dentistry

1. MEDICAL EMERGENCIES IN DENTAL
OFFICE

2. STRESS!!
SYNCOPE SEIZURE
ANGINA
ASTHMATIC
ATTACK
HYPOGLYCAEMIA
CARDIAC
ARREST
ALLERGIES
HYPERVENTILATION
MYOCARDIAL
INFARCTION
2

3.  Primary response to all emergencies
 P-A-B-C-D
 Position >Airway >Breathing >Circulation
>Defebrilation
P-A-B-C-D MODIFIED TO
P-C-A-B-D
15 compressions – 2 rescue breaths
4 cycles – 1 minute
Cardio Pulmonary Resuscitation
CPR

4. Steps in CPR
Recognize cardiac arrest
Check for unresponsiveness
SHAKE AND SHOUT
CPR
Cardio Pulmonary Resuscitation

5. ABC of CPR
A – Airway
B- Breathing
C- Circulation
Airway
Head tilt / chin lift
Sniffing morning air position Jaw thrust method
Check for Carotid
pulse

6. Breathing
Look for rise and fall of chest
Listen and feel for movement of air
Breathing
Mouth to mouth
Mouth to nose
Endotracheal intubation
Oesophageal obturator airway
Position of hands to
administer chest compression

7.  Oxygen, Ambu bag with
mask
 Suction
 Syringes and needles
 Tourniquets
 Cricothyrotomy equipment
 Airways, laryngoscope
 Epinephrine
 Diphenhydramine
 Diazepam
 Hydrocortisone
 Morphine
 Dextrose 50%

8.  Introduction
 Classification
 Syncope
 Postural hypotension
 Acute adernal insufficiency
 Foreign Body Airway Obstruction
 Hyperventilation
 Asthma
 Diabetes Mellitus: Hypoglycemia
 Cerebro vascular Accident
 Epilepsy
 Angina Pectoris
 Acute Myocardial Infarction
 Drug releated emergencies.
 Drugs indicated and contraindicated in pregencacy.
 Conclusion
 References

9.  Medical emergencies in dental practice are a minefield into
which the unsuspecting dental practitioner may tread if he
is not aware of basic life support. These are those life-
threatening emergencies for which every practitioner must
be aware and alert so that needless death and morbidity
can be prevented.
Any medical emergency is managed in five basic steps:
 1. Initial evaluation
2. Basic life support
3. Advanced life support
 4. Post-resuscitation care
 5. Long-term management

10.  Unconsciousness Seizure disorders
 syncope Drug related emergencies
 Postural hypotension Chest pain
 Acute adernal insufficiency ANGINA
 Respiratory difficulty MI
 Airway obstruction
 Hyperventilation
 Asthma
 Altered consciousness
 Diabetes mellitus: hypoglycemia
 Cerebrovascular emergencies
Classification based clinical signs
and symptoms:

11.  Physical status classification system (1962, American Society of Anesthesiologists)
 ASA I : A patient without systemic disease, a normal healthy patient
 Healthy patients with little orno anxiety are classified as ASA 1.
 ASA II : A patient with mild systemic disease
 well controlled asthma, epilepsy.
 ASA III : A patient with severe systemic disease
 exercise induced asthma
 ASA IV : A patient with incapacitating systemic disease that is a constant threat to life.
 unstable angina pectoris

12.  ASA V : A moribund patient not expected to survive 24 hrs with or
with out surgery.
 end stage cancer ,renal diseases, hepatic diseases.
 ASA VI : Clinically dead patient being maintained for harvesting
organs.
 ASA E : Emergency operation of any variety; E precedes the number,
indicating the patients physical status ( ASA E-III)

13.  SYNCOPE: vasovagal syncope is most common
complication associated with the use of LA.
 Clinical signs closely resemble those shock , these
reaction readily respond to placcing the patient in
supine position , few drugs administrated 1 hr prior to
dental appointement if necessary [diazepam,
pentobarbital}
 Syncope occurs when patient is ijn upright pposition
,althoough it occurs whe sitting ,it will never occur
when lying

14.  Typical features of cardic, vasovagal syncope &seizurres
 premonitary symptoms cardic: palpitation, chest pain
,breathness .
 Vasovagal :nausea , lightheadness , sweating.
 Seizures: confusion ,hallucination ,aura.
 Unconsicious peroid cardic:extreme death like pallor,
 Vasovagal: pallor seizures:unconsicious ,tongue biting
In cardic arrest patients pulse is absent.cyanosis &dilated pulpis
apperciated.
 In syncope sweating is present.
 Retrosternal pain radiating down the left arm classic feature of
myocardial infraction.
 anaphylaxis signs include facial oedma, urticaria ,rash pallor,
sweating ,rapid & weak pulse and wheezing.

