Dental Emergency Handout PDF

Students: -  Mohamed Al-Hujeari  Mohamed al-abduallah  Khalid alzahrani  Ammar allehyani PG. 1  Content Dental emergencies Introduction----------------------------------------------------------- 3 Anaphylaxis------------------...

Students: -  Mohamed Al-Hujeari  Mohamed al-abduallah  Khalid alzahrani  Ammar allehyani PG. 1  Content Dental emergencies Introduction----------------------------------------------------------- 3 Anaphylaxis-------------------------------------------------------- 4-6 Angina----------------------------------------------------------------7-8 Hypoglycemia-----------------------------------------------------9-10 Vasovagal syncope--------------------------------------------11-12 Asthma------------------------------------------------------------13-15 Seizure and epilepsy------------------------------------------16-19 References-----------------------------------------------------------------20 PG. 2  Introduction: - Dental emergencies can be more serious for patients with conditions like anaphylaxis, angina, hypoglycemia, vasovagal syncope, asthma, seizures, and epilepsy. These conditions require careful management during dental procedures. Dental professionals must be aware of these risks, act quickly if needed, and understand the patient’s medical history to ensure safety. The dental members have a responsibility to ensure they deliver a safe and effectiveness service to their patients, by Proper management to medical emergencies, needing for appropriate equipment, Training, knowing the risk factor and management. PG. 3  Anaphylactic shock  Definition: anaphylaxis is defined as ‘‘a serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death.’  Mechanism of anaphylactic reaction: Sensitized mast cells produce histamine, which mediates the anaphylactic response.  Triggers: Product Examples  Antibiotics (eg, amoxicillin and penicillin)  Analgesics (eg, NSAIDs) Drugs  Antiseptics (eg, chlorhexidine)  Sedatives (eg, midazolam, propofol)  Local anesthetics  Used in endodontics (eg, formaldehyde and sodium Dental materials hypochlorite)  Used in impressions (eg, alginate impression material)  Gloves, bite blocks, prophy polishing cups, dental rubber dams, items contain latex orthodontic elastics, adhesive tape, impression materials containing latex, masks, and gutta percha PG. 4   Signs & Symptoms: Organ\System Clinical features  Erythema, and conjunctival erythema. Skin  Itching of lips, tongue, palate, palms, and soles.  Edema; swelling of lips, tongue, or uvula.  Throat: itching and tightness, hoarseness, dry cough.  Increased respiratory rate. Respiratory  Shortness of breath.  Respiratory arrest.  Nausea, vomiting, dysphagia. GIT  Abdominal pain, and diarrhea  Chest pain  Tachycardia, arrhythmias, and palpitations CVS  Hypotension  Cardiac arrest PG. 5 Management of anaphylactic reaction: 1. Eliminate the triggering agent. 2. Evaluate Airway Breathing Circulation Disability Exposure Call ambulance, state "Anaphylaxis". 3. Inject epinephrine into the mid-anterolateral portion of the thigh at a dose of 0.01 mg/kg of a 1:1,000 (Img/mL).  For adults, a maximum of 0.5 mg. For children, 0.3 mg.  Repeat adrenaline at 5 minutes. 4. Patient should be placed in a supine position with their lower extremities raised. 5. Deliver high-flow supplementary oxygen (6-8 L/minute) when necessary. 6. Perform cardiopulmonary resuscitation (CPR) if indicated at any stage. PG. 6  Angina  Definition: Also known as angina pectoris, is chest pain or pressure occurs due to insufficient blood flow to the heart muscle.  Types: 1. Classic (stable) angina (atherosclerotic angina):  Triggered by stress or physical exertion.  Results from atheromatous partial obstruction in large coronary vessels. 2. Unstable angina:  Worsens progressively in severity and frequency over a short period (e.g., a day).  Caused by narrowing or partial blockage of coronary arteries due to thrombi or platelet aggregation.  A warning sign of a potential heart attack, requiring immediate medical attention. 3. Variant (Prinzmetal, vasospastic) angina: This condition is relatively uncommon and typically occurs at rest or during sleep, often affecting young individuals.  It is caused by coronary artery vasospasm  Generally, responds quickly to vasodilators.  Sign and symptoms:  Increased heart rate.  Elevated blood pressure  Weak pulse  Pale skin  diaphoresis  Abnormal heart sounds  cyanosis (rare) PG. 7   management of Angina: ease breathing and reduce the workload  stop the dental procedure. on heart by reduce venous return.  positioning Sit the patient in upright position.  Administer Nitroglycerin: Provide a sublingual nitroglycerin tablet or spray (0.3– 0.6 mg). Repeat every 5 minutes, up to three doses.  