Dental Stewardship Implementation and Antimicrobial Resistance Awareness in India: Prescribing Patterns, Knowledge Gaps, and Barriers

doi:10.21203/rs.3.rs-8273148/v1

Background:

Antimicrobial resistance (AMR) is a major global health concern, with estimates suggesting up to 10 million deaths annually by 2050. India, one of the world’s largest consumers of antibiotics, faces significant challenges in addressing AMR. Dental practitioners contribute nearly 10% of national antibiotic use, yet antimicrobial stewardship (AMS) in dental settings remains poorly developed and understudied. This systematic review evaluates AMR awareness and AMS implementation among dental professionals in India, focusing on knowledge gaps, prescribing behaviours, and barriers to effective stewardship.

Methods:

A systematic search was conducted in accordance with PRISMA guidelines across PubMed, Web of Science, CINAHL, Scopus, and Google Scholar for studies published between January 2014 and December 2024. Eligible studies assessed AMR awareness, AMS-related behaviours, or antibiotic-prescribing practices among Indian dental practitioners. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist.

Results:

From 1,852 records, 14 studies involving 3,602 participants met inclusion criteria. Marked deficits in AMR awareness and limited understanding of AMS principles were consistently identified. Common prescribing problems included inappropriate antibiotic selection, incorrect dosing and duration, and frequent use of broad-spectrum agents where narrow-spectrum options were appropriate. Educational interventions showed short-term improvements, though sustained practice change was seldom assessed. Major barriers included insufficient undergraduate AMS training, limited access to dental-specific guidelines, and the absence of institutional stewardship structures.

Conclusions:

Substantial gaps persist between AMR awareness and effective AMS practice in Indian dentistry. Strengthening undergraduate and continuing education, improving access to context-specific guidelines, and establishing formal AMS programmes are essential to optimise antibiotic use and contribute to India’s AMR containment strategies.

Infectious Diseases

General Microbiology

Clinical Pharmacology

Dentistry

Health Policy

Other Public Policy

Antimicrobial Resistance

Antibiotic Atewardship

Dentistry

Dental Stewardship

India

Prescribing Practices

In his 1945 Nobel Prize Lecture, Sir Alexander Fleming warned that inadequate antibiotic dosing could enable bacteria to develop resistance. This insight has since materialized into one of the most serious global health challenges of the modern era.¹ Today, antimicrobial resistance (AMR) undermines decades of medical progress, threatening to render common infections difficult to treat and routine procedures increasingly hazardous. The World Health Organization (WHO) identifies AMR as a major threat to global health, given its substantial contribution to mortality, morbidity, and economic loss worldwide.² Projections from the O’Neill Review estimate that drug-resistant infections could cause 10 million deaths annually by 2050.³ positioning AMR as a silent pandemic and one of the greatest threats to achieving the Sustainable Development Goals, particularly in low- and middle-income countries (LMICs).^4,5 If unaddressed, AMR could reduce global GDP by up to 3.8% and push millions into extreme poverty.⁶

To counter these threats, antimicrobial stewardship (AMS) has been strongly advocated by the UK Health Security Agency (UKHSA) and international bodies as a core strategy for ensuring appropriate antibiotic use across all healthcare settings.⁷ AMS encompasses coordinated, evidence-based interventions to ensure optimal antibiotic choice, dose, route, and duration, thereby improving patient outcomes while reducing toxicity, resistance emergence, and healthcare costs.^8,9

The WHO South-East Asia Region, which includes India, is recognised as having the highest burden and transmission risk of AMR globally.¹⁰ India, the world’s most populous country and one of the largest consumers of antibiotics, faces distinctive challenges, including high infection burdens, widespread over-the-counter antibiotic access, regulatory gaps, and significant variation in healthcare quality. Within this context, dentistry represents an important yet often overlooked sector. Dentists prescribe approximately 10% of all antibiotics,^11,12 primarily for odontogenic infections, cellulitis, and perioperative prophylaxis.¹³ Although antibiotics are essential for managing conditions such as dental abscesses or preventing infective endocarditis, they are intended to be adjuncts, not substitutes, for definitive dental treatment such as drainage, endodontic therapy, or extraction.^14,15 Nevertheless, inappropriate dental prescribing, such as routine antibiotics for irreversible pulpitis, uncomplicated toothache, or simple extractions, remains widespread and contributes significantly to AMR.^16,17

Despite the importance of rational prescribing, the undergraduate dental curriculum in India contains minimal content on antibiotic stewardship, resistance mechanisms, or evidence-based prescribing.¹⁸ Document analysis from a Leeds University case study further indicates an absence of national dental antibiotic stewardship guidance and a lack of continuing professional development (CPD) materials for Indian dental practitioners.¹⁹ Combined with a high burden of oral disease and frequently inappropriate prescribing practices,²⁰ the need for structured dental AMS programmes is clear.

There is therefore an urgent need to embed dental antimicrobial stewardship into routine practice, develop evidence-based guidelines, strengthen undergraduate and postgraduate curricula, and establish CPD frameworks to enhance prescribing behaviours.¹⁶ Context-specific interventions tailored to India’s epidemiological, regulatory, and socioeconomic environment are essential.

