E m e r g e n c y Dr u g s f o r t h e

D ental O ff i c e
Harry Dym, DDS, Golaleh Barzani, DMD*, Naveen Mohan, DDS

KEYWORDS
 Emergency drugs  Management of airway emergencies  Dental office emergencies

KEY POINTS
 The health care professional and the staff should always be prepared to use emergency
drugs to deal with emergency situations in their dental office.
 Preparedness of the dental office staff and their prompt recognition of emergencies will be
the most important factor in managing the emergencies in any dental office.
 Health care professionals should follow the recommendations in this article to maintain a
guideline for their staff and office and conduct regular emergency drills to examine the
equipment and preparedness of their staff.

INTRODUCTION

Medical emergencies in the dental office are an unavoidable part of the profession.
Even though precautions to prevent such events are undertaken, these events are
inevitable and the dental practitioner must be prepared. Malamed1 reported in his
book that 96.6% of respondents of a survey among practicing dentists had a medical
emergency occur in the office.
Emergencies can range from relatively benign conditions to life-threatening situa-
tions. Syncope and hyperventilation are two of the most common complications
seen in the dental office. One must keep in mind that even these seemingly mild issues
can escalate and cause significant morbidity. Although uncommon, major emergen-
cies, including cardiac, pulmonary, and neurologic events, can occur. The dentist
must be able to manage such situations until emergency medical responders arrive
to the clinic.
Lastly, urgent or emergent situations can occur at any point during the patients’ visit
to the dental office. The patients’ anxiety about the procedure can cause an event in
the waiting room or even intraoperatively. Medications administered can also cause
adverse reactions intraoperatively or even postoperatively.

Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Delslb
Avenue, Brooklyn, NY 11201, USA
* Corresponding author.
E-mail address: gbarzani@gmail.com

Dent Clin N Am 60 (2016) 287–294

http://dx.doi.org/10.1016/j.cden.2015.11.001 dental.theclinics.com
0011-8532/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
288 Dym et al

This article aims to provide the dental practitioner with an overview of emergency
adjuncts and medications. It is advisable for dental practitioners to also have formal
training to manage emergencies, including basic life support and advance cardiac
life support.

Emergency Equipment
Most essential emergency equipment in the dental office includes basic devices used
for management of airway emergencies (Box 1). Dental office staff should be prepared
at all times to provide 100% oxygen through a portable source, such as an E cylinder
or an installed oxygen portal on the wall with use of a face mask, nasal cannula, or use
of nonrebreather mask. Oral airway equipment, such as nasopharyngeal and oropha-
ryngeal airway devices, can also be very useful in managing airway obstructions in
case of airway emergencies. Dental professionals and office staff should routinely
run emergency drills in their dental office (Box 2). It is the responsibility of the dental
professional to assure that all the emergency equipment and oxygen tanks are full
and operational at all times. Running emergency drills in the dental office will assure
that the staff is prepared to deal with emergencies and the equipment are functioning
properly.2
Other tools used in the dental office for management of emergencies are those used
to assess patients’ vital signs. A pulse oximeter, sphygmomanometer, and stetho-
scope should be readily available in every dental office. If the dental office is equipped
with a monitor, the heart rate, blood pressure, and oxygen saturation can be assessed
simultaneously. Practitioners should keep in mind that both adult- and child-sized
cuffs should be available for use with the sphygmomanometer.
In addition to the aforementioned equipment, it is recommended that dental practi-
tioners are trained and proficient in starting an intravenous (IV) line. Necessary equip-
ment includes IV lines, IV catheters of varying gauges, alcohol gauze, and tourniquets.
IV fluids of 1000 mL bags with normal saline 0.9%, dextrose 50%, or lactated ringers
should be part of the emergency armamentarium.

Box 1
Basic emergency equipment for the dental office

Portable or installed oxygen portals with nasal cannula

Bag-valve-mask device
Nonrebreather mask with reservoir
Automated external defibrillator
Oropharyngeal and nasopharyngeal airways
Stethoscope and sphygmomanometer
Yankauer suction tips
Magill forceps
Stethoscope
Sphygmomanometer with small, medium, and large cuff sizes
Wall clock with second hand

Adapted from Rosenberg M. Preparing for medical emergencies: the essential drugs and equip-
ment for the dental office. J Am Dent Assoc 2010;141(Suppl 1):16S; with permission.
 Emergency Drugs for the Dental Office 289

Box 2
Emergency preparedness checklist

 Everyone in the dental office should have specific assigned duties.

 Contingency plans are in place in case a staff member is absent.
 Everyone has received appropriate training in the management of medical emergencies.
 Everyone is trained in basic life support.
 The dental office should be equipped with emergency equipment and supplies that are
appropriate for that practice.
 Unannounced emergency drills should be conducted every few months.
 Emergency telephone numbers should be placed near each phone.
 Oxygen tanks and oxygen delivery systems should be checked regularly.
 All emergency medications are checked monthly and replaced if expired or to be expired.
 All emergency supplies are restocked immediately after use.
 One staff member is assigned to review this checklist regularly.

