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 Detailed Contents

Part One: Prevention, 1

1 Introduction, 1
Morbidity, 1
Death or Permanent Brain Damage, 4
The State of Preparation for the Recognition and
Management of Medical Emergencies in Dental
Offices, 7
Risk Factors, 8
Increased Numbers of Older Patients, 8
Medical Advances, 11
Longer Appointments, 12
Increased Drug Usage, 12
Classification of Life-Threatening Situations, 13
Outline of Specific Emergency Situations, 14
References, 15
2 Prevention, 18
Evaluation Goals, 18
Physical Evaluation, 19
Medical History Questionnaire, 22
Medical History Questionnaire, 40
Physical Examination, 40
Vital Signs, 41
Visual Inspection, 49
Additional Evaluation Procedures, 51
Recognition of Dental Fear and Anxiety, 51
Psychological Examination, 51
Determination of Medical Risk, 53
Medical Consultation, 55
Stress-Reduction Protocol, 56
Recognition of Medical Risk and Anxiety, 56
References, 59
3 Preparation, 63
General Information, 63
Geographic Requirements for Emergency
Training, 63
Office Personnel, 64
Emergency Drugs and Equipment, 69
Proprietary Versus Homemade Emergency Drug
Kits, 69
Emergency Drug Kits, 70
Components of an Emergency Kit, 72
Administration of Injectable Drugs, 73

Module One: Essential Emergency Drugs and

Equipment, 74
Essential Injectable Drugs, 74
Essential Noninjectable Drugs, 78
Essential Emergency Equipment, 83
Module Two: Secondary (Nonessential) Emergency
Drugs and Equipment, 88
Secondary Injectable Drugs, 89
Secondary Noninjectable Drugs, 94
Module Three: Advanced Cardiovascular Life
Support (ACLS), 98
ACLS Essential Drugs, 98
ACLS essential: O2
, 99

ACLS Essential: Antidysrhythmic, 99

Module Four: Antidotal Drugs, 101
Antidotal Drugs, 101
Organization of the Emergency Drug Kit, 103
References, 105
APPENDIX: Parenteral Administration of Drugs, 109
IM Drug Administration, 109
IV Drug Administration, 110
4 Legal Considerations, 112
Modern Liability Insurance Crises, 112
Theories of Liability, 113
Statute Violations, 113
Contract Law, 113
Criminal Law, 114
Tort Law, 114
Duty, 114
Breach of Duty, 114
Causation, 115
Damage, 115
Reasonableness, 115
Consent, 115
Statute of Limitations, 115
Emergency Situations, 116
Standard of Care During Emergencies, 116
Consent During Emergencies, 117
Defining an Emergency, 117
Emergency Rescues—Good Samaritan
Statutes, 117
Relationship Between the Doctor and an Emergency
Patient, 118
Foreseeability, 118
Limiting Liability for Emergencies, 118
Prevention and Preparation, 119
Poor Decisions, 119
Respondeat Superior, 119
Community Standards, 119
Professional Relationships, 119
Collegiality, 119
Philosophical Aspects of Treating Emergencies, 119
References, 121
Part Two: Unconsciousness, 123
5 Unconsciousness: General Considerations, 123
Predisposing Factors, 123
Prevention, 125
Clinical Manifestations, 125
Pathophysiology, 125
Inadequate Cerebral Circulation, 126
Oxygen Deprivation, 126
General or Local Metabolic Changes, 126
Actions on the Central Nervous System, 127
Psychic Mechanisms, 127
Management, 127
Recognition of Unconsciousness, 127
Management of the Unconscious Patient, 127
References, 137
6 Vasodepressor Syncope, 140
Predisposing Factors, 140
Prevention, 141
Positioning, 141
Anxiety Relief, 141
Dental Therapy Considerations, 142
Clinical Manifestations, 142
Presyncope, 142
Syncope, 142
Postsyncope (Recovery), 143
Pathophysiology, 143
Presyncope, 143
Syncope, 143
Recovery, 144
Management, 144
Presyncope, 144
Syncope, 144
Delayed Recovery, 146
Postsyncope, 146
ADDENDUM Case Report #1—Vasodepressor
Syncope, 147
ADDENDUM Case Report #2—Vasodepressor
Syncope, 147
References, 147
7 Postural Hypotension, 149
Predisposing Factors, 149
Drug Administration and Ingestion, 150
Prolonged Recumbency and Convalescence, 150
Inadequate Postural Reflex, 150

