Prevalence and Predictors of Inappropriate Antibiotic Prescriptions Among Dentists in Muscat Governorate, Oman

Summary

Objectives:

Inappropriate antibiotic prescriptions represent a major healthcare concern, contributing to increasing antimicrobial resistance. Dentists account for up to 10% of antibiotic prescriptions, highlighting the need for rational prescribing practices. This study aimed to assess the prevalence and predictors of inappropriate antibiotic prescriptions by dentists in primary health clinics in Muscat Governorate, Oman.

Methods:

This retrospective cross-sectional study was conducted on dental antibiotic prescriptions issued between July and December 2024 in government and private dental care facilities across Muscat Governorate. Clinics were randomly selected and data were extracted from electronic patient records using a structured form. Descriptive statistics, Chi-square tests and logistic regression were performed.

Results:

A total of 401 dental antibiotic prescriptions were analysed. The most frequent diagnosis for which antibiotics were prescribed was pulpitis (28.4%). Most prescriptions (84.5%) were issued by dentists with more than 10 years of experience and 67.8% were prescribed without clinical intervention. Amoxicillin was most prescribed (56.6%). Overall, 69.1% of prescriptions were inappropriate, with rational prescriptions associated with dentist experience (P <0.001) and the presence of diffuse swelling (P <0.001). Logistic regression analysis identified dentist experience as the only significant predictor of inappropriate prescribing, with more experienced dentists being less likely to prescribe antibiotics inappropriately (adjusted odds ratio = 0.65, 95% confidence interval: 0.54–0.79; P <0.001).

Conclusions:

A high proportion of antibiotic prescriptions by dentists in Muscat were unjustified, with dentist experience identified as a key predictor of appropriate prescribing practices. These findings underscore the need for targeted interventions and antibiotic stewardship programmes to promote rational prescribing among dentists.

Advances in Knowledge

• A high proportion of antibiotic prescriptions by dentists in Muscat Governorate, Oman, were inappropriate (69.1%).

• Dentists displayed inappropriate antibiotic prescribing practices regardless of clinic sector (government or private) with no significant differences in prescribing appropriateness.

• This study highlights the factors that are significantly associated with rational prescribing practice including dentist experience and the presence of diffuse swelling.

• This research is among the first studies to investigate the prevalence and predictors of inappropriate antibiotic prescriptions in Muscat Governorate.

Application to Patient Care

• This study addresses the need for national guidelines on antibiotic prescription for routine dental care.

• Clinical intervention is important and can help avoid unnecessary prescriptions.

• This study highlights the need for combined efforts to combat antimicrobial resistance by implementing targeted strategies to promote rational antibiotic prescribing which include continuous professional development, prescription auditing and the implementation of local antibiotic stewardship programmes.

• This study addresses the need for improved documentation practices by dentists and the importance of triage phase for dental patients.

1. Introduction

The World Health Organization (WHO) defines rational drug use as the use of medications in alignment with the clinical needs of the patient, prescribed in appropriate dosages for the correct duration and at the lowest cost to both the patient and society.¹ Despite this, antimicrobial resistance (AMR) has emerged as a significant global health concern, primarily driven by the inappropriate use of antibiotics.^2,3 In 2019, AMR was associated with an estimated 4.95 million deaths, including 1.27 million directly attributable to antibiotic-resistant infections.⁴ Without effective antibiotic stewardship, the WHO has warned that AMR-related deaths could increase to 10 million annually by 2050.⁵

Dentists are responsible for approximately 10% of all antibiotic prescriptions worldwide, with more than 2.9 million prescriptions issued annually in the USA alone.^6,7 A retrospective study from Croatia found that 48.8% of dental emergency visits resulted in antibiotic prescriptions.⁸ Similarly, in Germany, 11% of outpatient antibiotic prescriptions per year are issued by dentists, of which 80% are considered inappropriate, as local dental interventions are often sufficient.^9,10 The frequency of antibiotic prescriptions by dentists highlights the need to ensure that these healthcare practitioners follow rational and justified prescribing practices to ensure that antibiotics are prescribed only for appropriate clinical indications.

