Infective endocarditis (IE) is a severe infection of the endocardium associated with significant morbidity and mortality despite advances in diagnostic and therapeutic strategies. According to the European Society of Cardiology (ESC) guidelines, the annual incidence of IE ranges between three and ten cases per 100,000 individuals, with in-hospital mortality rates reaching 20% - 25% [1]. Recent epidemiological data indicate a progressive increase in the incidence of IE in Europe over the last decades, particularly among elderly patients and those with underlying cardiac conditions [2]. Clinically, IE remains a complex disease with heterogeneous presentations and potentially life-threatening complications, including heart failure, systemic embolism, and septic shock. Clinical reports continue to describe substantial morbidity, prolonged hospitalizations, and a high risk of recurrence, underlining the importance of effective preventive strategies [3]. Among the identified sources of bacteremia leading to IE, the oral cavity represents a major portal of entry. Poor oral hygiene, untreated dental infections, and invasive dental or oral surgical procedures are recognized contributors to transient bacteremia involving oral streptococci and other microorganisms implicated in IE pathogenesis [4]. As a result, oral health management and procedural risk assessment play a critical role in IE prevention. Antibiotic prophylaxis before dental procedures has long been advocated to reduce the risk of procedure-related bacteremia. However, evidence supporting its systematic use remains controversial. A Cochrane systematic review concluded that robust evidence demonstrating the effectiveness of antibiotic prophylaxis in preventing IE following dental procedures is limited, raising concerns about unnecessary antibiotic exposure and antimicrobial resistance [5]. In the specific context of oral surgery, the risk-benefit balance of preventive strategies is particularly challenging. Several studies have emphasized the need for tailored preventive approaches in patients undergoing oral surgical procedures, especially those with underlying cardiac risk factors [6]. Consequently, multiple national and international scientific societies have issued guidelines to standardize IE prevention in dental and oral surgical practice. Guidelines published in the United Kingdom and Europe have progressively restricted indications for antibiotic prophylaxis, emphasizing risk stratification rather than systematic prescription [7]. The National Institute for Health and Care Excellence (NICE) notably questioned the routine use of prophylaxis, prompting ongoing debate and periodic reassessment of recommendations [8]. Earlier French recommendations also reflected this evolution, highlighting a shift toward more selective preventive strategies [9]. More recently, the 2023 ESC guidelines introduced significant updates in IE prevention, including refined risk stratification and revised indications for antibiotic prophylaxis [10][11]. These changes have direct implications for oral surgery practice, particularly regarding which procedures are permitted, discouraged, or require specific preventive measures in patients at risk of IE.

This narrative review aims to analyze recent literature and guideline updates concerning the prevention of infective endocarditis in oral surgery. It focuses on the evolution of risk classification, antibiotic prophylaxis strategies, and procedural recommendations, with the objective of clarifying current best practices and supporting evidence-based clinical decision-making.

The methodological quality and level of evidence of the included publications were assessed using an evidence hierarchy adapted from evidence-based medicine principles. Meta-analyses and international clinical guidelines were considered to provide the highest level of evidence, followed by large observational cohort studies. Narrative reviews, expert commentaries, and consensus statements were considered lower levels of evidence. Case series and educational texts were considered to provide the lowest level of evidence.

This classification approach was inspired by commonly used evidence-grading frameworks, particularly the GRADE(GradingofRecommendationsAssessment,DevelopmentandEvaluation) system, which is widely applied in clinical research to assess the strength and certainty of evidence (Table 1).

Table 1. Descriptive methodological overview of included studies.

Recent systematic reviews and observational studies have evaluated the risk of infective endocarditis following invasive dental and oral surgical procedures, highlighting the heterogeneity of patient-related and procedure-related risk factors [12]-[14]. Position statements and expert reviews have further emphasized the need for refined risk stratification and selective antibiotic prophylaxis in dental practice, particularly in patients with underlying cardiac conditions. These findings have contributed to the evolution of international recommendations and informed recent guideline updates [15].

The current classification of infective endocarditis is based on risk stratification, allowing preventive strategies to be adapted accordingly. The 2023 ESC recommendations define three risk categories. High-risk patients include individuals with a history of infective endocarditis, prosthetic heart valves, complex congenital heart disease, or ventricular assist device implantation. Intermediate-risk patients include those with severe degenerative valvular disease, bicuspid aortic valve, or moderate congenital heart disease [10]. Low-risk patients are individuals without structural cardiac abnormalities or significant cardiac history. The major change introduced by this classification is the reintroduction of the intermediate-risk category, which had been removed in previous guideline versions. In addition, patients with ventricular assist devices are now systematically classified as high risk (Table 2).

Table 2. Dental management of patients at risk of infective endocarditis (IE).

