Presented at Annual Dental Conference of Nepal Dental Association on 2nd February 2013 at Chitwan, Nepal.

1. Preparedness in
Dentistry
Prevention and
Preparedness in
Dentistry
Dr Neil Pande
BDS MFGDP(UK) MFDS RCS(Eng)
General Dental Practitioner

2. Guidance
Medical emergencies can occur at any time.
All members of staff need to know their role in
the event of a medical emergency.
Members of staff need to be trained in dealing
with such an emergency.
Dental teams should practise together regularly
in simulated emergency situations.

3. Unexpected Events
Accidental or willful bodily injury,
Central nervous system stimulation and
depression,
Respiratory and circulatory disturbances,
Allergic reactions.

4. Medical Emergency Plan
Prevention
Action plan
Diagnosis and Management
Emergency drugs and equipment

5. Prevention
Medical History Questionnaire
Verbal History
Medical History Update
Physical Examination
Assessment of Risk
Stress Reduction
Pain Control

7. Medical History
Questionnaire
First thing in dental practice
Simple language understandable to the patient
All relevant questions asked
Signed and dated (Minor: Guardian/Parent)
Helped by the reception staff in case of difficulty
(Training and understanding of the staff)

8. Verbal Medical History
Re-enforces Medical History Questionnaire
More information on conditions
Degree of severity
Gives out information that patient feels is
irrelevant to dentistry
Medical Interactions

10. D
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11. Medical History Update
Should be a part of every long interval dental
visits
Noted in the record in every instance

12. Physical Examination
Visual Inspection
Baseline Vital Signs:
Pulse, BP, Breathing, Temperature

13. Risk Assessment
ASA PS Classification System
PS 1: Normal Healthy Patient (-60)
PS 2: Mild Systemic Disease (Anxiety, fear,
+60)
PS 3: Severe Systemic Disease that limits
activity but not incapacitating
PS 4: Incapacitating Systemic Disease that is
constant threat to life
PS 5: Not expected to survive 24 hours

14. ASA 1
Patients are considered to be normal and
healthy.
Patients are able to walk up one flight of stairs
or two level city blocks without distress.
Little or no anxiety.
Little or no risk.
This classification represents a "green flag"
for treatment.

15. ASA 2
Patients have mild to moderate systemic disease
or are healthy ASA I with extreme anxiety and fear
Patients are able to walk up one flight of stairs or two
level city blocks, but will have to stop after completion
of the exercise because of distress.
Minimal risk during treatment.
Examples: History of well-controlled disease states
including non-insulin dependent diabetes,
prehypertension, epilepsy, asthma, or thyroid
conditions; ASA I with a respiratory condition,
pregnancy, and/or active allergies. May need medical
consultation.

16. ASA 3
Patients have severe systemic disease that limits
activity, but is not incapacitating.
Able to walk up one flight of stairs or two level city
blocks, but will have to stop enroute because of
distress.
Stress reduction protocol and other treatment
modifications are indicated.
Examples: History of angina pectoris, myocardial
infarction, or cerebrovascular accident, congestive
heart failure over six months ago, slight chronic
obstructive pulmonary disease, and controlled insulin
dependent diabetes or hypertension. Will need
medical consultation.

17. High Risk Patients
Frequent Exertional Angina and hospital
admission
Asthmatic under oral and inhalational therapy
/nebuliser / steroid / hospitalisation
Epileptic with recent change in medication/
precipitating factor and time of last attack to be
noted
Insulin treated diabetics more prone to
hypoglycemia / Poorly controlled less aware
diabetics!!!
Previous reactions to local anaesthetics,
antibiotics and latex
Preferred to be treated in medically supported

18. Stress MDAS
Increased catecholamines
(epinephrine/norepinephrine)
Increase load to the heart
Increased Heart Rate
Increased strength of Myocardial
Contraction
Increased Oxygen Requirement
PS1 can tolerate, but PS 2,3,4 less able to
tolerate

