Prescribing medication is an essential part of clinical dentistry, particularly concerning the use of antibiotics for acute odontogenic infections, surgical prophylaxis, and care of medically compromised patients. Research on dental students' knowledge and perception of antimicrobial prophylaxis in dental practice is notably lacking in Nepal. This study aims to bridge that gap by assessing the level of understanding among Nepali dental students.

An online, questionnaire-based cross-sectional study was carried out among dental students all over Nepal. A total of 288 dental students from Nepal took part in the study, comprising 189 undergraduate students, 62 interns, and 37 postgraduate students. A standard structured questionnaire that included 12 clinically relevant and three perception-based questions was distributed online. The results were analyzed via descriptive statistics.

The mean ± SD correct answers were 6.79 ± 2.26. More than three-fourths of the total students (288), i.e., 76.04% (219), answered more than half of the questions correctly. In the dosage and timing scenario, 76.3% of the students answered correctly wherein interns provided the most correct responses (91.0%). In deciding their knowledge of specific scenarios, 73.7% of the students knew when to prescribe correctly in four of five relevant scenarios, with postgraduates performing better (76.1%). Performance declined significantly when it involved evaluating scenarios deemed inappropriate for prophylaxis. Additionally, self-reported perceptions highlighted significant gaps in knowledge (38.6%) and confidence (40.9%). These deficiencies emphasize the strong need for further education, as acknowledged by two-thirds (65.4%) of the students.

While most students demonstrated a basic understanding of antibiotic prophylaxis, significant shortcomings were noted, particularly in avoiding unnecessary prescriptions. To ensure appropriate prescribing practices and reduce antibiotic overuse, the integration of a standardized antimicrobial stewardship (AMS) curriculum in all dental institutions in Nepal is strongly recommended.

The global issue of antibiotic resistance has risen substantially, with the World Health Organization (WHO) recognizing it as a severe public health risk facing humanity [1]. The primary method for reducing antibiotic resistance and its harmful effects is to minimize unnecessary antibiotic use. Antimicrobial stewardship (AMS) has been advocated by several health organizations, including the WHO and the Centers for Disease Control and Prevention (CDC), to reduce suboptimal antibiotic use and improve patient outcomes [2].

Dentists can independently prescribe and deliver oral medications, which account for up to 10% of antibiotics worldwide [2, 3]. Since a significant number of antibiotic prescriptions are for dental procedures, it is crucial that aspiring new dentists have a strong foundation in antimicrobial stewardship (AMS) to ensure responsible prescribing practices [4]. AMS aims to optimize patient safety, improve treatment outcomes, and minimize healthcare costs by preventing the overuse and misuse of antibiotics, thereby combating antimicrobial resistance (AMR). Its success relies on strong leadership, prescriber accountability, pharmaceutical oversight, and comprehensive education for both clinicians and patients [5, 6].

Antibiotics have historically been recommended as a preventive strategy since they have been linked to bacteraemia caused by dental operations in patients with predisposing cardiac lesions [7]. Antibiotic prophylaxis has been used in dentistry for medically compromised patients, among which infective endocarditis or prosthetic joint infection is most common [8]. Globally, the annual incidence of infectious endocarditis is estimated to be 10 per 100,000 people [9]. The incidence of heart disease may be greater in developing nations such as Nepal because of a lack of studies and accurate reporting [10]. Even when treated with antibiotics, infective endocarditis has a 30% mortality rate, making it an extremely dangerous condition [9].

Despite the critical role of dentists in antibiotic prescribing, studies indicate that dental professionals and students often under- and overprescribe antibiotics, influenced by their familiarity with at-risk cardiac conditions and relevant dental procedures [11]. A survey among dental practitioners in Chitwan, Nepal revealed that while many had average knowledge of antibiotic resistance, they frequently prescribed antibiotics without adhering to established guidelines, indicating a need for improved education and awareness [12].

