Prescription Behaviors and Rational Drug Use Awareness Among Future Dentists: A Class‐Based Comparative Study

ABSTRACT

Objective

This study aimed to evaluate dental students' knowledge, attitudes, and behaviors regarding rational drug use (RDU), including antibiotics and analgesics, and to analyze how the educational process influences this awareness.

Materials and Methods

This cross‐sectional study included 408 dental students (170 third‐year, 132 fourth‐year, and 106 fifth‐year students). Data were collected using a structured questionnaire covering demographic characteristics, prescribing habits, patient education practices, drug selection criteria, and the influence of social insurance status. Statistical analyses were performed using IBM SPSS Statistics 22.0. Chi‐square test and Fisher–Freeman–Halton exact test were applied, with a significance level at p < 0.05.

Results

Among the participants, 82.4% reported explaining the disease to patients, though this decreased to 75.5% among fifth‐year students (p = 0.001). The evaluation of treatment outcomes dropped from 63.5% in third‐year to 35.8% in fifth‐year students. Willingness to confirm patient understanding and awareness of social insurance differences also declined in senior years. Notably, the influence of pharmaceutical representatives was minimal across all groups.

Conclusion

Although students' overall sensitivity to RDU appears to improve, their awareness of treatment costs and systematic patient education practices remains limited. It is recommended that pharmacoeconomics, ethical prescribing, and case‐based interactive training modules be integrated into the dental curriculum.

1. Introduction

Rational drug use (RDU) is a key public health priority that aims to ensure patients receive medications appropriate to their clinical needs, in the correct dose, for an adequate duration, and at the lowest possible cost. The World Health Organization (WHO) first defined this concept at the Nairobi Conference in 1985, emphasizing its role as a cornerstone of sustainable pharmaceutical management within global health systems [1]. However, according to WHO data, more than 50% of prescriptions worldwide are issued irrationally, leading to serious consequences such as antibiotic resistance, treatment failure, and increased healthcare expenditures [2].

A similar trend has been observed in countries with high overall medication consumption [3]. According to international reports, some countries rank among the highest in the use of various drug categories, including antibiotics. In response, national health authorities have implemented Rational Drug Use Action Plans, including policies such as banning over‐the‐counter antibiotic sales and launching public education campaigns aimed at promoting more responsible medication practices [4]. However, promoting RDU is not solely the responsibility of practicing clinicians. Medication‐related attitudes and behaviors begin to form during early training, making dental students' competencies a crucial reflection of current health education policies and future clinical practice.

Among practicing dentists, challenges in RDU extend beyond antibiotics to include analgesics and other commonly used agents. Authoritative guidelines recommend non‐opioid analgesics. International studies show that dentists account for roughly ∼10% of oral antibiotic prescriptions in primary care settings such as England and the United States [5, 6]. In addition, large U.S. cohorts report that the majority of antibiotic prophylaxis prescriptions before dental procedures over 80% are unnecessary or non‐guideline‐based [7]. Surveys also reveal variation in dentists’ analgesic prescribing. In our country, national data mirror these patterns, indicating gaps in both antibiotic and analgesic stewardship in routine dental care [8, 9]. In dental settings, antibiotics, analgesics, and topical agents are among the most frequently prescribed medications. Approximately 10% of all antibiotic prescriptions worldwide are issued by dentists, yet studies from countries such as the United States, the United Kingdom, and Australia indicate that 70%–90% of these prescriptions are either unnecessary or non‐guideline‐based [10]. As prescribing responsibilities continue to expand for dental professionals, RDU must be integrated as a core element of dental education. In a study, over 95% of dental students were reported to be aware of antibiotic resistance; however, clinical experience was found to significantly influence their prescribing decisions [11, 12].

Similar challenges have also been observed at the international level. Students’ pharmacological knowledge and their attitudes toward medication use play a significant role in shaping future prescribing behaviors. International studies have reported that dental students’ knowledge regarding medication use varies by academic year, with irrational prescribing attitudes tending to decrease as education progresses [13]. However, various studies have also indicated that students do not always possess sufficient knowledge about general medication use, and that there are notable differences in attitudes toward the prescribing process [14]. Furthermore, a lack of ethical awareness has been associated with inappropriate prescribing behaviors, highlighting the need for RDU education to extend beyond pharmacological content and include ethical, economic, and communication‐based components [15].

Given that prescribing habits developed during dental education often persist into professional practice, enhancing RDU training at the undergraduate level represents a strategic opportunity for long‐term improvement in clinical decision‐making. While pharmacological knowledge is essential, modern dental curricula must also foster competencies in communication, cost awareness, and ethical prescribing. In this context, the present study aims to assess the self‐reported knowledge, attitudes, and prescribing‐related tendencies of dental students across different academic years. The goal is to identify curricular areas that may benefit from targeted enhancement to support the development of responsible and patient‐centered prescribing practices.

