Medical Emergencies in Dental Practice

By Orrett E. Ogle, Harry Dym and Robert J. Weinstock

The active use of preventive measures is invaluable in clinical practice, but the best way to ensure effective management of a medical emergency is to be prepared in advance. Practitioners and their entire dental staff must be ready to confront medical emergencies that may arise during treatment with sufficient medical knowledge to initiate appropriate primary treatment. This accessible manual addresses the most common medical emergencies encountered during dental treatment. Step-by-step treatment guidelines and decision-making algorithms outline the steps for immediate treatment and make this practical book an essential office manual.

• Language: English
• Publisher: Quintessence Publishing Co, Inc
• Release date: Oct 1, 2019
• ISBN: 9780867159110

Book preview

1

Pretreatment Evaluation of the Dental Patient

Orrett E. Ogle, DDS

Prevention is the most important aspect of preparation for medical emergencies. The dental practitioner can prevent many emergencies by conducting a thorough medical history, making appropriate alterations to dental treatment as required, and optimally stabilizing the patient’s medical condition when possible. This chapter will discuss pretreatment assessments that are essential to ensuring that the dentist can provide dental treatment that is also medically appropriate for each patient.

Medical Assessment

A thorough initial medical evaluation to identify correctable medical abnormalities and determine the residual risk is mandatory for all patients undergoing dental treatment. The preoperative evaluation is the foundation for minimizing undesirable outcomes; the clinician can use the assessment to identify and mitigate risk factors and develop a plan that will best balance the risks, benefits, and alternatives that are available.

Routine preoperative evaluation will vary among patients, depending on their age and general health. In evaluating a patient for any interventional procedure, the dental surgeon must consider two aspects: (1) the necessary work-up that must be performed prior to treatment and (2) whether the patient can safely undergo the planned dental or surgical procedure.

Medical questionnaire

The most efficient method of obtaining the medical history is to use a medical questionnaire. The form should be detailed and comprehensive (Fig 1-1). All health questions must be answered. Pertinent positive answers must be addressed, and certain negative answers, such as allergies or bleeding history, must be confirmed. The patient should be verbally questioned about the severity and control of the disease. All medications must be noted.

Fig 1-1 Sample of long medical history form. NSAIDs, nonsteroidal anti-inflammatory drugs.

Any medical condition that could affect dental treatment or that could be affected by dental treatment should be noted on the record treatment page under a section for past medical history. If the condition is critical (eg, allergies or heart conditions), the external portion of the chart should be flagged with a sticker for medical alerts or annotated in red ink. Electronic records should also be flagged using the method available in the software system.

Emergency telephone numbers should be prominently posted on the health questionnaire. For individuals with serious illness, the name and telephone number of the primary care physician should also be obtained.

If there are serious health issues, the health history should be updated at every visit, and any changes in the condition should be noted in the record. The health history must be dated and signed by the patient or parent/guardian and the dentist. Failure to sign the form may imply that the dentist did not review it.

A detailed medical history will identify potential management problems (physiologic and pharmaceutical) and allow the dental surgeon to formulate a treatment plan in light of the medical status. A patient may present with one or multiple established medical diagnoses, which may alter how dental care is delivered. The role of the dentist is to determine how these medical problems will influence care or how dental care may affect medical treatment. Medical illness may predispose the patient to acute physiologic decompensation under stress or failure to do well posttreatment, or it may lead to drug interactions. The dentist must be aware of potential results and what precautions must be taken to minimize risks. Clinicians must identify issues that should be addressed prior to treatment (eg, insulin, warfarin, or aspirin use), illnesses that may cause physiologic decompensation during treatment (eg, angina, seizure disorders, or asthma), and conditions that may affect the posttreatment phase (eg, diabetes [infection and delayed wound healing] or aspirin use [impaired hemostasis]).¹

Medications

The patient’s medical record must list all drugs that the patient is currently taking. The dentist should know what each drug is and why it is being used. Information on drugs can be obtained very quickly from programs downloaded to smartphones or laptop or tablet computers. Some available apps are Epocrates (Athenahealth), Davis Drug Guide (Unbound Medicine), Pocket PC drug guide (Softonic), and Drugs.com medication guide (Drugs.com).

