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adequately control underlying inflammation that contributes to acute dental pain8,24,25,29,37. Additionally, there are more adverse effects associated with opioid therapy than other analgesic medications. Therefore, opioids should be reserved for severe pain after optimization of other medication classes or for patients that cannot take other pain medications such as NSAIDs or APAP. Also, codeine is contraindicated in children < 12 years of age and tramadol is contraindicated in children < 18 years of age. All patients should be counseled not to combine acetaminophen/opioid combination prescriptions with other over the counter medications containing acetaminophen. 4 General Recommendations • Follow the recommendations laid out in the ADA Statement on the Use of Opioids in the Treatment of Dental Pain. See Appendix A. • Dentists should be knowledgeable about educational and consultative services available to help them with decisions regarding opioid prescribing. See Appendix B. • Dentists should be knowledgeable about medications, such as benzodiazepines, that cause sedation and should avoid prescribing opioids to patients who are currently taking sedating medications. See Appendix C. • Dentists practicing within the Indian Health Service are required to complete responsible opioid prescribing curriculum per IHS Special General Memo 16-05. Specifically all Federal prescribers, contractors (that spend 50 percent or more of their clinical time under contract with the Federal Government), clinical residents and trainees are expected to comply with this mandatory training requirement. To successfully complete this requirement, all prescribers meeting the above established criteria, must pass the post test of the IHS Essential Training on Pain and Addictions course. Dental prescribers must also complete refresher training every three years. • Address pain control expectations of patients, with the goal of 30%-50% pain reduction. Patients should be educated that post-operative pain is often less than pre-operative pain if infection or pulpal inflammation was present. A pain medication that was not effective prior to treatment may be sufficient post-operatively. • Extended-release / long-acting opioid formulations should not be used for acute dental pain. • If opioid therapy is being considered, patients and/or guardians should be counseled on the risks of opioid therapy, including adverse effects and risk of misuse and abuse with opioid medications. • Dentists should be knowledgeable about local substance abuse programs / resources and become comfortable referring patients to these programs and discussing patient resources. • Medical history questionnaires should include questions about substance use, abstinence-based therapy, or medication-assisted therapy for opioid misuse38. • Dentists practicing in clinics attached to health centers and hospitals should consider utilizing urinary drug screening whenever an opioid prescription is being considered but current drug or alcohol use is suspected. • The IHS strongly recommends utilizing the prescription drug monitoring program (PDMP) any time opioid therapy is being considered for any duration or quantity and documenting that this was done, along with any significant PDMP findings. This is a requirement for all opioid prescriptions greater than 7 days. • Surgical intervention to clean/remove the infected tissue is the standard of care for dental pain due to underlying