2. Materials and Methods

This descriptive and cross‐sectional study was conducted in March 2025 at the Faculty of Dentistry of a public university. The target population consisted of third‐, fourth‐, and fifth‐year dental students. A total of 408 students participated, including 170 third‐year, 132 fourth‐year, and 106 fifth‐year students. In the context of dental education, the first to third‐years are classified as preclinical, primarily involving theoretical and laboratory‐based instruction, whereas the fourth and fifth years constitute clinical training, including hands‐on patient care. Third‐year (preclinical) students were deliberately included to assess the progression of knowledge, attitudes and self‐perceived behaviors regarding RDU across the entire undergraduate curriculum. Although they have not yet begun independent clinical practice, third‐year students receive formal courses in pharmacology, therapeutics, ethics and communication, participate in simulated clinical exercises, and observe patient care under supervision. Consequently, their responses to items such as “evaluating treatment outcomes” or “ensuring patient understanding” reflect perceived competencies developed through coursework and simulated or supervised activities rather than unsupervised practice. In our institution, all prescriptions in clinical training are issued under faculty supervision; students do not prescribe medications independently.

Participation was voluntary and conducted anonymously. The study protocol was approved by the relevant Institutional Review Board (Approval No: blinded). The study was carried out in accordance with the principles of the Declaration of Helsinki and relevant institutional ethical standards. Informed consent was obtained from all participants, and the confidentiality of all responses was strictly maintained.

Data were collected online via Google Forms using a structured questionnaire developed by the researchers. The questionnaire aimed to assess participants’ knowledge, attitudes, and behaviors regarding RDU, as well as the variables they considered during the anamnesis process. The questionnaire was developed by the research team based on World Health Organization recommendations on RDU, the National Ministry of Health Rational Drug Use Action Plan, and previously published surveys in dental and medical education. Its content validity was assessed by a panel of five experts in oral and maxillofacial radiology, pharmacology, and public health, who evaluated each item for relevance and clarity. A pilot test was conducted with 25 dental students not included in the main study to ensure comprehensibility and refine wording. Internal consistency of the attitudinal and behavioral items was evaluated using Cronbach's alpha, which demonstrated acceptable reliability (α = 0.82 for the full scale and 0.76–0.85 across subdomains). The survey remained open for 4 weeks, and reminder emails were sent to students to enhance participation. Students accessed the form via a link and completed it anonymously, with no personally identifiable information being collected. The questionnaire consisted of two main sections:

• Demographic Information: Gender and academic year.

• RDU Behaviors: This 14‐item section asked participants to respond with “yes,” “sometimes,” or “no” to a series of statements assessing their knowledge and prescribing and patient education practices. Items assessing “evaluation of treatment outcomes” referred to simulated or supervised educational activities (e.g., preclinical laboratory tasks, case‐based exercises, OSCE‐style stations, and supervised clinical observations) rather than unsupervised clinical practice. Thus, responses from preclinical students reflect self‐perceived competencies developed during training.

Before starting the questionnaire, students were presented with an introductory explanation outlining the general aim of the study, which was to assess their prescribing behaviors and awareness of RDU. The questions were not limited to any specific drug category, such as antibiotics, and participants were not directed to focus on particular medication types. The survey invitation was distributed via institutional communication channels (class group emails and announcements), and participation was entirely voluntary and anonymous. No incentives or academic advantages were provided, and students were clearly informed that their responses would have no effect on their academic standing. The total number of eligible third‐, fourth‐, and fifth‐year students during the 2024–2025 academic year was approximately 470. With 408 valid responses collected, the estimated response rate was 86.8%. Because the survey was anonymous and did not collect personal identifiers, no demographic data were available for non‐respondents, and thus no comparison could be made between respondents and non‐respondents.

All statistical analyses were conducted using IBM SPSS Statistics version 22.0. Demographic variables and responses to questionnaire items were summarized using frequency and percentage distributions. The chi‐square test was employed to examine associations between categorical variables such as academic year and gender, and the questionnaire responses. In cases where expected cell frequencies were low, the Fisher–Freeman–Halton exact test was applied. A p value of < 0.05 was considered statistically significant.

Prior to data collection, an a priori power analysis was performed using G*Power software (version 3.1) to determine the adequacy of the sample size. Based on 2 degrees of freedom, a medium effect size (Cohen's w = 0.30), an alpha level of 0.05, and a power of 0.95, the minimum required sample size was calculated as 172. The actual sample of 408 participants substantially exceeded this threshold, indicating sufficient statistical power for the analyses.

