Antibiotic therapy in oral surgery: a paradigm between efficacy and resistance

The prescription of antibiotics in oral and maxillofacial surgery, although essential, faces a major public health challenge: excessive and often empirical use. This inappropriate practice fuels global bacterial resistance, a phenomenon that the WHO ranks among the critical threats of the 21st century. In the practice, the management of odontogenic infections — involving a mixed flora (Streptococcus viridans, Prevotella spp., Fusobacterium spp.) — requires increased pharmacological rigor to avoid the selection of resistant strains, particularly to beta-lactams and clindamycin.

This integrative literature review, synthesizing 39 studies selected between 2020 and 2026, aims to analyze current scientific evidence regarding prophylactic and curative antibiotic therapy. The study precisely evaluates clinical indications for third molar extractions, osseointegrated implant placement, and orthognathic surgery. It also seeks to define optimal protocols for the treatment of cellulitis and abscesses, while measuring the impact of antimicrobial stewardship programs on clinical outcomes and the sustainability of first-line molecules such as amoxicillin.

A rigorous selection for evidence-based practice

Far from a simple narrative review, this work is based on an integrative literature review targeting the most current data (2020-2026), while incorporating pivotal studies dating back to 2015. The challenge: to define prescription standards in oral surgery in the face of the global challenge of bacterial resistance.

The research protocol was deployed across four major databases (PubMed/MEDLINE, Scopus, Web of Science, and SciELO). Out of a total of 312 identified studies, the authors performed a drastic filtering process to retain only 39 articles constituting the final sample. This selection includes randomized clinical trials, meta-analyses, and observational studies focusing exclusively on adult patients.

The analysis is structured around the PICo framework to evaluate the impact of antibiotics on:

• Prophylaxis: implants, third molars and orthognathic surgery.
• Treatment: odontogenic infections, cellulitis and abscesses.
• Risks: evolution of resistance to beta-lactams and clindamycin.

The strength of this methodology lies in its ability to synthesize various study designs to provide a global vision of clinical efficacy vs. the risk of selecting resistant strains.

Synthesis of data on antibiotic therapy in oral surgery

This integrative review, having analyzed 39 selected studies from 312 initial references, highlights precise protocols and emerging consensuses for clinical practice. The compiled data confirm that amoxicillin remains the reference molecule, although the emergence of bacterial resistance necessitates more rigorous prescription.

Prophylaxis protocols and clinical indications

The synthesis of the included studies identifies significant clinical benefits for antibiotic prophylaxis in specific scenarios. The standard protocol validated by recent literature is based on the administration of amoxicillin (2 g orally, 60 minutes before the procedure).

Microbiology and curative antibiotic therapy

The authors report that odontogenic infections present a mixed microbiology, dominated by aerobic gram-positive and anaerobic species (Streptococcus viridans, Peptostreptococcus spp., Prevotella spp., and Fusobacterium spp.). For curative treatment, the data indicate:

• First intention: Amoxicillin alone or combined with clavulanic acid.
• Alternative (hypersensitivity): Clindamycin remains the primary option, although resistance rates are increasing.
• Specific targets: Metronidazole is preferred for infections with a strong strictly anaerobic component, while azithromycin is cited as an adjuvant option.

Bacterial resistance and irrational use

A major finding of this review is the increase in strains resistant to beta-lactams and clindamycin. The analyzed studies highlight that empirical prescription, often lacking clinical justification in healthy patients for simple procedures (non-complex exodontia), directly contributes to this public health phenomenon. The authors insist on the need to limit the duration of treatment to the shortest possible effective period.

Clinical significance and risk management

This integrative review, synthesizing 39 studies selected from 312 references, confirms that amoxicillin (2 g orally, 60 minutes preoperatively) remains the gold standard protocol for prophylaxis in high-risk procedures, particularly the placement of osseointegrated implants and orthognathic surgery. However, the data highlight a clinical drift: a significant portion of dental prescriptions lacks scientific foundation, promoting the emergence of resistance to beta-lactams and clindamycin.

The results highlight a clear distinction between prophylaxis and treatment. While antibiotic therapy is imperative for odontogenic infections with systemic manifestations (cellulitis, abscesses), its systematic use for simple exodontia in healthy patients is being questioned. The study reports that the benefit-risk balance does not justify exposure to adverse effects and bacterial selection pressure in these routine cases.

A major limitation identified by the authors lies in the methodological heterogeneity of the available clinical studies, which complicates the establishment of strict universal recommendations. Nevertheless, the implication for practice is immediate: the practitioner must prioritize shorter treatment durations and limit prophylaxis to validated surgical indications (implants, immunocompromised patients, high-risk third molars). The adoption of antimicrobial stewardship programs in the dental practice is no longer an option, but a necessity to preserve the efficacy of available molecules.

Summary of results

This integrative review of 39 studies (2020-2026) confirms that antibiotic prophylaxis with amoxicillin (2 g, 60 minutes before the procedure) significantly reduces risks in implantology, orthognathic surgery, and complex extractions in fragile patients. However, it warns of the increasing resistance to beta-lactams and clindamycin resulting from systematic prescriptions that are not clinically justified.

In concrete terms, for the practitioner:

• Target your prescriptions: Reserve prophylaxis for implant placement, orthognathic surgery or medically compromised patients; routine use for simple extractions in healthy patients should be discontinued.
• Optimize the dose: Prioritize the flash protocol (single 2 g dose, 1 hour preoperatively) to ensure maximum serum concentration during the procedure while limiting selective pressure on the flora.
• Curative rigor: Only prescribe therapeutic antibiotic therapy in the presence of systemic signs (fever, lymphadenopathy) or infectious spread (cellulitis), aiming for the shortest possible effective treatment duration.

Lexicon of the study on antibiotic therapy in oral surgery

Antibiotic prophylaxis: Preventive administration of antimicrobials, specifically recommended at a dose of 2 g of amoxicillin 60 minutes before the procedure for high-risk procedures (implants, third molars in at-risk patients, orthognathic surgery).

Antimicrobial resistance: A phenomenon of bacterial adaptation resulting from excessive or inappropriate prescriptions, characterized in this study by an increase in resistance to beta-lactams and clindamycin.

Odontogenic infections: Infectious pathologies originating from caries or periodontopathies, involving mixed flora and capable of progressing to severe forms such as cervicofacial cellulitis or necrotizing fasciitis.

Antimicrobial stewardship: Rational management programs aimed at restricting the use of antibiotics to specific indications, at appropriate dosages and for the shortest effective duration to optimize clinical outcomes.

Beta-lactams: A class of antibiotics (including amoxicillin and amoxicillin-clavulanate) constituting the first-line agents for prophylaxis and treatment in oral and maxillofacial surgery.

Mixed microbiota: Complex bacterial flora combining aerobic gram-positive and anaerobic species (such as Streptococcus viridans, Prevotella spp. and Fusobacterium spp.) involved in the pathogenesis of oral infections.

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