History and Physical Examination

A thorough knowledge of all existing medical conditions, physical or psychological, that may predispose the patient to development of a medical complication will help prevent the vast majority of emergency situations. This knowledge is gained through the medical history and physical examination as well as an assessment of the patient’s psychological outlook to dental treatment. The medical history is generally obtained via a written questionnaire, which is completed by the patient or parent. Many standardized forms are available, but they may require modification for pediatric dental practice. These forms should include questions pertaining to any present or past medical conditions, allergies or adverse drug reactions, hospitalizations and surgeries, medications, and so forth. Questions regarding dental concerns as well as past dental treatment are frequently included. The dentist reviews this form, notes positive findings, and conducts a brief interview with the patient to clarify any positive responses and expand on the questionnaire. It must be emphasized that clarifications and further explanations of positive findings should also be written by the dentist on the record to document that these questions were thoroughly investigated. For instance, if the parent or patient circles “asthma” on the past medical history, the dentist needs significantly more information than the mere fact that the patient currently has or has had asthma in the past. The dentist should further document the frequency and severity of the asthma attacks, what causes them, how they are managed, whether or not past episodes were ever so severe that treatment was emergently needed in the hospital or emergency room, when the last attack occurred, and finally whether the patient is breathing easily today. Based on the assessment of these documented clarifications, the dentist may feel comfortable providing the needed dental treatment at that appointment or may decide to postpone treatment until the patient is medically optimized by their physician.

The physical examination should include baseline vital signs (blood pressure, pulse rate and rhythm, respiratory rate and character), a thorough head and neck examination, and observation of general appearance (gait, mental status, skin tone and color, etc.). Further physical evaluation should be dictated by the dentist’s training and expertise. If a practitioner intends to use moderate sedation techniques that may depress the patient’s cardiovascular or respiratory function, it is recommended that the practitioner possess supplemental skills in physical examination such as lung auscultation to assess basic breathing abnormalities as well as airway assessment.

A thorough history and physical examination will help make the dentist aware of any preexisting conditions that may potentially lead to a medical emergency. In general, conditions involving the cardiac, pulmonary, and endocrine systems are of greatest concern regarding potential medical emergencies. Patients with a history of seizures also warrant special consideration. This knowledge should allow the development of a treatment protocol for the patient that will decrease the likelihood of a serious medical event. This may involve the use of minimal or moderate sedation for stress-induced conditions (e.g., cardiac arrhythmias, asthmatic attacks, or epileptic seizures), proper timing of appointments, infective endocarditis prophylaxis, assistance of an office-based dental or medical anesthesiologist during the procedure, or use of a hospital operating room, if necessary.

Medical Consultation

If any questions arise regarding the management of a medically compromised child, it is highly desirable to consult with the patient’s physician for further information to aid the dentist in forming a patient management plan and, in some cases, for guidance. After obtaining all of the pertinent medical information from the primary care physician and/or medical specialists, in most instances, the outdated concept of obtaining “medical clearance” from a medical consultant before initiation of a dental procedure has now been superseded by requesting the consultant’s statement that “the patient is in optimal condition for the planned procedure.”

Patient Monitoring

The level of monitoring that is necessary to treat a pediatric dental patient safely will vary, depending on the procedure to be provided, the patient’s underlying medical condition, and the patient management technique being used. Patient monitoring involves the observation of physiologic parameters over time to detect any change and to intervene, if necessary, before a potentially dangerous situation develops. The dentist should always monitor (observe) the general appearance of the patient, including the level of consciousness, level of comfort, muscle tone, color of the skin and mucosa, and respiratory pattern. For the majority of healthy patients being treated with local anesthesia alone or with minimal sedation as defined by the American Dental Association, this is all the monitoring that is necessary.

