Antimicrobial resistance stewardship in dental practice: a knowledge, attitudes, and practices study of dentist in Al-Ahsa, Saudi Arabia

Introduction

Modern dental practices cannot be carried out without the use of antibiotics, which are often administered in order to prevent or treat infections that are acquired after the administration of procedures like tooth extractions, implants, and periodontal therapies (1,2). But not all the use is appropriate; such inappropriate use as unnecessary prescription, inaccurate dose or overly-long periods of a treatment lead to the global increase of antimicrobial resistance (AMR) (3). AMR decreases the treatment efficacy, increases health expenditures, and the morbidity and mortality risks. AMR is among the leading global health threats that are identified by the World Health Organization (WHO) (4).

The task of antibiotic stewardship requires the participation of dentists. Their practice in regard to prescriptions is directly related to the outbreak and control of resistant strains of bacteria since they are common prescribers in outpatient facilities (5). However, studies indicate that the use of antibiotics is frequently recommended in a case that has not been indicated like, irreversible pulpitis or uncomplicated dental pain. Predisposing factors are diagnostic uncertainty, pressure by patients and lack of awareness of existing clinical guidelines (6,7).

In Saudi Arabia, the situation is further aggravated by the simple access to antibiotics and their abuse on both healthcare professionals and patients levels (8,9). Resistance of certain bacteria, including Klebsiella pneumoniae, Escherichia coli and multi-resistant Staphylococcus aureus (MRSA) has been noted to increase thus jeopardizing the effectiveness of commonly used antibiotics such as amoxicillin and penicillin (10,11). Al-Ahsa region (rich in its population and inadequately advanced healthcare system) represents an appropriate environment to explore these issues. Clinical experience, workload, and availability of continuing dental education (CDE) might also intervene with the prescribing habits of dentists (12).

Although this has become a matter of greater concern, there is a paucity of regional data on the knowledge, attitudes and practices (KAP) of dentists regarding the use of antibiotics and AMR. Research evidence of other nations shows that dentists usually have a good theoretical background, but it is not necessarily followed by proper prescribing habits. As an example, a survey conducted in Croatia, Bosnia and Herzegovina and Serbia realized that although the knowledge scores were high, a number of dentists continued to prescribe antibiotics out of patient anticipation or lack of training (13). On the same note, in Hyderabad, India, a number of dentists were not conversant with the WHO Access, Watch, and Reserve (AWaRe) classification, and the principles of antibiotic stewardship (14).

The gap between knowledge and practice is caused by some factors. These are archaic undergraduate training, accessibility to revised guidelines, dependence on personal clinical experience, and social pressures by the patients (15,16). Dentists would use antibiotics in other instances to avert the invasive procedure or due to the demands of patients when no clinical reason is involved (17,18).

This matter is even more worrying in pediatric dentistry. Children present a higher risk of being affected by the effects of antibiotic overutilization, but dentists tend to use antibiotics in order to avoid complications or because of the lack of confidence in the other methods (19,20). Overdosing is even more significant in the case of private practices; in practice, regulatory oversight might not be as strict, and due to a lack of common rules and easy access to up-to-date knowledge, the situation is even worse (21). Also, certain dentists are not linked to the long-term implications of AMR, making them less accountable and not eager to embrace evidence-based prescribing habits (22).

These issues are multidimensional and hence need multifaceted approach to address. To ensure that the dentists are up-to-date with the latest evidence-based recommendations as well as the principles of antibiotic stewardship, it is crucial to organize regular professional development and conduct training programs regularly (23,24). One way of decreasing variability and encouraging rational prescribing of dental antibiotics is by creating national guidelines on dental antibiotic prescribing that are unified and highly available to all healthcare providers (25).

In other than the clinical setting, there are concerns to do with the antibiotic misuse regarding broader public health variables. Unequal access to dentists or unequal access to oral care and environmental exposures contribute to increased rate of infection and overprescription. One of the studies was a systematic review (26) that identified higher levels of fluoride in the groundwater with more prevalence of dental fluorosis in the socially disadvantaged populations. This underlines the importance of the social and environmental determinants in oral health and the necessity of the complex interventions decreasing the inequality and achieving the objectives (26).

