Management of Medical Emergencies in the Dental Setting

Dr. Nanna Kreutzfeldt-Jensen

Medical Emergencies in the Dental Office by Dr Stanley Malamed,Mosby, Missouri, 6th edition

Objectives
- Knowledge of common medical emergencies
- Competency in managing medical emergencies at BOH level

Crisis Resource Management

1. Know Your Environment
2. Anticipate and Plan
3. Call for Help Early Enough
4. Take a Leadership Role
5. Communicate Effectively
6. Allocate Attention Wisely & Use All Available Information
7. Distribute Workload & Use All Available Resources

Common Types of Medical Emergencies

- Faint (vaso-vagal syncope)
- Postural Hypotension
- Adrenal insufficiency
- Hyperventilation
- Airway obstruction
- Hypertension
- Asthma
- Acute myocardial infarction/ cardiac arrest
- Diabetes
- Seizures
- Bleeding disorders
- Anaphylaxis
- Cerebrovascular accident

Faint (vaso-vagal syncope)

- Is the most frequently observed emergency, accounting for approx. 50% of ALL reported
emergencies
- Fainting has been associated with all forms of dental care, but most specifically extractions
and other forms of surgery and well as administration of L.A.
- Fainting has occurred upon being seated in the dental chair and even when an individual
first entered the office.
- It is usually a benign occurrence and a self-limiting process, but if managed incorrectly it
may be life threatening
- Definition: A sudden, transient loss of consciousness, that usually occurs secondary to a
period of cerebral ischemia (Malamed, 2000)
- Aetiology:
o Group 1: Psychogenic factors (fear, anxiety, emotional stress, pain- especially
sudden and unexpected pain, sight of blood) leads to increased vagal stimulation (
the fight or flight response and, in the absence of muscular movement by the
patient, sudden diffuse peripheral vasodilatation and bradycardia (HR<50 bpm).
- Result: A reduction in blood supply to the brain, and cerebral hypoxia (Juniper and Parkins,
1990)

Postural Hypotension
- Group 2: The non-psychogenic factors:
 - Fainting due to pooling of blood in the dependent parts of the body on standing/ sitting
upright
- Hunger from a missed meal
- Exhaustion, poor physical condition
- Hot, humid environment
- Most often male gender and between 16-35 years (however rare in children)
- Commonly seen in the elderly taking anti-hypertensive medications Faint (vaso-vagal
syncope)
- Usually it is relatively harmless situation where the victim falls gently to the floor or is laid by
a second party. The individual regains consciousness almost immediately upon restoration
of blood flow to the brain, and within a short period appears to have recovered completely.
- Signs and symptoms:
- A feeling of warmth in the neck and face, loses colour (ashen gray skin colour), becomes
bathed in cold sweat noted primarily on the forehead. During this time the patient usually
reports feeling bad or faint and may also become nauseous
- The blood pressure is maintained at this time near normal, whereas the heart rate
increases significantly to 100-120 beats per minute..
- Soon after pupils dilate, the patient is yawning and the hands and feet turns cold. Both the
heart rate and blood pressure become acutely depressed (hypotension and bradycardia)
and the patient will loose consciousness perhaps accompanied by vision disturbance.

Faint (vaso-vagal syncope)

- During unconsciousness the breathing is irregular and shallow
- Convulsive movements and muscular twitching of the hands, legs and facial muscles are
common when the brain very shortly becomes hypoxic.
- During syncope a heart rate of 50 bpm is normal
- Once the patient is positioned in the supine position the duration is usually very brief, ranging
from a few seconds to several minutes. If this is not the case the diagnosis is mostly wrong.
- Recovery:
- The patient may experience a short period of confusion or disorientation

Management:
Follow the position airway, breathing, circulation and definite care pathway
1. Assess consciousness ( shake and shout)
2. Activate the dental office emergency system
3. Position the patient supine
4. Check circulation head tilt and chin lift will most often open airways artificial ventilation may
be necessary in those cases where natural breathing ceases
5. Definite care: administration of O2 and monitor vital signs
6. Loosing of tight clothes, belts, cold towel on patients forehead or blankets if patient is cold

Consider the reasons behind the faint

Do NOT place the victims head in between the legs because it may further impede the return of
blood from the legs through a partial obstruction of the inferior vena cava
- Consider modifications to future dental treatment to avoid recurrence, only continue treatment if
both patient and dentist feel it is appropriate

- Prevention
- Adequate air-condition
- Ask about a possible missed meal eat a light snack before dental appointment to minimise the
risk of developing hypoglycemia in addition to a psychogenic response
- Avoid treating ASA III and greater because they will be more likely to development a life
threatening situation
- Proper positioning
- Ask the patient about the fear. Most patients do not want to admit unless asked directly.
- If so the consider psycho sedation and stress reducing protocols.
- All these factors can nearly eliminate the occurrence of syncope
Proper Positioning:
- Probably the most important contributing factor in most cases of vaso-vagal syncope is the
patient's position in the dental chair.
- The risk is greatly increased if the patient is seated upright during treatment
- Today most patients will be placed supine or semi supine, which is a practice that has prevented
many instances of syncope in the dental chair.
- Even if you prefer to stand THE procedure that creates vasopressor syncope is injection of local
anaesthetics
If the dentist can administer LA to a patient who is in a supine position, syncope will rarely occur.

