Syncope pallor, nausea, diaphoresis,
(90% of all emergencies) dizziness, faint feeling, loss of
consciousness
Hyperventilation (9% of all tachypnea, prolonged may lead to
emergencies) syncope; ‗tight‘ chest pain,
stomach ache, leg cramp, arm
numbness
Anaphylactic Shock hives, rash, pruritus, erythema,
angioedema, tongue swells,
dyspnea, wheezing
Asthma gagging, dyspnea, wheezing,
stridor, cyanosis, unresponsive
Aspiration gagging, dyspnea, wheezing,
stridor, cyanosis, unresponsive
MI SOB, angina, anxiety,
diaphoresis, hypotension
- Trendelenburg position
- Ensure patent airway (head tilt-
chin lift)
- Give oxygen or ammonia
(smelling salts)
- Monitor vital signs
- Postpone further dental care.
Patient must leave w/ escort
- Calm patient and seat upright
- Apply rebreathing (plastic head-
rest cover or ambu bag with O2
but no ventilation)
- Monitor vital signs.
- Identify allergen and discontinue
- Mild: give Benadryl
- Severe: give EpiPen
(1:1000,0.3-0.5 cc IM)
- Maintain airway and give
oxygen.
- Monitor vital signs
- Calm patient
- 2-3 puffs of Albuterol and
monitor vitals
- If good air exchange, encourage
patient to breathe and cough.
- If poor air exchange, do
Heimlich maneuver and/or CPR,
and monitor vitals
- Take patient to Hospital to x-
ray/ surgery
- Position patient upright.
- Give Nitroglycerin and monitor
vitals.
- If pain persists: assume MI.
Give oxygen and/or do CPR until
EMS arrives
- If Arrhythmia - use Defibrillator
(3x) and continue CPR until EMS
arrives
Hypoglycemia combative, dizziness, weakness,
confusion, intense hunger, sudden
collapse, unresponsive,
diaphoretic
- If conscious: give PO sugar
- If unconscious: start IV with
dextrose 50%
- Maintain airway and give O2
- Monitor vital signs.

Seizure sudden collapse, unresponsive,

diaphoretic, eyes roll back under
lids, seizure, patient may vomit,
twitch
- Protect patient: move
instruments, try to control patient
head
- Maintain airway and give O2.
- Many need to start IV, give
valium 1mg/min until seizure
stops

Local Anesthesia Overdose biphasic response: drowsy, visual

disturbances, circum-oral
numbness, increased
talkativeness, apprehension,
slurred speech, muscular
twitching, convulsions, seizure,
loss of consciousness
- Position patient supine.
- Maintain airway and give 02
- Monitor vital signs and wait for
EMS
-Discontinue treatment for this
appointment

Stress Reduction Protocol Diabetes Protocol

- Morning appointments - Normal pre-appt meal
- Short appointments - Normal or slightly reduced insulin dose
- Sedation - Glucose on hand
- Pain control - Watch for hypoglycemia
- Minimize wait time - Reduce post-op insulin if caloric intake is
- Premedication hindered
- Recognize signs of disease

Medical Conditions and Necessary Precautions Recommended Action

Condition
Cardiac Valve disease/Joint prostheses
- Antibiotic prophylaxis (See guidelines)

Coronary Artery disease

- Stress reduction protocol
- Nitroglycerin on hand
- Minimal epinephrine
- Good pain control

Asthma
- Bring inhaler to appointment
- Stress reduction protocol
- Avoid: aspirin, NSAIDS, LA with sulfites
- Triad: Asthma + aspirin + nasal polyps
anaphylactic shock
Hypertension
- ASA Guidelines
o ASA II : 140-160/ 90-95 : stress reduction protocol
o ASA III : 160-200/ 95-115 : stress reduction protocol,
physician consult
o ASA IV : >200/ >115 : no treatment
- Minimize Epinephrine (< 0.04mg)