In the Gulf region, research from Saudi Arabia has revealed poor antibiotic prescribing patterns among dentists.¹¹ In Oman, a prior study conducted at the dental and maxillofacial surgery clinic of a tertiary hospital in Muscat Governorate, Oman, found that drug prescribing patterns were in line with international norms, with 5.2% of patients receiving antibiotics.¹² However, the authors did not assess the rationale for these prescriptions to determine their appropriateness.

Therefore, the present study aimed to determine the prevalence and predictors of inappropriate antibiotic prescriptions among dentists working in both government and private dental clinics in Muscat Governorate. At the time of data collection, Oman did not have an established national guideline governing antibiotic use in dental practice. This study provides baseline data on prescribing patterns before the introduction of a national guideline in 2025 and further research may be needed to assess the impact of the newly launched guideline on prescribing practices.

2. Methods

This retrospective, cross-sectional, observational study analysed antibiotic prescriptions issued by dentists between July and December 2024 at both government and private sector primary health centres in Muscat Governorate. Data were collected randomly from dental clinics in public primary health centres and various private clinics distributed across the governorate. Two researchers with similar dental backgrounds were assigned to collect data independently from both sectors. The data collection process took place between February and April 2025.

The required sample size was calculated using a single proportion formula, based on an expected rate of inappropriate antibiotic prescriptions of 27.8%, as reported in a previous study conducted in the Gulf region.¹¹ Assuming a 5% margin of error and a 95% confidence interval (CI), the minimum sample size was estimated to be 310 prescriptions. A total of 4 of the 6 wilayats (provinces) in the Muscat Governorate—Bawshar, Seeb, Amerat and Muttrah—were purposely selected due to their higher concentration of dental healthcare facilities. From these selected wilayats, and depending on the sample size needed, 1 health centre was included for each, along with 10 private dental clinics chosen randomly using a computerised number generator. Although the minimum required sample size was 310, additional dental prescriptions were analysed beyond this threshold to enhance the statistical power and robustness of the findings.

Relevant data concerning the antibiotic prescriptions were retrieved from the electronic patient records system. Collected information included data about both the prescribing dentists (i.e., gender, subspecialty and years of experience) as well as the patients for whom antibiotics were prescribed (i.e., relevant medical history, diagnosis and any evidence of systemic involvement, such as elevated temperature, diffuse swelling or lymphadenitis). Additionally, important prescription details were recorded, including the type of antibiotic prescribed, duration of treatment and whether the prescription was rational and justified. As per standard international guidelines, rational prescribing was defined as the use of antibiotics in cases with systemic involvement.^13,14,15

All data were analysed using the Statistical Package for the Social Sciences (SPSS) software, Version 26 (IBM Corp., Armonk, New York, USA). Descriptive statistics were used to summarise the characteristics of dentists, patients, prescriptions, and diagnoses. Categorical variables were expressed as frequencies and percentages. Associations between prescription appropriateness and independent variables were assessed using the Chi-square test of independence.

To identify predictors of inappropriate antibiotic prescriptions, a binary logistic regression analysis was performed. The model was refined by excluding variables with sparse or unstable values to improve its fit. Results were reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All statistical tests were two-tailed, with the level of statistical significance set at P <0.05.

3. Results

A total of 401 antibiotic prescriptions were analysed; 204 (50.9%) were issued by dentists in government sector clinics, while the remaining 197 (49.1%) were from private sector clinics. Most prescribing dentists were female (69.9%), had more than 10 years of clinical experience (84.5%) and were general dental practitioners (93.0%). The majority of patients for whom antibiotics were prescribed did not have chronic illnesses (76.3%). The most common diagnosis resulting in antibiotic prescriptions was pulpitis (28.4%), followed by periapical abscesses (20.7%) and pericoronitis (5.7%). In most cases, antibiotics were prescribed without any clinical intervention (67.8%). Among the remaining cases, interventions included simple extractions (11.5%), surgical extractions (3.7%) and root canal treatments (7.5%). Amoxicillin was the most frequently prescribed antibiotic, accounting for 56.6% of prescriptions, followed by amoxicillin/clavulanic acid (36.4%) and metronidazole (31.9%). Neither clindamycin nor ciprofloxacin were prescribed. Most prescriptions involved a single antibiotic, with the majority prescribed for 4–5 days (97.3%). Overall, only 30.7% of prescriptions were clinically justified, while 69.1% were deemed inappropriate based on international guidelines [Table 1].

