Antibiotic Stewardship

The U.S. Centers for Disease Control and Prevention (CDC) defines antibiotic stewardship as “the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.”¹ The American Dental Association (ADA) has adopted an evidence-based approach to guideline development in the area of dental antibiotic use, which has resulted in recommendations for decreased indications for and use of prophylactic antibiotics in people with heart conditions and those who have had joint replacements, as well as recommendations for antibiotic use in periodontal infections, and the urgent management of dental pain and intra-oral swelling. A 2018 systematic review² in JADA found dentists regularly prescribing antibiotics for inappropriate purposes (e.g., administering prophylactic doses in healthy patients and treating oral infections with systemic antibiotics when localized treatment would suffice), and that “…it is reasonable to believe that a well-implemented antibiotic stewardship initiative can change dentists’ antibiotic prescription practices.” Additionally, a 2013 survey³ of antibiotic prescribing by dentists found considerable geographic variability in prescribing practices and called for additional study to “better understand the reasons for this variability and identify areas of possible intervention and improvement.”

Effective antibiotic stewardship in dentistry is considered a public health priority to preserve the effectiveness of currently available antibiotics, as the increase in antibiotic-resistant pathogens allows the otherwise susceptible bacteria to survive antibiotic treatment.^4-6 Inappropriate antibiotic use is also a patient safety and quality-of-care issue, as unnecessary exposure can increase the risk of adverse drug events, drug interactions, and delays in appropriate definitive treatment.⁶ Therefore, the use of antibiotics by dental practitioners must consider the balance between avoiding patient complications and minimizing antibiotic resistance.⁴

In 2026, the ADA Council on Scientific Affairs issued a clinical practice statement, “Antibiotic Stewardship: Balancing Patient Care and Public Health.”⁴ The ADA’s recommendations for antibiotic stewardship strategies⁴ are based on CDC resources and core principles^{1, 7-9} and are summarized in the following list:

• Verify Patient History and Risk Factors
  Identify situations that may increase risk, including allergies to an antibiotic, preexisting intestinal disease (e.g., Crohn disease or history of ulcerative colitis), and advancing age.

• Prioritize Definitive Dental Treatment
  Use clinical intervention (e.g., drainage, pulpotomy, pulpectomy, nonsurgical root canal therapy, or extraction) as the primary means of eliminating odontogenic infection; recognize that dentists prescribe approximately 10% of outpatient antibiotics, making stewardship essential to patient safety and resistance prevention.

• Limit Antibiotic Use
  Prescribe systemic antibiotics only when there are clear signs of systemic involvement or for severely immunocompromised patients, in accordance with evidence-based guidelines.

• Optimize Antibiotic Selection and Duration
  Select the right antibiotic when indicated; avoid clindamycin whenever a safer alternative is available to reduce the risk of Clostridioides difficile infection. Prescribe the shortest effective duration and use a single preprocedural dose when prophylaxis is indicated. Discontinue antibiotics within 48 hours after systemic signs and symptoms resolve.

• Standardize Prescribing Practices
  Incorporate guideline-concordant antibiotic use into clinic workflows through written policies, checklists, and clinical decision–support tools aligned with Centers for Disease Control and Prevention Core Elements of Outpatient Antibiotic Stewardship.

• Communicate Risks and Educate
  Counsel patients about the potential harms of unnecessary antibiotic use, including microbiome disruption and C. difficile infection, to align expectations and improve adherence. 

• Adhere to Evidence-Based Guidelines
  Monitor antibiotic prescribing patterns and educate clinical staff to support continuous improvement in stewardship practices. Follow American Dental Association and Centers for Disease Control and Prevention recommendations when treating dental infections and stay updated as clinical guidance evolves.

Antibiotic resistance—when bacteria no longer respond to antibiotics—is a growing problem.  According to the Centers for Disease Control and Prevention, more than 2.8 million people in the U.S. become infected with bacteria that are resistant to antibiotics and at least 35,000 people die each year as a direct result of these infections.¹⁰

Improving understanding of how antibiotics work will be helpful in preventing the spread of antibiotic-resistant bacteria.  Education regarding the responsible use of antibiotics will help practitioners to identify the circumstances when antibiotics are indicated, to choose the right antibiotic, and to prescribe it at the right dose for the right duration.

In addition to problems associated with antibiotic resistance, antibiotics are a major cause of adverse effects from systemically administered medications. A 2018 study found over 145,000 emergency hospital visits for systemically administered antibiotic adverse events in adults between 2011 and 2015 in the United States.¹¹ More than half of the visits were from adults aged 20 to 50 years, and approximately 75% of the cases involved allergic reactions to antibiotics. Oral sulfonamides were the most frequent cause of adverse events, followed closely by penicillins, and, lastly, fluoroquinolones.¹¹ These results were similar to a 2008 study that stated, “[m]inimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events.”¹² The development of adverse events may also depend on the length of the antibiotic regimen. A 2019 systematic review¹³ in JAMA found that extended course (i.e., ≥72 hours) antibiotic prophylaxis may increase the risk of developing adverse events (e.g., diarrhea, nausea, rash, gastric pain, and fever) by 140% compared to short course (i.e., ≤24 hours) antibiotic prophylaxis.