Adapted from Rosenberg M. Preparing for medical emergencies: the essential drugs and equip-
ment for the dental office. J Am Dent Assoc 2010;141(Suppl 1):15S; with permission.

The American Heart Association now requires every health care professional office to
be equipped with an automated external defibrillator (AED). It is the responsibility of the
general dentist in charge to assure that his or her staff is trained to operate an AED. This
training involves taking basic life support courses and having a current certificate.3

EMERGENCY MEDICATIONS

Dental practitioners should maintain an emergency kit with key basic drugs for emer-
gencies in the clinic (Fig. 1). This article provides a general guideline for the emergency
drugs used in a dental office. These drugs can be administered via various routes, such
as subcutaneous, intramuscular, sublingual, IV, or intraosseous routes. It is recommen-
ded that the dental practitioners have a designated person assigned to regularly inspect
the emergency equipment and the emergency kit to assure all oxygen tanks are full and
operational and no emergency medications have expired. The following medication list
can serve as a guideline for emergency kits for dental practitioners.

Fig. 1. Emergency kit.

290 Dym et al

Oxygen
Hypoxemia is a common occurrence in many medical emergencies, highlighting the
importance and the need for delivery of supplemental oxygen. Multiple routes are
available for delivery of oxygen, and the authors recommend that all offices should
have a bag-valve-mask device (Ambu-bag, Ambu, Ballerup, Denmark) and a full-
face mask to allow for positive-pressure ventilation (Fig. 2).2,3

Respiratory Stimulants: Aromatic Ammonia

Syncope is a commonly encountered medical emergency in the dental office. Return
to consciousness is typically achieved by placing patients in the Trendelenburg posi-
tion, administering supplemental oxygen, and using aromatic ammonia. Aromatic
ammonia, when cracked or crushed and held 4 to 6 in under the nose, allows the
release of a noxious odor that stimulates the respiratory and vasomotor centers of
the medulla.2,3

Antiplatelets: Aspirin
If patients are experiencing chest pain and there is a suspicion of myocardial infarction
or ischemia, aspirin should be given to chew. Rapid and sustained anticoagulative ef-
fects are achieved by having patients chew for 30 seconds and then swallow a non–
enteric-coated aspirin (325 mg). Caution, however, should be used in administering
aspirin to patients with severe bleeding disorders and allergies to aspirin.2,3

Fig. 2. Oxygen tank and bag-valve-mask device.

 Emergency Drugs for the Dental Office 291

b2-agonists
A bronchodilator, such as albuterol, is used in the treatment of patients with acute
wheezing and bronchospasm secondary to asthma. These agents can be used 2 or
3 times every 1 or 2 minutes up to 3 times as needed. Albuterol is available in a
metered-dose inhaler and is the most selective of the b2-agonists, which cause bron-
chial smooth muscle relaxation. Fewer side effects are reported with albuterol than
other bronchodilators.2,3
Antihypoglycemic Agents: Glucose
Offices should carry oral hypoglycemic agents to increase blood glucose levels in
conscious patients with hypoglycemia. Simple sources, such as fruit juice, cola, or
candy, are sufficient for conscious patients; however, oral formulations of glucose
should never be administered to unconscious patients because of the risk of aspira-
tion. If patients are unable to swallow and the dentist can obtain IV access, dextrose
50% in water can be administered with IV.2,3
Nitroglycerine
Nitroglycerine, a vasodilator, is recommended for the relief of acute chest pain in pa-
tients who have a past history of angina or undiagnosed angina with symptoms of
myocardial infarction. The most common formulations found in the dental office
setting are the 0.4-mg metered aerosol and sublingual tablets. Recommended dose
for nitroglycerine tablets is 0.4 mg administered sublingually or in the form of translin-
gual spray every 5 minutes up to 3 doses. 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 and loses potency after 12 weeks. Common side effects of nitro-
glycerin are headaches, dizziness, and flushing. Nitroglycerine should not be
administered to patients taking medication for erectile dysfunction.2,3
Epinephrine
Epinephrine, a sympathomimetic drug, acts on a-adrenergic and b-adrenergic recep-
tors. Epinephrine can be administered as auto-injections or preload syringes or am-
pules: 1:1000 solution subcutaneously, intramuscularly or sublingually; adult dose of
0.3 mg, children 0.15 mg.3 The primary effects of epinephrine include bronchodilation,
vasoconstriction, increased heart rate and contractility, increased cerebral blood flow,
and stabilization of mast cells (involved in severe allergic reactions). These effects make
epinephrine useful during severe bronchospasm, cardiac arrest, and anaphylaxis.2,3
Diphenhydramine
Diphenhydramine is histamine blocker used to reverse the effects of mild or delayed-
onset allergic reactions. It is available in oral and parental forms. A dose of 50 mg of
diphenhydramine can be administered intramuscularly or 25 to 50 mg orally every 3
to 4 hours.3

EMERGENCY MEDICATIONS FOR INTRAVENOUS SEDATION

Dentists and specialists providing IV sedation should also maintain supplemental

injectable drugs, including but not limited to analgesics, anticholinergics, anticonvul-
sants, antihypertensives, corticosteroids, vasopressors, and reversal agents, with the
other emergency medications present in the office. The onset of action is faster when
drugs are injected via IV. The following medications are typically used when in-office IV
sedation is being performed and IV access has already been established. Many of
292 Dym et al

these medications can also be used in an emergency situation involving nonsedated

patients.

