Management Of Medical Emergencies In

The Dental Office

Fady Faddoul, DDS, MSD,FICD
Professor and Vice-Chairman
Department of Comprehensive Care
Director, Advanced Education in General Dentistry
Case Western Reserve University
School Dental Medicine

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Management of Medical Emergencies

Medical emergencies can and do happen

Advances in medicine
Longer lifespan
Multiple medications
Medically compromised
Longer appointments

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Incidence

A survey done in the 90s showed that, over

a 10 year period, 90% of dentists have
encountered at least one medical
emergencies.

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Types
TYPE OF EMERGENCY

NUMBER

PERCENT

Altered Consciousness

17,782

59

Cardiovascular

4,280

14

Allergy

2,887

9.5

Respiratory

2,718

Seizures

1,595

999

Diabetes-Related
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Management of Medical Emergencies

Basic Life Support
Advanced Life Support

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Management of Medical Emergencies

Emergency situations
Managed properly most emergencies are resolved satisfactorily
Mismanaged even benign emergencies can turn disastrous
Recognize
Position
Stabilize
Diagnose
Treat
Refer
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Management Of Medical Emergencies

1.
2.
3.
4.
5.
6.

Recognition
Prevention
Preparation
Basic life support (BLS)
Cardiopulmonary resuscitation (CPR)
Specific medical emergencies

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Prevention

IS THE BEST
TREATMENT

Know your patient

Never treat a STANGER

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Prevention
90% of life-threatening situations can be
prevented
10% will occur in spite of all preventive
efforts (sudden unexpected death)

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Prevention
Medical History
Physical Evaluation
Vital Signs
Dialogue History
Determination of Medical Risk
Stress Reduction

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Prevention
MEDICAL HISTORY
Review
Update
Medication
Medical consultation

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Prevention
PHYSICAL EVALUATION
Length of time since last evaluation
Vital signs
Visual inspection of patients
Referral to physician

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Prevention
VITAL SIGNS

Blood pressure
Pulse rate
Respiratory rate

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Temperature
Height
Weight

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Prevention
DIALOGUE
HISTORY
Putting it all together
Check accuracy of
medical history
Recognize anxiety
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Prevention
DETERMINATION OF MEDICAL RISK.
Ability of patient to safely tolerate dental
treatment.
Does patient represent increased medical
risk?
Can patient be managed in the dental
office?
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Determination Of Medical Risk

American Society of
Anesthesiology
Physical Status Classification
System

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ASA I

A patient without
systemic disease
A normal healthy
patient

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Can tolerate stress involved

In dental treatment
No added risk of serious
Complications
Treatment modification
Usually not necessary

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ASA II
A patient with mild systemic
disease
Example:
-Well-controlled diabetic
-Well-controlled asthma
-ASA I with anxiety

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Represent minimal risk

during dental treatment
Routine dental treatment
With minor modifications
-Short early appointments
-Antibiotic prophylaxis
-Sedation

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ASA III
A patient with severe systemic
disease that limits activity but is
not incapacitating
Example:
- a stable angina
- 6 mos. Post - MI
- 6 mos. Post - CVA
- COPD

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Elective Dental Treatment

is not Contraindicated
Treatment Modification is
Required
- Reduce Stress
- Sedation
- Short Appointments

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ASA IV
A patient with incapacitating
systemic disease that is a
constant threat to life
Example:
- Unstable angina
- M I within 6 months
- CVA within 6 months
- BP greater than 200/115
- Uncontrolled diabetic
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Elective dental care

should be postponed
Emergency dental care
only

Rx only to control
pain and infection
Other treatment in
hospital

(I&D, extraction)
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ASA V
A morbid patient not
expected to survive
Example:
- End stage renal disease
- End stage hepatic disease
- Terminal cancer
- End stage infectious disease

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Elective treatment
definitely
contraindicated
Emergency care only
to relieve pain

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Prevention
STRESS REDUCTION
Premedication
Sedation
Pain control (intra and post-op)
Early appointments
Short appointments
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Preparation
Team Effort
BLS for all office personnel
CPR for all office personnel
Emergency drills
Emergency phone numbers (911)
Emergency equipment

