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Brazilian Journal of Oral Sciences
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Original Research • Braz J Oral Sci. 25 • 2026 • https://doi.org/10.20396/bjos.v25i00.8678911 linkcopy

Open-access Understanding antimicrobial use in dentistry: insights into knowledge and practice among students at different levels and clinicians

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

Abstract

Aim  Microbially induced oral diseases are highly prevalent worldwide. As a result, antimicrobial agents are widely used in clinical practice, and concerns about antimicrobial resistance have become a significant issue. However, there is limited information regarding the overall knowledge of antimicrobial use in dentistry at different stages of career progression, which was evaluated in this study.

Methods  Cross-sectional study evaluating the knowledge and behaviors of dental students and practicing dentists regarding the use of antimicrobials. Students from the basic sciences, preclinical and clinical years of dental school (n=50 per level, for a total of 150 students), as well as dentists with 2-5 years of clinical practice (n=50), were included. Questionnaires were administered, and descriptive, bivariate, and logistic regression analyses were conducted.

Results  There is a clear improvement in knowledge levels as professional levels increase when comparing students at different stages and clinicians. However, most dentists accessed scientific evidence more than one year prior to the survey (43.9%) and still prescribing antibiotics for oral conditions that typically do not require. The negative self-perception of knowledge regarding antimicrobial was associated with career level (p=0.05), a lack of confidence in prescribing antimicrobials (p=0.001), a lack of interest in receiving educational information (p=0.007), and among individuals who do not recommend systemic antibiotics for treating implant-related infections (p=0.002) or for patients with heart diseases (p=0.002).

Conclusion  Although there is a clear trend toward improved knowledge and attitudes regarding antimicrobial use throughout a dental career, the findings highlight an urgent need for educational programs with up-to-date information.

Keywords:
Anti-infective agents; Dentists; Students, dental; Knowledge

Introduction

The human oral cavity provides a unique environment for microbial adhesion and polymicrobial accumulation, as it hosts more than 700 microbial species1. The diverse biogeography of the oral environment allows different microbial species to accumulate, interact, and induce biofilm-related diseases2. Once adhered to biotic and abiotic surfaces into oral cavity, microorganisms can accumulate, leading to the formation of a complex and well-organized structures, known as biofilms3. Biofilm induced oral diseases, such as dental caries and periodontitis, affect billions of people in the world, being considered important prevalent health concern imposing significant costs on patients, clinicians, and healthcare systems4. Besides these prevalent diseases, patients are also often affected by odontogenic infections, even those acquired after dental and surgical procedures5. Some of these conditions can even result in serious complications, hospitalization, and compromise people’s quality of life6. Therefore, although the oral microbiota in a symbiotic state play an essential role in diverse biological functions in the human body, these microorganisms are often associated with oral diseases and complications, which highlight the need to develop and apply strategies to prevent, control, or treat microbial accumulation.

Thus, antimicrobial agents are widely used in dental clinical practice or even as at home health products. A wide range of oral products (e.g. toothpastes, mouthwashes) includes antimicrobials in their composition. Moreover, the prescription of antimicrobials in clinical practice, even as medication, is highly prevalent, mainly due to the high prevalence of oral infections and biofilm-associated oral diseases7. Among them, antibiotics stand out as one of the main antimicrobials used in clinical practice, mainly to treat or prevent oral infections8. It is estimated that dentists are responsible for prescribing 10% of antibiotics prescribed to humans in the world9. Another important antimicrobial agent used in dentistry is chlorhexidine digluconate, mainly for home care products to control oral disease and reduce microbial accumulation, being applied in oral surgery, periodontics, and even general dentistry10. Furthermore, newly developed toothpastes, including antimicrobial agents in their formulation, have been widely tested and used worldwide11. However, as the prescription of antimicrobials increases, the concern regarding antimicrobial resistance has become an important issue for scientists and clinicians, mainly related to the indiscriminate use of some agents.

Incorrect prescription of antimicrobials by healthcare professionals can lead to adverse risks. Common prescription errors, such as related to concentration and use time, can even result in treatment failure12. Evidence has highlighted that basic pharmacology concepts learned at school may not be sufficient for building knowledge about drug administration13. Hence, some conditions require that only patients at risk for infections should receive antibiotics; however, dentists may also prescribe them for healthy patients with no risk for infections, such as in implant placement14. Moreover, there is a clear need to revisit dental education in terms of important antimicrobial use concepts and applications7. Previous evidence has explored the knowledge levels and behaviors of dentists regarding antimicrobial prescription and has pointed out low levels of knowledge and worrisome attitudes15-17. Evidence has demonstrated that the level of knowledge regarding antimicrobial use in dentistry is directly influenced by the professional level of practitioners, particularly when comparing dental students to practicing dentists18. However, most of the evidence has focused on antimicrobial prescriptions for specific oral conditions or on comparing limited levels of dental education. There is no clear information regarding the overall knowledge of antimicrobial use in dentistry and the products prescribed when comparing dental students at different levels with practicing dentists.

