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'At-risk' dental procedures

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'At-risk' dental procedures

This implementation advice makes two recommendations for antibiotic prophylaxis prior to ‘at-risk’ dental procedures for patients at high risk of infective endocarditis, applicable to two different groups of dental procedures.

For all patients at high risk of infective endocarditis undergoing an ‘at-risk’ dental procedure, there is a requirement for shared decision-making that reflects the patient’s values and preferences. The potential benefits and harms of antibiotic prophylaxis should be discussed to allow the patient to make an informed decision about whether prophylaxis is appropriate for their individual situation. More information on points to cover during this discussion is provided in Patient discussion aid.

Recommendation for extractions and oral surgery procedures 

For patients at high risk of infective endocarditis, offer antibiotic prophylaxis prior to extractions and oral surgery procedures.

Examples of these procedures include:

  • Dental extractions
  • Incision and drainage of abscess
  • All oral surgical procedures
  • Periodontal and endodontic surgery
  • Placement of dental implants including temporary anchorage devices and mini-implants
  • Uncovering implants and implant components that are sub-mucosal

Recommendation for procedures that involve manipulation of the gingival or periapical region of the teeth

For patients at high risk of infective endocarditis, consider antibiotic prophylaxis for dental procedures that involve manipulation of the gingival or periapical region of the teeth.

  • The consideration of antibiotic prophylaxis for these dental procedures must involve reaching a shared decision with the patient. This will require a discussion about the uncertain risk of infective endocarditis associated with the dental procedure and the potential benefits and harms of antibiotic prophylaxis, and consideration of the patient’s individual oral health status. The shared decision must fully reflect the patient’s values and preferences. A list of important points to discuss with the patient is available (see Patient discussion aid).

Examples of these procedures include:

  • PMPR* (including supra- and subgingival scaling)
  • Full periodontal examinations (including pocket charting in diseased tissues)
  • Plaque and bleeding indices
  • Subgingival restorations including fixed prosthodontics
  • Placement of preformed metal crowns 
  • Placement of subgingival rubber dam clamps and subgingival matrix bands
  • Placement and removal of orthodontic separators and bands
  • Endodontic treatment before apical stop has been established
  • Basic periodontal examination (BPE)**

*PMPR: professional mechanical plaque removal 32 (see Dental glossary)
**When considering antibiotic prophylaxis for BPE, take account of the patient’s oral health status (see below). 

The European Society of Cardiology (ESC) guideline19 defines ‘at-risk’ dental procedures as dental extractions, oral surgery procedures (including periodontal surgery, implant surgery, and oral biopsies) and procedures that involve manipulation of the gingival or periapical region of the teeth (including scaling and root canal procedures) (Class I recommendation; level of evidence B). This is consistent with the definition of dental procedures for which antibiotic prophylaxis is suggested in the American Heart Association (AHA) guideline.23 

There is a lack of high certainty evidence to support the definitions from these guidelines. A systematic review of observational studies33 found statistically significant associations between tooth extraction or oral surgery procedures and increased incidence of infective endocarditis in high risk patients. However, no significant associations were observed with endodontic treatment or scaling. 

The certainty of the evidence from this systematic review is low due to the observational nature of the included studies and other methodological limitations. However, given the high morbidity and mortality associated with infective endocarditis, this implementation advice makes two recommendations in favour of antibiotic prophylaxis prior to ‘at-risk’ dental procedures for patients at high risk of infective endocarditis.

The wording of each recommendation reflects the evidence for the dental procedures described, and, where relevant, patient-specific factors such as oral health status. In all situations, there is a requirement for shared decision-making that reflects the patient’s values and preferences.

Oral health status

Evidence suggests that patients with good oral health may be at less risk of bleeding during procedures that involve manipulation of the gingival tissues than those with signs and symptoms of gingivitis or unstable periodontitis.20 Therefore, the oral health status of the patient, as well as their values and preferences, should be taken into account when considering antibiotic prophylaxis for procedures that involve manipulation of the gingival or periapical region of the teeth. This emphasises the importance of providing advice on maintaining good oral health for patients at high risk and moderate risk of infective endocarditis (see Prevention of infective endocarditis and Patient discussion aid).

For example, when making a shared decision with a high risk patient about antibiotic prophylaxis for a basic periodontal examination (BPE), consider the oral health status of the patient and discuss with them:

  • the implications of their oral health status for their risk of IE
  • the uncertain risk of IE associated with the BPE 
  • the potential benefits and harms of antibiotic prophylaxis
  • their own values and preferences regarding antibiotic prophylaxis

The patient can then make an informed decision about whether or not they wish to have antibiotic prophylaxis for the BPE. 

Treatment planning

When treatment planning for a high risk patient who has chosen antibiotic prophylaxis for ‘at-risk’ dental procedures, consider carrying out multiple ‘at-risk’ procedures at the same visit (e.g. some periodontal indices, PMPR and subgingival restorations) to reduce the number of instances that the patient will need to take antibiotic prophylaxis.

Note that as patient factors, for example oral health status, experience of treatment and patient preferences, may change, it is likely that the shared decision about antibiotic prophylaxis for ‘at-risk’ procedures will have to be revisited for each new course of treatment. For dental procedures that are usually part of a routine examination, such as the BPE, the shared decision on prophylaxis should be revisited if these patient factors change. 

Antibiotic prophylaxis is not recommended for the following procedures or situations:

  • infiltration or block local anaesthetic injections in non-infected soft tissues 
  • supragingival restorations 
  • removal of sutures 
  • radiographs 
  • placement or adjustment of removable orthodontic or prosthodontic appliances
  • adjustment of fixed orthodontic appliances which does not involve placement or removal of orthodontic separators and bands 
  • following exfoliation of primary teeth
  • following trauma to the lips or oral mucosa

For advice on the management of patients at high risk or moderate risk of IE having ‘at risk’ dental procedures, see Management of patients at increased risk of infective endocarditis and Management flowchart.

For further explanation of the dental terms used in this implementation advice, see Glossary of dental terms.