Table 1.

Characteristics of antibiotic prescriptions issued by dentists in primary health centres in Muscat Governorate according to clinic sector (N = 401).

	Sector, n (%)
Characteristic	Government (n = 204)	Private (n = 197)	Total (N = 401)
Dentist characteristics
Gender
Male	26 (12.7)	96 (48.7)	122 (30.4)
Female	178 (87.3)	101 (51.3)	279 (69.6)
Nationality
Omani	203 (99.5)	15 (7.6)	218 (54.4)
Other	1 (0.5)	182 (92.4)	183 (45.6)
Subspecialty
General dental practitioner	203 (99.5)	170 (86.3)	373 (93.0)
Endodontist	0 (0)	5 (2.5)	5 (1.2)
Paedodontist	0 (0)	5 (2.5)	5 (2.5)
Periodontist	0 (0.0)	5 (2.5)	5 (1.2)
Prosthodontist	0 (0.0)	12 (6.1)	12 (3.0)
Other	1 (0.5)	0 (0.0)	1 (0.2)
Years of clinical experience
≤5	5 (2.5)	20 (10.2)	25 (6.2)
6–10	2 (1.0)	29 (14.7)	31 (7.7)
11–15	105 (51.5)	51 (25.9)	156 (38.9)
16–20	32 (15.7)	45 (22.8)	77 (19.2)
>20	54 (26.5)	52 (26.4)	106 (26.4)
Unknown	6 (2.9)	0 (0.0)	6 (1.5)
Patient characteristics
Medical history
Diabetes	23 (11.3)	10 (5.1)	33 (8.2)
HTN	21 (10.3)	8 (4.1)	29 (7.2)
Cardiovascular disease	5 (2.5)	1 (0.5)	6 (1.5)
Renal conditions	2 (1.0)	1 (0.5)	3 (0.7)
Diagnosis *
Pulpitis	66 (32.4)	48 (24.4)	114 (28.4)
Periapical abscess	41 (20.1)	42 (21.3)	83 (20.7)
Pericoronitis	7 (3.4)	16 (8.1)	23 (5.7)
Cellulitis	17 (8.3)	1 (0.5)	18 (4.5)
Moderate periodontitis	4 (2.0)	11 (5.6)	15 (3.7)
Periodontal abscess	7 (3.4)	6 (3.0)	13 (3.2)
Dry socket	3 (1.5)	3 (1.5)	6 (1.5)
Peri-implantitis	0 (0.0)	2 (1.0)	2 (0.5)
Other	56 (27.5)	57 (28.9)	111 (27.7)
Unknown	3 (1.5)	16 (8.1)	19 (4.7)
Systemic involvement
Yes	54 (26.5)	36 (28.3)	90 (22.4)
No	141 (69.1)	154 (78.2)	295 (73.6)
Unknown	9 (4.4)	7 (3.6)	16 (4.0)
Evidence of systemic involvement *
Elevated temperature	3 (1.5)	1 (0.5)	4 (1.0)
Diffuse swelling	58 (28.4)	40 (20.3)	98 (24.4)
Lymphadenitis	0 (0.0)	2 (1.0)	2 (0.5)
Clinical intervention
Simple extraction	9 (4.4)	37 (18.8)	46 (11.5)
Root canal	1 (0.5)	29 (14.7)	30 (7.5)
Surgical extraction	5 (2.5)	10 (5.1)	15 (3.7)
Other	15 (7.4)	23 (11.7)	38 (9.5)
None	174 (85.3)	98 (49.7)	272 (67.8)
Prescription
Type of antibiotic prescribed *
Amoxicillin	184 (90.2)	43 (21.8)	227 (56.6)
Amoxicillin/clavulanic acid	14 (6.9)	132 (67.0)	146 (36.4)
Ampicillin	1 (0.5)	0 (0.0)	1 (0.2)
Azithromycin	0 (0.0)	1 (0.5)	1 (0.2)
Cephalexin	1 (0.5)	0 (0.0)	1 (0.2)
Cephalosporin	0 (0.0)	2 (1.0)	2 (0.5)
Ciprofloxacin	0 (0.0)	0 (0.0)	0 (0.0)
Clindamycin	0 (0.0)	0 (0.0)	0 (0.0)
Erythromycin	1 (0.5)	0 (0.0)	1 (0.2)
Metronidazole	65 (31.9)	63 (32.0)	128 (31.9)
Other	1 (0.5)	2 (1.0)	3 (0.7)
Duration of treatment in days
≤3	2 (1.0)	8 (4.1)	10 (2.5)
4–5	202 (99.0)	188 (95.4)	390 (97.3)
6–7	0 (0.0)	1 (0.5)	1 (0.2)
Appropriateness of prescription †
Yes	66 (32.4)	57 (28.9)	123 (30.7)
No	138 (67.6)	140 (71.1)	278 (69.3)