3. Results

A total of 408 dental students participated in the study, including 206 males (50.5%) and 202 females (49.5%). Participants ranged in age from 19 to 26 years, with a mean age of 21.29 ± 1.39 years. Of the respondents, 170 (41.7%) were third‐year students, 132 (32.4%) were fourth‐year students, and 106 (26.0%) were fifth‐year students. Among the participants, 82.4% stated that they always explain the disease and its underlying causes to patients, while 16.7% reported doing so sometimes, and 1.0% indicated that they never do. Similarly, 85.0% reported that they explain the rationale behind the treatment, whereas 12.7% did so sometimes and 2.2% did not. In response to the question “Do you prescribe medication without a physical examination?,” 92.2% answered “no,” while only 0.7% said “yes” and 7.1% answered “sometimes.” However, when asked whether they prescribe medications specifically requested by the patient, 57.8% responded “sometimes,” 3.2% “yes,” and 39.0% “no.” Regarding information provision, 75.0% of students reported that they inform patients about the medications they prescribe; 21.6% do so sometimes, and 3.4% never do. However, when asked whether patients understand the treatment‐related information provided, only 28.4% answered “yes,” while 68.6% said “sometimes,” and 2.9% responded “no.” In response to the question “Do you utilize all possible means to ensure patient understanding?,” 54.7% answered “yes,” 40.7% “sometimes,” and 4.7% “no.” When asked “Do you ask patients to repeat the information you provided?,” 31.1% responded “yes,” 47.8% “sometimes,” and 21.1% “no.” Regarding the recommendation of non‐pharmacological treatments, 58.8% stated “sometimes,” 23.5% “yes,” and 17.6% “no.” When asked whether they evaluate treatment outcomes, 51.5% answered “yes,” 39.0% “sometimes,” and 9.6% “no.” However, only 8.3% of students reported being aware of the prices of the medications they prescribe. Regarding differences in drug selection based on patients' insurance status, 18.4% responded “yes,” 42.4% “sometimes,” and 39.2% “no.” To the question “Are you influenced by pharmaceutical sales representatives?”, only 7.1% responded “yes,” 37.3% “sometimes,” and 55.6% “no.” When asked whether other physicians are influenced by such representatives, 67.2% answered “sometimes,” 15.4% “yes,” and 17.4% “no” (see Figure 1).

FIGURE 1.

Distribution of responses to questions on rational drug use.

A statistically significant difference was found between academic years for the item “explaining the disease to the patient” (p = 0.001); the “yes” response rate was 90.0% among third‐year students, 78.0% in fourth‐year students, and 75.5% in fifth‐year students. A significant difference was also observed in the item “prescribing medication without examination” (p = 0.041), with the highest rate of “no” responses in fourth‐year students (97.0%). The frequency of “no” responses to the question “Do you ask the patient to repeat the treatment information?” increased with academic year (p = 0.024). The highest rate of recommending non‐pharmacological treatments was observed in fifth‐year students (p = 0.001).

The frequency of evaluating treatment outcomes decreased with academic year, from 63.5% in third‐year students to 35.8% in fifth‐year students (p = 0.001). The proportion of students who reported being aware of drug prices was inversely related to academic year: 15.3% in third‐year students and only 0.9% in fifth‐year students (p = 0.001). Awareness of differences in drug selection based on patients' insurance status was highest in third‐year students (27.6%) and lowest in fifth‐year students (9.4%) (p = 0.001). The perception of being influenced by pharmaceutical representatives was also more prevalent among third‐year students (p = 0.001). No statistically significant differences were found in the remaining items (see Table 1).

TABLE 1.

Comparison of responses to rational drug use questions by academic year.