The dentist should pay special attention to side effects associated with the patient’s medications, because some side effects may affect dental treatment. For example, heart medications, blood pressure drugs, sedatives, muscle relaxants, and other medications may contribute to bladder control problems. Patients taking these drugs need to urinate frequently and will not be able to tolerate long appointments. Pregabalin (Lyrica, Pfizer), thiazides, all diuretics, and carbonic anhydrase inhibitors are other drugs that will cause frequent urination and urgency.

Another common medication side effect that impacts dental care is xerostomia. More than 500 drugs can cause xerostomia. Medication use is the most frequent cause of xerostomia complaints, especially among the elderly.² Xerostomia can affect the comfort of removable prostheses, cause angular cheilitis, and promote candidal infections.

Medical consultation

Medical consultations are necessary when diagnostic medical questions are present or when the patient has medical problems that are beyond the dentist’s knowledge base. The dentist should ask the consultant at least these basic questions:

• Is the patient in optimal condition to undergo routine dental treatment in an office setting?

• Does the patient have reversible disease?

• Where is the patient in the continuum of disease?

Simply sending a request asking a physician to clear a patient for a dental procedure is likely to yield an equally uninformative response of patient cleared and must be avoided.¹ Even when a physician states that a patient is medically cleared, the final decision regarding treatment is the responsibility of the dental surgeon. A medical consultation is simply a tool for risk assessment and is not a green light to the dentist indicating that all will be well.

Risk Analysis

A useful step in patient assessment is to assign an American Society of Anesthesiologists (ASA) physical status classification (Fig 1-2).¹ This will inform the dental team of the degree of risk the patient’s physical ailments constitute. Figure 1-3 and Table 1-1 provide further classification strategies¹,⁴ for patients who have cardiac disease. Nondisease factors that are not listed in the ASA classification but that must be regarded as an additional risk are extreme age (more than 80 years), increased body mass index, and pregnancy that is close to the estimated date of delivery.¹

Fig 1-2 ASA classification of physical status. (Reprinted from the ASA³ with permission.)

Fig 1-3 Canadian Cardiovascular Society classification of angina pectoris. (Modified from the Canadian Cardiovascular Society⁴ with permission.)

*Modified from Petranker et al¹ with permission.

†See Fig 1-2.

The dental practitioner must emphasize risk reduction strategies and find a balance between the risks and benefits of performing an oral procedure. The risk-benefit ratio must always stay in the patient’s favor. The clinician should also consider alternative approaches and when it is appropriate not to perform any intervention.

The first step in risk mitigation is to ensure that the patient is in as healthy a condition as possible. Table 1-2 outlines an approach for evaluating patients depending on the answers provided in the medical history.¹ Disease that can be reversed, should be.¹ Patients at risk for cardiovascular disease who are not currently under medical care should be evaluated by an internal medicine specialist for disease and managed medically before dental treatment is initiated. At-risk patients include elderly patients; patients with long-standing diabetes, hypertension, or dyslipidemia; and patients with a history of smoking, previous myocardial infarction, or angina. Figure 1-4 presents an algorithm for pre-treament evaluation and classification of the dental patient to determine when to continue with routine dental care, modify treatment, or refer for medical consultation.

*Modified from Petranker et al¹ with permission.

  NSAID, nonsteroidal anti-inflammatory drug; INR, international normalized ratio.

Fig 1-4 Algorithm for pretreatment evaluation and classification of the dental patient. MI, myocardial infarction; UA, unstable angina; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.

Conclusion

The dentist can prevent many emergencies by completing a thorough pretreatment assessment to identify the risks associated with treatment for each patient. The assessment begins with a medical history questionnaire, including an investigation of all medications the patient is taking. When necessary, the patient’s physician or medical specialists should be consulted prior to treatment. Classifying the patient’s health enables the dentist to alter the treatment plan as required and optimally stabilize the patient’s medical condition prior to dental treatment.

References

1.  Petranker S, Nikoyan L, Ogle OE. Preoperative evaluation of the surgical patient. Dent Clin North Am 2012;56:163–181.

2.  Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:28–46.

3.  American Society of Anesthesiologists. ASA physical status classification system. Last approved October 15, 2014. http://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed March 3, 2015.

