Dental offices need standards for medical emergency preparedness (MEP). Recent deaths in dental offices continue to appear in the news and on social media. Outside groups continue to question the validity of dentists who provide sedation and anesthesia. Establishing standards in sedation and MEP within the dental office insulates our profession from outside entities seeking to introduce their agendas or guidelines.
This is an overview of the educational needs and physical items necessary to treat dental patients in that time between the identification of a medical emergency and the arrival of outside assistance. These educational and physical initiatives make up the Six Links of Survival that every dental office must have in place—dentist training, staff training, practice drills, a rapid response plan, emergency medication, and emergency equipment—if it wants to do well during a life-threatening emergency.
Sadly, our profession has no nationwide standards in this area, merely state guidelines, nor are there office inspections covering critical areas such as personnel training, emergency medication and equipment, proper documentation, and simulated emergency readiness. Self-governed office inspections can be biased, so independent third parties would be best for conducting them. Outside entities can assist state dental boards that do not have the manpower to maintain established criteria for office inspections or the dedicated time to do so.
Furthermore, dental malpractice companies do not mandate sedation preparedness or MEP for their insured dentists. Some companies may provide a brief article or oversight on MEP, but they don’t place any directives on their insured dentists to follow the educational and physical initiatives seen in the Six Links of Survival.
Dental malpractice carriers need to be at the forefront of advocating strong MEP among their insureds. Not only is it in the financial interest of both the company and their client, it also is the ethically responsible thing to do for the public at large. Improper medical emergency planning and protocols will lead to negative outcomes.
Emergencies will always continue to be an issue in the dental practice. MEP is critical to promoting the safety of patients and preventing catastrophic outcomes. Emergencies including sedation incidents can, do, and will continue to happen. Only you, the practicing dentist, can take charge and implement the steps that are critical to ensuring patient safety.
You will not get the chance to go back and redo an emergency with a negative outcome. Your decisions could be the difference between a career-defining or a career-ending result. You need to be able to show your due diligence and regular substantiation with MEP and office inspections so you can prove your preparedness if you’re ever challenged.
The Role of Education
Dentist training, staff training, and practice drills represent the educational initiatives in the Six Links of Survival. A rapid response plan, emergency medications, and emergency equipment are the physicial requirements in the Six Links.
Dentists, who are the number one link, must take their role very seriously in developing the other five links. Dentists should participate in emergency medicine lectures either in person or online so they stay current with the latest information regarding MEP on an annual basis.
For example, dentists need to take a course on basic life support (BLS) for healthcare providers that is equivalent to those offered by the American Heart Association (AHA) or the American Red Cross at least every two years. The AHA believes that two years is the absolute maximum between BLS reviews.
Many healthcare providers would benefit from more frequent study and practice. Depending on the nature of the dental practice, the medical health of the anticipated clientele, and the complexity of the services offered, more frequent review may be appropriate. Medical emergency courses are recommended once a year, and some state dental boards now require such training.
The dentist should be the team leader when a medical emergency occurs in the office. A lackadaisical approach to this role will filter down to the staff, and the lack of preparation ultimately will affect any patients suffering from a medical emergency.
If you administer any form of sedation or anesthesia, you should enroll in advanced cardiovascular life support (ACLS) or pediatric advanced life support (PALS) courses.
You also should be able to recognize medical emergencies related to sedation and various forms of anesthesia as well as potential complications from the use of these drugs. This knowledge will allow you to effectively recognize adverse reactions to drugs and implement appropriate interventions.
Patient Risk Factors = Potential Medical Emergencies
Medical emergencies may occur at any moment when you’re treating patients who exhibit particular risk factors, which include but aren’t limited to:
- Geriatric patients
- Pediatric patients
- Medical advances prolonging life
- Advanced surgical techniques
- Longer procedure times
- Increased use of local anesthestics, sedatives, narcotics, analgeics, and antibiotics
- Increased drug combinations including local anesthetics, sedatives, or narcotics
- Medically compromised patients with one or more conditions including diabetes, hypertension, stroke, dialysis, hepatitis, coronary artery disease, peripheral vascular disease, compromised immune systems, obesity, and obstructive sleep apnea
- Medications for single or multiple diseases
- Patients who aren’t compliant with their pharmacological therapy
The patient’s history and physical examination are essential in reducing the risk of a medical emergency in the dental office. Dental offices always should collect adequate information to establish a complete baseline history of all new patients and adequately update the history of all patients returning to the office.
