Despite significant advances in pharmaceuticals and their widespread use, the global burden of diseases continues to increase. Factors such as rapid globalization and economic development have significantly contributed to the rising incidence of illnesses worldwide. Medications play a crucial role in maintaining health, reducing morbidity, managing chronic illnesses, and curing diseases. Effective communication of medication plans through prescriptions is essential for the safe and efficient delivery of medications to patients. However, prescribing drugs is a complex task that requires both theoretical knowledge and practical experience. Recently, there has been growing concern over the misuse of medications, including self-medication by patients and inappropriate prescribing practices by healthcare professionals (1).

Antimicrobial Resistance (AMR) is a critical global health challenge that complicates the treatment of infectious diseases and undermines the effectiveness of established therapies (1). While resistance is a natural evolutionary process in microorganisms, substantial evidence indicates that its acceleration is largely driven by the overuse and misuse of antimicrobials. According to the Centres for Disease Control and Prevention (CDC), AMR occurs when drugs fail to eliminate the organisms they are designed to target, allowing these pathogens to survive, grow, and spread. This presents a significant global health threat, as it makes the treatment of common infections increasingly difficult (1).

The escalating use of antibiotics by healthcare professionals, particularly physicians and dentists (2), has led to their misapplication and overuse, significantly contributing to the rise in antibiotic resistance (3, 4). As a result, AMR has become a major concern across all healthcare sectors, including dentistry, highlighting the urgent need to optimise prescribing practices, especially in dental care.

Studies have revealed alarming statistics regarding antibiotic prescriptions in dentistry. For example, research in the United Kingdom found that only 19% of antibiotics prescribed for acute dental conditions followed the recommendations of the guidelines (5). Similarly, a study in the United States found inappropriate antibiotic prescriptions for prophylaxis use in more than 80% of the cases (6). Such high rates of inappropriate antibiotic prescribing by dentists underscore the essential role of the dental profession in tackling the rise of bacterial resistance (7).

In dentistry, the most commonly prescribed medications are non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics (8, 9) However, inappropriate antibiotic prescriptions in dental practice have been linked to serious adverse outcomes, including anaphylaxis, colitis, and the development of drug-resistant infections (10, 11). To help dentists balance the risks of dental infections with the potential harms of antibiotic prescriptions, clinical guidelines have been developed (7, 12).

In Palestine, where dental education and practice face unique challenges due to ongoing severe geopolitical conflict, no studies have yet assessed antibiotic use among dentists (13). However, two recent studies on antibiotic use among primary care providers in Palestine raised concerns about the overuse of these medications (14, 15).

Understanding prescribing practices among future dentists is therefore essential. Palestinian dental students, from juniors to interns, are at the forefront of learning and applying pharmacological knowledge in clinical settings. Typically, they gain clinical experience by treating patients under close supervision in university outpatient clinics. Students are introduced to antibiotic use during pharmacology courses and are expected to apply this knowledge in clinical training under supervision during their 4th, 5th, and internship years, aiming to develop safe prescribing skills based on university-developed guidelines (16, 17).

Despite numerous studies globally examining the antibiotic knowledge and prescribing behaviours of dental practitioners, most have predominantly focused on practising dentists (18), with limited attention given to the knowledge and attitudes of dental students. Therefore, this study aimed to evaluate the knowledge, attitudes, and prescribing behaviors of Palestinian dental students regarding antibiotic use. Given the unique challenges in Palestinian dental education and healthcare, including the absence of studies on antibiotic prescribing among dentists in Palestine, this study sought to fill this gap by exploring antibiotic stewardship at the educational level. It aims to identify key factors influencing prescribing decisions among dental students, with a focus on the development of safe and evidence-based antibiotic prescribing practices in clinical settings.

The findings of this study will inform dental educators, professional associations, and health ministries in developing dental antibiotic stewardship interventions, including educational programs and standardised guidelines for Palestine. By promoting appropriate prescribing practices, the Palestinian dental community can contribute to global efforts to preserve the efficacy of antimicrobial agents and ensure optimal patient outcomes.

The study was approved by the research ethics committee at Al-Quds University, ensuring compliance with all necessary ethical standards. The committee's decision letter was received on December 12, 2022, with reference No. 222/REC/2022.

No statistically significant differences were observed in the "Actual Knowledge" scores across gender (t = 2.316, p = 0.129), year of study (F = 0.380, p = 0.684), or having a family member in the medical field (t = 1.837, p = 0.176).