Thus, this study aimed to evaluate and assess the knowledge and behaviors of dental students and dentists regarding the use of antimicrobials in dental practice, from the beginning of their undergraduate studies through to graduation and subsequent clinical practice as a dentist.

Materials and Methods

Ethical considerations

The present study was approved by the local Research Ethics Committee (protocol: 77306523.8.0000.5146), according to the Brazilian National Health Council Resolution for research on human beings. The participants were informed about the study and signed a consent form.

Study design and sampling

A cross-sectional, quantitative, and epidemiological survey was conducted among dental students at different levels of undergraduate education in a private Brazilian dental school and among dentists. Sampling estimation (n= 50 per level) considered a sample power of 90% and α of 5%, based on data provided from a previous study19. In Brazil, undergraduate education is divided into semesters, and most dental schools have 8-10 semesters. The school included in the study has a 10-semester program. The school included in the study has a 10-semester program. Thus, the dental students were divided into three levels: initial (first, second, and third semesters), middle (fifth, sixth, and seventh semesters), and final (eighth, ninth, and tenth semesters), which represent basic sciences years, preclinical years and clinical years. Only dentists from private clinics and with 2-5 years of clinical practice after dental school were included. All students from the selected semesters in the dental school were invited to participate in the survey simultaneously during regular lectures. Questionnaires were administered until the target sample size per level was reached among students who agreed to participate (n = 50 per level). Dentists in the undergraduate programs at the same school were also invited to answer the survey according to the inclusion criteria. The questionnaires were distributed to those who agreed to participate until the required sample size was achieved. Data were collected using a structured, self-administered questionnaire.

Self-administered questionnaire

A structured self-administered in person questionnaire assessing socioeconomic characteristics, knowledge and practices related to antimicrobial use and prescription, antimicrobial resistance, common antimicrobial products used in dentistry, clinical situations to prescribe antimicrobials, and information sources to learn about antimicrobials were considered. To ensure the reliability of the developed questionnaire, a test-retest technique was employed. For this, the questionnaire was applied to 15 students on two separate days, with a 7-days interval between applications. Then, Kappa values were computed to estimate reliability, and values over 0.95 were found for all questions. Thus, minor modifications were included before final questionnaire application.

The questionnaire considered four main sections. In the first part, the sociodemographic characteristics included the following questions: age and sex. The second part included questions related to the self-perceived knowledge level of antimicrobial use in dentistry, previous education related to the topic, and knowledge regarding antimicrobial resistance. The third part included clinical situations and the association of oral problems with systemic conditions that may or may not require the prescription of antimicrobials, as well as the attitudes of individuals. The fourth part included access to information and scientific evidence regarding antimicrobial use and protocols in dentistry. The questionnaire was developed based on previous studies and current evidence regarding the use of antimicrobials in Dentistry. Data were collected between January and March 2024.

Statistics

SPSS 20.0 was utilized for statistical analysis. Descriptive analysis was performed to estimate averages, percentual, and absolute values. Bivariate analyses were conducted using the Chi-square test to assess the differences between knowledge and attitudes among the different undergraduate levels (initial, middle, and final) and dentist according to all variables evaluated. Multiple models using binary logistic regression were estimated, considering the entire sample and using the self-perceived level of knowledge regarding the use of antimicrobials in dentistry as the dependent variable. The variables associated to the negative self-perception were considered. Only adjusted models were considered, and odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. A significance level of 5% was adopted for all models.

Results

Two hundred participants were included in the study, with 50 individuals per professional level (dental students at the initial, middle, and final stages, and dentists). The average age was 19.3 (± 1.68) years at the initial level, 21.83 (± 2.56) at the middle level, 24.9 (± 5.01) at the final level of school, and dentists had an average age of 30.19 (± 6.40). There is a clear trend of improvement in knowledge and attitudes regarding antimicrobial use as professional level increases, when comparing students at different stages and clinicians, with a rise in positive self-perception (Very good/Good) over the years for most of the variables included (Table 1). Of the 43 questions included in the questionnaire, significant differences (p < 0.05) in knowledge levels between dental students at different levels and clinicians were identified for 29 variables (Table 1). However, although there is an improvement in knowledge levels regarding the use of antimicrobials when comparing dental students and dentists, most dentists accessed scientific evidence more than one year prior to the survey (43.9%) and are still prescribing systemic antibiotics for oral conditions that typically do not require this type of medication, such as implant placement and pulpitis (Table 1). Moreover, dental students in the middle and final years demonstrated the same level of knowledge regarding antimicrobial resistance as dentists (approximately 30%) (Table 1). Furthermore, more than 20% of individuals at all levels believe that fluoride has some antimicrobial effect (Table 1). Thus, although there is a clear trend of improving knowledge and attitudes among the different levels of a dental career, dentists may also exhibit some low levels of knowledge or poor attitudes regarding antimicrobial use, such as not checking scientific evidence on the topic.