Also, dental offices should design a history format that works best for them. Subjects that should be covered in the history and physical exam include:
- Baseline history
- Past and current medical conditions
- Need for and results of medical consultation
- Baseline vital signs, including pulse, blood pressure, respiration, and temperature
- American Society of Anesthesiologists (ASA) classification
- Airway (or Mallampati) classification
- Body mass index
During the potential patient health history interview, the dental office should obtain the history, address major medical issues, and review systems and any pre-existing conditions. Doses and frequencies of current medications also should be reviewed, including home remedies, nonprescription drugs, vitamins, dietary supplements, and medications prescribed to other people such as friends and family members yet used by the patient anyway.
Some drugs have known associations with some medical emergencies, and members of the staff should know the appropriate medical emergency protocol when patients who use these drugs are treated.
Syncope can be caused by alpha 1-adrenergic receptor blockers (used to treat hypertension), nitroglycerin, some tricyclic antidepressants, and those antipsychotics that inhibit dopamine type 2 receptors and block alpha 1-adrenergic receptors.
Orthostatic or postural hypotension also can be caused by medication in these drug classes. In addition, this condition has occurred in patients taking angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, or beta-adrenergic receptor blockers for hypertension.
Hypoglycemia is associated with oral antidiabetic drugs. These associations are not always obvious, but the dentist should be attentive to the increased risk when patients are taking drugs in these therapeutic categories.
Allergies must be covered in detail so the dentist is made aware of any known pre-existing allergies, either to environmental agents or medications. Allergic reactions in the dental office can result in serious life-threatening symptoms. Recognizing any predisposing history may prevent life-threatening emergencies from occurring.
The patient’s history, general health, and current physical evaluation will indicate if the patient requires medical consultation. The decision to seek medical consultation should be documented in the patient’s record. The reason for the consultation as well as the outcome of such consultation should be clearly placed in the record so the dentist and staff are aware of the result at each subsequent visit.
During the physical examination that the dentist provides for each new patient and every recall, vital signs including blood pressure, heart rate, respiratory rate, and temperature should be recorded. Pulse oximetry also is a great adjunct since it gives you a baseline room air oxygenation saturation rate.
This information should be available and readily accessible in every patient’s chart so if a medical emergency occurs, the dental team and EMS personnel can compare the status of the patient during the emergency with the baseline data.
How to Prepare
The ASA offers help in examining patients by providing its Physical Status Classification System:
- ASA I: A normal, healthy person
- ASA II: A person with a mild to moderate systemic disease that does not limit functionality, such as diabetes mellitus, obesity, essential hypertension, or bronchitis
- ASA III: A person with severe systemic disease that limits functionality, including uncontrolled hypertension, angina pectoris, a history of myocardial infarction, or poorly controlled diabetes melliyus
- ASA IV: A person with severe disease that is life-threatening with or without surgery, such as congestive heart failure, persistent angina pectoris, or advanced heart, renal, or pulmonary dysfunction
- ASA V: A moribund person who has a fatal condition such as a ruptured aortic abdominal aneurysm or pulmonary embolus and is not expected to survive without surgery
Dentists who want to take emergency medicine coursework should look for classes that cover several key areas. For example, courses should review normal physiology with an emphasis on the systems that play important roles during a medical emergency, such as the peripheral nervous, respiratory, cardiovascular, and neurological systems. Caregivers must know what happens where in the body so they know how to treat emergencies.
Also, dentists should be aware of the six P’s of preparation for medical emergencies:
- Prevention: Complete a proper medical history on every patient who comes into the dental office. Be sure to update that history every time the patient visits you. Having your staff also check on this history may help you prevent a medical emergency.
- Personnel: Staffing requirements and task pre-assignments are imperative in every dental office. Your staff is valuable when a medical emergency happens, and resolving these emergencies should be team efforts.
