Detail explanation of diagnosis and management of emergencies in dental office.

1. Emergency Management
in Dental Office
By Dr. Ishfaq Ahmad

2. Introduction
 Any dental emergency like an injury to the teeth or gums can be potentially serious and
should not be ignored. Ignoring a dental problem can increase the risk of permanent
damage as well as the need for more extensive and expensive treatment later on.

3. What is Dental Emergency
 An acute disorder of oral health that requires dental and/or medical attention,
including broken, loose, or avulsed teeth caused by traumas,infections and
inflammations of thesoft tissues of the mouth; and complications of oral surgery,
such as dry tooth socket.

4. Anxiety recognition& stress reductionprotocol
 Recognize patient’s anxiety level.
 Consider using pre-medication or sedation
 Schedule morning appointments.
 Minimize waiting time and watch appointment length.
 Make sure to use adequate pain control. This will vary from patient to
patient.
 Monitor vital signs.
 Medical consult if required.

5. When & Where To Refer
 According to the General Dental Council’s ‘Standards for Dental Professionals’,
2009, registered dentists are expected to:
Work within your knowledge, professional competence and physical abilities. Refer patients for a
second opinion and for further advice when it is
necessary, or if the patient asks. Refer patients for further treatment when
it is necessary to do so.
As such, the need for referral may be that the situation lies outside:
the knowledge
the skill
the experience
the facilities available to the referring dentist.
 Careful consideration should be made with regard to where, and whom to
refer a patient.

7. How Can An Emergency Arise
 Dental Emergencies
 Medical Emergencies

8. Protocol for Management of Dental
Emergencies
 Prompt Diagnosis
 Reassurance
 Pain relief
 Medication
 Referral for definitive treatment

9. Dental Emergencies
 Acute Oral Medical and Surgical Conditions
 Restorative Dental Emergencies
 Acute Presentations of Chronic Oro-Facial Pain Conditions
 Traumatic Injuries to the Teeth and Oral Soft Tissues
 Pain Relief in the Dental Emergency Clinic
 Management of the Special Needs Patient

10. Acute Oral Medical and Surgical Conditions
 Blistering disorders of the oral mucosa
 Oral ulceration
 Disturbed oro-facial sensory or motor function
 Hemorrhage
 Other acute conditions
 Bony pathology
 Fracture

11. Restorative Dental Emergencies
 Pain management
 Infections and soft tissue problems
 Crack, fracture and mobility of teeth and dental restorations
 Fractured and loose implants
 Fractures and swallowing of removable prostheses

12. Traumatic Injuries to the Teeth and Oral
Soft Tissues
 Assessment of the traumatized patient
 Management of traumatic dental injuries
 Injuries to the hard dental tissues, the pulp and the alveolar process
 Injuries to the periodontal tissues
 Dento-alveolar fractures

13. Acute Presentations of Chronic Oro-
Facial Pain Conditions
 Oro-facial pain history
 Examination of patients with oro-facial pain
 Special investigations for oro-facial pain
 Presentation, investigations and initial management of acute non-odontogenic
oro-facial pain

14. Management of the Special Needs
Patient
 Assessment
 Diagnosis
 Symptomatic relief
 Counselling
 Referral

15. Medical Emergencies in the Dental Clinic
 The commonest medical emergencies seen in the dental emergency clinic are
faints. Hypoglycemia, asthma, anaphylaxis, angina and seizures may also be
seen but are less common. All members of the dental team need to be aware
of what their role would be in the event of a medical emergency and should
be trained appropriately with regular practice sessions.

16. Medical Emergencies in the Dental Clinic
 Vasovagal syncope (faint)
 Hyperventilation/‘panic attack’
 Acute asthma attack
 Angina/myocardial infarction
 Epileptic seizures
 Diabetic emergencies
 Allergies/hypersensitivity reactions
 Choking and aspiration
 Adrenal insufficiency
 Stroke
 Local anesthetic emergencies
 Problems with hemostasis

18. Contents of the emergency drug box

20. The ‘ABCDE’ approach to an emergency
patient
Medical emergencies can often be prevented by early recognition. An abnormal
patient color, pulse rate or breathing can signal some impending
emergencies.

21. Basic life support (BLS)

22. Advanced CardiovascularLife Support (ACLS)

23. Vasovagal syncope (simple faint)
 Fainting – signs and symptoms
Patient feels faint/light headed/dizzy
Pallor, sweating
Pulse rate slows
Low blood pressure
Nausea and/or vomiting
Loss of consciousness
 Fainting – treatment
Lay the patient flat and raise the legs – recovery will normally be rapid.
A patent airway must be maintained.
If recovery is delayed, oxygen should be administered and other causes of
loss of consciousness be considered.

24. Hyperventilation
 Hyperventilation – signs and symptoms
Anxiety
Light headedness
Dizziness
Weakness
Paresthesia
Tetany
Chest pain and/or palpitations
Breathlessness
A demonstration of carpal spasm.

25. Hyperventilation
 Hyperventilation – treatment
A calm and sympathetic approach from the practitioner is important. The
diagnosis, particularly in the early stages, is not always as obvious as it may
seem:
Exclude other causes for the symptoms.
Encourage the patient to rebreathe their own exhaled air to increase the
amount of inhaled carbon dioxide – a paper bag placed over nose and mouth
allows this.
If no paper bag is handy, the patient’s cupped hands would be a (less satisfactory)
alternative.

