Large, well-designed studies suggest that amoxicillin has a highly statistically significant impact on reducing the incidence and duration of bacteremia and changes the species identified after dental procedures in children.45 It is not clear whether this antibiotic elimination of bacteria takes place in the gingi- val crevice or the bloodstream or whether it reduces the risk for IE. Given the variability in outcomes from bacteremia stud- ies and the mounting evidence that dental office procedures are at most a rare cause of IE, there has been a steady shift in the direction away from an emphasis on antibiotic prophy- laxis and toward a focus on oral hygiene and diseases as far more important risk factors for cases of IE that result from Impact of Oral Disease and Hygiene Versus Dental Procedures on Bacteremia AHA guidelines have long proposed that maintaining oral health may be important in the overall effort to prevent IE,67,69 and there is increasing support from studies that report a fre- quent occurrence of bacteremia with toothbrushing (39% It has also been suggested that chewing food may result in bacteremia, but there are no studies to confirm this in Some studies reported no impact from oral hygiene or disease on bacteremia after dental procedures.49,51,55 Other studies of bacteremia after den- tal procedures support an association between various indices of oral hygiene and gingival and dental disease (caries) with the incidence of bacteremia from dental office-based proce- dures and from routine daily activities. Virtually all dental office procedures have the potential to create a transient bacteremia. Because children are recom- mended to have dental cleaning procedures every 6 months, this suggests that office-based bacteremia may occur upwards of twice per year. 