- Products: Monitor your patients’ medications and airway adjuncts. Enough can’t be stated about having equipment such as a glucometer, an automated external defibrillator, an emergency drug kit, and proper airway equipment. If you are involved in any form of sedation or anesthesia, this equipment is a must.
- Protocols: Office manuals outlining planned responses to medical emergencies should be readily accessible by everyone in the office. A medical emergency plan or program should be developed and should remain an ongoing, continual process rather than an occasional event. A one-page document that substitutes for a medical emergency program is not going to be sufficient for the team to be fully ready for a medical emergency.
- Practice: Ongoing training and review should occur in every dental office. With the many medical emergencies that could happen, you must stay up to date to provide proper care. You can’t accomplish successful results with training once a year. The members of your team need to practice monthly and take their roles very seriously.
- Pharmaceuticals: Having the proper medication on hand will serve you best when a medical emergency occurs. There are specific medications that should be present in all dental offices unique to different emergencies. You and your staff should always know the location of these emergency medications. Also, never keep any expired drugs. Use an automatic renewal system so your drugs stay current.
By taking the six P’s of preparation seriously, your team can prevent the seventh P, which is panic. Panic doesn’t do anyone any good during a chaotic event like a medical emergency. When you panic, you’re going to forget what to do. When you forget, you risk your patient’s life. Or to put it another way:
Know planning = no chaos
No planning = know chaos
Medical & Sedation Emergency Preparedness Standards
Dental offices need to be inspected thoroughly by an outside vendor or independent third party to ensure substantiation and due diligence while also removing the potential for bias. How can dentists do well during a medical emergency or sedation emergency when their facility lacks lifesaving medication, equipment, and training?
Deaths due to inappropriately used sedation and anesthesia have become a critical safety issue in dentistry. Deaths have even occurred in dental offices due to local anesthesia. As a result, criteria are needed for reviewing offices to ensure they are properly prepared and equipped.
These customized audits should focus on every dental office regardless of whether or not a dentist uses sedation there. These audits need to be performed at least every three years to ensure everything is current and up to date.
Also, these audits should cover local anesthesia and/or nitroius oxide, pediatric sedation, minimal sedation, moderate sedation, and deep sedation or general anesthesia. No matter which type of sedation or anesthesia is being delivered, each audit should examine:
- Personnel qualifications and training
- Proper documentation
- The office facility and equipment
- Emergency medications
- Written emergency protocols for medical and sedation emergencies
- Emergency equipment such as basic ventilation and capnography equipment
In addition to meeting these criteria for office inspections, dentists should conduct monthly drills to practice their response to potential sedation and anesthesia emergencies. The entire staff should practice with a different emergency each month. These drills should be recorded in a log book to prove that they have taken place.
Also, offices should use anesthesia and sedation emergency checklists to prevent sedation- or anesthesia-induced medical mishaps. Plus, personnel should participate in medical emergency training or attend a medical emergency lecture once a year. If your office administers any type of sedation, participate in a course that specifically covers sedation each year too.
CANAL Treatment and Training
Medical emergencies happen in dental practices, and office personnel must be ready to react and respond. The five most significant types of emergencies can be summed up with the acronym CANAL, which stands for Cardiac, Airway, Neurological, Allergic (and drug) reaction, and Loss of consciousness. Caregivers should be prepared to provide specific treatment for each of these situations.
Cardiac emergencies include and require:
- Chest pain: oxygen, nitroglycerin
- Myocardial infarction: oxygen, aspirin
- Dysrhythmias: advanced cardiac life support (ACLS) drugs
- Sudden cardiac arrest: automated external defibrillator (AED)
- Ventricular fibrillation: ACLS drugs
Airway emergencies include and require:
- Foreign body obstruction: airway techniques
- Bronchospasm; albuterol, oxygen, epinephrine
- Larygnospasm: oxygen, succinylcholine
- Hyperventilation: calm the patient, rebreath carbon dioxide
- Aspiration/emesis: airway techniquesthe
Neurological emergencies include and require:
- Seizures: anticonvulsant
- Transient ischemic attack: immediate medical attention
- Stroke: immediate medical attention
- Panic attack: antianxiety agent
- Anxiety: antianxiety agent
Allergic and drug reactions include and require:
- Latex allergy: diphenhydramine
- Anaphylaxis: epinephrine, diphenhydramine, albuterol, dexamethasone
- Allergic reaction: diphenhydramine
- Epinephrine overdose: maintain airway, provide oxygen, reassure the patient
- Benzodiazepine overdose: flumazenil
- Local anesthetic overdose: oxygen
- Narcotic overdose: narcan
Loss of consciousness includes and requires:
- Syncope: ammonia
- Sudden cardiac arrest: AED
- Hypoglycemia: glucose
- Stroke: immediate medical attention
Plus, the personnel of every dental office should have the appropriate level of training for the services that the practice provides. All offices should maintain a basic level of training.
