National Emergency Standards Will Increase Dental Patient Safety

John B. Roberson, DMD

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Dental offices need a national standard for medical emergency preparedness (MEP) and inspections. Well publicized deaths in dental offices are prompting outside groups to question the validity of dentists who provide sedation and anesthesia. By establishing standards in sedation and MEP along with dental office inspections, though, dentistry can insulate the profession from these other entities looking to impose their own guidelines and agendas.

This is an overview of the educational requirements and physical items necessary to fulfill the needs of a dental patient in that time period between the identification of a medical problem and the arrival of outside assistance. They comprise the Six Links of Survival that every dental office must have in place to guarantee the safety of its patients during a life-threatening emergency.

The Six Links of Survival

The educational requirements of the Six Links of Survival include:

  • Dentist training
  • Staff training
  • Mock practice drills 

The physical items include:

  • A written emergency plan
  • Emergency medications
  • Emergency equipment

Sadly, our profession has no nationwide standards in any of these areas. We merely have state guidelines. The same could be said about dental office inspections covering critical areas such as personnel training, emergency medications and equipment, proper documentation, and simulated emergency readiness.

Self-governed office inspections can be biased, so independent third parties would be best. Outside entities can assist state dental boards that don’t have the manpower to maintain established criteria for inspections or the dedicated time to perform them. 

Also, dental malpractice companies don’t have any requirements regarding sedation and anesthesia, MEP, or dental office inspections. Some companies may provide a brief article about MEP, but they don’t have any directives for their insured dentists to follow in regards to the Six Links of Survival. Dental malpractice carriers, though, need to be at the forefront of advocating for strong MEP and dental office inspections among their insureds. It is the ethically responsible thing to do for the public.

Improper medical emergency planning and protocols, along with poorly inspected dental offices, will lead to negative outcomes. Medical emergencies will always continue to be an issue in dental practices. Preparedness is critical to promoting the safety of patients and preventing catastrophic outcomes.  

Only the practicing dentist can take charge and implement critical procedures during an emergency that will save the patient’s life. Dentists will not get the chance to go back and redo emergencies that have negative outcomes. The decisions they make during an emergency could be career-defining or career-ending. Dentists must be able to prove their due diligence through MEP and office inspections if they are ever challenged. 

The average response time for medical emergency services (EMS) to respond to a 911 call can be 11 minutes in an urban setting and 15 minutes in a rural setting—and that’s when the primary EMS unit is available and not responding to another call, necessitating the dispatch of an alternate squad. Consequently, dental offices should be prepared to manage a medical crisis for up to 30 minutes without outside assistance. Preparation begins with training and drilling. 

Training and Drilling

Every member of the dental team should take a Basic Life Support (BLS) class at the healthcare provider level equivalent to those offered by the American Heart Association (AHA) or the American Red Cross at least every two years. According to the AHA, two years is the absolute maximum time that should be allowed between BLS reviews.

Many healthcare providers would benefit from even more frequent study and practice. Depending on the nature of the dental practice, the medical health of the clientele, and the complexity of services offered, more frequent review may be appropriate.

Dental personnel also should take one or more continuing education courses about medical emergencies every two years. Regardless of any state licensing requirements, the coursework over the two-year period should review normal physiology with an emphasis on the systems that play important roles during a medical emergency, including the peripheral nervous system, the respiratory system, and the cardiovascular system. Continuing education courses also should cover the six P’s of preparation for a medical emergency: 

  • Prevention: proper use of a medical history
  • Personnel: staffing requirements and task pre-assignments
  • Products: monitors, medications, and airway adjuncts
  • Protocols: office manuals to develop a planned response
  • Practice: ongoing training and review
  • Pharmaceuticals: having the proper medication on hand

Further, continuing education coursework should cover the recognition of and response to medical problems common to dental offices, including allergic reactions, anaphylaxis, asthma, blood pressure anomalies (hypertension and hypotension), cardiovascular disease (angina, infarction, and cardiac arrest), cerebrovascular accident (stroke), diabetes, foreign body obstruction with airway management, hyperventilation, local anesthetic toxicity, seizures, sudden cardiac arrest, and syncope.