15.  Retrosternal pain radiating down the left arm classic
feature of myocardial infraction.
 anaphylaxis signs include facial oedma, urticaria ,rash
pallor, sweating ,rapid & weak pulse and wheezing.

17. Syncope is a general term referring to a sudden, transient loss of
consciousness that usually occurs secondary to a period of cerebral
ischemia.
Predisposing factors:
Psychogenic factors
 Fright
 Anxiety
 Emotional stress
 Receipt of unwelcome news
 Pain especially sudden &unexpected
 Sight of blood/ surgical/ dental instruments
 (e.g. local anesthetic syringe)
Non psychogenic factors
Erect sitting or standing posture
Hunger from dieting or a missed meal
Exhaustion
Poor physical condition
Hot, humid, crowded environment
Male gender
Age between 16 and 35 years

18. Vasovagal syncope is usually defined as a transient loss of
consciousness due to cerebral ischaemia caused by a
reduction in blood supply to the brain.
Vasodilatation causes pooling of blood in peripheries, and
vagal stimulation causes slowing of the heart; this combination
causes a dramatic fall in blood pressure.
 Signs and symptoms:
Nausea , slow pulse ,Hypotension ,Confusion , Weakness
Sweating.
 Causes:
Psychologic factor--pain or fear ,Postural changes ,Anoxia

19. DENTAL CONSIDERATIONS
 Premedicate the patient with
hypnotics for a relaxed sleep the
night before the surgery
 Premedicate the patient with
sedatives on the day of surgery
 Schedule the surgery in the morning
 Minimize the patient waiting time
 Consider psychosedation during
surgery
 Administer adequate pain control
during surgery
 Effective postOperative analgesics
 Management of syncope
 1. Discontinue treatment.
 2. Unfold the dental chair, lift the
lower limbs (the structure and
mechanics of each dental chair allows
positioning the patient in the
Trendelenburg position).
 Administer oxygen at rate of 6–8
L/minute.
 ABC – Basic life support as needed
 Definitive management : Monitor vital
signs
 Administer aromatic ammonia
 Administration of atropine(0.1mg/ml
 If seizure lasts longer than 1 minute or
for repeated seizures, administer a 10
mg dose of diazepam rectal or
intravenously (IV)or 5 mg of
midazolam, IM, IV, or

20. 
Postural hypotension is a problem, which occurs due
to peripheral pooling of blood in a region that is not
re-mobilized quick enough to prevent cerebral
ischaemia when a patient rapidly assumes an upright
posture. It is a common cause of transient and altered
state of consciousness during the dental procedures.
Orthostatic (postural) hypotension differs from
vasodepressor syncope in that there is only reduction
in the bloodpressure where as in syncope peripherial
circulatory failure is also present

21. Predisposing factors:
 Administration and ingestion of drugs e.g. antihypertensives like
sodium depleting diuretics, calcium channel blockers
 Inadequate postural reflex
 Late stage pregnancy
 Advanced age
 Venous defects in legs (e.g. varicose veins)
Clinical manifestations:
 Precipitous drops in blood pressure and lose consciousness
whenever they stand or sit upright
 Do not exhibit any prodromal signs and symptoms
 May become lightheaded, or develop blurred vision
 Blood pressure during syncopal period is quite low
 Un like vasodepressor syncope , heart rate during postural
hypotension remain at the baseline level or somewhat higher

22.  Dental considerations:
Patients undergoing treatment in supine or semi-supine
position should not rise rapidly. By changing the patient’s chair
position two to three times within one minute or by
uprighting the chair position gradually after the treatment, we
can prevent postural hypotension.
Management
The unconscious patients should be placed in a supine
position with the legs elevated. This helps in cerebral
perfusion.
 Administer: Phenylephrine spray 0.25-0.5 mg IV 2-3mg IM ,
Ephedrine 10-25 mg IV
 If the patient does not regain consciousness airway patency
must be established. Perform BLS, administer oxygen and
monitor vital signs. When the episode is over, slowly reposition
the chair and discharge the patient. If hypotensive episodes
continue, medical assistance should be summoned

24. A third potentially life - threatening situation that may result in the
loss of consciousness. The condition is uncommon, is potentially life –
threatening, but is readily treatable.
Predisposing factors:
 Lack of gluco-corticosteroid hormones
 Mechanism 1: sudden withdrawal of steroid hormones in the patient
who suffers primary adrenal insufficiency (Addison’s disease)
 Mechanism 2: After the sudden withdrawal of steroid hormones from a
patient with normal adrenal cortices but with a temporary
insufficiency resulting from cortical suppression through prolonged
exogenous gluco-corticosteroid administration (secondary
insufficiency)
 Mechanism 3: Stress either physiologic or psychological.