This systematic review examines the implementation of antimicrobial stewardship and AMR awareness among dental professionals in India. It identifies existing knowledge gaps, evaluates prescribing behaviours, analyses barriers to effective stewardship, and offers evidence-informed recommendations to strengthen AMS in Indian dental practice.

Protocol Registration and Review Framework

Prior to commencing the review, the protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42025116672). The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure methodological rigor and transparent reporting.

Eligibility Criteria

Eligibility criteria were established using the PICOS (Population, Intervention, Comparison, Outcome, Study design) framework to ensure systematic and comprehensive identification of relevant studies (Table 1).

Table 1. PICO Framework for Systematic Review

PICO Framework	Description
Population	Dental professionals - students, interns, residents, general dentists, specialists, faculty and patients in dental settings where antibiotics are prescribed or used.
Intervention	AMS related exposure or intervention (e.g., guidelines, audits/feedback, education/CPD, decision support, policies, surveillance, prescribing restrictions), or studies assessing AMR/antibiotic use awareness/knowledge/attitudes/practices in dentistry.
Comparison	Standard practice/usual care, pre-intervention periods
Outcome	Reviewing AMR and AMS in Indian Dentistry.
Study design	Randomized Controlled Trials (RCTs), cross-sectional studies, qualitative studies, case-control and cohort studies, and interrupted time series designs

Note: PICO = Population, Intervention, Comparison, Outcome; AMS = Antimicrobial Stewardship; AMR = Antimicrobial Resistance; CPD = Continuing Professional Development. This framework guided the formulation of the systematic review question and the development of the search strategy.

Inclusion/ Exclusion Criteria:

Studies were included if they were published in English between January 2014 and December 2024; focused on dental professionals, students, or dental settings in India; examined antimicrobial resistance awareness, antimicrobial stewardship practices, antibiotic prescribing behaviours, or related educational interventions; and used quantitative, qualitative, or mixed-methods designs. Studies were excluded if they involved non-dental healthcare settings, medical or surgical specialties alone, were not in English, lacked original data, were systematic reviews, or were conducted outside India or combined countries without separate Indian analysis (Table 2).

Table 2. Inclusion and Exclusion Criteria for Study Selection

	Inclusion Criteria	Exclusion Criteria
Participants	Studies targeting the patient's antibiotics use in dentistry. Dental professionals including students responsible for the prescription, dispensation, or administration of antibiotics	Studies not focused on dentistry patients and dentists administering antibiotics
Intervention	Studies that are focused on antimicrobial stewardship intervention	Studies not focused on antimicrobial stewardship intervention
Comparison	A comparison with control group in dentistry that dispensed antibiotics without antimicrobial stewardship intervention
Outcome	Reviewing the Antimicrobial resistance awareness. Reviewing the antimicrobial stewardship in India
Study design	Randomized Controlled Trials (RCTs), cross-sectional studies, qualitative studies, case-control and cohort studies, and interrupted time series designs	Systematic reviews, literature reviews, case reports, case studies, meta-analyses, and conference abstracts

Note: Criteria were applied sequentially during title/abstract screening and full-text review stages. Studies were required to meet all inclusion criteria and have no exclusion criteria to be included in the final synthesis.

Information Sources and Search Strategy

A comprehensive search strategy was developed using iterative pilot searches across PubMed, Web of Science, CINAHL, Scopus, and Google Scholar. The search included studies published from January 2014 to December 2024, aligning with national initiatives following India’s 2011 AMR containment policy. Boolean operators were used to combine terms related to antimicrobial resistance (“antimicrobial resistance,” “antibiotic resistance,” “AMR”), stewardship (“antimicrobial stewardship,” “prescribing practices”), dental context (“dentistry,” “dental professional”), and geography (“India”). Search strategies were tailored to each database’s indexing and controlled vocabulary requirements (Table 3).

Table 3. Electronic Database Search Strategy

#	Search Strategy
1	"Antimicrobial stewardship" OR "antibiotic stewardship" OR "antibiotic use" OR "antibiotic utilisation" OR "antibiotic utilization"
2	"dentistry" OR "dental practice" OR "dentist" OR "oral health" OR "dental professionals"
3	"awareness" OR "knowledge" OR "attitude" OR "perception"
4	"implementation" OR "intervention" OR "barrier" OR "facilitator" OR "adoption" OR "uptake"
5	"India"
6	1 AND 2 AND 3 AND 4
7	Limit to 2015 to 2025, Language: English

Databases Searched: PubMed, Web of Science, Cochrane Library, Scopus, and Google Scholar were systematically searched using the above strategy. The search was conducted in [August,2025] with final updates in [October, 2025].

Note: Search terms were combined using Boolean operators (AND, OR). Quotation marks indicate exact phrase searching. The search strategy was adapted for each database according to its specific syntax requirements. Citation searching and reference list screening supplemented the electronic database searches. Grey literature searches included relevant institutional repositories and government health databases.

Study Selection Process

Following the comprehensive database search, all identified records were imported into reference management software, and duplicates were removed. Two independent reviewers screened titles and abstracts against predetermined eligibility criteria. Studies deemed potentially relevant were subjected to full-text review, conducted independently by the same reviewers. Disagreements at any stage were resolved through discussion and consensus, with involvement of a third reviewer when necessary. The selection process was documented using a PRISMA flow diagram to ensure transparency and reproducibility.

