MEDICAL EMERGENCIES IN THE DENTAL OFFICE

CHAPTER 1

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 INTRODUCTION
▪ Life-threatening emergencies can and do occur in the practice of dentistry.

▪ They can happen to anyone - a patient, a doctor, a member of the office staff,
or a person who is merely accompanying a patient.

▪ Factors can increase the likelihood of emergencies in the dental office:

• The increasing number of older persons seeking dental care

• Therapeutic advances in the medical and pharmaceutical professions

• The growing trend toward longer dental appointments

• The increasing use and administration of drugs in dentistry.

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 INTRODUCTION

▪ Factors that minimize the development of life-threatening situations.

• Pretreatment physical evaluation of each patient

• Medical history questionnaire

• Dialogue history

• Physical examination

• Modifications in dental care to minimize medical risks.

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 MORBIDITY

▪ In a survey of medical emergencies occurring in dental offices in Scotland,

four deaths were reported in persons sustaining cardiac arrest who were
listed as “bystanders”, that is, persons not scheduled for dental treatment in
the office in which they died

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 ▪ About 50% of these emergencies were listed
as syncope (e.g., fainting), usually a benign
occurrence.

▪ Beware the word benign in any description of

an emergency.

▪ When improperly managed, any emergency -

even “simple” faint - can turn into a
catastrophe.

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 EMERGENCIES

▪ Although any medical emergency can develop in the dental office, some are
seen more frequently than others.

▪ Many such situations are stress related (e.g., pain, fear, and anxiety) or
involve preexisting conditions that are exacerbated when patients are placed
in stressful environments.

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 EMERGENCIES

▪ Stress-induced situations include vasodepressor syncope (your body

overreacts to certain triggers, such as the sight of blood or extreme emotional
distress) and hyperventilation

▪ preexisting medical conditions that can be exacerbated by stress include

most acute cardiovascular emergencies, bronchospasm (asthma), and
seizures

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 DEATH

▪ Most emergency situations that occur in dental practice are defined as

potentially life threatening.

▪ Only on rare occasions does a patient actually die in a dental office

▪ In a 1962 American Dental Association survey of nearly 4000 dentists, 45

deaths in dental offices were reported.

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 DEATH

▪ In addition, 7 such deaths occurred in the waiting room before the patients
had been treated.

▪ Chapman, in 1997, reporting on emergency preparedness and experiences of

811 Australian dentists, noted that 20 “CPR [cardiopulmonary resuscitation]
emergencies were reported and 75% survived.”

▪ Five patients died. He reported 4 cases of anaphylaxis, 3 of which developed

into cardiac arrest, with all patients surviving.

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 DEATH

▪ Adequate pretreatment physical evaluation, combined with proper use of

the many techniques for pain and anxiety control, can help prevent many
emergencies and deaths.

▪ It is this author’s firm belief that all dental practitioners must pursue prevention
vigorously.

▪ Unfortunately, even the most stringent precautions and preparation cannot

always prevent a death from occurring.

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 DEATH

▪ Each year in the United States, 10% of all nonaccidental deaths occur
suddenly and unexpectedly in relatively young persons believed to be in good
health - thus the term “sudden, unexpected” cardiac arrest.

▪ The cause of death most often is a fatal cardiac dysrhythmia, usually

ventricular fibrillation.

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 DEATH

▪ Preventive measures cannot entirely eliminate this from happening so we, the
dental profession, must be prepared.

▪ However, not all such deaths occur within the confines of the dental office.

▪ The stress associated with dental treatment can potentially trigger events that
result in a patient’s demise days after treatment.

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 RISK FACTORS

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 INCREASED NUMBER OF OLDER PATIENTS

▪ The life expectancy of persons born in the United States is increasing

steadily.

▪ In 1900 the life expectancy for a white male was 46.6 years; for a white
female, 48.7 years.

