Operative stewardship: reclaiming the role of surgical source control in dental antimicrobial stewardship

Dentistry accounts for approximately 10% of all antibiotic prescriptions globally, with evidence consistently demonstrating that the majority of these prescriptions are inappropriate. Current dental antimicrobial stewardship programs are defined almost exclusively around prescribing behavior-optimizing antibiotic choice, dose, and duration. This pharmacological framing, while necessary, is structurally incomplete. It overlooks the primary clinical intervention that renders antibiotics unnecessary in the first place: surgical source control through incision and drainage or tooth extraction. In established odontogenic abscesses, systemic antibiotics operate in a profoundly hostile environment-avascular, necrotic tissue with acidic pH and pus containing antibiotic inhibitors-rendering antibiotic monotherapy insufficient as a definitive treatment and clinically inadequate as a substitute for operative source control. A growing pattern of defensive prescribing in community dental practice, driven by time pressure, patient expectations, and avoidance of operative procedures, delays definitive treatment and drives infection progression to secondary care. Maxillofacial emergency departments increasingly function as stewards of last resort, performing the drainage procedures that were clinically indicated days prior, at substantially greater cost to patients and health systems. This perspective argues that true antimicrobial stewardship in dentistry must expand its definition to encompass the operative decision itself: when infection is drainable or its source is extractable, operative management is the stewardship act. We propose the concept of Surgical Stewardship and outline its implications for clinical practice, dental education, and the community-to-hospital referral interface.