Quality Assessment

The methodological quality of included studies was assessed using the appropriate Critical Appraisal Skills Programme (CASP) checklists based on study design. Two reviewers independently appraised each study, resolving disagreements through discussion. Appraisal focused on study aims, methodological appropriateness, recruitment, data collection, ethical considerations, analytical rigour, and clarity of findings. No studies were excluded based solely on quality; instead, appraisal outcomes informed the interpretation and synthesis of results.

Data Extraction and Synthesis

A standardized data extraction form was developed and piloted before use. Extracted data included study characteristics (author, year, location, design, setting), participant details (profession, training level, sample size), aims, methods, AMR awareness measures, AMS practices or interventions, prescribing behaviours, barriers and facilitators, educational or regulatory context, key findings, outcomes, and quality ratings. One reviewer extracted data and a second verified accuracy. Due to substantial heterogeneity across study designs and outcomes, a narrative synthesis was conducted. Studies were grouped thematically, and key findings were summarised by identifying patterns, consistencies, and notable differences.

Study Selection and Characteristics

The search strategy identified 414 records, reduced to 357 after removing 38 duplicates and 19 non-eligible items. Title and abstract screening excluded 214 articles, leaving 143 full texts; 18 were inaccessible. A further 111 reports were excluded for lacking empirical data, weak methodology, or not addressing dentistry-related AMR/AMS outcomes. Following the PRISMA process, 14 studies met all inclusion criteria and were included in the synthesis, representing 3,602 participants across Indian dental settings (Figure 1).

Study designs were predominantly cross-sectional surveys (6/14, 43%), followed by KAP surveys (3/14, 21%), narrative reviews (2/14, 14%), one quantitative survey (1/14, 7%), and one implementation evaluation (1/14, 7%). Participants included dental practitioners (2,263 individuals; represented in 5/14 studies, 36%), dental students (1,038 participants; 6/14 studies, 43%), students and faculty (231 participants; 1/14 study, 7%), and junior residents (70 participants; 1/14 study, 7%). Settings ranged from dental colleges 4 of 14 (29%) and private clinics (3/14; 21%) to mixed or unspecified clinics (6/14; 43%) and endodontic specialist centres (1/14; 7%). Most studies were of moderate methodological quality 11/14 (79%) based on CASP appraisal (Table 4).

Table 4. Characteristics of Included Studies Assessing AMR Awareness, Antibiotic Prescribing, and AMS Practices Among Dental Professionals in India

Study ID / Author(s) and Year	Healthcare setting	Study design	Study population/ participants	Sample size	Aims/objectives	AMR awareness	AMS practices/ strategies/ interventions	AMS outcomes
Chhabra et al., 2019 (21)	Dental departments of 2 medical colleges	Quantitative survey	Junior resident dental doctors	70	Assess prescription knowledge, attitude, preference, and common errors	Gaps in knowledge; many unaware of WHO Good Prescribing	Education, guideline dissemination	Prescribing practices, compliance with prescription standards, knowledge scores
Doshi et al., 2017(22)	Dental colleges	Cross-sectional survey	Dental students	870	Evaluate knowledge and practices for antibiotics/analgesics	Variable awareness among students	Undergraduate curriculum exposure	Prescribing practices, awareness scores, appropriateness of antibiotic choice
Jaber et al., 2024(23)	Dental clinics (unspecified)	Cross sectional + lab	Dental professionals	304	Assess MRSA nasal carriage among dental professionals		Infection control practices, awareness training	Resistance prevalence (MRSA carriage), awareness/knowledge scores
Kamate et al., 2023(24)	Dentistry context-India	Narrative review	NA	NA	Summarize AMR in dentistry and prevention strategies	Highlights awareness deficits and irrational prescribing	Education, rational prescribing, advocacy for stewardship	Prescribing practices (irrational vs rational use prevalence)
Lokhasudhan & Nasim, 2017(25)	Dental practitioners (South India)	KAP survey	Dental practitioners	315	Assess antibiotic use and attitudes		CME, guideline reinforcement	Prescribing practices, self-reported compliance with stewardship guidelines
Manohar & Sharma, 2018(26)	General dentists & endodontists	Survey	Dental practitioners	150	Awareness of intracanal medicaments		Structured education	Awareness scores, prescribing practices (choice of intracanal medicaments)
Punj et al., 2018(27)	Private dental clinics, Mangalore	Cross sectional survey	Private dental practitioners	173	Assess knowledge/awareness and prescription patterns	Awareness present but gaps on prophylaxis indications	Guideline use; stewardship policy	Prescribing practices (overuse/misuse frequency), compliance rates
Puranik et al., 2018(28)	Dental practices, Bangalore	Cross sectional survey	Dental practitioners (BDS/MDS)	400	Assess knowledge and practices; resistance awareness	Mixed awareness; indications inconsistent	Educational reinforcement, awareness campaigns	Knowledge/awareness scores, prescribing practices, inappropriate use prevalence
Ramachandran et al., 2019(29)	Multiple clinics (India)	Cross sectional survey	Dental practitioners (BDS/MDS)	361	Compare awareness and overprescription between BDS and MDS	General awareness present but many unaware of formal rules	Stewardship training, CME, guideline awareness	Prescribing practices, frequency of overprescription, compliance with rational use
Rela et al., 2021(30)	Urban dental practices, India	Cross sectional (questionnaire)	Dental surgeons (general dentists)	250	Inspect prescribing practices and knowledge of prophylaxis	Many follow guidelines: gaps remain	Partial guideline-based prophylaxis; standardized AMS protocols	Compliance rates with prophylaxis guidelines, prescribing practices
Sharma & sharma, 2015(31)	Medical & dental college	Questionnaire survey	Undergraduate medical & dental students	168	Assess attitudes toward AMS	Varied attitudes; need for AMS teaching	Curriculum inclusion, stewardship education	Awareness scores, attitudes toward AMS
Siddique et al., 2021(32)	Dental hospital/policy context	Narrative review	NA	NA	Outline challenges and opportunities for AMS in dentistry		AMS framework (education, audit-feedback, stewardship teams)	Compliance rates and prescribing behaviour
Telang et al., 2021(33)	Dental school (India)	Implementation evaluation	Students/faculty	231	Evaluate AMS improvements		AMS programme implemented (audit-feedback, education, surveillance)	Prescribing practices, compliance rates, improvements in rational use post-intervention
Vengidesh et al., 2023(34)	Endodontic practice settings, India	KAP survey	Dentists involved in endodontic procedure	310	Assess prescription patterns for endodontic conditions		Stewardship training, guideline adherence promoted	Prescribing practices, frequency of broad-spectrum antibiotic use, compliance rates

