Antibiotic Prophylaxis and Dental Trauma Guidelines for the INBDE
Give antibiotic prophylaxis only to the four highest-risk cardiac groups, and only before procedures that manipulate the gingiva or periapical region or perforate the mucosa: amoxicillin 2 g (children 50 mg/kg) as one dose 30 to 60 minutes before. Clindamycin is no longer recommended, and most patients with joint replacements need no antibiotics. For a knocked-out permanent tooth, replant it at once or store it in milk, then use a flexible splint for 2 weeks; never replant a primary tooth.
How The Study Boards helps you with prophylaxis and trauma guidelines
The INBDE rarely asks “what is the dose?” on its own. It hides a valve replacement or an avulsed incisor inside a long case. Our Modules and Master Files teach these guidelines, and our INBDE course drills them in case format across the Master Tests, Grand Tests and nightly 9 PM New York time live tests. The course is extremely personalised: red lines and assignments are given to you on the go, the course learns from the way you study, and faculty are there to assist you.
Who needs antibiotic prophylaxis before dental treatment?
The current rules come from the American Heart Association’s 2021 scientific statement, written with the American Dental Association. It made no changes to the 2007 patient groups: prophylaxis is still only for the patients at highest risk of a bad outcome from endocarditis.1 At The Study Boards, we teach these four groups as a short checklist you run through for every medical history on the exam.
| Group | Cardiac condition: prophylaxis suggested |
|---|---|
| 1. Prosthetic material | Prosthetic cardiac valve, including transcatheter-implanted valves (TAVI/TAVR) and homografts; prosthetic material used for valve repair, such as annuloplasty rings, chords or clips; left ventricular assist devices and implantable hearts |
| 2. Previous endocarditis | Any history of infective endocarditis, including relapse or recurrence |
| 3. Congenital heart disease (only these) | Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits; a defect completely repaired with prosthetic material or a device, for the first 6 months after the repair; repaired congenital heart disease with residual shunts or valvular regurgitation at or next to a prosthetic patch or device |
| 4. Heart transplant | Cardiac transplant recipients who develop valve regurgitation due to a structurally abnormal valve (valvulopathy) |
From the AHA 2021 statement and the ADA’s prophylaxis summary.12
Which dental procedures need it?
Only patients in the four groups above get prophylaxis, and only for certain procedures.1
Prophylaxis suggestedAll dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa. Extractions and scaling and root planing are the classic examples.
Prophylaxis not suggestedAnesthetic injections through non-infected tissue, dental radiographs, placing removable prosthodontic or orthodontic appliances, adjusting orthodontic appliances, placing orthodontic brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa.
Wording of both lists from AHA 2021, Table 4. The “classic examples” are our illustration of the rule.1
AHA 2021 prophylaxis regimens
One single dose, 30 to 60 minutes before the procedure.1
| Situation | Drug | Adults | Children |
|---|---|---|---|
| Oral | Amoxicillin | 2 g | 50 mg/kg |
| Cannot take oral medicine | Ampicillin or cefazolin or ceftriaxone |
2 g IM or IV 1 g IM or IV |
50 mg/kg IM or IV 50 mg/kg IM or IV |
| Penicillin or ampicillin allergy, oral | Cephalexin* or azithromycin or clarithromycin or doxycycline |
2 g 500 mg 100 mg |
50 mg/kg 15 mg/kg under 45 kg: 2.2 mg/kg; over 45 kg: 100 mg |
| Penicillin allergy and cannot take oral medicine | Cefazolin or ceftriaxone* | 1 g IM or IV | 50 mg/kg IM or IV |
*Do not use cephalosporins in a patient with a history of anaphylaxis, angioedema or urticaria with penicillin or ampicillin.1
Clindamycin is outThe 2021 statement says clindamycin is no longer recommended. It may cause more frequent and severe reactions than the other options, including Clostridioides difficile infection, even after a single dose.1
Forgot the dose?If prophylaxis was not given before the procedure, it may be given up to 2 hours after it.1
Azithromycin cautionThe statement flags the risk of serious heart-rhythm events with azithromycin in patients with a prolonged QTc interval (over 450 ms).1
Prosthetic joints: the ADA 2015 guideline
A short rule that comes up often on the exam.
