MADH22O • Massachusetts Dental Hygienists and Assistants 2022-2023

Table of Contents

MADH22O • Massachusetts Dental Hygienists and Assistants 2022-2023

How to Receive Credit

NetCE 5 Hour Course #54051 • Infection Control for Dental Professionals

54051 • Infection Control for Dental Professionals

1. INTRODUCTION

2. OSHA REGULATIONS

3. MODES OF TRANSMISSION

4. BLOODBORNE PATHOGENS

5. PREVENTION STRATEGIES

6. ENVIRONMENTAL CONTROL MEASURES

7. ENGINEERING AND WORK PRACTICE CONTROLS

8. PROTECTING DENTAL HEALTHCARE WORKERS

9. CONCLUSION

Works Cited

NetCE 5 Hour Course #54354 • Medical Emergencies in the Dental Setting

54354 • Medical Emergencies in the Dental Setting

1. INTRODUCTION

2. PATIENT ASSESSMENT AND MEDICAL HISTORY

3. COMMON MEDICAL EMERGENCIES IN THE DENTAL SETTING

4. ALLERGIC REACTIONS DURING DENTAL TREATMENT

5. ASPIRATED AND INGESTED OBJECTS DURING DENTAL TREATMENT

6. STAFF PREPARATION AND TRAINING FOR MEDICAL EMERGENCIES

7. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

MADH22O • Massachusetts Dental Hygienists and Assistants 2022-2023

William E. Frey, DDS, MS, FICD

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

MADH22O • Massachusetts Dental Hygienists and Assistants 2022-2023

Expiration Date: 01/31/2025

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

54051 • Infection Control for Dental Professionals

William E. Frey, DDS, MS, FICD

www.netce.com

Copyright © 2022 NetCE, All rights reserved.

Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

Table of Contents

54051 • Infection Control for Dental Professionals

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. OSHA REGULATIONS

BLOODBORNE PATHOGENS STANDARD

AEROSOL TRANSMISSIBLE DISEASE STANDARD

3. MODES OF TRANSMISSION

AEROSOLS, DROPLETS, AND SPLATTER

FOMITE TRANSMISSION

4. BLOODBORNE PATHOGENS

HEPATITIS B VIRUS

HEPATITIS C VIRUS

HIV/AIDS

5. PREVENTION STRATEGIES

STANDARD PRECAUTIONS

RESPIRATORY HYGIENE

ASEPTIC TECHNIQUE

SAFE INJECTION PRACTICES

HAND HYGIENE

PERSONAL PROTECTIVE EQUIPMENT

6. ENVIRONMENTAL CONTROL MEASURES

ENVIRONMENTAL CLEANING

MEDICAL WASTE MANAGEMENT

DENTAL UNIT WATERLINES, BIOFILM, AND WATER QUALITY

7. ENGINEERING AND WORK PRACTICE CONTROLS

CLEANING, DISINFECTION, AND STERILIZATION

8. PROTECTING DENTAL HEALTHCARE WORKERS

OCCUPATIONAL EXPOSURES

TUBERCULOSIS PREVENTION

VACCINATION

TRAINING AND EDUCATION

9. CONCLUSION

Works Cited

54051 • Infection Control for Dental Professionals

Education Category. Infection Control / Internal Medicine

Release Date. 02/01/2022

Expiration Date. 01/31/2025

Course Overview

Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

Audience

This course is designed for all dentists, dental hygienists, and dental assistants in all practice settings.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this activity for 5 continuing education credits. AGD Subject Code 148. This course meets the Dental Board of California's requirements for 5 unit(s) of continuing education. Dental Board of California course #05-3841-24345. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

Course Objective

The purpose of this course is to familiarize dental professionals with infection control techniques in order to minimize the risks of microbial transmission in the dental healthcare setting.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline OSHA regulations that impact the provision of dental care.

2. Analyze potential modes of transmission and pathogens that can result in infection in dental facilities.

3. Discuss potential prevention strategies for infection control, including the use of precautions, hand hygiene, and personal protective equipment.

4. Describe effective environmental control measures that should be applied in dental care.

5. Identify steps that should be taken to protect dental professionals, including vaccination, education, and exposure responses.

