Antibiotic Prophylaxis of Infective Endocarditis in Dentistry: An Update on the ESC, AHA, and NICE Guidelines

Infective endocarditis (IE) is a rare but life-threatening infection of the endocardial surface of the heart, usually arising when circulating microorganisms colonise the cardiac valves; it carries an in-hospital mortality of roughly 15–30%. Because oral viridans group streptococci cause a substantial proportion of community-acquired cases, antibiotic prophylaxis (AP) before invasive dental procedures has historically been central to prevention, placing dental practitioners at the centre of a long-standing and unsettled debate. This narrative review synthesises the contemporary evidence and the divergence between major guideline bodies. The 2023 European Society of Cardiology (ESC) guidelines raised AP for high-risk patients to a Class I recommendation, and the 2021 American Heart Association (AHA) statement remains closely aligned, restricting AP to those at highest risk of adverse outcome. The United Kingdom’s National Institute for Health and Care Excellence (NICE), by contrast, has advised against AP since 2008 (and, since a 2016 amendment, against its routine use). This divergence has produced an international discordance that leaves clinicians and patients facing conflicting advice. This review examines the pathogenesis and microbiology of oral-origin IE, the conditions and procedures that define risk, and the contested epidemiological evidence, including population-level data linking reduced prescribing to rising IE incidence. It then discusses the implications for clinical practice and the central role of oral health. The evidence base remains observational and associative rather than causal; definitive randomised data are lacking. The review argues that, pending stronger evidence, dentists should identify the framework governing their jurisdiction, apply it consistently, prioritise oral health, and share documented decisions with patients.