Pregnancy, 150
Age, 151
Venous Defects in the Legs, 151
Recovery from a Sympathectomy for High Blood
Pressure, 151
Addison’s Disease, 151
Physical Exhaustion and Starvation, 151
Chronic Postural Hypotension (Shy-Drager
Syndrome), 151
Prevention, 151
Physical Examination, 152
Dental Therapy Considerations, 152
Clinical Manifestations, 152
Pathophysiology, 153
Normal Regulatory Mechanisms, 153
Postural Hypotension, 154
Management, 154
Step 1: Assessment of Consciousness, 155
Step 2: Activation of the Office Emergency
System, 155
Step 3: P (Position), 155

Step 4: C → A → B (Circulation-Airway-
Breathing), 155
Step 5: D (Definitive Care), 155
Step 6: Subsequent Management, 155
Step 6a: Delayed Recovery, 155
Step 7: Discharge, 155
References, 156
8 Acute Adrenal Insufficiency, 158
Predisposing Factors, 160
Prevention, 162
Dental Therapy Considerations, 163
Glucocorticosteroid Coverage, 164
Stress-reduction Protocol, 164
Additional Considerations, 164
Clinical Manifestations, 164
Pathophysiology, 165
Normal Adrenal Function, 165
Adrenal Insufficiency, 167
Management, 168
Conscious Patient, 168
Unconscious Patient, 170
References, 171
9 Unconsciousness: Differential Diagnosis, 174
Age of Patient, 174
Circumstances Associated With Loss of
Consciousness, 174
Position of the Patient, 174
Presyncopal Signs and Symptoms, 175
No Clinical Symptoms, 175
Pallor and Cold, Clammy Skin, 176
Tingling and Numbness of the Extremities, 176
Headache, 176
Chest “Pain”, 176
Breath Odor, 176

xii Contents

Tonic-Clonic Movements and Incontinence, 176

Heart Rate and Blood Pressure, 176
Duration of Unconsciousness and Recovery, 177
Part Three: Respiratory Distress, 178
10 Respiratory Distress: General
Considerations, 178
Predisposing Factors, 178
Prevention, 178
Clinical Manifestations, 178
Pathophysiology, 179
Management, 180
Step 1: Recognition of Respiratory Distress, 180
Step 2: Discontinue the Dental Procedure, 181
Step 3: P (Position the Patient), 181
Step 4: C → A → B (Circulation-Airway-Breathing)
BLS, as Required, 181
Step 5: D (Definitive Care), 181
References, 181
11 Foreign Body Ingestion and Aspiration, 182
Incidence, 182
Prevention, 183
Rubber Dam, 184
Oral Packing, 184
Chair Position, 184
Dental Assistant and Suction, 184
Magill Intubation Forceps, 185
Tongue-Grasping Forceps, 185
Ligature, 185
Management, 186
Management of Ingested Foreign Bodies, 188
Tracheobronchial Foreign Bodies, 188
Recognition of an Airway Obstruction, 188
Basic Airway Maneuvers, 191
Establishing an Emergency Airway in the Presence
of an FBAO, 192
Invasive Procedures: Tracheostomy Versus
Cricothyrotomy, 198
References, 201
12 Hyperventilation, 205
Predisposing Factors, 205
Prevention, 206
Medical History Questionnaire, 206
Physical Evaluation, 206
Vital Signs, 206
Dental Therapy Considerations, 206
Clinical Manifestations, 206
Signs and Symptoms, 206
Effects on the Vital Signs, 207
Pathophysiology, 207
Management, 208
References, 210

