Dentists’ perceptions of antimicrobial use for dental procedures

To the Editor—The importance of promoting antimicrobial stewardship in dentistry is being increasingly recognized; up to 10% of all antimicrobials are prescribed by dentists in high-income countries, ^{1 , 2} and a previous study revealed that only 8.2% of antimicrobial prophylaxes for dental procedures were appropriate. ³ Although professional societies widely recommend antimicrobial prophylaxis against infective endocarditis (IE) among high-risk populations, ^{4 , 5} no recommendations exist for antimicrobial prophylaxis against local infections or complications following invasive dental procedures, including tooth extraction and dental implant placement. Recent systematic reviews have revealed that antimicrobial prophylaxis can prevent local infections and other complications due to these procedures. ^{6 , 7}

Although understanding dentists’ perceptions of antimicrobial use and prescribing patterns is essential to promoting antimicrobial stewardship in the discipline, these perceptions are still poorly understood. The aim of the study was to investigate dentists’ perception of antimicrobial use to promote antimicrobial stewardship in the field.

Material and Methods

An online questionnaire on antimicrobial use before and after a dental procedure was administered to regional dental conference attendees (Japanese Society of Oral and Maxillofacial Surgeons, JSOMS) in December 2018. In total, 54 close-ended survey questions were used to collect data, including current patterns of antimicrobial prophylaxis against IE, infections and complications following tooth extraction or dental implant surgery, and dentists’ perceptions of antimicrobial use.

Results

Of the 231 dentists attending the session, 111 (48.1%) responded to the questionnaire. Moreover, 70% of respondents were male, with the median age of 36 years (range, 24–64 years) and median postgraduate duration of 11 years (range, 1–44 years). University hospitals were the most common place of employment (n = 49, 44.1%) (Appendix 1 online).

Table 1 shows the respondents’ perceptions of antimicrobials prophylaxis. Regarding antimicrobial prophylaxis against IE, although >80% of respondents reported that they understood the guidelines for the prevention of infective endocarditis, ^{4 , 5} >70% believed that continuing postprocedural antimicrobial administration was important for IE prevention, and >80% reported having prescribed prophylactic antimicrobials against the current guidelines to patients with high-risk cardiac conditions in both the pre- and postprocedural periods (Appendix 2 online). ^{4 , 5} Moreover, antimicrobial prophylaxis against IE was commonly administered to patients with other cardiac conditions, such as those with a pacemaker or history of percutaneous coronary intervention. The prescribing practices were influenced by the fear of a lawsuit (64.9%), previous training in antimicrobial prophylaxis (60.4%), and/or the prescribing culture at the respondents’ current place of employment (54.1%) (Table 1).

Table 1. Dentists’ Perceptions of Antimicrobial Prophylaxis Against Infective Endocarditis and Infection or Complications After Selected Dental Procedures

NOTE. IE; infective endocarditis, AHA; American heart association, N/A; not available.

Regarding antimicrobial prophylaxis to prevent infections or complications following selected dental procedures in patients with no underlying illness, 81.1% of respondents reported that they did not prescribe antimicrobials for noninvasive procedures but did so for dental implant placements (95.5%), wisdom tooth extractions (93.7%), frenotomies (76.6%), and orthodontic premolar tooth extractions (64.9%) (Appendix 2 online). Although more than half the respondents considered pre- and postprocedural antimicrobial prophylaxis necessary to prevent infections or complications, they frequently prescribed antimicrobials only after a dental procedure (Appendix 2 online).

Discussion

The current study revealed that among dentists, behaviors dictating their prescription of antimicrobial prophylaxis against IE, local infections, and complications following common dental procedures varied widely. Moreover, respondents’ self-reported behavior demonstrated that periprocedural antimicrobial overprescribing apparently stems from deeply entrenched misperceptions about the relevant pathophysiology, litigation fears, and prevailing culture despite putative familiarity with current recommendations against this behavior.

Most respondents reported understanding the current guidelines for IE prevention using antimicrobial prophylaxis but considered it important to continue postprocedural antimicrobial administration in contradiction to the guidelines. They also prescribed antimicrobial prophylaxis for non–high-risk cardiac conditions. Both the extended duration and expanded use of antimicrobial prophylaxis are likely to be associated with entrenched beliefs regarding periprocedural antimicrobial therapy. The current guidelines recommend antimicrobial prophylaxis only before a procedure in patients with a high-risk cardiac condition, such as cyanotic heart disease, a history of IE or prosthetic valve. ^{4 , 5} However, in real-life settings, antimicrobial prophylaxis was frequently prescribed postprocedurally. ³ The frequency of litigation related to dental procedures in Japan may be influencing dentists’ prescribing behavior. ⁸ In terms of the association between antimicrobial prescribing patterns and previous education or workplace culture, dentists’ perception of antimicrobial prophylaxis did not differ significantly between hospital settings in this study (Appendix 3), suggesting that inadequate education and the failure to update antimicrobial practice in dentistry may be quite widespread in Japan.

Current evidence supports prophylactic antimicrobial use against local infections and complications following invasive dental procedures, such as tooth extractions and dental implantations. ^{6 , 7} In this study, more than half of the respondents reported prescribing antimicrobials only after a dental procedure (Appendix 2 online). In principle, antimicrobial prophylaxis should be administrated before an invasive procedure. Moreover, continuing postprocedural administration to reduce further the risk of local complications or infections remains controversial. ^{6 , 7} Previous studies have also cited the inappropriate continuation of postprocedural prophylaxis. ^{3 , 9}

This study has a number of limitations. The sample size was small, and selection bias may have occurred because the respondents were attendees of a regional academic conference. Moreover, their responses may not reflect their actual antimicrobial prescribing practices. Also, the questionnaire did not ask about the specific types of antimicrobial most frequently prescribed.

Dental antimicrobial prescribing practices for the prevention of IE, local infections, and complications following common dental procedures varied widely, and multiple factors influenced the decision to prescribe. Dentists often prescribed antimicrobials postprocedurally despite limited supporting evidence. Current practice patterns suggest that antimicrobials may be overprescribed in dentistry. Intervention is urgently needed to optimize antimicrobial prescription in dentistry.