Medical emergencies can occur when the dentist isn’t physically on the premises. Or, the medical crisis may happen to the dentist. That’s why all staff need to be trained how to handle an emergency. Although not universally available, dental professionals should favor participatory training with hands-on involvement. It also is imperative to train newly hired staff to be competent and productive members of the team during a medical emergency. Practices should have a documented plan to ensure this training happens.

In addition to training, practices need to conduct mock drills or practice medical emergency protocols at least every other month and ideally every month. These drills should not be mere lectures but opportunities for the dentist and staff to interact. The equipment used in particular scenarios should be demonstrated. Plus, the date of the drill, who attended, and the topic covered all should be documented. Mock drills may be developed within the office or purchased from an outside vendor. 

Drills should be dedicated to individual staff assignments during any medical emergency. Drill scenarios should include allergic reactions, anaphylaxis, asthma, blood pressure anomalies (hypertension and hypotension), cardiovascular disease (angina, infarction, and cardiac arrest), cerebrovascular accident (stroke), diabetes, foreign body obstruction with airway management, hyperventilation, local anesthetic toxicity, seizures, sudden cardiac arrest, and syncope. 

The Physical Items 

Each dental office should have an easily accessible written medical emergency response plan kept in the clinical area of the facility, although multiple copies of the plan placed throughout the office may be appropriate for some practices.

Plans should detail specific task assignments for each member of the dental team, both full-time and part-time. All tasks must be covered, even with a reduced staff. Also, plans should provide general instructions for calling EMS, including the address of the office and the best point of entry into the office for EMS personnel. Further, plans should provide a general review of CPR guidelines, airway management, and patient positioning according to the Trendelenberg or Semi-Fowler’s model.

Plans additionally should detail the signs and symptoms of and provide an algorithm for responding to allergic reactions, anaphylaxis, asthma, blood pressure anomalies (hypertension and hypotension), cardiovascular disease (angina, infarction, and cardiac arrest), cerebrovascular accident (stroke), diabetes, foreign body obstruction with airway management, hyperventilation, local anesthetic toxicity, seizures, sudden cardiac arrest, and syncope. 

The dental office should create its own emergency response plan or purchase one from a vendor, supplemented with office-specific information. Also, offices offering dental hygiene services under general supervision should have a set of supplemental algorithms for when the dentist is not on the premises. 

The list of necessary emergency medications varies in dental offices varies based on the nature of the dental practice, the health of the anticipated clientele, and the complexity of the services offered. However, all dental offices should keep the following medications on hand: 

  • One bottle of 25 aspirin (81-mg chewable tablets)
  • One albuterol inhaler
  • Nitroglycerin, either 0.4-mg tablets or spray
  • Two 50-mg/cc ampules of diphenhydramine
  • Two 1-mg/cc (1:1000) ampules of epinephrine
  • One box of 10 ammonia inhalants
  • One 10-count vial of 15-mg glucose tablets
  • One tube of instant glucose

As part of your documented emergency response plan, schedule regular inventory inspections and designate one person to check and document these medications to ensure that none of them will expire before the next anticipated inspection.

Dental offices also should keep an adequate number of 1-cc/25 Ga x 5/8-inch and 5-cc/22 Ga x 1-inch syringes for the delivery of medications via subcutaneous, intramuscular, or sublingual techniques. 

Offices that don’t routinely load syringes are encouraged to purchase epinephrine and preloaded devices such as EpiPens. Some states don’t permit EMS units to carry epinephrine, which has a short half-life and may need to be re-administered. Consequently, the epinephrine inventory may need to be increased based on the length of time it takes for EMS to respond and transport the patient to the nearest emergency room. 

Monitors should be available as well. For example, dental practices should have a glucose monitor, though inspection is required to ensure its battery is working and its test strips have not expired. Practices also should have a stethoscope and options for taking blood pressure. 

Aneroid sphygmomanometers typically are made with the cuff permanently attached, so multiple sizes are necessary. Dental offices need at least three sizes: adolescent (or small adult), standard adult, and large adult. Practices with pediatric patients may need different or a wider range of sizes.

Automatic blood pressure machines designed for home monitoring are inaccurate at low blood pressures and should not be relied upon during an emergency. Hospital-grade automatic blood pressure machines may be reliably used, but a manual backup should be available in the event of device failure. 

