Antibiotic prophylaxis for dental procedures: an update

SUMMARY

The Australian Therapeutic Guidelines: Oral and Dental and Antibiotic were updated in 2025 with revised indications for antibiotic prophylaxis for dental procedures and recommendations for prophylactic regimens.

Most community-based patients undergoing minor oral surgeries do not require antibiotic prophylaxis, unless they are profoundly immunocompromised; in which case, antibiotic prophylaxis may be considered in consultation with the treating medical specialist or team. Antibiotics may also be considered following reinsertion of avulsed (knocked-out) teeth.

Antibiotic prophylaxis is recommended for hospital-based patients undergoing specific oral and maxillofacial surgeries. It is also recommended for patients with high-risk cardiac conditions undergoing invasive dental procedures to prevent infective endocarditis.

 

Introduction

Transient bacteraemia is most commonly caused by routine oral hygiene practices, such as toothbrushing and interdental cleaning with dental floss, interdental brushes and toothpicks.¹ While these activities cause frequent, short-lasting bacteraemia, dental procedures associated with gingival manipulation or bleeding disrupt the oral biofilm, introducing bacteria into the systemic circulation and increasing the risk of infection at a surgical site or distant location in specific patient populations.¹ Administering antibiotics prior to undertaking specific transmucosal procedures can: (i) reduce infection risk at the surgical or trauma site, (ii) reduce the risk of systemic infection in profoundly immunocompromised patients, and (iii) prevent infective endocarditis in at-risk patients.

The presence and magnitude of bacteraemia can be directly proportional to the severity of oral inflammation.² This underscores the importance of maintaining good daily oral hygiene, particularly for patients at increased risk of infective endocarditis or prosthetic joint infections. These patients must receive clear guidance on effective plaque removal, as well as dietary and hydration advice, to support their gingival health to reduce their overall risk of infection.

In 2025, the Australian Therapeutic Guidelines: Oral and Dental³ and Antibiotic⁴ (‘the guidelines’) were updated to include revised indications for antibiotic prophylaxis for dental procedures and guidance on antibiotic selection. This article outlines the indications for antibiotic prophylaxis in dentistry and guideline-recommended drug regimens.

 

Indications for surgical antibiotic prophylaxis

In patients who are not profoundly immunocompromised and who do not have specific cardiac conditions, antibiotic prophylaxis is only indicated for specific oral and maxillofacial procedures (Table 1).

Table 1 Dental procedures and surgical antibiotic prophylaxis in patients who are not profoundly immunocompromised and who do not have high-risk cardiac conditions³

Dental procedures that do NOT require antibiotic prophylaxis	Dental procedures that do require antibiotic prophylaxis
Minor oral surgeries including: third molar (wisdom tooth) surgery tooth extractions insertion or removal of dental implants including peri-implant surgery periodontal surgery periapical surgery soft-tissue removal (e.g. biopsy) hard-tissue removal (e.g. alveoloplasty)	Some oral and maxillofacial procedures such as: procedures involving insertion of prosthetic material, with the exception of dental implants open reduction and internal fixation of mandibular or midfacial fractures intraoral bone grafting procedures orthognathic surgery (major jaw realignment surgery) cleft lip and palate surgeries
Adapted with permission from: Antibiotic prophylaxis for dental procedures [published 2025 Sep]. In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; accessed 2026 Mar 12. https://www.tg.org.au

Low rates of infections after minor oral surgery (1% for third molar extractions and 1 to 2% for implant surgery)^3,5 mean the risks of adverse drug reactions and development of antimicrobial resistance outweigh the benefits of administering antibiotic prophylaxis.^3,6,7

Despite Australian guideline recommendations, antibiotic prophylaxis has frequently been prescribed for minor oral procedures in Australia. In a national survey published in 2020, 24% of general dentists and 61% of oral and maxillofacial surgeons reported providing antibiotic cover for the surgical removal of third molars, with higher rates of prophylaxis for implant surgery (62% of general dentists and 72% of oral and maxillofacial surgeons).⁶ Notably, antibiotics were administered postoperatively for third molar surgery by 61% of dental clinicians, despite consistent evidence from Australia and overseas over the past 2 decades indicating limited benefit from this practice.^5,8

 

Reinsertion of avulsed (knocked-out) teeth

Antibiotic prophylaxis may be considered following reinsertion of avulsed (knocked-out) teeth. The rationale is that systemic antibiotics after replantation may reduce infection-related reactions and inflammatory root resorption.⁹ However, the evidence to support this recommendation is inconclusive – human studies have found nonsignificant associations between systemic antibiotic use and tooth survival, periodontal healing or pulpal revascularisation.^10,11

 

Special populations

Certain populations are at higher risk of dental procedure–related infections.

Patients who are profoundly immunocompromised

Antibiotic prophylaxis may be required for patients who are profoundly immunocompromised as these patients are highly susceptible to systemic infections from transient bacteraemia during dental procedures. Some medical conditions and drugs can result in profound immunocompromise (see Box 1 for drug examples). For more information, refer to the Australian Immunisation Handbook and Therapeutic Guidelines: Oral and Dental.

