Management Of Medical Emergencies In

The Dental Office

Fady Faddoul, DDS, MSD,FICD

Professor and Vice-Chairman
Department of Comprehensive Care
Director, Advanced Education in General Dentistry

Case Western Reserve University

School Dental Medicine

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Management of Medical Emergencies

Medical emergencies can and do happen

Advances in medicine
Longer lifespan

Multiple medications

Medically compromised

Longer appointments

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Incidence

A survey done in the 90s showed that, over

a 10 year period, 90% of dentists have
encountered at least one medical
emergencies.

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Types
TYPE OF EMERGENCY NUMBER PERCENT

Altered Consciousness 17,782 59

Cardiovascular 4,280 14
Allergy 2,887 9.5
Respiratory 2,718 9
Seizures 1,595 5
Diabetes-Related 999 3
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Management of Medical Emergencies

Basic Life Support

Advanced Life Support

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 Management of Medical Emergencies
Emergency situations
Managed properly most emergencies are resolved satisfactorily
Mismanaged even benign emergencies can turn disastrous
Recognize
Position
Stabilize
Diagnose
Treat
Refer

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Management Of Medical Emergencies

1. Recognition
2. Prevention
3. Preparation
4. Basic life support (BLS)
5. Cardiopulmonary resuscitation (CPR)
6. Specific medical emergencies

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Prevention
IS THE BEST
TREATMENT

Know your patient

Never treat a STANGER

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Prevention
90% of life-threatening situations can be
prevented
10% will occur in spite of all preventive
efforts (sudden unexpected death)

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Prevention
Medical History
Physical Evaluation
Vital Signs
Dialogue History
Determination of Medical Risk
Stress Reduction

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Prevention

MEDICAL HISTORY
Review
Update
Medication
Medical consultation

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Prevention
PHYSICAL EVALUATION
Length of time since last evaluation
Vital signs
Visual inspection of patients
Referral to physician

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 Prevention

VITAL SIGNS

Blood pressure Temperature

Pulse rate Height
Respiratory rate Weight

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Prevention
DIALOGUE
HISTORY
Putting it all together
Check accuracy of
medical history
Recognize anxiety

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Prevention
DETERMINATION OF MEDICAL RISK.
Ability of patient to safely tolerate dental
treatment.
Does patient represent increased medical
risk?
Can patient be managed in the dental
office?

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Determination Of Medical Risk

American Society of
Anesthesiology
Physical Status Classification
System

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 ASA I
A patient without Can tolerate stress involved
systemic disease In dental treatment
A normal healthy No added risk of serious
patient Complications
Treatment modification
Usually not necessary

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 ASA II
A patient with mild systemic Represent minimal risk
disease during dental treatment
Example: Routine dental treatment
-Well-controlled diabetic With minor modifications
-Well-controlled asthma -Short early appointments
-ASA I with anxiety -Antibiotic prophylaxis
-Sedation

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 ASA III
A patient with severe systemic Elective Dental Treatment
disease that limits activity but is is not Contraindicated
not incapacitating Treatment Modification is
Example: Required
- a stable angina - Reduce Stress
- 6 mos. Post - MI - Sedation
- 6 mos. Post - CVA - Short Appointments
- COPD

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 ASA IV
A patient with incapacitating Elective dental care
systemic disease that is a should be postponed
constant threat to life Emergency dental care
Example: only
- Unstable angina Rx only to control
- M I within 6 months pain and infection
- CVA within 6 months Other treatment in
- BP greater than 200/115 hospital
- Uncontrolled diabetic (I&D, extraction)

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 ASA V
A morbid patient not Elective treatment
expected to survive definitely
Example: contraindicated
- End stage renal disease
- End stage hepatic disease Emergency care only
- Terminal cancer to relieve pain
- End stage infectious disease

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Prevention
STRESS REDUCTION
Premedication
Sedation
Pain control (intra and post-op)
Early appointments
Short appointments

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Preparation
Team Effort
BLS for all office personnel
CPR for all office personnel
Emergency drills
Emergency phone numbers (911)
Emergency equipment

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 BASIC LIFE SUPPORT
(BLS)