		Third‐year n (%)	Fourth‐year n (%)	Fifth‐year n (%)	p
Do you explain the patient's condition and its underlying causes to them?	Yes	153 (90%)	103 (78%)	80 (75.5%)	0.001 *
	Sometimes	17 (10%)	29 (22%)	22 (20.8%)
	No	0 (0%)	0 (0%)	4 (3.8%)
Do you inform the patient about the reasons for the proposed treatment?	Yes	146 (85.9%)	114 (86.4%)	87 (82.1%)	0.074
	Sometimes	21 (12.4%)	18 (13.6%)	13 (12.3%)
	No	3 (1.8%)	0 (0%)	6 (5.7%)
Do you prescribe medication without examining the patient?	Yes	1 (0.6%)	0 (0%)	2 (1.9%)	0.041 *
	Sometimes	14 (8.2%)	4 (3%)	11 (10.4%)
	No	155 (91.2%)	128 (97%)	93 (87.7%)
Do you prescribe medications that are specifically requested by patients?	Yes	5 (2.9%)	3 (2.3%)	5 (4.7%)	0.738
	Sometimes	95 (55.9%)	81 (61.4%)	60 (56.6%)
	No	70 (41.2%)	48 (36.4%)	41 (38.7%)
Do you provide information to the patient about the medications you prescribe?	Yes	137 (80.6%)	97 (73.5%)	72 (67.9%)	0.117
	Sometimes	28 (16.5%)	32 (24.2%)	28 (26.4%)
	No	5 (2.9%)	3 (2.3%)	6 (5.7%)
Do your patients understand the information you provide about their treatment??	Yes	44 (25.9%)	35 (26.5%)	37 (34.9%)	0.067
	Sometimes	121 (71.2%)	96 (72.7%)	63 (59.4%)
	No	5 (2.9%)	1 (0.8%)	6 (5.7%)
Do you use all available means to ensure that the patient understands the information related to their treatment?	Yes	97 (57.1%)	69 (52.3%)	57 (53.8%)	0.901 a
	Sometimes	65 (38.2%)	56 (42.4%)	45 (42.5%)
	No	8 (4.7%)	7 (5.3%)	4 (3.8%)
Do you ask the patient to repeat the information you have provided?	Yes	62 (36.5%)	35 (26.5%)	30 (28.3%)	0.024 a , *
	Sometimes	84 (49.4%)	66 (50%)	45 (42.5%)
	No	24 (14.1%)	31 (23.5%)	31 (29.2%)
Do you recommend non‐pharmacological treatment options to your patients?	Yes	33 (19.4%)	23 (17.4%)	40 (37.7%)	0.001 a , *
	Sometimes	110 (64.7%)	79 (59.8%)	51 (48.1%)
	No	27 (15.9%)	30 (22.7%)	15 (14.2%)
Are you able to evaluate the outcomes of your treatment?	Yes	108 (63.5%)	64 (48.5%)	38 (35.8%)	0.001 a , *
	Sometimes	53 (31.2%)	59 (44.7%)	47 (44.3%)
	No	9 (5.3%)	9 (6.8%)	21 (19.8%)
Are you aware of the prices of the medications you prescribe?	Yes	26 (15.3%)	7 (5.3%)	1 (0.9%)	0.001 a , *
	Sometimes	93 (54.7%)	41 (31.1%)	20 (18.9%)
	No	51 (30%)	84 (63.6%)	85 (80.2%)
Does your choice of medications differ between patients with and without social insurance?	Yes	47 (27.6%)	18 (13.6%)	10 (9.4%)	0.001 a , *
	Sometimes	88 (51.8%)	57 (43.2%)	28 (26.4%)
	No	35 (20.6%)	57 (43.2%)	68 (64.2%)
Are you influenced by pharmaceutical representatives' presentations when selecting medications?	Yes	17 (10%)	6 (4.5%)	6 (5.7%)	0.001 a , *
	Sometimes	83 (48.8%)	42 (31.8%)	27 (25.5%)
	No	70 (41.2%)	84 (63.6%)	73 (68.9%)
Are other physicians influenced by pharmaceutical representatives' presentations when selecting medications?	Yes	28 (16.5%)	18 (13.6%)	17 (16%)	0.306 a
	Sometimes	118 (69.4%)	92 (69.7%)	64 (60.4%)
	No	24 (14.1%)	22 (16.7%)	25 (23.6%)

Note: For preclinical (third‐year) students, ‘evaluation of treatment outcomes’ indicates perceived ability within simulated/supervised tasks (preclinical labs, case‐based/OSCE activities, supervised observations), not independent clinical care. Fisher–Freeman–Halton Exact Test.

^a Chi‐square test.

^* p < 0.05.

A statistically significant gender‐based difference was observed only in the behavior of prescribing medications upon patient request (p = 0.012); 64.1% of male students responded “sometimes,” compared to 51.5% of female students. No significant gender differences were found in any of the other items (see Table 2).

TABLE 2.

Comparison of responses to rational drug use questions by gender.

		Male n (%)	Female n (%)	p
Do you explain the patient's condition and its underlying causes to them?	Yes	168 (81.6%)	168 (83.2%)	0.730
	Sometimes	35 (17%)	33 (16.3%)
	No	3 (1.5%)	1 (0.5%)
Do you inform the patient about the reasons for the proposed treatment?	Yes	174 (84.5%)	173 (85.6%)	0.942
	Sometimes	27 (13.1%)	25 (12.4%)
	No	5 (2.4%)	4 (2%)
Do you prescribe medication without examining the patient?	Yes	0 (0%)	3 (1.5%)	0.217
	Sometimes	13 (6.3%)	16 (7.9%)
	No	193 (93.7%)	183 (90.6%)
Do you prescribe medications that are specifically requested by patients?	Yes	3 (1.5%)	10 (5%)	0.012 a , *
	Sometimes	132 (64.1%)	104 (51.5%)
	No	71 (34.5%)	88 (43.6%)
Do you provide information to the patient about the medications you prescribe?	Yes	156 (75.7%)	150 (74.3%)	0.080 a
	Sometimes	47 (22.8%)	41 (20.3%)
	No	3 (1.5%)	11 (5.4%)
Do your patients understand the information you provide about their treatment?	Yes	57 (27.7%)	59 (29.2%)	0.940 a
	Sometimes	143 (69.4%)	137 (67.8%)
	No	6 (2.9%)	6 (3%)
Do you use all available means to ensure that the patient understands the information related to their treatment?	Yes	110 (53.4%)	113 (55.9%)	0.055 a
	Sometimes	91 (44.2%)	75 (37.1%)
	No	5 (2.4%)	14 (6.9%)
Do you ask the patient to repeat the information you have provided?	Yes	53 (25.7%)	74 (36.6%)	0.058 a
	Sometimes	107 (51.9%)	88 (43.6%)
	No	46 (22.3%)	40 (19.8%)
Do you recommend non‐pharmacological treatment options to your patients?	Yes	42 (20.4%)	54 (26.7%)	0.223 a
	Sometimes	123 (59.7%)	117 (57.9%)
	No	41 (19.9%)	31 (15.3%)
Are you able to evaluate the outcomes of your treatment?	Yes	99 (48.1%)	111 (55%)	0.220 a
	Sometimes	83 (40.3%)	76 (37.6%)
	No	24 (11.7%)	15 (7.4%)
Are you aware of the prices of the medications you prescribe?	Yes	13 (6.3%)	21 (10.4%)	0.249 a
	Sometimes	83 (40.3%)	71 (35.1%)
	No	110 (53.4%)	110 (54.5%)
Does your choice of medications differ between patients with and without social insurance?	Yes	37 (18%)	38 (18.8%)	0.868 a
	Sometimes	90 (43.7%)	83 (41.1%)
	No	79 (38.3%)	81 (40.1%)
Are you influenced by pharmaceutical representatives' presentations when selecting medications?	Yes	15 (7.3%)	14 (6.9%)	0.769 a
	Sometimes	80 (38.8%)	72 (35.6%)
	No	111 (53.9%)	116 (57.4%)
Are other physicians influenced by pharmaceutical representatives' presentations when selecting medications?	Yes	33 (16%)	30 (14.9%)	0.943 a
	Sometimes	137 (66.5%)	137 (67.8%)
	No	36 (17.5%)	35 (17.3%)