Adrenal Insufficiency
- The adrenal gland is an endocrine gland that produces more than 30 steroid hormones
- Cortisol (a glucocorticoid) is the most important
- It helps the body adapt to stress and it is therefore extremely vital in survival
- Hyper secretion of cortisol leads to increased fat deposition in the face and back as well as
elevated blood pressure clinically it is called Cushings syndrome (can be corrected by surgical
removal of part or whole of the adrenal gland)
- Cortisol deficiency: may lead quickly to unconsciousness and death.
Clinically it is called Addisons Disease
- Administration of exogenous cortisol can correct most effects associated with Addisons Disease
- Clinical manifestations of adreno-cortical insufficiency usually do not develop until at least 70-
80% of the adrenal cortex is destroyed
- The administration of exogenous steroids to a patient with a functional cortex may produce a
second form of adrenocortical hypo-function
- Glucocorticosteroid drugs are widely prescribed to release a variety of disorders such as allergic
diseases, eye diseases, gastrointestinal diseases, hematopoietic disorders (e.g. anaemia),
infections, inflammations, arthritis ( injected locally), metabolic diseases, pulmonary diseases, skin
diseases.
- When used in this way the exogenous administration produces disuse atrophy of the adrenal
cortex, diminishing the ability of the adrenal cortex to increase corticosteroid levels in response to
stressful situations
- This is very common.
- Result is peripheral vascular collapse, cardiac arrest and death

- The dentist is often the stress factor

- Therefore all dental personnel should be able to recognize an acute adrenal crisis and be able to
prevent it from happening
- Unusual stressful situations will require the patient to modify their steroid dose.
- The unpredictability of the adrenal gland response may continue for years after the therapeutic
use is completed.

- Medical use of synthetic corticosteroids include:

_Addisons disease
_Hypopituitarism
_Asthma
_Suppression of inflammatory & allergic disorders
_Preventing acute transplant rejection
_Immune disorders e.g. rheumatoid arthritis

- Prevention
- Acute adrenal insufficiency is best managed through prevention
that is careful medical history taking in regards to what medication the patient is taking, if the
patient has arthritis, rheumatism etc, administration route (topical application do not affect the
adrenal gland)
- Dental Therapy considerations:
- A complete medical and dental evaluation should be completed with a provisional treatment plan
and the patients physician should be contacted before any treatment is started
- These patients may require extra administration of glucocorticosteroids before, during and
possibly after the stressful situation to increase the blood level of steroids
- The patient may even require hospitalization and receive large doses
- Extreme fatigue, weakness
- Pale and clammy skin
- Anorexia
Signs and symptoms of individuals with acute adrenal insufficiency:
- Gastrointestinal symptoms
- Mental confusion
- Muscle weakness
- Pain in the abdomen, lower back and legs
- Nausea and vomiting
- Low blood pressure
- Loss of consciousness and coma

- In the dental setting the acute situation will be noted by severe mental confusion
- The patient will experience extreme pain in the abdomen, lower back and legs and the
cardiovascular system deteriorates turns into loss of consciousness and coma
- In acute situations resulting in death hypoglycemia is most common, then followed by adrenal
insufficiency
- Cease all dental treatment
- Supine & legs raised (position, check airway, breathing, circulation)
Management:
- Call for medical assistance immediately
- Oxygen (definite care)
- Administration of hydrocortisone IV (100 mg IV or IM)
- Transfer to hospital
- Take accurate past and present drug history
- Prophylactic hydrocortisone by GP/ DO

Prevention is most Important!!!

- Stress reductiondesensitisation techniques

Differential Diagnosis - Unconsciousness

- Assess Consciousness Management of the unconscious:
- Stimulate patient
- No response: unconscious
- Terminate dental treatment
- Check position (supine with slight elevated feet)
- Maintain airway (head tilt - chin lift, or sideways in the recovery position later)
- Assess breathing (look, listen, feel)
- Assess circulation (palpate carotid pulse 10 sec)
- Provide chest compressions if necessary
- Definite care: monitor vital signs
- Summon medical assistance
- O2
- IV access ( in hospital/ ambulance)

Differential Diagnosis - Unconsciousness

- Causes of Unconsciousness:
- Child:
- Hypoglycemia
- Epilepsy
- Congenital Heart lesions
- Teen to mid 30s:
- Psychogenic reactions
- Hypoglycemia
- Epilepsy
- More than 40 years:
- Cardiovascular disorders (myocardial infarction, cerebrovascular accident etc)

Differential Diagnosis - Unconsciousness

- Presyncopal Signs and symptoms
- No clinical symptoms: postural hypotension is likely
- Pallor, cold, clammy skin, nausea, vomiting: fainting most commonly may also be
hypoglycemia, adrenal insufficiency and myocardial infarction
- Tingling and numbness of extremities: hyperventilation is likely
- Headache: cerebrovascular accident is likely
- Chest pain: angina pectoris is likely
- Breath odor: ?? Alcohol question the patient about anxiety
- Sweet, fruity odor of acetone: hyperglycemic or ketoacidotic patient is likely
- Tonic-clonic movements: seen in unconscious patients in the upright position and is due to
decreased cerebral perfusion will not be seen with correct treatment
- To differentiate from real epileptic seizures: here it is typical with sphincter muscle relaxation and
tongue biting

