Emergencies can and do happen. Most dentists will, at some point in their career, be faced with an in-office emergency. The combined findings of surveys by Fast and Malamed showed 30,602 emergencies occurring over a 10-year period in the offices of the 4,309 dentists reporting.1,2 More than 54 percent of the emergencies occurred during or right after local anesthesia. The types of treatments cited with the greatest percentage of emergencies are two procedures associated with potential high patient anxiety - tooth extraction and pulp extirpation.2
An additional consideration that may lead to increased medical emergencies in dentistry is the growing number of elderly patients in the population who seek dental treatments such as implants and crown and bridge reconstruction. These patients are typically more medically compromised, so dentists who treat these patients may see an increase in the number of medical emergencies.3
With proper prevention techniques, 90 percent of medical emergencies can be avoided.4 What are the steps to prevention? The importance of a thorough medical history cannot be overemphasized. Written answers are just the beginning of your history. An oral medical history must be taken and affirmative answers to medical history questions should be explored further for comprehensive information.5 Update information regularly and review before each visit. It may be necessary to consult the patient’s medical doctor for additional information or guidance.
The next step in prevention is a physical exam. An integral part of the physical exam is the monitoring of vital signs. Before beginning dental treatment, take baseline vital signs (including but not limited to blood pressure, pulse, and heart rhythm).4
Based on all findings, the dentist should modify dental treatment to decrease potential risk to the patient. It is important to note that, excluding procedures involving anesthesia, liability is more apt to occur for causing an emergency; i.e., the dentist fails to take a thorough medical history or fails to follow procedures that might have prevented the emergency.6
We simply cannot prevent every emergency; therefore, we must be prepared to recognize and appropriately manage medical emergencies when they occur. In March 2002, the American Dental Association Council on Scientific Affairs7 set forth guidelines for preparedness, which include the following:
· Current basic life support (BLS) certification for all office staff
· Didactic and clinical courses in emergency medicine
· Periodic office emergency drills
· Telephone numbers of EMS or other appropriately trained health-care providers
· Emergency drug kit and equipment, and the knowledge to properly use all items.
The ADA mandates specific training and emergency drugs and equipment necessary for dentists who use conscious sedation, deep sedation, or general anesthesia.8-10 The ADA “Guide to Dental Therapeutics” provides information for dentists who utilize the above sedation modalities.11-12 In addition, dental specialty organizations and many state dental boards have guidelines that must be followed. Dentists should review their state’s or specialty board’s requirements and plan accordingly. Certain insurance companies have set forth guidelines as well, and should be contacted by the insured dental practitioners for specific requirements about emergency drugs and equipment.
The general dentist who does not use the sedation or general anesthesia described above should follow the “Keep It Simple” principle.13 Design of the emergency kit is dictated by the expertise of the dentist with various drugs and techniques; i.e., IV drug administration and endotracheal intubation. Dentists should not have drugs and equipment in the emergency kit that they do not know how to use or administer.
Another consideration is the location of the dental office. The dentist should determine in advance who will be called upon to help in an emergency (usually EMS - 911) and how long it will take for help to arrive. A dentist located in a rural area may have to wait 30 to 45 minutes for paramedics to arrive. In these situations, it is prudent for the dentist to become certified in Advanced Cardiac Life Support and design the emergency drug kit and equipment to fit his or her needs.3 These dentists may want to include an automated external defibrillator, or AED, in their office emergency equipment. Soon, defibrillators will become a requirement for dentists in Florida. In February 2006, Florida will mandate AEDs in dental offices as an office safety requirement and part of the dentist’s minimum standard of care.14 Other states may follow. Dentists should keep abreast of current regulations concerning defibrillators in their state.
What constitutes a minimum emergency drug kit? The ADA Council suggests the following:7
• Epinephrine 1:1000 (injectable)
• Histamine blocker (injectable)
• Oxygen with positive pressure administration capability
• Nitroglycerin (sublingual tablet or aerosol spray)
• Bronchodilator (asthma inhaler)
Similarly, Malamed indicates, the “five drugs you absolutely must have are: oxygen, a bronchodilator, a histamine blocker for anaphylaxis, nitroglycerin, and epinephrine.”15
Clearly, every dental office should have at least the drugs outlined above in the office emergency kit. The dentist also must have the knowledge to administer these drugs in the proper doses as treatment for specific emergencies. Read package inserts and instructions before an emergency when assembling a drug kit and review periodically; i.e., at periodic office emergency drills. Dentists may choose to create their own emergency kit, placing drugs in drawers of small tool kits or clear bags labeled with the name of the drug, the condition it treats, instructions for administration, and contraindications for usage (Figure 1). Keep the emergency kit in a cool, dry area and maintain with current drugs. A warning or notice of emergency drug expiration dates can be placed on the appointment book a few weeks prior to actual expiration to allow the dental team time to replace soon-to-expire drugs.