Invasivedental procedures refer to interventions involving manipulation of gingival tissues, the periapical region of the teeth, or perforation of the oral mucosa. These procedures include tooth extractions, periodontal surgery, implant placement, endodontic treatment beyond the apex, and other oral surgical interventions associated with bleeding. Such procedures may induce transient bacteremia and are therefore considered relevant when evaluating the need for antibiotic prophylaxis in patients at risk of infective endocarditis.

Highlyinvasiveprocedures refer to oral surgical interventions associated with extensive manipulation of infected tissues, significant bleeding risk, or prolonged surgical exposure. Examples include extensive periodontal surgery, guided bone regeneration procedures, treatment of advanced peri-implantitis, and complex implant surgery involving bone grafting or regenerative membranes. These procedures may increase the magnitude and duration of bacteremia and therefore require careful risk assessment in patients susceptible to infective endocarditis.

The introduction of an intermediate-risk category in the 2023 ESC guidelines represents a major evolution in infective endocarditis prevention [10][18]. This classification allows more precise identification of patients who may benefit from antibiotic prophylaxis, particularly those with bicuspid aortic valves or degenerative valvular disease, previously considered low risk [1][10]. Unlike earlier recommendations that restricted prophylaxis to high-risk patients only, the ESC 2023 guidelines promote a more individualized clinical assessment [10]. Furthermore, patients with ventricular assist devices are now classified as high risk, resulting in modified preventive strategies [18].

The 2023 European Society of Cardiology (ESC) guidelines have reintroduced an intermediate-risk category for infective endocarditis (IE) prevention, offering a more nuanced approach to identifying patients who don’t clearly fit into high- or low-risk groups [10]. This group includes people with degenerative valve disease, bicuspid aortic valve, or partially corrected congenital heart disease, who were previously considered low risk under older guidelines [10]. This new classification is intended to support more personalized decisions about prophylaxis, but applying it in oral surgery can be challenging. Accurate risk assessment requires detailed knowledge of a patient’s cardiac history and current valve condition, often needing input from a cardiologist [16][17]. Incomplete records or borderline cardiac conditions can make it difficult for dentists to classify patients correctly, introducing ambiguity [12][16]. In intermediate-risk patients, routine antibiotic prophylaxis is not recommended according to the ESC 2023 guidelines [18]. However, in clinical practice, prophylaxis may occasionally be considered in selected situations involving highly invasive procedures or additional systemic risk factors after multidisciplinary evaluation. Such decisions are generally based on expert consensus or national recommendations rather than explicit ESC guideline indications.

Preventing infective endocarditis (IE) in oral surgery requires coordinated, multidisciplinary management, integrating patient-specific cardiac risk, procedure complexity, and antibiotic stewardship. Dentists and oral surgeons assess risk, plan procedures, and implement preventive measures such as chlorhexidine use and prophylaxis, while cardiologists confirm risk categories, advise on prophylaxis, and monitor patients with prosthetic valves or complex congenital heart disease, and primary care physicians support overall health, manage comorbidities, and facilitate communication between teams [16]. The decision-making pathway involves an initial evaluation of dental history and procedure invasiveness, risk stratification according to ESC 2023 criteria, cardiology consultation for high- or intermediate-risk or ambiguous cases, development of a preventive plan including antibiotic and adjunctive measures, and postoperative follow-up to monitor healing and detect early infections [12][14][16]. Standardized local protocols and ongoing staff education ensure consistent application of guidelines, proper documentation, and accountability [14][16]. Multidisciplinary care reduces variability in prophylaxis practices, optimizes patient safety through evidence-based interventions, and improves communication among specialists, minimizing errors and inappropriate treatment [12][16]. Visual tools, such as flowcharts or decision trees, can illustrate the patient pathway from evaluation to postoperative monitoring, highlighting points for cardiology input and preventive measures, thereby facilitating implementation of ESC 2023 recommendations in daily practice.

A key objective of the new guidelines is to reduce routine antibiotic use to minimize adverse effects and bacterial resistance. Recent studies have shown that a substantial proportion of antibiotic prescriptions in oral surgery were unjustified prior to guideline updates [14]. Since the progressive adoption of the ESC 2023 recommendations, a significant reduction in inappropriate antibiotic use has been reported in clinical practice [14][17]. Moreover, increasing resistance to macrolides and β-lactams among oral Streptococcus viridans strains further supports the need for targeted and rational antibiotic use [14][17]. These data reinforce the importance of reserving prophylaxis for patients at genuinely high risk [19].

Another critical aspect of the 2023 recommendations is the removal of clindamycin from prophylactic regimens due to its association with Clostridioides difficile infection [10][11][13]. Recommended alternatives for penicillin-allergic patients now include cephalexin, azithromycin, or pristinamycin, administered one hour before invasive procedures [13][15].

