Discussion

This systematic review reveals a convergence of knowledge deficits, behavioral inconsistencies, and institutional barriers that collectively undermine rational antibiotic use in Indian dentistry. ^{Reference Chhabra, Nidhi and Jain26,Reference Puranik, Sabbarwal and Bose33} While AMR awareness was generally high, it did not reliably translate into appropriate prescribing, confirming that structural, educational, and behavioral reinforcement are needed alongside awareness. ^{Reference Punj, Shenoy, Thomas and Ramesh32,Reference Ramachandran, Rachuri, Martha, Shakthivel, Gundala and Battu34}

A central finding was the knowledge–practice gap: antibiotic prescribing for non-indicated conditions including dental caries (53%), simple extraction (54.5%), and acute pulpitis (60.9%) contradicted established guidelines. ^{Reference Cope, Francis, Wood and Chestnutt17,Reference Doshi, Asawa and Bhat27,Reference Kamate, Vibhute, Belgaumi and Kadashetti29} Non-clinical pressures—patient expectations, fear of litigation, and habitual prescribing patterns—drove this discordance over evidence-based decision-making. ^{Reference Punj, Shenoy, Thomas and Ramesh32,Reference Ramachandran, Rachuri, Martha, Shakthivel, Gundala and Battu34}

Guideline awareness varied markedly between BDS (15%) and MDS (71%) practitioners. ^{Reference Doshi, Asawa and Bhat27,Reference Ramachandran, Rachuri, Martha, Shakthivel, Gundala and Battu34} Private practitioners relied heavily on empirical prescribing, reflecting limited institutional support, ^{Reference Kamate, Vibhute, Belgaumi and Kadashetti29,Reference Punj, Shenoy, Thomas and Ramesh32} indicating that stewardship strategies must be tailored to practitioner background and workplace context.

These findings are not unique to India and reflect a global pattern of inadequate dental AMS. Vázquez-Cancela et al., in the most comprehensive systematic review of dentists’ knowledge, attitudes, and practices of antibiotic prescribing to date, examined 37 studies across multiple countries and found that inappropriate prescribing is predominantly driven by modifiable factors, including complacency, fear of litigation, lack of guideline trust, and tendency to defer definitive treatment, rather than by absence of awareness. ^{Reference Vázquez-Cancela, Zapata-Cachafeiro, Herdeiro, Figueiras and Rodríguez-Fernández24} This mirrors precisely the non-clinical pressures identified across our included Indian studies. In the United Kingdom, dentists account for approximately 10% of all primary care antibiotic prescriptions, and the UKHSA Dental Subgroup has acknowledged that prescribing rates have remained above prepandemic levels despite sustained stewardship efforts. ⁴² Scotland’s Antimicrobial Prescribing Group has similarly identified the need for structured dental stewardship infrastructure, including audit tools, education programs, and CPD frameworks, to translate policy into practice. ⁴³

In the United States, Goff et al. demonstrated that combining targeted education with individualized audit and feedback improved appropriate antibiotic use among private practice dentists from 19% to 87.9%, yet this intervention reached only 15 dentists, underscoring the scale of the challenge in reaching the majority of practitioners who operate outside institutional oversight. ^{Reference Goff, Mangino, Trolli, Scheetz and Goff25} The World Dental Federation has similarly called on national dental associations globally to embed AMS within national AMR action plans, recognizing that the dental profession carries a distinct and under-addressed responsibility in global resistance containment. ⁴⁴ Taken together, these international findings confirm that the knowledge–practice gap identified in Indian dentistry is a systemic global phenomenon, but one that is demonstrably amenable to structured, multifaceted intervention. The Indian context, characterized by a large prescriber population, absent national dental AMS guidelines, and minimal stewardship infrastructure, represents both an urgent priority and a significant opportunity for scalable impact.