Oxygen sources should include a portable oxygen source, including an E-tank, holding apparatus, regulator, and universal oxygen port. There also should be a supplemental oxygen source such as a second E-tank of oxygen or a nitrous oxide unit. A portable nitrous oxide unit with multiple oxygen tanks would meet the requirement for both an oxygen source and a reserve, if it is fitted with a universal oxygen port.

To treat breathing patients during an emergency, offices should have three nasal cannulas and three non-rebreathing masks. To treat non-breathing patients, offices should have a set of oral-pharyngeal airways in seven sizes, a pocket mask, and a disposable bag-valve-mask, commonly called a BVM or an Ambu bag.

Patients with an obstructed airway that cannot be cleared by noninvasive means will require a commercially available cricothyrotomy kit or a 10-Ga angiocatheter, with a 5-cc syringe with the needle removed and a No 7 endotracheal tube.

Other necessary supplies include a paper bag, backup suction, Magill forceps, a thermometer, medical tape, a flashlight, a penlight, and pen and paper to record the history of the event. Commercial forms are available for recording as well.

Patient Risk Factors

Some patients, such as geriatric and pediatric patients, are at greater risk for medical emergencies than others. Other risks include medical advances that prolong life, advanced surgical techniques, longer procedure times, and the increased use of local anesthetics, sedatives, narcotics, analgesics, and antibiotics.

Increased drug combinations involving local anesthetics, sedatives, and narcotics present risks as well. Patients who don’t comply with their pharmacological therapy also are at greater risk. Conditions that further increase risks include coronary artery disease, peripheral vascular disease, obesity, and obstructive sleep apnea.

Finally, medically compromised patients who have a disease or multiple diseases such as diabetics, hypertensives, stroke victims, dialysis patients, hepatic patients, and immunocompromised patients present greater risks for medical emergencies, especially if they are on multiple medications for multiple diseases.

One of the best ways to reduce the risks of a medical emergency in the dental office, then, is to get the patient’s medical history and perform a physical examination. Of course, this only reduces the risks, as medical emergencies cannot be completely prevented. That’s why all dental professionals need to be prepared.

The dental staff always should collect adequate information to establish a complete baseline history on all new patients and update the history of each returning patient. Each dental office should design a history format that works best for its personnel and records keeping system. 

The history and examination need to cover the baseline history, medications, past and current medical conditions, the need for and results of any medical consultations, body mass index, airway classification using the Mallampati score, and baseline vital signs, including pulse, blood pressure, respiration, and temperature. Pulse oximetry is a great adjunct, as it provides a baseline for the room’s air oxygenation saturation rate.

The baseline vital signs should be available and readily accessible in every patient’s chart so that if a medical emergency does occur, the dental team can compare the patient’s status during the emergency to the baseline and provide that information to EMS personnel when they arrive.   

Allergies to environmental agents or medications must be covered as well and in detail because allergic reactions in the dental office can result in serious life-threatening symptoms. Recognizing allergies in the patient’s history can prevent life-threatening emergencies from occurring. 

Plus, the history should include the American Society of Anesthesiologists (ASA) Classification of Physical Status:

  • ASA 1: A normal, healthy person
  • ASA 2: A person with mild to moderate systemic disease that doesn’t limit function, such as diabetes mellitus, obesity, essential hypertension, or bronchitis
  • ASA 3: A person with severe systemic disease that limits function, such as uncontrolled hypertension, angina pectoris, history of myocardial infarction, or poorly controlled diabetes mellitus
  • ASA 4: 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 5: A moribund person who is not expected to survive regardless of surgery, such as patients with a ruptured aortic abdominal aneurysm or pulmonary embolus
  • ASA E: A person who needs emergency surgery 

The patient’s general history and current physical evaluation should provide dental professionals with the information they need 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 its outcome should be in the record as well so the dentist and staff are aware of its results at each subsequent dental visit.

Levels of Preparation

The levels of required emergency preparation vary, from basic to intermediate to advanced, based on the types of procedures that each dental office performs and the types of patients that it serves. 

The basic level applies to all dental offices. All dentists and members of the staff should hold current certification in BLS for Healthcare Professionals by the AHA or an alternative CPR program recognized by their state dental board. 