4.  Canadian Cardiovascular Society. Grading of angina pectoris. http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/Ang_Gui_1976.pdf. Accessed March 13, 2015.

2

Essentials of an Emergency Kit

Curtis Holmes, DDS

Harry Dym, DDS

Opening a private dental office can be a complicated task for a new general dentist. Aside from the known clinical responsibilities, the practitioner faces numerous nonclinical areas of concern, including patient billing, accounting, insurance, infection control, and appointment scheduling. A critical area that is often overlooked is preparation for a medical emergency.

Medical emergencies are unexpected and infrequent, but dentists are expected to have the ability to diagnose and treat medical emergencies. Dentists are often held legally responsible for any unfavorable outcomes resulting from mismanagement of those medical emergencies. The ability and preparation of the clinician and staff to respond to an emergency play a key role in potential outcomes. Therefore strategic planning for the management of medical emergencies in the dental office should be forefront in the mind of professionals starting a new office. In addition, established practitioners must ensure that the office remains ready to respond promptly and efficiently to such events.

Considering that dentists treat numerous patients who are taking multiple medications for underlying medical conditions and the fact that the dental office can be a stressful environment for some patients, it is not surprising that medical emergencies may arise. Some of the commonly encountered medical emergencies in the dental office include adverse drug reactions, altered mental status, shortness of breath, chest pain, diabetic complications, and seizures. This chapter focuses solely on the policies, equipment, and personnel needed to prepare for management of emergencies, should they occur. Diagnosis and management of specific medical emergencies are covered in subsequent chapters. Detailed discussion of the pharmacology of the drugs used, the techniques, and the underlying physiology is readily available elsewhere.¹,²

Staff Preparation

To successfully prepare for medical emergencies, dental professionals must formulate policies and an emergency protocol. The core of the emergency plan is having the dental office team certified and prepared to provide basic life support and seek emergency medical services in an efficient and timely manner. All office personnel should have specific responsibilities in the event of an emergency. Front office staff should have emergency telephone numbers readily available. Establishing a code word that informs the staff of an emergency and elicits the appropriate emergency response is beneficial.³

Mock emergencies should be performed regularly so that the staff will respond appropriately should the need arise. It is recommended that the mock emergencies be unannounced and occur quarterly or semiannually.

Office Equipment

Dental offices should be prepared and equipped to provide basic airway management to a patient in need (Fig 2-1). Oxygen is a key component in a medical emergency, and office personnel should be able to administer 100% oxygen through a portable source (E cylinder; see Fig 2-2). The office should have devices that allow supplemental oxygen administration to both the conscious and unconscious patient. Oxygen can be delivered via a nasal cannula, face mask, or face mask with reservoir. Nasopharyngeal and oropharyngeal airway devices can be useful adjuncts to overcome airway obstruction (see Fig 2-3). Dental professionals must frequently check to ascertain the status of the oxygen tank, even if multiple backup tanks are present.³

Fig 2-1 Emergency equipment for the dental office.

Fig 2-2 Type E oxygen cylinder.

Fig 2-3 Nasopharyngeal and oropharyngeal airways.

Equipment that allows the monitoring and assessment of a patient’s vital signs is useful to have. Ideally, a stethoscope and sphygmomanometer (with child- and adult-sized cuffs) should be considered basic emergency equipment in the dental office. If possible, automated vital sign monitors can be used to assess heart rate, blood pressure, and oxygen saturation.

An automated external defibrillator (AED) should be present in the office (see Fig 2-4). The AED eliminates the need for training in rhythm recognition but it does require that the dentist and key staff be trained in its use by participating in the American Heart Association’s basic life support course.

Fig 2-4 Automated external defibrillator.

Fig 2-5 Magill forceps and laryngoscope.

If the office personnel have advanced training, provide intravenous sedation, or are proficient in venipuncture, a few other items should be a part of the emergency armamentarium (see Fig 2-1). Offices with this level of training should have tourniquets, alcohol gauze, angiocatheters, and an assortment of syringes and needles. Intravenous fluids (normal saline 0.9% and dextrose 50% in water) should also be available.³

The emergency kit, like the oxygen tanks, should be checked and updated regularly.