Note: AMR = Antimicrobial Resistance; AMS = Antimicrobial Stewardship; BDS = Bachelor of Dental Surgery; MDS = Master of Dental Surgery; KAP = Knowledge, Attitudes, and Practices; CME = Continuing Medical Education; MRSA = Methicillin-Resistant Staphylococcus aureus; WHO = World Health Organization; NA = Not Applicable. Sample sizes represent the total number of participants in each study.

Antimicrobial Resistance Awareness and Knowledge

Across the included studies, substantial AMR knowledge gaps were consistently reported among both students and qualified practitioners. A majority of student-focused studies (4/6; 67%) identified insufficient understanding of AMR mechanisms, prophylaxis indications, and evidence-based dental prescribing. Although AMR was widely recognised as a public health threat among practitioners (reported in 5/5 practitioner studies; 100%), this awareness did not equate to familiarity with stewardship principles. Several studies demonstrated poor knowledge of WHO Good Prescribing practices, uncertainty about appropriate first-line antibiotic choices, and limited awareness of national or international guidelines. Dentists frequently reported relying on empirical experience, peer norms, or faculty guidance rather than formal prescribing algorithms, indicating a systemic lack of structured AMR education across training pathways (Table 5).

Table 5. Summary of Included Studies on AMR Awareness, Prescribing Practices, and Dental Stewardship Implementation in India

Study ID / Author(s) and Year	Facilitators of AMS implementation	Prescribing behaviour / compliance	Regulatory/ educational context	Key findings	Outcomes reported	Quality appraisal rating (CASP)
Chhabra et al., 2019 (21)		Common errors included posology knowledge; reliance on faculty; amoxicillin widely prescribed	Undergraduate curriculum context	Resident dentists showed prescribing errors and insufficient AMS training.	Knowledge gaps and frequent errors; need for improved education	Low
Doshi et al., 2017(22)		Reported prescribing intentions varied; need for curriculum strengthening		Dental students had patchy antibiotic knowledge and poor guideline adherence.	Suboptimal knowledge in areas; training gaps highlighted	Moderate
Jaber et al., 2024(23)				MRSA carriage was detected among dentists with only moderate awareness.		Moderate
Kamate et al., 2023(24)	Guidelines, education, leadership emphasized			Narrative review highlighted irrational dental prescribing and called for AMS guidelines.	Proposes flowchart and strategies to reduce AMR in dentistry	Low
Lokhasudhan & Nasim, 2017(25)				Practitioners had mixed knowledge and frequent empirical prescribing.		Moderate
Manohar & Sharma, 2018(26)				Dentists varied in awareness of intracanal medicaments, showing training gaps.		Moderate
Punj et al., 2018(27)		High daily prescribing; penicillin/amoxicillin first-line; frequent postop prophylaxis	Calls for guidelines and CME to standardize prescribing	Private dentists often prescribed antibiotics beyond evidence-based need.	Therapeutic prescribing varied and often suboptimal	Moderate
Puranik et al., 2018(28)		Antibiotics often for routine conditions; 5-day courses common		Resistance knowledge existed but did not consistently shape practice.	Knowledge-practice gaps; need for stewardship education	Moderate
Ramachandran et al., 2019(29)		Overprescription higher in BDS; amoxicillin most common; differing durations (3 vs 5 days)		Overprescription was widespread and influenced by clinician qualification	Highlights overuse and need for guideline adherence	Moderate
Rela et al., 2021(30)		67.6% followed formal guidelines; variability in choices for penicillin allergy	Reference to AHA/AAOS guidelines	Urban dentists showed partial adherence to prophylaxis guidelines with variability.	Inconsistent adoption of prophylaxis guidance	Moderate
Sharma & sharma, 2015(31)				Undergraduates supported stewardship but lacked structured training.		Low
Siddique et al., 2021(32)	Leadership and policy support as enablers			AMS framework proposed with key institutional barriers and facilitators.	Framework for implementing AMS in dental settings	Low
Telang et al., 2021(33)				Dental school AMS programme improved antibiotic prescribing practices.		Moderate
Vengidesh et al., 2023(34)				Endodontic practitioners showed overuse of broad-spectrum antibiotics.		Moderate

