Introduction

Medical emergencies are a recognized occurrence in the dental environment. The most frequently reported emergency is syncope, accounting for 50% of cases, followed by mild allergic reactions (8%), angina pectoris (8%), and orthostatic hypotension (8%).1 Smereka, J., Aluchna, M., Aluchna, A., et al. Medical emergencies in dental hygienists' practice. Medicine (Baltimore). 2019;98:e16613. Notably, these emergencies are most likely to arise following the administration of local anesthetics, as well as during tooth extractions or endodontic procedures.2 Malamed, S. F. Medical emergencies in the dental office. 8th ed. Philadelphia: Elsevier Mosby; 2022. It is anticipated that, due to the aging patient population and advancements in healthcare, including pharmaceuticals, surgical interventions, and life-extending treatments, the incidence of medical emergencies in dental settings will increase.

Importance of the Medical History

Obtaining a comprehensive and accurate medical history is crucial in mitigating the risk of medical emergencies in the dental setting. Patients may disclose medical conditions that indicate an elevated risk for such emergencies, making it essential for dental practitioners to remain vigilant. Furthermore, it is imperative to update the medical history at every visit, as patient health can change over time.

Conditions of particular relevance include, but are not limited to, histories of heart disease, asthma, stroke (CVA), frequent headaches, epilepsy, thyroid disorders, diabetes, corticosteroid use, allergies, and bleeding disorders. When patients report these or similar conditions, the dental practitioner should engage in a detailed discussion to gather additional information that could aid in preventing a medical emergency. Inquiries should focus on the frequency, severity, and potential triggers of the conditions to assess the likelihood of an emergency occurring. In many cases, it may be prudent to defer treatment until the patient has been evaluated by their primary healthcare provider.3 American Stroke Association. Health conditions a dentist might find that have nothing to do with your teeth. Published August 11, 2022. Accessed December 20, 2024. https://www.stroke.org/en/news/2022/08/11/health-conditions-a-dentist-might-find-that-have-nothing-to-do-with-your-teeth

Vital Signs and Medical Emergencies

An essential component in the prevention and management of medical emergencies is the accurate measurement and documentation of a patient's vital signs.4 Southerland, J. H., Gill, D. G., Gangula, P. R., Halpern, L. R., Cardona, C. Y., Mouton, C. P. Dental management in patients with hypertension: Challenges and solutions. Clin Cosmet Investig Dent. 2016;8:111-120. doi: 10.2147/CCIDE.S99446. PMID: 27799823; PMCID: PMC5074706. Vital signs, which include pulse, respiration, blood pressure, and temperature, provide critical information about a patient's overall health and can help identify potential risks.5 Sapra, A., Malik, A., Bhandari, P. Vital sign assessment. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Published May 1, 2023. PMID: 31985994. In light of the COVID-19 pandemic, the routine measurement of temperature has become increasingly common in dental practices.

Patients with hypertension or hypotension are at an elevated risk for experiencing various medical emergencies.6 Stamler, J., Vaccaro, O., Neaton, J. D., Wentworth, D. Diabetes, other risk factors, and 12-year cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care. 1993;16:434-444.,7 Hu, G., Jousilahti, P., Tuomilehto, J. Joint effects of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the risk of coronary heart disease. Eur Heart J. 2007;28:3059-3066. The same holds true for individuals presenting with abnormal vital signs, such as tachycardia, bradycardia, tachypnea, bradypnea, or dyspnea.6 Stamler, J., Vaccaro, O., Neaton, J. D., Wentworth, D. Diabetes, other risk factors, and 12-year cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care. 1993;16:434-444.,7 Hu, G., Jousilahti, P., Tuomilehto, J. Joint effects of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the risk of coronary heart disease. Eur Heart J. 2007;28:3059-3066. Having baseline vital signs is crucial for comparison during an emergency, as it allows for a more accurate assessment of any deviations from normal.5 Sapra, A., Malik, A., Bhandari, P. Vital sign assessment. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Published May 1, 2023. PMID: 31985994. In healthy adults, a normal pulse rate typically ranges from 60 to 80 beats per minute; however, individuals who engage in regular physical exercise may exhibit lower pulse rates, between 40 and 60 beats per minute.5 Sapra, A., Malik, A., Bhandari, P. Vital sign assessment. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Published May 1, 2023. PMID: 31985994. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute.8 Simel, D. L. Approach to the patient: History and physical examination. In: Goldman, L., Schafer, A. I., eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020: chap 6. Additionally, normal blood pressure for adults is characterized by a systolic pressure ranging from 100 to 120 mmHg and a diastolic pressure between 60 and 80 mmHg.8 Simel, D. L. Approach to the patient: History and physical examination. In: Goldman, L., Schafer, A. I., eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020: chap 6.