Differential Diagnosis - Unconsciousness

- You may also look at the duration of the syncope:
- Short:
- Postural hypotension
- Vasopressor syncope
- Cardiac Dysrhythmias
- Prolonged
- Hypoglycemia
- Hyperglycemia
- Adrenal Insufficiency
- Cardiac Dysrhythmias

Airway obstruction
- Tongue
- Cotton rolls/ gauzes
- Gastric contents
Causes:
Other causes:
- Partial dentures
- Fractured teeth
- Impression materials
- Blood clots
- Nasal secretions
- Etc.
Airway obstruction
- To avoid syncope the recommended position of the patient is supine this has increased the
likelihood of aspiration or swallowing of foreign objects
- The objects may either enter the GI tract or trachea.
- More than 90% of swallowed foreign matters will successfully pass through the oesophagus into
the stomach and pass through the GI-tract without problems.
- Problems that may arise: GI blockage, perforation
- Aspiration of objects can cause infection, lung abscess, pneumonia etc., and will have to be
removed.
- If you suspect a foreign matter ALWAYs a lung x-ray is necessary
- Prevention: Use of rubber dam and oral packing (sedation)
Patent airway
Obstructed airway
Airway obstruction
- Partial obstruction signs: wheezing, stridor (noisy inspiration), difficulty in breathing, coughing
spasms, cyanosis
- Complete obstruction signs: Complete silence-- patient unable to speak, breathe, cry or cough
Paradoxical breathing-- chest and accessory respiratory muscles working hard to draw air in

How to Relieve Airway obstruction

- The lateral position the recovery position
- Clearing the airway
5 standard manoeuvres:
- Head tilt
- Chin lift
- Jaw thrust
- Instruct patient to bend over chair arm with head down
- Encourage to cough
- Back blows
- Chest thrusts
- Suction
- Magill forceps
- Laryngoscope
- Cricothyrotomy (an incision is made inferior to the thyroid cartilage and superior to cricoid
cartilage the Cricothyroid membrane)
- Back blows
--Give 5 back blows between the shoulder blades using the heel of the hand and check for
breathing between blows
- Chest thrusts (Heimlich manoeuvre)
--If still no sign of breathing, give 5 chest thrusts (sharper and harder than cardiac compressions)
and check for breathing after each thrust

Hyperventilation
- Definition:
- Ventilation in excess of that required to maintain normal arterial oxygen tension and arterial
carbon dioxide tension
- It is produced by an increase in the frequency or depth of respiration or both
- Hyperventilation which is common in the dental office almost always is a result of extreme
anxiety
- Organic causes such as pain may however also cause hyperventilation
- The patients most often remains conscious during the episode, but the patient may feel faint, light
headed, but do not loose consciousness
- CO2 is blown off resulting in respiratory alkalosis
- Symptoms:
_ tingling fingers and toes
_ tightness or pain in the chest
_ _pulse, _ RR
_ blurring of vision
_ light-headedness, dizziness, but does not lose consciousness
Management:
- Terminate dental treatment
- Seat the pt. upright and remove all materials from the mouth
- Reassure pt, loosen tight clothing
- Encourage slow breathing/ breathe through cupped hands/nose breathing/ abdominal breathing
- No need for supplemental oxygen

Asthma
Asthma: a chronic inflammatory disorder that is characterized by reversible obstruction of the
airways
Affects an estimated 5% of adults and approx. 10% of children
More than 100 million persons worldwide, suffer from asthma
A typical asthmatic patient is usually free of symptoms between acute episodes but exhibits
varying degrees of respiratory distress during the acute episode
Asthma represents the third leading cause of emergency department visits (more than 2
million/year)
It is estimated that 5000-6000 deaths are caused by asthma per. year in the U.S.

- Aetiology uncleara complex disorder involving immunological, infectious, biochemical, genetic

and psychological factors (Welbury, 1997)
- Status asthmaticus is a potentially fatal emergency in spite of drug therapy.
- It is characterized by an acute and persistent exacerbation that remains unresponsive to
bronchodilators. The typical presentation involves persistent wheezing with sternal retractions

Type 1: Extrinsic Asthma: also known as allergic asthma affects 50% of patients with asthma, and
often in children and young adults (often shows an inherited allergic predisposition) ex. dust,
feathers, furniture stuffing, fungal spores etc.
Food and drugs may also precipitate allergic asthma ex cows milk, tomatoes, egg, fish, chocolate,
shellfish, penicillin, vaccines, aspirin etc
Bronchospasm usually develops within minutes after the exposure to the allergen (antigen). This
response is called is called a type I hypersensitivity reaction in which immunoglobulin E (IgE)
antibodies are produced in response

Type 2: Intrinsic Asthma

Affects the other 50%
Usually affects adults older than 35
Nonallergic factors- respiratory infection, physical exertion and air pollution are causes.
A viral infection is usually the cause
Psychological and physiologic stress can also contribute to asthmatic episodes
- a dental appointment is a good example. Acute signs and symptoms usually resolve dramatically
by simply removing the child from the treatment room into a less threatening environment

Prevention
The long term goal is to maintain the patients pulmonary status as close to normal as possible.
New long lasting medicaments makes this possible
- Prevention of acute episodes through careful medical history taking and a good dialogue with the
patients MD
- Currently: emphasis on prophylactic medications to prevent episodes rather than treating acute
attacks
- Preventive Agents: Disodium Cromogricate (Intal) and oral corticosteroids such as prednisolone
and inhaled corticosterioids such as beclometasone dipropionate (Beclovent) and Salmeterol
xinafoate (Seratide)