Clostridioides (formerly Clostridium) difficile is a spore-forming, Gram-positive anaerobic bacillus that is a cause of 15 to 25% of all episodes of antibiotic-associated diarrhea.¹⁴  It is commonly found at low levels within the commensal microbiota of the human gut.¹⁵  Among those organisms, it is considered to be pathobiont, meaning that within its indigenous community, it is benign; however, when homeostasis is disrupted, it acts as a pathogen.¹⁵ Factors that can alter this homeostatic balance include antibiotic treatment, tissue damage, changes to diet, and immune deficiencies.¹⁶

C. difficile infection (CDI) is increasing in both prevalence and severity. While the majority (56%) of reported cases are associated with a stay in a healthcare facility, the remaining (44%) cases, numbering 65.8 cases/1000 individuals, are considered community-associated CDI.¹⁷ Of these, it has been estimated that 65% of the community associated CDI occurred after the use of antibiotics.¹⁷ Manifestations of CDI range from mild to life-threatening sequelae. CDI can result in pseudomembranous colitis, toxic megacolon, colon perforations, sepsis, and, rarely, death.¹⁴

Clinical factors associated with increased risk of CDI include age older than 65 years, the presence of underlying disease, and recent courses of antibiotics.¹⁸ Dentists are estimated to prescribe 10% of outpatient antibiotics, so while they are not the sole source of these drugs in the community, they make a measurable contribution to it.³ There is some overlap among the antibiotics commonly prescribed by dentists and those reported to carry higher risk for CDI. Antibiotics associated with higher risk of CDI include clindamycin, the cephalosporins, and the fluoroquinolones,¹⁸ which are reported to account for 14%, 5%, and less than 1% of the antibiotics prescribed by dentists, respectively.³

Some clinicians prescribe probiotics during a course of antibiotics for the prevention of CDI. According to the Infectious Diseases Society of America (IDSA), there are insufficient data supporting the effectiveness of probiotics in preventing CDI, and the administration of probiotics for this purpose is therefore not recommended by the IDSA at this time.¹⁹

As part of antibiotic stewardship, antibiotic prophylaxis prior to dental procedures should be reserved for patients who are at the greatest risk of post-treatment bacterial-related complications. The following are ADA resources related to antibiotic prophylaxis:

• An evidence-based clinical practice guideline for dental practitioners about antibiotics prior to dental work in patients who have joint replacements, published in the Journal of the American Dental Association (JADA), states that, in general, antibiotics are not recommended prior to dental procedures for patients with prosthetic joint implants.²⁰
• According to the ADA Chairside Guide, in cases where antibiotics are deemed necessary prior to dental treatment in people with joint replacements, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.
• A 2026 ADA Council on Scientific Affairs Position Statement, “Shared decision making in oral health care for patients with prosthetic joint replacements,” states that for patients with prosthetic joint replacements, decisions about timing of dental care and any rare use of prophylactic antibiotics should be based on shared decision making among the dentist, orthopedic team, and patient, rather than routine delays or automatic premedication.²¹
• Guidelines²² from the American Heart Association (AHA) about the prevention of infective endocarditis approved by the ADA Council on Scientific Affairs as they relate to dentistry, were published in JADA and clarify the conditions for which prophylaxis should be considered, as well as the regimens that should be used, if indicated. These guidelines were updated in 2021 with a scientific statement²³ from the AHA that recommended no changes to the findings of the earlier guideline; however, the 2021 AHA scientific statement no longer recommends use of clindamycin as an oral or parenteral alternative to amoxicillin or ampicillin in individuals with allergies to these drugs because clindamycin “may cause more frequent and severe reactions than other antibiotics used for [antibiotic prophylaxis]” (including C. difficile infection).²³

Antibiotic stewardship also involves the responsible use of therapeutic antibiotics to treat existing infections, as it can be common for clinicians to inappropriately prescribe antibiotic treatment. According to the CDC, appropriate antibiotic prescribing means that antibiotics are prescribed when needed, i.e., the right antibiotic is selected at the right dose and for the right duration; and antibiotics are prescribed in accordance with national and local guidelines and recommendations.²⁴ Some of the reasons that dentists may misuse antibiotics include inadequate knowledge about management of infections, pressure from patients requesting antibiotics, failure to consider treatments other than systemic antibiotics (e.g., surgery), belief that broad-spectrum antibiotics are the most effective treatment, and the demands of running a busy practice.²⁵  Raising awareness about the risks of unnecessary use of antibiotics should be included as part of a dental antimicrobial stewardship strategy.²⁶ 