A healthy patient with a hip or knee replacement needs no premedication for routine dental care, including extractions.
If the patient had complications with their joint replacement surgery and needs a procedure with gingival manipulation or mucosal incision, consider antibiotics only after talking with the patient and the orthopedic surgeon.2
If antibiotics are judged necessary, it is most appropriate for the orthopedic surgeon to recommend the regimen and, when reasonable, write the prescription.2
Avulsion of a permanent tooth (IADT 2020)
The International Association of Dental Traumatology (IADT) updated its guidelines in 2020. For avulsion, the outcome depends mostly on one thing: how long the root surface stayed dry.
First aid at the scene
Primary teeth should not be replanted.4
If it is dirty, rinse it briefly in milk, saline or the patient’s saliva, and replant it right away.4
In descending order of preference: milk, HBSS (Hanks’ Balanced Salt Solution), saliva, saline. Water is a poor medium, but it is better than letting the tooth dry in air.4
After 30 minutes of dry time, most periodontal ligament (PDL) cells are no longer viable.4
Management in the clinic, by PDL condition
| Situation | PDL cells | Key steps |
|---|---|---|
| Replanted at the scene (within about 15 minutes) | Most likely viable | Leave the tooth in place; correct position with light pressure if needed; flexible splint 2 weeks |
| Kept in milk, HBSS, saliva or saline; total dry time under 60 minutes | May be viable but compromised | Rinse off debris, irrigate the socket with saline, replant slowly with light finger pressure, check with a radiograph, flexible splint 2 weeks |
| Total dry time over 60 minutes (stored or not) | Likely non-viable | Still replant in almost all cases. The PDL is necrotic and ankylosis-related (replacement) resorption is expected, but replanting keeps bone and the tooth can be removed later if needed. Flexible splint 2 weeks |
From the IADT 2020 avulsion guideline.4
Mature toothStart root canal treatment within 2 weeks of replantation. Calcium hydroxide can be used as an intracanal medicament for up to 1 month before the final filling.4
Immature toothThe pulp may revascularize on its own, so avoid root canal treatment unless follow-up shows clear signs of necrosis and infection. Review more often: inflammatory resorption is very rapid in children.4
- Splint: passive, flexible, for 2 weeks: stainless steel wire up to 0.016 inch (0.4 mm) or nylon line, bonded on the labial surfaces. Use a more rigid splint for about 4 weeks if there is an alveolar or jaw fracture.4
- Antibiotics: give systemic antibiotics. Amoxicillin or penicillin are first choice; tetracycline or doxycycline are generally not recommended under 12 years of age.4
- Tetanus: do not assume it is up to date. Refer to a physician to check whether a booster is needed.4
- Home care: avoid contact sports, soft diet for up to 2 weeks, chlorhexidine 0.12% rinse twice a day for 2 weeks.4
- Follow-up (closed apex): 2 weeks (splint off), 4 weeks, 3 months, 6 months, 1 year, then yearly for at least 5 years.4
Splint duration by injury
Tap a tab. The 2020 guidelines use passive, flexible splints almost everywhere; what changes is how long they stay on.