25. Clinical manifestations: Nausea ,fatigue
,vomitings , hypotension ,pain in legs ,abdomen
.Prevention of acute adernal insufficiency
Rule of TWOs
 In a dose of 20 mg or more of cortisone or its
equivalent
 Via oral or parenteral route for a continuous period
of two weeks or longer
 Within 2 years of dental therapy

26.  Dental consideration
Acute adrenal insufficiency patients are unable to adapt to stress, therefore
their blood steroid level should be increased by administration of exogenous
steroids. Minor Operations under local anaesthesia may be covered by giving
steroids two hours postand preoperatively.
 Aspirin and other NSAIDs should be avoided as they may increase the risk of
peptic ulceration in those on corticosteroids.
 Susceptibility to infection is increased by systemic steroid use, no prophylactic
antibiotic may be indicated.
Management
 Terminate all dental procedures, monitor vital signs, summon medical
assistance, administer glucocorticosteroid, provide basic life support (BLS),
transport to hospital for emergency medical care.
 Administer 200 mg hydrocortisone IV and summon for medical assistance.
 Check blood level for glucose and give glucose (oral or IV) if hypoglycaemic.
Repeat 200 mg hydrocortisone at 4-6 hours interval as required and monitor
BP.
 Phenytoin and rifampicin also can increase cortisol metabolism and should be
used with caution in patients with AI.

27.  RESPIRATORY DISTRESS
Foreign Body Airway Obstruction
Hyperventilation
Asthma

28. Prevention:

29. Causes: Foreign body (usually food) ,Infection or posttraumatic
hematoma,Obstruction by the tongue ,Trauma
Clinical features:
• Coughining ,choking sensation ,dyspnoea ,stridor ,cyanosis .
General Signs and Symptoms
 Gasping for breath, Patient grabs at throat, Panic
 Suprasternal or supraclavicular retraction
 Inability to speak, breathe, cough
If Partial Obstruction
 Snoring
 Wheezing
 Crowing sound on inspiration
 Forceful cough
 Wheezing between cough
 Absent or altered voice sounds
 Possible cyanosis, lethargy, disorientation
If Total Obstruction - No noise

30. Visible objects – if assistant is
present
Place patient into supine or
Trendelenburg position
Use Magill intubation forceps or
suction
if assistant is not present
Instruct patient to bend over arm of
chair with their head down
Encourage patient to cough
Aspirated foreign bodies
Place patient in left lateral decubitus
position
Encourage patient to cough

31. CONSCIOUS victim with obstructed airway
Identify complete airway obstruction Ask – ‘Are you choking’
Apply abdominal thrusts until foreign body is expelled
Have medical or paramedical personnel to evaluate the patient

32. CONSCIOUS victim with known obstructed airway who loses
consciousness
Place victim in supine position with head in neutral position
Maintain airway (head tilt – chin lift)
Look in mouth for foreign object prior to ventilation.
If INEFFECTIVE:
Perform abdominal thrust, repeating until the object is expelled
Check for foreign body. If visible, perform finger swipe to remove

33.  As soon as we notice that an object has entered the
oropharynx of the patient, terminate the dental
treatment. Try to remove the instrument or object by
picking up with a Magill intubation forceps. It is
preferable to place the patient in Trendelenburg
position, which might allow the object to move closer
to the oral cavity due to gravity. If this does not work
out, ask the patients to cough out the object. If the
object is still not retrievable, it is located with the help
of radiographs. If the symptoms persist, perform
Heimlich manoeuvre

34. 34

35.  It is defined as ventilation in excess of that required to maintain
normal blood pa O2 (arterial oxygen tension) and pa CO2 (arterial
carbon dioxide tension). It is produced by increase in frequency or
depth of respiration, or both.
 Common emergency occur in dental office , almost always occur is a
result of extreme anxiety.
Prevention:
 Through prompt recognition and management of anxiety
 Physical evaluation of the patient
 The vital signs of apprehensive patients may deviate from normal.
Recording the vital signs at the patient’s initial visit
 Stress reduction protocol is the primary means of preventing
hyperventilation

36. Clinical manifestations:
system Signs and symptoms
cardiovascular Palpitations
Tachycardia
Precordial”pain”
Neurologic Dizziness
Lightheadedness
Disturbance of consciousness
Disturbance of vision
Numbness and tingling of
extremities
Tetany (rare)
Respiratory Shortness of breath
Chest “pain”
Dryness of mouth
Gastro intestinal Globus hystericus (subjective
feeling of a lump in the throat)
Epigastric pain
Musculoskeletal Muscle pain and cramps
Tremor
Stiffness
Carpopedal tetany
Psychological Tension
Anxiety and nightmares

