients based on their risk of IE; whereas AHA guideline recommendations for AP very specifically are based on a high risk of IE adverse outcomes, not a high risk of developing IE. Because this study addressed whether AP affected the likelihood of a diagnosis of IE and not whether AP affected the outcome of IE, the study results seem to support broadening AHA recommendations to include AP for all patients at high lifetime risk of developing IE rather than restricting AP only to those at the highest risk of an adverse outcome. Although this study did not show a reduction in the incidence of IE among those at moderate risk, this may be a function of study power, and in the absence of data supporting adverse drug reactions or antibiotic resistance promoted by AP, re-broadening AP recommendations to include all individuals at increased risk of IE might be appropriate.

Clinical Topics: Prevention, Valvular Heart Disease

Keywords: Antibiotic Prophylaxis, Dentistry, Drug Resistance, Microbial, Endocarditis, Endocarditis, Bacterial, Heart Valve Diseases, Mouth Mucosa, Primary Prevention, Risk, Minimally Invasive Surgical Procedures, Surgical Procedures, Operative, Tooth Extraction

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