You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


AHA Updates Recommendations for Antibiotic Prophylaxis for Dental Procedures

  • Authors: News Author: Steve Stiles
    CME Author: Charles P. Vega, MD
  • CME/CE Released: 4/24/2007; Reviewed and Renewed: 4/23/2008
  • Valid for credit through: 4/23/2009
Start Activity

Target Audience and Goal Statement

This article is intended for primary care clinicians, cardiologists, and other specialists who care for patients at risk for infective endocarditis.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • List patients at high risk for infective endocarditis after dental procedures.
  • Identify routine procedures that increase the risk for infective endocarditis among susceptible patients.


As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Steve Stiles

    Steve Stiles is a journalist for, part of the WebMD Professional Network. He has been reporting on cardiovascular medicine since 1984 and for the past 4 years has been a journalist for Steve is a graduate of Kenyon College and has an MS from the journalism department at Boston University. He can be contacted at [email protected]


    Disclosure: Steve Stiles has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P Vega, MD

    Associate Clinical Professor; Residency Program Director, Family Medicine, University of California-Irvine, Orange, California


    Disclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.

Accreditation Statements

    For Physicians

  • Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape, LLC designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity. Medscape Medical News has been reviewed and is acceptable for up to 300 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 09/01/07. Term of approval is for 1 year from this date. This activity is approved for 0.25 Prescribed credits. Credit may be claimed for 1 year from the date of this activity. AAFP credit is subject to change based on topic selection throughout the accreditation year.

    AAFP Accreditation Questions

    Contact This Provider

    For Nurses

  • Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Approved for 0.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 5 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.


AHA Updates Recommendations for Antibiotic Prophylaxis for Dental Procedures

Authors: News Author: Steve Stiles CME Author: Charles P. Vega, MDFaculty and Disclosures

CME/CE Released: 4/24/2007; Reviewed and Renewed: 4/23/2008

Valid for credit through: 4/23/2009


April 24, 2007 — Prophylactic antibiotic therapy for dental procedures is unlikely to prevent many cases of infective endocarditis and should be restricted to patients who would be at highest risk for the infection, such as those with prosthetic valves or certain congenital heart defects, according to updated guidelines by the American Heart Association (AHA) published online April 19 in the Publish Ahead of Print issue of Circulation.

"We've concluded that if giving prophylactic antibiotics prior to a dental procedure works at all — and there's no evidence that it does work — we should reserve that preventive treatment only for those people who would have the worst outcomes if they get infective endocarditis," noted Chair of the new guidelines writing group Walter R. Wilson, MD, from Mayo Clinic in Rochester, Minnesota, in a statement issued by the AHA. "This changes the whole philosophy of how we have constructed these recommendations for the last 50 years."

Based on an analysis of available literature, the document concludes that "random bacteremia" resulting from routine daily activities, such as chewing food or tooth brushing, is far more likely to cause IE [infective endocarditis] than bacteremia secondary to dental procedures.

"There should be a shift in emphasis away from a focus on a dental procedure and antibiotic prophylaxis toward a greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis and those conditions that predispose to the acquisition of infective endocarditis," write the authors of the updated guidelines.

Prophylactic antibiotics, the authors state, should not be given based on a lifetime risk for infective endocarditis but are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients, according to the guidelines, include those with the following:

  • Prior infective endocarditis

  • Prosthetic cardiac valves

  • Unrepaired cyanotic congenital heart defects, including palliative shunts and conduits

  • Congenital heart defects completely repaired with prosthetic material or a device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure

  • Repaired congenital defects with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device

  • Cardiac transplants and development of cardiac valvulopathy

Patient groups that may have received routine antibiotic prophylaxis in the past but are no longer candidates for it include those with mitral and aortic valve disease, rheumatic heart disease, or structural disorders like ventricular or atrial septal defects or hypertrophic cardiomyopathy, according to the AHA statement.

The revised guidelines were developed with the participation of and have been endorsed by the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics.

Disclosures of relevant financial relationships for the writing group and the document's reviewers are included in the guidelines.

