Prevention of Emergencies

Prevention of Emergencies Oral health care providers must be completely familiar with each patient's medical history and current condition to provide care safely and prevent harm. The most important aspect of preventing a life-threatening emergency may just be in knowing all potential risks, taking precautionary steps, and preparing for the worst case scenario.

A thorough medical history is not only a legal and moral necessity, but can literally be the difference between life and death for some patients. At the very least, it may aid the oral health care practitioner in providing safe and effective treatment for all patients. The medical history questionnaire and interview must contain thorough and relevant questions to accurately record the patient's condition. Dental hygienists should be familiar with the questions and with the drugs being taken by each patient and the possible effects of those drugs. One of the wisest investments a clinician can make to ensure safe treatment is to acquire a concise and specific drug reference book designed for dental practitioners, such as Wynn, Meiller and Crossley's Drug Information Handbook for Dentistry or Gage and Pickett's Mosby's Dental Drug Reference.

Other patient information that may be useful in preventing emergencies can be gained from monitoring of vital signs visual inspection, and function tests as ordered by the dentist. Specific things to look for will be addressed under each relevant condition.

One of the most critical vital signs to monitor is the blood pressure. Hypertension can result in both heart attack and stroke, and can contribute to a myriad of other problems. If at all possible, blood pressure readings should be recorded on a routine basis. In 1993, the Joint national Committee on Detection, Education and Treatment of High Blood Pressure established standards for classifying blood pressure (Table 1). Malamed described a University of Southern California (USC) physical evaluation system that combines the Joint Committee's system with the American Society of Anesthesiology Medical Risk classification system (described later) to provide an easy-to-use system that suggests the following 3:

• If systolic is less than 140 and diastolic is less than 90, the patient should be routinely checked in six months-rated and treated as ASA I.
  
  
• If systolic is 140-159 and/or diastolic is 90-84 the patient should be rechecked for three consecutive appointments and if measurement exceeds these values - rated and treated as ASA II.
  
  
• If systolic is 160 -199 and/or diastolic is 95-114, the patient should be rechecked in five minutes and if still at these values, medical consultation should be done before dental therapy is initiated-rated and treated as ASA III.
  
  
• If systolic is greater than 200 and/or diastolic is greater than 115, the patient should be rechecked in five minutes and if pressure is still levated, immediate medical consultation is indicated-rated and treated as ASA IV.

Anxiety recognition is another important factor that can be determined by questions on the medical history, by communicating with the patient and by observing physical signs and symptoms of anxiety. Specific signs and symptoms include the following:

a. cold, sweaty palms or forehead (diaphoresis);

b. unnaturally stiff posture;

c. the individual fiddles with items in his or her hands;

d. "white-knuckle" syndrome, the person grips the hands, a chair armrest, or other object so tightly that the knuckles turn white from decreased blood circulation; and

e. more severe anxiety may be manifested by increased blood pressure and heart rate, trembling,excessive sweating, and dilate pupils.

The American Society of Anesthesiology (ASA) has provided a classification system for determining medical risk, especially for surgical patients that may be helpful in determining risk and actions to reduce risk for dental patients (Figure 1). The system is not meant to be all inclusive, but is merely a tool to help treat patients in the best possible way. The ultimate decision of whether or not to treat a particular patient, or if a decision is made to treat, the modifications or precautions necessary is most frequently made by the dentist who also assumes the bulk of the liability.

Consultation with the physician is not indicated for every patient who has a medical condition. There are many conditions for which treatment modifications are standard, but if there is any question or doubt in making the best decisions, consulting with the patient's physician or other medical or dental colleagues is recommended. A consultation or referral is simply a request for additional information and/or advice about the medical implications of oral health care treatment. A written request and reply referral is ideal, since there is no doubt about either the question or the answer. The request should be specific, concise and directly to the point. Therefore, a form may be used to standardize and simplify the written request and answer (Figure 2). If there is an immediate need for the information, an informal telephone consult may be done with a request for written follow-up documentation that can be added to the patient's chart. All details of the call should be included in the patient's written treatment progress notes. The written documentation is important for future reference and legal requirements.

Most medical emergencies that occur in the dental office can be prevented by simply using the knowledge gleaned from the health history. It should be emphasized that the clinician must routinely gather information that may help prevent an emergency. Even patients who may have been seen routinely for many years should expect to provide current health information at each appointment. A thorough and complete medical history form is of no use whatsoever unless the information it contains is updated routinely and used to implement procedures and precautions that may be necessary.