Dentists may want to consider the following when deciding whether or not to prescribe antibiotic treatment:²

• The overall health and immunity of the patient
• Preexisting conditions of the patient
• The type and location of the infection
• Whether the infection shows signs of spreading
• If the condition can be treated with surgical treatment
• If the patient has symptoms other than localized pain

Endodontic Infection. The treatment of endodontic infections is one area where dentists can exercise responsible antibiotic administration. A 2019 ADA ACE Panel Report on antibiotic use in endodontic infections²⁷ suggested that the management of endodontic infections is best achieved through proper root canal debridement, disinfection, and drainage of the abscess and discourages the use of systemic antibiotics due to their inability to reach necrotic tissue and their contribution to antibiotic resistance and CDI. The same report found that of 391 member dentists surveyed, 51% had decreased their antibiotic prescribing patterns from 5 years ago, 43% remained similar, 2% increased their prescribing patterns, and 4% were unable to prescribe.

Chronic Periodontal Infection. A 2015 ADA clinical practice guideline on nonsurgical treatment recommended scaling and root planing as initial therapy and concluded that adjunctive systemic doxycycline (at a subantimicrobial dose) may yield a small additional clinical attachment gain in moderate to severe cases.²⁸ Subsequent international guidance applying the 2018 staging and grading framework, including the European Federation of Periodontology stage 3–level guideline for the treatment of stage I-III periodontitis, similarly advises against routine systemic antibiotics.^{29, 30}

Pulpal- and Periapical-related Dental Pain and Intraoral Swelling. In 2019, an ADA guideline panel developed a clinical practice guideline³¹ on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intra-oral swelling. The guideline, based on a systematic review and meta-analysis,^{32, 33} came to the folloing recommendations:

• The guideline recommends against using antibiotics for most pulpal and periapical conditions and instead recommends only the use of dental treatment and, if needed, over-the-counter pain relievers such as acetaminophen and ibuprofen.
• Instead of prescribing antibiotics, dentists should prioritize dental treatments such as pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage for symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess in adult patients with a normal immune response.
• If a patient’s condition progresses to systemic involvement, showing signs of fever or malaise, then dentists should prescribe antibiotics.