Faculty

William E. Frey, DDS, MS, FICD, graduated from the University of California School of Dentistry, San Francisco, California, in 1966. In 1975, he completed residency training in Periodontics and received a Master's degree from George Washington University.
Dr. Frey retired from the United States Army Dental Corps in 1989 after 22 years of service. Throughout the course of his professional career, he has continuously practiced dentistry, the first 7 years as a general dentist and the past more than 40 as a periodontist. His military experience included the command of a networked Dental Activity consisting of five dental clinics. In his last assignment, he was in charge of a 38-chair facility. Colonel Frey was selected by the Army to serve on two separate occasions as the Chair of the Periodontal Department in Army General Dentistry Residency Training Programs.
Dr. Frey is the founder and president of Perio Plus, a practice management firm specializing in creating individually-designed hygiene and periodontal care programs for general dentists. He is also the creator of the Inspector Gum patient education series.

Faculty Disclosure

Contributing faculty, William E. Frey, DDS, MS, FICD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mark J. Szarejko, DDS, FAGD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In 2018, there were more than 750,000 jobs in dental occupations in the United States [1]. Most of these dental workers come in daily contact with a variety of infectious diseases in their workplace and are at risk for both transmitting and contracting these diseases. The same infection control precautions apply to all patients, and all body fluids, except sweat, are considered potentially infectious. Universal Precautions are measures taken when exposed to blood, while Standard Precautions apply to all potentially infectious materials. While most elements of Standard Precautions evolved from Universal Precautions, developed for protection of healthcare personnel, additional elements of Standard Precautions focus on protection of patients. Contact Precautions are used to prevent transmission of an infectious agent associated with environmental contamination (e.g., treating all environmental surfaces as potentially contaminated) that is not interrupted by Standard Precautions alone. A written protocol should be developed for proper instrument processing, operatory cleanliness, and management of injuries, and a copy of infection control regulations should be conspicuously posted in each dental office [2].

2. OSHA REGULATIONS

Legal issues first began to impact infection control practices at the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the early 1980s. The need to protect healthcare workers from bloodborne exposures resulted in the publication of the Bloodborne Pathogens Standard by OSHA in 1991 [3]. The OSHA Standard requires employers whose employees have exposure to blood or other potentially infectious material to implement safe work practices, education, and barriers to exposure. The Standard was later amended to cover the safe use of sharps.

BLOODBORNE PATHOGENS STANDARD

The OSHA Bloodborne Pathogens Standard requires that every healthcare worker who may have contact on the job with blood or other bodily fluids (referred to as other potentially infectious material or OPIM) must receive specific annual education, which includes instruction in the basics of infection control and prevention. Training must also cover bloodborne pathogens, modes of transmission, the proper use of needles, and Contact Precautions.

AEROSOL TRANSMISSIBLE DISEASE STANDARD

In 2009, the California Division of Occupational Safety and Health (Cal/OSHA) adopted the nation's first aerosol transmissible disease (ATD) standard [4,15]. The standard is designed to protect healthcare workers from diseases spread by an airborne or droplet route. The ATD standard requires healthcare employers to develop exposure control procedures and train employees to follow those procedures [4,15]. Basic exposure precautions, such as source screening, infection control, hand hygiene, and cleaning and decontamination procedures, are a fundamental part of the standard. Employees must be included in the periodic review and assessment of these procedures.

As of 2022, California remains the only state with such a permanent standard, but the coronavirus disease (COVID) pandemic of 2019–2022 highlighted the need for a standard addressing infectious pathogens spread by aerosols or droplets [27]. During the pandemic, OSHA did issue interim guidance for safe workplaces, and some states issued emergency temporary standards. Experts have called for these requirements to be codified in order to ensure the safety of professions and patients [27].

3. MODES OF TRANSMISSION

Almost all pathogens are transmitted by being carried from one place to another. The mode or means of transmission is the weakest link in the chain of infection, and it is the only link that can be eliminated entirely. Most infection control efforts are aimed at preventing transmission of pathogens from a reservoir to a susceptible host. Both Standard and Contact Precautions are designed to interrupt the mode of transmission.

The most common modes of transmission in the healthcare setting are the hands of healthcare workers and items that move from patient to patient, both of which are examples of indirect transmission (Table 1). Items moving between patients should be cleaned and sterilized after each use to avoid indirect transmission of pathogens. Because it addresses the weakest link in the chain of transmission, hand hygiene is still the single most important procedure for preventing the spread of infection.