Oxygen Therapy  Monitor Vital Signs  Call for Help  Emergency medication: 1. Nitrates: a. Short-acting (10 minutes): Glyceryl trinitrate (GTN and Nitroglycerine) – EMERGENCY. b. Long acting (1 hour): Isosorbide dinitrate, Isosorbide mononitrate, Erythrityl tetranitrate, Pentaerythritol tetranitrate. PG. 8  Hypoglycaemia  Definition and mechanism: Hypoglycemia is a clinical syndrome that confirmed when glucose levels drop below 70 mg/dL and symptoms are promptly relieved upon restoring glucose levels.  Prevalence: WHO in 2014 reported that the diabetes prevalence in Saudi Arabia is very high, and it ranked 7th in the world.  Sign and symptoms:  Shaking or tremors  Sweating Adrenergic  Palpitations Symptoms  Anxiety or nervousness  Hunger  Confusion  Dizziness Neurogenic  Fatigue or weakness Symptoms  Blurred vision  Headache  Seizures Severe Symptoms  Loss of consciousness  Coma  Types: 1. Mild hypoglycemia is defined as any degree of hypoglycemia in which patient can help himself to treat hypoglycemia symptoms. 2. Biochemical definition of severe hypoglycemia is, any glucose levels below 40mg/dl PG. 9   Management: In case pt Conscious AND able to drink:  Give 15 gram of glucose (sugar) orally (1/2 cup apple or orange juice or one table spoonful sugar dissolved in water or one tablespoon of honey)  Repeat blood glucose test after 15 minutes If blood glucose is still ≤ 70mg/dl repeat the process x 3 till glucose is >70mg/dl  Then give a snack of 15-20 gram of complex carbohydrate such as one toasts In case pt Unconscious OR unable to drink: release the glucose  MILD (40-70mg/dl): slowly and for a longer duration.  Administer 25 mL 50 % dextrose IV over 1-3 minutes  Repeat blood glucose test after 5 minutes If blood glucose is still ≤ 70mg/dl repeat the process x 3 till glucose is >70mg/dl  Give a snack of 30 gram of complex carbohydrate such as 2-3 toasts  SEVERE (< 40mg/dl):  Administer 50 mL of 50 % dextrose IV over 1-3 minutes  Repeat blood glucose test after 5 minutes If blood glucose is still ≤ 70mg/dl repeat the process x 3 till glucose is >70mg/dl  Give a snack of 30 gram of complex carbohydrate such as 2-3 toasts NO SECURED INTRAVENOUS ACCESS:  Administer 1 mg glucagon subcutaneously or intramuscular  Repeat blood glucose test after 15 minutes If blood glucose is still ≤ 70mg/dl repeat the process x 3 till glucose is >70mg/dl  When the patient is conscious and able to eat give a meal of 30 gram of complex carbohydrate such as 2-3 toasts. PG. 10  Vasovagal syncope  Definition Neurogenic reflex-mediated fainting episode characterized by sudden, transient, and self- limiting symptoms, due to transient cerebral ischemia caused by a reduction in blood supply to the brain.  Prevalence: (VVS) has the highest occurrence rate among emergent medical events. However, the overall incidence of VVS is extremely low. The low incidence and sudden nature of vasovagal syncope often lead to improper management by most dental practitioners when encountering this condition for the first time  Mechanism: 1) Emotional or environmental triggers. 2) Activation of parasympathetic nervous system. 3) Vasovagal reaction. 4) Drop in blood pressure & reduction in brains oxygen supply. 5) Cerebral hypoperfusion & loss of consciousness.  Sign and symptoms:  Feels faint, dizzy, lightheaded  Collapse and loss of consciousness  Pale  Sweaty  Low blood pressure  Slow heart rate  Preliminary examination: 1. Comprehensive medical history 2. Physical examination. 3. Blood pressure measurement. PG. 11  For patients with a history of anxiety, fear, and cardiac arrhythmias, necessary measures should be taken prior to surgery. intraoperative monitoring of the patient’s cardiac rhythm changes should be conducted.  Management: 1. Discontinue treatment. 2. Airway, Breathing, Circulation, Disability, Exposure 3. Supine position (due to brain hypoxia). 4. Administer oxygen – not usually necessary (at least open the window). 5. Assess the pulse, arterial blood pressure, state of consciousness. 6. If it’s slow recovery: administer oxygen therapy at a rate of 2-3 L/min, consider alternative diagnosis. 7. Unresponsive: check signs of life. Call ambulance PG. 12  Asthma  Definition Asthma causes chronic inflammation of the lung airways making them narrow and more difficult to breathe through.  Reversible airflow  Limitations airway hyper responsiveness to a range of stimuli  Inflammation of the bronchi It can be life-threatening. There is no cure for asthma, but it can be managed to live a normal, healthy life.  Prevalence As per asthma patients and their families guide is sued by the Ministry of Health (MOH),as part of the national program to combat asthma 2016  There are more than 300 million people suffer from asthma worldwide.  It causes the death of one person out of 250 deaths around the world.  The prevalence of asthma in Saudi Arabia regions ranges between 15%-25%.  