Next, practices that offer moderate sedation by nitrous oxide, oral sedatives, intravenous medications, or any combination thereof would require additional education and practice.
Offices that offer deep sedation or general anesthesia where respiratory depression is an anticipated byproduct of treatment and some medications may have cardiovascular effects would require advanced training.
On the basic level, all dentists and members of the staff of all offices should be currently certified in basic life support for healthcare professionals by the AHA or an alternative CPR program recognized by their state dental board.
Plus, every two years, every dentist in the office should take a course of at least four hours on medical emergencies that cover office preparation for an emergency, identification of a medical emergency, and response to a variety of medical conditions.
Also every two years, each staff member in the office should take a course of at least 2 hours about medical emergencies covering how they can best assist the dentist during a medical crisis. Staff providing dental care under general supervision should have the same coursework as dentists: four hours on preparation for, identification of, and response to emergencies.
Additionally, each office should maintain a medical emergency plan that covers identification and responses to syncope, hypoglycemia, hyperventilation, hypertension, hypotension, myocardial infarction, respiratory arrest, cardiac arrest, stroke, seizure, and uncontrolled bleeding.
Offices should hold and document mock drills at least every three months as well, assisting the dentist and dental team in identifying a medical crisis and practicing their respective roles. Plus, offices should maintain a drug kit containing aspirin, a ventolin inhaler, diphenhydramine, epinephrine, ammonia inhalants, glucose tablets, glucose gel, and nitroglycerin tablets. They also should have and maintain:
- Paper bags
- Syringes and needles
- A flashlight
- A portable oxygen tank with a regulator
- A reserve supply of oxygen (either a second tank or a nitrous oxide unit)
- Extension tubing
- Double-ended male oxygen adapters
- Nasal canulae
- A non-rebreathing mask
- Oral-pharengeal airways or an alternative device such as I-gel
- A bag-valve-mask with reservoir
- Equipment to provide a cricothryroidotomy
- A glucose monitor with strips and lancets
- An AED with pads
- A stethoscope
- Manual sphygmomanometers in at least three sizes
At the basic level, dentists should be proficient in identifying and treating:
- Myocardial infarction
- Cardiac arrest
- Diabetes (insulin shock)
- Sudden cardiac arrest (SCA)
- Cerebrovascular accident (stroke)
- Foreign body obstruction (FBO) with airway management
- Local anesthetic toxicity
In addition to meeting all of the standards of the basic level, dentists who offer moderate sedation by nitrous oxide, oral sedatives, intravenous medications, or any combination thereof should take a course of at least four hours that covers patient monitoring, recognition of the state of unconsciousness, pharmacology of medications being used and reversing agents, and emergency airway management during unconsciousness every two years.
Additionally, every staff member should take a course of at least two hours that covers assisting the dentist in patient monitoring, recognition of the state of unconsciousness, pharmacology of medications being used and reversing agents, and emergency airway management during unconsciousness, also every two years.
These offices should maintain an emergency plan that covers the overdose of administered medications and airway management. Plus, in addition to the quarterly drills on general medical emergencies, there should be two drills (six total) that address situations unique to moderate sedation. Reversing agents for any medications that are offered should be on hand as well. And, these offices should have and maintain pulse oximetry exuipment and a pre-cordial stethoscope.