37. Stop the dental treatment as soon as you notice the symptoms and
reassure the patient. Make the patient lie in semi-erect position. If the
patient is conscious, ask him/her to rebreath into paper bags to increase
inspired CO2 and to overcome alkalization. If the patient is unconscious,
maintain proper airway until he/she regains consciousness.
This condition is a self limiting one and eventually the patient will
settle. If the previously discussed steps fail to terminate an episode of
hyperventilation, an exceedingly unlikely situation, parenteral drugs may have
to be administered to reduce the patient’s anxiety and to slow the rate of
breathing.
The drugs of choice in this situation are diazepam or midazolam.
If possible, the drug should be administered intravenously, in which case it is
titrated until the patient is able to control breathing.
The dose is approximately 10 to 15 mg diazepam, or 3 to 5 mg
midazolam, for the average adult.

38.  In 1830 Eberle, a Philadelphia physician, defined it as “paroxysmal affection of the
respiratory organs, characterized by great difficulty of breathing, tightness across
breast, and a sense of impending suffocation, without fever or local inflammation.”
Predisposing factors:
Extrinsic or allergic asthma,
 The allergens may be airborne – house dust, feathers, animal dander, furniture
stuffing, fungal spores, or plant pollens.
 Food and drugs – cow’s milk, egg, fish, chocolate, shellfish, tomatoes, penicillins,
vaccines , asprin, and sulfites.
 Type I hypersensitivity reaction – Ig E antibodies produced in response to allergen
Intrinsic or non allergic, idiosyncratic, non atopic asthma:
 Usually develops in adult age > 35 years
 Non – allergic factors – respiratory infection (viral infection is more common
causative factor), physical exertion, environmental and air pollution, and
occupational stimuli

39. Clinical manifestations:
 Feeling of chest congestion
 Cough, with or without sputum production
 Wheezing, Dyspnea
 Patient wants to sit or stand up
 Increased anxiety and apprehension
 Tachypnea (>20 - >40 in severe cases)
 Rise in B.P, Increase in heart rate (>120 bpm in severe cases)
 DRUGS TO BE AVOIDED IN ASTHMATIC PATIENTS
 Drugs containing aspirin
 Nonsteroidal antiinflammatory drugs (patients with intrinsic asthma).
 Opiates: these can cause respiratory depression and histamine release.
 Local anesthetics: use solutions without adrenalin or levonordefrin, due to
the sulfite preservative contents.
 If the patient is receiving prolonged systemic corticosteroid treatment,
supplements may be needed (prior to dental procedures that might cause
stress).

40. Dental therapy considerations:
 Stress reduction protocol in case of emotional stress
 Contraindication of barbiturates and opioids as increase the risk of bronchospasm
 Some inhalational anesthetics like ether irritates respiratory mucosa
 Special care should be taken while prescribing analgesics
 Some patients are sensitive to bisulphites, local anesthesia is contraindicated
Commonly prescribed drugs for the management:
Bronchodilators:
Sympathomimetic:
 Albuterol
 Salmeterol
 Metaproterenol
anticholinergic:
 Ipratropium
Corticosteroids:
 Beclomethasone , Triamcinolone

41.  If asthmatic attack occurs in dental chair, stop the procedure.
 Administer antiasthamatic drug normally used by the
patient followed immediately by hydrocortisone 200 mg
intravenously along with oxygen.
 If there is no response within 2 to 3 minutes, give salbutamol
or terbutaline by slow intravenous injection.
 Avoid anxiety which may precipitate an asthmatic attack.
 Patient should not be treated during sickness e.g. flu-like
symptoms.
 Allergy to penicillin may be more frequent.
 Epinephrine, erythromycin, clindamycin and azithromycin
are contraindicated for patients on theophylline.
 epinephrine (1:1000 in solution, 0.01 mg/kg body weight,
with a maximum dose of 0.3 mg}

42.  Infrequent attacks of asthma can be managed by salbutamol
(asthalin) inhalers or can be used prophylactically if an attack
is predicted. e.g. before exercise or prior to a stressful event
such as dental treatment.
 If the attacks are more frequent, the salbutamol should be
used regularly.
 In severe cases systemic steroids may be prescribed.
 Aspirin and NSAIDs should be avoided as they are considered
asthma precipitating drugs.
 Patients on steroid inhalers are prone to oral and pharyngeal
thrush and those on ipratropium bromide may have dry
mouth.
 Avoid antihistamines such as promethazine and
diphenhydramine because of their drying effect that can
exacerbate the formation of tenacious mucus in acute attack.