If patients who are profoundly immunocompromised require a transmucosal dental procedure (e.g. subgingival debridement, tooth extraction), antibiotic prophylaxis may be considered after consulting with the treating medical specialist or multidisciplinary team.³

If a dental clinician is uncertain whether antibiotic prophylaxis is needed (e.g. unable to assess severity of the immunosuppression), consult the treating medical specialist or team who can provide this assessment and advise on the need for prophylaxis.

Patients with high-risk cardiac conditions

Antibiotic prophylaxis to prevent infective endocarditis is recommended for patients with certain high-risk cardiac conditions undergoing invasive dental procedures associated with a higher risk of bacteraemia (Box 2). The list of cardiac indications for infective endocarditis prophylaxis has been expanded in the 2025 Therapeutic Guidelines: Antibiotic and now includes all patients with rheumatic heart disease.^4,13

Supragingival instrumentation

Current evidence and expert consensus do not support the routine use of antibiotic prophylaxis for supragingival instrumentation. Supragingival instrumentation (often referred to as supragingival debridement or scaling) and commonly performed as part of professional mechanical plaque removal, is generally performed with full visual access, removing hard (calculus) and soft (biofilm) tooth deposits above the gingival margin. In contrast, subgingival instrumentation (also referred to as subgingival debridement and previously termed scaling and root planing) is a transmucosal procedure involving removal of subgingival hard (calculus) and soft (biofilm) tooth deposits attached to the tooth root, in close apposition to the inflamed internal lining of the periodontal pocket.

The previous inclusion of supragingival debridement as an indication for endocarditis prophylaxis in the guidelines may reflect the fact that the cited literature does not clearly distinguish between supragingival and subgingival procedures. In particular, the term ‘scaling’ is often used interchangeably with ‘scaling and root planing’¹⁵ or incorporated into broad definitions of ‘invasive dental procedures’, without considering supragingival instrumentation as a discrete intervention. This is despite supragingival instrumentation being less invasive than subgingival instrumentation.^16,17 Evidence from the United Kingdom demonstrates that, even when supragingival and subgingival instrumentation are grouped together as an ‘invasive dental procedure’, there is no significant difference in the incidence of infective endocarditis per million dental procedures, whether or not antibiotic prophylaxis is used, in high-risk patients.¹⁸ A June 2026 update of Therapeutic Guidelines: Antibiotic no longer includes supragingival debridement as an indication for endocarditis prophylaxis and acknowledges that evidence is conflicting.⁴

Patients with prosthetic joint replacements

The guidelines do not routinely recommend antibiotic prophylaxis for patients with prosthetic joint replacements.⁴ This is supported by the 2014 American Dental Association expert panel, which concluded that the potential risk of adverse effects outweighs the potential benefits of prophylaxis due to the low risk of bacteria seeding the joint prosthesis and subsequent infection.¹⁹

Recent evidence continues to support this conclusion; no positive temporal association has been demonstrated between transmucosal dental procedures and prosthetic joint infection, including late prosthetic joint infections occurring 3 months or more after surgery.^20,21

In situations where an orthopaedic surgeon recommends antibiotic prophylaxis contrary to the dentist’s recommendation, it is appropriate for the orthopaedic surgeon to discuss the risks and benefits of prophylaxis with the patient and prescribe the antibiotic, thus assuming responsibility for potential adverse effects arising from antibiotic use. Additionally, the patient must be informed of the rationale for the dentist’s decision not to prescribe antibiotic prophylaxis based on current guidelines.

However, for patients with a history of complications associated with their prosthetic joint (e.g. previous infection), prophylactic antibiotics may be required. This decision should be made in consultation with the orthopaedic surgeon after the dentist has undertaken a thorough assessment of the patient’s medical history.¹⁹

 

What antibiotics to prescribe for prophylaxis and when

The therapeutic principle underlying prophylaxis is to ensure peak plasma concentration of antibiotic at the time of procedure-induced bacteraemia, thus reducing the risk of infection.²² This requires administering the antibiotic before the procedure (except when antibiotics are considered after replanting an avulsed tooth).

Surgical antibiotic prophylaxis regimen

Intravenous antibiotics are used in a hospital setting before specific oral and maxillofacial surgical procedures to prevent infection at the surgical site (Table 1). The guidelines recommend intravenous benzylpenicillin 1 hour prior to procedures that involve incision through the oral mucosa only (e.g. cleft lip and palate repairs). For procedures involving incision through the skin and oral mucosa (e.g. temporomandibular joint replacement), intravenous cefazolin 1 hour before the procedure, plus metronidazole 2 hours before, is recommended.^3,4

Intravenous cefazolin plus metronidazole is recommended for patients who have had a nonsevere (immediate or delayed) or severe immediate hypersensitivity reaction to a penicillin (Table 2).⁴ For patients who have had a severe delayed hypersensitivity reaction to a penicillin (Table 2), clindamycin is recommended.⁴

Table 2 Symptoms of penicillin hypersensitivity reaction categorised by onset and severity³