Because of the urgent nature of epinephrine administration in anaphylactic shock, prefilled syringes provide a quicker, more foolproof method for administering this life-saving drug. Auto-injectors are available at local pharmacies or in dental supply catalogs in both adult and pediatric doses. These EpiPens are designed to inject a single .3 mg dose (adult) or .15 mg dose (pediatric) when pressed against the patient’s thigh. It will inject through clothing. In some cases of systemic allergic reactions, clinical signs of bronchospasm and hypotension persist after the first dose of epinephrine. In these patients, administer .3 mg of epinephrine every five minutes until help arrives or the clinical signs are relieved. It is, therefore, prudent to have more than one dose of epinephrine available.
Another vitally important component of the dentist’s emergency kit is oxygen, which can be beneficial in almost every emergency. A Series E portable oxygen tank is recommended with a low-flow regulator. The system should be equipped with a positive pressure mask, one portable self-inflating bag-valve mask (ambubag), and one pocket mask for each staff member.4 Several sizes of full-face masks are suggested, preferably clear so that fogging or vomiting can be recognized. Although it is not mandatory in every state, the ambubag is very valuable when treating patients who are not breathing on their own. Delivering 100 percent oxygen via a bag-valve-mask device to a nonbreathing patient is the primary ventilation alternative to tracheal intubation.16
Nitroglycerin is available in both aerosol spray and sublingual tablets. Remind patients with a history of angina to bring their own nitroglycerin to their dental appointment. Although the sublingual tablets are less expensive, most patients prefer the translingual spray. It has a longer shelf life and may be better absorbed by some patients.13
If you have assembled the emergency drugs and equipment to meet the needs of your practice and are comfortable with their use and dosage, the next step is to assign tasks and conduct practice drills for your team members as to their roles before and during a medical emergency. Figure 2 provides a sample documentation form for review and practice of emergency protocol. Usually, the assistant will bring the drug kit and oxygen and assist the doctor with administration of the emergency drugs, taking vital signs and assisting with BLS. Another team member calls 911, if needed, and makes a chronological record of the details of the medical emergency. See Figures 3a and 3b for examples of “Team Cards” that can serve as flash cards, dictating step-by-step instructions specific for team members both in preparation for a medical emergency, as well as for his or her role during a medical emergency. The cards can be used as a training tool, a quick refresher, or mid-emergency reference guide.
Continuing-education courses in medical emergencies should be attended by the dental team. To find out what is offered in your area, call your state licensing board or contact a nearby dental school. Another excellent resource is Stanley Malamed’s book Medical Emergencies in the Dental Office and his 1993 JADA (Journal of the American Dental Association) article, “Managing Medical Emergencies” (see cited references).
Preparing for medical emergencies can seem overwhelming. It takes time, financial resources, and continual practice and review. However, not taking the proper prevention and preparation steps may be devastating for both the patient and the dentist.
1 Fast TB, Martin MD, Ellis TM. Emergency preparedness: a survey of dental practitioners. JADA 1986; 112(4):499-501.
2 Malamed SF. Managing medical emergencies. JADA 1993; 124:40-53.
3 Biron C. Emergency drugs. RDH 1993; 13:48,50,54.
4 Malamed SF. Medical emergencies in the dental office, 5th ed., Mosby; 2000:13.
5 Norris L. Prepare for medical emergencies. J Mass Dent Soc 1994; 43:27-9.
6 Wakeen LM. Dental office emergencies. JADA 1993; 124:54-58.
7 ADA Council on Scientific Affairs. JADA 2002; 133:364-5.
8 American Dental Association. Guidelines for the use of conscious sedation, deep sedation, and general anesthesia for dentists. Chicago: American Dental Association; 2000.
9 American Dental Association. American Dental Association policy statement: the use of conscious sedation, deep sedation, and general anesthesia in dentistry. Chicago: American Dental Association; 1999.
10 American Dental Association. Guidelines for teaching the comprehensive control of anxiety and pain in dentistry. Chicago: American Dental Association; 2000.
11 Malamed SF. Drugs for medical emergencies in the dental office. In: Ciancio SG, ed. ADA guide to dental therapeutics. 2nd ed. Chicago: American Dental Association; 2000:257-92.
12 Malamed SF. Managing medical emergencies in the dental office. In: Ciancio SG, ed. ADA guide to dental therapeutics. 2nd ed. Chicago: American Dental Association; 2000:293-305.
13 McCarthy FM. A minimum medical emergency kit. Compend Contin Educ Dent 1994; 15:214-224.
14 Florida’s Health. The Florida Department of Health. Dentistry Board Overview. Available at http://www.doh.state.fl.us./mqa/dentistry/dn_home.html. Accessed June 21, 2004.
15 Anderson K. Preparing for medical complications in the dental office. CDS Review 1996; 89:28-30.
16 Ma OJ. Emergency medicine: just the facts. 2nd edition, McGraw-Hill; 2004:9.
Pamela Sparks Stein, DMD
Dr. Stein is on the faculty full-time at the University of Kentucky College of Medicine and College of Dentistry in both the Dept. of Anatomy and Neurobiology and the Dept. of Restorative Dentistry. She authored the award-winning “Dental Emergency Protocol Manual” and In-Office Emergency Protocol Software Program. Contact her at [email protected].