Bivariate correlation tests revealed a statistically significant positive correlation between Actual Knowledge and Perceived Knowledge (r = 0.205, p < 0.05), as well as between Actual Knowledge and Confidence in prescribing antibiotics (r = 0.153, p < 0.05). Notably, a strong positive correlation was found between Perceived Knowledge and Confidence (r = 0.792, p < 0.05).

Additionally, the findings demonstrated a positive correlation between Actual Knowledge and attitudes toward the responsibility of combating antibiotic resistance (r = 0.192, p < 0.05).

A strong positive correlation (r = 0.817, p < 0.05) was observed between “Confidence” score and “Antibiotic Prescription Guidance Accessibility”. This included access to guidelines, materials for providing advice on prudent antibiotic use, and opportunities to advise individuals on prudent antibiotic use. Students who responded from “strongly disagree” to “strongly agree” reported a lower frequency of antibiotic prescribing.

Further analysis revealed additional significant associations between the current study composite variables and the antibiotic prescribing frequency. Perceived Knowledge (ρ = −0.272, p < 0.001), Confidence (ρ = −0.201, p < 0.001), Attitude (ρ = −0.258, p < 0.001), and Accessibility (ρ = −0.205, p < 0.001) scores were all significantly and negatively correlated with prescribing frequency, indicating that higher levels of perceived preparedness, access to guidance, and stewardship attitudes were associated with lower reported antibiotic use. In contrast, Actual Knowledge showed no significant association (ρ = 0.035, p = 0.419). These findings suggest that perceptions, confidence, and system-level support may have a stronger influence on behaviour than factual knowledge alone.

The frequency of antibiotic prescriptions in the last week was significantly associated with the year of study (χ² = 55.618, p = .000). Advanced students, particularly interns, prescribed antibiotics more frequently than 4th- and 5th-year students.

Knowledge-related variables showed significant negative associations with prescribing frequency. Statements such as “I know what information to give to individuals about prudent use of antibiotics and antibiotic resistance” (χ² = 82.650, p = .000), “I have sufficient knowledge about how to use antibiotics appropriately for my current training” (χ² = 76.644, p = .001), and “I am confident in making antibiotic prescribing decisions” (χ² = 84.250, p = .000) revealed that increased knowledge and confidence correlated with reduced prescribing frequency.

Access to resources also influenced prescribing behaviour. Greater access to guidelines (“I have easy access to guidelines I need on managing infections”, χ² = 106.441, p = .000) and educational materials “I have easy access to the materials I need to give advice on prudent antibiotic use and antibiotic resistance”, χ² = 80.271, p = .000) was associated with lower prescribing frequency.

Opportunities to provide advice on prudent antibiotic use were significantly associated with prescribing behaviours (“I have good opportunities to provide advice on prudent antibiotic use to individuals”, χ² = 70.586, p = .004). Greater opportunities correlated with lower prescribing rates. Confidence in available guidelines (“I have confidence in the antibiotic guidelines available to me”, χ² = 79.656, p = .000) and feeling supported in decision-making (“I feel supported to not prescribe antibiotics when they are not necessary”, χ² = 111.133, p = .000) were similarly linked to reduced prescribing frequency.

Considering antibiotic resistance during patient treatment was significantly related to prescribing behaviour (“I consider antibiotic resistance when treating a patient”, χ² = 75.524, p = .001), with greater consideration associated with lower prescribing frequency.

Bad/inappropriate practices such as prescribing antibiotics due to uncertainty about infection diagnosis (χ² = 504.414, p = .000), inability to avoid prescribing (χ² = 670.491, p = .000), and early discontinuation of prescriptions (χ² = 609.207, p = .000) showed significant positive correlations with prescribing frequency. These challenges increased the frequency of antibiotic prescribing.

When stratified by university, significant associations were observed. Al-Quds University (AQU) students had the highest number of respondents agreeing or strongly agreeing with the following statements:

“I am confident in making antibiotic prescribing decisions” (n = 99, χ² = 501.850, p = .000).