Table 1: Common Modes of Infection Transmission

Category

Definition

Direct

Person-to-person transmission of pathogens

Indirect

An intermediate person or item (e.g., an instrument) acts as a transport between the portal of exit in one person and the portal of entry to the next person (e.g., unwashed hands)

Fomites

Contact with soiled objects, such as used gloves, pens, used tissues, and soiled laundry

Source: Compiled by Author

AEROSOLS, DROPLETS, AND SPLATTER

Aerosols, droplets (produced by the respiratory tract), and splatter contaminated with blood and bacteria are produced during many dental procedures [9]. Devices such as dental handpieces, ultrasonic and sonic scalers, air polishers, air-water syringes, and air abrasion units produce visible aerosol clouds and possible airborne contamination. Splatter generated by dental procedures such as drilling is a primary risk for transmission of bloodborne pathogens. In general, because of their smaller size, aerosols pose the greatest risk for airborne infection.

Several studies have shown that aerosol or droplet nuclei may extend up to 6 feet away from the source and can remain airborne for up to 30 minutes after a procedure. TB is of special concern because it is a large particle that can remain airborne or can dry on a surface and become airborne again as part of a dust particle.

The American Dental Association recommends that in addition to using standard barriers, such as masks, gloves, and eye protection, the proper sterilization of instruments and treatment of dental unit waterlines is necessary to reduce or eliminate this source of potentially contaminated dental aerosols. Preprocedural rinsing with an antimicrobial mouthwash such as chlorhexidine is also recommended, although it is only effective for oral bacteria found in saliva and those adhering to mucous membranes. It does not penetrate subgingivally and likely has no effect on bacteria in the nasopharynx [6].

Diseases known to spread by aerosols or droplet include:

- TB

- Pneumonic Yersinia pestis infection (plague)

- Influenza

- Legionellosis (Legionnaires' disease)

- Severe acute respiratory syndrome coronavirus (SARS and COVID)

Procedures or equipment aimed at eliminating the means of transmission include [6]:

- Universal preprocedural rinses

- Dental dams for certain procedures

- High-volume evacuator (HVE) at the treatment site (An HVE can only remove airborne contamination if it removes a large volume of air. A saliva ejector does not remove enough air to be classified as an HVE.)

- High-efficiency particulate arresting and ultraviolet filters in the ventilation system

- Gloves to minimize contamination of hands, discarded after each patient

- Cleaning, disinfection, and sterilization of equipment used by more than one patient

- Environmental cleaning and disinfection, especially of high-touch surfaces

FOMITE TRANSMISSION

Devices can transmit pathogens if they are contaminated with blood or bodily fluids or are shared without cleaning, disinfecting, and sterilizing between patients; these are classified as fomites. Surgical instruments that are inadequately cleaned between patients or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial, fungal, and viral pathogens. Clothing, uniforms, laboratory coats, or gowns used as personal protective equipment (PPE) may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent [7].

Contaminated clothing and laboratory coats can potentially transmit infectious agents to successive patients. A 2007 study in a Maryland teaching hospital revealed that 27% of the white coats worn by 109 physicians and other healthcare professionals were colonized with Staphylococcus aureus and 6% were colonized with methicillin-resistant S. aureus (MRSA). In a follow-up questionnaire, 65% of the healthcare workers reported they had last washed their white coat more than a week ago and nearly 16% had last washed their coat more than 30 days ago [8]. A study presented at the American Society of Microbiology Conference in 2012 identified clothing and household linens (e.g., cotton towels) as a significant transmission source of infectious pathogens [30]. However, evidence linking clothing to hospital infection rates is lacking, and additional research is necessary to determine the actual extent of this risk [31].

Dental equipment and dental unit waterlines are both potential sources of transmission and potential reservoirs. Routine cleaning and sterilization and adherence to the American Dental Association's recommended procedures for treating dental unit waterlines have been shown to be effective in eliminating transmission of infectious organisms via these devices.

4. BLOODBORNE PATHOGENS

Healthcare employees can be exposed to blood through needlestick and other sharps injuries, damaged mucous membranes, and broken skin exposures. The pathogens of primary concern to dental professions are human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus.

