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 90’s 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 9
Seizures 1,595 5
Diabetes-Related 999 3
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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. Recognition
2. Prevention
3. Preparation
4. Basic life support (BLS)
5. Cardiopulmonary resuscitation (CPR)
6. 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  Temperature

 Pulse rate  Height
 Respiratory rate  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  Can tolerate stress involved
systemic disease In dental treatment
 A normal healthy  No added risk of serious
patient Complications
 Treatment modification
Usually not necessary

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 ASA II
A patient with mild systemic  Represent minimal risk
disease during dental treatment
Example:  Routine dental treatment
-Well-controlled diabetic With minor modifications
-Well-controlled asthma -Short early appointments
-ASA I with anxiety -Antibiotic prophylaxis
-Sedation

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 ASA III
A patient with severe systemic  Elective Dental Treatment
disease that limits activity but is is not Contraindicated
not incapacitating  Treatment Modification is
Example: Required
- a stable angina - Reduce Stress
- 6 mos. Post - MI - Sedation
- 6 mos. Post - CVA - Short Appointments
- COPD

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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 Elective treatment
expected to survive definitely
Example: contraindicated
- End stage renal disease
- End stage hepatic disease Emergency care only
- Terminal cancer to relieve pain
- End stage infectious disease

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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

Ampicillin
Adults: 2 gr IM or IV
Children: 50 mg/kg IM or IV

Within 30 minutes of procedure

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 Management of Medical Emergencies
Antibiotic Prophylaxis

 Amoxicillin vs. Penecillin

 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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