45. It is a group of diseases marked by high levels of blood glucose resulting
from defects in insulin production, insulin action, or both
Predisposing factors:
Type I diabetes:
 Genetic factors
 Environmental factors like drugs, toxins and viruses (mumps, rubella)
 Autoimmune factors
Type II diabetes:
 Genetic factors
 Insulin secretion
 Insulin resistance
 Obesity
 Adipocyte derived hormones and cytokines

46.  A common emergency situation encountered in a diabetic patient is
hypoglycaemiai.e. Blood sugar level less than 70 mg /dl. resulting
from mismatch of insulin dose and serum glucose. Usually it results
from failure to take food or over dosage of insulin, hypoglycaemic
drugs or alcohol.
Clinical manifestations of hypoglycemia:
Early stage – mild reaction
 Diminished cerebral function
 Changes in mood
 Decreased spontaneity
 Hunger
 Nausea
More severe stage
 Sweating
 Tachycardia
 Piloerection

49. 1. Stress reduction protocol is of paramount importance in managing
these patients.
2. Appointments should be of short duration and early in the
morning.
3. Routine dental procedures and minor surgical procedures under
local anaesthesia can be carried out just after a meal (preferably
breakfast) and routine antidiabetic medication with no special
precautions.
4. Antibiotic cover prior to dental surgery is advised to prevent
infection.
5. Complicated oral surgical procedures should be avoided in such
patients until blood glucose levels are stabilized.
6.Patients with low plasma glucose levels <70mg/dl should be given
oral carbohydrate before treatment to minimize the risk of
hypoglycemic event.

50.  STOP THE PROCEDURE IMMEDIATELY.
 Essentially, a quick-acting carbohydrate needs to be given, followed by a
longer-acting carbohydrate.
 Initially Glucose 10-20 g is given by mouth, either in liquid form or as
granulated sugar (two teaspoons) or sugar lumps.
 Repeat capillary blood glucose after 10-15 minutes; if the patient is still
hypoglycemic then the above can be repeated (probably up to 1-3 times).
 If hypoglycemia causes unconsciousness, or the patient is unco-operative:
Intravenous administration of 75-80 ml 20% glucose or 150-160 ml of 10%
glucose (the volume will be determined by the clinical scenario).
 25 ml of 50% glucose concentration is viscous, making it more irritant and
more difficult to administer intravenously. It is rarely used now.
 Once the patient regains consciousness, oral glucose should be
administered, as above.
 Check the blood sugar with glucometer.

51. Hypoglycemia – conscious patient
Recognize problem (altered consciousness)
Discontinue dental treatment
Activate office emergency team
P – Position, patient comfortably
A → B → C –Assess and perform basic life support as needed
D – Definitive management:
Administer oral carbohydrates
If successful If unsuccessful
Permit patient to recover Activate EMS
Discharge the patient Administer parenteral
carbohydrates
Monitor patient
Discharge patient

52. Hypoglycemia: unconscious patient
P – Position patient in supine position with feet elevated
D – Definitive management
Summon EMS
Administer oral carbohydrates
IV 50% dextrose solution
1 mg glucagon via IM or IV
Transmucosal sugar, or rectal honey or syrup
Monitor vital signs every 5 minutes
Administer O2
Allow patient to recover and discharge per medical recommendations


53. Defined as ‘any vascular injury that reduces cerebral blood flow to a
specific region of the brain, causing neurologic impairment’. ‘Stroke’,
‘cerebral apoplexy’ & ‘brain attack’
Classification:
 cerebral ischemia and infarction – atherosclerosis & thrombosis,
cerebral embolism
 Intracranial hemorrhage – arterial aneurysms & hypertensive
vascular disease
 Others – TIA – transient ischemic attacks

54. Predisposing factors:
 Consistently elevated blood pressure is a major risk factor
 Diabetes mellitus
 Cardiac enlargement
 Hypercholesterolemia
 Use of oral contraceptives
 Cigarette smoking
Prevention:
 Medical history questionnaire
 Dialogue history
 Physical examination

55. Dental therapy considerations:
 Length of time elapsed since the CVA – should not undergo elective dental
care within 6 months of the episode
 Minimization of stress – morning appointments, effective pain control,
psychosedation during treatment
 Assessment of bleeding – most of CVA patients on antiplatelet or
anticoagulant therapy
 dental treatment produces bleeding(teeth extraction, pulpectomy,
subgingival scaling, periodontal surgery), anticoagulant systemic medication
may cause serious haemorrhage, therefore anticoagulant drugs like heparin
should be stopped at least 6-12 hours before treatment.
Clinical manifestations:
 Common signs and symptoms – headaches, dizziness, vertigo, drowsiness,
chills, nausea, vomiting. Loss of consciousness and convulsive movements
are less common. Weakness or paralysis of extremities occurs in contralateral
side. Speech defects may be seen
 Neurological signs and symptoms – paralysis of one side of body,
difficulty in breathing and swallowing, inability to speak or slurring of
speech, loss of bladder and bowel control, unequal pupil size
 Infarction – gradual onset of signs and symptoms whereas embolism and
hemorrhage – abrupt onset of signs and symptoms