1. U.S. Centers for Disease Control and Prevention. Core Elements of Antibiotic Stewardship. https://www.cdc.gov/antibiotic-use/hcp/core-elements/index.html. Accessed September 23, 2026.
2. Stein K, Farmer J, Singhal S, et al. The use and misuse of antibiotics in dentistry: A scoping review. J Am Dent Assoc 2018;149(10):869-84 e5.
3. Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148(3):172-78 e1.
4. ADA Council on Scientific Affairs. Antibiotic stewardship: balancing patient care and public health: American Dental Association Council on Scientific Affairs Clinical Practice Statement. J Am Dent Assoc 2026.
5. Gross AE, Hanna D, Rowan SA, Bleasdale SC, Suda KJ. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infectious Diseases 2019;6(3).
6. Paumier TM. Appropriate antibiotic use in dentistry: a review of the literature and clinical recommendations. Gen Dent 2024;72(1):27-33.
7. U.S. Centers for Disease Control and Prevention (CDC). Dentists, Be Antibiotics Aware: Treating Patients with Dental Pain and Swelling. U.S. Department of Health and Human Services. https://www.cdc.gov/antibiotic%2Duse/media/pdfs/ADA%2Dtreatment%2Dguidelines%2D508.pdf. Accessed September 25, 2026.
8. U.S. Centers for Disease Control and Prevention (CDC). Checklist for Antibiotic Prescribing in Dentistry. U.S. Department of Health and Human Services. https://www.cdc.gov/antibiotic%2Duse/media/pdfs/dental%2Dfact%2Dsheet%2D508.pdf. Accessed September 25, 2026.
9. U.S. Centers for Disease Control and Prevention (CDC). Antibiotic Use for a Safe Dental Visit. U.S. Department of Health and Human Services. https://www.cdc.gov/antibiotic%2Duse/media/pdfs/au%2Ddental%2Dtrifold%2Dbrochure%2Dp.pdf. Accessed September 25, 2026.
10. U.S. Centers for Disease Control and Prevention. About Antimicrobial Resistance. U.S. Department of Health & Human Services. https://www.cdc.gov/antimicrobial-resistance/about/. Accessed September 23, 2026.
11. Geller AI, Lovegrove MC, Shehab N, et al. National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015. J Gen Intern Med 2018;33(7):1060-68.
12. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008;47(6):735-43.
13. Oppelaar MC, Zijtveld C, Kuipers S, et al. Evaluation of Prolonged vs Short Courses of Antibiotic Prophylaxis Following Ear, Nose, Throat, and Oral and Maxillofacial Surgery: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2019;145(7):610-16.
14. U.S. Centers for Disease Control and Prevention. C. diff: Facts for Clinicians. U.S. Department of Health and Human Services. https://www.cdc.gov/c-diff/hcp/clinical-overview/. Accessed September 20, 2026.
15. Kamada N, Chen GY, Inohara N, Nunez G. Control of pathogens and pathobionts by the gut microbiota. Nat Immunol 2013;14(7):685-90.
16. Hajishengallis G, Lamont RJ. Dancing with the Stars: How Choreographed Bacterial Interactions Dictate Nososymbiocity and Give Rise to Keystone Pathogens, Accessory Pathogens, and Pathobionts. Trends Microbiol 2016;24(6):477-89.
17. U.S. Centers for Disease Control and Prevention. 2015 Annual Report for the Emerging Infections Program for Clostridium difficile Infection. National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/hai/eip/Annual-CDI-Report-2015.html. Accessed September 30, 2026.
18. Rupnik M, Wilcox MH, Gerding DN. Clostridium difficile infection: new developments in epidemiology and pathogenesis. Nat Rev Microbiol 2009;7(7):526-36.
19. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018;66(7):987-94.
20. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(1):11-16 e8.
21. ADA Council on Scientific Affairs. Shared decision making in oral health care for patients with prosthetic joint replacements: American Dental Association Council on Scientific Affairs position statement. The Journal of the American Dental Association 2026;157(6):667-69.
22. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):1736-54.
23. Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation 2021;143(20):e963-e78.
24. U.S. Centers for Disease Control and Prevention (CDC). Antibiotic Use in the United States. U.S. Department of Health and Human Services. https://www.cdc.gov/antibiotic-use/hcp/data-research/antibiotic-prescribing.html. Accessed September 23, 2026.
25. Dana R, Azarpazhooh A, Laghapour N, Suda KJ, Okunseri C. Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview. Dent Clin North Am 2018;62(2):279-94.
26. Teoh L, Thompson W, Suda K. Antimicrobial stewardship in dental practice. J Am Dent Assoc 2020;151(8):589-95.
27. American Dental Association. ACE Panel Report: Antibiotic Use in Endodontic Infections.  2019. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ace/ace-panel-report_antibiotic-use-in-endodontic-infections_final.pdf. Accessed September 30, 2026.
28. Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. The Journal of the American Dental Association 2015;146(7):525-35.
29. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification. J Periodontol 2018;89 Suppl 1:S1-s8.
30. Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol 2020;47 Suppl 22(Suppl 22):4-60.
31. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc 2019;150(11):906-21.e12.
32. Tampi MP, Pilcher L, Urquhart O, et al. Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis—a report of the American Dental Association. J Am Dent Assoc 2019;150(12):e179-e216.
33. Tampi MP, Pilcher L, Urquhart O, et al. Plain language summary for "Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: systematic review and meta-analysis-a report of the American Dental Association". J Am Dent Assoc 2019;150(12):1048-50.

For Professionals:

• ADA Council on Scientific Affairs Position Statement: Antibiotic stewardship: balancing patient care and public health (JADA)
  • Chairside Guide: Antibiotic Stewardship:  A prescribing decision aid for Odontogenic and Selected Periodontal Infections in Immunocompetent Adults (Treatment, Not Prophylaxis) (Infographic PDF)
• Antibiotic Use for the Urgent Management of Dental Pain and Intra-oral Swelling Clinical Practice Guideline (2019) 
• ACE Panel Report: Antibiotic Use in Endodontic Infections (PDF)
• ADA Oral Health Topic: Antibiotic Prophylaxis Prior to Dental Procedures
• Search JADA for articles related to antibiotic stewardship
• ADA Store: ADA Dental Drug Handbook: A Quick Reference (Item #J05921BT)
• ADA Library Services: DynaMedPlus Online Drug Reference (ADA member login required)

For Patients:

• For the Patient: Using antibiotics wisely
• MouthHealthy: Will antibiotics help treat my dental pain?

Centers for Disease Control and Prevention:

• Antimicrobial Resistance
• Antibiotic Stewardship Resource Bundles
• Antibiotic Stewardship Strategies: Outpatient Dental Settings (PDF)
• Antibiotic Use for a Safe Dental Visit Patient Brochure (PDF)
• Antibiotic Use in the United States, 2017: Progress and Opportunities (PDF)
• CDC Checklist for Antibiotic Prescribing in Dentistry (PDF)
• Dentists: Be Antibiotics Aware – Treating Patients with Dental Pain and Swelling Fact Sheet (PDF)