Hypertension is a prevalent primary diagnosis, yet many individuals are unaware that they are affected by this condition. As such, it is crucial for dental professionals to consistently and accurately assess the blood pressure of every patient they treat. This proactive approach helps in identifying undiagnosed hypertension and mitigating the associated risks.9 World Health Organization. Global report on hypertension: The race against a silent killer. Published September 2023. Available at: https://www.who.int/publications/i/item/9789240081062-eng.pdf

In 2017, the American Heart Association and the American College of Cardiology introduced a revised blood pressure classification system, which includes four distinct categories: Normal Blood Pressure, Elevated Blood Pressure, Stage 1 Hypertension, and Stage 2 Hypertension. The updated classifications are as follows:

  • Normal Blood Pressure: Systolic <120 mm Hg and Diastolic <80 mm Hg
  • Elevated Blood Pressure (formerly known as pre-hypertension): Systolic 120-129 mm Hg and Diastolic <80 mm Hg
  • Stage 1 Hypertension: Systolic 130-139 mm Hg or Diastolic 80-89 mm Hg
  • Stage 2 Hypertension: Systolic ≥140 mm Hg or Diastolic ≥90 mm Hg10 American Heart Association. Understanding blood pressure readings. Published 2024. Accessed December 20, 2024. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings.

Dental professionals should refer any patient with a blood pressure reading above 120/80 mm Hg to their physician for further evaluation.11 Hupp, W. S. Cardiovascular diseases. In: Patton, L. L., Glick, M., eds. The ADA Practical Guide to Patients with Medical Conditions. 2nd ed. Hoboken, NJ: John Wiley &amp; Sons, Inc.; 2016. While finding time during a patient appointment can be challenging, taking vital signs is a quick process. Measuring the pulse takes approximately 10 seconds, multiplied by 6 for a full minute; respiration can be assessed in 15 seconds, multiplied by 4 for a minute; and using an electronic blood pressure cuff typically requires no more than 35 seconds. In total, taking vital signs should take no more than one minute. By prioritizing this brief but crucial task, dental professionals can help prevent medical emergencies and potentially save their patients' lives.

CPR Certification

In addition to ensuring that an AED is readily available, maintaining current CPR certification is crucial for effectively managing medical emergencies and potentially saving a patient's life. It is recommended that dental professionals remain up to date with healthcare provider CPR, which includes training in adult, child, and infant CPR, as well as airway obstruction techniques.12 Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15. Regular practice of CPR ensures that the steps are more readily accessible in the event of a real medical emergency. Furthermore, CPR protocols evolve as ongoing research identifies the most effective methods to enhance patient survival.12 Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15.

Emergency Simulations

Since medical emergencies are unpredictable and may occur suddenly, practicing simulated emergency scenarios within the office is a vital preparatory step.13 Kishimoto, N., Sanuki, T., Liu, Y., Tran, S. D., Seo, K. Simulation training for medical emergencies of dental patients: A review of the dental literature. Jpn Dent Sci Rev. 2023;59:104-113. doi: 10.1016/j.jdsr.2023.02.004. These simulations help ensure that all staff members are familiar with their roles and can significantly reduce the anxiety associated with actual emergency situations when they arise.13 Kishimoto, N., Sanuki, T., Liu, Y., Tran, S. D., Seo, K. Simulation training for medical emergencies of dental patients: A review of the dental literature. Jpn Dent Sci Rev. 2023;59:104-113. doi: 10.1016/j.jdsr.2023.02.004. It is recommended that each individual be aware of their specific responsibilities based on the location of the emergency within the office. For example, Person 1 (P1) remains with the patient and provides appropriate emergency treatment. Person 2 (P2) assists P1, taking vital signs and administering oxygen if necessary, while also recording events and medication delivery times on the Emergency Treatment Record. Person 3 (P3) is responsible for retrieving the emergency kit and oxygen tank and preparing any required emergency medications. The office receptionist (OR) is tasked with making the necessary phone calls.14 Grimes, E. B. Medical emergencies: Essentials for the dental professional. 2nd ed. Upper Saddle River, NJ: Pearson Education, Inc.; 2023.,16Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian Journal of Conservative and Endodontics. 2019;4(1):1-8

Oxygen

For most medical emergencies, the administration of oxygen is essential. At a minimum, dental offices should be equipped with a size E portable oxygen tank, which provides approximately 30 - 45 minutes of oxygen.15 Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023. Accessed December 20, 2024. https://www.oralhealthgroup.com If emergency medical services (EMS) are expected to take longer than 30 minutes to arrive, a larger oxygen tank should be available. Normal blood oxygen saturation levels typically range from 92% to 98%.15 Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023. Accessed December 20, 2024. https://www.oralhealthgroup.com A pulse oximeter is the recommended device for measuring a patient's oxygen saturation levels and should be an essential component of every dental office's medical emergency kit.15 Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023. Accessed December 20, 2024. https://www.oralhealthgroup.com This device provides quick and accurate readings to help guide appropriate intervention during medical emergencies. Additionally, the office should be stocked with a non-rebreather mask, nasal cannula, and bag-valve mask, with all staff trained in their proper usage and the appropriate flow rates for each device.15 Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023. Accessed December 20, 2024. https://www.oralhealthgroup.com The nasal cannula is used for patients who require minimal oxygen supplementation, with a flow rate of 1-6 L/min. For patients experiencing significant dyspnea, a non-rebreather mask should be utilized, providing oxygen at a flow rate of 10-15 L/min. In cases of apneic patients, a bag-valve mask is necessary, delivering oxygen at a flow rate of 12-15 L/min to ensure adequate ventilation.15 Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023. Accessed December 20, 2024. https://www.oralhealthgroup.com

Emergency Kit and AED

Dental professionals must be fully prepared for any medical emergency that may arise in their office. A well-stocked medical emergency kit and an Automated External Defibrillator (AED) are essential components of this preparedness.12 Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15. The AED is designed to correct irregular heart rhythms and is the only definitive treatment for ventricular fibrillation. As dental offices are healthcare facilities, the inclusion of an AED is imperative.12 Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15. The AED selected should be user-friendly, guiding the operator through the CPR steps, and delivering a shock only when necessary.12 Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15.

The medical emergency kit selected for a dental office should be tailored to the office's location and the staff's comfort level with using its contents.16Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian Journal of Conservative and Endodontics. 2019;4(1):1-8 In areas where emergency medical services (EMS) may take longer to arrive, a more comprehensive kit is necessary compared to offices located near EMS facilities. The contents of the medical emergency kit must be regularly monitored to ensure that all items are current and functional.16Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian Journal of Conservative and Endodontics. 2019;4(1):1-8 The kit should include both injectable and non-injectable medications. Many companies offer specialized emergency kits for dental offices, some with automatic replenishment services, which can be highly convenient. At a minimum, the emergency kit should contain: nitroglycerin tablets or spray for angina pectoris, low-dose aspirin for myocardial infarction, albuterol spray for asthma attacks, glucose tablets or gel, and injectable glucagon for severe hypoglycemia, oral diphenhydramine or chlorpheniramine for mild allergic reactions, injectable diphenhydramine for moderate allergic reactions, and injectable epinephrine in both adult and pediatric dosages for anaphylaxis.16Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian Journal of Conservative and Endodontics. 2019;4(1):1-8,17 Mohideen, K., Thayumanavan, B., Balasubramaniam, A.M., Vidya, K.M. , Rajkumari, S., Indu Bharkavi, S. K., Basics of management of medical emergencies in dental office and emergency drug kit. International Journal of Scientific Study. 2017;5(4):273-297. Other essential items to include in your emergency kit are a pulse oximeter to assess the patient's blood oxygen level, a glucometer to measure blood glucose levels in the event of a diabetic emergency, and a spacer device for patients experiencing an asthma attack.14 Grimes, E. B. Medical emergencies: Essentials for the dental professional. 2nd ed. Upper Saddle River, NJ: Pearson Education, Inc.; 2023.,16Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian Journal of Conservative and Endodontics. 2019;4(1):1-8,17 Mohideen, K., Thayumanavan, B., Balasubramaniam, A.M., Vidya, K.M. , Rajkumari, S., Indu Bharkavi, S. K., Basics of management of medical emergencies in dental office and emergency drug kit. International Journal of Scientific Study. 2017;5(4):273-297. These tools are crucial for quickly evaluating and managing specific medical conditions that may arise during dental treatment. It is also recommended that the kit be reviewed regularly with all staff members to ensure they feel confident in using the supplies during an emergency.

Conclusion

Following these steps will help ensure that dental offices are well-prepared to handle a medical emergency should one arise. There is no such thing as too much preparation when it comes to patient safety and emergency response.

References

  • 1. Smereka, J., Aluchna, M., Aluchna, A., et al. Medical emergencies in dental hygienists' practice. Medicine (Baltimore). 2019;98:e16613.
  • 2. Malamed, S. F. Medical emergencies in the dental office. 8th ed. Philadelphia: Elsevier Mosby; 2022.
  • 3. American Stroke Association. Health conditions a dentist might find that have nothing to do with your teeth. Published August 11, 2022. Accessed December 20, 2024. https://www.stroke.org/en/news/2022/08/11/health-conditions-a-dentist-might-find-that-have-nothing-to-do-with-your-teeth
  • 4. Southerland, J. H., Gill, D. G., Gangula, P. R., Halpern, L. R., Cardona, C. Y., Mouton, C. P. Dental management in patients with hypertension: Challenges and solutions. Clin Cosmet Investig Dent. 2016;8:111-120. doi: 10.2147/CCIDE.S99446. PMID: 27799823; PMCID: PMC5074706.
  • 5. Sapra, A., Malik, A., Bhandari, P. Vital sign assessment. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Published May 1, 2023. PMID: 31985994.
  • 6. Stamler, J., Vaccaro, O., Neaton, J. D., Wentworth, D. Diabetes, other risk factors, and 12-year cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care. 1993;16:434-444.
  • 7. Hu, G., Jousilahti, P., Tuomilehto, J. Joint effects of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the risk of coronary heart disease. Eur Heart J. 2007;28:3059-3066.
  • 8. Simel, D. L. Approach to the patient: History and physical examination. In: Goldman, L., Schafer, A. I., eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020: chap 6.
  • 9. World Health Organization. Global report on hypertension: The race against a silent killer. Published September 2023. Available at: https://www.who.int/publications/i/item/9789240081062-eng.pdf
  • 10. American Heart Association. Understanding blood pressure readings. Published 2024. Accessed December 20, 2024. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
  • 11. Hupp, W. S. Cardiovascular diseases. In: Patton, L. L., Glick, M., eds. The ADA Practical Guide to Patients with Medical Conditions. 2nd ed. Hoboken, NJ: John Wiley &amp; Sons, Inc.; 2016.
  • 12. Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15.
  • 13. Kishimoto, N., Sanuki, T., Liu, Y., Tran, S. D., Seo, K. Simulation training for medical emergencies of dental patients: A review of the dental literature. Jpn Dent Sci Rev. 2023;59:104-113. doi: 10.1016/j.jdsr.2023.02.004.
  • 14. Grimes, E. B. Medical emergencies: Essentials for the dental professional. 2nd ed. Upper Saddle River, NJ: Pearson Education, Inc.; 2023.
  • 15. Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023. Accessed December 20, 2024. https://www.oralhealthgroup.com
  • 16.Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian Journal of Conservative and Endodontics. 2019;4(1):1-8
  • 17. Mohideen, K., Thayumanavan, B., Balasubramaniam, A.M., Vidya, K.M. , Rajkumari, S., Indu Bharkavi, S. K., Basics of management of medical emergencies in dental office and emergency drug kit. International Journal of Scientific Study. 2017;5(4):273-297.
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