The approach to antibiotic prophylaxis within the dental profession varies across different regions of the globe. More recently, adhering to evidence-based guidelines presented by organizations such as Therapeutic Guidelines Limited (Australia), European Society of Cardiology (ESC), and American College of Cardiology/American Heart Association (ACC/AHA), nations such as Australia, the United States, and most European countries still recommend prophylaxis for a specific group of patients identified as high-risk [13,14,15,16]. Nepal, on the other hand, lacks standardized national guidelines for antibiotic prophylaxis for dental procedures, leading to variability in the prescribing habits of dental professionals [10].

Research on Nepalese dental students'knowledge and perception of antimicrobial prophylaxis remains limited. A recent investigation of the knowledge, attitudes, and practices (KAPs) of antibiotic use by medical and nonmedical students in Nepal identified serious gaps, underscoring the urgent need for focused educational interventions [17]. With the growing burden of AMR fueled by widespread irrational antibiotic use and systemic healthcare challenges, evaluating dental students'understanding of prophylaxis is essential to developing effective strategies for improving prescribing practices [18].

Although similar studies have been carried out in other countries, there is little information available about the specific training and knowledge levels of Nepalese dental students addressing antibiotic prophylaxis. While global recommendations for antibiotic prophylaxis exist, their applicability in Nepalese dentistry education and practice is questionable. Therefore, this study attempts to analyze how well Nepalese dental students comprehend and apply antibiotic prophylaxis guidelines in a clinical context. Thus, this study aims to investigate the knowledge and perception of dental students on the use of antibiotics as a preventative measure.

The questionnaire used in this study was adapted from Thanissorn et al. [3], which assessed dental students'knowledge and perception of antibiotic. There are currently no official guidelines for antibiotic prophylaxis in dentistry with regard to cardiac conditions in Nepal. As a result, the Australian standards have been embraced because they closely coincide with the recommendations of the American Dental Association (ADA) and the American Heart Association (AHA), all of which are extensively followed around the world [19, 20]. The questionnaire underwent expert review before distribution to ensure content clarity and appropriateness for the Nepalese dental education context.

The study got approval from the Department Research Unit, College of Dental Surgery, BPKIHS, Dharan, Nepal (Approval Number: DRU/88/023). Participants provided informed consent prior to participation, and confidentiality was strictly maintained; they were unable to submit their responses unless consent had been given in the earlier section.

The study included a total of fourteen dental colleges in Nepal, each offering a five-year program with compulsory internship. Students begin their supervised clinical practice in the third year of their studies. The study was conducted among undergraduate dental students (third, fourth, and final years), interns, and postgraduate students from various institutions across Nepal (Table 1).

An anonymous online, questionnaire-based cross-sectional study was carried out among dental students all over Nepal. The questionnaire, available in English, consisted of demographic details (gender, age, dental school attending, primary dental qualification, year level), twelve case vignettes, and three linear scale opinion-based questions (0–100). Opinion-based questions assessed students’ attitudes and perceptions of antibiotic prophylaxis. In the case vignettes, correct and incorrect responses were scored, with 0 assigned to incorrect responses and 1 assigned to correct responses.

There were 12 case vignettes related to antibiotic prophylaxis. The questionnaire was divided into two halves. The first half, with 4 questions, assessed knowledge regarding the dosage and timing of antibiotic prophylaxis [scenario 1], and the second half, with 8 questions, assessed the appropriate use of antibiotic prophylaxis in various clinical scenarios [scenario 2].

The questionnaire was distributed through an online Google Forms link. Given the absence of a centralized database of dental students, a non-probability convenience sampling method was employed. Representatives from various dental colleges were identified through personal contacts and professional networks and were provided with information about the study and its aim. These representatives disseminated the online survey link to students via email, social media platforms (Facebook, WhatsApp), and internal college groups. The confidentiality of the collected data was ensured, and the data were exported into a Microsoft Excel sheet before being transferred to SPSS for statistical analysis.