The aim of this study is to assess the knowledge, attitude, practices of dentists in Al-Ahsa, Saudi Arabia, regarding the antibiotics usage and AMR. Through the filling in of knowledge gaps and contributing factors, the results will assist the policy makers, the educators, and other stakeholders in the healthcare industry to develop specific education programs and carry out the necessary strategies in antibiotic stewardship. Such initiatives play an important role in stimulating responsible prescribing and fighting the further menace of AMR in dentistry and elsewhere. We present this article in accordance with the SURGE reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-106/rc).

Methods

Study design and setting

It was a descriptive, cross-sectional, and questionnaire-based study done both in the public and the private dental clinics of Al-Ahsa, Saudi Arabia. A comprehensive list of all authorized public and private dental clinics and licensed dentists in the Al-Ahsa health cluster was obtained from the Ministry of Health (MOH). The target population of the study was that of licensed dentists, who were practicing members of the Al-Ahsa sanitary circle. The study sample included only dentist who were on duty at the time of the site visit and who complete the survey questionnaire. A universal sampling method, in which individual did not have equal or known probabilities of selection (14), was applied where 541 dentists were contacted as illustrated in Figure 1. Only 424 participated (response rate =78.4%). Data collection was conducted over a six months period, from January through the end of June 2024. The authors visited privately-owned hospitals and individual dental clinics affiliated with the Al-Ahsa health cluster to identify eligible dentist and invite participation; the questionnaire itself was completed electronically used a self-administered Google Forms survey accessed by participants during visit.

Figure 1 Distribution of dentists in Al-Ahsa. MOH, Ministry of Health.

Inclusion criteria were licensed dentists (general practitioners, specialists, or consultants) who were officially registrant and authorized to practice in the Al-Ahsa health cluster, as verified through the MOH registry, and who were actively practicing and on duty at the time of data collection during the study period. Exclusion criteria were dentists not actively practicing during data collection, interns or students without independent licensure, those on leave at the time of clinic visits, and participants who declined participation or submitted incomplete questionnaires were excluded from the study.

Study tool

The research used a structured questionnaire that was created and used to collect information. The questionnaire was developed using a hybrid approach, combining items adapted from previously published and validated KAP instruments assessing antibiotic use and AMR among dental and healthcare professionals, with additional items developed de novo to reflect the local clinical context. Item development was guided by antimicrobial stewardship principles and KAP theory, which conceptualizes prescribing behavior as an interaction between knowledge, attitudinal beliefs, and clinical practice. Clinical scenario-based items were selected to represent common dental conditions associated with antibiotic prescribing decisions (e.g., acute odontogenic infections, prophylactic use, pediatric dosing, and penicillin allergy) and were aligned with contemporary dental-specific antibiotic guidelines, including WHO AWaRe recommendations and established international dental prescribing guidance. Content validity was further ensured through expert review by subject-matter specialists, who evaluated item relevance, clarity, and alignment with current clinical practice. To guarantee reliability and validity, the instrument was tested in two stages, validation. In the first part, the reliability of the questionnaire was tested by administering it to 20 dentists in King Faisal Hospital, Al-Ahsa. Internal consistency of the questionnaire was assessed based on the Cronbach alpha based on which the coefficient was outstanding, 0.994. Internal consistency reliability was assessed using Cronbach’s alpha for each domain of the questionnaire (KAP) rather than solely for the instrument as a whole. Subscale-specific reliability assessment was undertaken in accordance with standard psychometric recommendations for KAP instruments. The overall alpha value reflects the cumulative internal consistency of the full instrument, while domain-level alpha values were examined to ensure conceptual coherence within each subscale and to minimize redundancy. High alpha values were interpreted in the context of closely related, guideline-driven items designed to capture overlapping aspects of antibiotic prescribing behavior in dental practice. It is pertinent to note that pilot participants were excluded from the main study.

The second step was performed to determine the content validity of the questionnaire in which three experts on the subject matter were utilized who were independent of the study. Content validity of the questionnaire was established through review by three independent subject-matter experts with demonstrated expertise in dental public health, antimicrobial stewardship, and clinical dentistry, each possessing more than 10 years of academic or clinical experience. The experts were not involved in study design, data collection, or analysis. They evaluated the questionnaire for relevance, clarity, and alignment with current dental antibiotic prescribing practices. Based on their feedback, minor modifications were made, including refinement of item wording to improve clarity, reordering of questions to enhance logical flow, and alignment of clinical scenario descriptions with contemporary dental antibiotic guidelines. No items were removed or substantively altered in their conceptual intent.

