Opioids are not generally regarded as a significant part of pain management protocols in general dental practice. Most dental pain can be managed with paracetamol, ibuprofen or a combination of these drugs.

An unsubstantiated emphasis is often placed on combination products containing codeine. The quantity of codeine in these combinations is insufficient for an effective analgesic effect and there is no greater benefit over paracetamol and ibuprofen alone.

Dental pain should always be addressed from a diagnostic approach. The pivotal step is identifying the cause of the pain. Once identified, managing the local cause such as an odontogenic infection will manage the pain. Analgesics then play a supportive but significantly less important role and paracetamol and ibuprofen are appropriate.

The main problems with opioids are patients who actively seek prescriptions. Contacting the patient's doctor is recommended.

Dental practitioners are responsible for the oral health care of patients on methadone programs. There are a number of very significant concerns with respect to the maintenance of oral health in an often adverse oral environment. When possible, patients should be under careful dental review with a stringent preventive program in place to intercept the irreversible damage that may be associated with methadone. The main concern is dry mouth. Salivary hypofunction is a major risk factor in the development of dental caries, but this can be overcome by careful education and support programs. Nausea and vomiting may also be problematic for some patients and should be discussed as a routine part of the dental consultation.

Conflict of interest: none declared.

Neil Savage

Deputy Chair, Dental Therapeutics Committee, Australian Dental Association