|Year : 2016 | Volume
| Issue : 1 | Page : 3-11
Formulation of guidelines to resolve medical emergencies in dental practice: An overview
Farouk M Sakr1, Kais G Al-Obaidy1, Lokesh J Shetty1, Fathy A Behery1, Mansour K Assery2, Abdel Nasser I Adam3, Mohamed J Patel1
1 Department of Pharmacy, College of Pharmacy and Allied Medical Sciences, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia
2 Department of Prosthodontics and Dental Implant, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia
3 Department of Basic Sciences, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Kingdom of Saudi Arabia
|Date of Web Publication||18-Jan-2016|
Farouk M Sakr
Riyadh Colleges of Dentistry and Pharmacy, PO Box 84891, Riyadh - 11681
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Dentists are prone to face unpredictable medical emergency crises in their patients during dental practice. These seldom but usually occurring events require diagnosis for safe and effective management. Therefore, dental care professionals are required to be equipped with information and training on how to manage medical emergencies (MEs) including drug administration. An outline of what essential basic life support equipment and medications require in dental clinics to manage MEs are provided with recommendation for training to handle those medical events. Effective and safe dental practice require to providing graduate and undergraduate dentistry students with updated information and training on medical emergencies and how to handle different equipment and drugs associated with such events.
Keywords: Dental care, dental clinic, dental intervention, dental practice, dentists, medical emergency
|How to cite this article:|
Sakr FM, Al-Obaidy KG, Shetty LJ, Behery FA, Assery MK, Adam AI, Patel MJ. Formulation of guidelines to resolve medical emergencies in dental practice: An overview. Saudi J Oral Sci 2016;3:3-11
|How to cite this URL:|
Sakr FM, Al-Obaidy KG, Shetty LJ, Behery FA, Assery MK, Adam AI, Patel MJ. Formulation of guidelines to resolve medical emergencies in dental practice: An overview. Saudi J Oral Sci [serial online] 2016 [cited 2020 Aug 15];3:3-11. Available from: http://www.saudijos.org/text.asp?2016/3/1/3/174289
| Introduction|| |
Medical emergencies (MEs) are identified as being unexpected onsets of serious health problems that may threaten a person's life. MEs occasionally occur during or after dental practice and most dentists may have experienced them at some point in their careers. ,,,,,,,, The prevention and treatment of dental ailments, maintenance of masticatory functions, and improvement of cosmetic appearance are among the prominent goals in many dental practices.  Accomplishing these goals without difficulties associated with the MEs is considered to be the norm in quality dental practice. ,,,
A survey of up to 2,704 dentists from North America,  founded that a total of 13,836 MEs had occurred within a 10-year period. However, none of these emergencies are actually truly dentally oriented but are potentially life-threatening medical problems that developed while the patients were in a dental clinic.
Other surveys on the existence of MEs in dental clinics in the USA,  the UK,  New Zealand,  and Australia,  demonstrated that though rare, potentially life-threatening situations do occur.
A combined findings of surveys , also showed 30,602 emergencies in the clinics of 4,309 dentists. More than 54% of these emergencies occurred during or right after local anesthesia. The greatest percentages of emergencies that were associated with potential high patient anxiety were tooth extraction and pulp extirpation. 
In Japan, a study was conducted by the Committee for the Prevention of Systematic Complications during dental treatment of the Japan Dental Society of Anesthesiology, under the auspices of the Japanese Dental Society.  The results showed that 19-44% of the dentists had a patient with a medical emergency in any one year. Approximately 90% of these complications were mild but 8% were considered to be serious. It was found that 35% of the patients were identified to have some underlying disease. Cardiovascular disease was found in 33% of those patients.
An additional factor that may lead to increased MEs in dental practice can be related to the increasing number of elderly patients who seek dental treatments such as bridge reconstruction, implants, and crowns. These patients are usually prone to many chronic diseases such as diabetes, hypertension, heart problems, and others. Dentists who treat these patients may see an increase in the number of MEs. 
MEs are most likely to occur during and after local anesthesia, primarily during tooth extraction and endodontic therapy. Over 60% of the emergencies were syncope, with hyperventilation being the next most frequent at 7%. 
