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.Reference Wilson, Taubert and Gewitz ^{4 ,} Reference Habib, Lancellotti and Antunes ⁵ However, in real-life settings, antimicrobial prophylaxis was frequently prescribed postprocedurally.Reference Suda, Henschel, Patel, Fitzpatrick and Evans 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.Reference Lodi, Figini, Sardella, Carrassi, Del Fabbro and Furness ^{6 ,} Reference Esposito, Grusovin and Worthington 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.Reference Lodi, Figini, Sardella, Carrassi, Del Fabbro and Furness ^{6 ,} Reference Esposito, Grusovin and Worthington ⁷ Previous studies have also cited the inappropriate continuation of postprocedural prophylaxis.Reference Suda, Henschel, Patel, Fitzpatrick and Evans ^{3 ,} Reference Durkin, Hsueh and Sallah 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.