Emergency Drugs

In addition to the armamentarium previously indicated, general dentists and dental specialists should develop an emergency kit stocked with key resuscitation drugs (Box 2-1 and Fig 2-6). Those offices providing intravenous sedation will certainly have more comprehensive emergency drugs available. Emergency medications should be checked regularly, and replacement drugs should be ordered before the expiration dates approach.

Fig 2-6 Emergency drug kit.

Oxygen

Hypoxemia is a common occurrence associated with many medical emergencies, making delivery of supplemental oxygen of primary importance. Multiple routes are available for delivery of oxygen; however, the authors believe that all offices should have a bag-valve-mask device (Ambu bag, Ambu) and a full-face mask to allow the dentist to provide positive-pressure ventilation should the need arise (Fig 2-7).

Fig 2-7 Bag-valve-mask device.

Aromatic ammonia

Syncope is a common medical emergency in the dental office. Aromatic ammonia is a general arousal agent indicated for use in these situations (Fig 2-8). It should be cracked or crushed, allowing the release of a noxious odor that stimulates the respiratory and vasomotor centers of the medulla. This agent, in combination with supplemental oxygen and placing the patient in the Trendelenburg position, causes most patients to return to consciousness.

Fig 2-8 Ammonia ampule.

Aspirin

It is recommended that patients experiencing chest pain suggestive of ischemia or any other symptoms of an acute myocardial infarction (heart attack) chew an aspirin. A non–enteric-coated aspirin (325 mg), chewed for 30 seconds and then swallowed with water, is thought to have rapid and then sustained anticoagulative effects. Caution should be used in administering aspirin to patients with severe bleeding disorders or allergies to aspirin.

Albuterol

Bronchodilators are the lead drug groups used for the treatment of acute wheezing and bronchospasm secondary to asthma attack. Selective β2-agonists cause bronchial smooth muscle relaxation. Albuterol is the most selective of the β2-agonists, and it is available in a metered dose inhaler. Albuterol also has fewer side effects than other bronchodilators.

Glucose

Some preparation of oral hypoglycemic agents should be present in the office to increase blood glucose levels in patients suffering from hypoglycemia. Offices should store a simple sugar source such as fruit juice, cola, or candy for the conscious patient. Oral formulations of glucose should never be administered if the patient is unconscious, because of the potential risk of aspiration. If the patient cannot swallow and the dentist has or can obtain intravenous access, dextrose 50% in water should be administered by any intravenous route (Fig 2-9). Alternatively, injectable glucagon is available (Fig 2-10).

Fig 2-9 Dextrose 50% in water emergency kit.

Fig 2-10 Glucagon kit for treatment of low blood sugar.

Nitroglycerine

Nitroglycerine is a vasodilator recommended for relief of acute chest pain in patients who have a past history of angina. It is also used in patients with undiagnosed angina with symptoms of myocardial infarction. Nitroglycerin is available in many forms, but in the dental office setting the 0.4-mg metered aerosol and sublingual tablet are most often used. The aerosol form does not require special storage and has a longer shelf life than the tablet form, which requires storage in light-resistant containers. Common side effects of nitroglycerin are headaches, dizziness, and flushing. Nitroglycerine should not be administered to patients taking drugs prescribed for erectile dysfunction.

Epinephrine

Epinephrine is a sympathomimetic drug that acts on α-adrenergic and β-adrenergic receptors. The primary effects of epinephrine include bronchodilation, vasoconstriction, increased heart rate, myocardial contractility, and cerebral blood flow, along with stabilization of mast cells (involved in severe allergic reactions.) The effects make epinephrine useful during severe bronchospasm, cardiac arrest, and anaphylaxis.

Diphenhydramine

Diphenhydramine is a histamine blocker used to reverse the effects of mild or delayed-onset allergic reactions. It is available in oral and parenteral forms.

Injectable drugs

Dentists with advanced training and specialists providing intravenous sedation should maintain supplemental injectable drugs with the other emergency medications present in the office. Supplemental injectable drugs include, but are not limited to, analgesics, anticholinergics, anticonvulsants, antihypertensives, corticosteroids, vasopressors, and reversal agents. The speed of drug action is increased when drugs are injected into the vascular system. During a medical emergency, it may