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infections. Adjunctive antibiotics and topical antiseptic mouthrinses (such as chlorhexidine gluconate) may be indicated if the patient has persistent infection, increased swelling, cellulitis, malaise, fever, prolonged healing, bisphosphonate use, elevated blood glucose, or is significantly immunocompromised to address the pain associated with infection33,39,40. Post-operative pain lasting more than 3 days may be an indication of a postoperative infection or alveolar osteitis. • Pain that increases 2-3 days post-operatively may be an indication of an alveolar osteitis, which is best treated with the placement of medicament into the extraction site. Opioid medications are generally not indicated for the treatment of alveolar osteitis. 5 • Selection of post-procedural pain management agent(s) should be guided by level of trauma to the tissue during the surgical intervention (Figure 2). Risk of increased post-operative pain and complications are also associated with increases in time it takes to complete a surgical procedure. • The recommendations in this document are focused on teenage and adult patients and are intended for general dentists. It is understood that there are some dental specialists, namely oral surgeons, within IHS that occasionally perform unique and complex surgical procedures that may require prescribing opioids in excess of these recommendations. Recommendations for Prescribing in the General Population: • Pre-operative pain management: o Using a single dose oral NSAID (see figure 1) 30-60 minutes prior to dental procedures may delay onset and reduce intensity of post-procedural pain, though contraindications and perioperative bleeding risks must be considered37,41-44. The use of a pre-operative NSAID is not recommended in procedures anticipated to introduce significant trauma or bleeding. o Consider the use of an antiseptic mouthrinse, such as chlorhexidine gluconate, to promote healing, prevent post-operative infection, and reduce post-operative pain. • Pre-operative or post-operative pain management: o The use of long-acting local anesthetics (e.g. bupivacaine) 5 minutes prior to procedure has been shown to significantly reduce, if not eliminate, acute post-operative dental pain following procedures such as third molar extraction43, reducing the amount of oral postoperative analgesics necessary for adequate pain control. o The use of long-acting local anesthetics (e.g. bupivacaine) immediately post-procedurally has also been shown to significantly reduce post-operative pain intensity, onset, and oral analgesic requirements necessary for adequate pain control45-46. o Long-acting local anesthetics are contraindicated for children under 12, pregnant women, and patients with an amide anesthetic or sodium metabisulfite allergy / sensitivity. Use with caution in elderly patients. Take care to prevent local anesthetic overdoses when used in combination with other local anesthetics. • Post-operative pain management: o Consider prescribing an antiseptic mouthrinse, such as chlorhexidine gluconate, to start 24 hours post-extraction, or immediately following treatment involving tissue trauma only, to promote healing and reduce post-operative pain. o Utilize non-pharmacological pain management strategies for post-procedural pain management (ice packs, heat, dietary restrictions, rest, etc.). o For home management of post-procedural acute dental pain utilizing NSAIDs and/or acetaminophen, consider scheduled