DENTAL EMERGENCIES

An emergency is a medical condition that demands immediate attention and successful management. These are the life‑threatening situations of which every practitioner must be aware of so that needless morbidity can be avoided. Emergencies can be prevented to a certain extent by a detailed medical history, physical examination, and patient monitoring. A survey revealed an incidence of 7.5% emergencies per dental surgeon over a 10‑year period. These emergencies may be related directly to dental therapy, or they may occur by chance in the dental office environment.

Preparation for an emergency and sound knowledge about the management of all emergencies in general is of prime concern to dental specialists.Best practice dictates that dental personnel must be prepared to provide effective basic life support (BLS) and seek emergency medical services in a timely manner.

 

BASIC PRINCIPLES OF MANAGEMENT OF MEDICAL EMERGENCIES

 

P

osition : The primary positions to manage an emergency are supine position, Trendelenburg position, and semi‑erect position

A

irway : airway is achieved usually by the head tilt‑chin lift manoeuvre. If clear airway is still not achieved, then invasive procedures like direct laryngoscopy and cricothyrotomy can be followed.

B

reathing : mouth‑to‑mouth technique or the bag‑valve‑mask technique.

C

irculation : by palpating the carotid pulse at the region of the sternocleidomastoid muscle. If pulse is absent, then CPR is initiated immediately.

D

efinitive therapy : administration of drug when indicated and contacting for emergency care.

 

SUGGESTED BASIC EMERGENCY EQUIPMENT FOR THE DENTAL OFFICE.

 

·         Portable oxygen cylinder (E size) with regulator

·         Supplemental oxygen delivery devices

(a) Nasal cannula

(b) Nonrebreathing mask with oxygen reservoir

(c) Nasal hood

·         Bag-valve-mask device with oxygen reservoir

·         Oropharyngeal airways (adult sizes 7, 8, 9 centimeters)

·         Magill forceps

·         Automated external defibrillator

·         Stethoscope

·         Sphygmomanometer with adult small, medium and large cuff sizes

·         Wall clock with second hand

 

BASIC EMERGENCY DRUGS

 

         DRUG                                                                           INDICATION

 

1.Epinephrine                                            Bronchospasm(Severe Allergic Reaction)

2.Diphenhydramine                                   Mild Allergic Reaction

3.Nitroglycerin                                           Angina

4.Bronchodilator (albuterol)                      Bronchospasm (Mild Asthma)

5.Glucose                                                    Hypoglycemia

6.Aspirin                                                     Myocardial Infarction

7.Aromatic ammonia                                   Syncope

 

SUPPLEMENTAL INJECTABLE DRUGS

 

Dentists with advanced training may consider including drugs and equipment in addition to those described earlier. These might include the following injectable drugs:

·         analgesics

·         anticholinergics

·         anticonvulsants

·         antihypertensives

·         antihypoglycemics

·         corticosteroids

·         vasopressors.

 

DENTAL COMPLICATIONS

 

More than dental emergencies which require an immediate attention and management, the occurrence of complications are of higher incidence in dental practice. The complications may be immediate  or  delayed  and are related to patient’s tolerance level, materials used and treatment procedures.

 

The most common complication is aspiration. Aspiration may be of the denture as a whole or a fractured part, a minimal extension acrylic removable prosthesis, crowns during removal, instrument slippage especially broaches reamers or files. Aspiration causes airway obstruction. Removal of broken instruments is performed using ultrasonics, operating microscopes or microtube delivery methods.

 

Allergy is another complication commonly encountered by a dental specialist. Allergy can be to latex, mercury, rubber dam, and impression material. Minimizing latex exposure is most effective when treating latex‑sensitive patients. Latex alternatives (vinyl, nitrite, or silicone) and powder‑free gloves should be used to prevent sensitization. Fixers like formacresol and devitalizers to be used carefully to prevent chemical burns.

 

Complications involving local anaesthetics are hypersensitivity, toxic reactions, and allergy. The most severe form of hypersensitivity is anaphylaxis which is a life‑threatening generalized or systemic reaction. Management involves administering prophylactic antihistamines, such as diphenhydramine or corticosteroids such as prednisone before dental treatment to those at known risk.

 

 

An immediate complication usually manifested during an endodontic therapy is hypochlorite accident wherein sodium hypochlorite is expressed beyond the apex and patients manifests with severe pain, swelling or profuse bleeding. Immediate management involves administration of a regional block and then wait till maximum drainage occurs.

 

COMPLICATIONS AND EMERGENCIES ENCOUNTERED DURING IMPLANT THERAPY

 

The intra‑operative complications related to surgery are haemorrhages, neurosensory alteration, damage to the adjacent teeth, and mandibular fractures.

 

Haemorrhages in the mandible most frequently occur in the intra‑foraminal region by damage to the descending palatine artery or the posterior palatine artery. Respiratory obstruction has also been reported due to perforation of the arteries supplying the mandible. Haemorrhages can be managed by strong finger pressure at the point of bleeding but if compressions don’t obtund bleeding then at times anastomoses necessitates ligation.

 

Another complication related to surgery is neurosensory disturbance which manifests as anaesthesia, paresthesia, hypoesthesia, or dysesthesia. If the patient suffers from paresthesia but implant is placed correctly with no damage to the nerve, then  retrieval of implant is not advised; instead wait for recovery. However, if the nerve is being compressed, it is always advisable to remove the implant to avoid permanent neural damage.

 

Complication associated with implant placement most importantly involves loss of primary stability which can be attributed to overworking of the implant bed, poor bone quality or use of short implants.   Loss of primary stability can be managed by using a wider and longer self‑tapping implant.

During implant placement in the maxilla in areas close to sinus or during sinus lift procedures, complications involving rupture of Schneider membrane can occur. Depending on the width of the tear, a resorbable membrane may be used which serves to contain the bone graft material, or if the tear is very wide, then surgery is postponed.

Mandibular fractures are rare and occur when implants are placed in atrophic mandible.

These emergencies and complications can be minimized by appropriate pre‑surgical planning, use of accurate surgical techniques, postsurgical follow‑up, respecting the osseointegration period, appropriate design of the superstructure, biomechanics, and advocating meticulous hygiene during the maintenance phase.

 

No drug can replace trained health care professional in managing an emergency but an emergency drug kit and equipment does play an integral role in the course and outcome of management of emergencies and complications in interdisciplinary dental practice.

 

                                                                                                            Dr. Anjusha Sharda