HEPATITIS B VIRUS

Healthcare personnel who have received the hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection. For a susceptible person, the risk from a single needlestick or cut exposure to hepatitis B-infected blood ranges from 6% to 30%, depending on the hepatitis Be antigen status of the source individual [9,11]. While there is a risk for hepatitis B infection from exposures of mucous membranes or nonintact skin, there is no known risk for infection from exposure to intact skin [9].

HEPATITIS C VIRUS

Hepatitis C is transmitted primarily through percutaneous exposure to infected blood. The average risk for infection after a needlestick or cut exposure to hepatitis C virus-infected blood is approximately 1.8% [11]. The risk following a blood exposure to the eye, nose, or mouth is unknown but is believed to be very small; however, hepatitis C virus infection from blood splashes to the eye has been reported [11]. There also has been a report of hepatitis C virus transmission that may have resulted from exposure to nonintact skin, but there is no known risk from exposure to intact skin [9]. Documented transmission of hepatitis C or hepatitis B virus has resulted from using the same syringe or vial to administer medication to more than one patient, even if the needle was changed.

The prevalence of hepatitis C virus infection among dentists and surgeons is similar to that among the general population, approximately 1% to 2% [11]. No studies of transmission from hepatitis C virus-infected dental healthcare personnel to patients have been reported, and the risk for such transmission appears limited [10].

HIV/AIDS

The average risk of HIV infection after a needlestick or cut exposure to HIV-infected blood is 0.3%; 99.7% of needlestick or cut exposures do not lead to infection [9,11]. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be 0.1%. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (i.e., a few drops of blood on skin for a short period of time) [9,11].

In the United States, the risk of HIV transmission in dental settings is extremely low. According to surveillance data from 1981 to 2010, a total of 57 cases of HIV seroconversion had been documented among healthcare personnel after occupational exposure to a known HIV-infected source, but none were among dental care personnel [12]. Transmission of HIV to 6 patients of a single dentist with AIDS has been reported, but the mode of transmission could not be determined [13].

Certain factors affect the risk of HIV transmission after an occupational exposure. Laboratory studies have determined if needles that pass through latex gloves are solid rather than hollow-bore or are of small gauge (e.g., anesthetic needles), less blood is transferred. In a retrospective, case-control study of healthcare personnel, an increased risk for HIV infection was associated with exposure to a relatively large volume of blood, as with a deep injury with a device that was visibly contaminated with the patient's blood or a procedure that involved a needle placed in a vein or artery [14]. The risk was also increased if the exposure was to blood from patients with terminal illnesses, possibly reflecting the higher titer of HIV in patients with late-stage AIDS.

5. PREVENTION STRATEGIES

In the past three decades, regulatory and legislative activity has focused on implementing a hierarchy of prevention and control measures to improve infection control in healthcare settings. Respiratory hygiene, safe injection practices, aseptic technique, hand hygiene, and the use of PPE are now accepted as essential components of an effective infection prevention strategy.

STANDARD PRECAUTIONS

The gradual acceptance of various infection prevention standards has changed the way we work in the provision of dental care. The use of Standard Precautions reduces the risk of infection to staff and patients and ensures that the right precautions are used with both known and unknown carriers of diseases due to bloodborne pathogens. Standard Precautions apply to contact with:

- Blood

- All bodily fluids, secretions, and excretions (except sweat), regardless of whether they contain blood

- Intact or nonintact skin

- Mucous membranes

A central tenet of Standard Precautions is to consider all patients to be potentially infected with a bloodborne pathogen. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions. For organisms other than bloodborne pathogens, early identification and prompt isolation are critical.

When adhering to Standard Precautions, always:

- Use good hand hygiene.

- Use gloves for contact with blood, bodily fluids, nonintact skin (including rashes), mucous membranes, used equipment, linens, and trash.

- Use a gown any time your clothing is soiled and if a patient has uncontained bodily fluids (e.g., blood, saliva).

- Use a mask and eye protection if you may be splashed or be exposed to droplets; glasses do not adequately protect you.

- Change gloves if they become heavily soiled when working on a patient or if you must go from a potentially more infective area to a lesser one.

In addition, never:

- Wear artificial fingernails.

- Touch a second patient with the same pair of gloves used on the first patient.

- Reuse gowns, even for repeated contacts with the same patient.

- Contaminate the environment with dirty gloves.

- Wear gloves outside the treatment area unless you can say why you are wearing them.