The survey questionnaire that was compiled consisted of four sections. The initial portion transferred sociodemographic data, enchanting the age of the respondent, his/her gender, the educational step of the person, and the number of years of professional expertise. In the second part personal knowledge about safe and wise use of antibiotics and the knowledge about AMR were measured with the help of scenario-based questions in order to examine the general knowledge on this topic. In the third section, investigations were done on the attitudes, belief and perceptions of the respondents regarding antibiotic prescription and resistance. In the last part, the fourth one assessed the real practices of antibiotics prescribing patterns and compliance with resistance management guidelines.

Statistical analysis

Data collected were inserted and analyzed in IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA). Prior to analysis, the dataset was screened for completeness and internal consistency. Given the categorical nature of the KAP variables, no statistical imputation was performed for missing responses. Questionnaires with incomplete or inconsistent responses in key KAP domains were excluded from inferential analyses using listwise deletion. This approach was adopted to avoid introducing bias through inappropriate imputation of categorical survey data and to preserve the validity of association estimates.

The demographic attributes of the participants together with their responses to the KAP questions were described to determine descriptive statistics such as mean, median, standard deviation (SD), frequencies, and percentages. Responses were coded in to pre-determined thresholds to derive the levels of knowledge, attitudes and practices; the predetermined thresholds were a score of 80 percent or better was rated as good level, score between 41 percent and 80 percent was rated as fair and score of 40 percent and below was rated as poor (27).

Inferential statistics were utilized to have answers to the research objectives of the study. In particular, regression analysis was carried out to compare the links between the KAP scores of dentists and demographics. The possible confounding factors were defined and statistically taken into account in order to provide the correctness of the seen lines of association. The results had a P value that was below 0.05, and it was interpreted based on the local dental practices as well as the implied implications on the antibiotics stewardship in the Al-Ahsa region.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical approvals were obtained from both the Institutional Ethical Committee of King Faisal University (Ref No. KFU-REC-2023-MAY-ETHICS880) and the Ethics and Research Committee at King Fahad Hospital (IRB Log No. 88-EP-2023). Both King Faisal Hospital and King Fahad Hospital are parts of the Al-Ahsa Health Cluster that includes all health facilities in Al-Ahsa. The Ethics and Research Committee at King Fahad Hospital serves as the central ethics review body for the entire Al-Ahsa Health Cluster system and it was mandatory to get ethical clearance from its relevant administration to conduct our study. All participants were informed of the study’s aims and procedures. Informed consent was obtained, and participation was voluntary. Confidentiality and anonymity were strictly maintained, and no personal identifiers were collected or disclosed.

Results

Demographic characteristics of the participants

Table 1 presents the demographic and professional characteristics of the 424 participating dentists in Al-Ahsa, Saudi Arabia. Variables include gender, nationality, type of dental center, professional specialty, years of clinical experience, number of patients examined per day, age distribution, number of antibiotic prescriptions in the previous week, and attendance in CDE programs related to antibiotics or resistance. Among the total participants (n=424), 66.75% (n=283) were male and 33.25% (n=141) were female. The majority were Saudi nationals (65.33%, n=277), and 34.67% (n=147) were non-Saudis. Most participants worked in private dental centers (47.41%, n=201), followed by public sectors (44.34%, n=188), and a smaller proportion in semi-government settings (8.25%, n=35).

Regarding professional level, general practitioner dentists made up the largest group (63.92%, n=271), followed by specialists (28.77%, n=122), and consultants (7.31%, n=31). In terms of clinical experience, most respondents had 1–5 years of experience (62.50%, n=265), followed by 6–10 years (17.45%, n=74), over 10 years (13.92%, n=59), and less than 1 year (6.13%, n=26).

The average age of the participants was 35.1 years (SD =5.99 years). Most dentists saw fewer than 10 patients per day (55.19%, n=234), while 38.44% saw 10–14 patients daily. A small percentage attended to more than 15 patients per day. Concerning antibiotic prescription patterns, 41.51% (n=176) reported prescribing antibiotics to 10–15 patients in the previous week.

CDE on antibiotic use or resistance had never been attended by 62.26% (n=264) of respondents, while only 6.84% had participated in such training within the last year.