Clinical Manifestations:
- Feeling of chest congestion
- Wheezing, prolonged expiratory phase
- Coughing
- Shortness of breath
- Restlessness
- Flushing
- Sweating
- Cyanosis of mucous membranes (lips & nails)
- Tachycardia

Management:
- Cease dental treatment
- Remove all materials from the mouth
- Sit upright position with arms thrown forward (position)
- Calm the patient
- Get pt to use their inhaler- 4~6 puffs (evaluate the airway, breathing, circulation)
- Give oxygen (definite care)
- DO to give salbutamol (bronchodilator)/ adrenaline if condition persists.
- Bronchodilators are the drugs used to manage acute Bronchospasm. The most potent and
effective dilators of bronchial smooth muscle are the beta-2 adrenergic agonists such as adrenalin
and albuterol (ventolin). In addition these drugs also inhibits histamine release from the mast cells
- Clinically the best administration way is inhalation via aerosolized sprays
- Avoid dental Rx if pt has upper respiratory tract infection
- Make sure that you evaluate the reasons behind the attack before next dental visit and discharge

Dental Implications
- The major concern is the exacerbation of an acute attack in the dental surgery
- Avoid any known precipitating factors prior to dental treatment
- Ensure the child has the appropriate medication (inhaler) for emergency use if an asthmatic
attack occurs during dental treatment
- Some bronchodilators and corticosteroid medications may cause extrinsic staining of the teeth
due to changes in the oral flora
- May also predispose to oral candidosis
- Children on high dose corticosteroids (more than 1600 ug/day) may be immuno-compromised
and may require additional supplemental corticosteroids on the day of dental treatment due to
adrenal suppression always consult
- Children are often mouth breathers causes gingivitis and swelling of the anterior gingival tissues
- B-2 agonists can cause a dry mouth
- Medication may lower the salivary pH favouring caries development
- Periodontal Inflammation is greater in asthmatics
- Occasionally tooth erosion from gastro-oesophageal reflux

Heart Associated Emergencies:

Congenital Cardiac Disease

Children with congenital cardiac disease represent one of the largest groups of medically
compromised children
- Most defects are sporadic
- 10-15% are part of other syndromes or chromosomal abnormalities.
- Ex. Trisomy 21/Downs syndrome and cardiac abnormality is well-known.
More than 70% being affected.
Congenital Cardiac Disease
Occurs in 8-10 cases per 1000 births
Has equal sex distribution
In most cases no etiological agent or genetic factors are found
Risk factors associated with congenital cardiac disease include
- maternal rubella,
- diabetes,
- alcoholism,
- irradiation and
- drugs (thalidomide, phenytoin and warfarin)

Defects are divided into

- Cyanotic
- Acyanotic

Acyanotic can be divided into

- Obstructive
- Stenotic (constriction)
- Left-right shunts
- Children with cyanotic heart disease are at significant risk during G.A.
- Consultation with cardiologist is essential

Acyanotic Defects with Shunts

- This group of conditions is characterized by a connection between systemic and pulmonary
circulations.
- Such anomalies present as
- murmurs and
- if significant, cardiac enlargement,
- congestive heart failure and
- failure to thrive.
- Shunts are from the left to the right.
- Ex. Atrial Septal Defect, Ventricular Septal Defect

Acyanotic Defects with Obstruction

- Ex. Coarctation of aorta a constriction of aorta distal to the subclavian artery
- Ex. Aortic Stenosis Narrowing of the aortic valve
- Ex. Pulmonary Stenosis Narrowing of the pulmonary valve

Cyanotic Defects
- Most of these defects will be corrected early in life
- Residual defects may persist however
- The basic defect is right-to-left shunting of desaturated blood
- Cyanotic defects are clinically evident if 50g/l of desaturated hemoglobin is present in arterial
blood
- Infants with mild cyanosis may be pink at rest but show cyanosis during crying or on exertion
- Ex. Tetralogy of Fallot (ventricular septal defect, pulmonary stenosis, right-to-left shunt, right
ventricular hypertrophy)
- Ex. Eisenmergers Syndrome cyanosis from any right-to-left shunt caused by increased
pulmonary resistance through a ventricular septal defect

Dental Implications
Clinical Appearance
- Clubbing of fingers
- Cyanosis of mucosa
- Shortness of breath
Cameron and Vidmer
Dental Management
- Risk of subsequent infective endocarditis all severe congenital anomalies require antibiotic
cover contact the cardiologist before any treatment is performed
- Amoxicillin 50 mg/kg up to adult dose 2 g
- Allergy to penicillin: clindamycin 20 mg/kg up to adult dose 600 mg
- Preoperative oral antiseptic mouthwash such as 0.2% chlorhexidine gluconate
- Resistance of bacteria some children have been prescribed long-term antibiotics but this merely
builds up resistant organisms.
Prescribing prophylactic antibiotics to these patients choose antibiotics from a different group
- Other medical conditions congenital cardiac disease is associated with numerous other
syndromes and medical conditions that may complicate dental treatment.
- Increased prevalence of enamel hypoplasia and dental caries in the primary dentition
- Aggressive treatment of pulpally involved teeth. Pulpotomy is contraindicated in these patients
because of the possibility of subsequent bacteraemias
- Coordination of treatment. It is often better to treat a child with many carious teeth under G.A. and
complete all the work in one session.
This removes the need to change antibiotics or wait 1 month between visits.
If a child is undergoing anesthesia for other medical procedures try to coordinate the dental work to
be performed at the same time.
- Vasoconstrictors there is no contraindication to the use of vasoconstrictors in L.A., provided
aspiration during administration is performed to prevent intravenous injection