RESPIRATORY HYGIENE

If dental clinics and offices comply with state regulations for screening of patients with ATDs, they are not required to comply with the new standards for prevention of transmission of ATDs [4]. However, because no screening process is universally effective, dental professionals should be aware of the potential dangers associated with transmission of pathogens via the airborne and droplet routes.

Respiratory droplets can transmit infection when they travel directly from the respiratory tract of the infected individual to the mucosal surfaces of the recipient, generally over short distances (i.e., 6 feet or less). Airborne transmission occurs with only a few organisms that can survive the drying of respiratory droplets. When the droplets evaporate, they leave behind droplet nuclei, which are so small they remain suspended in the air and can travel over longer distances. Respiratory droplets and droplet nuclei are generated when an infected person coughs, sneezes, or talks during procedures. Facial masks or shields generally provide direct protection from droplet transmission. Some pathogens transmitted via the airborne route (e.g., TB) require the use of an N95 respirator or better (e.g., N99, N100) due to the small particle size.

ASEPTIC TECHNIQUE

Aseptic technique involves the handling, preparation, and storage of medications in a manner that prevents microbial contamination. It also applies to the handling of all supplies used for injections and infusions. To avoid contamination, medications should be drawn in a clean medication preparation area. Any item that may have come in contact with blood or other potentially infectious material should be kept separate from medications.

SAFE INJECTION PRACTICES

In 2000, the Federal Needlestick Safety and Prevention Act authorized OSHA to revise its Bloodborne Pathogens Standard to require the use of safety-engineered sharp devices in healthcare settings [16]. Guidelines on the design, implementation, and evaluation of a sharps injury prevention program have been developed by the CDC.

Safe injection practices are designed to prevent disease transmission within the healthcare setting. The absence of visible blood or other signs of contamination in a used syringe does not mean the item is free from potentially infectious agents. Bacteria and other microbes can be present without any visible evidence of contamination. All used injection supplies and materials should be considered potentially contaminated and should be discarded.

To ensure safe injection practices, use aseptic technique throughout all aspects of injection preparation and administration. A new, sterile syringe and needle should be used to draw up medications while preventing contact between the injection materials and the nonsterile environment. Practice proper hand hygiene before handling medications, and discard medication vials upon expiration or any time there are concerns regarding the sterility of the medication.

Never leave a needle or other device inserted into a vial or bottle for multiple uses. This provides a direct route for micro-organisms to enter the vial and contaminate the fluid. Medications should never be administered from the same syringe to more than one patient, even if the needle is changed.

Dental professionals should follow proper technique when using and handling needles, cannulae, and syringes. Whenever possible, use sharps with engineered sharps injury protections (e.g., non-needle or needle devices with built-in safety features or mechanisms that effectively reduce the risk of an exposure incident). Do not disable or circumvent the safety feature on devices.

Cases of bloodborne pathogen transmission as a result of improper injection practices have common themes [16]. Often, aseptic technique and Standard Precautions were not carefully followed. Infection control programs may be lacking or responsibilities unclear. In several instances, failure to recognize an infection control breach has led to prolonged transmission and a growing number of infected patients. In all cases, investigations were time-consuming and costly and required the notification, testing, and counseling of hundreds and sometimes thousands of patients.

HAND HYGIENE

Despite the simplicity and effectiveness of hand hygiene in preventing the spread of infectious disease, adherence to hand hygiene practice remains unacceptably low [35]. Adherence varies among professional categories of healthcare workers but is usually estimated as less than 50%, a rate that has not changed in more than a decade [17,34,35]. Healthcare providers might need to clean their hands as many as 100 times in a 12-hour shift, depending on the number of patients and intensity of care [34]. For dental healthcare workers, strict adherence to hand hygiene protects both the patient and the worker. Hand hygiene should be done when you first come to work, before you touch your first patient or clean equipment, and before and after every patient contact—including after touching intact skin. In addition, perform hand hygiene:

- After contact with any bodily fluids, including your own

- Before any non-invasive or invasive procedure

- Each time you remove your gloves

- When your hands feel or look dirty

- After contact with contaminated things or environments, such as charts

- After handling used equipment or linen

- After using the bathroom

- Before contact with any portal of entry, your patient's or your own

- Before and after eating

A number of conditions restrict dental healthcare professionals from participating in direct patient care. These include weeping dermatitis, exudative lesions, or any hand conditions that increase the risk of disease transmission.

