IS YOUR OFFICE PREPARED FOR AN
EMERGENCY?
Ellen B. Grimes RDH, MA, MPA, Ed.D
1CE
CREDIT
Introduction
Medical emergencies are a recognized occurrence in the dental environment. The most frequently reported
emergency is syncope, accounting for 50% of cases, followed by mild allergic reactions (8%), angina pectoris
(8%), and orthostatic hypotension (8%). 1 Notably, these emergencies are most likely to arise following the
administration of local anesthetics, as well as during tooth extractions or endodontic procedures. 2 It is
anticipated that, due to the aging patient population and advancements in healthcare, including
pharmaceuticals, surgical interventions, and life-extending treatments, the incidence of medical emergencies in
dental settings will increase.
Importance of the Medical History
Obtaining a comprehensive and accurate medical history is crucial in mitigating the risk of medical emergencies
in the dental setting. Patients may disclose medical conditions that indicate an elevated risk for such
emergencies, making it essential for dental practitioners to remain vigilant. Furthermore, it is imperative to
update the medical history at every visit, as patient health can change over time.
Conditions of particular relevance include, but are not limited to, histories of heart disease, asthma, stroke (CVA),
frequent headaches, epilepsy, thyroid disorders, diabetes, corticosteroid use, allergies, and bleeding disorders.
When patients report these or similar conditions, the dental practitioner should engage in a detailed discussion
to gather additional information that could aid in preventing a medical emergency. Inquiries should focus on the
frequency, severity, and potential triggers of the conditions to assess the likelihood of an emergency occurring. In
many cases, it may be prudent to defer treatment until the patient has been evaluated by their primary healthcare
provider. 3
Vital Signs and Medical Emergencies
An essential component in the prevention and management of medical emergencies is the accurate
measurement and documentation of a patient's vital signs. 4 Vital signs, which include pulse, respiration, blood
pressure, and temperature, provide critical information about a patient's overall health and can help identify
potential risks. 5 In light of the COVID-19 pandemic, the routine measurement of temperature has become
increasingly common in dental practices.
Patients with hypertension or hypotension are at an elevated risk for experiencing various medical
emergencies. 6 , 7 The same holds true for individuals presenting with abnormal vital signs, such as tachycardia,
bradycardia, tachypnea, bradypnea, or dyspnea. 6 , 7 Having baseline vital signs is crucial for comparison during an
emergency, as it allows for a more accurate assessment of any deviations from normal. 5 In healthy adults, a
normal pulse rate typically ranges from 60 to 80 beats per minute; however, individuals who engage in regular
physical exercise may exhibit lower pulse rates, between 40 and 60 beats per minute. 5 A normal respiratory rate
for an adult at rest is between 12 and 20 breaths per minute. 8 Additionally, normal blood pressure for adults is
characterized by a systolic pressure ranging from 100 to 120 mmHg and a diastolic pressure between 60 and 80
mmHg. 8
Hypertension is a prevalent primary diagnosis, yet many individuals are unaware that they are affected by this
condition. As such, it is crucial for dental professionals to consistently and accurately assess the blood pressure of
every patient they treat. This proactive approach helps in identifying undiagnosed hypertension and mitigating
the associated risks. 9
In 2017, the American Heart Association and the American College of Cardiology introduced a revised blood
pressure classification system, which includes four distinct categories: Normal Blood Pressure, Elevated Blood
Pressure, Stage 1 Hypertension, and Stage 2 Hypertension. The updated classifications are as follows:
Normal Blood Pressure: Systolic <120 mm Hg and Diastolic <80 mm Hg
Elevated Blood Pressure (formerly known as pre-hypertension): Systolic 120-129 mm Hg and Diastolic <80
mm Hg
Stage 1 Hypertension: Systolic 130-139 mm Hg or Diastolic 80-89 mm Hg
Stage 2 Hypertension: Systolic ≥140 mm Hg or Diastolic ≥90 mm Hg 10 .
Dental professionals should refer any patient with a blood pressure reading above 120/80 mm Hg to their
physician for further evaluation. 11 While finding time during a patient appointment can be challenging, taking
vital signs is a quick process. Measuring the pulse takes approximately 10 seconds, multiplied by 6 for a full
minute; respiration can be assessed in 15 seconds, multiplied by 4 for a minute; and using an electronic blood
pressure cuff typically requires no more than 35 seconds. In total, taking vital signs should take no more than one
minute. By prioritizing this brief but crucial task, dental professionals can help prevent medical emergencies and
potentially save their patients' lives.