| Injury | Splint | Other key point |
|---|---|---|
| Concussion | None | No treatment; monitor the pulp for at least 1 year |
| Subluxation | Usually none; up to 2 weeks only if very mobile or tender on biting | Monitor the pulp for at least 1 year |
| Extrusive luxation | 2 weeks (add 4 weeks if the marginal bone is fractured) | Reposition gently under local anesthesia |
| Avulsion | 2 weeks | About 4 weeks, more rigid, if there is an alveolar fracture |
| Lateral luxation | 4 weeks | Disengage the apex from its “locked” position, then reposition; closed apex: start root canal treatment |
| Intrusive luxation | 4 weeks after surgical repositioning | Immature: let it re-erupt, orthodontic repositioning if no movement in 4 weeks. Mature: under 3 mm let it re-erupt (reposition if none by 8 weeks); 3-7 mm reposition surgically (preferred) or orthodontically; over 7 mm surgically. Mature teeth: root canal treatment at 2 weeks |
| Root fracture | 4 weeks; up to 4 months for a cervical-third fracture | No endodontic treatment at the emergency visit; if necrosis follows, it is usually in the coronal fragment only |
| Alveolar fracture | 4 weeks | Reposition the segment; root canal treatment is contraindicated at the emergency visit |
From the IADT 2020 guidelines for fractures and luxations, and for avulsion.45
| Injury | Management |
|---|---|
| Subluxation | No treatment; observe |
| Extrusive luxation | No occlusal interference: let it reposition on its own. Excessively mobile or extruded more than 3 mm: extract under local anesthesia |
| Lateral luxation | Little or no occlusal interference: let it reposition (usually within 6 months). Severe: extract if there is a risk of swallowing or inhaling it, or reposition and splint 4 weeks if unstable |
| Intrusive luxation | Let it reposition on its own, whatever the direction of displacement; usually within 6 months, sometimes up to 1 year. Refer within a couple of days to a child-oriented team |
| Avulsion | Do not replant |
| Root fracture | Extract only the loose coronal fragment and leave the apical fragment to resorb; or reposition the coronal fragment and splint 4 weeks if unstable |
| Alveolar fracture | Reposition a mobile or interfering segment; flexible splint 4 weeks |
From the IADT 2020 guideline for the primary dentition.6
Primary vs permanent teeth: key differences
Most trauma questions turn on one idea: in a young child, protecting the developing permanent tooth matters more than saving the primary one.
| Topic | Permanent teeth | Primary teeth |
|---|---|---|
| Avulsion | Replant (almost always, even after 60 minutes dry) | Never replant |
| Intrusion | Depends on root maturity and depth: wait, orthodontic or surgical repositioning | Let it re-erupt on its own, whatever the direction |
| Extrusion | Reposition and splint 2 weeks | Let it settle if no interference; extract if over 3 mm or very mobile |
| Root fracture | Reposition and splint 4 weeks (cervical: up to 4 months) | Remove only the loose coronal part; leave the apical part to resorb |
| Chlorhexidine | 0.12% rinse twice a day for 2 weeks (avulsion) | Alcohol-free 0.1-0.2%, applied with a soft brush or cotton swab twice a day for 1 week |
| Main goal | Keep the tooth and its PDL alive; prevent resorption | No harm to the developing permanent successor; avoid long-term dental anxiety |
Three quick questions
1. A 58-year-old with a transcatheter aortic valve replacement (TAVR) is allergic to penicillin. His history says the reaction was hives. He needs an extraction. What is the best prophylaxis?
- Clindamycin 600 mg
- Cephalexin 2 g
- Azithromycin 500 mg
- No prophylaxis is needed
Show answer
C. Azithromycin 500 mg A TAVR is a prosthetic valve, so he needs prophylaxis. Hives (urticaria) with penicillin rules out cephalosporins, and clindamycin is no longer recommended.
2. A 10-year-old’s permanent central incisor was knocked out 20 minutes ago. Which storage medium is best if it cannot be replanted at the scene?
- Tap water
- Milk
- Saline
- A dry tissue
Show answer
B. Milk The IADT 2020 order of preference is milk, HBSS, saliva, then saline. Water is poor, and drying is worst.
3. A 3-year-old has an intruded primary maxillary central incisor. There are no other injuries. What is the right management?
- Reposition surgically and splint 4 weeks
- Extract immediately
- Allow spontaneous repositioning and review
- Orthodontic extrusion
Show answer
C. Allow spontaneous repositioning For primary teeth, the IADT advises letting an intruded tooth re-erupt on its own, whatever the direction of displacement, with a prompt referral to a child-oriented team.