In the United States and Canada, many studies concluded that syncope was the most common medical emergency faced by dentists. , Syncope represented approximately 50% of all emergencies reported in one particular study, with the next most common event, allergic reactions representing only 8% of all emergencies. In addition to syncope, other emergencies that occurred were angina pectoris/myocardial infarction, cardiac arrest, postural hypotension, seizures, bronchospasm, and diabetic emergencies.
Effective management of an emergency situation in the dental office is ultimately the dentist's responsibility.  Unfortunately, many studies reported that dental students and even dental practitioners have little understanding on how to manage MEs, and there is very little in-depth data about the importance they place on this area that is fundamental to their professional training.  The lack of training and inability to cope with MEs can lead to tragic consequences and sometimes legal action.  For this reason, all health professionals including dentists must be well-prepared to attend to MEs. ,,
Although education on MEs has been taught in most European ,, and American,  dental schools in recent times, little has been published about the self-perceived competence and confidence of dentists and dental undergraduates with regard to managing a medical emergency with basic life support (BLS) or cardiopulmonary resuscitation (CPR) in dental practice. Only 30% of general dental practitioners in Great Britain consider themselves to be well-prepared to manage MEs at graduation  and more than half of New Zealand's dentists were dissatisfied with the training they had received for MEs as undergraduate students.  In fact, Kieser and Herbison reported that one of the greatest anxieties of dental students in general clinical situations was "dealing with medical emergencies."  Another study, however, hypothesized that dental students' poor overall results in CPR skills could be associated with a low level of interest in that topic. 
The aim of this overview was, therefore, to provide basic background of knowledge and information for undergraduate/postgraduate dental students, dental practitioners, and hygienists in preventing, preparing, recognizing, and effectively managing MEs. The most frequently occurring dentistry MEs and their management were highlighted, together with the drugs that should be essentially available to the dentist to cope with such emergencies. Therefore, dentists must obtain as much information as possible about their patients' medical status before starting any dental intervention.
| Literature Reviews Search Procedure|| |
The search was electronically conducted through the EBSCO Searching Host from 2010 to 2015. A total of 1,142 articles were identified; however, only those items written in English were screened and included in the presented review. The key words and key phrases used were medical emergencies, medical emergencies in dentistry, medical emergencies dental, medical emergencies in dentistry diagnosis, and treatment.
| Literature Review Search Outcome|| |
Dental residents and assistants are supposed to deliver safe and pain-free dental procedures after graduation from dental schools. This not only includes competent dentistry skills but also the use of drugs such as opioids, ketamine, local anesthetics, and benzodiazepines for sedation and analgesic purposes. These drugs have inherent risks of cardiovascular and respiratory complications, which may be more evident with the current complexity of medical problems in patients at the extremes of age. ,,,
The extent of treatment by the dentist requires knowledge about the most prevalent MEs that he/she may face during dental practice and he/she should be aware of the medical and social events that may necessitate an alteration or modification of his/her treatment procedure for patient safety. Essentially, dentists are also required to be trained on the preparedness, prevention, and management of MEs crises when they occur. Background information is to be provided on the essential drugs needed to resolve such emergencies, together with understanding their actions, interaction, contraindication, dosage forms, and dose and method of administration. On the other hand, providing BLS and CPR training courses to the dentists will contribute most importantly as a first-aid emergency procedure until a definitive treatment for a medical emergency can be given.
| Common Medical Emergencies in Dental Practice|| |
Dentists must be aware of the most common MEs that they might face during their treatment procedures. [Table 1] illustrates the most common medical crises in the dental office with a hint of their cause, the signs and symptoms, treatment precautions, and on how they can be resolved.
| Chronic Medical Events, Which May Alter Dental Treatment|| |
[Table 1] is representative of chronically exiting medical events, which may alter dental treatment procedures as they could initiate unexpected serious health problems if not carefully monitored by the dentists. Preventing MEs permits the dental practitioner to conduct his/her planned dental treatment in an optimal environment by taking comprehensive information about the medical status of their patients before starting their treatment.
Prevention is accomplished by conducting a thorough medical history with appropriate alterations to dental treatment as required. The most important aspect of nearly all MEs in the dental office is to prevent or correct insufficient oxygenation of the brain and heart. Therefore, management of all MEs should include ensuring that oxygenated blood is being delivered to these critical organs. This is consistent with basic cardiopulmonary resuscitation, with which the dentist must be competent. This provides the skills to manage most MEs, which begin with the assessment and if necessary the treatment of airway, breathing, and circulation (the ABCs of CPR). Usually, only after these ABCs are addressed, should the dentist consider the use of emergency drugs.