CPR Certification
In addition to ensuring that an AED is readily available, maintaining current CPR certification is crucial for
effectively managing medical emergencies and potentially saving a patient's life. It is recommended that dental
professionals remain up to date with healthcare provider CPR, which includes training in adult, child, and infant
CPR, as well as airway obstruction techniques. 12 Regular practice of CPR ensures that the steps are more readily
accessible in the event of a real medical emergency. Furthermore, CPR protocols evolve as ongoing research
identifies the most effective methods to enhance patient survival. 12
Emergency Simulations
Since medical emergencies are unpredictable and may occur suddenly, practicing simulated emergency scenarios
within the office is a vital preparatory step. 13 These simulations help ensure that all staff members are familiar
with their roles and can significantly reduce the anxiety associated with actual emergency situations when they
arise. 13 It is recommended that each individual be aware of their specific responsibilities based on the location of
the emergency within the office. For example, Person 1 (P1) remains with the patient and provides appropriate
emergency treatment. Person 2 (P2) assists P1, taking vital signs and administering oxygen if necessary, while also
recording events and medication delivery times on the Emergency Treatment Record. Person 3 (P3) is responsible
for retrieving the emergency kit and oxygen tank and preparing any required emergency medications. The office
receptionist (OR) is tasked with making the necessary phone calls. 14 , 16
Oxygen
For most medical emergencies, the administration of oxygen is essential. At a minimum, dental offices should be
equipped with a size E portable oxygen tank, which provides approximately 30 - 45 minutes of oxygen. 15 If
emergency medical services (EMS) are expected to take longer than 30 minutes to arrive, a larger oxygen tank
should be available. Normal blood oxygen saturation levels typically range from 92% to 98%. 15 A pulse oximeter
is the recommended device for measuring a patient's oxygen saturation levels and should be an essential
component of every dental office's medical emergency kit. 15 This device provides quick and accurate readings to
help guide appropriate intervention during medical emergencies. Additionally, the office should be stocked with
a non-rebreather mask, nasal cannula, and bag-valve mask, with all staff trained in their proper usage and the
appropriate flow rates for each device. 15 The nasal cannula is used for patients who require minimal oxygen
supplementation, with a flow rate of 1-6 L/min. For patients experiencing significant dyspnea, a non-rebreather
mask should be utilized, providing oxygen at a flow rate of 10-15 L/min. In cases of apneic patients, a bag-valve
mask is necessary, delivering oxygen at a flow rate of 12-15 L/min to ensure adequate ventilation. 15
Emergency Kit and AED
Dental professionals must be fully prepared for any medical emergency that may arise in their office. A well-
stocked medical emergency kit and an Automated External Defibrillator (AED) are essential components of this
preparedness. 12 The AED is designed to correct irregular heart rhythms and is the only definitive treatment for
ventricular fibrillation. As dental offices are healthcare facilities, the inclusion of an AED is imperative. 12 The AED
selected should be user-friendly, guiding the operator through the CPR steps, and delivering a shock only when
necessary. 12
The medical emergency kit selected for a dental office should be tailored to the office's location and the staff's
comfort level with using its contents. 16 In areas where emergency medical services (EMS) may take longer to
arrive, a more comprehensive kit is necessary compared to offices located near EMS facilities. The contents of the
medical emergency kit must be regularly monitored to ensure that all items are current and functional. 16 The kit
should include both injectable and non-injectable medications. Many companies offer specialized emergency kits
for dental offices, some with automatic replenishment services, which can be highly convenient. At a minimum,
the emergency kit should contain: nitroglycerin tablets or spray for angina pectoris, low-dose aspirin for
myocardial infarction, albuterol spray for asthma attacks, glucose tablets or gel, and injectable glucagon for
severe hypoglycemia, oral diphenhydramine or chlorpheniramine for mild allergic reactions, injectable
diphenhydramine for moderate allergic reactions, and injectable epinephrine in both adult and pediatric dosages
for anaphylaxis. 16 , 17 Other essential items to include in your emergency kit are a pulse oximeter to assess the
patient's blood oxygen level, a glucometer to measure blood glucose levels in the event of a diabetic emergency,
and a spacer device for patients experiencing an asthma attack. 14 , 16 , 17 These tools are crucial for quickly
evaluating and managing specific medical conditions that may arise during dental treatment. It is also
recommended that the kit be reviewed regularly with all staff members to ensure they feel confident in using the
supplies during an emergency.
