Medical Emergencies in Dental Practice

Orrett E. Ogle, Harry Dym, Robert J. Weinstock

• Publisher: Quintessence Publishing Co, Inc
• Year: 2019
• eBook ISBN: 9780867159110
• Topic: Medicine
• Subtopic: Dentistry

The active use of preventive measures is invaluable in clinical practice, but the best way to ensure effective management of a medical emergency is to be prepared in advance. Practitioners and their entire dental staff must be ready to confront medical emergencies that may arise during treatment with sufficient medical knowledge to initiate appropriate primary treatment. This accessible manual addresses the most common medical emergencies encountered during dental treatment. Step-by-step treatment guidelines and decision-making algorithms outline the steps for immediate treatment and make this practical book an essential office manual.

1

Pretreatment Evaluation of the Dental Patient

Orrett E. Ogle, DDS

Prevention is the most important aspect of preparation for medical emergencies. The dental practitioner can prevent many emergencies by conducting a thorough medical history, making appropriate alterations to dental treatment as required, and optimally stabilizing the patient’s medical condition when possible. This chapter will discuss pretreatment assessments that are essential to ensuring that the dentist can provide dental treatment that is also medically appropriate for each patient.

Medical Assessment

A thorough initial medical evaluation to identify correctable medical abnormalities and determine the residual risk is mandatory for all patients undergoing dental treatment. The preoperative evaluation is the foundation for minimizing undesirable outcomes; the clinician can use the assessment to identify and mitigate risk factors and develop a plan that will best balance the risks, benefits, and alternatives that are available.

Routine preoperative evaluation will vary among patients, depending on their age and general health. In evaluating a patient for any interventional procedure, the dental surgeon must consider two aspects: (1) the necessary work-up that must be performed prior to treatment and (2) whether the patient can safely undergo the planned dental or surgical procedure.

Medical questionnaire

The most efficient method of obtaining the medical history is to use a medical questionnaire. The form should be detailed and comprehensive (Fig 1-1). All health questions must be answered. Pertinent positive answers must be addressed, and certain negative answers, such as allergies or bleeding history, must be confirmed. The patient should be verbally questioned about the severity and control of the disease. All medications must be noted.

Fig 1-1 Sample of long medical history form. NSAIDs, nonsteroidal anti-inflammatory drugs.

Any medical condition that could affect dental treatment or that could be affected by dental treatment should be noted on the record treatment page under a section for past medical history. If the condition is critical (eg, allergies or heart conditions), the external portion of the chart should be flagged with a sticker for medical alerts or annotated in red ink. Electronic records should also be flagged using the method available in the software system.

Emergency telephone numbers should be prominently posted on the health questionnaire. For individuals with serious illness, the name and telephone number of the primary care physician should also be obtained.

If there are serious health issues, the health history should be updated at every visit, and any changes in the condition should be noted in the record. The health history must be dated and signed by the patient or parent/guardian and the dentist. Failure to sign the form may imply that the dentist did not review it.

A detailed medical history will identify potential management problems (physiologic and pharmaceutical) and allow the dental surgeon to formulate a treatment plan in light of the medical status. A patient may present with one or multiple established medical diagnoses, which may alter how dental care is delivered. The role of the dentist is to determine how these medical problems will influence care or how dental care may affect medical treatment. Medical illness may predispose the patient to acute physiologic decompensation under stress or failure to do well posttreatment, or it may lead to drug interactions. The dentist must be aware of potential results and what precautions must be taken to minimize risks. Clinicians must identify issues that should be addressed prior to treatment (eg, insulin, warfarin, or aspirin use), illnesses that may cause physiologic decompensation during treatment (eg, angina, seizure disorders, or asthma), and conditions that may affect the posttreatment phase (eg, diabetes [infection and delayed wound healing] or aspirin use [impaired hemostasis]).¹

Medications

The patient’s medical record must list all drugs that the patient is currently taking. The dentist should know what each drug is and why it is being used. Information on drugs can be obtained very quickly from programs downloaded to smartphones or laptop or tablet computers. Some available apps are Epocrates (Athenahealth), Davis Drug Guide (Unbound Medicine), Pocket PC drug guide (Softonic), and Drugs.com medication guide (Drugs.com).

The dentist should pay special attention to side effects associated with the patient’s medications, because some side effects may affect dental treatment. For example, heart medications, blood pressure drugs, sedatives, muscle relaxants, and other medications may contribute to bladder control problems. Patients taking these drugs need to urinate frequently and will not be able to tolerate long appointments. Pregabalin (Lyrica, Pfizer), thiazides, all diuretics, and carbonic anhydrase inhibitors are other drugs that will cause frequent urination and urgency.

Another common medication side effect that impacts dental care is xerostomia. More than 500 drugs can cause xerostomia. Medication use is the most frequent cause of xerostomia complaints, especially among the elderly.² Xerostomia can affect the comfort of removable prostheses, cause angular cheilitis, and promote candidal infections.

Medical consultation

Medical consultations are necessary when diagnostic medical questions are present or when the patient has medical problems that are beyond the dentist’s knowledge base. The dentist should ask the consultant at least these basic questions:

• Is the patient in optimal condition to undergo routine dental treatment in an office setting?

• Does the patient have reversible disease?

• Where is the patient in the continuum of disease?

Simply sending a request asking a physician to “clear a patient” for a dental procedure is likely to yield an equally uninformative response of “patient cleared” and must be avoided.¹ Even when a physician states that a patient is medically cleared, the final decision regarding treatment is the responsibility of the dental surgeon. A medical consultation is simply a tool for risk assessment and is not a “green light” to the dentist indicating that all will be well.

Risk Analysis

A useful step in patient assessment is to assign an American So...

Table of contents

• Cover
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Preface
• Contributors
• 1 Pretreatment Evaluation of the Dental Patient
• 2 Essentials of an Emergency Kit
• 3 Respiratory Emergencies
• 4 Acute Chest Pain
• 5 Syncope
• 6 Allergy and Anaphylaxis
• 7 Seizures, Epilepsy, and Stroke
• 8 Nausea and Vomiting
• 9 Hemorrhagic Emergencies
• 10 Emergencies in the Pregnant Dental Patient
• 11 Hypertension and Hypotension
• 12 TMJ Emergencies
• 13 Diabetic Emergencies
• 14 Malignant Hyperthermia
• 15 Thyroid Crisis
• 16 Local Anesthesia Emergencies
• 17 Adrenal Crisis
• 18 Basic Life Support
• Index