Curbing overuse of dental antibiotics proves daunting

In 2022, Congress passed the Medication Access and Training Expansion Act, or MATE Act, requiring clinicians who prescribe controlled substances to take eight hours of continuing education on safe opioid prescribing.

Like opioid addiction, antibiotic resistance can destroy both individual lives and the health of entire communities, said Goff, who’s also an infectious disease specialist at Ohio State’s Wexner Medical Center. 

That’s because drug-resistant microbes can easily spread from person to person and throughout hospitals and nursing homes. “You can have an entire swath of the population that suddenly is resistant to a particular drug,” said Purnima Kumar, DDS, PhD, a spokesperson for the American Dental Association (ADA). 

Confusion over guidelines 

Dentistry has only recently begun to grapple with reducing the use of antibiotics.

“Dental antibiotic stewardship needs to become the standard of care,” said Emily McDonald, MD, MPH, a medical officer with the Centers for Disease Control and Prevention’s office of antibiotic stewardship. “Most dental practices are still in the early stages of that process.”

In 2019, the ADA published guidelines encouraging the profession “to move from a ‘just in case’ approach of antibiotic prescribing to a ‘when absolutely needed’ approach.” In 2021, the American Heart Association (AHA) recommended dentists stop using clindamycin as a preventive treatment because it’s much more likely than other antibiotics to lead to C difficile infections.

While surveys show that dentists approve of such guidelines, research suggests clinicians don’t always understand which antibiotics to use or which high-risk patients need them. 

That confusion is reflected in prescribing data provided exclusively to CIDRAP News by the IQVIA Institute for Human Data Science, an organization based in Parsippany, New Jersey, that provides research and analysis on health care data.

In a sign of progress, dental prescriptions for clindamycin declined 35% from 2020 to 2025, although it remains the second-most common antibiotic prescribed. 

Prescriptions for the top dental antibiotic, amoxicillin, increased almost 13%. Prescriptions for the third-most common antibiotic, azithromycin—which can be a safer alternative to clindamycin for patients who are allergic to amoxicillin—climbed 83%, according to the IQVIA data. Overall, dental antibiotic prescriptions rose nearly 6% during that time, for a total of 27.3 million prescriptions in 2025.

Although dentists haven’t reduced their overall use of antibiotics, the data suggest they are “improving their antibiotic selection,” McDonald said.

“It’s easier to get clinicians to change the drug that they're prescribing and to shorten the duration of an antibiotic prescription,” McDonald said. “It is a lot harder to get them to stop prescribing the antibiotic when it’s not needed.”

Should lawmakers get involved?

Elliot Abt, DDS, who co-wrote the ADA’s 2019 antibiotic guidelines in 2019, said it’s frustrating that dentists still write so many prescriptions.

“If we keep writing so many unnecessary prescriptions for antibiotics, they're going to lose their effectiveness and they're just going to make people sick,” said Abt, an adjunct associate professor of oral medicine at the University of Illinois College of Dentistry. 

"I think the use of clindamycin is a case of clinical inertia,” Abt said. Dentists continue practicing as they did in the past, thinking, “‘This is what I learned in dental school so this is what I do,’” Abt said, “rather than reading the 2019 clinical practice guidelines.”

State dental boards require dentists to complete continuing education classes to renew their licenses.

While webinars in antibiotic stewardship are available, they’re not required, Goff said. Given a choice of subjects, many dentists gravitate to other topics, such as how to perform a new procedure or use artificial intelligence in their practice.

Dentists may also skip webinars in antibiotic stewardship because they don’t realize that new information is available, Goff said.

“They think, ‘I know how to prescribe antibiotics. I don’t need to go to that talk,’” she said.

Some antibiotic stewardship experts suggest that state dental boards should require dentists to take continuing education about smarter use of antibiotics. State lawmakers could nudge this along by passing legislation to require antibiotic education for dentists, Kennedy said.

Abt said he agrees that education in safe antibiotic prescribing should be mandatory.

“Some method of ensuring clinicians have been trained in antibiotic stewardship is key,” Abt said.

Experts also have suggested that states add antibiotics to their prescription monitoring programs, which currently track only controlled substances, such as narcotics.

Including antibiotics in drug monitoring programs would help doctors and dentists who can’t access each other’s electronic health record systems, said Amesh Adalja, MD, an infectious disease physician, critical care expert, and senior scholar at the Johns Hopkins Center for Health Security. “If your dentist is thinking about prescribing you Vicodin, the doctor can look it up” to learn if the patient has recently been prescribed other opioids, Adalja said. “They don’t have that system for antibiotics.”

“It would be incredibly useful” to have access to patients’ medical charts, said B. Jason Kyles, DDS, clinical assistant professor of oral and maxillofacial pathology, radiology and medicine at the New York University College of Dentistry. “Prior antibiotic exposure is a major risk factor for developing resistant or C. diff infections. If a patient recently took an antibiotic for a medical issue, prescribing that same drug for a dental issue increases the likelihood that it will fail due to bacterial resistance, as well as increase the risk of C diff infection.”

Other dental professionals say antibiotic overuse is very different from opioid misuse, arguing that state mandates would be harmful.

“While antibiotic overuse is a legitimate stewardship concern, it does not carry the same risks of dependence, diversion, or acute harm, and the public health implications are fundamentally different,” said Steven J. Katz, DDS, president of the American Association of Endodontists, which represents dentists who specialize in diseases or injuries affecting the nerves and blood vessels inside the teeth.

Expanding state PDMPs to include antibiotics “would impose unnecessary administrative and financial burdens on both the state and practitioners, without providing proportional benefit,” said Katz, who practices in Beachwood, Ohio.

And though “education is always valuable,” Katz said there’s no need to mandate courses in antibiotic stewardship.

While it's important to prescribe antibiotics responsibly, Katz said, antibiotics do not "warrant the same regulatory approach” as managing opioids.

Data can spur change

As a board member at ADS, Kennedy teaches practicing dentists around how to monitor their antibiotic prescribing.

Kennedy uses an online database, for example, to track how many antibiotic prescriptions she writes and whether they conform to guidelines. The database also tells Kennedy how her antibiotic prescribing stacks up against dentists around the country. ADS also has developed a printable version that dentists can download.

“When I work with clinicians,” Kennedy said, “they will often say, ‘Oh, I didn't realize there was a new guideline for patients with total joint and knee replacements,’ or, ‘Oh, I didn't realize there are guidelines for tooth pain and swelling.’”

Before prescribing any medication, Kennedy said, she always discusses drug allergies. Many of her patients report being allergic to penicillin, a cousin of amoxicillin, which dentists use more than any other antibiotic because of its safety and effectiveness. Dentists typically prescribe alternative antibiotics––including clindamycin––for these patients. But second-choice antibiotics are often more toxic and less effective.

So Kennedy makes an effort to get to the heart of the issue by investigating whether her patients have a true penicillin allergy. Although 10% of people think they’re allergic to penicillin, less than 1% actually are. 

She suggests that her patients with reported penicillin allergies see an allergist for definitive testing. “It is really important for us to understand what you're truly allergic to, so that we can provide you the safest drug possible if you do absolutely need an antibiotic,” Kennedy said.

By prescribing fewer antibiotics, Kennedy said, “I’m honoring my grandmother, but more importantly, I’m honoring the people I serve in health care.”