KAP related to antibiotic use

Knowledge

Dentists demonstrated varied levels of knowledge regarding antibiotic use. Most respondents correctly identified that antibiotics should be prescribed when pain, swelling, fever, and sinus tract/fistula are present (62.26%, n=264). A majority also correctly rejected the notion that antibiotics are a replacement for surgery (67.92%, n=288) and opposed their pre-procedural use solely for reducing inflammation or pain (63.68%, n=270). However, notable gaps were observed concerning appropriate antibiotic choices for penicillin-allergic patients and pediatric dosing of metronidazole.

Attitudes

The majority of dentists agreed or strongly agreed that antibiotics are beneficial for managing cellulitis (93.87%) and acute ulcerative gingivitis (79.48%). Furthermore, 85.14% strongly agreed that AMR is a global issue, and 77.12% considered it a problem within Saudi Arabia as well. However, opinions were more divided regarding the perception that resistance cannot develop if antibiotics are used as prescribed.

Practices

Regarding practices, 80.42% of dentists always kept records of antibiotics prescribed, and 70.99% consistently informed patients about the consequences of improper antibiotic use. Only 1.18% reported always requesting sensitivity testing after draining an abscess, indicating a significant gap in evidence-based practice. Over half (53.54%) admitted that patient pressure sometimes influenced their prescription decisions, and 45.99% reported workload as a contributing factor.

Table 2 details the frequency and percentage responses of dentists on key items assessing their KAP regarding antibiotic prescription and AMR. It includes perceptions about indications for antibiotics, use of prophylactic antibiotics, pediatric dosing, beliefs on resistance, and prescription behaviors such as record-keeping, patient education, and response to external pressures.

Classification of KAP

Knowledge

Among respondents, 63.7% were classified as having poor knowledge, 23.6% as fair, and only 12.7% as having good knowledge. Poor knowledge was more prevalent among specialists (78.7%) and those with over 10 years of experience (76.3%). Knowledge classification differed by self-reported antibiotic prescribing frequency (P<0.001). A higher proportion of good knowledge was observed among dentist reporting 15-15 prescription/week compared with low-prescribing group; however, this indicates that higher knowledge did not necessarily correspond to lower prescribing volume, suggesting a potential knowledge-practice gap. Similarly, those attending CDE more recently showed better knowledge classification.

Attitude

Attitude scores were significantly associated with nationality, type of dental center, experience, antibiotics prescribed, and CDE attendance (P<0.05). Dentists working in private centers and those with less experience had more favorable attitudes. Attitude scores varied across categories of CDE attendance. Dentists who attended CDE on antibiotics use in the last year demonstrated a higher proportion of poor attitude scores, whereas higher proportion of good attitude scores were observed among dentists who had never attended CDE.

Practice

Regarding practices, male, Saudi, and public sector dentists were more likely to have poor practices compared to their counterparts. Practice scores varied significantly by clinical experience and prescribing frequency (P<0.001). the distribution across experience classification was observed among dentist with <1 year of experience. In addition, recent CDE attendance was not associated with better practice classification in the descriptive analysis. A strong association was found between clinical experience, specialty, number of antibiotics prescribed, and practice scores (P<0.001).

Table 3 classifies dentists’ KAP scores into “Poor”, “Fair”, and “Good” categories and explores their distribution across different demographic and practice-related variables. P value statistics are used to assess the association between KAP levels and variables such as gender, nationality, clinical experience, number of patients seen per day, and CDE attendance.

Multinomial logistic regression analysis

Table 4 summarizes the results of multinomial logistic regression models evaluating predictors of dentists’ KAP related to antibiotic use. Independent variables include gender, nationality, dental clinic type, professional specialty, years of experience, number of antibiotics prescribed per week, patient volume, and CDE attendance. Nagelkerke R² values and significance levels are reported for each model.

Multinomial logistic regression revealed significant predictors for KAP levels. For knowledge, specialty (P=0.001), number of antibiotics prescribed (P=0.001), patients seen daily (P=0.02), and CDE attendance (P=0.03) were significant predictors. Attitude was significantly predicted by antibiotic prescription frequency (P=0.001) and CDE attendance (P=0.008). In terms of practice, significant predictors included gender (P=0.040), specialty (P=0.02), clinical experience (P=0.002), and antibiotic prescription frequency (P=0.001).

