Is antibiotic prophylaxis (use of antibiotics to prevent infection) necessary for dental procedures after a Transcatheter Aortic Valve Replacement (TAVR) procedure?

Antibiotic Prophylaxis After TAVR for Dental Procedures

Yes, antibiotic prophylaxis is reasonable and recommended before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients who have undergone TAVR. 1

Rationale for Prophylaxis

TAVR patients have prosthetic cardiac valves (transcatheter-implanted prostheses), which places them in the highest-risk category for infective endocarditis (IE). 1 The 2020 ACC/AHA Valvular Heart Disease Guidelines explicitly include "transcatheter-implanted prostheses" in their Class IIa recommendation for antibiotic prophylaxis before high-risk dental procedures. 1

Why TAVR Patients Are High-Risk

• IE occurs after TAVR at rates equal to or exceeding surgical aortic valve replacement (SAVR), with a devastating 75% one-year mortality rate. 1, 2
• Patients with prosthetic valves face the highest risk of developing IE and experiencing the worst outcomes if IE occurs. 1
• The mortality and morbidity burden justifies prophylaxis despite the lack of randomized controlled trial evidence. 1

Which Dental Procedures Require Prophylaxis

Antibiotic prophylaxis is indicated for: 1, 2

• Procedures involving manipulation of gingival tissue
• Procedures involving manipulation of the periapical region of teeth
• Procedures that perforate the oral mucosa
• Dental extractions and oral surgical procedures (these carry the highest risk) 3

Recommended Antibiotic Regimens

Standard Regimen (No Penicillin Allergy)

• Amoxicillin 2 g orally, given 30-60 minutes before the procedure 1, 2, 4

Penicillin Allergy Alternatives

• Clindamycin 600 mg orally or IV 1, 2, 4
• Cephalexin 2 g orally OR Cefazolin 1 g IM/IV (but cephalosporins should NOT be used in patients with history of anaphylaxis, angioedema, or urticaria with penicillin) 1, 2
• Azithromycin or clarithromycin 500 mg orally 1

If Unable to Take Oral Medication

• Ampicillin 2 g IM or IV 1
• Cefazolin or ceftriaxone 1 g IM or IV 1

Procedures That Do NOT Require Prophylaxis

Antibiotic prophylaxis is NOT recommended for non-dental procedures, even in high-risk TAVR patients, in the absence of active infection. 1 This includes: 1

• Transesophageal echocardiography (TEE)
• Esophagogastroduodenoscopy
• Colonoscopy
• Cystoscopy
• Other gastrointestinal or genitourinary procedures

Evidence Quality and Important Caveats

Strength of Evidence

• No randomized controlled trials exist demonstrating that antibiotic prophylaxis prevents IE. 1, 5 A 2022 Cochrane systematic review concluded there is insufficient evidence to determine whether prophylaxis is effective or ineffective. 5
• The recommendation is Class IIa (reasonable), Level of Evidence C-LD (limited data), based on pathophysiological reasoning, observational data, and expert consensus. 1

Supporting Observational Evidence

• A 2022 case-crossover study of nearly 8 million U.S. subjects demonstrated a significant temporal association between invasive dental procedures and subsequent IE in high-risk patients (OR: 2.00), with antibiotic prophylaxis associated with a 51% reduction in IE incidence (OR: 0.49). 3
• The association was strongest for dental extractions (OR: 11.08) and oral-surgical procedures (OR: 50.77). 3

Common Pitfalls to Avoid

• Do not prescribe prophylaxis for routine, non-invasive dental procedures (simple examinations, radiographs, fluoride treatments, orthodontic appliance adjustments). 1
• Do not use Augmentin (amoxicillin-clavulanate) as first-line prophylaxis—plain amoxicillin 2 g is the standard regimen. 4
• Do not prescribe prophylaxis for GI or GU procedures solely to prevent endocarditis in TAVR patients. 1, 4

Most Important Prevention Strategy

Optimal oral hygiene and regular professional dental care are MORE important than antibiotic prophylaxis for preventing IE. 1, 2, 4 Transient bacteremia from daily activities like brushing teeth (20-68% incidence) and chewing food (7-51% incidence) occurs far more frequently than from dental procedures. 1 Therefore:

• Encourage patients to maintain excellent oral hygiene with regular brushing, flossing, and dental visits. 1, 2, 4
• Eliminate sources of dental sepsis ideally at least 2 weeks before TAVR if possible. 4

Clinical Decision Algorithm

For a patient with TAVR presenting for a dental procedure:

1. Identify the type of dental procedure:

   • Does it involve gingival manipulation, periapical manipulation, or oral mucosa perforation? → YES: Give prophylaxis 1
   • Is it a simple examination, radiograph, or non-invasive procedure? → NO: No prophylaxis needed 1

2. Assess for penicillin allergy:

   • No allergy → Amoxicillin 2 g orally 30-60 minutes before 1, 2
   • Allergy without anaphylaxis/angioedema → Cephalexin 2 g orally OR Clindamycin 600 mg 1, 2
   • Severe allergy (anaphylaxis/angioedema) → Clindamycin 600 mg OR Azithromycin 500 mg 1, 2

3. Document the prophylaxis and reinforce oral hygiene counseling. 1, 2, 4