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

Accidental or willful bodily injury,
Central nervous system stimulation and
depression,
Respiratory and circulatory disturbances,
Allergic reactions.
Medical Emergency Plan

Prevention
Action plan
Diagnosis and Management
Emergency drugs and equipment
Prevention
Medical History Questionnaire
Verbal History
Medical History Update
Physical Examination
Assessment of Risk
Stress Reduction
Pain Control
Medical Emergency Prevention and Preparedness
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)
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
Medical Emergency Prevention and Preparedness
D
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Medical History Update


Should be a part of every long interval dental
visits
Noted in the record in every instance
Physical Examination


Visual Inspection
Baseline Vital Signs:
  Pulse, BP, Breathing, Temperature
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
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.
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.
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.
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
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
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
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
Post -operative Pain
Management
Availability of dentist via telephone round the
clock
Analgesics
Antibiotics
Antianxiety drugs
Muscle Relaxants
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
CPR




        QuickTime™ and a
      H.264 decompressor
are needed to see this picture.




       30:2
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
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
Chain of Survival




Early recognition of a “sick” patient, a team
                  effort...
Medical Emergency Prevention and Preparedness
“Remember to breathe.

It is after all, the secret of life.”
Medical Emergency Prevention and Preparedness
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.
Medical Emergency Prevention and Preparedness
Oropharyngeal Airway
Team Training

Monthly equipment Checks
Regular Updates
Mock Trials
Audit
Medical Emergency Prevention and Preparedness
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
 _________________.
Medical Emergency Prevention and Preparedness
Medical Emergency Prevention and Preparedness
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)
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
Medical Emergency Prevention and Preparedness
Medical Emergency Prevention and Preparedness

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Medical Emergency Prevention and Preparedness

  • 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 r u g M I e n d t s e c r a a p c t e i o n
  • 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.
  • 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