Sir, as aerosol generating procedures (AGPs) are currently under a moratorium due to COVID precautions, dentists are being advised to use analgesia as a pain temporising method much more than in normal dental practice.

Ibuprofen is being recommended at doses of up to 2,400 mg/day and much more extensive use of diclofenac is being advised. Both are likely to be used for much longer periods than the 5-7 days familiar to dental practitioners.1 These are NSAID drugs which are safely used by dentists in healthy individuals, but in certain medical conditions it is important that dentists are aware of the serious adverse effects that they can cause. Patients with asthma, renal disease, liver disease, allergy/angioedema, peptic ulcer disease, acute cardiac and stroke risk and cardiac failure are all groups where special caution is required when using NSAID analgesics. They are also not recommended for use into the third trimester of pregnancy. NICE has issued guidance to medical practitioners starting these medicines for longer term or high dose use and dentists would be well advised to look at this guidance until more specific dental focussed information is available.2 In many of these risk groups paracetamol is a safer alternative.

Drug interactions are important and dentists should check a patient's existing medication through the BNF/eBNF/BNFC for unfamiliar interactions when considering high dose or high potency NSAID prescribing. Warfarinised patients should not routinely be given an NSAID. New oral anticoagulants, such as apixaban and dabigatran, are more tolerant of NSAID use although some platelet effects may cause mildly prolonged bleeding. High dose ibuprofen should not be used in patients taking aspirin 75 mg/day as it reduces the cardioprotective effect.3

Dentists should remember that in these risk patients, paracetamol and codeine (co-codamol 8/500) may be preferred to a NSAID and is available over the counter at a pharmacy or as Solpadeine Max (12.8/500). A stronger version of co-codamol (15/500) is available through a GP's prescription as are other opioid medicines. Where the dentist is unsure about providing high dose or long course analgesia, or when prescribing in the risk groups above, it is sensible to contact the patient's GP for advice before issuing the prescription.