1. 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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2. 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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3. Incidence
A survey done in the 90’s showed that, over a 10 year period, 90% of dentists have encountered at least one medical emergencies.
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4. Types Altered Consciousness 17,782 59 Cardiovascular 4,280 14 Allergy
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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5. Management of Medical Emergencies
Basic Life Support
Advanced Life Support
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6. 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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7. Management Of Medical Emergencies
Recognition
Prevention
Preparation
Basic life support (BLS)
Cardiopulmonary resuscitation (CPR)
Specific medical emergencies
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8. Prevention IS THE BEST TREATMENT Know your patient
Never treat a STANGER
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9. 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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10. Prevention Medical History Physical Evaluation Vital Signs
Dialogue History
Determination of Medical Risk
Stress Reduction
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11. Prevention MEDICAL HISTORY Review Update Medication
Medical consultation
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12. Prevention PHYSICAL EVALUATION Length of time since last evaluation
Vital signs
Visual inspection of patients
Referral to physician
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13. Prevention VITAL SIGNS
Blood pressure
Pulse rate
Respiratory rate
Temperature
Height
Weight
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14. Prevention DIALOGUE HISTORY Putting it all together Check accuracy of
medical history
Recognize anxiety
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15. 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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16. Determination Of Medical Risk
American Society of Anesthesiology
Physical Status Classification System
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17. ASA I Can tolerate stress involved A patient without systemic disease
A normal healthy patient
Can tolerate stress involved
In dental treatment
No added risk of serious
Complications
Treatment modification
Usually not necessary
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18. ASA II Represent minimal risk during dental treatment
A patient with mild systemic disease
Example:
-Well-controlled diabetic
-Well-controlled asthma
-ASA I with anxiety
Represent minimal risk during dental treatment
Routine dental treatment
With minor modifications
-Short early appointments
-Antibiotic prophylaxis
-Sedation
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19. ASA III Elective Dental Treatment is not Contraindicated
A patient with severe systemic disease that limits activity but is not incapacitating
Example:
- a stable angina
- 6 mos. Post - MI
- 6 mos. Post - CVA
- COPD
Elective Dental Treatment is not Contraindicated
Treatment Modification is Required
- Reduce Stress
- Sedation
- Short Appointments
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20. ASA IV Rx only to control pain and infection
A patient with incapacitating systemic disease that is a constant threat to life
Example:
- Unstable angina
- M I within 6 months
- CVA within 6 months
- BP greater than 200/115
- Uncontrolled diabetic
Elective dental care should be postponed
Emergency dental care only
Rx only to control pain and infection
Other treatment in hospital
(I&D, extraction)
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21. ASA V A morbid patient not expected to survive Example:
- End stage renal disease
- End stage hepatic disease
- Terminal cancer
- End stage infectious disease
Elective treatment definitely contraindicated
Emergency care only to relieve pain
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22. Prevention STRESS REDUCTION Premedication Sedation
Pain control (intra and post-op)
Early appointments
Short appointments
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23. 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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24. BASIC LIFE SUPPORT (BLS) CARDIOPULMONARY RESUCITATION (CPR)
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25. 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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26. 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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27. 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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28. 3/31/2017

29. 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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30. 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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31. 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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32. 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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33. 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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34. Management of Medical Emergencies Antibiotic Prophylaxis
Patient already taking antibiotic used for prophylaxis:
Select an antibiotic from a different class, rather than increasing the dosage
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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35. Management of Medical Emergencies Antibiotic Prophylaxis
Prophylaxis for dental patients with
TOTAL JOINT REPLACEMENT
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36. 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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37. Management of Medical Emergencies Antibiotic Prophylaxis
Patients at potential increased risk of total joint infection
Immunocompromized/Suppressed patients
Other Patients:
Insulin Dependent diabetics
1st 2 years following joint replacement
Previous prosthetic joint infection
Malnourishement
Hemophilia
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38. 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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