Medical Emergencies in Dentistry

Medical Emergencies

Introduction and Prevention

• A medical emergency is an injury or illness that poses an immediate threat to a person's health or life, requiring help from a doctor or hospital.

Preventive Measures

• Comprehensive health history and risk assessment, paying attention to medication usage.
• Monitoring vital signs: Blood pressure (BP), pulse, respiration, and blood sugar levels (especially for patients with diabetes).
• Anxiety recognition and management, for example, using nitrous oxide.
• Stress reduction protocols, such as shorter appointments.
• Well-trained dental professionals are essential.

Life-Threatening Emergencies in Dentistry

• Life-threatening emergencies can occur in dental practices.
• They can happen to anyone: clients, dentists, staff, or accompanying individuals.
• Although infrequent, several factors can increase the likelihood of such incidents.

Factors Contributing to Medical Emergencies

1. Increased number of older clients and the prevalence of chronic diseases.
2. Medical advancements.
3. Longer appointments.
4. Increased drug use.

Common Medications/Drugs Used in Dental Treatments

• Local anesthetics (e.g., lidocaine).
• Antibiotics (e.g., amoxicillin).
• Sedatives (e.g., nitrous oxide).
• Rinses (e.g., chlorhexidine).
• Fluoride.
• Analgesics (e.g., ibuprofen, acetaminophen).

Aging Population

• As life expectancy increases, so does the number of older clients seeking dental care, increasing the risk of emergency situations.
• Clients may be less likely to tolerate the stress of dental procedures due to complications, increasing the incidence of medical emergencies.
• Cardiovascular disease is the leading cause of death in persons over the age of 65.

Therapeutic Advances in the Medical Profession

• Advanced research, surgical techniques, and education have increased people's lifespan.
• The incidence of disease also rises with age.
• Clients with medical conditions like diabetes and cardiovascular disease are living longer.
• Coronary bypass operations are more common, allowing people to pursue active lives after these surgeries.
• Radiation and chemotherapy allow cancer clients to live longer.
• Single and multi-organ transplants have higher success rates and are performed more frequently.

Cancer Treatments

• Chemotherapy: Medication, typically given intravenously, that stops cell division and is absorbed through the entire system.
• Radiation: Localized treatment that uses high-energy beams to target the tumor itself.

Coronary Artery Bypass Grafting (CABG)

• Surgical procedure to improve blood flow to the heart using a vein graft to bypass blocked coronary arteries affected by plaque.

Record Keeping for Diabetic Patients

• For patients with a history of diabetes (type 1, 2, or gestational), the dental hygienist should record:
  1. A summary of medical and medication history, including advice from the physician/primary care provider.
  2. The decision made by the dental hygienist, with reasons.
  3. Compliance with precautions required.
  4. All procedures used.
  5. Any advice given to the patient.
• Remind patients the night before their appointment to take their medication and monitor blood glucose levels before coming. Also, ask them to bring a list of any new medications.

Items to Have on Hand When Treating a Diabetic Patient

• Hypoglycemia:
  • Orange juice can be helpful in quickly raising blood sugar levels.
• Hyperglycemia:
  • Monitor blood glucose levels.
  • Fluids: Water or sugar-free fluids to help dilute blood sugar levels and prevent dehydration.
  • Avoid sugary foods or drinks, as this will worsen the hyperglycemia.

Medical Clearance for Diabetic Patients

• Yes, if blood glucose is < 3.9 mmol/L [70 mg/dL] or > 11.1 mmol/L [200 mg/dL].
• Yes, if poorly controlled or concerns about dental invasive procedures being performed.

Management of Chronic Disorders

• More effective drug therapies are available today to manage chronic disorders like hypertension, diabetes (type 1 and 2), HIV.
• These medical advances increase longevity.
• The RDH must manage the oral health needs of clients who suffer from chronic disorders that are managed or kept under control.
• These clients are more susceptible to medical emergencies.

Increased Complexity of Dental Procedures and Appointment Length

• As dentistry advances, so do the appointment lengths.
• Crowns, bridges, periodontics, endodontics (e.g., RCT), and prosthesis (e.g., implants) are becoming more common and generally require longer appointments.
• Longer appointment times cause more stress for both healthy and compromised clients, increasing the chances of a medical emergency.