56. Management of CVA :
Conscious patient
Discontinue dental treatment
P – Position patient comfortably
A → B → C –Assess and perform basic life support as needed
D – Definitive management:
Monitor vital signs
Manage signs and symptoms
If B.P elevated, semi – fowler position (450 position)
Administer O2
Do not administer CNS depressants
Symptoms resolve Symptoms persist CVA Loss of
consciousness
Follow up management Hospitalization P – position with
feet elevated slightly
A → B → C –Assess and perform basic life support as needed
Monitor vital signs
If B.P elevated, reposition patient (slight head &chest elevation)
D definitive care: establish IV access & transport to EMT

57.  Epilepsy is a term that describes a group of disorders
characterized by chronic, recurrent, paroxysmal changes in
neurologic function (seizures) that are caused by abnormal
electrical activity in the brain
 Partial seizures
 Simple partial
 Complex partial
 Partial seizures evolving to generalized tonic – clonic
 Generalized seizures
 Absence seizures (true petitmal)
 Myoclonic seizures
 Tonic – clonic seizures
 Unclassified epileptic seizures

58. Causes:
 Congenital abnormalities
 Perinatal injuries
 Metabolic and toxic disorders
 Head trauma
 Tumors
Predisposing factors:
 Hypoxia , hypoglycemia, hypocalcemia
 Flashing lights, fatigue, decreased physical health, a missed
meal, alcohol ingestion, physical or emotional stress, sleep and
menstrual cycle
Prevention:
 Care in selection of LA agent & use of proper technique
 Medical history questionnaire about fainting spells, seizures
 Dialogue history about previous experience of seizures, onset,
duration, management

59.  CAUSES OF SEIZURES IN DENTAL OFFICE:
• Hypoxia secondary to syncope
• Hypoglycemia
• Local anesthetic overdose
• Missing of antiepileptic drug before treatment
• Head injury
TRIGGERING FACTORS WHICH MAY PRECIPITATE
EPILEPSY SYMPTOMS IN DENTAL OFFICE:
• Flashing lights
• Emotional or physical stress
• Missed meal
• Epileptogenic drugs
• Withdrawal of anticonvulsant medication

60. Dental Consideration f an Epileptic Patient
 Adequate history regarding the disease should be obtained
with specific reference to its duration and predisposing
factors, types of drugs taken, and duration of medication.
 Treatment should be undertaken only if the patient is under
good control.
 Premedication with anti-anxiety drugs and stress reduction
protocol should be followed.
 Optimal dosage of local anaesthesia.
Management
 Terminate the dental treatment, place the patient in the
supine position, loosen any tight clothes, avoid restraining the
patient.
 If the seizure lasts for more than 5 minutes Administer
diazepam 5 mg per minute IV/IM or midazolam 3 mg per
minute IV/IM. Once the seizure stops monitor the vital signs,
administer oxygen and transport to emergency care facility

61.  Aspirin and NSAIDs should
not be administered to
patients taking valporic acid
(medicine used in treatment
of epilepsy).
 Phenobarbital used in Partial
and secondarily generalized
seizures sideeffects includes
Drowsiness/sedation,
osteomalacia
 Carbamazepine used in
Partial and secondarily
generalized seizures ,side
effects includes Xerostomia,
stomatitis, gingival bleeding,
osteomalacia

63.  Angina is a symptom of ischemic heart
disease produced when myocardial
blood supply cannot be increased to
meet the increased oxygen
requirement as a result of coronary
heart disease.
 Dental aspects:
 Preoperative glyceryl trinitrate and
oral sedation must be e.g.
Tremazepam are advised .
 Effective local anesthesia is essential.
 Ready access to medical help, oxygen
and nitroglycerine are essential.
 The mainstay in the treatment of
angina pectoris due to spasm of the
blood vessels is the nitrates, which
produce dilation of the peripheral
arterioles including the coronary
vessels.

65. Recognize problem (chest pain – angina attack)
Discontinue dental treatment
Activate office emergency team
P – Position, patient comfortably usually upright
A → B → C –Assess and perform BLS
D – definitive management
HISTORY OF ANGINA PRESENT NO HISTORY OF ANGINA
Administer vasodilator and O2 Activate EMS
Transmucosal nitroglycerine spray O2 and nitroglycerine
Or sublingual nitroglycerine tablet Monitor and record
0.3 – 0.6 mg for every 5 min (3 doses)
IF PAIN RESOLVES IF PAIN DOES NOT RESOLVE
continue with dental procedure summon medical care
Administer aspirin
Continue to monitor and record vital
signs
MANAGMENT

