Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures

J Am Coll Cardiol. 2022 Sep 13;80(11):1029-1041. doi: 10.1016/j.jacc.2022.06.030. Epub 2022 Aug 17.


Background: Antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) is recommended to prevent infective endocarditis (IE) in those at high IE risk, but there are sparse data supporting a link between IDPs and IE or AP efficacy in IE prevention.

Objectives: The purpose of this study was to investigate any association between IDPs and IE, and the effectiveness of AP in reducing this.

Methods: We performed a case-crossover analysis and cohort study of the association between IDPs and IE, and AP efficacy, in 7,951,972 U.S. subjects with employer-provided Commercial/Medicare-Supplemental coverage.

Results: 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 (OR: 2.00; 95% 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).

Conclusions: We demonstrated a significant temporal association between IDPs (particularly extractions and oral-surgical procedures) and subsequent IE in high-IE-risk individuals, and a significant association between AP use and reduced IE incidence following these procedures. These data support the American Heart Association, and other, recommendations that those at high IE risk should receive AP before IDP.

Keywords: antibiotic prophylaxis; dental procedures; guidelines; infective endocarditis; prevention; risk.

MeSH terms

  • Aged
  • Antibiotic Prophylaxis / methods
  • Cohort Studies
  • Dentistry
  • Endocarditis* / etiology
  • Endocarditis* / prevention & control
  • Endocarditis, Bacterial* / epidemiology
  • Endocarditis, Bacterial* / etiology
  • Endocarditis, Bacterial* / prevention & control
  • Humans
  • Inosine Diphosphate*
  • Medicare
  • United States / epidemiology


  • Inosine Diphosphate