Medical emergencies in the dental office

Unfortunately, yes. Surveys of the incidence of medical emergencies, in countries throughout the world, have shown that a medical emergency is likely to occur in a dental office every 2 to 4 years.^3-5 A 2018 American Dental Association survey of emergencies reported that more than 30% of respondents (N=512) had seen syncope, epinephrine reaction and/or postural hypotension within the past 12 months.⁶

Dentists are doctors who specialize in oral health.¹ Responsibilities include diagnosing oral disease, promoting oral health and disease prevention and creating treatment plans to maintain or restore the oral health of their patients. A medical emergency is defined as “an acute injury or illness that poses an immediate risk to a person’s life.”²

In the dental office environment, a medical emergency may be defined as any occurrence in which the doctor has to stop treatment of a patient because their major concern at that moment is protecting the life of the patient, no longer the dentistry being done.

Syncope (fainting) is the most common medical emergency reported in all published surveys, accounting for 39%⁶ to 50.3%³ of all in-office medical emergencies. Other common medical emergencies include: anginal pain, acute asthmatic episodes (i.e., bronchospasm), seizures, hyperventilation, hypoglycemia and mild or moderate allergy. Acutely life-threatening medical emergencies are less common, but include myocardial infarction, anaphylaxis and cardiac arrest. Table 1 (click to download the table) presents the top 3 medical emergencies in dental settings as reported in surveys in seven countries.

Yes – many, but not all. Approximately 75% of the most common medical emergencies are stress related. The patient has an underlying medical condition that, while at rest, remains asymptomatic, but when stressed – either physiologically or psychologically – is exacerbated.

Stress-related medical emergencies include exacerbations of nonallergic (i.e., exercise-induced) asthma, stable angina and epilepsy. Under stress, anyone can experience syncope (i.e., faint). However, it is much more likely that when stressed, people with asthma can have acute difficulty breathing (i.e., bronchospasm), patients with angina can experience chest pain and persons with epilepsy may have seizures.

Published surveys have shown that 55% of medical emergencies in the dental office developed during or immediately after the administration of local anesthetics, while 22% occurred during the subsequent dental treatment.^3,7,8 Dentists need to recognize and treat a patient’s dental fear/anxiety and provide adequate pain control during treatment. The two important factors contributing to medical emergencies in the dental office environment are (1) failure to recognize, or ignoring, a patient’s dental fears and anxiety; and (2) inadequate pain control.

Fear of needles – trypanophobia – is quite common. Recognition of a patient’s fear of injections is paramount in preventing stress-related medical emergencies. Front-office personnel may be asked questions by a patient regarding injections, for example, “Does the doctor give good shots?” This information should be communicated to the doctor prior to local anesthetic administration.

Not infrequently, patients will ask their doctor or hygienist: “Do you have to give me a shot to do this?” or say, “I hate getting shots, but once I’m numb I’m OK.”

"...the two most important factors patients consider when choosing a dentist are treatment that doesn’t hurt; and a painless injection technique."

In a 2004 paper, Jennifer De St. Georges noted that the two most important factors patients consider when choosing a dentist are (1) treatment that doesn’t hurt; and (2) a painless injection technique.⁹

Stress-induced medical emergencies during local anesthetic administration can be prevented (or minimized) by: (1) positioning of the patient for the injection, and (2) the use of sedation.

POSITIONING: Syncope occurs when a needle-phobic patient receives an injection while seated in an upright position; this can be treated by repositioning the patient into a supine position with their feet elevated slightly – thereby increasing blood flow to the brain. The dental chair is ideally suited for this position. Consciousness is usually regained within 10 seconds. Syncope can be prevented by placing the patient in the supine position (or as close to supine as the patient will allow) prior to the injection of local anesthetics.

SEDATION: Dentists have at their disposal many means of allaying a patient’s fear and anxiety. Common techniques include iatrosedation and pharmacosedation.¹⁰

• Iatrosedation is defined as nondrug techniques of relaxation, and include the doctor’s chairside manner; audio (music); video; and increasingly, virtual reality glasses.
• Pharmacosedation techniques include minimal sedation with nitrous oxide and oxygen, orally administered drugs (e.g., triazolam), and intravenous moderate sedation.

Pain hurts – representing a considerable physiological and psychological stress to the patient. Fortunately, dentistry has excellent local anesthetic drugs that are both safe (when used properly) and highly effective in almost all clinical situations. Table 2 (click to download the table)

However, lack of adequate pain control was responsible for 22% of medical emergencies reported by Hiroyuki Matsuura.⁸ Dental procedures being undertaken when medical emergencies occurred during treatment included: tooth extraction (38.9%), and pulpal extirpation (26.9%) – situations where adequate pain control is oftentimes difficult to achieve.⁸ Most often, these situations occurred during treatment of the mandibular molars.¹¹

The clinical availability of various local anesthetic drugs, buffering local anesthetics, and specific injection techniques (e.g., Gow-Gates mandibular nerve block, intraosseous anesthesia) can help increase success rates in these difficult clinical situations.¹²

Medical emergencies can – and do – occur in the dental office. A culture of safety implies an effort on the part of the dental office to prevent as many of these occurrences as possible. Recognition and management of a patient’s dental fears and clinically adequate pain control together can prevent up to 75% of medical emergencies seen in dental offices.

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Stanley F. Malamed, DDS is a dentist anesthesiologist and emeritus professor of dentistry at the Ostrow School of Dentistry of USC as well as a continuing education lecturer on anesthesia, sedation, and emergency medicine. He has authored more than 170 scientific papers and three textbooks that are used around the world.

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10. Malamed SF. Sedation in dentistry. Dental Learning. dentallearning.net
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12. Malamed SF. Dental pain control and local anesthesia: a 40-year journey. Dent Today. 2021 Sept;40(7):00-00.