If any dental emergency occurs in a dental clinic

Stop the treatment right away and remove any dental items from the mouth.
Accommodate the patient in a supine position.
Assess if the patient is conscious or unconscious ( ask questions or try to shake him).
If patients unconscious check for breathing by looking at the chest if its rising or not.
Check for the carotid pulse by placing two fingers at the carotid arterial located on the lateral side of the neck

If patient has a pulse but is not breathing

If patient still unconscious activate EMS by calling 911 and start BSL (basic life support).
Tilt patients head backward by placing one hand on the front and the other hand on the chin pushing towards 12 o’clock.
Open patients mouth and check for any possible objects that can obstruct the patients airway.
If the patients is still not breathing start breathing resuscitation mouth to mouth by pinching the nose and occluding his mouth with your mouth (remember to control patients chin with the index finger so mouth to mouth contact is firm and sealed).
For adults blow slowly two breaths every 2 seconds and if you see that the patient is responding  and there’s a pulse present reduce the time to two slow breaths every 5 seconds.
For a proper breathing resuscitation one should make sure that the chest is rising and falling during the dental emergency resuscitation.
If the chest doesn’t rise then this is an indication of either an airway obstruction or the positioning of the neck is not appropriate.
If the breathing is not slow or the pressure of the breathing is to high then it will cause a an opening of the esophageal way bringing air to the stomach and provoking vomiting which can make the breathing rescue impossible.

If patient is not breathing and doesn’t have a pulse

Start chest compressions by placing a both hands on top of each other and compressing at the lower part of the sternum where ribs join the sternum ( follow the last rib edge that joints sternum until you feel the sternum notch which is located exactly where the lower sternum extremity is located)

The right amount of time between each compression is the same as the amount of time riqured by the clinician to say one-one thousand. For example : Give the first compression and say 1:100 second compression 2:1000 third compression 3:1000. This way you will remember how many compression you have given and
make sure that each compression is given accurately after the proper amount of time.
The compression should be 2 inches in adults whereas in infants its just required gentle pressure.
Once you have given 15 compression and theres still no signs of the patient recovering give two breaths.
The regular time for reassessing the patient is after 4 cycles of 2 breaths and 15 chest compressions.
Continue this cycle untill medical emergency services arive. During the chest compressions you could get tired thats why its always best to have another partner present when performing basic life support.

Remember every dental emergency could be presented with similar symptoms but different causes, so renewing the license every 1-2 years is necessary and mandatory

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What is blood pressure?

When heart contracts blood exerts heart and goes against arterial walls traveling in all parts of the body. This force or pressure created by the contractions of the heart is called blood pressure. A normal heart beats or contractions create a 120 mm/Hg systolic pressure and 80 mm/Hg diastolic pressure.

What is a systolic or diastolic pressure?

Systolic blood pressure is considered the maximum pressure against the arterial walls during cardiac ventricular contraction. This is the number we see on the sphygmomanometer at the first heart beat we hear while performing a blood pressure examination.

Diastolic blood pressure is the number we see on sphygmomanometer on the last beat we hear. Diastolic pressure measures the minimum blood pressure occurring against the arterial walls due to ventricular relaxes. These two numbers identify the blood pressures parameters. As i mentioned earlier the normal range blood pressure readings for an adult are 120/80.

Why do we need to know blood pressure?

By knowing the blood pressure readings we are in able to identify heart activity, functionality, risk of diseases that might occur in the future and any possible emergency that might occur in a dental operatory. Blood pressure readings are a major factor in discovering early cardiovascular mortality that’s why dentists and dental hygienists have the obligation to make accurate readings for new patients that come in the office.

Dental considerations

High blood pressure or hypertension is the number one leading death disease in North America, that’s why taking the right precautions (assessing Vital signs) in preventing dental emergencies are strongly recommended to be done periodically. The patient should be considered an hypertensive patient if the systolic pressure is more then 140 and diastolic is more 90.

When a dental practitioner assesses the blood pressure it is necessary to document the findings, write the date, arm side taken and initials the chart every time the patient comes in the office for a recall. ASA classifications provide dentists and dental hygienists with guidance towards the management of cardiac clients.

Factors influencing blood pressure

AGE - As people age blood pressure rises because the reduction of the elasticity in arteries, causing an increase of the blood pressure. As the blood pressure remains high for a long period of time the client is classified as hypertensive therefore concerns from the dental team need to be addressed appropriately by referring the patient to a physician, and making sure that the patients blood pressure is taken at any recall appointment to avoid any complications during the dental treatment.

RACE - Prevalence of hypertension is lower in the black or Hispanic populations.

WEIGHT - Obese and overweight people tempt to have an elevated blood pressure compare to people the same age but lower in weight. Cholesterol is one of the factors.

STRESS - Cardiac output is controlled by the sympathetic nervous system. When the client is under the influence of stress hormonal levels of adrenaline in blood stream increase and stimulate the sympathetic nervous system, increasing the cardiac output. This makes the heart pump harder and as a outcome increasing the blood pressure.

GENDER - Since the hormonal levels are responsible for controlling the blood stream even the blood pressure will change if we have to different people with a different hormonal production needs. Male differ from female in this point because it’s a known fact that male have a higher hormonal secretion then female. This hormonal variation makes male having a normal higher blood pressure, and female having a normal lower pressure compare to male.

PAIN - Pain can increase B.P. but shock will lower it, sometimes catastrophically.