Hypertension
- Definition:
Elevation of BP either systolic and/or diastolic
- Normal BP:
Systolic: 90-140 mmHg
Diastolic: 60-90 mmHg
- Recorded as: (Systolic) / (Diastolic) mmHg
E.g.. 120/80 mmHg
Classification of Hypertension
Blood
Pressure
Grade 1 Grade 2 Grade 3
SBP
140-159 160-179 >/= 180
WHO/ ISH (2004)
(mm Hg)
DBP
(mm Hg)
90-99 100-109 >/=110
Hypertension Management
- Encourage patients to take regular medications before dental sessions
- Routinely check BP at the beginning of dental sessions to patients>/= 45 yrs
- Cease dental sessions if BP>/= 140-160/100 mmHg
- Refer to GP or emergency if required

Ischaemic Heart Disease

- Angina Pectoris is important to dentistry because it is usually a sign of a significant degree of
coronary artery disease
- The onset of anginal pain indicates that the myocardium is not receiving adequate oxygen supply
and

Angina Pectoris
- Myocardial ischemia is due to constricted coronary arteries
- Precipitating Factors: physical activity, hot humid environment, cold weather, large meals,
emotional stress
- Chest pain/ suffocation/ tightness
- Lasts a few minutes, radiating to shoulders, arms, neck and mandible
- Relieved with O2, rest and Nitroglycerin spray/tablet
Ischemic Heart Disease
Angina Pectoris
Identify the patients at risk by careful medical history taking and make sure to reduce emotional
and physical stress as the primary preventive measure
Patients with unstable angina or daily episodes are considered ASA 3-4, so avoid treatment and
redirect the patient to GP
Make short appointments, supplemental oxygen, complete pain control is really important and
perhaps use psychosedation.
Test vital signs before treatment is started

Ischaemic Heart Disease

- Atherosclerotic obstruction of coronary arteries leads to necrosis of cardiac muscle and cellular
death
- Prolonged sub-sternal crushing chest pain, not relieved by nitro-glycerine
Acute myocardial infarction
- Complications associated with MI include shock, heart failure and cardiac arrest
- Laboured breathing, sweating, nausea & vomiting maybe observed
Acute Myocardial Infarction/ Cardiac Arrest
- Discontinue dental treatment
- Call for ambulance
Management:
- Position patient for comfort
- Oxygen + vital signs
- If unconscious, CPR!

Epilepsy
- Is a common neurology disorder
- Predominant etiology: birth injury and congenital abnormalities
Convulsions can be classified as:
- Generalized, either tonic-clonic (grand mal) or absence (petit mal)
- Focal (partial) either simple or complex

Grand Mal
- Causes: epilepsy, fever, brain damage, brain tumours,alcoholism, hypoglycaemia, hypoxia
secondary to syncope, local anaesthetic overdose, or idiopathic (25%)
- Usually begins in the preschool child
- Manifests with a warning - aura followed by loss of consciousness, convulsions and a
prolonged recovery
- The aura may consist of mood change, irritability, brief hallucinations, sensation of strong smell
- Initially the face becomes pale and pupils dilate, respiratory muscle spasm, cyanosis.
- Incontinence, biting tongue or lips
- In the clonic phase there are repetitive jerking movements of the whole body
- Vomiting
- Followed by a semi-coma 10-15 minutes then recovery

Petit Mal
- Minimal or no movements
- Eye blinking like a blank stare
- Brief sudden loss of awareness or conscious activity last only seconds
- Recurs often
- Decreased learning (.may be daydreaming)

Treatment
- Is restricted to the use of anticonvulsant medication and slowly increasing the dose to achieve
therapeutic blood levels and minimizing side effects
- About 70% of children do very well with minimal problems even in long term treatment
- Common side effects:
- Drowsiness
- Ataxia (reduced coordination of motor skills)
- Excessive Salivation
- Hyperactivity
- Phenytoin Sodium (Dilantin) is still the most effective drug for grand mal seizures but the side
effects of hirsutism (increased hair growth) and gingival hypertrophy has meant reduced use.
- Most common medication now is carbamazepine (Tregretol)

Dental Implications
- Gingival Enlargement
- Precipitation of a seizure in the clinic
Dental Management
- Gingival hypertrophy
- Depends on oral hygiene and dental development
- In the permanent dentition: a full mouth gingivectomy may be required
but overgrowth will continue if oral hygiene is not optimal
- Maintenance of adequate oral hygiene may be difficult in children with additional intellectual
disability and are dependent on the parents
- Use electric toothbrush, chlorhexidine gel

Dental Management
- Avoidance of a seizure before treatment:
- You need to know the type of epilepsy
- If there are any precipitating factors
- Medications
- Dosage
- Compliance
- Degree of seizure control
- Check potential new medication and the interaction with the anticonvulsants
- Consult with the childs neurologist
- Avoidance of a seizure during treatment:
- Reduce stress by behavioral management,
- Conscious sedation
- Reduce direct overhead light
- Avoid seizure promoting medications ex local anesthetics with adrenaline
- Emergency drugs such as oxygen, diazepam should be available
- Pre arranged transfer to pediatric hospital if required.
- General Anesthesia is preferred in children with poor seizure control (no abnormal neural activity
is possible during the procedure)