Note: AMR = Antimicrobial Resistance; AMS = Antimicrobial Stewardship; BDS = Bachelor of Dental Surgery; CASP = Critical Appraisal Skills Programme; CME = Continuing Medical Education; MRSA = Methicillin-Resistant Staphylococcus aureus; AHA = American Heart Association; AAOS = American Academy of Orthopaedic Surgeons. Quality ratings based on CASP checklist: color-coded cells indicate Low (pink), Moderate (yellow), and High (green) quality ratings.

Antibiotic Prescribing Practices and Behaviours

Prescribing behaviours across the studies revealed high rates of inappropriate antibiotic use. Incorrect dosing and duration errors appeared in 5/14 studies (36%), while overuse of broad-spectrum antibiotics was reported in 8/14 studies (57%). Amoxicillin and amoxicillin–clavulanate were the most commonly prescribed antibiotics, collectively accounting for 62% of documented prescriptions (Figure 2).

Across 7/14 studies (50%), antibiotics were prescribed for conditions that could be managed with local measures alone, including acute pulpitis, uncomplicated caries, and routine extractions. Several studies documented prophylactic antibiotic use absent a clear clinical indication, and heavy reliance on senior colleagues' prescribing habits in the absence of accessible guidelines (Supplementary Figure S1).

Antimicrobial Stewardship Implementation and Interventions

AMS activity within Indian dentistry was found to be limited and fragmented. As shown in Table 6, all 14 studies referenced guideline-based strategies, but only 1/14 (7%) incorporated a multidisciplinary AMS team, and 1/14 (7%) implemented prospective audit and feedback. This demonstrates a heavy reliance on passive, guideline-linked stewardship and limited integration of higher-level AMS infrastructures. The most commonly assessed AMS-related outcomes were prescribing practices (12/14; 86%), compliance (8/14; 57%), and knowledge/awareness (6/14; 43%). Educational interventions in two studies showed short-term improvements in knowledge and self-reported prescribing intentions, though none included long-term outcome validation (Table 6).

Table 6. AMS Strategies and Outcomes in Implementing Dental Stewardship in India

Study ID / Author(s) and Year	AMS Core Strategies		AMS Supplemental Strategies	AMS Outcomes
	Multidisciplinary team	Prospective audit & feedback	Guidelines and Clinical Pathways	Compliance	Prescribing practices	Knowledge/ Awareness
Chhabra et al., 2019	✓		✓	✓	✓	✓
Doshi et al., 2017					✓	✓
Jaber et al., 2024			✓			✓
Kamate et al., 2023			✓		✓
Lokhsadhan & Nasim, 2017			✓	✓	✓
Manohar & Sharma, 2018			✓		✓
Peng et al., 2016			✓	✓	✓
Puranik et al., 2018			✓		✓	✓
Ramachandran et al., 2019			✓	✓	✓
Rola et al., 2021			✓	✓	✓
Sharma & Sharma, 2015			✓			✓
Saseendran et al., 2021	✓		✓	✓	✓
Talang et al., 2021		✓	✓	✓	✓
Taraceon et al., 2023			✓
Total (n=14)	2	1	14	9	12	6

Note: Checkmarks (✓) indicate that the study reported the respective AMS strategy or outcome. AMS = Antimicrobial Stewardship.

Barriers and Facilitators to AMS

Thematic synthesis revealed persistent systemic barriers. Educational barriers included curriculum deficiencies, a lack of CPD opportunities on AMR, and insufficient clinical training in evidence-based prescribing. Institutional barriers involved the absence of formal AMS programmes, poor access to dental-specific guidelines, a lack of audit-feedback systems, and limited microbiology support. Regulatory challenges involved OTC antibiotic availability, weak enforcement of prescribing restrictions, and minimal integration of dental prescribing data into AMR surveillance. Clinical barriers encompassed patient pressure, medico-legal concerns, and time constraints. Despite these challenges, facilitators identified across studies included widespread recognition of AMR as a public health threat, willingness among professionals to engage with AMS activities, and enthusiasm for digital guideline tools and continuous education (Supplementary Figure S2).

