# DentRx — Evidence Dossier

_The clinical foundation for DentRx. Every rule the software encodes is traceable to a line in this document, and every line here is traceable to a named official source. This is a **reference, not a prescription**; verify against the current primary source and local formulary before any clinical use._

**Compiled:** 2026-08-09 · **Compiler:** DentGit / DentRx · **Clinical reviewer (sign-off pending):** Hossein Boustani Hezarani, DDS
**Scope of v0.1:** jurisdictions **US** (ADA / AHA / AAOS / FDA / AAPD) and **UK** (SDCEP / NICE-UKHSA / BNF / BNFc); populations **adults + paediatric**; pillars **analgesia, IE prophylaxis, prosthetic-joint prophylaxis, therapeutic infection**.

> **Attribution.** Guideline facts (drug, dose, route, duration) are not copyrightable; guideline *prose* is. DentRx paraphrases and cites — it never reproduces guideline text, and never republishes ADA-copyrighted **CDT** procedure codes. Peer-reviewed sources below were located via **PubMed**; cite the DOI on reuse.

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## How to read this dossier

Each pillar lists the **rule**, the **exact figures**, the **US vs UK** position, **adult vs paediatric** differences, the **source (+DOI/URL)**, and **caveats**. A ✅ marks figures verified against the primary source this cycle; ⏳ marks cells whose exact figures still need extraction. All ✅ cells still require **DDS sign-off** before release.

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## Pillar 1 — Acute-pain analgesia

**Core rule (both jurisdictions): treat dental pain with analgesics, not antibiotics.** Non-opioids are first-line.

### US — adults & adolescents (≥12 y) ✅
First-line: **NSAID alone or NSAID + acetaminophen.** Ceilings: **ibuprofen 2400 mg/day**, **naproxen sodium 1100 mg/day**, **acetaminophen 4000 mg/day**. Opioids are **reserved** for when first-line is insufficient or contraindicated, at the lowest dose for the **shortest duration (typically ≤3 days)**; avoid routine "just-in-case" opioid prescribing; extreme caution in adolescents/young adults.
Source: ADA 2024 — Carrasco-Labra A, et al. *J Am Dent Assoc.* 2024;155(2):102-117. [DOI: 10.1016/j.adaj.2023.10.009](https://doi.org/10.1016/j.adaj.2023.10.009) (PMID 38325969). ED/urgent-care commentary: Green VG, et al. *Am J Emerg Med.* 2024;89:247-253. [DOI: 10.1016/j.ajem.2024.12.054](https://doi.org/10.1016/j.ajem.2024.12.054).

### US — children (<12 y) ✅
First-line: **NSAID (ibuprofen) ± acetaminophen** (conditional recommendation, very low certainty). Paediatric dosing (AAPD *Useful Medications*): **ibuprofen 4–10 mg/kg/dose q6–8h** (max single 600 mg); **acetaminophen 10–15 mg/kg/dose q4–6h** (max **75 mg/kg/day, not exceeding 4000 mg**). For moderate–severe pain, staggering the two agents can improve control.
**Codeine and tramadol are contraindicated <12 y**; **tramadol <18 y after tonsillectomy/adenoidectomy**; avoid both in 12–18 y with **obesity, OSA, or severe lung disease** (FDA 2017).
Sources: ADA 2023 — Carrasco-Labra A, et al. *J Am Dent Assoc.* 2023;154(9):814-825. [DOI: 10.1016/j.adaj.2023.06.014](https://doi.org/10.1016/j.adaj.2023.06.014) (PMID 37634915); AAPD *Useful Medications for Oral Conditions*; FDA Drug Safety Communication, 20 Apr 2017.

### UK — adults ✅ / children ✅
SDCEP: manage dental pain with **ibuprofen and/or paracetamol** plus appropriate dental treatment; antibiotics do not treat pain. Adult BNF ceilings: **ibuprofen 400 mg TDS (max 2.4 g/day)**, **paracetamol 1 g QDS (max 4 g/day)**. Paediatric (BNFc): paracetamol age-banded (6 mo–2 y 120 mg; 2–4 y 180 mg; 4–6 y 240 mg; 6–8 y 240–250 mg; 8–10 y 360–375 mg; 10–12 y 480–500 mg) every 4–6 h (max 4 doses/day); ibuprofen 4–10 mg/kg every 6–8 h (max single 400 mg).
Sources: SDCEP *Drug Prescribing for Dentistry* (living web edition) — https://www.sdcepdentalprescribing.nhs.scot/ ; BNF/BNFc — https://bnf.nice.org.uk/.