Good handwashing is difficult to practice, is rarely known or taught, and is one of the single most effective ways to prevent transmission of many diseases, including influenza. Everyone knows to wash their hands before eating and after using the restroom. However, few do little more than remove obvious dirt. Good handwashing involves removing the skin oils where organisms can remain even when the hands look clean. A quick pass under the water faucet and fast dry with a towel may remove visible dirt, but the oils and organisms remain.

To effectively remove the oils and organisms, the process should take at least 20 seconds, or the amount of time it takes to sing "Twinkle, Twinkle Little Star." The hands should be soaped and rubbed vigorously for 15 seconds to create a good lather and to assure that all parts of each hand are soaped and rubbed well. Then, the hands should be rinsed thoroughly and dried, preferably with a paper towel. The towel should be used to turn off the water faucet and then properly thrown away. Such handwashing removes the oils that harbor the organisms. However, 20 seconds is a long time in the busy life of a healthcare provider, and this 20 seconds has been identified as a major barrier to handwashing, particularly among those who consider themselves "too busy" to wash their hands [35]. If there is no visible dirt or contamination, a waterless hand sanitizer with at least 60% alcohol can be used between patients. However, nothing is as good as washing well with soap and water. Some mistakenly think that hot water must be used to kill the organisms. Water hot enough to kill organisms would be too hot to touch. Warm water softens oils but mainly adds to comfort and encourages better washing technique (i.e., longer duration). Careful attention to handwashing and cleansing may result in chapped skin, so the dental professional must find effective lotions to care for his/her hands.

Certain soaps contain stronger antiseptic compounds, such as chlorhexidine, and these soaps may be considered in cases in which exposure to potentially infectious material is likely. Antiseptic soaps or surgical preparation liquids have been found more effective than plain soap in removing bacteria from healthcare workers hands both pre- and postprocedure [28,29]. In addition, antiseptics may be added to alcohol-based handrubs in order to achieve persistent germicidal activity [10]. Possible side effects associated with frequent use of antiseptic hand scrubs include skin irritation, dermatitis, allergic reactions, and potential development of microbial resistances. Chlorhexidine products are considered safe for regular use in dental practice; however, if associated side effects are bothersome, they may result in decreased hand hygiene compliance.

In summary, start and end each work day using an antibacterial soap. Gloves provide a breeding ground for microbial growth, and washing before and after use is encouraged. If hands are not visibly soiled, a waterless hand sanitizer (at least 60% alcohol) may be used. For surgical procedures, wash hands with antimicrobial soap prior to gowning and gloving.

PERSONAL PROTECTIVE EQUIPMENT

PPE is defined as special coverings designed to protect healthcare personnel from exposure to or contact with infectious agents [18]. Under OSHA's General Duty Clause, PPE is also required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure its proper disposal. If reusable, it must be properly cleaned or laundered, repaired, and stored after use [37]. PPE must fit the individual user, and it is up to the employer to ensure that PPE is available in sizes appropriate for all their workers. Employees are prohibited from taking PPE home to launder.

In addition to the familiar gloves and gowns, PPE includes a variety of barriers and respirators used alone or in combination to protect skin, mucous membranes, and airways from contact with infectious agents. The selection of PPE is based on the nature of the patient/provider interaction and the likely mode of transmission. Primary PPE used in oral healthcare settings includes gloves, surgical masks, protective eyewear, face shields, and protective clothing.

Procedures that generate splashes or sprays of blood, bodily fluids, secretions, excretions, or chemical agents require either a face shield (disposable or reusable) or mask and goggles. The wearing of masks, eye protection, and face shields in specified circumstances (when blood or other potentially infectious material exposures are likely to occur) is mandated by the OSHA Bloodborne Pathogens Standard. Sterile barriers for invasive procedures and masks or respirators for the prevention of droplet contamination are also required.

The use of PPE is not a substitute for safe work practices. Avoid contaminating yourself by keeping your hands away from your face and not touching or adjusting equipment. PPE is a potential means of transmission if not changed between patients. All PPE should be removed when leaving patient care areas.