Students demonstrated moderate actual knowledge (mean = 4.22/7) and perceived knowledge (mean = 9.45/15). Only 40.3% expressed confidence in their prescribing decisions. Inappropriate prescribing behaviours—such as prescribing due to diagnostic uncertainty (13.3%) and to meet patient expectations (12.1%)—were common. Interns prescribed antibiotics more frequently than 4th- and 5th-year students (χ² = 55.618, p < 0.001). Access to guidelines and confidence in prescribing were strongly associated with reduced antibiotic use (p < 0.001). See Appendix I for detailed results on Tables 2–7.

A strong positive correlation (r = 0.817, p < 0.05) was observed between the Confidence Composite variable score and the “Antibiotic Prescription Guidance Accessibility” composite variable. The frequency of antibiotic prescriptions during the last week was significantly and positively associated with the year of study (χ² = 55.618, p = .000), with more advanced students, particularly interns, prescribing antibiotics more frequently compared to earlier-year students (4th- and 5th-years).

Regarding perceived knowledge-related variables and prescribing frequency, a significant negative association was found between the statement “How often did you prescribe antibiotics during the last one week?” and each of the following:

“I know what information to give to individuals about prudent use of antibiotics and antibiotic resistance” (χ² = 82.650, p = .000).

Access to resources showed significant associations with prescribing behaviour. Greater access to guidelines, “I have easy access to the guidelines I need on managing infections”, (χ² = 106.441, p = .000) and educational materials “I have easy access to the materials I need to give advice on prudent antibiotic use and antibiotic resistance”, (χ² = 80.271, p = .000) was associated with a lower frequency of antibiotic prescribing.

Opportunities to provide advice on antibiotic use were also significantly associated with prescribing behaviours, as reflected in responses to “I have good opportunities to provide advice on prudent antibiotic use to individuals” (χ² = 70.586, p = .004), where better opportunities correlated with lower prescribing rates. Confidence in available guidelines (“I have confidence in the antibiotic guidelines available to me”, (χ² = 79.656, p = .000) and feeling supported in decision-making (“I feel supported to not prescribe antibiotics when they are not necessary”, χ² = 111.133, p = .000) were similarly associated with a lower frequency of prescribing.

Considering antibiotic resistance during patient treatment was also significantly related to prescribing behaviours “I consider antibiotic resistance when treating a patient”, (χ² = 75.524, p = .001), Students who responded from “strongly disagree” to “strongly agree” with the previous statement reported a lower frequency of antibiotic prescribing.

Higher prescription frequency was correlated positively with some inappropriate practice variables, such as “How often would you have preferred not to prescribe an antibiotic but were not able during the last one week?” (χ² = 670.491, p = .000), “How often did you stop an antibiotic prescription earlier than the prescribed course length during the last one week?” (χ² = 609.207, p = .000), and “How often did you prescribe an antibiotic because you were uncertain about the diagnosis of infection during the last one week?” (χ² = 504.414, p = .000).

When stratified by university, significant associations were found for several statements. For instance, Al-Quds University (AQU) had the highest number of students who agreed or strongly agreed with the statement “I am confident in making antibiotic prescribing decisions” (n = 99, χ² = 501.850, p = .000). Similarly, AQU students also reported the highest number agreeing with the statement “I have a key role in helping control antibiotic resistance” (n = 104, χ² = 444.476, p = .000). Regarding the statement “I consider antibiotic resistance when treating a patient” (χ² = 35.773, p = .008), AQU again had the highest number of students who agreed or strongly agreed (n = 110), followed by Arab American University (AAU) (n = 68). Furthermore, for the statement “I have sufficient knowledge about how to use antibiotics appropriately for my current training”, AQU students were again the most likely to agree or strongly agree (n = 105, χ² = 42.132, p = .000). Table 8A presents the abbreviated bivariate analysis results. See Appendix I, Table 8B for complete bivariate analysis results.

Antibiotic resistance is a global health crisis, exacerbated by the overuse and misuse of antibiotics across various healthcare sectors, including dentistry. While existing studies have explored antibiotic knowledge and prescribing behaviours among practicing dentists, limited attention has been given to dental students, particularly in Palestine. This study is the first of its kind in Palestine, addressing a critical gap in the literature regarding dental students' knowledge and practices related to antibiotic prescriptions.

The findings reveal that while Palestinian dental students possess foundational knowledge about antibiotic resistance, significant gaps exist in their confidence and ability to apply this knowledge in clinical practice. A statistically significant positive correlation was observed between actual knowledge and confidence in prescribing practices. However, a substantial proportion of students reported inappropriate prescribing behaviours, often driven by uncertainty in diagnosis, fear of complications, time constraints, and patient expectations.