Institutional and educational barriers are among the most entrenched challenges. Multiple studies identified the absence of formal AMS frameworks, limited guideline access, negligible ADR reporting, and insufficient continuing dental education (CDE) as key drivers of inappropriate prescribing. ^{Reference Chhabra, Nidhi and Jain26,Reference Puranik, Sabbarwal and Bose33} Nearly half of resident doctors were unaware of WHO prescribing guidelines, reflecting foundational undergraduate and postgraduate training gaps that structured curricula and CDE must address. ^{Reference Chhabra, Nidhi and Jain26,Reference Puranik, Sabbarwal and Bose33,Reference Sharma, Jain and Sharma36}

These findings align with India’s National Action Plan on AMR priorities on education, training, and optimal antimicrobial use. ^{Reference Garg, Agrawal, Tewari, Kumar and Chandra14,35} , Dentistry-specific guidelines and systems-level support—including decision-support tools, prescription monitoring, and audit feedback—are critical for translating policy into clinical practice. ^{Reference Puranik, Sabbarwal and Bose33,Reference Rela, Sejao and Singh40,Reference Madhu, Siddique, Chhabra, Reche, Kunghadkar and Kalmegh37,Reference Telang, Nerali, Kalyan, Siddiqui and Telang38}

Taken together, these findings underscore the need for coordinated, multifaceted action across education, policy, and institutional frameworks to address the deep-rooted barriers to AMS implementation.

The findings of this review point to several clear and actionable recommendations. At the policy level, there is an urgent need to develop national dental-specific antibiotic prescribing guidelines and clinical pathways, as their absence represents one of the most consistently identified barriers across included studies. Prescribing practices must be formally measured as a core AMS outcome to monitor progress and drive improvement. At the institutional level, dental settings should establish formal AMS programs incorporating local guidelines, prescription monitoring, and adverse drug reaction reporting, with audit and feedback embedded as routine practice, since evidence consistently demonstrates that guidelines alone do not change prescribing behavior. At the educational level, undergraduate and postgraduate dental curricula must integrate practical AMS training, supported by CPD throughout practitioners’ careers. At the clinical level, individual dentists must strengthen diagnostic reasoning, consult guidelines regularly, and resist non-clinical pressures that drive unnecessary prescribing. Multidisciplinary collaboration involving pharmacists and microbiologists further enhances stewardship capacity. Meaningful and sustained improvements in dental antibiotic prescribing in India will require coordinated, aligned action across policy, education, institutions, and clinical practice. Future work should focus on implementation science to bridge the knowledge-practice gap. Priority areas include clinical decision-support tools, audit and feedback mechanisms, behavioral nudges, and digital guideline platforms. Evaluating these interventions across varied Indian practice settings will be critical to advancing effective dental stewardship.

This review has several important strengths. It provides a comprehensive synthesis of AMS implementation in Indian dental settings, addressing a critical evidence gap in a country with one of the highest global AMR burdens. The review followed rigorous PRISMA 2020 guidelines, employed dual independent screening with substantial inter-rater agreement, and applied CASP quality appraisal to all included studies. The synthesis draws on evidence from 3,602 dental professionals across diverse Indian practice settings, lending breadth and relevance to the findings. Collectively, the evidence provides a strong empirical basis for urgently developing India-specific dental AMS strategies that are tailored to the educational, regulatory, and institutional realities of the Indian dental context, rather than simply adopting frameworks designed for high-income healthcare systems.

Several limitations must be acknowledged. The restriction to English-language publications may have excluded relevant studies or gray literature published in Indian regional languages. The predominance of cross-sectional survey designs introduces susceptibility to social desirability bias, and the absence of longitudinal studies or randomized controlled trials limits conclusions about the sustained impact of AMS interventions on prescribing behavior. Substantial heterogeneity in study design, outcome measurement, and participant populations precluded meta-analysis and complicates direct comparisons across studies. The inclusion of two narrative reviews, while providing useful contextual insight, deviates from strict systematic review methodology. Finally, the findings may not be fully generalizable beyond the urban and dental college settings that predominated in the included studies, and the experiences of rural or private practitioners may be underrepresented.