At the intermediate level, dentists should be proficient in identifying and treating all of the emergencies described at the basic level, plus:
- Benzodiazepine overdose
- Narcotic overdose
- ACLS algorithms
In addition to basic and intermediate training, dentists in offices that offer deep sedation or general anesthesia where respiratory depression is an anticipated byproduct of treatment and some medications may have cardiovascular effects should be currently certified in ACLS for healthcare professionals by the AHA or an alternative CPR program recognized by their state dental board. If pediatric sedation is occurring, then they also should be certified in PALS for healthcare professionals by the AHA.
Every two years, every dentist in the office should take a course of at least four hours that covers patient monitoring, recognition of the state of unconsciousness, the pharmacology of medications being used and reversing agents, and emergency airway management during unconsciousness.
Also every two years, every staff member in the office should take a course of at least two hours that covers assisting the dentist in patient monitoring, recognition of the state of unconsciousness, pharmacology of medications being used and reversing agents, and emergency airway management during unconsciousness. Some staff members may be warranted to participate in ACLS and PALS.
The office’s emergency plan should cover the overdose of any administered medications and airway management. Along with the quarterly drills on general medical emergencies, there should be drills that address situations unique to deep sedation and general anesthesia. Reversing agents for any offered medications, ACLS medications, and PALS medications all should be kept in stock. And, these offices should keep and maintain:
- Pulse oximetry equipment
- A pre-cordial stethoscope
- Advanced airway management equipment
- Electrocardiogram monitors
At the advanced level, dentists should be proficient in identifying and treating all of the emergencies described at the basic and intermediate levels.
Dental healthcare practitioners don’t know when they will face a medical emergency that will require the use of the Six Links of Survival. That is why they should stay up to date when it comes to responding to medical emergencies. Develop a regular protocol with your staff to rehearse various emergencies using your emergency drugs and equipment every month.
None of us know when our patient’s life may depend on our readiness. Should you lose a patient in your office, it will be on you. Not your staff, not your dental board, not your partner, not your malpractice company, but you.
Were you ready? Did you complete enough training? Did you have your office inspected to identify any strengths or weaknesses? Did you practice mock drills? Did you fail to keep up with the material presented in this article? Yes, your state dental board or malpractice company may have provided some guidelines, but did you do enough in your office to truly prepare? As stated earlier, will this be a career-defining or career-ending medical emergency?
Please do everything possible to make yourself defensible and representable by proper documentation, training, and preparedness. Your defense team will certainly appreciate it.
if you don’t have the knowledge to respond to an emergency, and you haven’t conducted your office emergency drills to perfection, when the pressurized emergency happens for real—and it is not a question of if, but when—you are are going to sink to the level of your training, meaning that you could lose a patient’s life.
Are you ready to accept something like this? Treat this matter seriously to prevent failures at many levels by preparing yourself and your team and reducing the potential for a catastrophic event that can affect your livelihood at so many levels. Get prepared, and stay prepared!
The author or publisher is not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting from any material contained herein. This publication includes information relating to general principles of medical care that should not be construed as specific instructions for individual patients. Manufacturers’ product information and package inserts should be reviewed for current information, including contraindications, dosages, and precautions.
The purpose of this program is to provide information only, rather than advice or opinion. Dental healthcare professionals accessing this program agree to assume full responsibility for the use of this information and hold harmless any third party, including but not limited to the author and publisher of this program for any claim, loss, injury, or damage arising from the use or dissemination of information within this program.
It is the sole responsibility of the dental healthcare practitioner to determine drugs, doses, and administration techniques based upon their overall assessment and evaluation of each individual situation. Dental healthcare practitioners are advised to continually seek confirmation of this material with other reputable sources and are advised to stay current with information as it becomes available.
Dr. Roberson obtained his DMD at the University of Mississippi School of Dentistry. He performed his residency in oral and maxillofacial surgery at the University of Cincinnati Medical Center. He is a dual-board certified oral and maxillofacial surgeon with board certifications from the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology. He is a member of the American College of Oral & Maxillofacial Surgeons, American Dental Association, American Academy of Oral Medicine, American Academy for Oral Systemic Health, Mississippi Dental Association, and South Mississippi Dental Association. He can be reached at firstname.lastname@example.org.