Increased Dental Use of Drugs

• Drugs are used in the dental practice for:

  1. Pain prevention.
  2. Pain management.
  3. Reduction of anxiety.
  4. Treatment of infection.
  5. Prevention of infection.

• All drugs have multiple effects.

• No drug is risk-free.

• Clinicians must know pharmacological actions and proper techniques to decrease the chance of drug-related emergencies.

• Remembering side effects like orthostatic hypotension is associated with many drugs used to manage high blood pressure.

Common Factors Leading to Orthostatic Hypotension

• Age.
• Dehydration.
• Heart disease.
• Anemia.

Common Drug Interactions Resulting in a Medical Emergency

• Local Anesthetic: Doesn’t mix well with alcohol.
• Barbiturates (drugs ending with –tal): Do not mix well with alcohol.
• Standard Opioids: Do not mix well with alcohol - Increase in CNS depressant.
• Metronidazole (anti-infective agent): Doesn’t mix well with alcohol - facial flushing, nausea, headaches, palpitations.
• Refer to Table 2-2 in your textbook (pages 31-35).

Classifying Common Medical Emergencies by Signs and Symptoms

• Classifications are designed to place each life-threatening situation in the category that most closely represents the usual clinical manifestation of the problem.
• However, several situations could also be included in a classification other than the one in which they have been placed.
• Example: Myocardial infarction (heart attack) and cerebrovascular accident (stroke) are possible causes of unconsciousness.
• Refer to Box 1-4 in your textbook (page 13).

Classifying Medical Emergencies by Cause

• Cardiovascular vs. Non-cardiovascular: Does it involve the heart or not?
• Stress-Related vs. Non-Stress-Related: Was it treatment or office induced, or did they present not?
• Table 1-16 in your textbook (page 12).

Cardiovascular – Stress Related

• Angina pectoris, acute myocardial infarction, cerebral ischemia and infarction, pulmonary edema, sudden cardiac arrest.

Non-Cardiovascular – Stress Related

• Vasodepressor syncope, hyperventilation, seizure, acute adrenal insufficiency, thyroid storm, asthma.

Cardiovascular – Non-Stress Related

• Acute myocardial infarction, sudden cardiac arrest.

Non-Cardiovascular – Non-Stress Related

• Orthostatic (postural) hypotension, overdose (toxic) reaction, hypoglycemia, hyperglycemia, allergy.

Potential Emergencies in a Dental Setting

• Syncope
• Shock
• Hyperventilation
• Asthma
• Angina Pectoris
• Cardiac Arrest
• Congestive Heart Failure
• Stroke
• Seizures
• Fluoride poisoning
• Adrenal Crisis
• Hypo/Hyperglycemia
• Allergies
• Hemorrhage
• Foreign Body in Eye
• Chemical Solutions in Eye
• Dislocated jaw
• Avulsed tooth
• Broken instrument
• Facial fracture

Basic Life Support Kit

• Oxygen
• Pulse oximeter (when oxygen is administered to the client)
• Epinephrine (acute allergic reaction)
• Benadryl (antihistamine – mild allergic reaction)
• AED (unresponsive patient, cardiac arrest)
• Albuterol (bronchodilator)
• Glucose
• Nitroglycerin
• Blood pressure unit
• Glucose (e.g., orange juice, sugar cubes, non-diet soft drinks)

Top Ten Emergencies in Private Practice

• Postural hypotension
• Asthmatic attack
• Angina pectoris
• Mild allergic reaction
• Epinephrine reaction
• Cardiac arrest
• Seizures
• Hyperventilation
• Insulin shock
• Syncope

ABC in Medical Emergencies

• A – Airway: Ensuring the airway is open and clear.
• B – Breathing: Checking if the patient is breathing and providing ventilation if needed.
• C – Circulation: Checking the patient’s circulation and performing CPR if necessary.