HTN = hypertension.

^*Percentages for this variable may exceed 100% as some individuals may have been classified under multiple categories.

^†Rational prescribing was defined according to international guidelines as the use of antibiotics in cases with systemic involvement.^13–15

A significant association was found between prescription appropriateness and dentist experience (P <0.001). The presence of diffuse swelling as a sign of systemic involvement was also significantly associated with justified prescriptions (P <0.001). Other variables, including dentist subspecialty, diagnosis, elevated temperature, lymph node involvement and clinic sector, did not show significant associations with rational prescribing practices [Table 2].

Table 2.

Variables associated with prescription appropriateness among antibiotic prescriptions issued by dentists in primary health centres in Muscat Governorate (N = 401).

Variable	P value
Dentist experience	<0.001
Diffuse swelling	<0.001
Dentist subspecialty	0.073
Elevated temperature	0.155
Clinic sector	0.245

Logistic regression analysis was conducted to identify predictors of inappropriate antibiotic prescribing. In the adjusted model, dentist experience remained the only significant predictor of prescription appropriateness, with more experienced dentists being significantly less likely to prescribe antibiotics unjustifiably (aOR = 0.65, 95% CI: 0.54–0.79; P <0.001). Other factors, including dentist subspecialty, specific signs of systemic involvement and clinic sector, were not statistically significant predictors [Table 3].

Table 3.

Predictors of prescription appropriateness among antibiotic prescriptions issued by dentists in primary health centres in Muscat Governorate (N = 401).

Variable	Coefficient (β)	P value
Dentist experience	–0.428	<0.001
Diffuse swelling	–0.083	0.453
Dentist subspecialty	–1.652	0.156
Elevated temperature	–0.271	0.245
Clinic sector	–0.428	0.245

4. Discussion

This study aimed to assess the prevalence and predictors of inappropriate antibiotic prescriptions issued by dentists at primary health centres in Muscat Governorate. The main finding was that only 30.7% of prescriptions were clinically justified, while 69.1% were unjustified based on standard international criteria. Similar findings have been reported from the USA, where a recent study found that 82.5% of antibiotic prescriptions issued by dentists were not justified according to consensus-based recommendations, and 35.7% were not even supported by relevant clinical literature.¹⁶ In Saudi Arabia, another study reported that 27.8% of dental visits resulted in antibiotic prescriptions that were neither recommended nor clinically indicated.¹¹ A Spanish study found that up to half of the dentists assessed exhibited inappropriate antibiotic prescribing practices.¹⁷

Amoxicillin was the most commonly prescribed antibiotic by dentists in the present study, accounting for 56.6% of all prescriptions. This was followed by amoxicillin/clavulanic acid, which constituted 36.4% of prescriptions. This prescribing pattern mirrors findings from multiple international studies including those conducted in the USA, Croatia and Saudi Arabia, where amoxicillin similarly emerged as the antibiotic most frequently prescribed by dental practitioners.^8,11,18 The majority of prescriptions involved a single antibiotic and the average treatment duration fell within the commonly observed range of 4–5 days. However, it should be noted that current clinical guidelines increasingly recommend shorter courses of 2–3 days.¹⁹