Up to 90% of MEs can be avoided with proper prevention technique. The first step in prevention is to take affirmative answers to medical history questions by the dentist to explore comprehensive information about the health status of the patients.  These information are to be regularly updated and reviewed before each clinic visit. It may be essential in some cases to consult the patient's general physician for additional information and guidance.
The next step in prevention is to subject the patient to physical examination. Before beginning dental treatment, dentists have to take the baseline vital signs (including but not limited to blood pressure, pulse, and heart rhythm).  The dentist should also modify the dental procedure to decrease any potential risk to their patients. It is important to observe that excluding the procedures involving anesthesia, liability is more apt to occur for causing an emergency, i.e., if the dentist fails to take a thorough medical history or fails to follow procedures that might have prevented the emergency. 
| Preparedness and Management of Medical Emergencies|| |
Dental practitioners cannot prevent every medical emergency; accordingly, they must be prepared to recognize and manage MEs when they exist. The American Dental Association (ADA) Council on Scientific Affairs  has set guidelines for preparedness, which include:
- Current BLS certification for all office staff.
- Didactic and clinical courses in emergency medicine.
- Periodic office emergency drills.
Telephone numbers of appropriately trained health care providers.
Emergency drug kit and equipment, and the knowledge to properly use all items.
The ADA mandates specific training and emergency drugs and equipment necessary for dentists who use conscious sedation, deep sedation, or general anesthesia. ,, The ADA "Guide to Dental Therapeutics" provides information for dentists who utilize the above sedation modalities. ,
The general dentist who does not use sedation or general anesthesia described above should follow the "keep it simple" principle.  The design of the emergency kit is dictated by the expertise of the dentist with various drugs and techniques, i.e., intravenous (IV) drug administration and endotracheal intubation. Dentists should not have drugs and equipment in the emergency kit that they do not know how to use or administer.
Another consideration is the location of the dental office. The dentist should determine in advance as to who would be called upon to help in an emergency and how long it would take for help to arrive. A dentist located in a rural area may have to wait for a considerable period of time for paramedics to arrive. In these situations, it is mandatorily for the dentist to become certified in Advanced BLS and design the emergency drug kit and equipment to fit his/her needs.  These dentists may want to include an automated external defibrillator (AED) in their office emergency equipment as part of the dentist's minimum standard of care. 
| Patient's Physical Evaluation|| |
The basic physical evaluation of dental patients compromises four consequent steps.
Patient's medical history questionnaire
This has to be completed by the patient and his/her guardian or parents. Computerized forms can be used to simplify the process. 
Dentist/patient medical history dialogue ,
After reviewing the completed form, dentist may further asks the patient about any reported medical problem to determine the significance of the reported disorder to the proposed dental plan.
Patient's physical examination
This includes visual inspection and monitoring the patient's baseline vital signs (e.g., temperature, heart rate, and blood pressure) that would provide valuable information about his/her cardiovascular system.
| Risk Assessment|| |
After completion of the patient's medical history questionnaire and conducting the dentist/patient medical history dialogue and physical examination, the dentist has to assign his/her patient to a physical status category using the American Society of Anesthesiologists Physical Status (ASA PS) classification system. , This will help to predict any perioperative adverse reactions in patients receiving general anesthesia.,, The ASA PS is used to study patients' risks and outcomes. , The system consists of six classifications - PS 1 to PS 6 - that indicate the potential medical risks that can develop while the patient is under general anesthesia. McCarthy and Malamed adapted the ASA PS system for use in dentistry. A patient in the PS 1 category is defined as normal and healthy. He/she is an excellent candidate for elective surgical or dental care, with minimal risk of experiencing an adverse medical event during treatment. Patients in the PS 2 category have a mild systemic disease  or are healthy patients (PS 1) who demonstrated extreme anxiety toward dentistry or are above than 60 years. This category is generally able to tolerate less stress compared to PS 1 category patients, and the dentist should consider possible treatment modification for the PS 2 category patients. The PS 3 category patients have severe systemic disease that limits activity but is not incapacitating.  When  the patient is at rest, he/she does not show any signs and symptoms of distress (fatigue, chest pain, and shortness of breath); however, when stressed, he/she exhibits such sign and symptoms. The dentist should proceed with caution and give serious consideration on implementing treatment modification. The PS 4 category patient has an incapacitating systemic disease that threatens his/her life.  This category of patients has medical problems of greater significance than the planned dental treatment. Elective dental care with this category should be postponed until the patient's physical condition has improved to at least a PS 3 classification. Patients in the PS 5 category are almost always hospitalized and terminally ill. Elective dental treatment is contraindicated; however, emergency care in the realm of palliative treatment (relief of pain, infection, or both may be necessary.  The PS 6 category refers to brain-death patients whose organs are being removed for donor purposes.  The ASA PS classification is meant to function as a relative value system based on the dentist's clinical judgment and assessment of the available relevant clinical data.  If the dentist is unable to determine the clinical significance of one or more diseases, then he/she is recommended to consult the patient's physician or other medical or dental colleagues. The ultimate responsibility for the health and safety of a patient lies solely with the dentist who decides on whether to treat or not treat the patient.