Demographic data with a normal distribution and the percentage of students who answered each question correctly were shown as counts and percentages. Except for the linear scale answers, all the responses to the questions were categorical, as required by the case vignettes'multiple-choice question format. The responses were then dichotomized into correct and incorrect categories. An analysis was then conducted to compare the results among dental students from different years. Tabular presentations were used to describe categorical variables.

The questionnaire was completed by 288 dental students from all 14 dental colleges. Most of the responses were from female students (59.7%), followed by male students (40.3%). The mean age of the participants was 24.36 ± 2.5 years. The maximum number of responses was obtained from undergraduate students (65.6%) (Table 2).

The mean number of correct responses was 6.79 ± 2.26. Of the total students (288), 76.04% (219) answered more than half of the questions correctly.

For dosage and timing [scenario 1], 76.3% correctly responded to all four questions with interns having the highest percentage of correct responses (91.0%). The majority of dental students (92.4%) were aware that intravenous route was the alternative route when oral route prophylaxis was not possible (Table 3).

In terms of clinical scenarios [scenario 2], there were scenarios that required antibiotic prophylaxis, and scenarios that had no indication of prophylaxis. The scenarios where patients required valvular replacement and patients with a history of previous infective endocarditis had the highest percentage of correct responses (85.4%), where PGs performed better (76.1%). Approximately three-fourths of the students (73.7%) knew when to correctly prescribe in four of the five appropriate scenarios. In scenarios where prophylaxis was not indicated, most of the UG (18.3%), Intern (21.5%) and PG (25.2%) students performed poorly, indicating a tendency toward overprescription. These scenarios were included to assess whether students could differentiate between necessary and unnecessary antibiotic use. However, the low accuracy suggests that many students prescribed antibiotics even when not required, highlighting a knowledge gap that may reflect broader prescribing practices in dental education. There were no significant variations in demographics (gender, year level, primary dental qualification) among dental students who responded to questions about transcatheter implanted prostheses and nil indication of prophylaxis. Details regarding the methods used to prescribe antibiotic prophylaxis are shown in Table 3.

In the case of self-reported perceptions of prescribing antibiotic prophylaxis, only one-third of the study participants [mean (± standard deviation): 38.6 (SD 32)] said that they were knowledgeable about the use of antibiotic prophylaxis in dental treatments. Additionally, less than half of them [mean (± standard deviation): 40.9 (SD 34)] expressed confidence in their ability to provide patients with safe and efficient antibiotic prophylaxis. Furthermore, approximately two-thirds of the participants [mean (± standard deviation): 65.4 (SD 37)] highlighted the need for more education in effective antibiotic prophylaxis in the dental curriculum (Table 4).

The primary goal of this study was to evaluate knowledge and perception regarding the appropriate dosage, duration, and route of administration in different clinical scenarios, both those that necessitate prophylaxis and those that do not. To our knowledge, this research represents the first comprehensive exploration of dental students'understanding of antibiotic prophylaxis all over Nepal. Overall, students correctly answered more than half of the questions, but failed to achieve a perfect score. Meanwhile, two-thirds of the students felt the need for further education. However, similar studies reported significantly higher awareness levels, indicating a stronger understanding of current guidelines for antibiotic prophylaxis [3, 21, 22].