Qualitative Thematic Analysis

Theme 1: Critical Deficiencies in AMR Awareness and Knowledge

This was the most prevalent theme (12 of 14 studies). Across both student and practitioner groups, fundamental misunderstandings existed regarding antibiotic indications, resistance mechanisms, and dosing principles. Nearly half of resident doctors were unaware of WHO prescribing requirements,²¹and guideline awareness was markedly lower among BDS practitioners (15%) than MDS practitioners (71%) (29). Several studies noted limited familiarity with prophylaxis standards, with only 67% of surgeons adhering to established recommendations.³⁰

Theme 2: The Knowledge–Practice Disconnect

Although awareness of AMR was high, this seldom translated into appropriate clinical behaviour.^27-28 Inappropriate prescribing remained common for uncomplicated caries (53%), simple extraction (55%), and acute pulpitis (61%).^27,28,16 Weak institutional pharmacovigilance, including minimal reporting and only 14% awareness of national ADR systems, exacerbated this gap.²⁸ Prescribing was further influenced by non-clinical pressures such as patient expectations, fear of medico-legal consequences, and diagnostic uncertainty.^28,35

Theme 3: Heterogeneous Prescribing Behaviour

Prescribing varied significantly by qualification and clinical setting. BDS dentists demonstrated higher overprescribing trends.²⁹ Private practitioners relied heavily on symptom-based empirical prescribing (66%) rather than guideline-driven decisions. Substantial inconsistency existed in drug selection, with 57% of dentists unable to correctly identify alternatives for penicillin-allergic patients.²⁷

Theme 4: Educational and Institutional Barriers

Most studies (11/14) identified systemic weaknesses: inadequate undergraduate stewardship coverage,²²scarce CPD opportunities, absent formal AMS programmes,^27,28 and minimal monitoring or audit mechanisms. Faculty themselves were often inadequately prepared to teach evidence-based prescribing,²¹ perpetuating generational gaps in stewardship competence.

This systematic review provides a comprehensive examination of antimicrobial stewardship in Indian dentistry, revealing a convergence of knowledge deficits, behavioural inconsistencies, and institutional barriers that collectively undermine rational antibiotic use.^21,28 Although awareness of antimicrobial resistance as a major health threat was generally high across studies, this did not reliably translate into appropriate prescribing behaviours, leading to persistent misuse and overprescription.^27,29 The findings underscore that awareness alone is insufficient; effective AMS requires structural, educational, and behavioural reinforcement.

A central and consistent finding was the knowledge–practice gap, where theoretical understanding of AMR failed to translate into evidence-based clinical decisions.^22,28 Several studies reported high rates of antibiotic prescribing for non-indicated conditions, including dental caries (53%), simple extraction (54.5%), and acute pulpitis (60.9%), all of which contradict established guidelines (16,28). This discordance highlights the influence of non-clinical pressures, such as patient expectations, fear of litigation, and reliance on habitual or senior-led prescribing patterns, over structured decision-making.^27,29

Significant variation between practitioner groups further highlights the uneven distribution of AMS competence. Differences between BDS and MDS practitioners were particularly striking: guideline awareness ranged from 15% among BDS graduates to 71% among MDS practitioners.^22,29 Setting-specific discrepancies also emerged, with private practitioners relying heavily on empirical or symptom-based prescribing, reflecting a lack of institutional support and oversight.^16,27 These variations suggest that stewardship strategies must be tailored to practitioner background, educational exposure, and workplace constraints.

Institutional and educational barriers are among the most entrenched challenges. Multiple studies identified the absence of formal AMS frameworks, limited access to updated guidelines, negligible adverse drug reaction (ADR) reporting, and insufficient opportunities for continuing dental education (CDE) as factors perpetuating inappropriate prescribing.^21,28 The finding that nearly half of resident doctors were unaware of WHO prescribing guidelines reflects foundational gaps in both undergraduate and postgraduate training, emphasising the need for curriculum reform.^21,31 Evidence also suggests that UG/PG training, scientific resources, and CDE programmes have a stronger influence on prescribing behaviours than patient demand or pharmacy availability, reinforcing the importance of structured educational interventions.²⁸

These findings align with India’s National Action Plan on AMR, particularly its priorities relating to education, training, and optimal antimicrobial use.³⁶ The development of dentistry-specific guidelines, combined with context-appropriate implementation strategies, is critical for translating policy into improved clinical outcomes.^32,33 Effective stewardship will require not only educational reinforcement but also systems-level support through decision-support tools, prescription monitoring, and feedback mechanisms.^28,30

Challenges for Dental Stewardship Implementation in India

The review highlights several persistent obstacles. AMR awareness remains low among key groups: nearly half of resident practitioners were unaware of WHO prescribing standards (28), only 15% demonstrated adequate familiarity with international guidelines and just 67% of surgeons adhered to any prophylaxis guidance.^15,16 A mere 13% of dentists routinely consulted prescribing guidelines, indicating deep-rooted educational and behavioural gaps.¹⁷ Weak institutional infrastructures—including low ADR reporting and minimal awareness of national pharmacovigilance programmes (14%), further exacerbate these issues.¹⁵ Variability in prescribing behaviour also poses challenges; BDS practitioners demonstrated substantially higher rates of inappropriate prescribing, and drug selection errors were common, particularly for penicillin-allergic patients (57% incorrect choices).^17,18 Limited institutional readiness, lack of AMS policies, absence of audit systems, and insufficient faculty preparation compound these challenges.^17,21

Strengths and Limitations

Strengths include a rigorous PRISMA-guided methodology, the use of CASP for quality appraisal, and synthesis of evidence from a large, diverse sample of 3,602 dental professionals. Limitations include restrictions to English-language studies, reliance on self-reported practices prone to social desirability bias, and heterogeneity that prevents meta-analysis.

