Antibiotic Stewardship in Oral Surgery and Implant Dentistry: From Procedure-Based Prescribing to Risk-Adapted Decision-Making—A Comprehensive Narrative Review

Background/Objectives: Antibiotic prescribing remains common in oral surgery and implant dentistry, although indications, regimens, and supporting evidence vary across procedures and patient populations. This comprehensive narrative review evaluated prophylactic and therapeutic antibiotic use within an antimicrobial stewardship framework and examined the transition from procedure-based prescribing toward risk-adapted decision-making. Methods: PubMed/MEDLINE, Scopus, and Web of Science were searched from inception to 15 September 2026 using a structured modular strategy, complemented by reference-list screening and targeted searches. Evidence addressing clinical indications, antimicrobial regimens, patient-related factors, antibiotic-related harms, resistance, microbiome and resistome alterations, antibiotic-sparing approaches, and stewardship was qualitatively synthesized. Study selection was independently performed by two reviewers, and extracted information was cross-checked. Results: Antibiotic benefit varied across clinical indications. Prophylaxis reduced selected postoperative outcomes in third-molar surgery and conventional implant placement, whereas evidence was less certain for reconstructive procedures and medically complex patients. Routine postoperative continuation did not provide a consistent additional benefit across several surgical settings. Patient vulnerability alone did not establish greater prophylactic benefit, while preventive indications differed according to the complication addressed. Adverse drug reactions, resistance selection, and microbiome and resistome alterations broadened the consequences relevant to antimicrobial exposure. Stewardship interventions improved prescribing outcomes, although evidence concerning appropriateness and longer-term outcomes remained limited. Conclusions: Antibiotic prescribing should be guided by indication and expected clinical benefit rather than by procedural complexity or patient vulnerability alone. Risk-adapted decision-making can support proportionate antimicrobial exposure while remaining anchored to indication-specific evidence and established clinical guidance.