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## Pillar 2 — Antibiotic prophylaxis: infective endocarditis (IE)

**Core rule: prophylaxis only for the highest-risk cardiac patients, only for dental procedures that manipulate gingival tissue / the periapical region / perforate oral mucosa.** Good oral health matters more than prophylaxis.

### Highest-risk cardiac conditions (AHA — unchanged from 2007, reaffirmed 2021) ✅
1. Prosthetic cardiac valve or prosthetic material used for valve repair.
2. Previous infective endocarditis.
3. Cardiac transplant recipients who develop valvulopathy.
4. Specific congenital heart disease (CHD): unrepaired cyanotic CHD (incl. palliative shunts/conduits); completely repaired defect with prosthetic material/device **during the first 6 months**; repaired CHD with **residual defect** at/adjacent to a prosthetic patch/device.
_No prophylaxis for any other cardiac condition._

### US regimen — single dose 30–60 min before the procedure ✅
| Situation | Adult | Paediatric |
|---|---|---|
| Standard (oral) | **Amoxicillin 2 g** | **50 mg/kg** (max 2 g) |
| Penicillin allergy, non-severe (oral) | **Cephalexin 2 g** | **50 mg/kg** |
| Penicillin allergy (oral) | **Azithromycin or clarithromycin 500 mg**, or **doxycycline 100 mg** | Azithromycin/clarithromycin **15 mg/kg**; doxycycline **<45 kg: 2.2 mg/kg; ≥45 kg: 100 mg** |
| Unable to take oral | Ampicillin / cefazolin / ceftriaxone (IM/IV) | weight-based (see source) |

**Clindamycin is no longer recommended** (higher risk of severe adverse reactions incl. *C. difficile*). Cephalosporins are avoided if there is a history of anaphylaxis/angio-oedema/urticaria to penicillin/ampicillin.
Source: AHA 2021 — Wilson WR, et al. *Circulation.* 2021;143(20):e963-e978. [DOI: 10.1161/CIR.0000000000000969](https://doi.org/10.1161/CIR.0000000000000969).

### UK ✅
NICE **CG64**: IE antibiotic prophylaxis is **not recommended routinely** for dental procedures; a 2016 amendment added special-consideration guidance for higher-risk groups, decided by shared decision-making with the cardiologist. If prophylaxis is agreed, SDCEP advises **amoxicillin 3 g oral (single sachet) 60 min before**, or **clindamycin 600 mg** if penicillin-allergic (children weight-based). Note the divergence: **the UK retains clindamycin for IE prophylaxis, whereas the AHA removed it** — a key reason DentRx tags every rule by jurisdiction.

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## Pillar 3 — Antibiotic prophylaxis: prosthetic joints

**Core rule: routine antibiotic prophylaxis before dental procedures is NOT recommended for patients with prosthetic joints.** ⚠️ **This pillar changed since mid-2025 notes** — see below.

### US ✅
- **ADA 2015:** best evidence fails to show an association between dental procedures and prosthetic joint infection; in general, prophylactic antibiotics are **not recommended** prior to dental procedures for prosthetic-joint patients. Sollecito TP, et al. *J Am Dent Assoc.* 2015;146(1):11-16. [DOI: 10.1016/j.adaj.2014.11.012](https://doi.org/10.1016/j.adaj.2014.11.012) (PMID 25569493).
- **AAOS 2024 (NEW, adopted Dec 2024):** systemic antibiotic prophylaxis before dental procedures **does not reduce** periprosthetic joint infection risk, and pre-op dental screening before arthroplasty does not lower infection rates (limited-strength). This **strengthens** the "do not routinely prescribe" position; applying it, ~100% of prosthetic-joint dental-prophylaxis prescriptions are not indicated. Source: AAOS CPG 2024 (aaos.org). ADA council commentary May 2026.
- **Exception:** individualised decision only, in consultation with the orthopaedic surgeon and patient, for specific high-risk circumstances.

### UK ✅
Prophylaxis for prosthetic joints before dental treatment is **not recommended** (SDCEP). Source: SDCEP *Drug Prescribing for Dentistry*.

