This week I was asked to run a simulation session for senior dental students that focused on emergencies a dentist might have to run in their office. A simulation for dentists!? I had never worked with dental students before. After some discussion and a brief literature review I found a case that fit the bill. This post was meant to summarize take-away points for the students that participated that day and was not intended to be seen by the regular readers of my blog. However, my plan to “publish without publicizing” didn’t quite work as planned and I had great comments from Heather Thiessen and Chris Nickson before I figured out exactly how to make that happen.
This case was inspired by a report from 1980 that I modified. Our patient was a 27 year old female that we affectionately dubbed Penelope. She arrived to the dentist’s office with a severe toothache that was diagnosed as pulpitis. A thorough history and exam was significant for only type 1 diabetes and poor dental hygiene secondary to a lack of insurance. She had no known allergies, although she vaguely recalls “getting a rash and feeling sick to my stomach” from a medication she had as a child. No collateral history is available.
The students elected to treat with either extraction or root canal and proceeded after anesthetizing the tooth using lidocaine with epinephrine. She was sent home with ibuprofen +/- antibiotics.
She returned to the clinic shortly after complaining of dizziness, shortness of breath and tightness in her throat. She then fell to the floor. On exam she was found to have a decreased level of consciousness, urticaria, perioral edema and a racing pulse. Glucose was normal on a chem strip. She roused slightly if given IM epinephrine before becoming pulseless. Her pulse returned and she became responsive with the first shock of an AED. She was quickly taken to the local emergency department by EMS.
While rare, medical emergencies can occur along with or as a result of dental procedures. Excluding vasovagal syncope (the most common and benign entity seen by dentists), a United Kingdom survey published in 1999 found that, on average, a dentist would see an emergency event once every 1.4 years. A document outlining standards for dental practitioners in the UK lists a number of medical emergencies (many more than I would have thought) that they feel dentists should be proficient at assessing and providing initial treatment for. They included (average number of years of practice per case in parentheses): asthma (15.1), anaphylaxis (75.5), myocardial infarction (151), epileptic seizures (7.2) hypoglycemia (5.6), vasovagal syncope (0.5), choking/aspiration (11.2) and cardiac emergencies such as hypertensive crisis (43.1), angina 5.7 and cardiac arrest (302).
While the American Dental Association documents that I found did not deal explicitly with this content area (perhaps these are not the correct documents?), with the collective prevalence of these events I think it is important for dentists to have an approach to assessing and providing basic treatment for them.
Take home points
The two objectives of this case were to reinforce the importance of a thorough medical history prior to using or prescribing a medication and to review an approach to the most common potential emergency a dentist will see: syncope. The take home points for the dental students are summarized below along with additional resources for those interested.
- Always take a thorough medical history – especially prior to using or prescribing a medication
- Vasovagal syncope is a diagnosis of exclusion – don’t assume it’s something common when it could be something scary (syncope and its diagnosis are complex, poke your head in to the American Heart Association guidelines if you dare or check out this amazing lecture by EM Education legend Amal Mattu)
- Hypoglycemia is an easily correctable cause of altered mental status – check the glucose (great summary from Life in the Fast Lane)
- The only effective treatment for anaphylaxis is IM epinephrine – give 0.3-0.5mL of 1:1000 IM (check out the 2012 World Allergy Organization 2012 Anaphylaxis update or, if you liked the last link, another summary from Life in the Fast Lane)
- BLS requires calling for help, starting effective CPR and using an AED – stay up to date (if you need a review, sign up for a course from the American Heart Association)
This concludes a case of simulation for dentists. I hope the participating students left with a better understanding of how to effectively treat some of the emergencies that they may see during their careers and enough curiosity to follow some of the links above to learn more.