To facilitate interpretation, the inferential findings highlight associative rather than predictive patterns. Multinomial logistic regression identified statistically significant relationships between dentists’ KAP and key professional characteristics, including specialty, clinical experience, prescribing frequency, patient volume, and participation in CDE. These associations indicate heterogeneity in antimicrobial stewardship behaviors across professional subgroups, underscoring that prescribing decisions are influenced by a constellation of clinical workload, professional role, and experiential factors rather than a single determinant.

Discussion

This study provides a comprehensive assessment of dentists’ knowledge, attitudes, and prescribing practices related to AMR in Al-Ahsa, Saudi Arabia. While awareness of AMR as a global and national health threat was high, the findings reveal a pronounced disconnect between knowledge and actual prescribing behavior. This divergence suggests that awareness alone is insufficient to ensure rational antibiotic use and highlights the influence of contextual, behavioral, and system-level factors in shaping clinical decision-making within dental practice. AMR becomes one of the significant global healthcare issues and the contribution of dentists to counteracting this problem becomes more and more apparent. The structure of KAP of dentists concerning the use of antibiotics is determined by a complicated interaction of factors, such as education, experience working with patients, culture, and medical environment. The paper gives an in-depth evaluation of the KAP of the dentists in Al-Ahsa, Saudi Arabia, an informative analysis of the local prescribing patterns and their effects on antimicrobial stewardship.

The age group of respondents showed that the respondents were male (66.75 percent) unlike in other countries such as South Africa and Nepal where female dentists compose a bigger percentage of the workforce (20,21). The mean age of participants was 35.1 years which was lesser compared to the mean age found in Lebanon (44.87 years) (22) but higher than the age found in Nepal (26.72 years) (23). Majority of the respondents were the Saudi nationals (65.33%), this is as consistent with the results recorded in Lebanon, where local qualifications are the dominant dental workforce (24).

The general doctors accounted for 63.92 percent of the sample, in line with related studies in Lebanon (25). The percentage of any respondents with 1–5 years clinical experience was also 62.5 percent which can be likened to what is currently going on in India where early-career dentists comprise the majority (26). The above demographic features give indispensable backstory to the interpretation of the KAP results and an idea about the groupings affecting the method of antibiotic prescribing in the area.

KAP regarding antibiotic use and resistance

Knowledge

The researchers also found that 62.26 percent of dentists mentioned clinical indicators including pain, swelling, fever, and sinus tract/ fistula to be the correct explanations to the use of antibiotics. Such is reflective of increasing awareness with regard to proper indications of antibiotics in dental care, in concurrence with its global trends (28-30). Nevertheless, the provision of misconceptions was clearly stated. On the positive side, the majority of them realized that antibiotics could not be an alternative to surgery, which was also noted by Agnihotry et al. (1), who stressed that antibiotics cannot be effective in treating reversible pulpitis or pain without other causes (31,32). As an example, 26.18 percent of respondents favored the application of pre-procedural antibiotics to treat inflammation or to alleviate pain even though there have been no grounds to apply the same except when there was a lot of bleeding or in instances of patients presenting with immunosuppression (33,34).

Most respondents (86.79%) answered correctly on the survey item assessing knowledge of the acceptable pediatric amoxicillin suspension dosing, while only 32.31% did so for metronidazole. These results are consistent with studies by George et al. and Goel et al. (28,29) which identified amoxicillin as the most commonly prescribed pediatric antibiotic due to its efficacy and safety profile (35,36).

However, knowledge gaps persisted as nearly one-third of participants were uncertain about the appropriateness of azithromycin as a first-line therapy, despite penicillins being the gold standard for odontogenic infections (37). Awareness of alternatives for penicillin-allergic patients was moderate, with erythromycin (58.73%) and clindamycin (29.48%) correctly identified, in line with CDC and ASM guidelines (38).

Attitudes

The study found generally positive attitudes toward responsible antibiotic use. A majority (60.85%) strongly agreed that antibiotics are beneficial in acute periapical infections with systemic signs, consistent with findings from (10,38,39). Similarly, strong agreement was observed for treating acute ulcerative gingivitis (64.39%) and cellulitis (77.12%), indicating awareness of conditions that warrant antibiotic intervention (40,41).

Most dentists (85.14%) recognized AMR as a global concern, paralleling findings from Italy, where 98.9% of dentists acknowledged the severity of the issue (42). Additionally, 77.12% viewed resistance as a national concern in Saudi Arabia, supported by reports of rising resistance rates in Klebsiella pneumoniae, Escherichia coli, and MRSA (43,44).

