Dental Emergencies Quiz

Medically Compromised Patients in Dentistry

• Cardiovascular diseases are a significant concern
• Ischemic heart disease is a type of cardiovascular disease that can affect blood flow to the heart
• Infected endocarditis is a bacterial infection of the heart lining or valves
• Hypertension and hypotension are related to blood pressure regulation

Importance

• Recognize existing medical conditions
• Adequate preparation is vital, including premedication and prophylaxis adjustments
• Prepare for adverse effects
• Postoperative considerations include controlling bleeding and infection

Urgency vs Emergency

• Urgency: a problem requiring immediate attention that, if not resolved quickly, can become life-threatening
• Examples of urgency include syncope, hypoglycemia, seizures, asthma attacks, angina, and mild allergic reactions
• Emergency: immediately life-threatening and requires immediate action
• Examples of emergency include cardiac arrest, anaphylaxis, and obstructed airways

Preparation for Emergencies

• Obtain a detailed and up-to-date medical history for each patient
• Remind patients to take their regular medications on the day of their appointment
• Train all staff in basic first aid and CPR
• Maintain a written emergency plan and post emergency contact numbers at each phone

Basic Life Support (BLS)

• Initial management in all medical emergencies involves BLS
• The application of needed steps of basic life support
• The ABCs of cardiopulmonary resuscitation (CPR) are assessment and treatment, taking place in that order (according to AHA 2010 guidelines):
  • Airway (maintain patency)
  • Breathing (respiratory movement)
  • Circulation (heart beat and blood pressure)
• Use of emergency drugs is a secondary action, after attending to the ABCs

CPR Steps

• Cardiopulmonary Resuscitation (CPR): Lay the patient flat, facilitate venous return to the heart, turn the head, and lift the chin to prevent the tongue from obstructing airflow to the lungs.
• Establish a clear airway by suctioning any secretions
• Provide artificial ventilation, using a face mask and an Ambu bag for oxygen delivery, if necessary
• Perform external cardiac massage, pressing on the lower sternum at a rate of 60-70 times per minute
• Call medical help and transport the patient as needed

Steps of Basic Life Support

• Step 1: Assess consciousness
• Step 2: Call for help
• Step 3: Position the patient (Trendelenburg position)
• Step 4: Assess and open airway (head tilt-chin lift or jaw thrust)
• Step 5: Assess airway patency and breathing
• Step 6: Provide artificial ventilation if needed
• Step 7: Assess circulation
• Step 8: Manage the patient's airway
• Step 9: Perform external chest compressions

Health Assessment

• Taking a thorough health history and vital signs is essential to identify "at-risk" patients
• Extensive procedures for at-risk patients may be best performed in a hospital setting

ABCs of any emergency

• Maintain the supine position
• Provide 100% oxygen
• Evaluate airway, breathing, and circulation
• Assess vital signs (temperature, blood pressure, pulse and respiratory rate)

Estimation

• It is estimated that one or two life-threatening emergencies may occur during the career of a general dentist

What Types of Emergencies Can Be Expected in the Dental Clinic?

• Syncope: 50.3%
• Mild allergic reactions: 8.4%
• Angina pectoris: 8.3%
• Hypotension: 8.0%
• Seizures: 55.2%
• Asthma attacks: 4.5%

Patients Classification

• Type I: Normal patient
• Type II: Mild to moderate systemic disease
• Type III: Severe systemic disease limiting patient activity
• Type IV: Severe systemic disease threatening life
• Type V: Morbid patient

Treatment Options

• Office treatment: ASA type I and II
• Hospitalization: ASA type III
• Hospitalization and emergency treatment only: ASA type IV
• Hospitalization and palliative treatment: ASA type V

Potential Problems Related to Dental Care

• Stress and anxiety reduction protocol:
  • Premedication
  • Short, morning appointments
  • Limiting epinephrine use
  • Nitrous oxide-oxygen

Stress Reduction Protocol

• Before appointment (night before or day of)
  • Valium 5-10 mg
  • Short-acting barbiturates (secobarbital 50-100 mg)
• During appointment
  • Relaxing music
  • Reassurance
  • Removing unnecessary noise
  • Surgical materials out of the patient’s view
  • Proficient local anesthesia
  • IV sedation
  • Nitrous oxide sedation
• After surgery
  • Further reassurance
  • Detailed postoperative sequelae information
  • Effective analgesics
  • A post-op phone call

Who are Medically Compromised Patients?