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Table 1
Descriptive analysis of the variables related to knowledge and behaviors regarding the use of antimicrobials in Dentistry among undergraduate students at different levels and practicing dentists. Dental students were divided into three levels: initial (first, second, and third semesters), middle (fifth, sixth, and seventh semesters), and final (eighth, ninth, and tenth semesters), which represent basic sciences years, preclinical years and clinical years. n = 200 (50 students per level, for a total of 150 students; and 50 dentists). Bivariate analysis using Chi-square test.

The logistic regression analysis showed the variables associated (p<0.05) to the poor (Fair/Poor/Very Poor) self-perception of knowledge level regarding antimicrobial use in Dentistry (Table 2). The poor self-perception was lower among dentists (p=0.05) compared to dental students; and among individuals who did not want to receive additional information regarding antimicrobial resistance (p=0.007), compared to those who did (Table 2). Furthermore, poor self-perception of knowledge regarding antimicrobial use was 5.3 times higher among individuals who did not feel confident prescribing antimicrobials (p=0.001); 6.09 times higher among individuals who did not recommend antimicrobial prophylaxis for patients with heart diseases (p=0.002); and 6.26 times higher among individuals who did not recommend systemic antibiotics to treat implant-related infections (p=0.002) (Table 2).

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Table 2
Multiple binary logistic regression analysis of variables associated with negative evaluation in participants’ perception of knowledge regarding the use of antimicrobials in Dentistry among undergraduate students at different levels and practicing dentists. Dental students were divided into three levels: initial (first, second, and third semesters), middle (fifth, sixth, and seventh semesters), and final (eighth, ninth, and tenth semesters), which represent basic sciences years, preclinical years and clinical years.

Discussion

The use of antimicrobials is common practice in dentistry for the management of prevalent oral diseases. Some concerns have been raised in the literature regarding the indiscriminate use of antimicrobials, which increases the chance of antimicrobial resistance20. In 2022, approximately 236 million antibiotic prescriptions by U.S. healthcare providers were reported, and at least 28% of antibiotic prescriptions in the country were considered unnecessary21,22. Among dentists, antibiotics have been considered the most commonly prescribed antimicrobial agents, mainly penicillins23. Interestingly, dentists commonly report a lack of awareness about guidelines for prescribing antimicrobial agents24. Moreover, evidence has highlighted the need to educate dental students regarding antimicrobial prescriptions and the risks associated with their use, mainly due to the variable levels of knowledge and attitudes reported19. Here, for the first time, we explored the levels of knowledge and attitudes regarding antimicrobial use in dentistry by comparing dental students at different levels and dentists after 2-5 years of graduation. Importantly, the findings suggest a clear improvement in knowledge levels and more positive attitudes regarding antimicrobial use in dentistry as professionals progress in their careers, when comparing students at different stages and clinicians. However, even practicing dentists still reporting poor access to guidelines and scientific evidence related to antimicrobial use, and in some clinical situations where evidence does not recommend antibiotic use, dentists continue prescribing them. These outcomes highlight the urgent need to improve dental school curricula to provide a better background and constant updates regarding antimicrobial use, as well as the development of educational programs for dentists to stimulate evidence-based clinical practice, mainly to reduce the chance of antimicrobial resistance.

The negative self-perception of knowledge regarding antimicrobial use in dentistry was associated with career level, a lack of confidence in prescribing antimicrobials, no interest in receiving additional information regarding antimicrobial resistance, and among individuals who do not recommend systemic antibiotics for treating implant-related infections or for patients with heart disease. As expected, dentists felt more confident regarding their knowledge levels related to antimicrobial use compared to dental students. In a dental career, a higher sense of confidence may enhance the ability to perform tasks and manage patients’ problems25. It is concerning that individuals who do not want to receive additional information regarding antimicrobial resistance also self-report a poor level of knowledge about the topic. This suggests that educational programs need to be encouraged, and the importance of the problem should be better discussed within the dental field.

