Is an in-person evaluation necessary before prescribing antibiotics for a toothache?

Do Not Prescribe Antibiotics Over the Phone for Toothache

When considering remote prescribing of antimicrobials for toothache, if a person is potentially ill enough to require antibiotics, arrange a face-to-face assessment—this should be usual practice. 1

Why In-Person Evaluation is Essential

The 2024 NICE guidance explicitly states: "Do not routinely prescribe antimicrobials based on a remote assessment" and emphasizes that face-to-face evaluation is preferable when antibiotics are being considered. 1 This recommendation is based on the understanding that:

• No evidence supports identifying specific symptoms by remote assessment as a reliable indicator of severe illness, requiring clinical judgment informed by direct examination. 1
• Antibiotics do not cure toothache—they only address bacterial infection, which requires proper diagnosis through examination. 2
• Dental pain has multiple etiologies (pulpitis, periapical abscess, periodontal infection, dry socket) that cannot be reliably differentiated over the phone, and most require definitive dental treatment, not antibiotics. 2

Critical Diagnostic Elements Requiring In-Person Assessment

You cannot adequately assess these key features remotely:

• Presence of facial swelling, cellulitis, or lymphadenopathy indicating spreading infection 1
• Intraoral examination to identify the source (carious tooth, periodontal abscess, pericoronitis) 2
• Signs of systemic involvement: fever, tachycardia, difficulty swallowing, trismus, or floor-of-mouth swelling suggesting Ludwig's angina 1
• Assessment for sepsis: "Could this be sepsis?" must be considered in any suspected infection 1

When Face-to-Face Assessment is Mandatory

Arrange urgent in-person evaluation if the patient reports: 1

• Difficulty breathing or swallowing (potential airway compromise)
• Facial swelling extending beyond the immediate tooth area
• Fever with rapidly worsening symptoms
• Confusion or altered mental status
• Immunocompromise, diabetes, or other comorbidities (lower threshold for complications)

The Antibiotic Resistance Problem

Inappropriate antibiotic prescribing for dental pain contributes significantly to antimicrobial resistance. 2 The belief that antibiotics are appropriate treatment for toothache is widespread among patients, but this expectation must be addressed through education, not inappropriate prescribing. 2, 3 Overuse of antibiotics leads to:

• Increased bacterial resistance 1
• Adverse events including diarrhea, allergic reactions, and Clostridioides difficile infection 1, 2
• Masking of diagnosis and delayed definitive treatment 1

What to Do Instead

Provide self-care advice and safety-netting: 1

• Recommend over-the-counter analgesics (acetaminophen, NSAIDs) for pain management
• Advise when and how to seek urgent care: if symptoms worsen rapidly, facial swelling develops, difficulty swallowing occurs, or fever develops
• Arrange dental evaluation for definitive treatment (the actual cure)
• Schedule face-to-face medical assessment if infection is suspected

Patient education is critical: Explain that antibiotics do not relieve dental pain directly and that definitive dental treatment (drainage, extraction, root canal) is necessary. 2 Studies show that when patient expectations are discussed and modified with appropriate information, satisfaction remains high even when antibiotics are not prescribed. 1

Common Pitfalls to Avoid

• Do not prescribe "just in case"—this encourages antibiotic-seeking behavior and contributes to resistance 1, 2
• Do not assume all dental pain requires antibiotics—most toothaches are due to pulpitis (inflammation), not infection 2
• Do not use antibiotics as a substitute for dental treatment—they only temporize true infections and do not address the source 2
• Do not prescribe without knowing the patient's allergy history, recent antibiotic use, and medical comorbidities—information that requires proper assessment 1

The evidence is clear: remote antibiotic prescribing for toothache is inappropriate practice that increases harm without providing meaningful benefit. 1, 2