Etiology  Respiratory infections, cold  Cigarette smoke  Allergic reactions (either seasonal or other substances or materials)  Vigorous exercise  Exposure to cold air or sudden Temperature change  Excitement/stress/anxiety. PG. 13   Sign and symptoms:  Difficulty breathing  Wheezing attacks  Chest tightness and cough  Symptoms tend to be intermittent worse at night and in the early morning and provoked by triggers  Brief Tips Before Dental Treatment for Asthmatic Patients To avoid Risk of precipitation of attack  Patient's appointment in late morning or afternoon as the attacks are commonly in early morning.  Confirm they take their dose.Prophylactic dose of B2 stimulant may be useful.  The patient's own inhaler bronchodilator should be on hand or present in emergency kit  Care with dental materials that may elicit asthmatic attack as dentifrice, enemal dust, fissure sealants, methyl methacrylates  Careful positioning of suction tips as they may elicit cough reflex  Avoid prolonged supine positioning  Management: Risk of attack developed during dental procedure:  ABCDE (Airway, Breathing, Circulation, Disability, Exposure)  Stop procedure, Sit upright  If available, follow patient's personalised asthma action plan (PAAP)  2 puffs (100 micrograms/puff) Beta 2 bronchodilator inhaler e.g. salbutamol; Dosages repetition may be required (using a spacer device is quite beneficial). PG. 14 Unsatisfactory/no response or if severe/ life threatening; Call ambulance While awaiting ambulance:  oxygen maximum 5 litres/min using nebulizer  Beta 2 bronchodilator via spacer given one puff at a time, inhaled separately using tidal breathing  Give another puff every 60 seconds, up to a maximum of 10 puffs, based on the response.  Dental professionals need to know how to use an inhaler correctly  Medication:  Inhaled Corticosteroids ICS (Preventers, prophylactic) They are commonly known as ‘brown or orange’ inhalers and are used regularly on a daily basis.  Long-acting beta antagonists LABA They are used in controlling moderate to severe persistent asthma and usually come as a combination with corticosteroids known as ‘green’  Short-acting beta agonists SABA (Relievers) They are commonly known as ‘blue’ inhalers and are used for short term relief of asthma exacerbations. Side effects of Inheald corticosteroids  Fungal infection (oral candidiasis)  Xerostomia  Sore mouth and throat  Dysphagia  Hoarse voice Management of side effect Rinsing after the dose and using spacer device PG. 15  Seizures and Epilepsy Seizure is the most common neurological disorders  Definition: A sudden, uncontrolled burst of electrical activity in the brain that leads to temporary changes in behavior, awareness, or physical movements, which can be noticed by the person experiencing it and by others. A seizure that lasts longer than 30 minutes, or multiple seizures occurring within that time frame without any return to normal consciousness, is known as status epilepticus  Mechanism of seizure: Imbalance of Excitatory and Inhibitory Signals: excessive excitatory activity or insufficient inhibitory control, leading to abnormal brain activity. PG. 16   Types:  Simple (Jacksonian epilepsy): Unusual feelings, strange sensations or uncontrollable jerky movements, but remain conscious and aware of the I. Partial seizure surroundings. (Within a limited area of  Complex (temporal lobe epilepsy): the brain) These seizures cause a change or loss of awareness. During these seizures, the person may appear confused, dazed, or unresponsive, and may engage in repetitive behaviors such as lip-smacking, hand rubbing, or walking in circles.  Tonic-clonic seizure “grand-mal”: The most common type. In the tonic phase of a seizure, the body stiffens from muscle contractions, followed by the clonic phase, where the muscles go through rhythmic contractions and relaxations, causing violent jerking motions, along with drooling, teeth clenching, and sometimes vomiting, followed by relaxing phase and then postictal phase. II. Generalized seizure  Absences seizure “petit-mal”: (The entire brain is A patient stops an activity and stares blankly, loss of consciousness involved) for a short period, rapid recovery.  Myoclonic seizures: Characterized by sudden, brief jerking movements of a muscle or group of muscles. These seizures typically involve rapid, involuntary muscle contractions and do not cause a loss of consciousness.  Clonic seizures: Characterized by rhythmic, jerking movements of muscles, typically on both sides of the body.  Tonic seizures: Characterized by the stiffening or rigidity of muscles, this stiffness typically lasts for a few seconds to a minute and may cause the person to fall or become temporarily immobile.  Atonic seizures: Characterized by a sudden loss of muscle tone, leading to a collapse or fall. PG. 17   Preoperative assessment: 1. Take a comprehensive medical and dental history  Type of seizure  What might trigger a seizure?  Is any of the trigger factors associated with dental care (i.e., stress, light, or infection)?  