| Dental Staff Emergency Training|| |
Every member of the dental team should have completed a basic first aid course and have annual training in CPR.  Retention studies have shown that if CPR skills are not used regularly, they are soon forgotten. A study on the perceptions of MEs among Brazilian dental students  indicated superficial knowledge of MEs that was derived from limited exposure in undergraduate classes, conferences, and the short preparatory course for acquiring a national driver's license. The students considered continual training in BLS to be necessary over their entire professional lives in order to control a medical emergency situation. The students demonstrated feelings of insecurity and responsibility since they would be the first on the scene of the emergency. In general, the dental students considered knowledge of medical emergency in the dental office to be essential for safe dentistry and believed that it must be more effectively taught in the undergraduate course.  The purpose of BLS is to prevent inadequate circulation or respiration through prompt recognition of the problem and intervention and/or early entry into the emergency medical service system as well as to support a victim's circulation and respiration through CPR.  However, a number of studies have found that about half the dentists from all over the world are not able to perform CPR properly. ,,, For this reason, medical emergency management training is gaining more importance for dental students. BLS is a core skill in which all health care professionals should be proficient but there is a great deal of variation in the training provided at the undergraduate level. 
| Emergency Drugs in Dental Practice|| |
Drugs that should be promptly available to the dentist can be divided into two categories. The first category represents those which may be considered essential. The second category contains drugs, which are also very helpful and should be considered as part of the emergency kit.
[Table 2] includes a list of the different category drugs including their indications and doses.
| Basic Emergency Drug Kit|| |
The availability of emergency drugs in dental office is mandated. It seems prudent to prepare an emergency drug kit. The ADA Council suggests the following seven drugs that include two injectable and five noninjectable drugs. ,,
- Epinephrine 1: 1000 and 1: 2000 (injectable).
- Histamine blocker (injectable).
- Oxygen with positive pressure administration capability.
- Nitroglycerin (sublingual tablet or aerosol spray).
- Bronchodilator (asthma inhaler).
Epinephrine represents the most important drug in the emergency kit, however it is probably the least likely to be used. Epinephrine is available and recommended as two Twinject ® (two-dose) preloaded syringes at concentration of 1: 1000 for adults and 1: 2000 for infants and children (between 1 year of age and the onset of puberty). The other injectable drug is a histamine-blocker, such as diphenhydramine 50 mg/mL. It is recommended that the emergency kit contain two or three 1-mL ampules of diphenhydramine.
Both injectable drugs are used to manage the allergic reactions, whether life-threatening or nonlife-threatening (anaphylaxis).
Oxygen can be administered during almost any emergency situation and is available in an "E" cylinder, which provides O 2 for approximately 30 min during ventilation of an unconscious or apneic adult. Nitroglycerin is used as a vasodilator to control the acute anginal episode. Nitroglycerin is recommended in the spray form rather than the sublingual tablets. Albuterol is the preferred bronchodilator used to manage bronchospasm (acute asthmatic episode). An antihypoglycemic is a sugar source needed to manage hypoglycemia (low blood sugar), which is a common occurrence in dentistry. A tube of a glucose gel should be included in the emergency drug kit. Alternatively, 340 g of orange juice or soft drink (nondiet) can be used. Aspirin, either chewable or tablets, is recommended in the prehospital management of "suspected myocardial infarction" victims. A dose of 325 mg (one adult tablet) is chewed and then swallowed. Aspirin inhibits platelet aggregation, thus minimizing the size of the blood clot that develops during the "heart attack." Dentists should continue to seek continual education to upgrade their knowledge and ability to safely and successfully employ emergency drugs.
