Gold standards for prophylaxis
The Dentaljuce audit app compares your prescriptions with a set of gold standards developed by academic and clinical staff at Dentaljuce.
These gold standards are used by the computer logic that allows the app to work.
This page lists and discusses the gold standards for when antibiotics are prescribed in general dental practice for prophylaxis.
Prophylaxis is used for two reaons:
- Prevention of post-operative infection at the site of a dental surgical procedure
- Prevention of systemic illness in medically compromised patients by reducing the transient bacteraemia associated with invasive dental procedures.
Historically, antibiotic prophylaxis was very common in dentistry. However, evidence has grown of its lack of effectiveness in many situations. At the same time, our knowledge of the bad effects of antibiotics on patients, the public and the environment has increased. This has caused its popularity to dimish.
The CGDent has summarised the available evidence for when prophylaxis is, and is not, indicated, and presented it in their guidelines publication Antimicrobial Prescribing in Dentistry - Good Practice Guidelines.
Medically compromised - routine treatment
Some dental procedures cause a transient bacteraemia. There is an argument that these bacteria might settle in various parts of the body and cause a localised infection there.
Bacterial endocarditis
If a patient is susceptible to bacterial endocarditis, it is believed that the oral bacteria that have entered the blood stream have the potential to settle on the rough surfaces in the heart and cause infection there.
The National Institute for Health and Care Excellence (NICE) reviewed the topic in 2008, and originally concluded that antibiotic prophylaxis was not needed for these patients, as transient bacteraemias are very common anyway (e.g. tooth brushing causes them).
In the UK, prescriptions for endocarditis prophylaxis virtually ceased after this. Scientific studies in subsequent years showed no increase in UK bacterial endocarditis, which tended to support the decision.
However, some cardiologists objected to NICE's broad-brush advice, and in 2016 NICE slightly reversed their position by stating there was a very small sub-group of "special consideration" endocarditis patients where, under the direction/advice of a cardiologist, prophylaxis may be provided for dental procedures.
In 2022, a paper was published that purported to show that having a tooth extracted, particularly a surgical extraction, definitely increased the risk of endocarditis in susceptible patients. This finding has not yet been reflected in the NICE guidelines.
When a cardiologist recommends prophylaxis in writing, and the dental patient fully understands the advantages and disadvantages (i.e. gives informed consent), a dental professional can prescribe antibiotic prophylaxis for bacterial endocarditis.
Prophylaxis for other conditions
Radiotherapy patients - prophylaxis may be recommended for dental extractions following an assessment of the risk of developing ORN
Prophylaxis is no longer normally or routinely recommended for other medical conditions, neither to prevent a localised dental infection occurring in someone "prone to infections" (i.e. immunocompromised patients), nor to prevent a distant infection elsewhere in the body. Specifically, it is not recommended for
- Joint replacements - not recommended
- Prosthetic implants - not recommended
- Renal dialysis - not normally recommended
- Intravenous access devices - not recommended
- Diabetes - not routinely recommended
- HIV - not routinely recommended
- Diabetes - not routinely recommended
- Chemotherapy - not normally recommended
- Solid organ transplants - not routinely recommended
- Haemopoietic or lymphoid tumours - not routinely recommended
- Prevention of MRONJ - not recommended
However, a dental professional should normally respect the advice, in writing, of a medical consultant who recommends that prohylaxis is provided. The dental professional should ensure that the patient fully understands the situation, and gives informed consent.
Medically compromised - emergency treatment
When a new patient is seen, and the history suggests that their medical consultant might advise prophylaxis with some dental procedures, the practice should seek confirmation in writing and keep the letter on file.
It is accepted that in some circumstances, e.g. emergency or domicillary visits with new patients, consultant advice may not be immediately available.
Here, when the patient believes that prophylaxis is essential, the dental professional may provide it after a full discussion of the risks and benfits.
Healthy patients
Dentists round the world frequently provide antibiotics following dental procedures to "prevent an infection setting in". The evidence shows that for the most part, this is un-necessary, and antibiotics make no difference to post-intervention healing.
There are two exceptions:
- Complex implant procedures (involving broad flaps)
- Bone augmentation procedures
Here, prophylaxis may be justified. Note that for normal implant placements, prohylaxis is not indicated.
Medically compromised - routine treatment
When a patient is medically compromised, the drug chosen for prophylaxis and its dose should be chosen by their medical consultant, and this information should be included in their letter stating the need for prophylaxis (which should be kept on file).
This applies even when the procedure is one where you would normally provide prophylaxis to any patient - for example a bone augmentation procedure.
Medically compromised patients may have special requirements regarding antibiotic therapy that are best decided by their medical team, so consult them whatever the reason for prophylaxis.
Medically compromised - emergency treatment
The CGDent recommend a single dose of amoxicillin 3g as first choice, taken one hour before treatment. The patient should take it at the practice, and wait there (in case an allergic reaction develops).
If allergic to penicillin (amoxicillin is a type of penicillin) then clindamycin 600mg single dose is recommended. Be aware that clindamycin can have very serious side effects, even with a single dose. If consultant advice is not available, the dental treatment cannot be deferred, and the patient is insistent about prophylaxis, be cautious when using clindamycin
Courses should not be given for prohylaxis: they increase the risk of side effects, and of bacterial resistance. Always use a single dose regime.
Healthy patients
The CGDent recommend a single dose of amoxicillin 3g as first choice, taken one hour before treatment. The patient should take it at the practice, and wait there (in case an allergic reaction develops).
If allergic to penicillin (amoxicillin is a type of penicillin) then clindamycin 600mg single dose is recommended. Be aware that clindamycin can have very serious side effects, even with a single dose.
If neither amoxicillin nor clindamycin are possible, the patient should be regarded as "medically compromised" and the advice of a consultant in infectious diseases should be sought.
Courses should not be given for prohylaxis: they increase the risk of side effects, and of bacterial resistance. Always use a single dose regime.