Note: Fisher–Freeman–Halton Exact Test.

^a Chi‐square test.

^* p < 0.05.

Among male students, the rate of explaining the disease to patients was 91.4% in the third‐year and 74.5% in the fifth‐year (p = 0.004). The highest frequency of recommending non‐pharmacological treatments was observed among fifth‐year male students (32.7%) (p = 0.048). The rate of evaluating treatment outcomes was 58.0% in the third‐year and 30.9% in the fifth‐year (p = 0.009). Knowledge of medication prices was significantly higher among third‐year males (p = 0.001). The rate of prescribing changes based on social insurance status was 25.9% in third‐year males (p = 0.001). In addition, 51.9% of third‐year male students reported that they were “sometimes” influenced by pharmaceutical representatives (p = 0.031). No significant differences were found in the other items (see Figure 2).

FIGURE 2.

Comparison of affirmative responses to rational drug use questions across academic years and genders.

Among female students, the highest rate of recommending non‐pharmacological treatments was observed in the fifth‐year (43.1%) (p = 0.043). The frequency of evaluating treatment outcomes declined with academic year, from 68.5% in third‐year students to 41.2% in fifth‐year students (p = 0.001). Awareness of medication prices was reported by 15.7% of third‐year female students, compared to only 2.0% in fifth‐year students (p = 0.001). Similarly, 29.2% of third‐year students acknowledged adjusting prescriptions based on patients' social insurance status, while this rate dropped to 11.8% in the fifth‐year (p = 0.001). No other statistically significant differences were observed (see Figure 2).

4. Discussion

RDU is a fundamental public health strategy universally recommended by the WHO, as it yields critical outcomes such as improving treatment effectiveness, reducing adverse drug events, and controlling healthcare expenditures. Considering prescribing habits formed during dental school often persist into professional practice, dental students’ competencies in RDU are crucial for both individual clinical effectiveness and broader public health outcomes. Dental students competencies in RDU are crucial for both individual clinical effectiveness and broader public health outcomes. Although theoretical knowledge is generally high, gaps in patient communication and behavior persist.

In a study conducted by Yurtsever et al. involving fourth‐year dental students, it was observed that participants had a solid understanding of the principles of RDU [12]. However, despite this positive finding, only one‐quarter of the students reported that patients always understood the information provided to them, while nearly 70% stated that patients understood it only “sometimes.” This communication gap is concerning, as effective patient education is a cornerstone of rational prescribing. In the same study, approximately one‐fifth of the students expressed uncertainty about informing patients of potential drug interactions and side effects [12]. Similarly, our findings revealed that although students demonstrated a strong theoretical understanding of RDU and patient‐centered communication, significant deficiencies persisted in practical application and awareness. While more than 80% of participants stated that they always explained the illness and treatment rationale to patients, the overall findings suggest that topics such as risk communication and confirmation of patient understanding should be more strongly emphasized during the educational process.