Diabetes
- Stick glucose
o <85 mg/dl : postpone treatment,
physician referral
o 85-200 mg/dl : stress reduction protocol, antibiotics for
high risk procedures
o 200-300 mg/dl : stress reduction protocol, antibiotics for
high risk procedures, physician referral
o >300 mg/dl : no treatment, send to the
ER
- Normal breakfast, . insulin dosage, have dextrose 50%
available, FSBG pre, intra and post-op, ↓ post-op insulin

Anticoagulants
- Dr. Flynn‘s Guidelines
o Aspirin: <100 mg/day: gelfoam +
sutures
o Aspirin: >100 mg/day : gelfoam +
sutures
o Plavix (Clopidogrel): gelfoam +
sutures
o Coumadin (INR <2.5) : no change
o Coumadin (2.5<INR<4) : physician consult, stop 2 days
pre-op
o Coumadin (4<INR) : physician consult, stop 2-5 days
pre-op, and check INR pre-op (<2.5)

Immunocompromised
- Antibiotic prophylaxis for high risk procedures
- Pts taking steroids: 2x or 3x normal dose 1hr before
procedure

Hemodialysis/ESRD
- Schedule treatment for day after dialysis
- Avoid kidney metabolized drugs
- No BP in same arm as shunt
- Antibiotic prophylaxis

Pregnancy
- Elective treatment only in middle trimester – use left
lateral decubitis position
- Safe drugs: penicillin, cephalosporin, clindamycin, Tylenol
- Avoid: nitrous oxide, metronidazole, tetracycline,
vancomycin, sulfonamides, NSAIDs, mepivicaine,
bupivicaine, opioids, flouroquinolones

ANTIBIOTIC PROPHYLAXSIS

Standard Amoxicillin Adults 2g, Kids 50mg/kg PO 1 hr prior

Penicillin allergy Clindamycin Adults 600mg, Kids PO 1 hr prior
20mg/kg
Azithromycin Adults 500mg, Kids 15mg/kg PO 1 hr prior
Unable to take oral Ampicillin Adults 2g, Kids 50mg/kg IM / IV 30mins prior
medication
Penicillin allergy AND Clindamycin Adults 600mg, Kids IM / IV 30mins prior
unable to take oral 20mg/kg
medications

Amoxicillin 500mg Clindamycin 150mg Azithromycin 250mg

Disp: 12 (twelve) tablets Disp: 12 (twelve) tablets Disp: 6 (six) tablets
Sig: Take 4 tabs PO 1 hr Sig: Take 4 tabs PO 1 hr Sig: Take 2 tabs PO 1 hr
prior to appointment* prior to appointment* prior to appointment*

Anxiety/ Sedation
Valium (diazepam) – half life of 20-100 hrs (long acting)
Ativan (lorazepam) – half life of 9-16 hrs
Halcion (triazolam) – half life of 2 hrs (short acting) *Pregnancy category X

Valium 5mg Ativan 1 mg Halcion 0.25 mg

Disp: 6 (six) tablets
Sig: Take 1 tablet PO hs and 1
tablet PO 1 hr before the
appointment*
Disp: 4 (four) tablets
Sig: Take 1 tablet PO hs and 2
tablets PO 1 hr before the
appointment* then bring the
last pill to the appointment
with you.
Disp: 4 (four) tablets
Sig: Take 1 tablet PO hs and 1
tablet PO 1 hr before the
appointment*
Contraindicated Patients with Pregnant patients Patients that are
Drugs in: Patients kidney disease breast feeding
with liver disease
Aspirin Acyclovir Aspirin Antihistamines
Benzodiazepines Penicillin Benzodiazepines Aspirin
Opioids Opioids Carbamazepine Benzodiazepines
Sedatives Cephalosporins Opioids Carbamazepine
Anti-histamines Benzodiazepines Cotrimoxazole Cotrimoxazole
NSAIDS NSAIDS NSAIDS Metronidazole
Erythromycin Tetracyclines Metronidazole Tetracyclines
Metronidazole Amphotericin Tetracyclines
Tetracycline