Antibiotic prophylaxis: 71 oral surgery procedures per case of endocarditis prevented
A scoping review of 34 papers: in patients at high cardiac risk, prophylaxis prevents one case of infective endocarditis per approximately 244 invasive dental procedures, 143 extractions or 71 oral surgery procedures.
The risk concentrates in extractions and oral surgery
The scoping review, conducted according to the PRISMA-ScR procedure, searched three databases for the period from January 2021 to October 2025 and tracked the citations of the main guidelines. Thirty-four papers entered the synthesis: guidelines, systematic reviews, observational studies and registry analyses.
The picture that emerges from them is not unanimous. The American Heart Association (2021) and the European Society of Cardiology (2023) recommend antibiotic prophylaxis for patients with high-risk cardiac conditions undergoing invasive dental procedures, defined as procedures involving manipulation of the gingiva or the periapical region and perforation of the mucosa. The British NICE does not recommend routine prophylaxis, but supports an individual decision with informed consent.
More recent figures show where the association is strongest. The short-term risk of infective endocarditis is most pronounced after extractions and oral surgery procedures in high-risk patients. To prevent a single case, prophylaxis has to cover about 244 invasive procedures, 143 extractions or 71 oral surgery procedures. The gap between those three figures is the message of the review: prophylaxis yields most where the procedure is most aggressive and the patient most vulnerable.
Limitations
The evidence is predominantly observational — registries and cohorts, without randomised trials — so the stated estimates of the number of procedures per case prevented carry considerable uncertainty. A scoping review by definition maps the literature and does not provide a pooled estimate of effect.
For your practice
- Before an extraction or an oral surgery procedure, check the cardiac risk category; it was precisely these procedures that carried the strongest association, not every contact with the gingiva.
- The guidelines diverge (AHA and ESC versus NICE), so record the decision and the discussion with the patient in the chart.
- Maintaining oral health is the foundation of prevention: fewer invasive procedures in a high-risk patient also means fewer opportunities for bacteraemia.