The Dental Prescription Notes Template

Prescribing antibiotics for pulpitis or dry socket without spreading infection or systemic involvement directly contradicts SDCEP. Below is a template for UK clinicians to paste into their PMS for every prescription.

Why this dental prescription template wins

• Explicit indication linked to clinical diagnosis — defends against SDCEP audit and antimicrobial stewardship review.
• Systemic signs CHECKLIST — defends "yes" for prescribing or "no" for declining.
• Allergy status confirmed at point of prescribing — protects against penicillin anaphylaxis errors.
• Patient counselling specific — 3-day review and stopping when resolved, side effects, safety-netting criteria.
• INN drug name — international non-proprietary, avoids prescribing errors.

The template (paste into your PMS notes field)

Paste the dental prescription template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

INDICATION (clinical reason for prescription): [Explicit link to dental diagnosis]

DRUG (non-proprietary name / INN):
- Name:
- Formulation and strength: [e.g. tablets 250 mg / capsules 500 mg / oral suspension mg per 5 ml]
- Dose:
- Frequency:
- Duration: [Antibiotic: usually 3-5 days — SDCEP]
- Quantity:
- Route: [Oral / topical / IM if relevant]

ALLERGY STATUS: [Reviewed and confirmed today — NKDA / specific allergies recorded]

PREGNANCY / BREASTFEEDING STATUS: [N/A / not pregnant / pregnant — trimester / breastfeeding — BNF checked]

PREVIOUS ANTIBIOTIC HISTORY (if antibiotic): [Recent antibiotic use / resistance concerns]

ANTIBIOTIC STEWARDSHIP DOCUMENTATION (if antibiotic):
- Spreading infection or systemic involvement present: [Y/N — specifics: swelling, cellulitis, lymph node involvement, fever, malaise]
- Observations: [Temperature / pulse / blood pressure]
- Localised infection alone: [Y/N — local measures to achieve drainage, not antibiotic]
- SDCEP-aligned indication: [Confirmed]
- Alternative considered (drainage / extraction / no antibiotic): [Y/N]

RED FLAGS — EMERGENCY HOSPITAL TRANSFER (SDCEP): [None / present]
- Significant trismus, floor-of-mouth swelling, difficulty breathing, difficulty swallowing, rapidly spreading cellulitis, involvement of deep or high-risk fascial spaces, or any clinical concern in an immunocompromised patient → transfer to hospital as an emergency
- Airway compromise or sepsis → call 999
- Record diagnosis and temperature / pulse / blood pressure before transfer

INTERACTION CHECK: [BNF interaction reviewed — patient's other medications considered]

REVIEW (if antibiotic): [Arranged — ideally at 3 days; stop the antibiotic if systemic signs and symptoms have resolved]

PATIENT COUNSELLING:
- Review at 3 days; stop when advised if systemic signs have resolved (if antibiotic): [Explained]
- Side effects: [Reviewed — specific to drug]
- Interactions (food / alcohol): [If applicable — metronidazole: avoid alcohol during treatment and for at least 48 hours after stopping]
- What to do if no improvement: [Return / A&E criteria]

PRESCRIPTION ISSUED VIA: [Paper FP10D / EPS / private]

Try the dental prescription note in the live demo → No account needed.

What good looks like — a worked example

The same dental prescription template, completed for a realistic case.

INDICATION: Acute apical abscess LR6 with spreading infection — localised buccal swelling LR6 with early cellulitis of the buccal sulcus, tender enlarged right submandibular lymph node, temperature 38.2°C. No extra-oral swelling, no trismus (MO 45mm, unchanged from baseline), no floor-of-mouth swelling, breathing and swallowing normal. Drainage achieved at chairside today via pulp extirpation LR6.

OBSERVATIONS: Temperature 38.2°C, pulse 92, BP 128/80.

DRUG:
- Name: Phenoxymethylpenicillin (penicillin V)
- Formulation and strength: Tablets 250 mg
- Dose: 500mg (2 tablets)
- Frequency: Four times daily (QDS), on an empty stomach — 30 minutes before or 2 hours after meals
- Duration: 5 days, with review at 3 days
- Quantity: 40 tablets
- Route: Oral

ALLERGY STATUS: Reviewed today. NKDA confirmed.

PREGNANCY / BREASTFEEDING STATUS: Not pregnant, not breastfeeding.

PREVIOUS ANTIBIOTIC HISTORY: None in past 6 months.

ANTIBIOTIC STEWARDSHIP:
- Spreading infection or systemic involvement present: YES — early cellulitis, lymph node involvement, fever (38.2°C).
- Localised alone: NO — clinical signs of spreading infection.
- SDCEP-aligned indication: CONFIRMED — antibiotic indicated alongside drainage for spreading infection with systemic involvement.
- Alternative considered: Drainage achieved (pulp extirpation today). Antibiotic is adjunctive for spread, not standalone.

RED FLAGS: None — no significant trismus, floor-of-mouth swelling, breathing or swallowing difficulty, rapidly spreading cellulitis or deep/high-risk space involvement. Managed in primary care.

INTERACTION CHECK: BNF reviewed. Patient on no other medications. No interactions.

REVIEW: Review booked for day 3. Patient told to stop the antibiotic at review if the fever and swelling have resolved.

PATIENT COUNSELLING:
- Review at 3 days; stop the antibiotic if advised at review that the systemic signs have resolved
- Side effects discussed: GI upset (nausea, diarrhoea), rash (return if develops — possible allergy), antibiotic-associated colitis (rare but explained warning signs)
- Interactions: Take on an empty stomach, doses spaced evenly through the day.
- What to do if no improvement: Return urgently if swelling spreads, eye closing, difficulty opening the mouth, swallowing or breathing develops, or feeling more unwell. 999 if breathing difficulty.

PRESCRIPTION ISSUED VIA: FP10D (NHS).

PATIENT INSTRUCTED to seek urgent care if no improvement within 48-72 hours.

Compliance: the medico-legal angle

• SDCEP Drug Prescribing for Dentistry (3rd ed, 2016; bacterial infections section updated May 2026) — first-line stewardship reference.
• BNF 91 — current dose / frequency / interaction reference.
• NICE NG15 — antimicrobial stewardship.
• GDC Principle 4 — prescribing decisions documented with clinical rationale.
• GMC Good Practice in Prescribing (cross-reference) — applies to all UK prescribers.

Common documentation mistakes

• Antibiotic for pulpitis or apical periodontitis WITHOUT systemic signs — SDCEP non-compliance, audit failure.
• Antibiotic for dry socket — drainage and analgesia indicated, NOT antibiotic per SDCEP.
• No allergy status recorded — penicillin anaphylaxis risk.
• "Antibiotic given as patient requested" — patient pressure is NOT a clinical indication.
• No safety-netting criteria — patient deteriorates, has no instructions to return.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• NICE CG64: Prophylaxis against infective endocarditis (accessed 18 October 2026)
• NICE NG15: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (accessed 18 October 2026)
• SDCEP: Drug Prescribing for Dentistry (accessed 18 October 2026)
• SDCEP Drug Prescribing for Dentistry: Bacterial infections (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Local Anaesthetic Maximum Doses in Dentistry: A UK Reference
• Dental Drug Interactions: A UK Reference
• Paediatric Dental Doses (UK): Antibiotics, Analgesics and Local Anaesthetic by Age and Weight
• Record-Keeping for Dentists (UK): A Dento-Legal Guide

Related dental note templates

Browse the full set of free dental notes templates.