“Inappropriate antibiotic use can be a symptom of health system inequity”

Iveta Ramonaite, Dental Tribune International

Wed. 12. November 2025

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Antimicrobial resistance is a mounting global health threat, and dentistry accounts for a notable share of antibiotic use. In conflict-affected settings like the Palestinian territories, structural constraints—restricted mobility, uneven access to care and disrupted follow-up—may nudge clinicians towards precautionary prescribing. In this interview with Dental Tribune International, Dr Elham Talib Kateeb—professor of dental public health in the Faculty of Dentistry and dean of scientific research at Al-Quds University in east Jerusalem—talks about a new study on antibiotic stewardship among Palestinian dental students. She discusses where sound knowledge fails to translate into clinical decisions, how context and patient expectations shape prescribing, what curricula can do to close the gap and how the war in Gaza has further complicated stewardship and training.

Al-Quds University’s Prof. Elham Talib Kateeb and her team are currently conducting a study across ten Arab nations to develop a regional profile of dental prescribing behaviours. (Image: FDI World Dental Federation)

Prof. Kateeb, why did you focus this study on antibiotic stewardship among Palestinian dental students?
Antibiotic resistance is increasingly recognised as one of the biggest global health threats of our time. Dentistry contributes approximately 10% of worldwide antibiotic prescriptions, yet many of these prescriptions are unnecessary and stem from uncertainty, habit-driven clinical decision-making or inadequate training. In Palestine, we are operating within a health system that is already stretched by political instability, restrictions on movement and unequal access to care. These realities influence prescribing patterns, often turning antibiotics into a “safety net” when clinical follow-up cannot be guaranteed.

Dental students represent the future stewards of antibiotic stewardship. Understanding their knowledge, attitudes and practices provides a direct window into where inappropriate prescribing can be prevented and care guided towards safe, evidence-based practice. Strengthening dentists’ prescribing behaviour early in their training is one of the most cost-effective interventions to curb antimicrobial resistance in the years ahead.

How did knowledge, clinical decision-making and contextual pressures interact to shape students’ antibiotic prescribing in your study?
In the study, Palestinian dental students demonstrated strong conceptual knowledge of the consequences of misuse and the importance of stewardship, reflecting positively on dental curricula in our region. At the same time, practical decision-making in clinical scenarios was inconsistent with their conceptual understanding. For example, students often indicated willingness to prescribe antibiotics for conditions for which local, evidence-based guidelines clearly recommend against their use. Variation across academic years also suggests that knowledge does not always translate into practice as clinical responsibilities increase.

We were particularly struck by students’ anxiety about patient expectations and follow-up access. These contextual pressures shape behaviour in ways that go beyond individual knowledge. Our findings provide salient insight into how clinical education must incorporate both scientific rigour and real-world complexity.

Several findings stood out, revealing patterns that reflect both Palestinian realities and broader trends in global dentistry. The first is that knowledge was not the main barrier. Most students clearly understood the dangers of antibiotic overuse and were aware of general stewardship principles. The real challenges emerged when knowledge collided with clinical uncertainty, social pressures and structural limitations.

The second finding was that overprescription was strongly tied to patient access challenges. Students often expressed concern that patients might not be able to return for follow-up owing to restrictions on movement, financial constraints or scarcity of appointments in overcrowded clinics. This environment fosters a “just in case” mentality that pushes providers towards prescribing antibiotics even when not clinically indicated. The insight is powerful: inappropriate antibiotic use can be a symptom of health system inequity rather than of a lack of professional knowledge.

The third finding was that misconceptions persisted in common dental scenarios. Even advanced students were more likely to prescribe antibiotics when not indicated, such as to treat symptomatic irreversible pulpitis or localised abscesses without systemic involvement. This finding aligns with international evidence showing that clinical translation remains a global challenge.

“In Palestine, we are operating within a health system that is already stretched by political instability, restrictions on movement and unequal access to care.”

The fourth finding was that students relied on peers and online resources over official guidelines. Many students reported turning first to colleagues or social media before consulting evidence-based clinical protocols. This reflects both the connectivity of the younger generation and the need to make stewardship guidelines more visible, practical and routinely incorporated in training.

The fifth finding was that ethical tension and professional identity were visible. Students acknowledged that part of their desire to prescribe antibiotics was linked to wanting patients to feel “treated”, especially when definitive procedures could not be delivered immediately. This mirrors a worldwide struggle: the intersection of patient expectations, professional responsibility and the fear of doing too little.

The sixth finding was that students had a strong motivation to improve. A highly positive finding was the overwhelming interest in receiving more robust stewardship training and interprofessional exposure. Students recognised that dentists are front-line antibiotic prescribers and embraced that responsibility.

Our study paints a realistic and hopeful picture. Palestinian dental students have the foundation needed to become powerful advocates for antimicrobial stewardship, but they require institutional and policy support that address both clinical competence and the broader social determinants shaping prescribing behaviour.

What practical changes to dental curricula and antimicrobial stewardship training do your findings support in both resource-constrained and well-resourced settings?
Our results reinforce a message that resonates far beyond Palestine: antibiotic stewardship training needs to move beyond lectures. Dental curricula must ensure that students gain the confidence, communication skills and ethical clarity needed to resist unnecessary prescribing in clinical encounters. Early exposure to national and international antimicrobial guidelines, structured decision-making tools and interprofessional collaboration with pharmacists and physicians can make a measurable difference.

In fragile and humanitarian settings, these improvements are even more critical. In global terms, settings like ours serve as a warning: when the infectious disease burden is high and the infrastructure challenged, antibiotic prescribing by dentists becomes a critical leverage point in stewardship.

Misuse driven by uncertainty can accelerate antimicrobial resistance in populations that already bear a heavy burden of infectious disease. The stakes here are not theoretical. They shape patient outcomes, future treatment success and the sustainability of our healthcare systems.

How has the war in Gaza affected follow-up access, prescribing decisions and stewardship teaching since your data was collected?
Although our data was collected before the current war on Gaza, the situation has since deteriorated in catastrophic ways. Healthcare facilities, including dental schools and clinics, have been destroyed or rendered non-functional, supply chains have collapsed, and both patients and providers have been displaced. Follow-up access is now extremely limited or, in many cases, impossible. The contextual pressures highlighted in our study have therefore been sharply amplified, especially for students and practitioners in Gaza, making responsible antibiotic stewardship even more challenging and simultaneously more essential in such settings.

Is there anything you would like to add?
We see this study not as a conclusion but as a beginning. With colleagues across the Arab region, we are now analysing comparable data from ten countries to build the first regional profile of antibiotic prescribing attitudes in dental education. This collaborative work aims to inform joint guidelines, capacity-building efforts and policy-making that align with global stewardship strategies such as the World Health Organization’s action plan on antimicrobial resistance.

Palestine may face unique challenges, yet our students’ aspirations and commitment to responsible, high-quality care mirror those of the global dental community. We believe that this research contributes not only to the science of dental education but also to the collective responsibility we share to preserve antibiotics as life-saving treatments for future generations.

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