Management during a seizure in the clinic:

- Summon help
- Stop treatment
- Lay the patient flat in the chair
- Do not try to move the patient while they are having the fit
- Protect the patient from injury
- Clear the area of equipment
- Do not attempt to restrain or hold the person down during the seizure
- Maintain the airway by gently extending the neck
- Remove excess saliva with suction
- If possible oxygen after seizure (10l/min)
- If the attack does not resolve within 5 minutes call for ambulance
- Monitor vital signs throughout and following cessation of seizure
- Remove any vomit/ mouth secretion using suction
- Observe the patient over the next 30min before allowing them to go home escorted
- With multiple seizures or >=5 min, call ambulance
- Seizures are characterised by alterations in consciousness, motor function and sensory
perception

Diabetes Mellitus
- Approximately 2% of populations are affected
- Only 50% is recognized
- More common in Indian and Pakistani populations
- Origin is multifactorial
- Genetic disposition
- Primary destruction of the pancreatic islets of Langerhans
- Endocrine anomalities ex hyperthyroidism
- Corticosteroid therapy
- Infectious viruses
Fasting Plasma Glucose
Normal range: 4.0-5.5 mmol/L
Diabetes Mellitus
Type 1
- Insulin dependent
- Most common form in children
- 2/1000 5 -18 years have diabetes type 1
- The development of type 1 diabetes is a result of viral or toxic insults to the pancreatic islets in a
child genetically predisposed to developing the disorder.
- The initiating factor can also be an autoimmune mechanism that destroys the insulin-producing B-
cells
Diabetes Mellitus
- Type 2
_ Insulin resistance with relative insulin deficiency
_ Secretory defect with/ without insulin resistance
- Gestational diabetes
_ 28 weeks~
- Other specific types drug induced, infections, endocrinopathies, exocrine pancreas diseases
Diabetes Mellitus
The Goal of Treatment:
- To control blood glucose to a normal level will reduce the potential complication of
hyperglycemia and ketoacidosis
- This is done by administration of insulin
- Pancreatic transplantation is now a potential cure for juvenile diabetes
- Is researched heavily currently
Diabetes Mellitus
Presenting Symptoms:
- Relatives of patients with diabetes are 2.5 times more likely to develop the disease than the rest
of the population
- Polydipsia (increased thirst)
- Polyuria (Increased volume of urine)
- Weight loss with polyphagia (disproportionate appetite or eating)
- Enuresis (involuntary urination)
- Recurrent infections and candidosis
- Glucosuria may also be present
- Ketoacidosis and coma may be seen in poorly controlled or undiagnosed cases
- A diagnosis of diabetes is made when fasting blood glucose levels are above 18mmol/L as well
as glucosuria
Diabetes Mellitus
Dental Implications
- Periodontal Disease is the most consistent oral finding in children with poorly controlled diabetes
- Increased alveolar bone resorption
- Inflammatory gingival changes.
- May mimic the clinical manifestation of chronic generalized (juvenile) periodontitis
- Xerostomia
- Recurrent intraoral abscesses may be present in severe cases
- Enamel hypocalcification and hypoplasia
- These factors may lead to increased risk of early childhood caries
- Altered oral flora changes can occur with an increase in Candida albicans
- Recurrent infections and delayed healing
Diabetes Mellitus
Dental Management
- Children with well-controlled diabetes can receive dental treatment in the usual way.
- For routine dental appointments the child should eat a normal meal prior to the dental procedure
- A glucose source should always be available to treat the sudden onset of hypoglycaemia
- Post-surgical healing can be delayed particularly in poorly controlled cases
- Prophylactic antibiotic therapy is recommended prior to surgical procedures
Diabetes Mellitus
Prognosis
- Overall effect on the body's microcirculation
- Visual Impairment
- Renal failure
- Gangrene
- Stroke or myocardial infarction
- Diabetics have decreased life expectancy and less quality of life in the long run.
Diabetes Mellitus
The main hazard during treatment is hypoglycemia (the dental treatment may disrupt the normal
pattern of food intake)
Can be avoided by planning:
- Give a tiny oral glucose just before the appointment
- Ensure the patient take their normal meals
- Ask to inform if they feel an episode starting
- If conscious: give glucose drink
- If drowsy: sublingual carbohydrate gel
- If unconscious: Call for ambulance - and DO if possible
- (Glucagon 1 mg intramuscularly)
Diabetes Mellitus
The main hazard during treatment is hypoglycemia (the dental treatment may disrupt the normal
pattern of food intake)
Can be avoided by planning:
- Give a tiny oral glucose just before the appointment
- Ensure the patient take their normal meals
- Ask to inform if they feel an episode starting
- If conscious: give glucose drink
- If drowsy: sublingual carbohydrate gel
- If unconscious: Call for ambulance - and DO if possible
- (Glucagon 1 mg intramuscularly)