• A patient with significant medical conditions that alter the course of treatment by a dentist
• "Medically compromised" is relative
• Includes patients who already have a referral to another specialist

Why Assess Patient Condition?

• To evaluate any infection or condition that could compromise medical or surgical therapy
• To restore optimal oral health and function

How the Dentist Assesses Patient Condition?

• Full-mouth intra-oral radiographs plus panoramic radiograph
• Panoramic radiograph only if edentulous
• Thorough medical and dental history
• Initiate preventive therapy
• Arrange treatment
• Arrange follow-up

Physical Evaluation and Risk Assessment

• The key to successful dental management for medically compromised patients is a thorough evaluation of risk, to determine if the patient can safely tolerate a planned procedure.
• Four components to consider:
  • The nature, severity, and stability of the patient's medical condition,
  • The patient's functional capacity,
  • The patient's emotional status, and
  • The type and magnitude of the planned procedure (invasive or non-invasive).
• All factors must be weighed carefully for each patient, and each situation requires thoughtful consideration to determine if the benefits outweigh the potential risks.

Physical Evaluation and Risk Assessment (continued)

• Example: a patient with symptomatic heart failure may have minimal risk for a noninvasive procedure like taking x-rays
• Conversely, in the same patient, a full-mouth extraction might have a significant risk if the patient is also very anxious
• A cornerstone for evaluation is taking a complete medical history, a physical examination, laboratory tests, and medical consultation

Physical Evaluation and Risk Assessment: Medical History

• A thorough medical history must be taken for every patient, using both direct interview and filled-out questionnaires
• Follow-up questioning should occur for more in-depth information on the patient’s medical history, as it pertains to dental treatment

Systemic Disorders

• Cardiovascular problems (high blood pressure)
• Endocrine disorders (diabetes)
• Hematological disorders (hemophilia)
• Gastrointestinal diseases and liver problems
• Respiratory diseases (asthma)
• Genitourinary tract diseases
• Neurological disorders (epilepsy)

Cardiovascular Diseases

• Any dental procedure can cause injury to soft tissues/bone, producing transient bacteremia
• Susceptible individuals can develop infective endocarditis, even from minor procedures (e.g., matrix band placement/tooth cleaning).

Main Signs & Symptoms of Cardiovascular Disease

• Chest pain
• Dyspnea (shortness of breath)
• Cyanosis (bluish discoloration of the skin)
• Palpitation (rapid or irregular heartbeat)
• Syncope (fainting)
• Edema of ankle
• Clubbing of fingers
• Cold or pale extremities
• Fatigue

Ischemic Heart Disease

• Decreased coronary blood flow and/or increased myocardial oxygen demand can cause ischemic heart disease.
• Main disorders include:
  • Angina pectoris
  • Myocardial infarction
  • Congestive heart failure

Angina Pectoris

• Myocardial ischemia due to an imbalance between coronary blood flow and oxygen demand
• Symptoms:
  • Substernal pain radiating to the left shoulder
  • Dull, heavy, or pressure sensation lasting less than 5 minutes
  • Relieved by rest or nitroglycerin
• Potential dental problems: stress, angina attack, MI, and sudden death (stable or unstable)

Dental Management Considerations

• Identification & medical consultation
• Short & morning appointments
• Semi-supine chair position
• Patient's sublingual tablets (e.g., nitroglycerin) on hand
• Preoperative medication (e.g., diazepam 2-5 mg & nitroglycerin)
• Local anesthesia with low-concentration epinephrine (1:100,000)
• Patient with stable angina (one sublingual tablet for pain relief, vital sign monitoring, emergency care if needed)
• Stress reduction protocol

