Antibiotics Before Dental Surgery—or Not?

In a case crossover study, researchers examine whether antibiotic prophylaxis during invasive dental procedures should be given to patients with cardiac conditions.


Does antibiotic prophylaxis protect patients with cardiac conditions against endocarditis from invasive dental procedures? Studies have long suggested both “yes” and “no.” Researchers from Université Paris Diderot and others note that clinical trials and cohort studies have not proved efficacy. Only 2 case-control studies done in the past 30 years have established an association between dental procedures and streptococcal infective endocarditis; neither was sufficiently powered to establish the efficacy of antibiotic prophylaxis.

Current U.S. and European guidelines vary in who must be covered: all patients, certain patients, or no patients at all. But a rise in the incidence of infective endocarditis among patients with prosthetic heart valves, implicating invasive dental procedures, “raised the question of whether the indications for antibiotic prophylaxis may be broadened again,” the researchers say. They cite 2016 NICE guidelines that “clearly specify” that it may be appropriate in individual cases.

Given that endocarditis can be fatal or expensive to treat—hospitals stays are long and valve surgery may be needed—the researchers decided to evaluate the association between invasive dental procedures and oral streptococcal infective endocarditis in a population-based cohort and a case crossover study.

In the first study of 138,876 patients with prosthetic heart valves, 69,303 underwent at least 1 dental procedure. Of 396,615 dental procedures, 26% were invasive. Patients received prophylactic antibiotics before half of the procedures.

Over a median 1.7 years of follow-up, 267 people developed infective endocarditis associated with oral streptococci. However, the rate of oral streptococcal infective endocarditis did not rise significantly in the 3 months after an invasive dental procedure, with or without antibiotic prophylaxis.

The case crossover study of patients with endocarditis indicated “the same direction of effect”: Although invasive dental procedures may be associated with oral streptococcal infective endocarditis, the magnitude of the association “remains uncertain.”


Tubiana S, Blotière PO, Hoen B, et al. BMJ. 2017;358: j3776.

doi: 10.1136/bmj.j3776.

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