68.  MI is a condition caused by
necrosis of a region of
myocardium due to decrease
in myocardial supply.
 It is characterized clinically
by substernal pain which
stimulates angina pectoris
but is of more intense and is
of longer duration.
 Signs and symptoms:
 Dyspnea
 Orthoponea
 Giddiness
 Nausea
 Vomiting
 Light headedness
 PATIENT WITH RECENT ATTACK
OF MI ( WITHIN 6 MONTHS ):
 These patients are on
anticoagulants and are on
increased risk of another
episode.
 Delay of dental treatment for
6 months is advisable.
 PATIENTS WITH EPISODE OF
MI( LESS THAN 6 MONTHS ):
 Anxiety reduction protocol
must be followed.
 Dental treatment must be
carried out with effective Local
anesthesia, less anxiety and
oxygen saturation.
MYOCARDIAL INFARCTION

69.  AN EPISODE OF MI ON DENTAL
CHAIR :
 Terminate all dental treatment if he
complaints of chest pain.
 Remove all foreign objects including
cotton gauge
 Change the patient’s position to
patient’s comfort. ( mostly upright) .
 Administer 0.5 mg Glyceryl trinitrate
( GTN) sublingually.
 Monitor vials.
 Postpone dental treatment if can be
done.
 Position the patient in a semi
reclined procedure if he is
unconscious.
 If conscious, change position to
sitting procedure.
 Repeat this after 5 minutes.

70.  Avoid overstressing the patient
 Supplemental oxygen via nasal cannula or nasal hood
during the treatment – 3-5 L/min and 5 – 7 L/min
 Pain control during therapy – appropriate use of local
anesthesia – smaller dose with maximum effect – slow
administration
 Psychosedation – N2O – O2 is preferable
 It is strongly recommended that elective dental care is
avoided until at least 6months after MI
 Inferior alveolar NB and Posterior superior alveolar NB
– risk of hemorrhage – should be avoided

73. Signs and Symptoms of Epinephrine Toxicity
 Agitation, weakness, and headache.
 Pallor, tremor, palpitation.
 Sharp rise in blood pressure and heart rate.
Signs and Symptoms of Local Anesthetic Toxicity
 Agitation.
 Muscular twitching and tremors.
 Increased blood pressure and heart rate.
 Light-headedness.
 Visual and auditory disturbances (Tinnitis, Difficulty focussing.)
 If moderate to high overdose of Local anesthetic can also have convulsions
and depression of blood pressure, heart rate, and respiration.

74. MANAGEMENT OF TOXIC REACTIONS TO EPINEPHRINE:
 Toxic effect of epinephrine is transitory rarely lasting more than a few
minutes
 Stop dental treatment.
 Place patient in most comfortable position.
 Monitor vital signs.
 Consider administering oxygen.
 Allow time for the patient to recover.
Dental Treatment Considerations for use of Epinephrine
 Due to its cardiovascular effects limit use in patients with history of
heart disease or stroke.
 Can cause uterine contractions in the pregnant female.
 Possible drug interactions (Especially MAO inhibitors and Cocaine.)
 Remember the patient has endogenous epinephrine production of this
is increased in stressful situations.

75. MANAGEMENT OF TOXIC REACTIONS TO LOCAL ANESTHETIC:
treatment varies with the onset and severity of the reaction.
MILD REACTION/RAPID ONSET (Example is an intravascular
injection)
 Reassure patient.
 Administer Oxygen.
 Monitor and record vital signs.
 Allow for recovery; determine if patient can be allowed to leave
unescorted.
MILD REACTION/SLOW ONSET
 Toxic reaction with a delayed onset is most likely a result of impaired
biotransformation.
 Evolves slowly, use caution.
 Monitor patient, record vital signs.

76. SEVERE OVERDOSE/RAPID ONSET, SEVERE OVERDOSE/SLOW ONSET
 ABC’s.
 Activate EMS.
 Administer Oxygen by mask at 10-15L/minute.
 Start IV if available (18 gauge catheter with Normal Saline.)
 If needed and available administer anticonvulsant, Versed (Midazolam)
2mg, then 1mg/min to effect (Monitor respiration.)
 Monitor and record vital signs.
 Allow for recovery and discharge with appropriate escort or transport to
hospital if required.

77.  Anaphylaxis is a potentially life-threatening immune reaction to
foreign material. Anaphylactic reactions may occur after a single
and first time exposure to certain substances such as drugs.
Anaphylaxis is a clinical syndrome of severe hypersensitivity
reaction characterized by cardiovascular system (CVS) collapse,
respiratory system depression, skin reactions and smooth muscle
contractions.
Signs and symptoms include:
 Cardiovascular shock including; pallor, syncope, palpitations,
tachycardia, hypotension, arrythmias, and convulsions.
 Respiratory symptoms include; sneezing, cough, wheezing,
tightness in chest, bronchospasm, laryngospasm.
 Skin is warm and flushed with itching, urticaria, and
angioedema.
 Nausea, vomiting, abdominal cramps, and diarrhea also possible.