▪ In 2009, these figures were 76.4 for white males, 81.2 for white females, 71.1
for black males, and 77.6 for black females

▪ Aging post - World War II baby boomers have turned the most rapidly growing
segment of the U.S. population into those 65 and older

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 INCREASED NUMBER OF OLDER PATIENTS

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 INCREASED NUMBER OF OLDER PATIENTS

▪ Although many older patients appear to be in good health, the dental

practitioner must always be on the lookout for significant subclinical disease

▪ All major organ systems (cardiovascular, hepatic, renal, pulmonary, endocrine,

and central nervous) must be evaluated in older patients, with the
cardiovascular system of particular importance.

▪ Cardiovascular function and efficiency decrease as part of the normal aging

process.

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 INCREASED NUMBER OF OLDER PATIENTS

▪ When subjected to stress (pain, fear, anxiety, high humidity, extremes of heat
and cold), the cardiovascular system of the older person may not be able to
meet the body’s demands for increased oxygen and nutrients, a deficit of
which may lead to acute cardiovascular complications such as life-threatening
dysrhythmias and anginal pain.

▪ Cardiovascular disease is the leading cause of death in persons over 65

years in the United States today

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ Central Nervous System

• Decreased number of brain cells

• Cerebral arteriosclerosis

• Cerebrovascular accident

• Decreased memory

• Emotional changes

• Parkinsonism

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ Cardiovascular System • Decreased contractility

• Coronary artery disease • High blood pressure

• Angina pectoris • Renovascular disease

• Myocardial infarction • Cerebrovascular disease

• Dysrhythmias • Cardiac disease

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ Respiratory System ▪ Genitourinary System

• Senile emphysema • Decreased renal blood flow

• Arthritic changes in thorax • Decreased number of functioning

• Pulmonary problems related to glomeruli

pollutants • Decreased tubular reabsorption

• Interstitial fibrosis • Benign prostatic hypertrophy

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ Endocrine System

• Decreased response to stress

• Type 2 (adult-onset) diabetes mellitus

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ Decreased tissue elasticity also affects the lungs. Pulmonary compliance

decreases with age and can progress to senile emphysema.

▪ Long-term exposure to smoke, dust, and pollutants can decrease respiratory

function in older patients, producing disorders such as asthma and chronic
bronchitis.

▪ Pulmonary function in the older patient is considerably diminished compared

with that of the younger patient

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ However, within the past three decades, dental practitioners have begun
treating more patients older than 60 years who have retained most of their
natural dentition.

▪ These patients require the full range of dental care - periodontics,

endodontics, crowns, bridges, restorative work, implants, and oral surgery

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 CHANGES THAT OLDER PATIENTS FREQUENTLY ENCOUNTER

▪ Because of their ages and the possibility of preexisting physical disabilities,

many of these patients are less able to handle the stress normally associated
with dental treatment

▪ This reduced stress tolerance should forewarn the dental practitioner that
older patients are at greater risk during dental treatment, even in the
absence of clinically evident disease

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 MEDICAL ADVANCES

▪ With age, the incidence of disease rises.

▪ Diabetic patients and patients with cardiovascular diseases (heart failure,

arteriosclerosis) face significantly longer life expectancies today than they did

▪ Many patients who were confined to their homes or who needed to rely on
wheelchairs and were unable to work and unlikely to seek dental care now live
relatively normal lives because of drug therapy and surgical technique
advances. 25 or 35 years ago.

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 MEDICAL ADVANCES

▪ Radiation and chemotherapy enable many patients with cancer to live longer.

▪ Surgical procedures, such as coronary artery bypass and graft surgery and
heart valve replacement, have become commonplace, permitting previously
incapacitated patients to pursue active lifestyles.

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 MEDICAL ADVANCES

▪ Single- and multiple-organ transplants have higher success rates and are
performed with greater frequency than in past years.

▪ Newer and more effective drug therapies are available for the management of
chronic disorders such as high blood pressure, diabetes, and human
immunodeficiency virus infection

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 LONGER APPOINTMENTS

▪ Recent years many doctors have increased the length of their typical dental
appointment.

