Medical Emergencies in the Dental Office

Types of Emergencies to Anticipate 

Virtually any kind of medical emergency may occur in the dental office, but some are more common than others. Among the most common are:^1,2,3,4,5 
 

• Syncope: it is the most common medical emergency seen in dental offices. The episode is preceded by “pre-syncope”, a brief period of lightheadedness, diaphoresis, bradycardia, and hypotension, followed by the syncopal loss of consciousness, which is usually brief and self-resolving.⁶ Syncope may be brought on by a number of causes, but fear of the dental procedure, pain, and the sight of instruments or blood are among the common causes in the dental chair. 

• Panic attacks: these are a manifestation of acute anxiety and may mimic a cardiac event. 

• Cardiac events: various cardiac emergencies may occur in the dental chair. These include: 

• • Acute coronary syndrome (ACS): ranging from angina pectoris to acute myocardial infarction. 

• • Arrhythmias: these include rapid atrial fibrillation (Afib), benign tachycardia (from anxiety or pre-syncope), and ventricular arrhythmias. 

• • Cardiac arrest: sudden cessation of heart function. May be from arrhythmias (particularly ventricular fibrillation), cardiac ischemia, extreme blood loss, etc. 

• Uncontrollable or unexpected bleeding: particularly in patients who are anticoagulated or taking aspirin. 

• Adverse drug reaction: may include drug–drug interaction between the patient’s usual medications and those administered in the dental office, allergy to drugs used during the procedure, or overdose toxicity (such as with local anesthetics). 

• Choking/airway obstruction: this may occur from debris or material from the procedure becoming lodged in the throat, or from aspiration of fluids or debris into the respiratory tract. 

• Asthma attack: an exacerbation of reactive airways can occur unpredictably and may be triggered by fumes, perfumes, or odors in the office setting, or bisulfites in local anesthetics.  

Staff Preparedness 

Some countries require dental professionals to undergo specific emergency training and to have certain knowledge in regard to emergency medications and equipment available. For example, in the USA, some states rely on the guidelines of the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the American Dental Association (ADA).  

The ADA suggests nine measures for emergency medical preparedness in dental offices. These are: ^8,9

1. A process for assessing the medical risk of patients. 
2. Dental practitioners and staff should adopt the PCABD (Positioning – Circulation – Airway – Breathing – Definitive Care) approach to emergency management. 
3. Emergency drugs and medical equipment should be immediately available. 
4. An automated external defibrillator (AED) should be immediately available. 
5. Dental practitioners and dental care professionals should be trained in cardiopulmonary resuscitation (CPR), basic airway management and the use of an AED. 
6. Regular practice using simulated emergencies. 
7. A plan in place for summoning emergency medical assistance (calling 911 or 112 where available). 
8. Staff skills should be kept current and up to date. 
9. Medical emergencies should be audited. 

The ADA recommends the following four steps for preparing dental office staff for medical emergencies:^8,9

1. Basic life-support (BLS) certification for all staff. 
2. Creating an "emergency-trained team”. 
3. Maintaining access to emergency medical services (EMS). 
4. Availability of emergency drugs and equipment. 

 The following six basic emergency medications should be considered:¹⁰

1. Oxygen 
2. Epinephrine 
3. Nitroglycerine 
4. Diphenhydramine 
5. Salbutamol inhaler 
6. ASA (non-enteric coated) 

A review article in the Journal of the American Dental Association (JADA) suggested the following basic emergency equipment:¹¹

• Portable oxygen cylinder (E size) with regulator 
• Supplemental oxygen delivery source 
• Nasal cannula 
• Nonrebreathing mask with reservoir 
• Nasal hood 
• Bag-valve-mask with reservoir 
• Oropharyngeal airways 
• Magill forceps 
• AED 
• Stethoscope 
• Sphygmomanometer with adult cuff sizes 
• Clock with second hand 
•  

Preventing Medical Emergencies 

Some kind of medical event in the dental office setting is almost inevitable.⁴ However, serious medical emergencies are often preventable or can at least be anticipated and planned for. The most efficacious way to prevent serious medical complications in the office setting is by patient risk assessment. This includes taking a thorough medical history that is updated on each visit.⁸ 

Handling patients’ anxiety and adequately treating pain are skill sets that also contribute to preventing problems.^8,9 

Emergency preparedness of the dental professional and staff is another key to preventing an emergency from becoming a tragedy.³ Staff will look to the dental professional for leadership in emergencies, and the professional should be prepared to assess a patient, take action, and give instructions to staff. Continuing professional development training that includes advanced skills training may be a wise and expedient option.³ 

Resources 

AAOMS Office Anesthesia Evaluation Manual, 9th Edition. Includes algorithms from Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), and AAOMS Parameters of Care. 

ADA Directory of State Dental Boards 

ADA Tip Sheet on Managing Patients’ Medical Emergencies 

Management of Medical Emergencies in Dental Office - A Review Article 

Medical Emergencies in the Dental Practice. British Dental Association (BDA) practice poster, revised and updated (2020) 

References 

1. Zingade J, Kumar G, Gujjar PK. Medical emergencies in dentistry: A review. J Health Sci Res. 2021;12(1):11-16. https://www.johsr.com/doi/JOHSR/pdf/10.5005/jp-journals-10042-1103

2. Al-Sebaei M.O. Frequency and features of medical emergencies at a teaching dental hospital in Saudi Arabia: A 14-year retrospective observational study. BMC Emerg Med. 2024;24:41. doi:10.1186/s12873-024-00957-4

3. Jevon, P. Medical emergencies in the dental practice poster: Revised and updated. Br Dent J. 2020;229:97-104. doi:10.1038/s41415-020-1789-y

4. Obata K, Naito H, Yakushiji H, et al. Incidence and characteristics of medical emergencies related to dental treatment: A retrospective single-center study. Acute Med Surg. 2021;8(1):e651. doi:10.1002/ams2.651

5. Kanupriya, Singh G, Gagandeep, et al. Management of medical emergencies in dental office - A review article. Intl J Res Rev. 2024;11(8). doi:10.52403/ijrr.20240824

6. Syncope. National Institute of Neurological Disorders and Stroke website. Published July 19, 2024. Accessed December 16, 2024. https://www.ninds.nih.gov/health-information/disorders/syncope

7. Dental licensure. American Dental Association website. Published 2024. Accessed December 26, 2024. https://www.ada.org/resources/careers/licensure#:~:text=The%203%20requirements%20for%20licensure,written%20examination%2C%20and%20clinical%20assessment.&text=Nearly%20all%20states%20require%20a,Learn%20more%20about%20the%20INBDE.&text=Applicants%20for%20dental%20licensure%20in,by%20each%20state%20and%20territory.

8. Malamed S. Preparation and management of medical emergencies. ADA Member Advantage website. Published 2024. Accessed December 26, 2024. https://www.adamemberadvantage.com/resources/culture-of-safety/preparation-and-management-of-medical-emergencies#:~:text=Dental%20practitioners%20and%20dental%20care%20professionals%20should%20all%20undergo%20training,based%20exercises%20using%20simulated%20emergencies.