Even among students who are theoretically familiar with the concept of RDU, inconsistencies between knowledge, attitude, and behavior are common. Although many studies report high rates of students claiming to always explain the rationale for treatment, discrepancies in knowledge and attitude levels remain evident. In a study conducted by Guzmán‐Álvarez et al., only 30% of students were able to determine appropriate drug doses and durations in accordance with WHO prescribing guidelines, while 74% demonstrated deficiencies in posology knowledge [14]. Similarly, a study by Ekici et al. found that among practicing dentists, the most insufficient areas were awareness of drug prices, bioequivalence, and adverse effects [16]. Consistent with these findings, our study also revealed a gap between high theoretical knowledge and its application in practice. Approximately 20% of students expressed uncertainty about whether they inform patients of drug interactions and side effects. This represents a clear example of how access to knowledge does not always translate into behavior. Although our questionnaire provided a broad evaluation of students’ general RDU‐related attitudes and behaviors, it did not include dedicated items on antibiotics, antibiotic resistance, or opioid prescribing. Given the critical importance of these drug categories in dentistry, future research should incorporate more detailed instruments focusing specifically on these areas to generate deeper insights. Collectively, these findings underscore the need for RDU education to go beyond information delivery and instead integrate training in professional ethics and clinical decision‐making skills.

Striking differences were observed based on academic year, particularly between preclinical (third‐year) and clinical (fifth‐year) students in terms of RDU behaviors. In a multicenter study conducted by Schneider et al. across four dental schools, the mean likelihood score of prescribing common therapeutic agents in unnecessary situations was 2.6 ± 0.5 among first‐ and second‐year students, and 2.8 ± 0.5 among third‐ and fourth‐year students (on a scale where 1 = “never” and 5 = “always”). [17] Similarly, our study revealed notable trends across academic levels. In several key areas, third‐year (preclinical) students demonstrated more ideal RDU behaviors than fifth‐year (clinical) students. For instance, while 90% of third‐year students reported that they explain the patient's condition, this rate dropped to approximately 75% among fifth‐year students. Likewise, the proportion of students who stated they evaluate treatment outcomes and are aware of medication costs was higher in the third‐year. These findings suggest that students who have recently received theoretical instruction may adhere more strictly to RDU principles. In addition, when asked whether they adjust prescriptions based on a patient's social insurance status, 27.6% of third‐year students responded “yes,” compared to only 9.4% of fifth‐year students (p < 0.001).

Although clinical experience is generally expected to reinforce positive behaviors, our findings indicate the opposite. Several factors may contribute to this outcome. During clinical years, students often face time constraints, increased patient loads, and intensive practical coursework, which may lead to the deprioritization of RDU principles. In addition, insufficient emphasis on these concepts within the curriculum over time may diminish their impact. This underscores the necessity of integrating RDU principles longitudinally throughout the dental education curriculum. A recent study demonstrated that a prescription‐writing training module specifically designed for dental students' significantly improved clinical competence in this area [18]. To sustain awareness of RDU principles during the clinical phase, approaches such as case‐based discussions, scenario‐based learning sessions, and regular application of current clinical guidelines should be implemented.

Effective communication with patients is a cornerstone of rational prescribing. In a study conducted by Maybury et al. involving 235 students, 87.7% reported that they had been taught the technique of asking patients to repeat information back to them, and 67.7% stated that they intended to apply this technique in clinical practice [19]. In a separate study with 242 students, the same authors found that 96.7% were familiar with the “teach‐back” method, while 74% indicated that they consistently used all available strategies to support patient understanding [20]. However, a study by Rozier et al. involving 2603 practicing dentists revealed that fewer than 25% consistently used patient verification techniques [21]. In our study, although the majority of students reported positive attitudes toward explaining treatment to patients, continuity in communication and verification of understanding appeared limited. Only 31.1% of students stated that they ensured patient comprehension by asking them to repeat the information. Moreover, just 54.7% reported always utilizing all available means to facilitate adherence and understanding. These findings indicate that patient education and the feedback loop are not fully established. The literature has emphasized that effective patient education is critical for RDU [22]. Our findings support these concerns. These communication strategies apply to all medication types and are vital for achieving therapeutic success, regardless of the drug class. Therefore, it is recommended that educational programs place greater emphasis on strategies to confirm patient understanding, such as the teach‐back method and comprehension checks through questioning. Strong patient communication not only promotes satisfaction but also enables adherence to rational prescribing principles, even in the face of inappropriate requests.

Another important finding relates to the dilemmas students face in their prescribing behaviors, particularly the tension between patient demands and the pressures of clinical practice. In a study conducted by Tercanlı et al. involving 388 students, only 2.3% believed that antibiotics should always be prescribed for patients presenting with dental pain, while 15.2% were uncertain, resulting in a total of 17.5% potentially open to irrational prescribing practices [11]. Similarly, in the study by Yurtsever et al., approximately 5% of students expressed uncertainty regarding prescribing medication without conducting a physical examination [12]. More strikingly, 58% of students in our study reported that they “sometimes” prescribe medications specifically requested by patients, and 28.6% in previous research expressed indecision on this matter [12]. In our study, only 1% of participants stated that they would prescribe medication without examining the patient, and 92% clearly opposed this practice. However, 7% gave an indecisive response of “sometimes.” Gender‐based analysis further revealed that female students were more inclined than males to respond positively to patient requests: 5.0% of females versus 1.5% of males answered “yes” to prescribing medications upon patient request (p = 0.012). Such social trends should be taken into account when designing ethics curricula on prescribing practices. These findings suggest that despite receiving appropriate training, students may compromise rational prescribing principles under the pressure of maintaining patient satisfaction. These gender‐based differences may be influenced not only by individual traits or training exposure, but also by broader sociocultural expectations and role perceptions. In the context of dental education and broader societal factors, attitudes toward patient interaction, decision‐making, and communication may differ by gender and merit further qualitative investigation. While shared decision‐making is important, yielding to inappropriate medication demands directly undermines the tenets of RDU. Reinforcing ethical decision‐making through teamwork and interprofessional education can help address this issue. Notably, interprofessional modules have been shown to significantly improve RDU, including but not limited to antibiotic stewardship, highlighting the benefit of structured repetition in dental education [23].