▪ Although appointments of less than 60 minutes are still commonplace, many

doctors now schedule 1- to 3-hour treatment sessions.

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 LONGER APPOINTMENTS

▪ Dental care can be stressful for the patient, for the doctor, and for staff
members, and longer appointments naturally create more stress.

▪ Medically compromised patients are more likely to react adversely under

these conditions than are healthy individuals, but even healthy patients can
suffer from stress, which can create unforeseen complications.

▪ Stress reduction has become an important concept in the prevention of

medical emergencies.

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 INCREASED DRUG USE

▪ Drugs play an integral role in contemporary dental practice.

▪ Drugs for preventing pain, managing fear, and treating infection are important
components of every doctor’s armamentarium.

▪ However, all drugs exert multiple actions; no drug is absolutely free of risk.

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 INCREASED DRUG USE

▪ Knowledge of the pharmacologic actions of a drug and of proper technique of

drug delivery will go far to decrease the occurrence of drug-related
emergencies.

▪ In addition, many dental practitioners must work with patients who ingest
drugs not prescribed by a doctor.

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 INCREASED DRUG USE

▪ Dental practitioners must take special care to anticipate and recognize

complications related to either the pharmacologic actions of a drug or the
complex interactions between commonly used dental drugs and other
medications.

▪ For example, orthostatic hypotension is associated with many drugs used in

the management of high blood pressure.

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 INCREASED DRUG USE

▪ Other examples include the potentially significant interactions between the

monoamine-oxidase inhibitors and opioids (e.g., meperidine and fentanyl) or
between epinephrine and noncardiospecific β-adrenergic blockers.

▪ Patients, both male and female, using phosphodiesterase inhibitors (Viagra™,

Cialis™, Levitra™) are at risk for significant hypotension in the event of an
acute anginal episode requiring administration of nitroglycerin

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 CLASSIFICATION OF LIFE-THREATENING SITUATIONS

▪ The traditional approach has been the systems-oriented classification, which

lists major organ systems and discusses life-threatening situations associated
with those systems

▪ Second classification method divides emergency situations into two broad

categories - cardiovascular and noncardiovascular emergencies, which both
can be broken down further into stress-related and non–stress-related
emergencies.

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 CLASSIFICATION OF LIFE-THREATENING SITUATIONS

▪ Although the cardiovascular emergency system is effective in emergency

prevention, doctors need a method that can help them to more easily
recognize and manage such situations.

▪ Therefore, we must abandon classifications based on organ systems.

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 OUTLINE OF SPECIFIC EMERGENCY SITUATIONS

▪ In the discussion of each emergency situation, various factors will be

presented. Included are the following headings and the aim of each:

▪ General considerations: An introductory section presents general

information about the situation. Definitions and synonyms are included when
relevant.

▪ Predisposing factors: Discussions focus on the incidence and cause of the

disorder and those factors that can predispose a patient to experience a life-
threatening situation.

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 OUTLINE OF SPECIFIC EMERGENCY SITUATIONS

▪ Prevention: This section builds on previous sections to minimize the

occurrence of an acute exacerbation of the disorder.

▪ The medical history questionnaire, vital signs, and dialogue history are used
to determine a risk category for each patient based on the system developed
by the American Society of Anesthesiologists.

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 OUTLINE OF SPECIFIC EMERGENCY SITUATIONS

▪ Suggestions for specific dental treatment modifications complete the

discussion.

▪ Clinical manifestations: This section focuses on the clinically evident signs

and symptoms that foster recognition of the disorder.

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 OUTLINE OF SPECIFIC EMERGENCY SITUATIONS

▪ Pathophysiology: Discussion centers on the pathologic process underlying

clinical signs and symptoms.

▪ A fuller understanding of the problem’s cause can better enable the doctor to
manage the situation.

▪ Management: The step-by-step management of clinical signs and symptoms

is this section’s aim.

▪ Differential diagnosis: Each section then closes with a chapter devoted to

helping the doctor identify the probable cause of that patient’s emergency.

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 Question?

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