Anticholinergics
Muscarinic receptors are the target of anticholinergic medications. When activated,
these receptors cause parasympathetic effects on specific organs. The 3 primary anti-
cholinergic medications are atropine, glycopyrrolate, and scopolamine. These medi-
cations are useful in the management of hypotension. Atropine has the fastest
onset time and is used to treat bradycardia in emergency situations. It blocks vagal
stimulation to the heart allowing for unopposed sympathetic stimulation. The typical
dose to treat bradycardia is 0.5 mg IV. Additional drug can be titrated to effect with
a maximum dose of 0.04 mg/kg. Dosing of less than 0.4 mg has been shown to cause
bradycardia.4

Ephedrine
Aside from parasympathetic suppression, another method of managing hypotension
is adrenergic agonism. Ephedrine displays both a1 and b1 adrenergic agonism. In
turn, the drug causes increased peripheral vascular resistance, positive cardiac chro-
notropic, and positive cardiac inotropy.5,6 It is useful in the treatment of moderate to
severe hypotension, particularly in situations when patients are bradycardic. Typical
dosing is 5-mg bolus every 10 minutes and titrated to desired effect. Onset time
can be up to 10 minutes.6

Phenylephrine
Phenylephrine is another useful adrenergic agonist used in the management of hypo-
tension. Unlike ephedrine, phenylephrine is a selective a1 agonist. Usage results in pe-
ripheral vasoconstriction causing increased blood pressure. This medication is useful
when patients have tachycardia or a normal heart in the presence of hypotension. It
has a fast onset and short duration of action of 5 to 10 minutes.5 A total of 100 mg
should be administered every 10 to 15 minutes for the hypotension. Reflex brady-
cardia typically accompanies administration. The clinician should be mindful of the
heart rate when treating hypotension with this medication.

Naloxone
Fentanyl is almost universally used in IV sedations in the dental office. Respiratory
depression and oversedation can occur when fentanyl is overdosed. Naloxone is an
opioid antagonist that will reverse all of the effects of opioids, including analgesia, res-
piratory depression, and chest wall rigidity.7 Dosing is 0.4 mg to 2 mg IV and can be
titrated in increments of 0.1 mg to effect.4 Caution must be exercised, as the duration
of action of naloxone is 30 to 45 minutes. If residual opioids are still present, it is
possible for their effects to manifest again.

Flumazenil
Along opiates, benzodiazepines are used in most IV sedations, specifically midazo-
lam. Effects of this class of medication include anterograde amnesia, sedation, and
anxiolysis. In association with other medications, respiratory and central nervous sys-
tem can occur requiring reversal agents.8 Usual dose is 0.1 mg to 0.2 mg incrementally
titrated to 1.0 mg.4 Like naloxone, the effects the benzodiazepine medication can be
present after flumazenil has been metabolized. Caution should be exercised when flu-
mazenil is used in patients with epilepsy.
 Emergency Drugs for the Dental Office 293

Labetalol
Labetalol is used in the management of hypertension. This medication blocks a1 and
b1 adrenergic receptors. In turn, it decreases peripheral vascular resistance and sym-
pathetic stimulation to the heart. In larger doses, labetalol can block b2 adrenergic re-
ceptors and lead to increased airway resistance. Dosage recommendations are 20 mg
initially followed by an additional 20 mg at 10-minute intervals.9,10 Precaution must be
used in patients with asthma, bradycardia, and congestive heart failure as the agent
can exacerbate these conditions.

MEDICATION STORAGE AND MONITORING

The emergency kit, medications, and oxygen should be placed in an area that is
readily accessible and familiar to personnel in the event of an emergency.
The following are suggestions to ensure patient safety and effective monitoring of
medications:
 Hold frequent (semiannual or quarterly) emergency drills in which every staff
member’s role is detailed.
 Store all emergency drugs and equipment in an easily accessible area.
 Perform an annual review to check for drug expiration dates and the level of the
oxygen tanks.
 Develop cheat sheets for what procedure to follow based on the nature of the
emergency.
 Have the telephone numbers of emergency personnel or the local volunteer
ambulance service readily available.
 Patient emergencies can occur in the office waiting area, so have airway equip-
ment that is mobile and easily transferable rather than fixed to a room.

SUMMARY

Any dental office can be faced with variety of medical emergencies; therefore, the
health care professional and the staff should always be prepared to deal with these
emergencies in their office. Preparedness of the dental office staff and their prompt
recognition of these emergencies will be the most important factor in dealing with
the emergencies in any dental office. Health care professionals should follow the rec-
ommendations in this article to maintain a guideline for their staff and office and
conduct regular emergency drills to examine the equipment and preparedness of their
staff.

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