Allergy/anaphylaxis
- Allergy is a hypersensitive state acquired through exposure to a particular allergen, followed by a
re-exposure which produces a heightened capacity to react.
- Allergic reactions cover a broad range of clinical manifestations, from mild, delayed reactions
developing as long as 48 hours after exposure to the antigen, to immediate and life threatening
reactions developing within seconds of exposure
- All allergic reactions are important, but are especially important in dentistry:
- Type 1 or anaphylactic reaction may present the dental office staff with the most acutely life
threatening situation
- Type IV or delayed seen as contact dermatitis (important for us as dental staff)
- Drugs used in dental practice that may potentially cause an allergic reaction: penicillin's,
tetracycline's, acetylsalicylic acid, aspirin, NSAIDS, codeine, LA (esters), monomers in composite,
acrylic
- Prevention:
- Careful medical history taking
- If in doubt consult with GP
- IgE mediated hypersensitivity (type 1)
- Occurs within minutes to within 2 hours after exposure to the allergen
- Signs and symptoms:
_ itching, flushing, erythema - urticaria (causes increased vascular permeability, vasodilation)
_ laryngospasm, laryngeal oedema, Bronchospasm (caused by increased vascular permeability,
vasodilation, stimulation of nerve-endings)
_ wheezing (caused by increased exocrine secretions, smooth muscle contractions in the
bronchioles)
_ sweating
_ tachycardia, hypotension (caused by increased vascular permeability, vasodilation, decreased
cardiac output)
_ loss of consciousness
_ cardiac arrest

Cerebrovascular Accident
- Haemorrhagic: bleeding in the brain due to arterial aneurysms or hypertension
- Occlusive: blockage of vessels due to atherosclerosis and thrombosis or cerebral embolism
- Transient Ischaemic Attack (TIA): brief episodes of cerebral ischemia with no permanent damage
- Treatment: supportive, supine, O2 & help

Bleeding Disorders
- Congenital (e.g. Haemophilia A/B, Von-Willebrands disease)
- Acquired (e.g. drug induced, alcohol abuse or due to systemic diseases-liver, kidney, bone
marrow)
- INR &/or coagulation tests
_ Normal INR (not on warfarin): <1.0
_ Therapeutic range (on warfarin): 1.0-2.5
_Acceptable upper limit for dental Rx (on warfarin): <3.5
Management:
(in specialist treatment)
- Postpone Rx if results abnormal, GP to adjust warfarin dose
- If bleeding will not stop after an extraction:
Pressure /vasoconstrictor/oxidised cellulose/tranexamic acid (4.8%) mouthwash/suture
- INR should be taken as close to Rx time as possible (within hours before appt)
- Never cease pts medication including warfarin
Important points:
- Refer to GP, inform your expected INR range
- Review patient and inform GP
Primary haemostasis is initiated after injury to a blood vessel with the formation of a primary
platelet plug.
- This is mediated by interactions between the platelets, plasmacoagulation factors and the vessel
wall.
Secondary haemostasis, with fibrin as the end product, is also triggered by the initial injury and
reaches its greatest intensity after the primary platelet plug is formed.
- It provides the framework for the formation of the stable clot.
Prolonged bleeding can occur when haemostasis is disturbed.
The clinical manifestations of a disorder vary depending on the phase affected.
- Defects in primary haemostasis generally result in bleeding from the skin or mucosal surfaces,
with the development of petechiae and purpura
- Ex. Thrombocytopenia, Von Willebrand Disease and defects in platelet function
- Defects in secondary haemostasis lead to bleeding that tends to be more deep seated in muscles
and joints in severe cases
- Ex Hemophilia
In both disorders uncontrolled prolonged oral bleeding can occur from even small insults such as
cheek biding and tongue laceration
This is why we ask have you or anyone in your family had extensive bleeding following tooth
extraction?