When moderate sedation is used, and especially in children in whom a much narrower margin of safety often exists because of smaller degrees of respiratory and cardiovascular reserve, additional monitoring should be routinely employed. This will include continual monitoring of blood pressure, usually via an automated blood pressure cuff, continuous monitoring of oxygenation and pulse rate via pulse oximetry, and continuous monitoring of ventilation, either with a pretracheal/precordial stethoscope (Figure 10-1; see also Figure 8-5) or a capnograph. These measures are particularly important for patients with whom continual verbal contact is difficult or undesirable. (See Chapter 8 for a detailed discussion of monitoring during sedation.) Presedation and discharge vital signs, including pulse rate, respiratory rate, and blood pressure should always be obtained unless prevented by the lack of patient cooperation.

Whenever deep sedation or general anesthesia is used, more sophisticated monitoring is essential. The vast majority of pediatric dentists are not trained in these advanced pain and anxiety control techniques, which should only be used by appropriately trained dentists and physicians in the dental office.

Personal Preparation

As previously stated, it cannot be expected that the practicing dentist will be able to diagnose and manage every possible medical emergency. However, it is possible to anticipate with some certainty which emergency situations are most likely to arise in the dental office, as well as those that have the greatest potential to cause patient morbidity or mortality, and be well prepared to deal with them. Examples include syncope, hyperventilation, seizures, hypoglycemia, acute asthmatic attack, allergic reactions, and airway obstruction. Certainly, any emergency situation that might logically occur as a direct result of medications or techniques being used must not only be anticipated and well understood; the dentist must also be prepared to quickly carry out an action plan to manage the situation. Examples include local anesthetic toxicity reactions and respiratory depression secondary to sedation. Personal preparation for the dentist should include, as a minimum, a working knowledge of the signs, symptoms, course, and therapy for common treatable conditions. Training in basic life support at the health care provider level (BLS-HCP, colloquially referred to as cardiopulmonary resuscitation [CPR]) should be considered the foundation of emergency medical management in the dental office regardless of whether this is required for dental licensure. Intramuscular (IM) injection techniques will be the most common method of emergency drug delivery, when needed. The deltoid region of the upper arm and the vastus lateralis region of the thigh are commonly employed sites. When needed because of lack of patient cooperation, injection can be performed through the patient’s clothes. If moderate sedation techniques are to be used, pediatric advanced life support (PALS) or advanced cardiac life support (ACLS) training may be desirable. However, it is appreciated that most dentists, including pediatric dentists, are generally not experienced and competent in emergently obtaining intravenous or intraosseous access, using intravenous medications, or performing endotracheal intubation. Therefore a course focusing on emergency airway management, such as the American Dental Association’s Recognition and Management of Complications During Minimal and Moderate Sedation course, is likely more beneficial.

Staff Preparation

Office personnel should be familiar with their role in the recognition and management of common medical emergencies. If moderate sedation is provided, it is desirable and often required that all office clinical staff members be certified in BLS-HCP. A team approach to medical emergencies will provide for organized management of emergency situations. Each staff member should have a preassigned role in case of an emergency so that emergency equipment, medications, and oxygen will be brought (and maintained) by assigned persons, and all tasks will be performed in an organized fashion. Fortunately, because medical emergencies occur relatively rarely in the dental office, it is desirable to regularly run mock medical emergency drills to keep the team protocol running smoothly and to reduce panic in an actual emergency.

Backup Medical Assistance

Another essential component of office preparation for medical emergencies involves securing backup medical assistance in advance. This involves having the current telephone number for activating EMS, which is usually 911. If the dentist is in a rural area that does not have access to EMS through 911, the dentist should have the telephone numbers of the nearest rescue squads and emergency room facilities conveniently displayed where they will be immediately available. The dentist should arrange in advance to have paramedics versus basic emergency medical technicians respond to dental office medical emergencies whenever available. When feasible, arrangements should be made with a physician whose office is nearby for immediate assistance should an emergency arise. Such a relationship must be prearranged, not assumed.

Office Preparation

Every dental office contains a great deal of equipment and supplies. There is a minimum of additional equipment that is essential for every office to be properly prepared for medical emergencies. These essentials can be divided into emergency equipment and emergency drugs.