How to prepare: our full plan
Prophylaxis and trauma questions show up on the INBDE and on the DLOSCE. Pick the plan for your exam.
The Study Boards INBDE courseINBDE Premium Boards, built by US-licensed dentists:
- 12 course sections with Modules and Master Files
- 35,000+ focused questions
- Grand Tests and two full 2-day simulation exams
- Live tests every night at 9 PM New York time
The Study Boards DLOSCE courseFor the clinical licensure exam, where antibiotic and analgesic prescriptions are their own task:
- 4,500 DLOSCE questions and 34 timed tests
- 45 days of full access for $399
- How DLOSCE prescription tasks work
Then plan your months with the INBDE study plan, check what is tested on the INBDE, and practise with our free INBDE practice questions.
Related high-yield topics
Frequently asked questions
Which heart conditions need antibiotic prophylaxis before dental treatment?
Four groups: a prosthetic heart valve or prosthetic material used for valve repair (including transcatheter valves); a history of infective endocarditis; specific congenital heart disease (unrepaired cyanotic disease, a repair with prosthetic material in the first 6 months, or a repair with a residual defect next to the prosthetic material); and a heart transplant with valve disease.
What is the amoxicillin dose for dental prophylaxis?
2 g for adults and 50 mg/kg for children, as a single oral dose 30 to 60 minutes before the procedure. If it was missed, it may be given up to 2 hours after.
Why was clindamycin removed from the prophylaxis guidelines?
The AHA 2021 statement notes that clindamycin may cause more frequent and severe reactions than the other options, including Clostridioides difficile infection after even a single dose. For penicillin-allergic patients, the oral choices are now cephalexin (if there is no history of anaphylaxis, angioedema or urticaria), azithromycin, clarithromycin or doxycycline.
Do patients with joint replacements need antibiotics before dental work?
In general, no. The ADA’s 2015 guideline does not recommend prophylactic antibiotics to prevent prosthetic joint infection. For a patient with a history of complications from joint surgery, antibiotics are considered only after talking with the patient and the orthopedic surgeon, who should recommend the regimen.
How long do you splint an avulsed tooth?
2 weeks, with a passive, flexible splint. Lateral luxations, root fractures and alveolar fractures need 4 weeks; a cervical-third root fracture may need up to 4 months.
How does The Study Boards help you prepare for these guidelines on the INBDE?
Our INBDE course teaches prophylaxis and trauma in the Modules and Master Files, then tests them inside patient-box questions in the Master Tests, Grand Tests and nightly 9 PM New York time live tests. US-licensed dentists answer your questions, not AI.
Not sure if your patient needs prophylaxis?
Send us the case on WhatsApp. Our Admin Team with Dr. T and Dr. Kaur will contact you over WhatsApp and walk you through the guideline.
References
- Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation. 2021;143(20):e963-e978. doi.org/10.1161/CIR.0000000000000969
- American Dental Association. Antibiotic Prophylaxis Prior to Dental Procedures (Oral Health Topics, last updated 15 July 2026). ada.org
- Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners. J Am Dent Assoc. 2015;146(1):11-16.e8. doi.org/10.1016/j.adaj.2014.11.012
- Fouad AF, Abbott PV, Tsilingaridis G, et al. IADT guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020;36:331-342. doi.org/10.1111/edt.12573
- Bourguignon C, Cohenca N, Lauridsen E, et al. IADT guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol. 2020;36:314-330. doi.org/10.1111/edt.12578
- Day PF, Flores MT, O’Connell AC, et al. IADT guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2020;36:343-359. doi.org/10.1111/edt.12576
- The Study Boards. INBDE Premium Boards and DLOSCE Course Blueprints. parmjitllc.com
Current as of October 2026. Guidelines change: check the AHA, ADA and IADT for updates before treating patients. The questions on this page are original teaching material, not real exam items.