Today there are many medically compromised patients coming to our offices. The U.S. and global population demographics are constantly changing, chronic diseases are becoming more prevalent, new medications are being developed and brought to the market.
Many of these patients are often treated in dental offices without an adequate medical history and evaluation being taken prior to the onset of treatment. It has been estimated that at least one or two office related deaths may occur during the career of a typical dental practitioner. These would not necessarily occur during the office visit, but could happen within 24 hours after the initial treatment. The overwhelming majority of medical emergencies that occur in dentistry happen during or immediately after local anesthetic administration. Anything a doctor can do to minimize stress at this time serves to prevent potential problems from developing. More than 50% of all postoperative deaths are cardiac in nature. Over 50% of emergencies that occur in the dental office are syncope or simple fainting. Even this simple fainting episode, improperly managed, may and has resulted in a fatal outcome.
This article will describe four important recommendations that can easily be implemented in any dental office that are all non-invasive, cost-effective, easy to learn and can be performed by the dentist or knowledgeable staff members.
Recommendation # 1:
A) Use the “DASH” approach.
Ask the patient, “Since your last visit to our office have you had any:
1) Drugs prescribed by your doctor?
2) Allergies or bad reactions to any medications, foods or environmental factors/items?
3) Surgeries performed (major or minor)?
4) Hospital visits or hospital stays?”
This should be documented in the chart for every visit and completed by the doctor or a staff member, and the patient. It should then be initialed and dated by both.
For any positive DASH response, the doctor must be notified prior to the initiation of any dental treatment.
B) Ask the question: “Has your driver’s license ever been suspended or revoked for any reason?” (This may indicate a medical condition(s) such as uncontrolled diabetes, vestibular balance disorders, epilepsy and alcohol abuse which the patient may otherwise fail to disclose.)
C) Measure and document the patient’s blood pressure. Hypertension is the “Silent Killer,” since it is a contributing factor to a number of other medical conditions and is often undiagnosed. Note that the drug inserts for local anesthetic agents state that a BP should be recorded when a local anesthetic is administered. This can be done with either an automatic apparatus or with a manual one. Many automatic devices also register pulse readings. The typical local anesthetic drug insert states:
“Cardiovascular vital signs (BP) and respiratory vital signs…should be monitored after each local anesthetic injection.” The insert further states that when administering a dental block (inferior alveolar)…”Patients receiving these blocks should have circulation (BP) and respiration monitored and be constantly* monitored.”
The above is in the fine print, and, as such, we are responsible for its content. Failure to comply could place the dentist at risk for legal action should the administration of the local anesthetic precipitate a medical emergency. In our legal system, ignorance is no excuse for an untoward outcome.
Recommendation # 2:
Purchase an automatic blood pressure machine with different cuff sizes to appropriately fit pediatric, adult, and obese patients, and, preferably, register the pulse at the same time. These can range from $65 to $100+, depending on optional features such as: a printout, and/or a USB connection to download multiple readings. Many are capable of detecting the presence of arrhythmias.
Recommendation # 3:
Determine the Rate Pulse Product as follows:
Rate Pulse Product (RPP): is a number that is determined by: multiplying the: Systolic BP X the Pulse Rate.
For example: 120/82 is the BP and the pulse is 80. Therefore the RPP would be 120 X 80 = 9,600
Any resulting product over 12,000 is of concern, as this patient may be at higher risk for developing a sudden medical emergency. This is especially true if there is a history of cardiac disease, angina, congestive heart disease and, now, according to the latest medical evidence, diabetes. Many of these patients should be considered for referral to their primary care physician for a diagnostic workup. Some of these patients should also be considered for oral anxiolytic premedication prior to dental treatment and others may elect to be treated with IV sedation. These options should be presented, discussed, and reviewed.
Recommendation # 4:
Have a Glucometer in the office
Since diabetes is the fastest growing condition in the U.S. and is now considered a Cardiac Disease Indicator rather than a risk factor for cardiac disease, a greater portion of the medical history should be devoted to questions about this medical disorder. For example: When was your last blood test (for diabetes) and what was the result? If unknown, and you suspect hypoglycemia, then use a Glucometer.
Recommendation # 5:
Purchase a Pulse Oximeter
In the past, a Pulse Oximeter would cost thousands of dollars, however, today the cost is less than $50. It can be purchased in a local drugstore or ordered online. Besides indicating the patient’s pulse rate, in real time, throughout the procedure (vs. the automatic BP/ pulse indicator which does not), it also tells you the Oxygen Saturation Percentage, which indicates the percentage of blood that is loaded with oxygen. More specifically, it measures what percent of hemoglobin (the protein in red blood cells that carry oxygen) is saturated. This is a very precise indicator of oxygen perfusion. Normal readings are between 95% and 100%. If it is lower than 93%, supplemental oxygen should be considered. The Oxygen Saturation Percentage is important, as the lower the saturation, the more likely it is that the patient can go into a crisis, as the parameters for a safety zone are significantly diminished. Administrating supplemental oxygen when the oxygen saturation is below 93% can significantly reduce the probability of a cardiac
perfusion and/or respiratory exchange crisis from occurring both intra-and postoperatively. The pulse rate is the most important indicator of the cardiovascular system, followed closely by the blood pressure. The Systolic BP correlates with changes in myocardial oxygen demand and the Diastolic BP is the important determinant of coronary perfusion.
The pulse oximeter also registers the pulse in real time. A patient experiencing stress/ anxiety and also having an increased pulse rate will experience less oxygen supplying the myocardium. This is because oxygen is only delivered to the myocardium during the phase of the heart cycle know as Diastole. With this increasing pulse, the relative time of the Diastole phase is reduced along with a corresponding increase in relative time given to Systole. If the heart muscle should already be compromised, this could become a problem. Therefore, a rising pulse, as seen and heard on the pulse oximeter, could be a strong indicator for a potential cardiac/angina episode. This could be preempted and avoided by determining (pre-treatment) the Rate Pulse Product as well as being apprised (both visually and by sound) of an increasing pulse rate prior to and/or during any dental procedure. Dealing with a medical emergency after it occurs is much more difficult than preventing one from occurring. Not all emergencies can be determined or prevented prior to their occurrence, however, implementing these recommendations can potentially reduce the likelihood of a medical crisis from taking place in your office.
“By failing to prepare you are preparing to fail”
There is an on-demand presentation titled “Updated on Medical Emergencies 2016”. This presentation will teach you how to respond to a life threatening crisis in your office or anywhere. The indications for emergency drug use along with the appropriate dosages will be reviewed. Developing and maintaining an Emergency Drug Kit will be taught. Make sure to register below to get the invitation. A certificate will be issued after passing the C.E. quiz and will grant you 1 ADA CERP credits.
Reference: 2014 Update on Basic Physical Diagnosis, by Daniel G. Pompa, an Oral and a Maxillofacial Surgeon.
Haider Maitham, DDS / Bondistry