Myocardial Infarction

• Occlusion of coronary arteries by thrombus causes insufficient coronary blood supply
• Anginal attack lasting several minutes
• Symptoms;
  • Prolonged anginal pain
  • Tachycardia and irregular pulse
  • Nausea and vomiting
  • Difficulty breathing
  • Pain unrelieved by rest or nitroglycerin
• Potential dental problems: cardiac arrest, MI, AP, congestive heart failure, infective endocarditis, pacemaker interference

Dental Management of Patients with Unstable Angina or recent MI

• Avoid elective dental care
• Emergency care only after consultation with physician and pain control (e.g., antibiotic for infection, pulpotomy rather than extractions)
• Pretreatment medication (e.g., valium 5mg)

Congestive Heart Failure

• Inability of the heart to pump sufficient blood to meet metabolic needs
• Symptoms: fatigue, dyspnea, ankle edema, orthopnea
• Potential dental problems: MI, bleeding, CVA, and endocarditis

Dental Management Considerations for Congestive Heart Failure

• Identification & medical consultation, up-righting position (to prevent fluid build-up in the lungs)
• Assess prothrombin and bleeding times
• Preoperative antibiotic
• Terminate appointment if patient is fatigued
• Avoid gag stimulation
• Avoid atropine
• Avoid vasopressors for local bleeding control (and gingival cord)
• Manage complications, if developed

Infective Endocarditis

• Inflammation of the inner tissue of the heart (especially heart valves) due to microbes
• Patients who have heart conditions should get antibiotic prophylaxis to prevent infections
• Risk factors include rheumatic heart disease, mitral valve prolapse, prosthetic valves, and prior infective endocarditis

Procedures that May Cause IE

• Tooth extraction, periodontal surgery and rubber dam placement are high-risk procedures
• Even routine procedures like brushing, flossing and chewing can trigger bacteremia

Is Antibiotic Prophylaxis Necessary?

• Recent Cochrane reviews suggest that there is often weak evidence supporting prophylactic antibiotic use
• The American Heart Association recommends antibiotic prophylaxis only for patients at highest risk of infective endocarditis, like those with prosthetic heart valves, previous IE, certain congenital heart diseases, or cardiac transplant patients who develop cardiac valve pathologies
• Patients at highest risk should get prophylaxis

Dosage of Antibiotics

• Normal: Amoxicillin 2 gm 1 hour before dental procedure.
• Unable to take oral medication; Ampicillin 2 grams, 1 hour before procedure
• Allergic to penicillins: Clindamycin 600 mg 1 hour before procedure
• If unable to take oral medication AND allergic to penicillin: Clindamycin 600 mg ampules

Special Cases

• Patients with prosthetic valves: always receive anticoagulant therapy; consider an INR-based reduced dose of antibiotics. Postponing treatment until anticoagulant therapy is completed may be beneficial.
• Patients already on penicillin: postpone dental treatment until therapy is finished if possible, and use clindamycin if an urgent procedure is needed

Hypertension

• Hypertension is defined as a blood pressure above a certain level either systolic OR diastolic (more than 140 mmHg systolic and/or 90 mmHg diastolic)
• Hypertension is a factor in cardiovascular and renal disease

Hypertension Classification

• Normal: 120 / 80
• (Mild/Pre-hypertension): 140-159 Systolic / 80 -90 Diastolic
• Grade 1 (Moderate): 160-179 Systolic / 90-100 Diastolic
• Grade 2 (Severe): >180 Systolic / >100 Diastolic

Be Alert For:

• High blood pressure: patients should report increasing blood pressure or symptoms like headaches, jittery feelings, or pressure behind the eyes to you.
• Profuse bleeding that exceeds expectations

Test your knowledge on dental emergencies and basic life support procedures. This quiz covers essential topics such as medical history techniques and the importance of premedication for patients with systemic disorders. Perfect for dental professionals looking to sharpen their emergency response skills.