Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Patients with Cardiac Conditions
Numerous cardiac conditions place patients at risk for endocarditis following dental manipulation. The American Academy of Pediatric Dentistry (AAPD) endorses the American Heart Association's (AHA) guideline on prevention of bacterial endocarditis. In addition to those diagnoses listed in the AHA guidelines, patients with a history of intravenous drug abuse and certain syndromes (e.g., Down, Marfan) may be at risk for developing bacterial endocarditis due to associated cardiac anomalies. The table below titled "Suggested Antibiotic Prophylactic Regimens," lists the suggested prophylaxis regimens.
Suggested Antibiotic Prophylactic Regimens*
| Children not allergic to penicillin |
Amoxicillin 50 mg/kg (maximum 2 grams) orally 1 hour prior to dental procedure |
| Children not allergic to penicillin and unable to take oral medications |
Ampicillin 50 mg/kg (maximum 2 grams) intravenous (IV) or intramuscular (IM) within 30 minutes before dental procedure |
| Children allergic to penicillin |
Clindamycin 20 mg/kg (maximum 600 mg) orally 1 hour prior to dental procedure or Azithromycin 15 mg/kg (maximum 500 mg) orally 1 hour prior to procedure |
| Children allergic to penicillin and unable to take oral medications |
Clindamycin 20 mg/kg (maximum 600mg) IV or IM or Cefazolin 25 mg/kg (maximum 1gram) IV or IM within 30 min before dental procedure |
*No second dose is recommended for any of these regimens. Adapted from: Dajani AS, Taubert KA, Wilson W, Bolger AF, et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. JAMA. 1997;227:1794-1801.
Patients with Compromised Immunity
Patients with a compromised immune system may not be able to tolerate a transient bacteremia following invasive dental procedures. This category includes, but is not limited to, patients with the following conditions:
- Human immunodeficiency virus (HIV)
- Severe combined immunodeficiency syndrome (SCIDS)
- Neutropenia
- Immunosuppression
- Sickle cell anemia
- Status post splenectomy
- Chronic steroid usage
- Lupus erythematosus
- Diabetes
- Status post organ transplantation
Discussion of antibiotic prophylaxis for patients undergoing chemotherapy, irradiation, and hematopoietic cell transplantation appears in a separate AAPD guideline.
Patients with Shunts, Indwelling Vascular Catheters, or Medical Devices
Bacteremia following an invasive dental procedure may lead to colonization of shunts or indwelling vascular catheters. Vascular catheters, such as those required by patients undergoing dialysis, chemotherapy, or frequent administration of blood products, are susceptible to bacterial infections. Ventriculoatrial (VA) or ventriculovenus (VV) shunts for hydrocephalus are at risk of bacteremia-induced infections due to their vascular access. In contrast, ventriculoperitoneal (VP) shunts do not involve any vascular structures and, consequently, do not require antibiotic prophylaxis.
The AAPD endorses the recommendations of the American Dental Association and the American Academy of Orthopaedic Surgeons for management of patients with prosthetic joints. Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it indicated routinely for most dental patients with total joint replacements. Antibiotics may be considered when high-risk dental procedures (See table below titled "Dental Procedures Associated with Higher Incidence of Bacteremia") are performed for dental patients within 2 years following implant surgery or for patients who have had previous joint infections. Consultation with the child's physician may be necessary for management of patients with other implanted devices (e.g., Harrington rods, external fixation devices).
Dental Procedures Associated with Higher Incidence of Bacteremia
- Dental extractions
- Periodontal procedures including surgery, subgingival placement of antibiotics fibers/strips, scaling and root planning, probing, recall maintenance
- Dental implant placement and replantation of avulsed teeth
- Endodontic instrumentation or surgery only beyond the apex
- Initial placement of orthodontic bands but not brackets
- Intraligamentary and intraosseous local anesthetic injections
- Prophylactic cleaning of teeth or implants where bleeding is anticipated
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