Classification
- Platelet Disorders
- Thrombocytopenia
- Thrombocytosis
- Platelet-function disorders
- Von Willebrands Disease
- Vitamin C deficiency
- Connective Tissue Diseases
Bleeding Disorders
Platelet Disorders
- Thrombocytopenia is defined as a platelet count below 150 x 10 in the 9th power / L
Thrombocytosis
- A rare disorder that may be caused by neoplasms, infection, pregnancy or adrenaline release.
- An increased number of platelets may be associated with bleeding caused by abnormal platelet
function (more than
1000 x 10 in the 9th power/L)
Bleeding Disorders
Platelet function Disorders
- May be congenital or acquired
- Most common cause of acquired platelet function is the use of non-steroidal anti-inflammatory
drugs
- Administration of cyclo-oxygenase inhibitors will result in blockage of the production of
Thromboxane A for the life of the platelet (7-9 days)
- This result in a decrease in platelet aggregation.
Bleeding Disorders
Connective Tissue Diseases
- Diseases of connective tissue such as scurvy (vitamin C deficiency) result in bruising and purpura
caused by vascular abnormalities and capillary fragility
Von Willebrands Disease
- Is a disorder of coagulation, but platelet function is also decreased
Bleeding Disorders
Dental Implications
- A decrease in the number of platelets or platelet function will result in failure of initial clot
formation
- Children with thrombocytopenia will bleed immediately after trauma or surgery, unlike
haemophiliacs who usually start to bleed 4 hours after the incident
- The most common oral manifestations are petechiae and purpura.
- There may also be spontaneous gingival bleeding andprolonged episodes of bleeding after minor
trauma or toothbrushing
Bleeding Disorders
Dental Management
- Preferable with platelet levels > 50 x 10 to the 9th power/L before extractions
- Endodontic procedures may be preferable to extractions in order to avoid the need for platelet
transfusion
- Good technique and good local measures
- Avoid block injections as these may be complicated by formation of hematoma and airway
obstruction
- Antifibrinolytics: tranexamic acid or aminocaproic acid
- Avoid the use of straws, pacifiers or bottles during antifibrinolytic treatment
Bleeding Disorders
Coagulopathies
- Result from a decrease in the amount of particular factors in the coagulation cascade
- Most common: Hemophilia A and Von Willebrands disease.
Both have a decrease in factor VIII levels.
- Factor VIII has 2 functions
- The Von Willebrand factor responsible for platelet aggregation
- The coagulation part which is responsible with factor IX for activation of
Factor X in the intrinsic pathway
Bleeding Disorders
Haemophilia A
- X-linked recessive disorder with deficiency of factor VIII
- 1:10 000 live male births, 30% spontaneous mutation
- May present in varying degree
Bleeding Disorders
Von Willebrand Disease
- Autosomal dominant
- Abnormality of factor VIII
- Platelet time also decreased
- Therefore both bleeding time and activated partial thromboplastin time APTT are elevated
- Type III Von Willebrands disease is the most severe form inherited from 2 asymptomatic parents
as an autosomal recessive disorder
Bleeding Disorders
Christmas disease (Haemophilia B)
- Factor IX deficiency
- Elevated APTT
Other disorders of coagulation
- Vitamin K deficiency
- Liver disease
- Overwhelming infection in children
Bleeding Disorders
Tests for coagulopathy
- Full blood count for platelets: 150-400 x 10 to the 9th power/L
- Skin bleeding time: 9 minutes
- Prothrombin time test of the extrinsic pathway: 11-17 seconds
- APTT test of intrinsic pathway: 24-38 sec.
- Different specific tests on platelet function and factor VIII
Bleeding Disorders
Dental Implications
- Consultation with physician/hematologist. ALWAYS consultand refer. Do not treat severe
bleeding disorders. Leave these patients to the specialists.
- Local measures to control haemorrhage
- Good local technique
- No block anaesthesia without factor cover
- In the absence of factor replacement, intraligamentary injections may be used carefully
- Nitrous oxide sedation can be effective for smaller restorative procedures to avoid L.A.
Bleeding Disorders
Dental Procedures
- Extractions must never be performed without first consulting the hematologist
- Endodontic therapy can be safely carried out without factorcover
- Periodontal therapy with scaling and subgingival curettage requires factor replacement
- Multiple extractions require hospital admission
- Use rubberdam to protect soft tissues
Management of Patients On Anticoagulants
- Dental Management is extremely difficult and should be undertaken in a hospital
- Anticoagulants are prescribed for any reasons. Ex. children with valvular heart disease and
prosthetic valves and patients with a past history of different types of thromboses etc.
- For dental extractions it is necessary to decrease the clotting times to allow adequate coagulation
but not to such an extent to cause emboli or clotting around the valves. Never give advice in
regards to the medication please refer to hematologist and let the specialist decide possible
changes.
- Management is complicated by the congenital heart defect and the need for prophylaxis against
infective endocarditis
Management of Patients On Anticoagulants
Therapeutic drugs used:
- Warfarin (coumarin)
- Vitamin K antagonist (factors II,VII,IX and X are depleted)
- 3-4 days required for full anticoagulation onset
- Assessed by prothrombin level (factor VII levels)
- International normalization ratio, INR: 2.0-2.5
- Heparin
- Shorter acting, immediate onset, given intravenously
- Inhibits thrombin and factors IX and X
Management of patients On Anticoagulants
Dental Management
- Prevention of dental disease
- Consultation with hematologist
- Local measures by application of topical thrombin, packing with oxidized cellulose and suturing of
the wounds
- Admission to hospital for all invasive procedures
- (Cessation of warfarin at least 3 days before the surgical procedure and commencement of
heparin infusion to decrease the INR to just above normal, as recommended by haematologist.)
- (Recommencement of warfarin 48 hours after surgery and reestablishment of correct
prothrombin)
Management of Oral Haemorrhage
Bleeding from the mouth can occur at any time
- May be a slow ooze for several days or,
- A sudden oral bleed
- May occur without warning
- May occur after procedures such as biopsy, restorative work and tooth extraction
Initial Management
- Identify the exact site of bleeding
- Controlling the haemorrhage
- Preventing reoccurrence
- If the bleeding isnt associated with any dental activity the clinician needs to take accurate
history of the bleeding, its duration, the volume and any causative factors (could be because of an
erupting tooth, trauma)
Management of Oral Haemorrhage
In cases of preventing oral haemorrhage following dental procedures
- A sensible limitation of surgical trauma
- Compress the alveolus following extraction
- Be aware of previous bleeding episodes and packing sockets with resorbable gels
- Adequate suture extraction sites
- Apply pressure to the extraction site postoperatively via gauze packs or removable appliances
- Give definite postoperative instructions regarding adequate rest, limitation of nicotine, avoid hot
foods

Management of Oral Hemorrhage

In cases of preventing oral hemorrhage following dental procedures
- For children with known bleeding tendencies fabrication of a mouth guard to be placed
postoperatively may be helpful
- In case of unexplained abnormal bleeding a hematologist consultation should be done
- In cases of massive bleeding following tooth extraction maybe due to arteriovenous
malformations the best method of controlling the bleeding is to replace the tooth in the first
instance.