On the basis of the responses received on knowledge evaluation, the students were relatively better informed about dosage, timing, and situations in which prophylaxis is indicated. This is evident from the fact that almost three-fourths of the students answered four out of five questions requiring correct indications of antibiotic prophylaxis appropriately. This was consistent with the previous studies [3, 23]. Similar international studies investigating dental students'appropriate prescription of antibiotic prophylaxis have highlighted the high awareness of past infective endocarditis [3, 24, 25]. Conversely, the scenarios in which antibiotics were considered inappropriate for prophylaxis showed significantly poorer performance, with only 18.3–25.2% of students correctly abstaining from prescribing antibiotics. This may be due to a lack of awareness regarding cardiac conditions that necessitate antibiotic use, leading to instances of antibiotic overprescription, as noted in other similar studies [3, 24]. The case scenarios in our study, in which fewer than half of the dental students responded properly, involved transcatheter-implanted prostheses and nil indications of prophylaxis. These scenarios were included to assess whether students could differentiate between necessary and unnecessary antibiotic use. These potential outcomes could lead to overprescription, illustrating that dental students typically overprescribe antibiotics owing to their understanding of at-risk cardiac disorders and dental operations according to pertinent standards. In contrast, international studies show that students got more thorough clinical decision-making training, which resulted in a greater understanding of both appropriate and incorrect prescribing scenarios [24, 26].

The lack of knowledge (38.6%) and confidence (40.9%) among the dental students in the current study signifies the misidentification of cardiac conditions and the overprescription of antibiotic prophylaxis, which has also been addressed in various similar studies [3, 23, 24]. Therefore, our study's dental students believed that there was a need for further education (65.4%) regarding the use of antibiotics in dentistry, a sentiment that was also shared by those in prior studies [3]. Conversely, studies from other countries have indicated that students feel more confident in their knowledge and application of antibiotic guidelines, which may be correlated with more extensive training and exposure during their education [21, 22]. By strengthening the curriculum's focus on appropriate antibiotic use and antimicrobial stewardship, dental schools can foster a culture of responsible prescribing practices among their students.

The comparison of interns, undergraduates, and postgraduates offers a comprehensive understanding of how clinical experience and academic progression influence knowledge and decision-making in antibiotic prophylaxis. The better performance of interns in dosage and timing scenarios suggests that hands-on experience and education are crucial for developing competence in these aspects of antibiotic prescription. This emphasizes the necessity of including practical training throughout the dental curriculum, giving students several opportunities to apply their knowledge in supervised clinical settings. In contrast, undergraduates performed poorly, especially in complex decision-making scenarios involving antibiotic prophylaxis. Lack of established guidelines and early exposure to clinical cases in faculty-supervised antibiotic decision-making could be the cause of this. While postgraduates performed well in specific scenarios, such as those requiring antibiotic prophylaxis, their overall performance was not consistently better than that of interns. The practical experience that the postgraduates had gained during their practice as dental surgeons in hospitals and/or private setups might have led them to better understand clinical scenarios where antibiotics were deemed necessary. Thus, the need for improved knowledge and compliance among dental students regarding guidelines for antibiotic prophylaxis was felt which had been discussed in previous study [11]. A distinct comparative analysis has been deemed necessary to evaluate the differences in prophylaxis between interns and postgraduates, as well as the ways in which clinical experience and education have contributed to these differences. The low correct response rates across all groups in identifying cases with no indication for antibiotic prophylaxis highlight a critical area for improvement in dental education. The overuse of antibiotics can contribute to the development of antibiotic resistance, which poses a significant public health concern.

When compared globally, studies indicate that antimicrobial stewardship (AMS) education in dental curricula is crucial for improving prescribing practices. A study in the USA emphasized the importance of integrating AMS into dental education to ensure responsible antibiotic use among future dentists [27]. Similarly, research on UK dentists revealed significant knowledge gaps regarding antibiotic prophylaxis, with many practitioners unaware of updated guidelines, contributing to antibiotic overuse in dental practice [11]. A study in India found that while 73% of students were aware of infective endocarditis prophylaxis, only one-third correctly identified the heart conditions and dental procedures requiring prophylaxis [28]. These aligns with our findings, where a considerable number of Nepalese dental students demonstrated uncertainty in cases with clear prophylaxis indications. The recurring trend across multiple countries, including Nepal, highlights an urgent need for strengthening antimicrobial education within dental curricula.