The dentist also must have the knowledge to administer these drugs in the proper doses as treatment for specific emergencies. Package inserts and instructions should be read before an emergency when assembling a drug kit and reviewed periodically.
Dentists may choose to create their own emergency kit, placing drugs in drawers of small tool kits or clear bags labeled with the name of the drug, the condition it treats, instructions for administration, and contraindications for usage. He/she should keep the emergency kit in a cool, dry place and keep it up-to-date with currently needed drugs. A warning or notice of emergency drug expiration dates can be placed on the appointment book a few weeks prior to the actual expiry to allow the dental team time to replace soon-to-expire drugs.
Similarly, Malamed indicates that the "five drugs that dentists are an absolute must have are: oxygen, a bronchodilator, a histamine blocker for anaphylaxis, nitroglycerin and epinephrine." ,
Oxygen delivery system including a positive pressure mask and/or a bag-valve-mask device with several sized face masks. Also recommended is a pocket mask to aid in mouth-to-mask ventilation. An AED is considered to be an absolutely essential part of emergency preparedness as early defibrillation is the most important intervention in successful resuscitation from cardiac arrest. Other equipment include syringes and needles for drug administration, suction and suction tips, tourniquets, and Magill intubation forceps (for easy retrieval of foreign objects from the posterior part of the oral cavity or the pharynx).  These items are described in [Table 3].
| Discussion and Conclusions|| |
MEs in the dental clinics frequently occur and may represent a possible serious threat to patients' health and could also hinder the delivery of the planned dental care procedure. It has been estimated that dentists may at least face one or two MEs during their lifetime practice. ,,,,,,,,, Special consideration should be paid to elderly patients and individuals with history of underlying medical conditions as they could also initiate the possibility of increasing MEs.
The prevention of MEs is basically affirmed on acquiring the knowledge and understanding of the varieties of medical emergency crises that dentists may face during their practice. The dentists should also be prepared to prevent emergency crises by gathering information about their patients' preexisting medical conditions, knowing the drugs and medications that their patients might have taken, and their possible interaction with their dental procedure or the other drugs that they might be using. The dentist can obtain this information through assigned patient questionnaires, personal dialogue, and physical evaluation before the start of the treatment.
The patient's physical evaluation consists of four components including the patient's medical history questionnaires, dentist/patient history dialogue, physical examination (including monitoring and recording vital signs and visual examination), and assessment of risk.
Dentists should be well-prepared with the essential emergency drugs and equipment to be available in their clinics to resolve any existing crisis. The dentist should also be prepared and ready to prevent existing MEs. It is mandatory also for the dentists and the dental team to acquire both theoretical and practical training courses including BLS and the CPR skills.
On the other hand, many studies in the literature revealed that dental students are lacking the essential knowledge and training on how to manage MEs such that they perceive the need for more intensive education in MEs.  Dental schools are, therefore, responsible for implementing the knowledge and training for their students to be acquainted with the essential knowledge to resolve possibly encountered MEs. Standardized courses in MEs including BLS/CPR, together with the knowledge on the variety of MEs and the necessary procedure, emergency drugs, and equipment that are needed to resolve these crises should be taught during the course of the study to the undergraduates and as a continuing education courses for postgraduates, especially those who are attending master degree programs. Continuing education courses in MEs should also be demonstrated and attended by the dental assistants.
Furthermore, dental students could routinely visit hospitals and emergency services to become familiar with the stress involved in a life-threatening situation. A 4-week hospital-based program for dental students had successful results in the evaluation and management of MEs. 
The authors would like to thank Riyadh Colleges of Dentistry and Pharmacy authority and their research center for the support and encouragement that made scientific research feasible for all staff and students. We also dedicate this overview to the undergraduate/graduate dentistry students and dental practitioners to provide basic knowledge and information that may increase awareness and enhance the preparedness to manage frequently occurring MEs in dental clinics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]