Antibiotic Prophylaxis for Dental Procedures in TAVR Patients
Patients with TAVR require antibiotic prophylaxis before all dental procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of the oral mucosa, following the same recommendations as for all prosthetic heart valves. 1, 2
High-Risk Status of TAVR Patients
TAVR patients are classified as high-risk for infective endocarditis (IE) because transcatheter prosthetic valves carry the same or higher IE risk compared to surgical valve replacements. 1, 2 The ACC/AHA explicitly expanded their 2017 guidelines to include patients with transcatheter prosthetic valves in the highest-risk category requiring prophylaxis. 1 IE rates after TAVR range from 0.3% to 3.4% per patient-year, with a devastating 75% one-year mortality rate when IE develops. 1, 2
Recommended Antibiotic Regimens
Standard Regimen (No Penicillin Allergy)
- Amoxicillin 2g orally, taken 1 hour before the dental procedure 3, 4, 2
- This can be given as ampicillin 2g IV if oral administration is not feasible 4
Penicillin Allergy Regimen
- Clindamycin 600mg orally, taken 1 hour before the procedure 3, 4, 2
- Alternative for patients without history of anaphylaxis, angioedema, or urticaria: Cephalexin 2g orally 3, 2
- Azithromycin or clarithromycin 500mg orally can also be used 4
Dental Procedures Requiring Prophylaxis
Prophylaxis is required for: 2
- All dental cleanings (routine prophylaxis)
- Dental extractions
- Periodontal procedures including surgery, scaling, root planing
- Dental implant placement
- Root canal instrumentation beyond the apex
- Any procedure involving gingival manipulation or oral mucosal perforation
Prophylaxis is NOT required for: 2
- Local anesthetic injections in non-infected tissue
- Treatment of superficial caries
- Suture removal
- Dental X-rays
- Placement or adjustment of removable appliances or orthodontic devices
- Shedding of deciduous teeth
Critical Supporting Evidence
Recent 2022 data demonstrated a significant temporal association between invasive dental procedures and subsequent IE in high-risk patients (OR: 2.00), with the strongest associations for extractions (OR: 11.08) and oral surgical procedures (OR: 50.77). 5 Importantly, antibiotic prophylaxis reduced IE incidence by approximately 50% following these procedures (OR: 0.49). 5
Essential Clinical Considerations
Optimal oral hygiene and regular professional dental care are more important than antibiotic prophylaxis alone for reducing IE risk. 1, 2 The ACC/AHA emphasizes that poor oral hygiene and periodontal disease from daily activities likely cause more IE cases than dental procedures themselves. 1
Eliminate all sources of dental sepsis at least 2 weeks before TAVR implantation whenever possible. 2 For patients who have already undergone TAVR, prophylaxis should be given at every qualifying dental visit. 1
Common Pitfalls to Avoid
- Do not withhold prophylaxis from TAVR patients undergoing high-risk dental procedures—this is a critical error given their prosthetic valve status 2
- Do not use fluoroquinolones or glycopeptides for routine prophylaxis due to unclear efficacy and resistance concerns 2
- Do not provide prophylaxis for low-risk dental procedures listed above or for non-dental procedures without active infection 3, 2
- Do not neglect the importance of counseling patients about daily oral hygiene, which provides greater long-term protection than procedural prophylaxis alone 1, 2