However, perceptions varied regarding whether proper antibiotic use eliminates resistance risk. While 37.03% strongly agreed, others expressed uncertainty, highlighting the complexity of resistance mechanisms and the need for more nuanced education (45). Encouragingly, 70.99% of dentists acknowledged their role in contributing to antibiotic resistance, reflecting findings from Italy and Nepal that emphasize the impact of dental prescriptions on public health (46,47).

Practices

In terms of practice, most respondents reported consistently documenting prescribed antibiotics (80.42%) and counseling patients on the consequences of misuse (70.99%). These behaviors reflect a commitment to responsible prescribing and patient education. However, only 1.18% consistently requested sensitivity testing, indicating a significant gap in evidence-based practice and diagnostic support. The extremely low rate of culture and sensitivity testing show in this study reflects routine dental practice, where most odontogenic infections are acute, localized, and managed empirically through clinical diagnosis, operative intervention, and short-course first-line antibiotics. Dental recommendations generally do not endorse routine testing for uncomplicated dental infections, reserving it for severe, recurrent, non-resolving infections, immunocompromised patients, or cases with potential antibiotic resistance.

Patient pressure influenced prescriptions in (53.54%) of cases, echoing findings by 50. While patient expectations are a known factor, a systematic review suggests that clinical factors more often drive prescriptions (48,49). Nonetheless, the influence of patient demand cannot be overlooked, especially in private practice settings.

Workload also emerged as a significant factor, with 45.99% of dentists reporting that high patient volume sometimes or always influenced their prescribing decisions. This finding is supported by qualitative research linking clinical workload to increased antibiotic use (50). These pressures highlight the need for systemic support and workflow optimization to reduce reliance on antibiotics as a time-saving measure.

Predictors, strategies, and broader implications

Predictors of KAP

The multinomial logistic regression analysis conducted in this study identified several significant predictors influencing the KAP of dentists regarding antibiotic use and resistance. The analysis showed that knowledge was significantly influenced by the dentist’s specialty, the number of patients to whom antibiotics were prescribed, the number of patients seen daily, and attendance at CDE programs. These variables collectively explained 33.8% of the variance in knowledge, as indicated by a Nagelkerke R² value of 0.338. The multinomial logistic regression models employed in this study were intended to explore associative relationships rather than to function as predictive models. In behavioral and public health research, particularly studies examining prescribing behavior, modest pseudo-R² values are expected due to the multifactorial and context-dependent nature of clinical decision-making. Therefore, the observed Nagelkerke R² values should be interpreted as indicative of meaningful but partial explanatory power, with statistical significance of predictors providing insight into relevant drivers of antibiotic prescribing rather than comprehensive variance explanation.

To enhance interpretability, the findings should be viewed collectively rather than in isolation. The convergence of descriptive patterns and regression findings consistently indicates that higher workload, frequent antibiotic prescribing, and professional specialty are associated with poorer stewardship practices, even among dentists demonstrating adequate knowledge. This integrated interpretation emphasizes that AMR in dental care is not solely a knowledge deficit issue, but one that is embedded within clinical workflows and organizational environments.

Attitudes toward antibiotic use and resistance were also significantly associated with the frequency of antibiotic prescriptions and participation in CDE programs. However, the distribution (Table 3) indicates that dentist who attended CDE within the last year had a higher proportion of poor attitude scores, and recent CDE attendance did not correspond to improved practice classification. This suggests that CDE participation alone may not translate into better stewardship behavior unless programs are standardized, competency-based, and reinforced through audit-and-feedback and institutional antimicrobial stewardship policies. The model accounted for 48.7% of the variance in attitudes (Nagelkerke R²=0.487), suggesting that both practical experience and ongoing education play a critical role in shaping dentists’ perspectives on antimicrobial stewardship.

In terms of practice, the analysis revealed significant relationships with gender, specialty, clinical experience, and the frequency of antibiotic prescriptions. These factors explained 34.1% of the variance in practice behaviors (Nagelkerke R²=0.341), highlighting the multifactorial nature of prescribing decisions in dental settings. Dental sectors, the type of dental clinic was not a significant predictor of dentists’ knowledge, attitudes, or practices regarding antibiotic use in the multinomial logistic regression analysis. However, this non-significant sectoral effect suggests that individual-level factors such as specialty, clinical experience, prescribing frequency, and CDE may exert a stronger effect on prescribing behavior than practice setting alone, consistent with recent regional and international antimicrobial stewardship literature aligned with WHO recommendations.