Conclusion
Following these steps will help ensure that dental offices are well-prepared to handle a medical emergency
should one arise. There is no such thing as too much preparation when it comes to patient safety and emergency
response.
References
1. Smereka, J., Aluchna, M., Aluchna, A., et al. Medical emergencies in dental hygienists' practice. Medicine (Baltimore).
2019;98:e16613.
2. Malamed, S. F. Medical emergencies in the dental office. 8th ed. Philadelphia: Elsevier Mosby; 2022.
3. American Stroke Association. Health conditions a dentist might find that have nothing to do with your teeth.
Published August 11, 2022. Accessed December 20, 2024. https://www.stroke.org/en/news/2022/08/11/health-
conditions-a-dentist-might-find-that-have-nothing-to-do-with-your-teeth
4. Southerland, J. H., Gill, D. G., Gangula, P. R., Halpern, L. R., Cardona, C. Y., Mouton, C. P. Dental management in patients
with hypertension: Challenges and solutions. Clin Cosmet Investig Dent. 2016;8:111-120. doi: 10.2147/CCIDE.S99446.
PMID: 27799823; PMCID: PMC5074706.
5. Sapra, A., Malik, A., Bhandari, P. Vital sign assessment. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2024 Jan–. Published May 1, 2023. PMID: 31985994.
6. Stamler, J., Vaccaro, O., Neaton, J. D., Wentworth, D. Diabetes, other risk factors, and 12-year cardiovascular mortality
for men screened in the multiple risk factor intervention trial. Diabetes Care. 1993;16:434-444.
7. Hu, G., Jousilahti, P., Tuomilehto, J. Joint effects of history of hypertension at baseline and type 2 diabetes at baseline
and during follow-up on the risk of coronary heart disease. Eur Heart J. 2007;28:3059-3066.
8. Simel, D. L. Approach to the patient: History and physical examination. In: Goldman, L., Schafer, A. I., eds. Goldman-
Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020: chap 6.
9. World Health Organization. Global report on hypertension: The race against a silent killer. Published September 2023.
Available at: https://www.who.int/publications/i/item/9789240081062-eng.pdf
10. American Heart Association. Understanding blood pressure readings. Published 2024. Accessed December 20, 2024.
https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings
11. Hupp, W. S. Cardiovascular diseases. In: Patton, L. L., Glick, M., eds. The ADA Practical Guide to Patients with Medical
Conditions. 2nd ed. Hoboken, NJ: John Wiley & Sons, Inc.; 2016.
12. Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) in the dental practice: Adopted by the FDI General
Assembly: 27-29 September 2021, Sydney, Australia. Int Dent J. 2022;72(1):14-15.
13. Kishimoto, N., Sanuki, T., Liu, Y., Tran, S. D., Seo, K. Simulation training for medical emergencies of dental patients: A
review of the dental literature. Jpn Dent Sci Rev. 2023;59:104-113. doi: 10.1016/j.jdsr.2023.02.004.
14. Grimes, E. B. Medical emergencies: Essentials for the dental professional. 2nd ed. Upper Saddle River, NJ: Pearson
Education, Inc.; 2023.
15. Kami, M. N. Oxygen and airway actions for medical emergencies occurring in dental practices. Published 2023.
Accessed December 20, 2024. https://www.oralhealthgroup.com
16. Mirza, M., Gupta, V., Bhatt, A., Baruah, L.C. and Rajkumar, B., Medical emergency in dental office: A review. Indian
Journal of Conservative and Endodontics. 2019;4(1):1-8
17. Mohideen, K., Thayumanavan, B., Balasubramaniam, A.M., Vidya, K.M. , Rajkumari, S., Indu Bharkavi, S. K., Basics of
management of medical emergencies in dental office and emergency drug kit. International Journal of Scientific
Study. 2017;5(4):273-297.