Our findings align with existing literature, highlighting significant discrepancies between knowledge and clinical practices in antibiotic prescribing among dental practitioners globally, including those in the Middle East. While dentists generally demonstrate a strong theoretical understanding of antibiotic use, studies consistently report widespread inappropriate prescribing, contributing to the growing challenge of antimicrobial resistance.

For instance, studies in Croatia, Bosnia, and Serbia found that dentists achieved high antibiotic resistance knowledge scores (6.40 out of 8); however, many still prescribed antibiotics at patient request, reflecting the influence of patient expectations on prescribing behaviours (20). Similarly, in Egypt, dental students frequently overprescribed antibiotics to satisfy patient demands (21). Roganović and Barac (22) further emphasized that inadequate ethical training contributed to inappropriate prescribing among European dental students, a concern echoed in our study. These ethical dilemmas highlight the need for enhanced training that emphasizes both evidence-based decision-making and ethical prescribing practices.

A concerning trend emerged among senior students, particularly interns, who exhibited a higher frequency of antibiotic prescriptions compared to their junior counterparts, despite having similar levels of theoretical knowledge. This aligns with findings from Jordan, where majority of dentists understood resistance mechanisms but lacked confidence in their prescribing decisions (18). Similarly, Palestinian students faced challenges akin to those identified in the Asia-Pacific region, where awareness of antimicrobial resistance did not translate into confident prescribing decisions (23). In contrast, Saudi dental students demonstrated overconfidence with increasing experience, leading to higher prescribing rates (24). These trends suggest that clinical exposure alone does not necessarily improve antibiotic stewardship and may, in some cases, reinforce inappropriate prescribing habits. The need for clear guidelines for both dental students and dentists is critical to promote appropriate antibiotic prescription practices.

In the current study, the absence of standardized clinical guidelines exacerbated inappropriate prescribing. A study among UK dentists demonstrated that guideline adherence improved prescribing appropriateness by 30% (5), reinforcing the importance of clear, standardized protocols. Consistently, our study found a statistically significant association between access to guidelines and lower prescribing frequency, underscoring the need for national and institutional policies to regulate antibiotic use.

A key finding of this study is the persistent gap between theoretical knowledge and practical application, mirroring trends observed in other regions. Tariq et al. (25) reported that although Brazilian dental students possessed general awareness of antibiotic resistance, a substantial gap remained in translating this knowledge into appropriate clinical decision-making. Similarly, a study in the United Arab Emirates highlighted moderate knowledge of antibiotics but significant misconceptions regarding their appropriate use and resistance mechanisms (26). These misconceptions reflect broader deficiencies in dental education that may negatively impact future prescribing behaviours. One potential contributor to these gaps is inadequate interprofessional collaboration and limited training with other healthcare professionals, which may hinder effective coordination in antibiotic stewardship efforts (27).

A European study identified seven key factors driving inappropriate prescribing, including reliance on outdated educational materials and inconsistencies in guidelines (28). Likewise, Suda et al. found that US dentists exhibited inappropriate prophylaxis prescribing in 80% of cases, often prioritizing perceived patient needs over established guidelines (29). These global patterns highlight the urgent need for curricular reforms that integrate evidence-based prescribing guidelines and interdisciplinary collaboration into dental education.

Despite widespread awareness of antibiotic resistance, the persistent gap between knowledge and practice underscores the need for continuous education and intervention strategies. Our study contributes to global antibiotic stewardship efforts by identifying key predictors of prescribing behaviours, including perceived knowledge, actual knowledge, attitudes, and confidence. Importantly, the use of composite scores in our analysis revealed that perceived knowledge, confidence, attitude toward stewardship, and access to prescribing resources were all significantly and negatively associated with antibiotic prescribing frequency. These findings indicate that improving students' self-efficacy, motivation, and access to support tools may be as important as increasing factual knowledge in reducing unnecessary prescribing. Interestingly, actual knowledge did not show a significant association with prescribing frequency, highlighting a misalignment between what students know and how they act. This reinforces the importance of educational interventions that go beyond knowledge transmission and focus on behavioral, environmental, and structural drivers of prescribing habits.