Syncope

• Definition: Sudden, transient loss of consciousness.
• Cause: Inadequate blood flow to the brain.
• Psychogenic factors: Anxiety, fear.
• Non-psychogenic factors: Hypoglycemia, position change, heat.
• Prevention:
  • Complete medical health history.
  • Dental health history.
  • Stress reduction protocol.
  • Supine position with legs slightly elevated for clients with a tendency to faint.
  • Administer oxygen.
  • Administer ammonia capsule under the patient's nose.
  • Postponing treatment.
  • Delayed recovery of 15-20 minutes: call EMS.
  • Check ABC.

Post Syncope

• Let the client remain in a supine position.
• Administer glucose (optional).
• Determine cause.
• Arrange for someone to accompany the client home.
• Referral for physician.

Orthostatic Hypotension (Postural Hypotension)

• Definition: Sudden drop in systolic BP from a change of body position.
• Systolic: Pressure in arteries during contraction.
• Diastolic: Pressure in the arteries in between beats.
• Causes:
  • Change in position (e.g., supine to sitting, or from sitting to standing).
  • Prolonged bed rest, medications, medical conditions, prolonged standing, pregnancy, age.
  • Addison’s disease.
  • Exhaustion and starvation.

Prevention of Orthostatic Hypotension

• Slowly raising the chair up and have the client sit for a couple of minutes, or asking the client to slowly get up from the chair.
• Signs and symptoms:
  • Lightheadedness, fainting, dizziness upon standing.
  • Pallor, syncope, and sweating.
• Management:
  • Assess the client.
  • Know client’s medical/dental health history.
  • Position client back to supine with feet slightly elevated.
  • Implement ABC.
  • Administer oxygen if needed.
  • Monitor vitals.
  • Delayed recovery: call EMS.

Asthma

• Avoid aspirin due to increased risk of hypersensitivity.
• Inhalers:
  • Short-acting: Albuterol (Salbutamol).
  • Long-acting: Flovent, Salmeterol.
• Instructions to give clients prior to their dental appointment.
• Signs and symptoms:
  • Dyspnea (shortness of breath), tachypnea (increased respiratory rate), tachycardia (increased heart rate), anxiety, chest tightening, nostril flaring, flushing of skin.
• Causes:
  • Extrinsic (allergies): dust, food, drugs.
  • Non-intrinsic (nonallergic): respiratory infections, physiological stress, environmental factors.

Management of Asthma

• Client in sitting position.
• Allow client to use his/her bronchodilators.
• Implement ABC.
• Administer oxygen if needed and then albuterol with nebulizer mask.
• Delayed recovery: call EMS.

Hyperventilation

• Management:
  • Client in sitting/upright position.
  • Calm the client.
  • Implement ABC.
  • Have them cup their hands over mouth and nose and breathe slowly.
  • Oxygen should not be administered.

Angina Pectoris

• Temporary lack of oxygenated blood supply to the myocardium.

Administering Nitroglycerin

• 1-2 metered sprays every 5 minutes.
• Do not exceed more than 3 doses in 15 minutes.

Cardiovascular Emergencies

• Congestive heart failure: Heart muscle incapable of keeping up with supplying blood; Terminate tx plan, call 911, administer oxygen, monitor vital signs.
• Myocardial infarction: Heart attack – not getting enough blood supply; Terminate tx plan, call 911, maintain airways, administer oxygen, monitor vital signs.
• Cerebrovascular accident: Interruption of oxygen to the brain; Terminate tx plan, call 911, maintain airways, administer oxygen, monitor vital signs, perform basic life support CPR if needed.
• Transient ischemic attack: ministroke; If symptoms subside, client to see MD. If symptoms persist: terminate tx plan, call 911, maintain airways, administer oxygen, monitor vital signs, perform basic life support CPR if needed.
• Aneurysms: Ballooning out of a weakened arterial wall which has burst; Terminate tx plan, call 911, maintain airways, administer oxygen, monitor vital signs.

Management of Cardiac Arrest

1. Terminate dental treatment.
2. Position patient: upright if difficulty breathing.
3. Patient position: supine if unconscious.
4. Maintain airways and provide oxygen.
5. EMS.
6. Monitor vitals.
7. Provide BLS.