78.  Clinical manifestations:
Pruritus ,Urticaria, Angioedema
Generalized erythema.
 Respiratory manifestations
Wheezing , Coughing , Stridor ,
Dyspnoea Laryngeal oedema
Respiratory arrest.
 GIT manifestations: Nausea ,
Vomiting , Abdominal cramps ,
Urinary incontinence
 CVS manifestations: Tachycardia,
Shock, Light headedness
Hypotension , Cardiac
dysrhythmias , Cardiac arrest

79. TREATMENT
General Treatment
 ABC’s
 Maintain airway, administer oxygen, and determine possible need for intubation or
surgical airway.
 Monitor vital signs.
 If in shock put patient in a horizontal or slight Trendelenburg position.
Mild Reactions
 Antihistamines usually effective. (Benadryl 50-100mg or Cholpheniramine maleate
4-12 mg IV, or IM.)
 Identify and remove allergen.
 Follow up medications in 4-6 hours.
Severe Reactions
 If available start IV Fluids
 Epinephrine is drug of choice. Usually prepackaged 1:1,000 in 1mg vials or syringe
 If IV in place titrate 1:1,000 solution to effect.
 If drop in blood pressure is minimal, start with 0.5ml (0.5mg.)

80. • Plaque Control oral hygiene instructions,
scaling, polishing curettage
• Avoid elective treatment urgent care only.
FIRST TRIMESTER
(1-12 WEEKS)
• Plaque Control oral hygiene instructions,
scaling, polishing curettage
• Routine dental care.
SECOND TRIMESTER
(13-24 WEEKS)
• Plaque Control oral hygiene instructions,
scaling, polishing curettage.
• Routine dental care.
THIRD TRIMESTER
(25-40 WEEKS)

81.  Best time for the dental procedures is the middle or
second trimester .
 DENTAL MANAGEMENT:
 Avoid painful stimuli
 Avoid placing the patient in supine position
 Avoid radiographs{used only after first trimester }
 LA is more suitable than GA
 Avoid drugs with tetraogenic potenial

82. ITEMS To be avoided preferablee
ANALGESICS Asprin
NSAIDs
Paracetamol
Antibiotics Tetracyclines
Aminoglycosides
Metronidazole
Streptomycin
Penicillin
Erythromycin
Cephalosporins
Others corticosteroids

83. FUNCTIONAL
EMERGENCIES

84.  Stop procedure immediately.
 Wash skin with disinfectant.
 Treat with running water and
encourage bleeding
 Dry area and cover with
antiseptic dressing
 Recording medical history
vital in case of an exposed
needle situation.
 Seek antidotal vaccination or
treatment if necessary.
Invariably associated with faulty
techniques such as:
bending the needle while
administering LA
inserting the needle up to the
hub
directing the needle against
resistance
May also occur if pt jerks head
during administration.
Most commonly with IANB.
NEEDLE
BREAKAGE

85.  Inform pt of the occurrence, tell him/her to remain
calm, keep mouth open and refrain from any jaw
movements.
 Retrieve the fragment, if visible, with a haemostat.
 A buried fragment needs to be located ASAP using
radiographs or CT scans & retrieved surgically.

86.  A proper case history and thorough clinical
examination must be done during dental treatment of
medically compromised patients.
 Every dental procedure or medication can alter
medical status of medically compromised individual.
 Management of these patients must be done carefully
and these patients must be provided special care with
proper planning .

87.  Handbook of Medical Emergencies in the Dental Office, Stanley F. Malamed
 Medical Emergencies in Dentistry, Jeffrey D. Bennett , Morton B.Rosenberg
 Text book of oral surgery :bhalaji
 Textbook of oral surgery :chitra chakravarthy
 Risk of adrenal crisis in dental patients Results of a systematic search of the
literature JADA, February 2013:144122:1520160.
 Angina Pectoris--Thoughts on its Management in the Practice of Dentistry ALLYN
S. ABRAMSON, D.D.S.
 Dental considerations in patients with respiratory problems J Clin Exp Dent.
2011;3(3):e222-7.
 Dental considerations in patients with heart disease
J Clin Exp Dent. 2011;3(2):e97-105.
 Endodontic management of patients with systemic complications Journal of
Pharmacy and Bioallied Sciences October 2016 Vol 8 Supplement 1
 Sudden episodes of loss of consciousness in dental practice Vo l . 2 1 / 2 0 1 2 , n r
4 3
 DENTAL MANAGEMENT IN STROKE PATIENTS TMJ 2008, Vol. 58, No. 3 - 4