19. Stress
Patient with
Angina may develop into chest pain and various
dysrhythmias
Heart Failure may develop into pulmonary
edema
Asthma may develop into acute respiratory
distress
Epilepsy may develop seizures
Hyperventilation and Syncope may develop in
PS 1

20. Stress Reduction
Protocols
Minimize Stress before, during and after
treatment
1. Communication / Consultation
2. Premedication Lorazepam 1mg night before
& 90 mins. before treatment
3. Appointment Scheduling
4. Waiting Time Reduction
5. Vital Signs Monitoring
6. Sedation, Iatrosedation or Hypnosis
Pain Control slideshar
e

21. Post -operative Pain
Management
Availability of dentist via telephone round the
clock
Analgesics
Antibiotics
Antianxiety drugs
Muscle Relaxants

22. Action Plan
Understandable by all the staff member
Goal: Manage until full recovery or until help
arrives
Sufficient Oxygenation to the brain
Patient Position
BLS
Role of Each member of the Team
Communication and hospital transfer

23. CPR
QuickTime™ and a
H.264 decompressor
are needed to see this picture.
30:2

24. Common Medical
Emergencies •Intravascular
Injection
Asthma
•Syncope
Anaphylaxis
•Postural
Angina Hypotension
Myocardial •Hyperventilation
infarction
•Stroke
Cardiac Arrest
•Choking and
Epileptic Seizure Aspiration
Hypoglycemia •Adrenal Insufficiency

25. DR ABCDE
International
Consensus on
Danger
Cardiopulmonary
Response Resuscitation and
Airway Emergency
Cardiovascular Care
Breathing
Science with
Circulation Treatment
Disability Recommendations
(CoSTR)
Exposure
October 2010

26. Chain of Survival
Early recognition of a “sick” patient, a team
effort...

28. “Remember to breathe.
It is after all, the secret of life.”

30. Oxygen cylinder with pressure reduction valve and
flowmeter/face mask with reservoir and tubing.
Basic set of oropharyngeal airways (sizes 1,2,3 and 4).
Pocket mask with oxygen port.
Self-inflating bag and mask apparatus with oxygen
reservoir and tubing / Child size also.
Portable suction with appropriate suction catheters
and tubing
Single use sterile syringes and needles.
‘Spacer’ device for inhaled bronchodilators.
Automated blood glucose measurement device.
Automated External Defibrillator.

32. Oropharyngeal Airway

33. Team Training
Monthly equipment Checks
Regular Updates
Mock Trials
Audit

35. Ambulance Summoning
Written telephone conversation guide:
It is an emergency. A patient has collapsed,
most likely, a _____________. I am calling from
__________ Dental Clinic located at
_________________________
opposite____________beside_________. Please
send us an ambulance. I will be waiting
outside the _______________ wearing
______________ and a flag. My number is
_________________.

38. References
Malamed SF. Knowing Your Patients. JADA
2010; vol. 141 no. suppl 1 3S-7S
MEDICAL EMERGENCIES AND
RESUSCITATION STANDARDS FOR CLINICAL
PRACTICE AND TRAINING FOR DENTAL
PRACTITIONERS AND DENTAL CARE
PROFESSIONALS IN GENERAL DENTAL
PRACTICE A Statement from The
Resuscitation Council (UK) July 2006 Revised
December 2012 Published by the Resuscitation
Council (UK)

39. References
European Resuscitation Council Guidelines for
Resuscitation 2010 Section 2. Adult basic life
support and use of automated external
defibrillators Rudolph W. Koster, Michael A.
Baubin, Leo L. Bossaert, Antonio Caballero,
Pascal Cassan, Maaret Castrén, Cristina Granja,
Anthony J. Handley, Koenraad G. Monsieurs,
Gavin D. Perkins, Violetta Raffay, Claudio
Sandroni.Published online 19 October 2010,
pages 1277 - 1292