Recommendations and Implications for Practice

A multi-level approach is crucial. Educational bodies should integrate practical AMS training into UG and PG curricula; institutions must implement AMS programmes with local guidelines, prescription monitoring, and ADR reporting systems; and policymakers should develop national dental prescribing standards. Clinicians must strengthen diagnostic reasoning, consult guidelines regularly, and resist non-clinical pressures to prescribe unnecessarily. Multidisciplinary collaboration with pharmacists and microbiologists would further enhance stewardship.

Future Research

Future work should focus on implementation science to bridge the knowledge-practice gap. Priority areas include clinical decision-support tools, audit-feedback mechanisms, behavioural nudges, and digital guideline platforms. Evaluating these interventions across varied Indian practice settings will be critical to advancing effective dental stewardship.

This review highlights significant gaps between AMR awareness and effective antimicrobial stewardship among dental professionals in India. Despite growing recognition of AMR as a major health threat, knowledge of stewardship principles and adherence to evidence-based prescribing remain limited. Inadequate undergraduate training, absence of formal AMS programmes, and systemic barriers contribute to inappropriate antibiotic use. Strengthening education, implementing dental-specific guidelines, and establishing institutional AMS structures are essential. With targeted support and policy alignment, meaningful improvements in dental prescribing are achievable, contributing to national and global efforts to combat antimicrobial resistance.

Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: A review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence. 2013 Feb 15;4(2):151–7.
Elshenawy RA, Umaru N, Alharbi AB, Aslanpour Z. Antimicrobial Stewardship Intervention Before and During The COVID-19 Pandemic in the Acute Care Settings: A Systematic Review [Internet]. In Review; 2022 [cited 2025 Oct 22]. Available from: https://www.researchsquare.com/article/rs-1947571/v1
O’Neill, J. (2014, December). Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations The Review on Antimicrobial Resistance Chaired by Jim O’Neill. https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf
World Health Organization (WHO). (2019). WHO implementation handbook for national action plans on antimicrobial resistance: guidance for the human health sector https://www.who.int/publications/i/item/9789240041981
Kanan M, Ramadan M, Haif H, Abdullah B, Mubarak J, Ahmad W, et al. RETRACTED: Empowering Low- and Middle-Income Countries to Combat AMR by Minimal Use of Antibiotics: A Way Forward. Antibiotics. 2023 Oct 2;12(10):1504.
Rupasinghe N, Machalaba C, Muthee T, Mazimba A. Stopping the Grand Pandemic: A Framework for Action - Addressing Antimicrobial Resistance through World Bank Operations [Internet]. World Bank; 2024 [cited 2025 Nov 10]. Available from: https://hdl.handle.net/10986/41533
UK Health Security Agency. (2023, September 12). Antimicrobial stewardship: start smart then focus. GOV.UK. https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus#:~:text=It%20is%20designed%20to%20aid,is%20provided%20alongside%20the%20toolkit
CDC. (2024). Core Elements of Antibiotic Stewardship. https://www.cdc.gov/antibiotic-use/hcp/core-elements/index.html
NICE. (2015, August 18). Overview | Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use | Guidance | NICE. https://www.nice.org.uk/guidance/ng15
Chereau F, Opatowski L, Tourdjman M, Vong S. Risk assessment for antibiotic resistance in South East Asia. BMJ. 2017 Sept 5;j3393.
Dyar, O. J., Huttner, B., Schouten, J., Pulcini, C., & ESGAP (ESCMID Study Group for Antimicrobial stewardshiP) (2017). What is antimicrobial stewardship?. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 23(11), 793–798. https://doi.org/10.1016/j.cmi.2017.08.026
Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, Hershow RC, et al. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open. 2019 May 31;2(5):e193909.
Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Oral antibiotic prescribing by NHS dentists in England 2010-2017. Br Dent J. 2019 Dec;227(12):1044–50.
Cope AL, Francis N, Wood F, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Oral Health Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2018 Sept 27 [cited 2025 Oct 22];2018(9). Available from: http://doi.wiley.com/10.1002/14651858.CD010136.pub3
Segura‐Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, et al. Antibiotics in Endodontics: a review. Int Endodontic J. 2017 Dec;50(12):1169–84.
Wasan H, Gupta P, Mathur A, Mutneja E, Mathur V, Gupta Y. Influence of qualification and practice settings of dental practitioners on antimicrobial prescribing in Delhi and National Capital Region, India. J Nat Sc Biol Med. 2017;8(2):229.
Dar-Odeh N, Abu-Hammad, Al-Omiri, Khraisat, Shehabi. Antibiotic prescribing practices by dentists: a review. TCRM. 2010 June;301.
Bhuvaraghan A, King R, Walley J, Thiruvenkatachari B, Aggarwal VR. Dental antibiotic policies, stewardship, and implementation in India: A policy document analysis. Comm Dent Oral Epid. 2024 Dec;52(6):844–60.
Grant, K. (2023, May 18). Antibiotics don’t cure toothache: A spotlight on antimicrobial resistance in Indian dental care. University of Leeds. https://www.leeds.ac.uk/antimicrobial-resistance/dir-record/profiles/19870/antibiotics-don-t-cure-toothache-a-spotlight-on-antimicrobial-resistance-in-indian-dental-care
Garg AK, Agrawal N, Tewari RK, Kumar A, Chandra A. Antibiotic prescription pattern among Indian oral healthcare providers: a cross-sectional survey. Journal of Antimicrobial Chemotherapy. 2014 Feb 1;69(2):526–8.
Chhabra, A., Nidhi, C., & Jain, A. (2019). Knowledge, attitudes and practice preference regarding drug prescriptions of resident dental doctors: A quantitative study. The International journal of risk & safety in medicine, 30(2), 91–100. https://doi.org/10.3233/JRS-180021
Doshi A, Asawa K, Bhat N, Tak M, Dutta P, Bansal TK, et al. Knowledge and Practices of Indian Dental Students Regarding the Prescription of Antibiotics and Analgesics. Medicine and Pharmacy Reports. 2017 Oct 30;90(4):431–7.
Jaber MA, Kamate W, Luke AM, Karande GS. Knowledge, Practices, and Nasal Carriage Rate of MRSA Amongst Dental Professionals. International Dental Journal. 2024 Apr;74(2):199–206.
Kamate W, Vibhute N, Belgaumi UI, Kadashetti V. Waking Up to Antibiotic Resistance. Journal of Pharmacy and Bioallied Sciences. 2023 July;15(Suppl 2):S840–2.
Lokhasudhan G, Nasim I. Knowledge, attitude, and practice survey on usage of antibiotics among dental practitioners in southern region of India.
Manohar M, Sharma S. A survey of the knowledge, attitude, and awareness about the principal choice of intracanal medicaments among the general dental practitioners and nonendodontic specialists. Indian J Dent Res. 2018;29(6):716.
Punj A, Shenoy S, Thomas B, Ramesh A. Knowledge awareness and prescription practice of antibiotics among private dental practitioners in Mangalore. J Educ Ethics Dent. 2016;6(2):72.
Puranik M, Sabbarwal B, Bose S. Dental practitioner’s knowledge and practices regarding antibiotic prescription and development of resistance: A cross-sectional study. J Indian Assoc Public Health Dent. 2018;16(2):144.
Ramachandran P, Rachuri N, Martha S, Shakthivel R, Gundala A, Battu T. Implications of Overprescription of Antibiotics: A Cross-Sectional Study. J Pharm Bioall Sci. 2019;11(6):434.
Rela R, Sejao AV, Singh A, Singh PK, Kumar M, Gupta SK, et al. Antibiotic Prescribing Knowledge, Awareness, and Attitude of Dental Surgeons Practicing in the Urban Indian Population. Journal of Pharmacy and Bioallied Sciences. 2021 Nov;13(Suppl 2):S1637–41.
Sharma K, Jain P, Sharma A. Knowledge, attitude and perception of medical and dental undergraduates about antimicrobial stewardship. Indian J Pharmacol. 2015;47(6):676.
Siddique S, Chhabra KG, Reche A, Madhu PP, Kunghadkar A, Kalmegh S. Antibiotic stewardship program in dentistry: Challenges and opportunities. Journal of Family Medicine and Primary Care. 2021 Nov;10(11):3951–5.
Telang LA, Nerali JT, Kalyan Chakravarthy PV, Siddiqui FS, Telang A. Antimicrobial Stewardship – Implementation and Improvements in Antibiotic-Prescribing Practices in a Dental School. Archives of Medicine and Health Sciences. 2021 Jan;9(1):80–6.
Vengidesh R, Kadandale S, Ramachandran A, Srinivasan S, Parthasarathy R, Thanikachalam Y, et al. Antibiotic Prescription Patterns for Endodontic Procedures in India: A KAP Survey. Cureus [Internet]. 2023 Apr 18 [cited 2025 Oct 22]; Available from: https://www.cureus.com/articles/150474-antibiotic-prescription-patterns-for-endodontic-procedures-in-india-a-kap-survey
Thompson W, Teoh L, Pulcini C, Sanderson S, Williams D, Carter V, et al. International Consensus on a Dental Antibiotic Stewardship Core Outcome Set. International Dental Journal. 2023 June;73(3):456–62.
World Health Organization: Country Office of India, (2017). National Action Plan on Antimicrobial Resistance (NAP-AMR) 2017 – 2021. https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-spc-npm/nap-library/national-action-plan-on-amr-(india).pdf?sfvrsn=9f396e90_1&download=true
Vázquez-Cancela O, Zapata-Cachafeiro M, Herdeiro MT, Figueiras A, Rodríguez-Fernández A. Dentists’ knowledge, attitudes and perceptions of antibiotic prescribing: A systematic review. Preventive Medicine. 2024 Aug;185:108043.

The authors declare no competing interests.

SupplementaryFigureS1.docx
Supplementary Figure S1. Problematic Prescribing Behaviors in Indian Dental Settings
SupplementaryFigureS2.docx
Supplementary Figure S2. Improvement Opportunities in Antibiotic Prescribing Practices to Promote Implementation of Dental Stewardship

Dental Stewardship Implementation and Antimicrobial Resistance Awareness in India: Prescribing Patterns, Knowledge Gaps, and Barriers

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Abstract

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Introduction

Materials and Methods