Life threatening emergencies do occur in the practice of dentistry. They can happen to anyone-a patient, a doctor, a member of the office staff, or a person who is merely accompanying a patient.
A total of 4309 respondents from all 50 states of U.S.A. and 7 Canadian provinces reported 30,608 emergencies over 10 years in combined findings of two surveys from United States. 96.6% of the respondents answered positively to the following question:“In the past ten years, has a medical emergency occurred in your dental office?” (Doctors used their own definitions of emergency situations.)
About 50% of these emergencies were listed as syncope. A notable portion (25.35%) of reported emergencies were related to the cardiovascular, central nervous, and respiratory systems, and were thus all potentially life threatening.
Although most situations arose while the patient was undergoing treatment, other developed whole the patient was not in the dental chair. A survey of medical emergencies arising in a U.S. dental school over an 8.5-year period reported that 20% events occurred in persons who were not patients at the time (e.g., faculty, students, persons accompanying patients).
Although any medical emergency can develop in the dental office, some are seen more frequently than others. Many such situations are stress related or involve preexisting conditions that are exacerbated when patients are placed in stressful environments. Stress-induced situations include vasodepressor syncope and hyperventilation, whereas preexisting medical conditions that can be exacerbated by stress include most acute cardiovascular emergencies, bronchospasm (asthma), and seizures. The effective management of pain and anxiety in the dental office is therefore essential in the prevention and minimization of potentially catastrophic situations.
Drug-related adverse reactions make up another category of life-threatening situations that occur more often than dentists expect. The most frequent are associated with local anesthetics.Psychogenic reactions, drug overdose, and drug allergy are just a few of the problems associated with the administration of local anesthetics. The overwhelming majority of such “drug-related” emergencies are stress related (psychogenic); however, other reactions (overdose, allergy) represent responses to the drugs themselves. Most adverse drug responses are preventable.
It is found that only 1.5% of the emergency situations occurred in the waiting room in a medical emergency situations evaluation in dental offices in Japan. The greatest percentage of medical emergencies, 54.9%, took palce during the administration of local anesthesia, which, according to both patients and doctors, is the most stressful procedure performed in the dental office. About 22% of these emergencies developed during dental treatment while 15% occurred in the dental office after completion of treatment. Most such emergencies were orthostactic hypotension or vasodepressor syncope.
Another survey of 1029 dentists in Britain demonstrated that most emergencies (36.7%) occurred during dental treatment; 23.1% occurred before the start of treatment; 20.1% after the administration of local anesthetic; and 16.4% after completion of the dental procedure. Approximately 3% of the events in England and Wales and 2.2% of those in Scotland affected persons who were not actually undergoing dental treatment. This group included persons who were accompanying patients, passersby, and five members of the dental staff, including a dentist and a technician.
It is found that 65% of cases developed during two types of dental care—tooth extraction (38.9%) and pulp extirpation (26.9%). In the British paper, 52.2% of events occurred during conservative dental treatment and 23.5% occurred during dentoalveolar surgery. Although information regarding the specific cause of the problem is not always available, these emergencies most likely occurred when the patient experienced sudden, unexpected pain.
Most emergency situations that occur in dental practice are defined as potentially life threatening. Only on rare occasions does a patient actually die in a dental office.
Failure to properly recognize and treat clinical signs and symptoms can turn a relatively innocuous situation into an office tragedy. Adequate pretreatment physical evaluation, combined with proper use of the many techniques for pain and anxiety control, can help prevent many emergencies and deaths.
Each year in the United States, 10% of all nonaccidental deaths occur suddenly and unexpectedly in relatively young persons believed to be in good health—thus the term “sudden, unexpected” cardiac arrest. The cause of death most often is a fatal cardiac dysrhythmia, usually ventricular fibrillation. Preventive measures cannot entirely eliminate this from happening so we, the dental profession, must be prepared. successful outcomes are possible when the dental “team” acts quickly to recognize and to manage the situation.
Emergencies/deaths developed “after [the patient had left] the dental office.”
However, not all such deaths occur within the confines of the dental office. The stress associated with dental treatment can potentially trigger events that result in a patient’s demise days after treatment. In the Southern California Society of Oral and Maxillofacial Surgeons survey, 10 such incidents were reported.17 Of particular interest are 3 deaths secondary to myocardial infarction and 1 secondary to cerebrovascular accident. Another death reportedly was related to an allergic reaction to propoxyphene hydrochloride, which the dentist had prescribed for postoperative pain relief. In Matsuura’s study in Japan, 5.5% of all medical emergencies developed “after [the patient had left] the dental office.”
- Increased number of older patients
The life expectancy of humans is increasing steadily. Although many older patients appear to be in good health, the dental practitioner must always be on the lookout for significant subclinical disease. Cardiovascular function and efficiency decrease as part of the normal aging process. In some instances, decreased efficiency manifests itself as heart failure or angina pectoris, but overt signs are not always apparent. When subjected to stress (pain, fear, anxiety, high humidity, extremes of heat and cold), the cardiovascular system of the older person may not be able to meet the body’s demands for increased oxygen and nutrients, a deficit of which may lead to acute cardiovascular complications such as life-threatening dysrhythmias and anginal pain. Situations that might have proved innocuous to a person at a younger age may well prove to be harmful 20 years later. The aging process involves both physiologic and pathologic changes that may alter the patient’s ability to successfully adapt to stress.
Dental practitioners have begun treating more patients older than 60 years who have retained most of their natural dentition. These patients require the full range of dental care—periodontics, endodontics, crowns, bridges, restorative work, implants, and oral surgery. Because of their ages and the possibility of preexisting physical disabilities, many of these patients are less able to handle the stress normally associated with dental treatment. This reduced stress tolerance should forewarn the dental practitioner that older patients are at greater risk during dental treatment, even in the absence of clinically evident disease. In addition, the dental practitioner must take every step to minimize this risk
- Medical advances
Many patients who were confined to their homes or who needed to rely on wheelchairs and were unable to work and unlikely to seek dental care now live relatively normal lives because of drug therapy and surgical technique advances. These medical advances are truly significant. They also mean that dental practitioners must manage the oralhealth needs of potentially at-risk patients, many of whom have chronic disorders that are merely being controlled or managed, not cured. McCarthy termed these persons “the walking wounded, accidents looking for a place to happen.”
- Longer appointment
Dental care can be stressful for the patient, for the doctor, and for staff members, and longer appointments naturally create more stress. Medically compromised patients are more likely to react adversely under these conditions than are healthy individuals, but even healthy patients can suffer from stress, which can create unforeseen complications. Stress reduction has become an important concept in the prevention of medical emergencies.
- Increased drug use
Drugs play an integral role in contemporary dental practice. However, all drugs exert multiple actions; no drug is absolutely free of risk.
41% of patients over 60 years were taking one or more medications regularly. Dental practitioners must take
special care to anticipate and recognize complications related to either the pharmacologic actions of a drug or the complex interactions between commonly used dental drugs and other medications.
Classification of life-threatening situations
The traditional approach has been the systems-oriented classification, which lists major organ systems and discusses life-threatening situations associated with those systems.
Although a systems approach is often considered suitable for educational purposes, from a clinical perspective it is lacking. A second classification method divides emergency situations into two broad categories—cardiovascular and noncardiovascular emergencies, which both can be broken down further into stress-related and non–stress-related emergencies.