In fields such as oral implantology and endodontics, where the risk of IE is elevated due to potential bacterial invasion, the recommendations have been specifically adapted. Oral implants may now be performed safely, but only after detailed clinical evaluation and under optimal aseptic conditions [6][16][17]. Endodontic treatments are permitted with antibiotic prophylaxis but require rigorous disinfection protocols and radiological follow-up to minimize infection risk [17].

In addition to antibiotic prophylaxis, several adjunct strategies can help reduce the risk of infective endocarditis (IE) in patients undergoing oral surgery. These approaches focus on lowering the oral bacterial load and addressing potential sources of bacteremia, especially in high- and intermediate-risk patients [5][6].

1)Chlorhexidine-BasedAntisepsis

Chlorhexidine is the most studied antiseptic in dental and oral surgery. Evidence suggests it can reduce postoperative infections, though direct proof of its effect on IE incidence is limited. Recommended practices include:

Pre-operativemouthrinse: 0.12% - 0.2% chlorhexidine gluconate for 30 - 60 seconds immediately before invasive procedures.Antisepticbrushingorgel: For patients with poor oral hygiene or localized infection, pre-operative brushing with chlorhexidine gel can further reduce bacterial load.Postoperativeuse: In selected cases, a short course of chlorhexidine rinses for 3 - 5 days may help control microbial recolonization.

Chlorhexidine is particularly useful for procedures with higher bacteremia risk, such as tooth extractions, implant placement, periodontal surgery, and endodontic procedures [6][14][20]. The evidence is moderate: RCTs support their role in reducing local infections, though data specifically on IE prevention are limited.

2)OptimizationofOralHealth

Good oral hygiene before surgery is critical, particularly for high-risk patients [14][16]:

Pre-operativedentalassessment: Identify and treat active infections, caries, or periodontal disease [14].Scalingandprofessionalcleaning: Reduce bacterial load and transient bacteremia risk [5][16].Patienteducation: Emphasize daily plaque control, use of interdental brushes, and maintenance of good oral hygiene [14][16].

3)ManagementofExistingOralInfections

Untreated dental infections can serve as portals for bacteremia [4][6]. Pre-operative management includes:

Treating abscesses or pulp infections with endodontic therapy or extraction [6][16].Managing advanced periodontitis to reduce bacterial reservoirs [14][16].

4)PostoperativeMonitoring

Close follow-up helps detect infections early and ensures preventive protocols are followed [12][16]:

Schedule visits according to risk: high-risk every 4 - 6 months; intermediate-risk every 6 - 12 months.Monitor for local or systemic infection and coordinate with the patient’s cardiologist if complications arise [16][20].

By combining these measures with selective antibiotic prophylaxis, clinicians can reduce IE risk while avoiding unnecessary antibiotic use [12][14][16].

A major challenge lies in the lack of harmonization among international guidelines. For example, the American Heart Association (AHA) has not incorporated the concept of intermediate risk into its guidelines, creating discrepancies with the ESC 2023 recommendations [15]. Additionally, some countries, such as the United Kingdom, with NICE guidelines, have opted for the complete removal of antibiotic prophylaxis in certain situations, further contributing to variations in clinical practice worldwide [18][21][22].

Despite these advances, some new contraindications are based on criteria requiring further validation. Although supported by recent studies, there remains a lack of robust longitudinal research to assess the long-term impact of these practices on IE prevention, particularly in the specific context of oral surgery [16][17].

The 2023 ESC guidelines introduced several key changes compared with earlier ESC 2015 and AHA 2007 recommendations, reflecting evolving evidence on risk stratification, antibiotic prophylaxis, and procedural safety in oral surgery. The most notable updates include the reintroduction of an intermediate-risk category, restriction of prophylaxis to high-risk patients, and the removal of clindamycin due to concerns about Clostridioides difficile infections. By contrast, ESC 2015 and AHA 2007 primarily recommended prophylaxis for high-risk patients and did not include the intermediate-risk classification, with broader indications for antibiotic use and continued support for clindamycin in penicillin-allergic patients. These differences underscore the need for clinicians to stay updated and tailor preventive strategies to current evidence [1][10][11] (Table 6).

Table 6. Comparison of ESC 2023, ESC 2015, and AHA 2007 guidelines for oral surgery prophylaxis [1][18][23].

The 2023 ESC guidelines introduce meaningful refinements in infective endocarditis prevention for oral surgery, particularly through redefined risk stratification and rationalization of antibiotic prophylaxis. However, the intermediate-risk category introduces interpretative variability, and the overall evidence base remains limited by the absence of randomized trials. Successful implementation requires enhanced practitioner training, structured interdisciplinary collaboration, and continuous evaluation of antibiotic stewardship outcomes. Future prospective registries and harmonized international research efforts are needed to determine whether these updated recommendations translate into measurable reductions in IE incidence without unintended consequences.