13 Asthma, 211
Predisposing Factors, 211
Extrinsic Asthma, 212
Intrinsic Asthma, 212
Mixed Asthma, 213
Status Asthmaticus, 213
Prevention, 213
Dialogue History, 216
Dental Therapy Considerations, 216
Clinical Manifestations, 217
Usual Clinical Progression, 218
Status Asthmaticus, 218
Pathophysiology, 218
Neural Control of the Airways, 219
Airway Inflammation, 219
Immunologic Responses, 219
Bronchospasm, 219
Bronchial Wall Edema and Hypersecretion of
Mucous Glands, 219
Breathing, 220
Management, 221
Severe Bronchospasm, 224
References, 225
14 Heart Failure and Acute Pulmonary
Edema, 228
The Impact of Demographics and Socioeconomic
Status, 229
Age, 229
Sex, 229
Race, 229
Socioeconomic Status, 229
Lifetime Risk of Heart Failure, 229
Prognosis, 229
Predisposing Factors, 230
Prevention, 230
Medical History Questionnaire, 230
Section II, Have You Experienced, 230
Section III, Do You Have, or Have You Had, 230
Section IV, Do You Have, or Have You Had, 230
Section V, Are You Taking, 230
Dialogue History, 231
Physical Evaluation, 232
Dental Therapy Considerations, 233
Clinical Manifestations, 235
Left Ventricular Failure, 236
Right Ventricular Failure, 236
Acute Pulmonary Edema, 237
Pathophysiology, 237
Normal Left Ventricular Function, 238
Heart Failure, 239
Management, 240
Step 1: Termination of the Dental
Procedure, 241
Step 2: P (Position), 241

Contents xiii

Step 3: Removal of Dental Materials, 241

Step 4: Activate Office Emergency Team and
Summons Emergency Medical Services, 241
Step 5: Calming of the Patient, 241
Step 6: C → A → B (Circulation-Airway-Breathing),
Basic Life Support as Needed, 241
Step 7: D (Definitive Care), 241
Step 8: Discharge, 242
Step 9: Subsequent Dental Treatment, 242
References, 242
15 Respiratory Distress: Differential
Diagnosis, 244
Medical History, 244
Age, 244
Sex, 244
Related Circumstances, 244
Clinical Symptoms Between Acute Episodes, 244
Position, 244
Accompanying Sounds, 244
Symptoms Associated With Respiratory
Distress, 245
Peripheral Edema and Cyanosis, 245
Paresthesias of the Extremities, 245
Use of Accessory Respiratory Muscles, 245
Chest Pain, 245
Heart Rate and Blood Pressure, 245
Duration of Respiratory Distress, 245
Part Four: Altered Consciousness, 246
16 Altered Consciousness: General
Considerations, 246
Predisposing Factors, 246
Prevention, 247
Clinical Manifestations, 247
Pathophysiology, 247
Management, 248
Step 1: Recognition of Altered
Consciousness, 248
Step 2: Termination of the Dental Treatment
and Activation of the Office Emergency
Team, 248
Step 3: P (Position), 248
Step 4: C → A → B (Circulation-Airway-Breathing)
Basic Life Support as Needed, 248
Step 5: D (Definitive Care), 248
References, 249
17 Diabetes Mellitus, 250
OVERVIEW, 250
Chronic Complications, 251
Acute Complications, 251
Predisposing Factors, 252
Type 1 Diabetes, 252
Type 2 Diabetes, 252