Onset of reaction	Severity of reaction
	Severe	Nonsevere
Immediate (typically within 1 to 2 hours of drug exposure)	anaphylaxis, compromised airway, airway angioedema, hypotension, collapse	urticaria, mild immediate rash, benign childhood rash, maculopapular rash
Delayed (typically days after starting treatment)	severe cutaneous adverse reaction or significant organ involvement such as acute interstitial nephritis	usually benign childhood rash, maculopapular rash
Adapted with permission from: Antimicrobial hypersensitivity in dental practice [published 2025 Sep]. In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; accessed 2026 Apr 10. https://www.tg.org.au

After reinsertion of avulsed teeth

The Therapeutic Guidelines: Oral and Dental is consistent with the International Association of Dental Traumatology guidelines and amoxicillin may be considered after replanting an avulsed tooth.^3,9

Doxycycline, previously the first-line prophylactic antibiotic for avulsed teeth, is now recommended only for patients with a penicillin hypersensitivity reaction.³ Doxycycline can be safely prescribed to children of all ages because short-term use (less than 21 days) is not associated with tooth discolouration, enamel hypoplasia or bone deposition.³

Liquid doxycycline is not available in Australia. Therefore, for paediatric patients with penicillin hypersensitivity who have difficulty swallowing tablets, the doxycycline dose can be rounded to the nearest 25 mg using available tablet formulations (50 mg and 100 mg), which can be safely halved or quartered to achieve the prescribed dose.

Infective endocarditis prophylaxis regimen

For adults without penicillin allergy who require endocarditis prophylaxis for dental procedures (e.g. those with high-risk cardiac conditions), oral amoxicillin is recommended 1 hour before the procedure.⁴ Amoxicillin has an elimination half-life of approximately 1 to 2 hours, with effective prophylactic plasma concentrations typically maintained for up to 4 hours.²³ Routine intraoperative redosing is not usually required.

If a procedure is delayed, amoxicillin concentrations may fall below prophylactic concentrations, and a full repeat dose may be required. Scheduling patients at times when a procedure is more likely to begin on time (e.g. beginning of the day, after lunchtime) may reduce the need for repeat dosing. However, if a procedure is delayed, a repeat dose should be administered immediately prior to the rescheduled procedure.²⁴ In rare situations where active tissue manipulation may be prolonged more than 3 hours (some oral and maxillofacial surgeries), a second dose may be considered. However, this decision must be based on procedural risk rather than elapsed time alone.²⁴

For adults who have had a nonsevere (immediate or delayed) penicillin hypersensitivity, oral cefalexin is recommended 1 hour before the procedure.⁴ For patients who have had a severe (immediate or delayed) penicillin hypersensitivity, doxycycline is the preferred alternative antibiotic. Azithromycin is an option if doxycycline cannot be used.⁴ Prescribers need to be aware that azithromycin can prolong the QT interval and is contraindicated in patients with congenital long QT syndrome.²⁵

Clindamycin is no longer recommended for endocarditis prophylaxis because it has been associated with a higher frequency of severe adverse outcomes compared with other antibiotics.²⁶

Assessment of penicillin allergy

While many patients report they are allergic to penicillin (9% of hospitalised patients), less than 1% have a true severe allergy.²⁷ Despite the fact that severe penicillin allergy is rare, patients who claim to have a penicillin allergy are generally prescribed an alternative non–beta-lactam antibiotic, which can lead to increased risk of drug-related adverse outcomes like clindamycin-associated Clostridioides difficile colonisation and infections.²⁸ When taking a comprehensive medical history, it is important that clinicians critique patient claims of antibiotic allergy as this guides antibiotic choice. Clinicians should ask about the nature of the reaction, when it occurred and whether treatment was needed to understand if the patient has a true allergy or a non–immune-mediated adverse effect (e.g. diarrhoea). This includes determining the severity (severe or nonsevere) and onset (immediate or delayed) of symptoms (Table 2). Referral to the patient’s general practitioner should be pursued to confirm the allergy status of the patient.

 

Conclusion

Updated Australian guidelines recommend antibiotic prophylaxis only for patients undergoing specific dental procedures to prevent surgical site infection, and for patients with cardiac conditions at increased risk of infective endocarditis. Antibiotic prophylaxis may also be considered in patients who are profoundly immunocompromised or following reinsertion of avulsed teeth. Appropriate prescribing of antibiotics in dentistry is essential to reduce unnecessary antibiotic use and preserve the long-term effectiveness of available therapies.

This article was finalised on 22 June 2026.

Conflicts of interest: Tihana Divnic-Resnik has received travel and accommodation support and payments from Curaprox for delivering continuing professional development courses and presentations. Tihana is a Branch Executive Committee member of the Australian Society of Periodontology.

Smitha Sukumar has received research funding from eviDent and the Royal Australasian College of Dental Surgeons. Smitha is a member of the Australian Dental Association Dental Therapeutics Committee.

Atieh Sadr and Elvis Trinh declared no conflicts of interest.

This article is peer reviewed.