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BASIC LIFE SUPPORT

(BLS)
CARDIOPULMONARY
RESUCITATION
(CPR)
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SBE Prophylaxis

In 2012, the guidelines were updated and now premedication is needed for
fewer conditions.
The conditions for which premedication is necessary includes:
artificial heart valves
a history of infective endocarditis
a cardiac transplant that develops a heart valve problem
the following congenital (present from birth) heart conditions:
*unrepaired or incompletely repaired cyanotic congenital heart disease,
including those with palliative shunts and conduits
*a completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first six months after the procedure
*any repaired congenital heart defect with residual defect at the site or
adjacent to the site of a prosthetic patch or a prosthetic device

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SBE Prophylaxis

Patients who previously needed antibiotic

prophylactic but no longer need them include:

mitral valve prolapse

rheumatic heart disease

bicuspid valve disease

calcified aortic stenosis

congenital (present from birth) heart conditions

such as ventricular septal defect, atrial septal
defect and hypertrophic cardiomyopathy

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SBE Prophylaxis

Procedures needing prophylaxis:

All dental procedures that involve manipulation
of gingival tissue or the periapical region of
teeth or perforation of the oral mucosa.
procedures that do not require prophylaxis are
radiographs, placement of removable
prosthesis, and placement orthodontic bracket.

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Management of Medical Emergencies

Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
AMOXCICILIN
Adults 2 grams
Children 50 mg/kg (not to exceed adult dosage)
Orally 1 hour before procedure
No repeat dose
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Management of Medical Emergencies

Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
Allergic to Penecillin
Adult

Children

Clindamycin

600 mg

20 mg/kg

Cefalexin or Cfadroxil

2 gr.

50 mg/kg

Azithromycin or Clanthromycin

500 mg

15mg/kg

ORALLY 1 HOUR BEFORE PROCEDURE

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Management of Medical Emergencies

Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
Unable to take Oral Medication

Adults:
Children:

Ampicillin
2 gr IM or IV
50 mg/kg IM or IV
Within 30 minutes of procedure

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Management of Medical Emergencies

Antibiotic Prophylaxis

Amoxicillin vs. Penecillin

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Both equally effective against Streptococus viridan

Amoxicillin is better absorbed from the GI tract, and
provides higher and more sustained serum level
2 gr. Provides as effective coverage as 3 gr. With less
GI adverse effects.
2nd dosage not required due to prolonged serum level
above the inhibitory period for most oral Streptococci.
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Management of Medical Emergencies

Antibiotic Prophylaxis

ERYTHROMYCIN
No longer recommended due to GI side
effects. Practitioners who have used it
successfully in the past, may continue to
use it following the previously published
regimen.
2 gr. 2 hours before procedure
1 gr. 6 hours later

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Management of Medical Emergencies

Antibiotic Prophylaxis

Patient already taking antibiotic used for prophylaxis:

1.
Select an antibiotic from a different class, rather than
increasing the dosage
2.
Delay treatment if possible 9 to 14 days after
completion of antibiotic to allow usual flora to
reestablish
Example: Amoxicillin, go to Clindamycin.
No Cephalosporin due to cross resistance

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Management of Medical Emergencies

Antibiotic Prophylaxis

Prophylaxis for dental patients with

TOTAL JOINT REPLACEMENT

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Management of Medical Emergencies

Antibiotic Prophylaxis
The most crucial period is up to 2 years
following a joint replacement
Prophylaxis not recommended for dental
patients with: Pins, Plates, and Screws.
Prophylaxis is not routinely indicated for
most dental patients with total joint
replacement

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Management of Medical Emergencies

Antibiotic Prophylaxis
Patients at potential increased risk of total joint
infection
Immunocompromized/Suppressed patients
Other Patients:
Insulin Dependent diabetics
1st 2 years following joint replacement
Previous prosthetic joint infection
Malnourishement
Hemophilia
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Management of Medical Emergencies

Antibiotic Prophylaxis

Procedures and regimens are the same as

discussed earlier for SBE prophylaxis.

A cephlosporin is preferable to Amoxicillin

due to its affinity to cynovial fluids

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