Types of Diabetes, 253

Type 1 Diabetes, 254
Type 2 Diabetes, 255
Gestational Diabetes Mellitus, 255
Prediabetes, 255
Metabolic Syndrome, 255
Hyperglycemia, 255
Hypoglycemia, 256
Control of Diabetes, 257
Management of Type 1 Diabetes – Monitoring, 257
Self-Monitoring of Blood Glucose Targets, 258
Measurement of Chronic Glycemic Control –
Hemoglobin A1C, 258
Management of Type 1 Diabetes – Treatment, 259
Injectable Insulin, 260
Management of Type 2 Diabetes, 261
Prevention, 261
Physical Examination, 263
Dental Therapy Considerations, 263
Clinical Manifestations, 264
Hyperglycemia, 264
Hypoglycemia, 265
Pathophysiology, 266
Insulin and Blood (Serum) Glucose, 266
Hyperglycemia, Ketosis, and Acidosis, 266
Hypoglycemia, 267
Management, 267
Hyperglycemia, 267
Hypoglycemia, 268
References, 271
18 Thyroid Gland Dysfunction, 275
Predisposing Factors, 275
Hypothyroidism, 275
Hyperthyroidism/Thyrotoxicosis, 277
Prevention, 278
Dialogue History, 278
Physical Examination, 279
Dental Therapy Considerations, 279
Clinical Manifestations, 282
Hypothyroidism, 282
Thyrotoxicosis, 283
Pathophysiology, 284
Hypothyroidism, 285
Hyperthyroidism and Thyrotoxicosis, 285
Management, 285
Hypothyroidism, 285
Thyrotoxicosis, 286
References, 287
19 Cerebrovascular Accident, 289
Classification, 291
Transient Ischemic Attack (TIA), 291
Cerebral Infarction, 292
Hemorrhagic Stroke: Intracerebral Hemorrhage and
Subarachnoid Hemorrhage, 292

xiv Contents

Predisposing Factors, 294

Hypertension, 294
Diabetes Mellitus, 295
Disorders of Heart Rhythm, 295
Smoking and Tobacco Use, 295
Physical Inactivity, 295
Nutrition, 296
Family History and Genetics, 296
Kidney Disease, 296
Risk Factors Specific to Females, 296
Sleep-disordered Breathing and Sleep
Duration, 296
Prevention, 296
Physical Examination, 298
Vital Signs, 298
Apprehension, 298
Dental Therapy Considerations, 298
Clinical Manifestations, 299
Transient Ischemic Attack, 300
Cerebral Infarction, 301
Cerebral Embolism, 301
Cerebral Hemorrhage, 301
Pathophysiology, 301
Cerebrovascular Ischemia and Infarction, 301
Hemorrhagic CVA, 302
Management, 302
Cerebrovascular Accident and Transient Ischemic
Attack, 304
Step 4b: Monitoring of Vital Signs, 305
Step 4c: Management of Signs and Symptoms, 305
Step 4d: Administration of O2
, 305

Conscious Patient with Resolution of Signs and

Symptoms: Transient Ischemic Attack, 305
Conscious Patient with Persistent Signs and
Symptoms: Cerebrovascular Accident, 305
References, 307
20 Altered Consciousness: Differential
Diagnosis, 311
Medical History, 311
Age, 311
Sex, 311
Related Circumstances, 311
Onset of Signs and Symptoms, 311
Presence of Symptoms Between Acute
Episodes, 311
Loss of Consciousness, 312
Signs and Symptoms, 312
Appearance of the Skin (Face), 312
Obvious Anxiety, 312
Paresthesia, 312
Headache, 312
“Drunken” Appearance, 312
Breath Odor, 312
Vital Signs, 312
Respiration, 312
Blood Pressure, 312