26. Asthma
 Asthma is a potentially life-threatening condition and should always be taken
seriously. An attack may be precipitated by exertion, anxiety, infection or
exposure to an allergen.
Asthma – signs and symptoms
Breathlessness (rapid respiration – more than 25 breaths per minute)
Expiratory wheezing
Use of accessory muscles of respiration
Tachycardia
Signs and symptoms of life-threatening asthma
Cyanosis or slow respiratory rate (less than 8 breaths per minute)
Bradycardia
Decreased level of consciousness/confusion

27. Asthma
 Asthma – treatment
 Most attacks will respond to the patient’s own inhaler, usually salbutamol
(may need to repeat after 2–3 minutes).
 If no rapid response, or features of severe asthma, call an ambulance.
A medical assessment should be arranged for patients who require additional doses of
bronchodilator to end an attack.
 A spacer device may need to be used if patient has difficulty using the
inhaler.
 If the patient is distressed or shows any of the signs of life-threatening
asthma, urgent transport to hospital should be arranged.

28. Cardiac chest pain
 Have a previous history of cardiac disease
The pain of myocardial infarction (MI) will often be similar to that of angina but more severe
and, unlike angina, will not be relieved by GTN.
Dental treatment may be best left until another day if there is an attack.
Chest pain that improves on stopping exertion is more likely to be cardiac in origin than one
that is not related.

29. Chest pain – possible causes

30. Myocardial infarction
 Myocardial infarction – signs and symptoms
Severe, crushing chest pain, which may radiate to the shoulders and down
the arms (particularly the left arm) and into the mandible.
Shortness of breath.
The skin becomes pale and clammy.
Pulse becomes weak and patient may become hypotensive.
Often, there will be nausea and vomiting.

31. Myocardial infarction
 Myocardial infarction – treatment
The practitioner should remain calm and be a reassuring presence.
Call emergency number.
Most patients will be best managed in the sitting position.
Patients who feel faint should be laid flat.
Give high-flow oxygen (15 L/min).
Give sublingual GTN spray.
Give 300 mg aspirin orally to be chewed (if no allergy) – ensure that when
handing over to the receiving ambulance crew that they are made aware of
this as thrombolytic therapy is given by some ambulance crews.
A patient who has had surgical dental treatment should be highlighted to
the ambulance crew as any significant risk of haemorrhage may affect the
decision to use thrombolytic therapy
If the patient becomes unresponsive, the practitioner should check for ‘signs
of life’ (breathing and circulation) and start cardiac pulmonary ressusication.

32. Epileptic seizures
 Epilepsy – signs and symptoms
The patient may have an ‘aura’ or premonition that a seizure is about to
occur.
Tonic phase – loss of consciousness, patient becomes rigid and falls and
becomes cyanosed.
Clonic phase – jerking movements of the limbs, tongue may be bitten. Urinary incontinence,
frothing at the mouth.
The seizure often gradually abates after a few minutes but the patient may
remain unconscious and may remain confused after consciousness has been
regained
Hypoglycaemia may present as a fit and should be considered (including in
epileptic patients). Therefore, blood glucose measurement at an early stage
is wise.

33. Epileptic seizures
 Epilepsy – treatment of a fit
As far as possible, ensure safety of the patient and practitioner (do not
attempt to restrain).
Midazolam given via the buccal or intra-nasal route (10 mg for adults). The
buccal preparation is marketed as ‘Epistatus’ (10 mg/mL)
 For children:
❜ Child 1–5 years-5 mg
❜ Child 5–10 years-7.5 mg
❜ Child more than 10 years-10 mg
The parents of some children with poorly controlled epilepsy will carry
rectal diazepam.
 In the absence of rapid response to treatment, call an ambulance.

34. Hypoglycaemia
 Hypoglycaemia – signs and symptoms
Trembling
Hunger
Headache
Sweating
Slurring of speech
‘Pins and needles’ in lips and tongue
Aggression and/or confusion
Seizures
Unconsciousness

35.  Hypoglycaemia – treatment
Lie the patient flat (remember A, B, C).
If the patient is conscious, give oral glucose (three lumps of sugar or
2–4 teaspoons of sugar) or Gluco Gel R (Figure 12.3).
If the patient is unconscious, give 1 mg glucagon intramuscularly (or
subcutaneously).
Get medical help.

38. Allergies/hypersensitivity reactions
 Anaphylaxis – signs and symptoms
Itchy rash/erythema.
Facial flushing or pallor.
Upper airway (laryngeal) oedema and bronchospasm leading to stridor,
wheezing and possibly hoarseness.
A respiratory arrest may occur leading to cardiac arrest.
Vasodilatation leading to low blood pressure and collapse, which may
progress to cardiac arrest.
Anaphylaxis – initial treatment
The ABCDE approach should be employed while the diagnosis is being made.
Manage airway and breathing by administering high-flow oxygen.
Restore blood pressure by lying the patient flat and raising the legs.
 In life-threatening anaphylaxis (hoarseness, stridor, cyanosis, dyspnoea,
drowsiness, confusion or coma), adrenaline should be administered:
Administer 0.5 mL of 1 in 1000 adrenaline IM and repeat and 5-minute
intervals if no improvement.
The optimum site for injection is the anterolateral mid-third of the thigh.

42. SUMMARY & CONCLUSION
 ALWAYS BE PREPARED
 Prompt recognition and efficient management of medical emergencies by a
well-prepared dental team can increase the likelihood of a safe & satisfactory
outcome.
 Basic life support training- A MUST
 As always, prevention is better than cure.
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