Circulation. Published online April 19, 2007.

The complete contents of Heartwire , a professional news service of WebMD, can be found at, a Web site for cardiovascular healthcare professionals.

Clinical Context

The AHA last updated its guidelines for the prevention of infective endocarditis in 1997. However, the authors of the updated guidelines note that while certain dental procedures are associated with a high risk for transient bacteremia, so are tooth brushing and flossing (rates of transient bacteremia up to 68%) and chewing food (rates up to 51%). Therefore, patients are more likely to get infective endocarditis from their daily activities than from infrequent dental procedures.

The current guidelines were designed with a focus on the relatively rare phenomenon of infective endocarditis following medical and dental procedures.

Study Highlights

  • Few published studies address the magnitude of bacteremia associated with routine dental procedures, and no published data show that a greater bacteremic load is associated with a higher risk for infective endocarditis. Moreover, it is unclear if the duration of exposure to bacteremia affects the risk for infective endocarditis. These issues make it difficult to specify dental procedures for which antibiotic prophylaxis is more beneficial.
  • A crude estimate of the risk for infective endocarditis associated with dental procedures in the United States is 1 case of infective endocarditis for every 14 million dental procedures. This risk rises to 1 case per 114,000 procedures among patients with a prosthetic valve and 1 case per 95,000 procedures among patients with previous infective endocarditis.
  • No prospective, randomized, placebo-controlled studies have investigated the efficacy of antibiotic prophylaxis in prevention of infective endocarditis following dental procedures. Even if antibiotics were 100% effective in preventing infective endocarditis, the relative benefit of antibiotic prophylaxis would be small.
  • The new guidelines call for antibiotic prophylaxis of infective endocarditis among high-risk patients undergoing manipulation of gingival tissue or the periapical region of teeth. High-risk patients also should receive prophylaxis if undergoing a procedure that will perforate the oral mucosa. Such procedures do not include routine anesthetic injections, adjustment of orthodontic appliances, or bleeding from trauma to the oral mucosa.
  • Patients eligible for antibiotic prophylaxis prior to dental or other high-risk procedures include those with a prosthetic heart valve, previous infective endocarditis, and cardiac transplantation with subsequent valvulopathy, and patients with some forms of congenital heart disease (eg, unrepaired cyanotic disease, repaired heart defect using prosthetic material within 6 months of surgery, and repaired defects with residual defects near the site of prosthetic material).
  • Amoxicillin at a dose of 2 g (or 50 mg/kg in children) is recommended for most patients requiring antibiotics. This medication should be given to patients 30 to 60 minutes before the procedure. High-risk adults with penicillin allergy may receive cephalexin, 2 g; clindamycin, 600 mg; or either azithromycin or clarithromycin, 500 mg.
  • No antibiotic prophylaxis is necessary before routine bronchoscopy, but high-risk patients undergoing drainage of a known respiratory tract abscess should receive antibiotics before the procedure.
  • Routine antibiotic prophylaxis is not necessary before routine gastrointestinal or genitourinary procedures, including esophagogastroduodenoscopy or colonoscopy. Again, antibiotics may be considered prior to procedures designed to treat infections in the gastrointestinal or genitourinary tracts.
  • High-risk patients undergoing procedures on infected skin also may receive preprocedure antibiotic prophylaxis, and this antibiotic should be active against staphylococci.

Pearls for Practice

  • The current guidelines state that patients eligible for antibiotic prophylaxis prior to dental procedures include those with a prosthetic heart valve, previous infective endocarditis, cardiac transplantation with subsequent valvulopathy, unrepaired cyanotic heart disease, or recently repaired (within 6 months) congenital cyanotic disease.
  • The current guidelines state that high-risk patients may be considered for treatment with prophylactic antibiotics prior to manipulation of gingival tissue or the periapical region of teeth. High-risk patients also should receive prophylaxis if undergoing a procedure that will perforate the oral mucosa. Prophylactic antibiotics are necessary before gastrointestinal, genitourinary, or skin procedures only if these locations have known infection.


  • Print