Seizures

• Prevention/Management
  • Short appointments
  • If prescribed medication, ensure the client has taken the medication prior to the appointment
  • Administer nitrous + oxygen (with 20% of oxygen recommended)
  • Supine position with legs elevated
  • ABC
  • Activate EMS

Top Ten Emergencies Ranked

1. Syncope
2. Mild allergic reaction
3. Angina pectoris
4. Postural hypotension
5. Seizures
6. Asthmatic attack
7. Hyperventilation – not O2
8. Epinephrine reaction
9. Insulin shock
10. Cardiac arrest

Factors That Can Minimize Emergencies in a Dental Practice

• Pre – treatment evaluation methods:
  • Medical history questionnaires (pages 23-30).
  • Dialogue histories.
  • Physical examination.
  • Possible modifications to dental treatment/need for premedication.
• During treatment:
  • Stress reduction techniques.
  • Maintain communication with your client.
• Post-treatment evaluations methods:
  • Stable conditions before dismissal.
  • Referral if needed.

Emergency Medications

• Epinephrine for anaphylactic shock/severe allergies.
• Benadryl for mild to moderate allergies.
• Albuterol for asthma attack.
• Nitroglycerin for chest pain (angina).
• Oral carbs (glucose): hypoglycemia.
• Diazepam for management of seizure.
• Ammonia inhalant for syncope.
• Oxygen for most emergencies (not for hyperventilation).

Diazepam

• Valium is the brand name for the drug diazepam and belongs to the benzodiazepine family.

ASA Physical Status Classification System

• The American Society of Anesthesiologists (ASA) adopted the ASA physical status classification system.
• This represents a method that a doctor can estimate the medical risk to a client who is scheduled to receive “anesthesia” for a surgical procedure.

ASA Classifications

• ASA 1: Normal, healthy client free of systemic disease.
• ASA 2: Client with mild systemic disease.
• ASA 3: Client with severe systemic disease.
• ASA 4: Client with incapacitating systemic disease that is a constant threat to life.
• ASA 5: Moribund client not expected to survive without operation.
• ASA 6: Declared brain-dead whose organs are being removed for donation.
• ASA E: Emergency operation of any varies, with E preceding the number to indicate the patient's physical status.

ASA I

• Normal healthy client without systemic disease with little or no dental anxiety.
• Able to walk two street blocks or one flight of stairs without distress.
• Able to tolerate planned treatment without added risk of complication.
• Green light for treatment.
• Treatment modification not required.

ASA II

• Client with a mild systemic disease or is ASA I with extreme dental anxiety and fear.
• Yellow light for treatment.
• Routine dental care permitted with some thought given to possible treatment modifications, such as prophylactic antibiotics, sedative techniques, length of appointment, possible medical consultation.

ASA III

• Have severe systemic disease that limits their activity but is not incapacitating.
• At rest: do not exhibit symptoms.
• But during physiologic or psychological stress, distress appears, e.g., an angina client is fine in the waiting room but once in the dental chair develops chest pain.
• Yellow light for treatment, elective dental care is not contraindicated, but risk during treatment is increased.
• Routine dental care permitted with some thought given to possible treatment modifications, such as prophylactic antibiotics, sedative techniques, length of appointment, possible medical consultation.
• Example: Moderate to severe COPD, poorly controlled diabetes, or significant cardiovascular disease (e.g., congestive heart failure).

ASA IV – Non-Invasive Treatment

• Have incapacitating systemic disease that is a constant threat to their lives.
• Their medical problems are of greater significance to their health than any planned dental treatment.
• Distress is present even at rest.
• Red light classification.
• Dental treatment should be noninvasive and include analgesics for pain, antibiotics, and treatment for infections.
• If immediate care is needed, it should be done in a hospital setting in case an acute medical emergency occurs.
• Example: Severe heart failure, end-stage renal disease on dialysis, advanced cancer, or other life-threatening conditions.

Readings

• Malamed, Stanley F. (2007). Medical emergencies in the dental office. 7th ed., Missouri: Mosby Inc. – Chapter 1 and 2

Diabetes

Hyperglycemia

• Blood sugar level: high
• Cause: insulin deficiency or resistance
• Treatment: insulin, hydration, manage blood sugar levels

Hypoglycemia

• Blood sugar level: low
• Cause: too much insulin, missed meals, or exercise
• Treatment: glucose, monitor levels