Heart Rate, 312

Summary, 313
Part Five: Seizures, 314
21 Seizures, 314
Types of Seizure Disorders, 315
Focal-onset Seizures, 317
Generalized Seizures, 317
Causes, 319
Predisposing Factors, 320
Prevention, 321
Nonepileptic Causes, 321
Epileptic Causes, 321
Physical Examination, 323
Psychological Implications of Epilepsy, 323
Dental Therapy Considerations, 323
Clinical Manifestations, 324
Partial Seizures, 324
Absence Seizures (Petit Mal), 324
Generalized Tonic-clonic Seizure, 325
Tonic-clonic Seizure Status (Grand Mal Status,
Convulsive Status Epilepticus), 326
Pathophysiology, 326
Management, 327
Absence Seizures and Partial Seizures, 327
Generalized Tonic-clonic Seizures, 328
Differential Diagnosis, 332
References, 333
Part Six: Drug-Related Emergencies, 337
22 Drug-Related Emergencies: General
Considerations, 337
Prevention, 337
Medical History Questionnaire, 338
Section I, Circle Appropriate Answer, 338
Section III, Do You Have or Have You Had, 338
Section V, Are You Taking, 338
Dialogue History, 338
Care in Drug Administration, 339
Classification, 340
Overdose Reactions, 340
Allergy, 340
Idiosyncratic Drug Reactions, 341
Drug-Related Emergencies, 342
Drug Use in Dentistry, 342
References, 346
23 Drug Overdose Reactions, 348
LAST – Local Anesthetic Systemic Toxicity, 349
Predisposing Factors, 349
Prevention, 353
Clinical Manifestations, 359
Onset, Intensity, and Duration, 359
Pathophysiology, 360
Management, 363

Contents xv

Epinephrine (Vasoconstrictor) Overdose

Reaction, 367
Precipitating Factors and Prevention, 367
Clinical Manifestations and Pathophysiology, 368
Management, 369
Central Nervous System Depressant Overdose
Reactions, 370
Predisposing Factors and Prevention, 371
Clinical Manifestations, 372
Management, 373
Summary, 377
References, 379
24 Allergy, 384
Predisposing Factors, 385
Antibiotics, 386
Analgesics, 387
Antianxiety Drugs, 387
Local Anesthetics, 387
Other Agents, 389
Prevention, 389
Medical Consultation, 391
Allergy Testing in the Dental Office, 391
Dental Therapy Modifications, 392
Management, 393
Alleged Allergy to Local Anesthetics, 393
Confirmed Allergy to Local Anesthetics, 394
Clinical Manifestations, 394
Onset, 394
Skin Reaction, 395
Respiratory Reactions, 396
Generalized Anaphylaxis, 397
Pathophysiology, 399
Antigens, Haptens, and Allergens, 399
Antibodies (Immunoglobulins), 399
Defense Mechanisms of The Body, 400
Type I Allergic Reaction—Anaphylaxis, 401
Respiratory Signs and Symptoms, 404
Cardiovascular Signs and Symptoms, 404
Gastrointestinal Signs and Symptoms, 404
Urticaria, Rhinitis, and Conjunctivitis, 404
Management, 404
Cutaneous Reactions, 404
Management – Rapid-onset Cutaneous
Reaction, 406
Step 1: Terminate the Dental Procedure and
Activate
the Dental Office Emergency Team, 406
Step 2: P (Position), 406
Step 3: C → A → B (Circulation, Airway,
Breathing). Basic Life Support (BLS), As
Needed, 406
Step 4: Monitor and Record the Vital Signs, 406
Step 5: D (Definitive Care), 406
Management – Laryngeal Edema, 409
Epinephrine and Anaphylaxis, 410
Management – Generalized Anaphylaxis, 411
References, 414

25 Drug-Related Emergencies: Differential

Diagnosis, 418
Differential Diagnosis, 418
Medical History, 418
Age, 418
Sex, 418
Position, 418
Loss of Consciousness, 419
Presence of Seizures, 419
Respiratory Symptoms, 419
Vital Signs, 419
Heart Rate, 419
Blood Pressure, 419
Summary, 419
Onset of Signs and Symptoms, 420
Prior Exposure to Drug, 420
Dose of Drug Administered, 420
Overall Incidence of Occurrence, 420
Signs and Symptoms, 420
Duration of Reaction, 420
Change in the Appearance of the Skin, 420
Appearance of Nervousness, 420
References, 422
Part Seven: Chest Pain, 423
26 Chest Pain, 423
General Considerations, 423
Predisposing Factors, 423
Risk Factors for Atherosclerotic Cardiovascular
Disease, 427
Prevention, 432
Clinical Manifestations, 433
Pathophysiology, 433
Atherosclerosis, 433
Location, 435
Chest Pain, 435
Management, 436
References, 436
27 Stable Ischemic Heart Disease – Angina
Pectoris, 441
Predisposing Factors, 441
Prevention, 443
Physical Examination, 447
Unstable Angina, 447
Dental Therapy Considerations, 447
Length of The Appointment, 448
Supplemental Oxygen, 448
Pain Control During Therapy, 448
Sedation, 450
Additional Considerations, 450
Clinical Manifestations, 450
Signs and Symptoms, 450
Physical Examination, 451
Complications, 451
Prognosis, 451