Every two years, all dentists and members of the staff under general supervision should take a course of at least 12 hours in medical emergencies covering office preparation for an emergency, identification of a medical emergency, and response to a variety of medical conditions. Also every two years, all other members of the staff should take a course of at least 12 hours in medical emergencies covering how they can best assist the dentist during a medical crisis.

The office should maintain a medical emergency plan that covers identification of and responses to syncope, hypoglycemia, hyperventilation, hypertension, hypotension, myocardial infarction, respiratory arrest, cardiac arrest, stroke, seizure, and uncontrolled bleeding.

Plus, the office should hold and document mock drills that assist the dentist and dental team in identifying a medical crisis and practicing their respective roles at least every three months. The office also should maintain a drug kit including aspirin, a Ventolin inhaler, diphenhydramine, epinephrine, ammonia inhalants, glucose tablets, glucose gel, and nitroglycerin tablets.

At the basic level, dental offices should have: 

  • Paper bags
  • Syringes and needles
  • A flashlight
  • A portable oxygen tank with regulator
  • A reserve supply of oxygen (either a second tank or nitrous oxide unit)
  • Extension tubing
  • Double-ended male oxygen adapters
  • Nasal canulae
  • A non-rebreathing mask
  • Oral-pharyngeal airways or an alternative device like I-gel
  • A bag-valve-mask with reservoir
  • Equipment to provide a cricothyroidotomy
  • A glucose monitor with strips and lancets
  • An automatic external defibrillator with pads
  • A stethoscope
  • Manual sphygmomanometers in at least three sizes

Dental offices that require basic levels of preparation should be proficient and competent in treating allergy/anaphylaxis, angina, asthma, cardiac arrest, cerebrovascular accidents (stroke), diabetes (insulin shock), emesis/aspiration, foreign body obstruction with airway management, hypertension, hyperventilation, hypotension, local anesthetic toxicity, myocardial infarction, seizures, sudden cardiac arrest, and syncope.

Dental offices that offer moderation sedation by nitrous oxide, oral sedatives, intravenous medication, or a combination of these means should have an intermediate level of emergency preparation. The intermediate level includes all of the standards of the basic level, as well as additional conditions. 

For example, every two years, each dentist in the office should take a course of at least 12 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. Also every two years, each staff member should take a course of at least 12 hours covering how to assist the dentist in these areas.

Plus, dental offices at the intermediate level should have a medical emergency plan that covers the overdose of the medications that are being administered and airway management. Along with the quarterly drills on general medical emergencies, these offices should run two additional drills for a total of six that address situations unique to moderate sedation. These offices should have reversing agents for any medications offered, pulse oximetry equipment, and a pre-cordial stethoscope as well.

Offices that offer deep sedation or general anesthesia where respiratory depression is an anticipated byproduct of treatment and some medications may have cardiovascular effects require advanced levels of preparation.

In addition to the training required at the intermediate level, all dentists in the office should be current in Advanced Cardiovascular Life Support (ACLS) for Healthcare Professionals by the AHA or an alternative CPR program required by their state dental board. If pediatric sedation is occurring, they also should be current in Pediatric Advanced Life Support (PALS) for Healthcare Professionals by the AHA. Some staff members may be required to participate in this training as well. 

In addition to the quarterly drills on general medical emergencies, offices that require advanced preparation should conduct drills that address situations unique to deep sedation and general anesthesia. These offices also should maintain reversing agents for any medications offered as well as ACLS and PALS medications. Equipment should include pulse oximetry, a pre-cordial stethoscope, capnography, advanced airway management equipment, and EKG monitors.

Dentists in offices that require intermediate and advanced levels of preparation should be proficient and competent in treating all of the emergencies that may occur in basic offices as well as ACLS algorithms, benzodiazepine overdose, laryngospasm, and narcotic overdose. 

The Patient’s Perception

In 2017, Dr. Larry Sangrik wrote a white paper for the American Association of Dental Boards recapping the results of a survey that assessed the dental community’s overall awareness of how to respond to medical emergencies during treatment. All regions of the United States were represented in the survey’s results.

All of the patients who were surveyed had a general dentist and had been seen within the previous two years. Also, 69% of the respondents were in practices with one or two dentists. Plus, 77% of these practices were privately owned, 11% were part of a dental services organization, and 13% of the patients were unsure.