What to expect when the patient has a seizure Date of the last seizure Frequency of seizure Duration of seizure  Any episodes of status epilepticus 2. Be Aware of the Effects of Antiepileptic Drugs (AEDs) on Oral Health:  Phenytoin: May cause gingival overgrowth after about 3 months. 3. Avoid drug interactions: 4. Develop a long-term treatment plan: 5. Consider fixed prostheses and fixed orthodontic appliances: 6. Use plastic (composite) fillings: 7. Normal doses of local anesthesia are safe: 8. Manage dental anxiety:  Management of seizure event in a dental clinic:  Air way Breathing Circulation Disability Exposure  Dental treatment must be ceased immediately  Record the time and duration of seizure  Recline dental chair to supine position - the patient should not be restrained  Do not remove mouth probe and rubber dam with secured clamp  Cleared mouth from saliva, blood, or any debris using saliva ejectors  Dental team should keep their fingers outside the patient mouth to avoid involuntary biting related to bruxism during seizures  Check that patient in a safe area and keep any hard objective/ equipment  Once the jerking movement cease: recovery position with frequent monitoring to the vital signs  Reassure patient’s family  Epileptic patient should not be discharged alone following the seizure PG. 18   Management of continuous seizure events in a dental clinic:  If the seizures stay longer than 3–5 min or repeated in a short period, the crash team should be called  Air way Breathing Circulation Disability Exposure  Carry on helping the patient until the crash team arrives  Oxygen saturation should be regularly monitored to be>90%, otherwise supplement of oxygen 2–3 L/min should be used  Pharmacological approach should be started using benzodiazepines  If the patient previously cannulated, give extra increment of midazolam (up to 5–10 mg), always check oxygen level to be>90%  If the patient not cannulated, give intramuscular midazolam (5 mg) or intramuscular diazepam (10 mg)  Monitor the patient’s vital signs regularly  Maintaining oropharyngeal airway open by applying head tilt, and neck, chin left, or jaw thrust maneuver  These steps should be followed until the seizure stops and the patient should be positioned to recovery position, or the crash team arrives PG. 19 References Jevon P. (2020). Medical emergencies in the dental practice poster: revised and updated. British dental journal, 229(2), 97–104. https://doi.org/10.1038/s41415-020-1789-y. Goto T. (2023). Management of Anaphylaxis in Dental Practice. Anesthesia Progress, 70(2), 93–105. https://doi.org/10.2344/anpr-70-02-16 Liu, B. , Dai, Q. and Zhang, Y. (2024) A Case of Vasovagal Syncope Induced by Tooth Extraction. Health, 16, 1042-1049. doi: 10.4236/health.2024.1611071. Sinyor B, Concepcion Perez L. Pathophysiology Of Asthma. [Updated 2023 Jun 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551579/ Abed, Hassan1,; Banjar, Assim2; Bamunif, Mohammad3. Special Care Dentistry and Epilepsy. King Khalid University Journal of Health Sciences 8(1):p 6-11, Jan–Jun 2023. | DOI: 10.4103/KKUJHS.KKUJHS_37_22 PG. 20  Bleeding disorder To understand types of most common bleeding disorder Effective dental care for all these types requires a team-based approach A- Vascular Wall Defects: Vascular defects, such as those seen in Marfan syndrome, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) and Ehlers-Danlos syndrome, typically do not result in severe bleeding after dental procedures (usually have mild bleeding tendencies ) and receive dental treatment in a primary care setting. B- Platelet Defects: Inherited platelet defects result in qualitative dysfunction, meaning platelets do not function properly. Patients with these defects require a hematologist's consultation, and platelet transfusion may be needed before invasive dental procedures. Diagnostic tests to assess platelet function include: - Bleeding time. - Platelet aggregation test. - Peripheral blood smear. C- Hemophilia B (Christmas disease): Is a genetic bleeding disorder caused by a deficiency in factor IX, a clotting protein. It is inherited in an X-linked recessive pattern, primarily affecting males. Symptoms include easy bruising, prolonged bleeding, and joint bleeds. The severity depends on the level of factor IX: severe cases may have spontaneous bleeding, while mild cases bleed only after injury. Diagnosis Confirmed with blood tests measuring factor IX levels and genetic testing.  D- Hemophilia A: Is an inherited X-linked recessive coagulation disorder caused by a deficiency of factor VIII. It predominantly affects males, with females being carriers if their factor VIII activity is below 50%, and they may experience mild symptoms. Classification: Hemophilia A is classified based on the level of factor VIII activity: Mild: 5-40% of normal factor VIII levels. Moderate: 1-5% of normal factor VIII levels. Severe: