Antibiotic prophylaxis

Two different questions, two different answers.

Antibiotics before a dental procedure have only two genuine jobs: preventing infective endocarditis in a small group of cardiac patients, and preventing surgical-site infection after a handful of (mostly specialist) procedures. For everyone else they are not indicated — and good daily oral hygiene protects a high-risk heart more than a pre-appointment tablet does.

Infective endocarditis (IE)

Stop a procedure-related bacteraemia from seeding a vulnerable endocardium.

Prophylaxis is indicated only when a high-risk cardiac condition AND a high-risk dental procedure are both present.

Cardiac condition

Prophylaxis indicated

Prosthetic heart valve — including transcatheter (TAVI) and homograft valves
Prosthetic material used to repair a valve — e.g. annuloplasty rings or chords
Previous infective endocarditis
Ventricular assist device (VAD)
Unrepaired cyanotic congenital heart disease — including palliative shunts and conduits
Repaired congenital defect with a residual leak at or next to a prosthetic patch or device
Rheumatic heart disease

Not indicated

Mitral valve prolapse
Atrial or ventricular septal defect (without the features opposite)
Pacemaker or other cardiac implantable electronic device (incl. ICD)
Any other valvular or structural heart disease not listed opposite

TG: Antibiotic — Prevention of infective endocarditis, Table 2.5 (Sept 2025, amended June 2026).

Dental procedure

High-risk — cover if a cardiac condition is also present

Tooth extractions
Dental implant placement
Biopsy
Removal of soft tissue or bone
Subgingival debridement (scaling / root planing below the gumline)
Replanting an avulsed tooth
Supragingival debridement — only if it manipulates the gingival tissue

Low-risk — no prophylaxis

Local anaesthetic injection through non-infected tissue
Dental radiographs (X-rays)
Fitting or adjusting removable prostheses, orthodontic appliances or brackets
Taking impressions; fluoride and preventive care
Supragingival scaling that does not disturb the gingiva
Restoration above the gumline; suture removal
Shedding of deciduous (baby) teeth

TG keys the decision to whether gingival or periapical tissue is manipulated, or the oral mucosa perforated — not to a fixed list, and not to whether there is 'significant bleeding' (the bacteraemia rate is similar either way). The low-risk examples are illustrative of procedures that do not breach those tissues.

TG: Antibiotic — Prevention of infective endocarditis, Table 2.5 / dental procedures (Sept 2025, amended June 2026).

If — and only if — both gates are met

First lineAmoxicillin 2 g orally, 60 minutes before the procedure. Child: 50 mg/kg up to 2 g. Single dose.record →

Non-severe penicillin allergyCefalexin 2 g orally, 60 minutes before (child 50 mg/kg up to 2 g). Verify the allergy first — cross-reactivity is possible.record →

Severe penicillin allergyDoxycycline 100 mg orally, 60 minutes before (child by weight). Or azithromycin 500 mg — QT-prolongation risk, check with the patient's doctor first.record →

Oral route preferred; parenteral only if oral is not possible.
Single dose — there is no value in a post-procedure dose.
Batch multiple procedures into one (at most two) sittings to avoid repeat dosing.
Clindamycin is no longer recommended for IE prophylaxis (C. difficile risk).
A patient already on long-term benzathine benzylpenicillin (rheumatic-fever prophylaxis) can still receive amoxicillin.

TG: Antibiotic — Prevention of infective endocarditis, oral regimens for dental prophylaxis (Sept 2025, amended June 2026).

Surgical-site infection

Prevent local wound infection — a separate question from endocarditis.

Rarely indicated in general dental practice; the potential benefit is usually outweighed by the harms (diarrhoea, hypersensitivity, resistance).

Procedure

May need prophylaxis — mostly specialist OMFS

Insertion of prosthetic material (except dental implants)
Open reduction / internal fixation of mandibular or midfacial (Le Fort, zygomatic) fractures
Intraoral bone grafting
Orthognathic surgery
Cleft lip and palate repair

Prophylaxis NOT required

Tooth extractions
Third molar (wisdom tooth) surgery
Insertion or removal of dental implants; peri-implant surgery
Periodontal surgery
Periapical surgery
Soft- or hard-tissue removal — biopsies, exostoses, alveoloplasty

These are largely specialist oral & maxillofacial procedures; if prophylaxis is given, the drug and timing are set by the treating specialist or team, before the incision. Routine implant insertion is not an indication — it does not reduce post-operative infection.

TG: Oral & Dental — Antibiotic prophylaxis for dental procedures, Table 13.12 (Sept 2025).

Prosthetic joints, breast implants, VP / VA shunts, deep brain stimulatorsDo NOT change the advice on antibiotic prophylaxis before a dental procedure.

Dry socket (alveolar osteitis)Not an infection — it is premature clot lysis. Antibiotics do not prevent it.

Replanting an avulsed toothDo consider prophylaxis (amoxicillin; doxycycline if penicillin-allergic).

TG: Oral & Dental — Antibiotic prophylaxis for dental procedures, Table 13.12 (Sept 2025).

Walk the IE decision step by stepAmoxicillin record

Quick reference, reconciled to current Australian Therapeutic Guidelines. You confirm the cardiac diagnosis, the patient's medical/medication history, and every dose before prescribing. Antibiotic prophylaxis is an adjunct, never a substitute for good oral health and source control.

Therapeutic Guidelines: Antibiotic — Prevention of infective endocarditis (Sept 2025, amended June 2026); Oral & Dental — Antibiotic prophylaxis for dental procedures (Sept 2025).

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