Guidance around the use of antibiotic prophylaxis for the prevention of infective endocarditis has changed significantly over the past couple of decades. The latest update, released earlier this year, has a major effect for dentists. Dr Leo Briggs, a qualified dentist and deputy head of the Dental Defence Union, sums up the latest guidance

UK dentists are being made aware of a recent major change to the use of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) following at-risk dental procedures.

Advice on preventing IE in high-risk patients undergoing dental procedures has evolved considerably over the last two decades.  Many clinicians have been left unclear around the most current expectations and where they stand from a medico-legal perspective. Recent updates from the Scottish Dental Clinical Effectiveness Programme (SDCEP), endorsed by NICE, aim to provide greater clarity and have important implications for everyday dental practice.

What is infective endocarditis?

IE is a serious bacterial infection of the heart valves, with a 30% mortality in the first year after diagnosis and significant ongoing morbidity among survivors. Approximately 30–40% of cases are caused by bacteria originating from the mouth, making prevention a primary focus of care for patients at highest risk.

Advice developments over the last two decades

For many years, AP was considered standard practice for high-risk patients undergoing certain dental procedures. That changed in 2008, when NICE Clinical Guideline 64 (CG64) recommended against all use of AP universally. In 2016, this approach was softened slightly, with the addition that AP was ‘not recommended routinely’ for high-risk patients.

Meanwhile, the SDCEP developed advice to help dental teams implement NICE guidance. In 2024, NICE endorsed SDCEP’s implementation advice for high-risk patients and directed dental professionals to use it when managing high-risk patients.

SDCEP’s implementation advice was subsequently updated in 2026 and now takes into account guidance from the updated 2023 European Society of Cardiology (ESC) guidance and the American Heart Association (AHA).

What has changed?

The 2026 update to SDCEP’s advice, endorsed by NICE, introduces significant changes to clinical practice. Dentists are now recommended to offer AP to all individuals at high-risk of IE before extractions or oral surgery procedures, and to consider AP for high-risk individuals undergoing any other at-risk dental procedures that involve manipulation of the gingival tissues or periapical region of the teeth.

Key points at a glance

The SDCEP's Patients at risk of infective endocarditis guidance states:

  • Antibiotic prophylaxis is recommended or should be considered for patients with high risk cardiac conditions
  • Antibiotic prophylaxis is not recommended for patients with moderate risk cardiac conditions
  • All patients at increased risk of infective endocarditis should be given advice about prevention
  • Dental teams should engage in shared decision making with their patients about antibiotic prophylaxis for at-risk dental procedures
  • Dental teams should explain the potential benefits and harms of antibiotic prophylaxis so that patients can make an informed decision about whether prophylaxis is appropriate for their individual situation

Prescribing antibiotic prophylaxis

The individual patient’s risk profile, alongside shared decision-making factors should be considered when prescribing AP, such as:

  • Specific information provided by the patient’s cardiology team;
  • The patient’s values and preferences;
  • The patient’s oral health status.

As with all prescribing decisions, principles of antimicrobial stewardship remain important. Antibiotics should only be prescribed where clinically indicated, using narrow-spectrum agents where possible and accurate assessment of allergy history should be assessed.

Patients should also be informed about the potential harms of antibiotic use, including adverse reactions that may occur even after a single dose. The indication for prophylaxis, the rationale for any prescribing decision and details of the discussion should all be clearly documented in the clinical record.

Oral health should also be taken into consideration. Patients with gingivitis or unstable periodontitis are more likely to experience bleeding during procedures involving manipulation of the gingival tissues. Maintaining good oral health remains an important component of reducing overall risk.

If a patient requires AP prior to seeing the dental hygienist or dental therapist, it’s the GDP’s responsibility to prescribe the antibiotics so they can be taken in advance of the appointment.

If collecting from the dental practice, the GDP should dispense the antibiotics directly to the patient. It’s important to note that non-dentists are not permitted to dispense antibiotics for AP. Therefore, antibiotics should not be left in a locked cupboard for a dental hygienist, dental therapist, or any other member of the dental team to dispense to patients.

Talking to patients about infective endocarditis

Patients and/or their carer or guardian must be made aware of their risk of infective endocarditis and be provided with advice about prevention, including:

  • the importance of maintaining good oral health, including individualised advice on oral hygiene and attending for regular dental check-ups (the frequency of recall should be based on an individual oral health risk assessment)
  • symptoms that may indicate infective endocarditis and when to seek expert advice;

A patient discussion aid is available from SDCEP.  The discussion should be recorded in the patient’s clinical notes.

For more information, go to Antibiotic Prophylaxis Against Infective Endocarditis