Antibiotic Prescribing in Acute Endodontic Conditions: Evidence, Clinical Practice, and Antimicrobial Stewardship From a Public Health Perspective

Antibiotic prescribing in dentistry represents an important component of antimicrobial stewardship because dental professionals contribute substantially to community antibiotic exposure. Acute endodontic conditions are frequently encountered in urgent dental care, although systemic antibiotics have a limited role in most localized pulpal and periapical diseases. This narrative review examined evidence concerning antibiotic indications in acute endodontic conditions, international prescribing recommendations, reported prescribing practices, determinants of inappropriate prescribing, and potential stewardship interventions. The evidence was synthesized qualitatively. Current recommendations consistently prioritize definitive local treatment and source control and discourage antibiotics for symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscesses without systemic involvement. Antibiotics are mainly indicated when infection is spreading or accompanied by systemic manifestations such as fever, diffuse swelling, cellulitis, progressive trismus, dysphagia, or other signs of significant infection. Nevertheless, inappropriate prescribing remains common and is associated with diagnostic uncertainty, fear of complications, patient expectations, time pressure, limited access to urgent operative treatment, and organizational barriers. Evidence from stewardship programmes suggests that education alone is less effective than multimodal interventions incorporating guidelines, decision-support tools, audit and feedback, and patient communication. Antimicrobial stewardship in endodontics should therefore be considered not only a clinical issue but also a public-health and healthcare-system challenge.