xvi Contents

Pathophysiology, 451
Management, 452
Patient With a History of AP, 452
References, 454
28 Acute Coronary Syndrome – Myocardial
Infarction, 458
Predisposing Factors, 459
The Blood Supply to The Heart — Coronary Artery
Anatomy, 460
Location and Extent of Infarction, 460
Collateral Circulation, 460
Prevention, 461
Physical Examination, 465
Dental Therapy Considerations, 465
Stress Reduction, 465
Supplemental Oxygen, 465
Sedation, 465
Pain Control, 466
Duration of Treatment, 466
Elapsed Time Since MI, 466
Medical Consultation, 466
Anticoagulant or Antiplatelet Therapy, 466
Clinical Manifestations, 467
Pain, 467
Other Clinical Signs and Symptoms, 467
Physical Findings, 469
Acute Complications, 469
Pathophysiology, 469
Management, 471
Immediate In-Hospital Management, 475
References, 477
29 Chest Pain: Differential Diagnosis, 483
Noncardiac Chest Pain, 483
Cardiac Causes of Chest Pain, 484
Medical History, 484
Age, 485
Sex, 485
Related Circumstances, 485
Clinical Symptoms and Signs, 485
Vital Signs, 486
Summary, 486
References, 486
Part Eight: Cardiac Arrest, 487
30 Cardiac Arrest, 487
Survival from Sudden Cardiac Arrest, 489
Witnessed Versus Unwitnessed, 489
Bystander CPR, 490
Response Time, 490
The Chain of Survival, 491
The First Link: Activation of Emergency
Response, 491

The Second Link: High-Quality CPR, 491

The Third Link: Rapid Defibrillation, 491
The Fourth Link: Effective Advanced
Resuscitation, 493
The Fifth Link: Post–Cardiac Arrest
Care, 493
The Sixth Link: Recovery, 493
The Dental Office, 493
Sudden Cardiac Arrest, 494
Pulmonary (Respiratory) Arrest, 494
Cardiac Arrest, 494
Basic Life Support (CPR), 497
Team Approach, 498
Basic Life Support, 498
Cardiac Arrest In The Dental Office, 498
CPR Sequence—Adult Victim, 499
CPR Specifics—Activating EMS, 501
CPR Specifics—Circulation, 501
CPR Specifics—Defibrillation, 504
Beginning and Terminating BLS, 506
Transport of Victim, 506
References, 507
31 Pediatric Considerations, 513
Preparation, 514
Basic Life Support, 514
Emergency Team, 515
Access To Emergency Medical Services, 515
Emergency Drugs and Equipment, 516
Basic Management, 516
Position, 516
Circulation, 516
Airway and Breathing, 516
Definitive Care, 517
Specific Emergencies, 518
Bronchospasm (Acute Asthmatic
Attack), 518
Generalized Tonic-Clonic Seizure (Grand Mal
Seizure), 518
CNS-depressant (Sedation) Overdose, 519
Local Anesthetic Systemic Toxicity (Last)
(Local Anesthetic Overdose), 520
Respiratory Arrest, 520
Cardiac Arrest, 523
AED Technique (Child), 526
References, 528
Appendix: Quick-Reference Section to
Life-Threatening Situations, 532
Index, 543

PART 1 Prevention
Introduction

Life-threatening emergencies can occur in dentistry

and can happen to anyone—a patient, a doctor, a
member of the office staff, or a person merely
accompanying a patient.