These findings underscore the importance of targeted educational interventions and professional development opportunities in promoting responsible antibiotic use. They also align with the conclusions drawn by Montebello et al. (38), who emphasized that education and specialization are more influential than sociodemographic variables in shaping effective antibiotic stewardship among dental professionals (51).

Strategies for improvement

The findings of this study suggest that improving antimicrobial stewardship in dental practice requires interventions that extend beyond knowledge dissemination alone. The observed knowledge-practice gap indicates that CDE must be standardized, competency-based, and explicitly linked to prescribing behavior, rather than relying on passive attendance. In addition, workload and patient pressure emerged as key influences on antibiotic prescribing, highlighting the need for system-level strategies such as clinical decision-support tools, clear prescribing protocols, and audit-and-feedback mechanisms to support dentists under high patient volumes.

Institutional antimicrobial stewardship programs tailored to dental settings may help mitigate time-pressured prescribing and reduce reliance on antibiotics as a substitute for operative intervention. Furthermore, specialty-specific stewardship guidance may be warranted, given the observed variation in prescribing practices across professional roles. Collectively, these findings support a shift toward integrated stewardship models that combine education, organizational support, and accountability mechanisms to promote rational antibiotic use in dental care (52).

Broader implications

While evidence-based guidelines are essential, they must be applied judiciously. Not all clinical scenarios can be addressed through randomized trials, and patient-specific factors must be considered. Evidence-based dentistry should integrate scientific evidence with clinical expertise and patient preferences, promoting individualized care.

Environmental and social determinants also influence oral health and prescribing behaviors. For example, Umer [2023] (26) highlighted how fluoride levels in groundwater contribute to dental fluorosis in disadvantaged communities, emphasizing the need for integrated public health strategies that address both environmental and clinical factors.

Strengths and limitations

This study is the first multi-centered cross-sectional investigation in Al-Ahsa evaluating dental professionals’ KAP regarding antibiotics and resistance. It included dentists from both public and private sectors with diverse clinical experience and specialties, enhancing the representativeness of the findings.

However, the study is limited to Al-Ahsa and may not be generalizable to all of Saudi Arabia. The use of an online self-administered survey introduces the possibility of self-report bias, including social desirability bias. The study sample was disproportionately composed of younger dentists, with 39.9% having fewer than 5 years of practice and 31.6% having between 5 and 10 years of experience. Additionally, the cross-sectional design limits causal inference. Future longitudinal and qualitative studies are recommended to explore the evolution of prescribing practices and the impact of interventions over time.

Conclusions

This study revealed a mixture of appropriate knowledge and notable misconceptions among dentists in Al-Ahsa, Saudi Arabia, regarding antibiotic use in dental practice. While many participants demonstrated sound understanding of clinical indications and resistance issues, gaps in knowledge and variability in attitudes remain evident. These findings emphasize the need for targeted educational interventions and the reinforcement of evidence-based prescribing practices to improve patient care and reduce the risk of AMR in dental settings.

Dentists expressed diverse attitudes toward antibiotic use, with many recognizing their role in mitigating resistance. In terms of practice, positive behaviors such as consistent record-keeping, patient education, and consulting updated guidelines were reported. However, external influences such as patient pressure and workload were noted to affect prescribing behaviors.

KAP varied significantly across demographic factors including gender, nationality, clinical experience, specialty, and workplace setting. These insights underscore the importance of tailoring interventions based on professional background and experience to foster responsible antibiotic stewardship among dental professionals. Therefore, improving stewardship in dental practice may require not only increased access to CDE, but also enhancement of CED quality and integration with system-level interventions such as prescribing protocols, audit-and-feedback mechanisms, and workload-sensitive stewardship support.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-106/rc

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-106/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-106/prf

Funding: This research was supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia (project No. KFU251497).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-2025-1-106/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical approvals were obtained from both the Institutional Ethical Committee of King Faisal University (Ref No. KFU-REC-2023-MAY-ETHICS880) and the Ethics and Research Committee at King Fahad Hospital (IRB Log No. 88-EP-2023). All participants were informed of the study’s aims and procedures. Informed consent was obtained, and participation was voluntary. Confidentiality and anonymity were strictly maintained, and no personal identifiers were collected or disclosed.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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