The WHO defines RDU as therapy that meets the patient's clinical needs at the lowest cost, administered in the correct dose, for an appropriate duration, and via the proper route supported by its six‐step prescribing model [24]. A lack of awareness regarding drug pricing directly contradicts the WHO's emphasis on cost‐effectiveness. Although often overlooked, cost awareness is a fundamental component of rational prescribing. Hammad et al. reported, only 65% of health sciences students had even heard of the term “pharmacoeconomics” [25]. Similarly, in the study by Yurtsever et al., approximately one‐third of students indicated that they either did not consider cost in their prescribing decisions or were uncertain whether they should [26]. In line with these findings, our study revealed that only 8% of students were aware of the prices of the medications they prescribed, while 53% stated they had no information on this matter. When asked whether they made different prescribing choices based on whether patients had social insurance, only 18% responded “yes.” At first glance, this may appear to reflect a commitment to providing equal treatment for all patients. However, when considered alongside the widespread lack of price awareness, it likely reflects a tendency to overlook the patient's financial burden. When analyzed by academic year, third‐year students demonstrated greater sensitivity to drug pricing, whereas nearly all fifth‐year students lacked this knowledge. This decline may be attributed to insufficient coverage of pharmacoeconomics during clinical training. Nevertheless, the WHO's definition of RDU explicitly emphasizes achieving treatment goals at the lowest possible cost [2]. Within this framework, practical activities such as researching drug prices and comparing generic alternatives in clinical training sessions may help foster greater cost‐awareness among students.

The influence of the pharmaceutical industry is a significant factor shaping students’ attitudes and behaviors. International studies have shown that increased exposure to pharmaceutical marketing weakens critical perspectives [26]. In a study conducted by Haaj et al., it was reported that dentists often relied on information provided by pharmaceutical representatives rather than independent sources, leading to irrational and high‐cost prescribing patterns [27]. Similarly, a study by Saito et al. found that the acceptance of promotional items from pharmaceutical companies increased significantly after students entered the clinical phase, with 72% of clinical students considering such promotional gifts acceptable [28]. In a multicenter study, Sierles et al. reported that 89% of clinical dental students had accepted at least one piece of promotional material such as brochures or similar items, and they recommended strengthening the ethical dimension of industry influence within medical curricula [29]. The low level of awareness observed in our study reflects a similar educational gap. Fifth‐year students appeared to adopt a more critical stance regarding interactions with pharmaceutical representatives; 69% of them reported not being influenced by such representatives, compared to only 41% of third‐year students. Undergraduate dental students do not formally engage with pharmaceutical representatives as part of the curriculum in the country where the study was conducted. However, during clinical rotations, it is common for students to indirectly encounter representatives while they are visiting faculty members. These informal and observational exposures may influence students’ perceptions, particularly in the absence of structured education on pharmaceutical ethics and critical evaluation. This may suggest that clinical experience enhances critical thinking skills and makes students more cautious toward industry marketing tactics. However, it is noteworthy that approximately one‐third of students nearing graduation still reported being occasionally influenced by pharmaceutical representatives. These findings indicate the need for a more structured approach in educating students on the ethical implications of pharmaceutical promotions and guiding them toward independent, evidence‐based sources of information.

Regarding commonly prescribed drug categories including antibiotics, analgesics, and topical agents the findings present a generally positive outlook. In a study conducted by Tercanlı et al. involving dental students, 95.1% of students acknowledged that unnecessary medication use could lead to negative health outcomes, and 82% opposed the automatic prescription of drugs for every dental pain [11]. Similarly, in our study, the majority of students reported prescribing medications only when clinically justified. These results suggest that dental students demonstrate relatively high awareness of rational prescribing principles. However, the same study revealed that 22% of students believed medications could be used for conditions such as the common cold, and 8% admitted to initiating medication use without consulting a physician [11]. This highlights the role of both knowledge gaps and persistent misconceptions. Likewise, in the study by Yurtsever et al., 20% of students expressed uncertainty about whether they should inform patients about potential drug interactions [12]. These findings collectively indicate that being a future healthcare professional does not inherently protect one from the risks of irrational drug use.