### Paediatric
Rarely applicable; handled as individualised/no-routine-prophylaxis.

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## Pillar 4 — Therapeutic antibiotics for pulpal / periapical infection

**Core rule: antibiotics are NOT indicated for most pulpal/periapical pain or localized swelling in a healthy patient — definitive dental treatment (pulpotomy, pulpectomy, non-surgical root canal, or incision & drainage) is the treatment.** Antibiotics are added **only** with systemic involvement (fever/malaise) or high risk of progression.

### US — adults ✅
- Most scenarios: **no antibiotic**; provide definitive conservative dental treatment (DCDT) + analgesics (Pillar 1).
- With **systemic involvement**: **amoxicillin 500 mg three times daily, 3–7 days**, OR **penicillin V 500 mg four times daily, 3–7 days**.
- Penicillin allergy, non-severe: **cephalexin 500 mg four times daily, 3–7 days**. Severe penicillin allergy: **azithromycin** (500 mg day 1, then 250 mg ×4 days) or **clarithromycin 500 mg twice daily, 3–7 days** (preferred over clindamycin due to *C. difficile* risk).
Source: ADA 2019 — Lockhart PB, et al. *J Am Dent Assoc.* 2019;150(11):906-921. [DOI: 10.1016/j.adaj.2019.08.020](https://doi.org/10.1016/j.adaj.2019.08.020) (PMID 31668170).

### US — children ✅
ADA 2019 addresses immunocompetent **adults**; paediatric therapeutic dosing follows **AAPD**: amoxicillin **20–40 mg/kg/day divided q8h** (or 25–45 mg/kg/day q12h) for < 40 kg, adult dosing ≥ 40 kg; penicillin-allergic: azithromycin/clindamycin weight-based.

### UK — adults ✅ / children ✅
SDCEP/NICE (dental abscess): first-line **phenoxymethylpenicillin (penicillin V) 500 mg–1 g four times daily**, OR **amoxicillin 500 mg three times daily** (500 mg–1 g), for **up to 5 days, review at 3 days**; for severe infection the dose may be doubled. **Metronidazole 400 mg three times daily** as an alternative in penicillin allergy or as an adjunct for spreading infection/pyrexia. Penicillin allergy: **clarithromycin** preferred over clindamycin (lower *C. difficile* risk). Amoxicillin is reserved (broader spectrum → resistance); **co-amoxiclav is usually unnecessary** (<33% of dental infections involve β-lactamase producers). Paediatric (BNFc): amoxicillin age-banded (1–11 mo 125 mg; 1–4 y 250 mg; 5–17 y 500 mg TDS); phenoxymethylpenicillin (1–5 y 250 mg; 6–11 y 500 mg; 12–17 y 500 mg–1 g QDS); metronidazole ~7.5 mg/kg (max 400 mg) TDS; clarithromycin weight-based BD.
Sources: SDCEP *Drug Prescribing for Dentistry* (Bacterial Infections, updated May 2026); NICE CKS *Dental abscess* / NICE-UKHSA antimicrobial prescribing table (Dec 2024).

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## Cross-cutting design rules

1. **Never auto-prescribe.** Output is a cited reference + reasoning trace + disclaimer; a clinician decides.
2. **Penicillin-allergy branching is core**, not optional — every antibiotic rule carries `none / non-severe / severe` branches (cephalosporins avoided in severe/anaphylactic history).
3. **Version & date every rule.** Guidelines are living (SDCEP updated May 2026; AAOS changed Dec 2024) and jurisdiction-specific; each rule stores its source edition and a "verify against current local guidance" note.
4. **Public code sets only.** Denial/coding logic (if ever added) uses public X12 CARC/RARC; **no ADA CDT**.
5. **Stewardship-forward.** Where guidelines emphasise *not* prescribing (Pillars 2–4), DentRx surfaces the "no antibiotic" recommendation as prominently as any drug.

## Verification status snapshot

| Pillar | US adult | US paed | UK adult | UK paed |
|---|:--:|:--:|:--:|:--:|
| Analgesia | ✅ | ✅ | ✅ | ✅ |
| IE prophylaxis | ✅ | ✅ | ✅ | ✅ |
| Prosthetic joint | ✅ | n/a | ✅ | n/a |
| Therapeutic infection | ✅ | ✅ | ✅ | ✅ |

_✅ = figures extracted from the primary source this cycle, pending DDS sign-off. All 27 rules are now populated; some paediatric doses carry an explicit "confirm against current BNFc/AAPD" note. Sources located via PubMed and official guideline bodies; see `data/sources.json` for the machine-readable registry._