The survey asked patients if they believed a standard of care for MEP was practiced based on what a “reasonable” patient would expect. First, it asked if the dental practice responded to emergencies with what is being taught on the subject, both in school and in continuing education courses. Second, it asked if what is being taught is reasonable to expect from a typical dentist.

The survey found that, in addition to BLS, 65% of patients believe dentists should receive medical emergency training at least every two years. Wisconsin mandates such training. Also, more than 50% of patients believe there should be training every years. According to the survey, 72% of patients are confident that their personal dentist had met this expectation, while 10% believed their dentist had not, and 16% were unsure.

Furthermore, in addition to BLS, 66% of patients believe that all dental staff should receive medical emergency training at least every two years, with more than 50% believing it should happen every years. Plus, 64% of respondents were confident that their personal dentists had met this expectation for their staffs, while 15% believed they had not, and 21% were unsure.

When it comes to mock drills, 61% of patients said they were “important” or “extremely important.” Only 12% believed that mock drills were of limited importance. Also, 40% of patients were confident that their personal dentist practiced such drilling, while 60% were unsure. 

The survey also asked about written emergency guides, and 80% of patients said they were important. Illinois mandates the use of written emergency guides. Also, 58% of patients were confident that their dental office had a written emergency guide, while 42% were unsure.

In terms of emergency supplies, 62% of patients were confident that their dentist had the seven emergency medications suggested by the ADA, while 38% were unsure. Also, 76% believed their dentist had supplemental oxygen for non-breathing patients, while 7% said no and 17% were unsure.

Most offices that don’t perform oral surgery, however, do not have supplemental oxygen. But while 69% of patients believe their dentist has supplemental oxygen on hand for non-breathing patients, 10% did not, and 21% were unsure.

When patients were asked about other gear, 62% believed their dentist had three sizes of blood pressure cuffs, and 38% did not; 52% believed their dentist ha a glucose monitor, and 48% did not; and 62% believed their dentist had an AED, and 38% did not.

Then, the survey asked patients how much they would be willing to pay per appointment to ensure that their dentist was compliant in all six areas of MEP:

  • $5 per appointment: 32%
  • $2 per appointment: 21%
  • $1 per appointment: 19%
  • $0.50 per appointment: 2%
  • Nothing: 25%

Patients also were asked what they would do if they learned their dentist was negligent in one of the six areas of MEP:

  • 24% would report the matter to the dental board with the expectation that the board would levy a penalty.
  • 20% would quietly change dentists.
  • 36% would confront the dentist and stop treatment until they were assured of changes.

That’s four out of five patients who would take action. 

Dental Office Inspections

Dentists and their staffs cannot expect to 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 patient safety issue in dentistry, so criteria are needed for reviewing dental offices to ensure they are properly prepared and equipped. 

Every dental office, whether or not it uses sedation, should have a sedation anesthesia medical emergency readiness inspection (SAMERI) at least every three years to ensure that the office’s equipment and practices are up to date. These inspections should be conducted thoroughly by an outside vendor or independent third party to ensure substantiation and due diligence while removing the potential for bias. These inspections would cover: 

  • Local anesthesia and/or nitrous oxide
  • Pediatric sedation
  • Minimal sedation
  • Moderate sedation
  • Deep sedation/general anesthesia

No matter which type of sedation or anesthesia is being performed, each audit also should include: 

  • Personnel qualifications and training
  • Proper documentation
  • Office facilities and equipment
  • Emergency medications
  • Written emergency protocols for medical/sedation emergencies
  • Emergency equipment such as basic ventilation equipment and capnography

The SAMERI surveyor should assess the dental office to see if it is proficient in responding to emergencies including allergies and anaphylaxis, angina, asthma, cardiac arrest, cerebrovascular accidents such as stroke, diabetes and insulin shock, emesis and aspiration, foreign body obstruction with airway management, hypertension, hyperventilation, hypotension, local anesthetic toxicity, myocardia infarction, seizures, sudden cardiac arrest, and syncope. Having the clinic check off an itemized list and say “Yes, we are proficient” is not enough.

Dentists who use any form of advanced anesthesia should be competent enough to handle all of these emergencies also should be able to handle ACLD algorithms, benzodiazepine overdoses, laryngospasms, and narcotic overdoses. 