MEDICATIONS - Medications can increase or decrease the blood pressure. Its very important to review medical history and update it as necessary at each appointment to determine the effect in blood pressure.

TABACCO  CAFFEINE ALCOHOL - All users are subject of having a high blood pressure.

DIURINAL VARIATION – Renal system controls metabolism. A dysphunction of this system might cause uncontrolled blood pressure. Also its important for the practitioner to know that the metabolic rates differ during the day causing increase or decrease in blood pressure.  For example BP in the morning is lower compare to early evening.

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Pulse is the beat of the heart that comes and goes in intervals and can be felt by touching radial artery walls. This is one of the most common sites recommended in certain situation to assess the pulse. The exact location to measure the pulse is the inner wrist on the thumb side. Always use the index and middle finger tips to feel the beating of the radial pulse. We use the two first fingers because they don’t have a pulse of their own as the thumb does.

When the heart pulse (rate) is elevated beyond normal limits Tachycardia occurs. Tachycardia doesn’t indicate heart disease at all times. It can occur due to physical exercises or as a normal response of the heart when stress or fear is experienced by the patient. Bradycardia is the opposite of tachycardia. Bradychardia is a phenomen that indicates a slow heart rate (below 60 BpM, see table).

In case the radial pulse is not found, the Carotid pulse is the best alternative. Carotid pulse is located on the side of the neck. If questions arise to either treat the patient or not medical advice should be required from the patient’s physician. Medical consultation should be done prior to the appointment if the client experiences weak very strong or irregular heart beats associated with other unusual symptoms. All these abnormal pulse readings are indications of heart diseases ventricular failure, high blood pressure etc.

Dental considerations :  Measuring Vital signs is very importand and should be done at each appointment for patients that suffer from heart disease or are future candidates for heart problems ( older adults over 70). Dental practitioners should never underestimate the importance of taking Vital Signs not onlyto avoid emergencies rising in the dental office, but also detecting early heard diseases and other health risks.

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Some factors that affect body temperature.

Physical activities like exercises might increase the body temperature. Hormonal dysfunction or/and hormonal crisis can decrease or increase body temperature. Before the ovulation process body temperature decreases below the normal limits. During the ovulation it increases. Menopause increases  the body temperature as a consequence of hormonal changes.

There’s a time variation that a needs to be considered before taking the body temperature measurements. For example during the beginning of the day early mornings the temperature is the lowest, during the day it rises slowly till it reaches the peak reading ( the highest) during evening time. Stress ( either emotional or physical) is an important factor in increasing the body temperature. The presence of an infection should always be considered an increaser of the body temperature. A dental practitioner should alwas keep in mind that no universal temperature reading is considered normal for all people. The process of body heat production is accompanied with a lost ( i.e sweating) of heat in the same time the sum of this two processes is equal the the Body Temperature  ( heat producer + heat lost = body temperature).

Types of thermometers used to take body temperature

Mercury in glass thermometer.  There’s three types available. Elongated tip that is (used orally), stubby (used for any site) and rectal ( called pear shaped tip). Its said the mercury thermometer is the most accurate in taking the body temperature. It has a low cost and a better reliability then other types. Because of these advantages it is one of the most common used thermometers.

Electronic thermometer. Used orally, rectally and axillary. It increases the clients comfort, easy to read, very efficient for health care workers, but it is not very reliable and it has a higher cost compare to mercury thermometer.

Disposable thermometers. It is not accurate and it comes with a higher cost to use in a dental clinic. The only advantages worth mentioning is infection control since it is disposable.

Tympanic thermometer. Not accurate in children 1-6 years of age. It is very practical to use by the health care workers, short reading time. Its mostly used in hospitals.

Dental Considerations: If the clients exceeds the normal range temperature which it usually is accompanied with other symptoms, then we might need to reschedule the patient another oral care appointment ( unless its an emergency). A referral to see the physician could be the next steep. Caution is shown because the high temperature in general indicates that the body is fighting an infection, and the dental treatment might compromises the immune system reducing the immune response in the infection site or complicating the situation even more. The same situation could rise in a different case scenario. If the temperature is low it could bring the client in a hypothyroidism situation that generally is caused by viral or bacterial infectious agents. Causes of Hypothyroidism can happen as a result of excess alcohol intake as well.

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Introduction of Vital signs

Vital signs include temperature, respiration and blood pressure. Knowing V/S reading helps the dental team identify the clients state of health. Knowing the V/S helps them identify early health problems that might arise during or after the dental treatment.

Some techniques that are used by the Dentist or Dental Hygienist are auscultation ( listening directly or indirectly the sounds produced by the body), palpation, and inspection. An acceptable range of vital signs indicates WNL ( within normal limits) health status. Some normal values for vital signs in children and adults will be presented in the table below.

• If the client is new we have to take baseline readings.
• Anualy is recommended even if the client is WN Limits.
• Every time a significant health change is noticed in clients.
• Before giving any local anesthetic.
• Before the administration of general anesthetic, nitrous oxide.
• Before and after surgical interventions.

Things that need to be considered by the dental practitioner during V/S assessment.

• Try minimizing factors that ca affect V/S readings. ( i.e. Warm and humidity in the room while assessing the temperature of the client)

• Don’t use the same blood pressure cuff between adults and children since the adult cuff is bigger then a child size, therefore it wont be accurate.

• Try minimizing stressful environment, be gentle and explain the procedure to the patient. Show you are caring and you are competent in what you are doing. ( this will give the client an assurance and will decrease anxiety)

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