Although life-threatening emergencies are generally

infrequent in dental offices, many factors are
combined to increase the likelihood of such
incidents, including (1) an increasing number of
older persons seeking dental care, (2) therapeutic
advances in the medical and pharmaceuti - cal
professions, (3) a growing trend toward longer
dental appointments, and (4) the increasing use and
administration of drugs in dentistry.

Fortunately, other factors can minimize the

occurrence of life-threatening events, such as a
pretreatment physical evaluation of each patient
involving a medical history questionnaire, dialogue
history, and physical examination, with subsequent
modifications to dental care to minimize medical
risks if necessary.

Morbidity Despite the most meticulous protocols

designed to prevent the development of life-
threatening situations, emergencies will still occur.
Consider, for example, the sudden and unexpected
deaths of young, well-conditioned athletes.1–5 Such
emergencies can occur in any environment. Indeed,
the occurrence of such a tragedy at a dental office is
not even a surprising event, given the stress that
many patients are associated with dental care. In a
survey of medical emergencies occurring in dental
offices in Scotland, four deaths from cardiac arrest
were reported in persons who were listed as
“bystanders,” that is, persons not scheduled for
dental treatment at the office in which they died.6
This text studies emergency situations that can
develop in dental practice.
However, dental practitioners must first understand
that there is no medical emergency that is unique to
dentistry.
For instance, local anesthetic overdoses can be
seen outside dentistry in patients with cocaine
abuse.

Table 1.1 presents the combined findings of two

surveys of dentists from the United States, one
completed by Fast, Martin, and Ellis7 in 1985 and
the other by Malamed8 in 1992. A total of 4309
respondents survey from all 50 US states and 7
Canadian provinces reported 30,608 emergencies
over 10 years. Of the respondents, 96.6%
responded positively to the following question: “In
the past ten years, has a medical emergency
occurred in your dental office?” (Doctors used their
own definitions of what constituted a medical
emergency.) About 50% of these emergencies
(15,407) were listed as syncope (i.e., fainting), which
is usually a benign occurrence.
However, the reader should be aware of the word
benign in any description of an emergency. When
improperly managed, any emergency—even a
“simple” faint—can turn into a catastrophe. The
reader is referred to the addendum in Chapter 6 as
an example. On the other hand, a notable proportion
(25.35%) of reported emergencies were related to
the cardiovascular (3381), respiratory (2718), and
central nervous (1663) systems and were thus
potentially life threatening.

Table 1.2 summarizes the medical emergencies that

occurred at the School of Dentistry clinics at the
University of Southern California (now the Herman
Ostrow School of Dentistry of USC) from 1973
through mid-2012. Although most of these situations
arose while the patient was under-going treatment,
others developed while the patient was not even in
the dental chair. For example, some patients
experienced episodes of orthostatic (postural)
hypotension in the rest room, several experienced
convulsive seizures in the waiting room, and one
experienced a seizure just outside the clinic
entrance. An adult accompanying a patient
developed an allergic skin reaction after ingesting
aspirin to treat a headache.9 In two other instances
a dental student viewing pictures of acute
maxillofacial injuries in a lecture hall and a dentist
treating a patient suffered episodes of
vasodepressor syncope. Such examples highlight
the need for dental practitioners to prepare for
emergency situations.
Table 1.3 summarizes the medical emergencies
arising at another US dental school over an 81⁄2-
year period. Twenty percent (17 of 84) of events
occurred in persons who were not patients at the
time (e.g., faculty, students, persons accompanying
patients).10 Previous editions of this text have
presented studies on the incidence of medical
emergencies in Australia,11 New Zealand,12 Fiji,13
and Brazil.14 Tables 1.4 to 1.10 present the results
of more recent studies carried out in Germany,15
Croatia,16 the Netherlands,17 United Kingdom,18
Poland,19,20 Saudi Arabia,21 and the United
States.22

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