Furthermore, our study evaluated whether student responses to key stewardship questions deviated significantly from expected distributions. The results supported the need for targeted improvements in areas such as confidence and resource accessibility, where observed response patterns were skewed toward uncertainty or lack of access. These findings provide concrete areas for educational and policy-based interventions.

Addressing these factors through structured educational interventions, standardized guidelines, and policy-driven reforms could significantly enhance prescribing confidence and promote responsible antibiotic use among future dental practitioners.

A recent systematic review found that dentists contribute to approximately 10% of all antibiotic prescriptions globally, with up to 90% of these being inappropriate (30). This reinforces the urgent need for enhanced antibiotic stewardship programs tailored to both practicing dentists and dental students. Strengthening appropriate prescribing behaviors requires a multi-faceted approach that integrates education, policy, and institutional support. Implementing evidence-based guidelines, improving access to up-to-date prescribing protocols, and fostering interprofessional collaboration could bridge the gap between knowledge and clinical practice, ultimately mitigating the impact of antibiotic resistance on global public health.

Aligning with global strategies, standardized guidelines, audit-feedback mechanisms, and stewardship training are pivotal in combating antimicrobial resistance (AMR). The WHO Global Action Plan (31) prioritizes education and the implementation of guidelines, reinforcing the need for structured stewardship programs in dental education. A successful model can be drawn from UK dental schools, where mandatory stewardship modules significantly reduced inappropriate prescribing, suggesting a viable framework for Palestinian dental education (32).

The findings of this study highlight the urgent need to integrate structured antibiotic stewardship programs into dental curricula. By providing students with access to updated clinical guidelines and organizing targeted training workshops on prudent antibiotic use, dental institutions can strengthen evidence-based prescribing practices and bridge the gap between theoretical knowledge and clinical decision-making. Additionally, standardized guidelines for antibiotic prescribing in dentistry, aligned with the best global practices, should be established to ensure consistency in prescribing behaviours.

From a policy perspective, effective interventions such as audit and feedback mechanisms have demonstrated potential in improving prescribing behaviours, though further research is needed to assess their long-term impact (30). Educational initiatives that address modifiable factors—such as prescribing confidence, ethical decision-making, and reliance on updated materials—are essential to curbing inappropriate antibiotic use (33). By integrating these strategies into dental education and healthcare policy, institutions can play a crucial role in mitigating antibiotic resistance and fostering responsible prescribing practices among future dental professionals.

Despite its contributions, this study has certain limitations. First, the cross-sectional design captures only a snapshot of students' knowledge and behaviours, limiting the ability to assess changes over time. Additionally, self-reported data may introduce response bias, as students might overestimate their confidence or underreport inappropriate practices. The study was also confined to Palestinian dental schools, and while it provides valuable regional insights, findings may not be directly generalizable to other populations. Future longitudinal studies are needed to assess how educational interventions influence prescribing behaviours over time.

Future research should explore the long-term impact of structured antibiotic stewardship training on students' prescribing behaviours. Additionally, qualitative studies could provide deeper insights into the barriers dental students face in adhering to antibiotic guidelines.

Expanding this research to practicing dentists and comparing their prescribing patterns with those of students would also offer valuable perspectives on how knowledge translates into professional practice.

This study identifies some important gaps in the knowledge, confidence, and prescribing behaviours of Palestinian dental students with regard to antibiotic stewardship. The findings underscore a pressing need for tailored educational interventions, enhanced access to prescribing guidelines, and the introduction of policy-driven initiatives to encourage more responsible antibiotic use in dental practice. Addressing these gaps is crucial to mitigating the rise of antibiotic resistance and fostering prudent prescribing practices among future dental professionals.

The insights gained from this study are particularly valuable for key stakeholders, including policymakers, dental educators, professional associations, and the Ministry of Health. These groups can leverage the findings to design targeted educational programs and update guidelines on optimal antibiotic prescribing in dentistry. As the first study of its kind in Palestine, this research establishes a vital baseline that can inform future policy development and educational strategies, contributing to global efforts to safeguard antibiotic efficacy and improve patient outcomes.

While acknowledging the study's limitations, it is essential that future research investigates the long-term impact of specific educational interventions. Expanding the study to broader geographical regions would further enrich our understanding. By addressing these gaps, we can better equip the next generation of dental professionals to tackle the global challenge of antibiotic resistance, ensuring they are well-prepared to contribute effectively to public health initiatives and provide responsible, evidence-based patient care.