After completing dental school in Nepal, dentists are qualified to practice independently and have the authority to prescribe a wide range of medications. This makes dental school the final structured opportunity to instill proper antibiotic prescribing practices, reinforcing the need for standardized AMS training across all institutions. Research on Chitwan dentists similarly highlighted gaps in knowledge, emphasizing the importance of structured education [12].

Dental students'limited understanding of antibiotic prophylaxis often leads to overprescription and misuse, contributing to antimicrobial resistance (AMR) and exacerbating public health challenges such as longer hospital stays, increased healthcare costs, and rising AMR [18, 29, 30]. This issue is particularly concerning in developing countries like Nepal, where it may hinder progress toward sustainable development goals [29]. Strengthening antibiotic stewardship within the dental curriculum can address these challenges by providing clear guidance on appropriate prescribing, dosage, and duration for specific procedures [30]. Additionally, fostering collaboration between dentists, physicians, and pharmacists can help establish evidence-based prescribing guidelines, ensuring students gain exposure to interdisciplinary best practices [31]. To improve dental students'understanding of antibiotic prophylaxis, effective strategies include incorporating AMS concepts into relevant modules, holding regular workshops on the latest guidelines, utilizing online learning resources, and implementing continuous assessments through quizzes and feedback mechanisms [21, 22, 26, 32]. By prioritizing antibiotic stewardship in dental education, Nepal can promote responsible prescribing, safeguard public health, and contributes to global efforts against antibiotic resistance.

This study has its own strengths and limitations. It effectively compares undergraduate, intern, and postgraduate performance, providing insights into how clinical experience and academic progression influence knowledge and decision-making. By identifying specific gaps, particularly in recognizing cases where prophylaxis is unnecessary, the findings can inform targeted educational strategies. The use of real-world clinical scenarios enhances the assessment of students'understanding and practical application of guidelines, making the results highly relevant to dental education. The absence of time limits and restrictions on accessing external information and resources mirrored a real-world scenario, where clinicians aren't limited to relying only on memory and can utilize other resources.

However, certain limitations must be acknowledged. The uneven response distribution, with a majority of participants from a single institution, limits the generalizability of the findings to the broader population of dental students in Nepal. Additionally, as a cross-sectional study, it captures knowledge at a single point in time, limiting the ability to assess long-term improvements. Future longitudinal studies tracking knowledge retention and the impact of AMS training over time would provide a more comprehensive understanding of how dental education influences prescribing behaviors. While this study offers valuable insights into the current gaps in antibiotic prophylaxis knowledge, its findings should be interpreted within the context of these limitations. Further research with a larger, more representative sample and follow-up assessments would strengthen the evidence base for improving dental education and antibiotic stewardship in Nepal.

The findings of this study offer important insights into how current dental students view the use of antibiotics as preventative care. Furthermore, it emphasizes the bigger picture by acknowledging that, owing to a lack of comprehensive understanding in the sector, dentists will never be able to distinguish between low- and high-risk cardiovascular disease completely [33, 34]. Therefore, if a multidisciplinary approach involving dentists, patients, and cardiologists/pediatricians/general physicians works well together to create a customized, individualized treatment plan, there may be a chance for the best possible patient care.

AMS:

Antimicrobial Stewardship

PG:

Postgraduates

UG:

Undergraduates

Download references

The manuscript was written through the contributions of all authors. AKG, MC, and AKY contributed to the conception and design of the study under the supervision of AS, TB, SKA, and UG. AKG carried out the statistical analysis. AKG, MC, and AKY wrote the original draft. All authors interpreted the results and critically reviewed the drafts of this manuscript. Both AKG and MC contributed equally to this work. All authors read and approved the final manuscript.

Correspondence to Akash Kumar Giri.

This study was conducted according to the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained from all subjects. This study was approved by Department Research Unit, College of Dental Surgery, BPKIHS, Dharan, Nepal (Approval Number: DRU/88/023).

Not applicable.

The authors declare no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions