Medical Emergencies In The Dental Office

Dental diseases were commonly neglected by the general population especially in the developing countries until the symptoms became unbearable. Presently, thanks to the increased awareness, courtesy the media (both digital and print) the number of patients attending dental offices have increased manifold. After medical service was incorporated into the consumer protection act, cases against doctors and dentists have increased manifold. The need of the hour is to be aware of the fact that every dental office should be prepared for any common medical emergency which might occur before, during and after a procedure or consultation. There should be adequate means and expertise available to provide the minimum management to such patients so that an attempt can be made to temporarily resuscitate the patient. It can be till the patient is shifted to a medical department or to the nearest hospital depending upon the location of the dental office inside or outside a hospital respectively. With the increasing number of non-communicable systemic diseases due to a sedentary life style in the upper and middle-class population like hypertension, diabetes, cardiac diseases and so on, the chances of a medical emergency arising is significantly high. Thus, the management of such a situation can be achieved by multiple ways starting from training the dentist to equipping the office with necessary gadgets and having a dedicated recovery room for such cases.

Following are some common emergencies which can happen and their subsequent managements:

VASOVAGAL SYNCOPE

It has been a common observation that majority of the patients come under a lot of stress just on visiting the dental office, or after being advised a surgical procedure. Sometimes, despite anaesthesia some patients have a lower pain threshold which causes a lot of pain. They can also become very anxious on seeing blood. This causes an overstimulation of the Vagus Nerve resulting in a transient drop in blood pressure and heart rate. The patient becomes unresponsive. This situation if happens in the waiting hall can cause the other patients to panic and the first step in that case would be to shift the patient to the dedicated recovery room. The patient should be made to lie down with his feet elevated by the helping people initially and then put on multiple pillows to hold the position. Blood pressure, pulse and capillary blood sugar byglucometers should be monitored to rule out any haemodynamic compromise or variation in blood sugar levels. If it occurs on a dental chair, the chair is to be inclined down to keep the patient in a head down feet elevated position and the above management done.

HYPOGLYCEMIA

Diabetes is one of the major causes for dental infections apart from poor maintenance of oral hygiene. Patients who are diabetic and are on insulin or other oral drugs like sulphonylureas can become suddenly hypoglycaemic as they don’t tend to eat adequately before coming to the dental clinic. This is because of the stress. Such patients manifest by suddenly starting to sweat profusely, feeling nauseous and sometimes having tremor. The incident is to be investigated by a capillary blood glucose test and if confirmed, patient is to be administered sugar packets or spoons of sugar mixed water. In scenarios where the event occurs during a dental procedure or the patient has got a low consciousness level, it is not advisable to administer anything orally. In such cases Glucagon Injection is to be administered intramuscularly (not more than) as it will bring up the blood glucose levels to ensure patient is for that moment out of danger for hypoglycaemic cardiac arrest.

DRUG ALLERGY

Drug allergy is seldom unknown to patients and can be as a consequence of any drug used in the clinic. This can manifest from mild skin itching and rashes to severe respiratory distress, tachypnoea, hypotension and tachycardia post administration of the culprit drug in severe cases. In such cases, the dental procedure needs to be abandoned for the moment and patient administered with a dose of injection Hydrocortisone immediately. Haemodynamic instability if observed like hypotension, tachycardia should be treated with Injection Adrenaline.

BLEEDING

Patients planned for invasive procedures like Root Canal Treatment, 3 rd molar extraction, removal of carious teeth and so on are always at a risk of increased intra and post-operative bleeding. It is thus imperative that a detailed drug history and background history of the patient is taken and anticoagulant drugs reviewed by his primary treating physician to be stopped on the procedure day. Coagulopathic disorders like Haemophilia, Von Willebrand disease, etc. can predispose the patient to excessive bleeding. Thus most of the precautions need to be taken before the surgery is undertaken and clearance from the primary treating physician is obtained. In patients with unknown/undiagnosed coagulopathic disorders, uncontrolled bleeding during the procedure must be managed by injection of tranexamic acid and tight packing of the operative site. Medical help needs to be sought without delay and haemodynamic monitoring done till they arrive and if necessary putting the patient on Intravenous fluids in case of severe blood loss.

ASTHMA

Adrenaline used as an adjuvant along with lignocaine can sometimes precipitate asthmatic attacks in patients resulting in them becoming short of breath. In this event , the patient needs to be nebulized by salbutamol and given an injection of hydrocortisone or methylprednisolone. The procedure needs to be abandoned and postponed to a suitable date as per the discretion of the dental surgeon.

SEIZURES

Occurrence of seizures is quite sudden and unpredictable and it can result in tongue bite causing profuse bleeding or in most severe cases a cardiac arrest. On witnessing a seizure, the patient needs to be administered a dose of midazolam or lorazepam to terminate the seizure episode and repeated if not controlled. The blood glucose must be checked as hypoglycaemia is a reversible cause of seizure and corrected by injection glucagon. Medical help must be sought ASAP.

CARDIAC ARREST

The most dreaded emergency which might arise by itself or secondary to any medical emergency like hypoglycaemia, cardiogenic syncope, seizure, etc. On suspicion of a cardiac arrest, the ambulance has to be informed by someone mentioning the event. 2 other people should carry out the AHA recommended guideline of Basic Life Support (BLS) must be applied which comprises Cardio Pulmonary Resuscitation (CPR) and applying Automated External Defibrillator (AED) for delivering shocks to revert any underlying shockable arrhythmias which might have caused the cardiac arrest. This must be continued until the patient has achieved Return Of Spontaneous Circulation (ROSC) or the paramedics take over after being called by the first person if it is outside the hospital setting or if inside the hospital, the Advanced Cardiac Life Support (ACLS) team takes over. It is imperative these days that every staff member working in a dental office be trained in Basic Life Support (BLS) administration. They should be made aware to call for help at the very early stage so that the medical emergency which has occurred can be managed from a very early stage. It is important to realize that “every event from hand to foot can be caused by a bad tooth”. So present dental offices should make sure that its infrastructure to handle medical emergencies is kept up to date. This way many catastrophes culminating from medical emergencies can be averted.

~By : Dr. Arpita Saha Ray

Dental practitioner (BDS)