When compared with the international literature, similar challenges are evident in other countries as well. For example, a study by Mazinska et al. reported that physicians exhibited suboptimal attitudes in the processes of prescribing and overall medication use, while Terzić et al. found that half of nursing students had never heard the term “antibiotic resistance” [30, 31]. These findings suggest that dental students in similar contexts or countries with comparable curricula may have relatively greater awareness in this area. Nonetheless, similar patterns have been observed elsewhere. In a study by Doshi et al. conducted, students were knowledgeable about antibiotic indications but showed deficiencies in analgesic prescribing and dose adjustment [32]. Shankar et al., in their study, noted that while educational interventions using the WHO “Guide to Good Prescribing” improved students’ competency in rational pharmacotherapy decision‐making, confusion persisted regarding cost‐based and patient‐specific drug selection [33]. In the United States and Canada, the fact that dentists are responsible for approximately 10% of all prescriptions has led to the integration of mandatory RDU training modules into dental curricula [34, 35]. Likewise, Guzmán‐Álvarez et al. reported that only 30% of students could correctly determine dosage and duration in accordance with WHO guidelines, and 74% had insufficient knowledge of posology [14]. This reflects a critical issue: access to information does not necessarily translate into behavioral change. In our study, although students exhibited strong theoretical knowledge across a variety of medication types, they demonstrated weaknesses in translating this knowledge into behavior especially in areas such as patient education, drug cost awareness, and resistance to inappropriate prescribing demands. These discrepancies highlight the need for educational programs that go beyond knowledge transmission and instead focus on building communication and decision‐making skills.

4.1. Limitations

This study has several limitations. Due to its cross‐sectional design, it cannot predict how students will behave as clinicians in the future or how their attitudes may evolve over time. Longitudinal studies tracking post‐graduation prescribing behavior would provide more in‐depth insights. In addition, since all data were based on self‐report, the potential for social desirability bias (e.g., idealized responses such as “I always inform my patients”) cannot be entirely excluded. While the anonymity of the survey aimed to mitigate this bias, it may not have fully eliminated it.

Another limitation is that, although the sample size was adequate, the study was conducted at a single institution. It is possible that different faculties may employ alternative educational approaches. However, the presence of similar trends in other studies conducted in Turkey suggests that these findings are not unique to this institution.

Moreover, because third‐year (preclinical) students have not yet begun independent clinical practice, their responses reflect self‐perceived competence and training in simulated or supervised settings rather than actual unsupervised patient care. Accordingly, comparability of the “evaluation of treatment outcomes” item between preclinical and clinical cohorts is limited, as preclinical responses indicate perceived competence in simulated/supervised tasks rather than independent clinical outcomes.

A further limitation is that, although the questionnaire covered a broad range of RDU behaviors, it did not include detailed sections on antibiotics and antibiotic resistance, opioid prescribing, or topical agents. Future research with more elaborate instruments focusing on these drug groups is warranted.

Finally, while the study included a self‐reported item on the influence of pharmaceutical representatives, it did not explore the frequency, context, or institutional policies surrounding such interactions in depth. Given that these dynamics may vary significantly across countries and institutions, this may limit the generalizability of findings related to industry influence.

4.2. Conclusions and Recommendations

This study demonstrates that dental students possess a strong theoretical foundation regarding the principles of RDU; however, this knowledge is not consistently translated into clinical practice. Areas such as drug cost awareness, resistance to patient‐driven prescribing, and critical evaluation of pharmaceutical promotions require greater emphasis in dental education. The differences observed across academic years indicate a decline in the impact of pharmacology training as students approach graduation, highlighting the importance of ongoing reinforcement throughout the curriculum.

As these students transition into practicing dentists, their prescribing habits will have direct implications for public health, antibiotic resistance, and healthcare expenditures. Overall, RDU awareness among dental students requires reinforcement across all commonly prescribed medications, including antibiotics, analgesics, and other therapeutics. Therefore, adopting an innovative and integrative approach to RDU in dental education is essential to enhance both professional quality and societal well‐being.

In addition to traditional theoretical instruction, our findings support the use of interactive, experiential methods such as case‐based OSCEs, clinical simulations, scenario‐based discussions, and targeted workshops to improve behavioral competence. Furthermore, the integration of modules on pharmacoeconomics and prescribing ethics into the curriculum may enhance student awareness. Such an approach can support students in applying RDU principles effectively across all commonly prescribed medications, while upholding patient‐centered communication and ethical standards.

Funding

This research was supported by the Scientific and Technological Research Council of Türkiye (TÜBİTAK) under the 2209‐A – Research Project Support Programme for Undergraduate Students.

Disclosure

This study was presented as an oral presentation at the 1st Fırat Dentistry Congress held in Elazığ on April 12–13, 2025. This manuscript has not been published previously, is not under consideration elsewhere, and represents original work that has not been submitted in substantially similar form. All authors accept full responsibility for the integrity of the study, attest to compliance with ICJME and COPE guidelines, and confirm that no plagiarism has occurred. Conflict‐of‐interest disclosure forms have been completed for every author and are submitted herewith.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon request. The data were not publicly available because they contained information that could compromise the privacy of the participants.