Premed Guidelines

Reviewed By: Rebecca Comstedt, RDH, BS

Date: June 23, 2019

Here are the current recommendations as found on This resource looks at the current literature and the statements from the applicable associations. It is a site for MD’s to stay current, and it is put together by MD’s. 


2014 ADA Clinical Recommendation: “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”

According to; “Patients with prosthetic joints do not require antibiotic therapy prior to dental procedures. Although antibiotics were commonly given in the past in such circumstances, the American Academy of Oral Medicine, the American Dental Association, the American Academy of Orthopedic Surgery, and the British Society for Antimicrobial Chemotherapy all advise against the routine use of antibiotics prior to teeth cleaning, teeth scaling, or routine procedures such as filling of a dental cavity. However, active dental infections in patients with prosthetic joints should be treated promptly, and good oral hygiene should be maintained.”





Guidelines for antibiotic prophylaxis — In the past, American Heart Association guidelines recommended that most patients with a heart murmur receive antibiotics prior to almost any dental procedure, even minor ones. However, these guidelines have changed considerably over time as more information has become available about the actual risk of dental procedures for patients with heart conditions. Review of studies performed between 1950 and 2006, which included thousands of patients, has shown that there was no benefit of using preventive antibiotics, except in the highest risk patients [1].

Highest risk — People with the following conditions are considered to be at the highest risk of developing IE. Preventive antibiotics are generally recommended for people with the following conditions before certain procedures:

●A prosthetic heart valve

●Valve repair with prosthetic material

●A prior history of IE

●Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits

●Completely repaired congenital heart defects with prosthetic material or device during the first six months after the procedure (whether placed by surgery or by catheter intervention)

●Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic patch or prosthetic device


Moderate risk — People with the following conditions are considered to be at moderate risk of developing IE. Antibiotic prophylaxis is NOT generally recommended for people with moderate risk conditions. This is an important change from prior recommendations [1].

●Valve repair without prosthetic material

●Hypertrophic cardiomyopathy

●Mitral valve prolapse with valvular regurgitation and/or valvular thickening

●Most other congenital cardiac abnormalities not listed above

●Unrepaired ventricular septal defect, unrepaired patent ductus arteriosus

●Acquired valvular dysfunction (eg, mitral or aortic regurgitation or stenosis)


Low risk — People with the following conditions are thought to have a low risk of IE. Antibiotics have never been recommended for people with these conditions:

●Physiologic, functional, or innocent heart murmurs

●Mitral valve prolapse without regurgitation or valvular leaflet thickening

●Mild tricuspid regurgitation

●Coronary artery disease (including previous coronary artery bypass graft surgery)

●Simple atrial septal defect

●Atrial septal defect, ventricular septal defect, or patent ductus arteriosus that was successfully closed (either surgically or with a catheter-based procedure) more than six months previously

●Previous rheumatic fever or Kawasaki disease without valvular dysfunction

●People with pacemakers or defibrillators

Preventative antibiotics are recommended for high-risk patients (as outlined above) undergoing dental procedures that involve manipulation of the tissue of the gums, the periapical region of the teeth, or perforation of the lining membranes of the gums such as tooth extractions, routine dental cleaning (scaling), or drainage of a dental abscess.

Other procedures such as anesthetic injections, dental X-rays, placement of orthodontic or prosthodontics appliances, loss of baby teeth, or bleeding from trauma to the lips or cheeks do not require antibiotics even in high-risk patients.

Dental care recommendations — Anyone who is at risk of developing IE should follow a program of careful mouth and tooth care. This includes a professional cleaning every six months, twice-daily tooth brushing, and daily flossing. These measures can help to prevent plaque and bacteria from building up around the gums and teeth.



American Heart Association, click here for full text



Breast Implants

There are some sources that recommend a premed prior to dental prophylaxis on a patient following breast implants; however, most of the more reputable resources do NOT recommend a premed.

According to (an evidence-based, Physician-authored, clinical decision support resource) “There are no data to support administration of prophylactic antibiotics to women with prosthetic breast implants prior to dental procedures, and we do not recommend it.”


A good resource for general questions about premedication:

American Heart Association’s statement on premed: “Infective Endocarditis”

ADA’s statement on prosthetic joint premed: “Management of patients with prosthetic joints undergoing dental procedures”.