Plus, the SAMERI surveyor should go through each piece of emergency equipment to verify that it is in good condition and fully operational. The surveyor also should review the medical and/or sedation emergency training log book showing when monthly emergency drills were practiced. 

Dentists should further incorporate anesthesia and sedation emergency checklists to prevent anesthesia or sedation induced medical mishaps. Checklists provide a proven track record that reduces errors and mishaps, potentially saving lives. Offices also should participate in a medical or sedation emergency training lecture once a year. 

The National Spotlight

The number of dental patients who died or are harmed due to inappropriately administered sedation and anesthesia in dental offices is increasing and continues to make the news. These horrible stories also are going viral on social media sites. Root cause analyses of these events clearly show that when an adverse outcome occurs, applicable sedation and anesthesia guidelines were violated, oftentimes on many fronts.   Because of these guidelines, both the public and government officials are now asking why these events are happening and what sort of oversight is in place.

The dental profession has reached a critical stage. It either must do a better job of policing itself or run the risk of an outside entity stepping in. For example, the California Society of Anesthesiologists voiced its concerns with the Dental Board of California after two children died under anesthesia in dental office settings.

So what will happen the next time failures occur on multiple levels in a dental office, leading to tragedy? Is the dental profession willing to take the chance that a medical association such as the American Society of Anesthesiology or American Association of Nurse Anesthesiologists will assume the oversight function of anesthesia and sedation services in dental offices? Or course not, and dentists should do everything they can to insulate themselves from these outside entities.

The profession should institute these recommendations:

  • Mandate MEP standards for dentists within the basic, intermediate, and advanced level as described here.
  • Mandate 12 hours of MEP training every two years for all dentists, hygienists, and assistants. The 12 hours may be an onsite lecture or online course. The team approach is best for MEP.
  • Mandate SAMERI for all dental offices every three years utilizing an outside entity.
  • Mandate AEDs in all dental offices.
  • Mandate BLS training for all dentists, hygienists, and assistants.

Conclusion 

No dental healthcare practitioner can determine when he or she will face a medical emergency that will require the Six Links of Survival. That’s why dental healthcare practitioners should stay up to date when it comes to medical emergencies and the drugs and equipment used to treat them. Dentists also need to maintain a professionally inspected dental office on a regular basis and develop a regular protocol with their staff to rehearse various emergencies using their emergency drugs and equipment every month.

There are state guidelines for dental office inspections, but there are no national standards. SAMERI needs to become the standard for dental offices. Establishing standards further insulates dentistry from outside entities seeking to introduce their agendas or guidelines. 

SAMERI should cover personnel training, emergency medications and equipment, proper documentation, and simulated emergency readiness. Office inspections that are self-governed can show a bias, which could lead to overlooked items, so independent third parties would be best for performing them. Outside entities can assist state dental boards who do not have the manpower to maintain established criteria for office inspections or the dedicated time to do so. 

Dental malpractice companies do not require their insured dentists to conduct office inspections, so they should take the lead in promoting SAMERI practices among their insureds. Doing so would help their insured dentists be more defensible in the event a negative outcome happens in one of their dental offices.

Medical and sedation emergencies can, do, and will continue to happen. Although dental office inspections can be recommended, only the practicing dentist and staff can take charge and implement them. You will not get a second chance to save a patient’s life. Your decision to conduct inspections could be a defining moment in your career. 

It is advised that you be able to show that office inspections were performed in your practice if you are ever challenged. This doesn’t mean that your inspection should be a one-time event. Instead, inspections should be recurring events, with a thorough and complete inspection or SAMERI every three years.   

If you don’t know how to respond to an emergency, and you haven’t drilled your responses to perfection, then when a pressurized emergency happens for real (and it is not a question of if, but when), you are going to sink to the level of your training, and you may lose a patient’s life. Are you ready to accept that responsibility? Treat the need for preparation seriously if you want to prevent failures at multiple levels by preparing yourself and your team and reducing the potential for a catastrophic event.

Disclaimer: The author and publisher are not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting from any material in this article. 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 article is to provide information only, rather than advice or opinion. Dental healthcare professionals accessing this article 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 article for any claim, loss, injury, or damage arising from the use or dissemination of information within this article. 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 drjohnroberson@megagate.com.

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