CARDIOPULMONARY
RESUCITATION
(CPR)

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SBE Prophylaxis
In 2012, the guidelines were updated and now premedication is needed for
fewer conditions.
The conditions for which premedication is necessary includes:
artificial heart valves

a history of infective endocarditis

a cardiac transplant that develops a heart valve problem
the following congenital (present from birth) heart conditions:

*unrepaired or incompletely repaired cyanotic congenital heart disease,

including those with palliative shunts and conduits
*a completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
six months after the procedure
*any repaired congenital heart defect with residual defect at the site or
adjacent to the site of a prosthetic patch or a prosthetic device

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 SBE Prophylaxis
Patients who previously needed antibiotic
prophylactic but no longer need them include:
mitral valve prolapse
rheumatic heart disease
bicuspid valve disease
calcified aortic stenosis
congenital (present from birth) heart
conditions such as ventricular septal defect,
atrial septal defect and hypertrophic
cardiomyopathy
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SBE Prophylaxis
Procedures needing prophylaxis:
All dental procedures that involve manipulation

of gingival tissue or the periapical region of

teeth or perforation of the oral mucosa.
procedures that do not require prophylaxis are

radiographs, placement of removable

prosthesis, and placement orthodontic bracket.

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Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures

AMOXCICILIN
Adults 2 grams
Children 50 mg/kg (not to exceed adult dosage)

Orally 1 hour before procedure

No repeat dose
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 Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
Allergic to Penecillin

Adult Children
Clindamycin 600 mg 20 mg/kg

Cefalexin or Cfadroxil 2 gr. 50 mg/kg

Azithromycin or Clanthromycin 500 mg 15mg/kg

ORALLY 1 HOUR BEFORE PROCEDURE

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 Management of Medical Emergencies
Antibiotic Prophylaxis
Prophylactic Regimen for Dental Procedures
Unable to take Oral Medication

Ampicillin
Adults: 2 gr IM or IV
Children: 50 mg/kg IM or IV

Within 30 minutes of procedure

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 Management of Medical Emergencies
Antibiotic Prophylaxis

Amoxicillin vs. Penecillin

Both equally effective against Streptococus viridan
Amoxicillin is better absorbed from the GI tract, and
provides higher and more sustained serum level
2 gr. Provides as effective coverage as 3 gr. With less
GI adverse effects.
2nd dosage not required due to prolonged serum level
above the inhibitory period for most oral Streptococci.

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 Management of Medical Emergencies
Antibiotic Prophylaxis
ERYTHROMYCIN
No longer recommended due to GI side
effects. Practitioners who have used it
successfully in the past, may continue to
use it following the previously published
regimen.
2 gr. 2 hours before procedure
1 gr. 6 hours later

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 Management of Medical Emergencies
Antibiotic Prophylaxis
Patient already taking antibiotic used for prophylaxis:
1. Select an antibiotic from a different class, rather than
increasing the dosage
2. Delay treatment if possible 9 to 14 days after
completion of antibiotic to allow usual flora to
reestablish

Example: Amoxicillin, go to Clindamycin.

No Cephalosporin due to cross resistance

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 Management of Medical Emergencies
Antibiotic Prophylaxis

Prophylaxis for dental patients with

TOTAL JOINT REPLACEMENT

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 Management of Medical Emergencies
Antibiotic Prophylaxis
The most crucial period is up to 2 years
following a joint replacement
Prophylaxis not recommended for dental
patients with: Pins, Plates, and Screws.
Prophylaxis is not routinely indicated for
most dental patients with total joint
replacement

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 Management of Medical Emergencies
Antibiotic Prophylaxis
Patients at potential increased risk of total joint
infection
Immunocompromized/Suppressed patients
Other Patients:
Insulin Dependent diabetics
st
1 2 years following joint replacement
Previous prosthetic joint infection
Malnourishement

Hemophilia

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 Management of Medical Emergencies
Antibiotic Prophylaxis
Procedures and regimens are the same as
discussed earlier for SBE prophylaxis.

A cephlosporin is preferable to Amoxicillin

due to its affinity to cynovial fluids

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