In the current study, most patients who were prescribed antibiotics did not have significant chronic illnesses, were medically healthy and no significant association was observed between inappropriate prescribing and patient medical history. This finding contrasts with previous studies identifying comorbidities as a predictor of antibiotic misuse and may be a factor driving inappropriate antibiotic prescriptions in primary care, including dental settings.^10,20,21 This discrepancy may be due to the relatively low proportion of patients with comorbidities in the current sample, as 76.3% of patients were otherwise healthy. Additionally, although several diagnoses were frequently reported as resulting in antibiotic prescriptions, including pulpitis and periapical abscesses, no specific diagnosis was found to be significantly associated with prescription appropriateness, suggesting inconsistent reliance on diagnostic criteria and limited adherence to evidence-based guidelines. This finding suggests that dentists may not consistently rely on diagnostic categories when making antibiotic prescription decisions, possibly reflecting limited adherence to or knowledge of evidence-based guidelines.^22,23,24

While certain diagnoses, particularly those involving acute infections with systemic involvement, warrant antibiotic use, prior research shows that unjustified prescriptions occur across a broad range of diagnoses.^13,14,15,25 For instance, a retrospective study from Turkey found that antibiotics were frequently prescribed in unjustified clinical contexts, including for dental caries (16.2%) and even following routine dental examinations (20.7%).²⁶ Only 3.4% of antibiotic prescriptions were issued for what was deemed the sole clearly appropriate indication: cellulitis and oral abscesses, indicative of a spreading odontogenic infection with systemic involvement. In contrast, the remaining 96.6% of antibiotic prescriptions were considered irrational or based on uncertain indications.²⁶

According to established international guidelines, antibiotic prescriptions for dental patients are considered justified in the presence of systemic involvement, typically characterised by diffuse swelling, elevated temperature and lymphadenitis.^13,14,15 In the present study, a significant association was observed between the documented presence of diffuse swelling and justified antibiotic prescriptions, a finding consistent with previous research.^27,28 However, no significant associations were found for other signs of systemic involvement, such as elevated temperature or lymphadenitis. This may be due to the fact that only 1% of cases in which antibiotics were prescribed included documented elevated temperatures, while a mere 0.5% recorded lymphadenitis. These low documentation rates may reflect inadequate record-keeping practices among dentists, representing a potential limitation of the study.

Many dentists do not maintain comprehensive clinical records and neglect to conduct extraoral examinations for enlarged lymph nodes.²⁹ Even when such assessments are performed, the findings are not always recorded into the electronic medical records system.³⁰ Additionally, unlike patients visiting general physicians in primary care settings, dental patients at both public and private clinics typically do not undergo a triage process. Consequently, vital signs such as temperature are often not recorded prior to dental consultations. This lack of routine documentation may help explain the low frequency of noted fevers in patient records in the current study. Moreover, dentists do not always indicate whether swelling is diffuse or localised in nature. This omission complicates retrospective assessment of whether an antibiotic prescription was warranted, as localised swelling alone does not typically justify antibiotic treatment.³¹

In the present study, only 19 prescriptions were deemed justified in the absence of documented signs of systemic involvement. These cases involved surgical procedures performed on teeth with established infections, such as abscesses of odontogenic origin, or procedures marked by operative difficulties and tissue trauma. This finding aligns with clinical guidelines issued by the Singapore Academy of Medicine and College of Dental Surgeons, which allow for antibiotic use in selected at-risk situations involving established odontogenic infections.¹⁵ Similarly, a study from the USA reported that 20.1% of antibiotic prescriptions issued by dentists were intended as prophylaxis to prevent post-surgical complications.¹⁶

Dentists in the present study displayed inappropriate antibiotic prescribing practices regardless of clinic sector, with no significant difference in prescribing appropriateness between government and private dental settings. Although government sector dentists exhibited a slightly higher rate of justified prescriptions compared to their private sector counterparts, this difference was not statistically meaningful. This finding mirrors a study conducted in Spain, which similarly assessed antibiotic prescribing patterns across both government and private sector dental practices and found no association between sector type and inappropriate antibiotic prescriptions.¹⁷

Conversely, dentist experience was significantly associated with rational antibiotic prescribing (P < 0.001). This association was further supported by the logistic regression analysis, which showed that greater clinical experience was linked to lower odds of inappropriate antibiotic prescribing (aOR = 0.65; P <0.001). Similar results were reported in a study from Pakistan, where less experienced dentists, including house officers, were more likely to prescribe antibiotics inappropriately compared to their more experienced peers.²⁷ However, findings from the aforementioned Spanish study indicated an inverse trend, with inappropriate prescribing being more likely among dentists with over 30 years of experience (OR = 4.58, 95% CI: 1.80–12.48).¹⁷

In the current study, the highest number of justified prescriptions was observed among dentists with 11–15 years of experience (41.5%). Interestingly, while dentists with less than five years of experience had a higher percentage of justified prescriptions within their category (64.0%), their overall contribution to total justified cases was relatively minimal (6.2%). These findings suggest that mid-career dentists may be at an optimal stage of clinical practice, balancing their accumulated experience with greater adherence to evidence-based guidelines.

Other factors, such as dentist subspecialty, did not show a significant association with antibiotic prescription appropriateness in the current study. This finding is supported by a similar study conducted in the USA, which revealed that although different dental specialties reported varying antibiotic choices and treatment durations, there was no evidence that being a specialist resulted in more appropriate prescribing compared to generalists.³² Similarly, another study conducted in Kuwait also found no significant difference in antibiotic prescribing practices between general dentists and specialists.³³ In contrast, the Spanish study identified certain dental subspecialties as being associated with inappropriate prescribing, specifically prosthodontics compared to endodontics (OR = 2.65, 95% CI: 1.26–5.71).¹⁷ The reasons for this discrepancy may relate to differences in clinical training or patient profiles, although further investigation is warranted.

Similarly, clinical intervention was not significantly associated with unjustified prescription practices in the current study. However, it is concerning that 67.8% of patients were prescribed antibiotics without undergoing any dental intervention. A previous study from Pakistan reported a comparable rate, with 61.7% of antibiotics prescribed in the absence of operative treatment.²⁷ This trend raises concerns about prescription appropriateness, as it suggests that antibiotics may be used in place of definitive dental care, rather than as an adjunct. According to various international guidelines, including those from the American Dental Association, antibiotics should not be utilised as the first line of treatment for localised dental infections that can be managed through procedures such as drainage or extraction.^13,14 Overreliance on antibiotics in the absence of intervention may stem from a range of factors, including high patient volumes, limited appointment durations, dentist caution in managing complex or medically compromised cases and patient refusal of clinical intervention in favour of medication.¹⁰

This study has several limitations that should be acknowledged. First, it relied on retrospective data from patient records, which may have been incomplete, affecting the accuracy of antibiotic prescription justification. Second, the cross-sectional design only captures prescribing patterns at a specific point in time, limiting the ability to identify trends or causal relationships. Third, the findings are based solely on primary healthcare dental settings within Muscat Governorate, which may restrict generalisability. Finally, although the assessment of prescription justification used established international guidelines, these may not account for clinical nuances such as procedural complications (e.g., trauma during extractions) or patient-specific factors that influence a dentist's decision to prescribe antibiotics.

5. Conclusion

This study revealed a high rate of unjustified antibiotic prescriptions among dentists in Muscat Governorate, with only 30.7% adhering to established clinical criteria. The most frequently prescribed antibiotics were amoxicillin and amoxicillin-clavulanate, often issued without any accompanying clinical intervention. The only factor significantly associated with appropriate prescribing was the dentist's experience. In 2025, a national antibiotic prescribing guideline for dental care was introduced in Oman, aligning closely with international recommendations for antibiotic use. Future research is needed to evaluate the impact of this guideline on prescribing behaviour and to assess improvements in clinical practice over time. The findings of this research highlight the need for strengthened antibiotic stewardship in dental settings through targeted training, prescription audits and improved documentation.

Authors' Contribution

Wajiha Abdul Majeed Al-Lawati: Conceptualization, Methodology, Software, Formal analysis, Writing - Original Draft, Writing - Review & Editing. Manar AlSanaa Ali AlZeedi: Methodology, Software, Formal analysis, Data Curation, Writing - Review & Editing. Elham Mohammadi: Methodology, Formal analysis, Resources. Noora Alhosni: Supervision, Project administration.

Ethics Statement

Ethical approval for this study was obtained from the Regional Research and Ethical Committee of the Directorate General of Health Services, Ministry of Health (MH/DGHS/P&S/2/2024).

Generative AI Declaration

This manuscript was revised using Grammarly's AI tool and OpenAI's ChatGPT for grammar and clarity improvements only. All scientific content, analysis and conclusions were developed solely by the authors.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

No funding was received for this study.

Data Availability

Data are available upon reasonable request from the corresponding author.