Managing dental pain in general practice.

Regarding the article about managing dental pain in primary care,1 I am disappointed that COX-2 inhibitors were not discussed, as they may be substituted when ibuprofen is not possible. I was also disappointed to see oxycodone so liberally advocated for pain. It is little surprise patients seeking potent opioids attend GP surgeries in out-of-hours settings for oxycodone scripts citing dental pain. Furthermore, atypical opioids (i.e. buprenorphine, tramadol, tapentadol) may be a better option. A recent article discusses their use in chronic pain to limit long-term abuse.2

Aovana Timmerman and Peter Parashos, the authors of the article, comment:

COX-2 selective non-steroidal anti-inflammatory drugs (NSAIDs) such as celecoxib can be considered as an alternative analgesic for patients with gastrointestinal, renal or cardiovascular problems, or for patients who cannot tolerate traditional NSAIDs.1a However, ibuprofen is preferred over celecoxib as it has been shown to be more effective for dental pain. Also, COX-2 inhibitors have been associated with an increase in cardiotoxicity.

In regard to ‘oxycodone so liberally advocated for pain’, we presume this refers to the questionnaire survey findings cited by Dr Teoh2a that ‘16–27% of dentists would preferentially use an opioid or paracetamol instead of NSAIDs for pain relief’. To clarify, this comment did not specifically identify oxycodone. The original paper3 indicated that ‘Only 4–9% of dentists would routinely prescribe inappropriate analgesics, including diclofenac, tramadol, mefenamic acid, ketoprofen, codeine, oxycodone, dexamethasone and diazepam’ from a sample of only 382 responses. Hence, oxycodone was only one of eight inappropriate drugs prescribed by a relatively small sample of dentists surveyed.

Because the effectiveness of opioids for patients with dental pain is modest, they are only used in combination with NSAIDs or paracetamol, and only for severe pain.1a