Antimicrobials are expected to be prescribed only for clinical situations and patients that need their effect. Although there is no consensus regarding the optimal treatment for implant-related infections26, systemic antibiotics have commonly been indicated as a promising alternative, in combination with mechanical biofilm removal27. The poor level of knowledge was associated with the lack of antibiotic prescriptions for the treatment of implant-related infections, which suggests outdated behavior. Moreover, the poor level was also associated with the no antibiotic prescription for patients with heart disease. Antibiotic use before or after dental procedures for patients with heart disease is still unclear, but the evidence has suggested that for high-risk individuals, antibiotic prophylaxis is associated with reduced risk of infective endocarditis after dental interventions28. Therefore, antimicrobials, mainly antibiotics, should be prescribed only for patients at high risk of developing further infections or complications. These indications should consider both local and systemic conditions, as well as the management of the dental problem being treated and any complications that arise during the intervention.

Health care should be directly and positively influenced by advancements in science. Therefore, it is expected that dental students and dentists consistently access scientific evidence to stay updated on the protocols and indications for antimicrobial use. The poor level of knowledge in certain areas may suggest outdated information. For example, some individuals indicated that fluoride has an antimicrobial effect. However, evidence shows that fluoride, which is not considered an antimicrobial agent, only exhibits some antimicrobial effect at high concentrations in biofilm fluid, where it can control certain bacterial metabolism29. Moreover, chlorhexidine, which has been indicated as the gold standard in dentistry for controlling biofilm accumulation10, was not recommended by some dental students. In fact, most respondents reported that they have not accessed scientific evidence regarding antimicrobial prescriptions in the past year. Thus, if the findings from scientific studies are not accessed by dental students or clinicians, the benefits generated are not directly translated to patient oral health care. Therefore, some dental professionals may not have applied evidence-based dentistry, considering the best scientific evidence for patient care, which may result in patients being exposed to treatments not supported by updated evidence regarding their effectiveness and safety. Furthermore, the dental industry is constantly seeking innovations, and new biomaterials with antimicrobial properties have been developed that can be further applied to clinical practice and need to be understood by clinicians30,31. However, previous evidence shows that Brazilian dentists have not widely used scientific evidence due to several barriers, such as difficulty understanding scientific papers, the high cost of accessing articles, and the fact that they are non-native English speakers32. Moreover, the increasing sharing of misinformation on social media, a powerful information tool nowadays, may negatively affect the application of scientific evidence in clinical practice.

Educational programs focusing on antimicrobial resistance field for dental students have shown promising results in improving knowledge levels and fostering positive attitudes, even when offered online33. Educational training may affects directly the quality of patient care, enhancing rational clinical decisions and health outcomes. Moreover, the inclusion of antimicrobial use guidelines and the constant pursuit of updated scientific information in school curricula or through educational programs needs to consider several aspects: understanding basic microbiological concepts, the association of oral problems with systemic conditions, correct antimicrobial prescription, categories of antimicrobials and their indications, antimicrobial resistance mechanisms and consequences, and learning how to access and critically read scientific papers to apply them in clinical practice. These reforms should be implemented across all dental areas and specialties, even after dental school and for postgraduate students. As a limitation, our findings cannot be simply extrapolated to other contexts. Although most schools in Brazil follow similar curricula, adjustments can be made for each institution. However, these findings underscore the need to improve knowledge of antimicrobial use in dentistry among dental students and clinicians, providing crucial insights for guiding further changes in dental school curricula, implementing educational programs, and creating regulatory guidelines to promote the correct use of these agents in clinical practice. Furthermore, it is important to note that this is a cross-sectional study, and longitudinal associations cannot be determined. Moreover, a statistical difference between dentists and dental students at the initial level in the logistic regression was found to be a borderline association, which may suggest limitations related to the outcome or sample size and needs to be further explored.

In conclusion, the findings showed that, overall, there is a clear trend toward improved knowledge levels and attitudes regarding the use of antimicrobials throughout a dental career, comparing dental students at different levels and dentists. However, when evaluating specific clinical settings, patients with systemic conditions, or the effects and mechanisms of commonly used agents in dentistry, such as chlorhexidine and fluoride, dentists still exhibit a poor level of knowledge. Importantly, overall, individuals have reported a low level of access to scientific evidence regarding the topic, which highlights the urgent need for educational programs with updated information.

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  • Data Availability Statement:
    Datasets related to this article will be available upon request to the corresponding author.

Edited by

  • Editor:
    Dr. Altair A. Del Bel Cury

Data availability

Datasets related to this article will be available upon request to the corresponding author.

Publication Dates

  • Publication in this collection
    09 Mar 2026
  • Date of issue
    2026

History

  • Received
    12 Jan 2025
  • Accepted
    27 Aug 2025
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