From prescription to resistance: integrating one health perspectives into dental antibiotic stewardship in Saudi Arabia.

Background: Antimicrobial resistance (AMR) is an escalating global threat, and dentists significantly contribute to antibiotic misuse. In Saudi Arabia, limited national data exist on the appropriateness of dental antibiotic prescribing and the impact of behavioral and One Health factors from prescribing practices. Objectives: This study aimed to assess the prescribing practices of dentists across Saudi Arabia, identify predictors of adherence to antibiotic prescribing guidelines, and explore awareness of emerging AMR drivers such as climate and diet. Methods: A national cross-sectional survey was conducted among 905 practicing dentists. The structured questionnaire assessed knowledge, prescribing behaviors, and awareness of antimicrobial resistance, prophylactic use, and One Health factors (climate and diet). Good prescribing practice was defined as correctly answering ≥60% of clinical scenarios. Prescribing appropriateness was evaluated according to established international evidence-based clinical practice guidelines, including recommendations from the American Dental Association (ADA), the American Heart Association (AHA), and the European Federation of Periodontology (EFP), as cited in the manuscript. Descriptive statistics and logistic regression analyses were used to identify predictors of appropriate prescribing. Results: The results show that only 39.6% adhered to guideline-supported antibiotic prescribing. Adherence was highest in restorative scenarios but notably poor in surgical and prophylaxis conditions. Only 5.5% assessed plaque before prescribing, and less than 10% correctly applied prophylaxis for infective endocarditis. Younger age and female gender were positively associated with appropriate prescribing. Awareness of climate and dietary influences on AMR was low (4.5% and 5.9%, respectively). Conclusion: Despite high awareness of antimicrobial resistance (AMR), inappropriate antibiotic prescriptions remain prevalent among dentists in Saudi Arabia. This study highlights the need for continuous review and enforcement of dental antibiotic guidelines. By integrating One Health perspectives, it underscores that AMR is influenced not only by clinical practice but also by environmental and behavioral factors such as climate and diet. These findings emphasize the importance of interdisciplinary stewardship interventions and targeted educational initiatives to promote rational antibiotic use within dental care.