Gloves

Dental personnel should wear gloves to prevent contamination of their hands when touching mucous membranes, blood, saliva, or other potentially infectious material. Gloves reduce the likelihood that micro-organisms present on the hands will be transmitted to patients during surgical or other patient-care procedures. Gloves used in the healthcare setting are subject to U.S. Food and Drug Administration (FDA) evaluation and clearance. Nonsterile, disposable medical gloves made of latex or nitrile should be available for routine patient care. Dental professionals should always use gloves when [19]:

- Anticipating direct contact with blood or bodily fluids, mucous membranes, nonintact skin, and other potentially infectious material

- Engaging in direct contact with patients who are colonized or infected with pathogens transmitted by the contact route, such as vancomycin-resistant enterococci or MRSA

- Handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces

Studies have repeatedly shown that vinyl gloves have higher failure rates than latex or nitrile gloves. For this reason, either latex or nitrile gloves are preferable for clinical procedures that require manual dexterity or those involving more than brief patient contact. Heavier, reusable utility gloves should be used for non-patient-care activities, such as handling or cleaning contaminated equipment or surfaces, handling chemicals, or disinfecting contaminated tools [19].

During dental procedures, patient examination gloves commonly contact multiple types of chemicals and materials, such as disinfectants and antiseptics, composite resins, and bonding agents, and these materials can compromise the integrity of latex, nitrile, and other synthetic glove materials. In addition, latex gloves can interfere with the setting of vinyl polysiloxane impression materials. Given the diverse selection of dental materials on the market, dental practitioners should consult glove manufacturers regarding the chemical compatibility of glove materials [10].

Wearing sterile surgeon's gloves during surgical procedures has a strong theoretical rationale. Sterile gloves minimize transmission of micro-organisms from the hands of surgical personnel to patients and prevent contamination of the hands of surgical personnel with the patient's blood and bodily fluids. In addition, sterile surgeon's gloves are more rigorously regulated by the FDA and may provide an increased level of protection for the provider if exposure to blood is likely [10].

Gloves should be removed and replaced if torn or punctured and discarded between patients to prevent transmission of infectious material. They should never be washed and reused, as micro-organisms cannot be removed reliably from glove surfaces. Glove reuse has been associated with transmission of MRSA and gram-negative bacilli [19].

When gloves are worn in combination with other PPE, they should be put on last. Gloves that fit snugly around the wrist are preferred for use with a gown because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands. Removing gloves properly also prevents hand contamination. Hand hygiene following glove removal ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or contaminated the hands during glove removal [19]. When processing contaminated sharp instruments, needles, and devices, heavy utility gloves should be used to prevent puncture injuries.

Cover Garb

Gowns are intended to protect the arms and exposed body areas and prevent contamination of clothing with blood, bodily fluids, and other potentially infectious material. The type of gown selected is based on the nature of the patient/provider interaction, including the anticipated degree of contact with infectious material and potential for blood and bodily fluid penetration of the barrier. Laboratory coats or jackets worn over personal clothing for comfort or purposes of identity are not considered PPE [19].

Masks, Protective Eyewear, and Face Shields

In general, dental professionals are required to wear surgical masks that cover both the nose and mouth, in combination with either chin-length plastic face shields or protective eyewear when there is potential for splashing or spattering of blood or other potentially infectious material. After each patient and during patient treatment (if applicable), masks must be changed if moist or contaminated. After each patient, face shields and protective eyewear shall be cleaned and disinfected, if contaminated [2].

Masks should fit snugly and fully cover the nose and mouth to prevent fluid penetration. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable. Surgical masks protect against micro-organisms generated by the wearer and also protect dental personnel from large-particle droplet spatter that might contain bloodborne pathogens or other potentially infectious material. If the mask becomes wet or contaminated, it should be changed between patients or even during patient treatment. For employees at increased risk of exposure to ATDs, such as those working in endemic areas or in areas designated for isolation or quarantine, the employer must provide a respirator at least as effective as an N95 respirator.

Most surgical masks are not National Institute for Occupational Safety and Health (NIOSH)-certified as respirators, do not protect the user adequately from exposure to TB, and do not satisfy OSHA requirements for respiratory protection. However, certain surgical masks (i.e., N95 respirators) do meet the requirements and are certified by NIOSH. The level of protection a respirator provides is determined by the efficiency of the filter material for incoming air (e.g., 95% for N95) and how well the face piece fits or seals to the face. N95 respirators are required to be labeled as such on the device.

Respirators are used when treating patients with diseases requiring Airborne Precautions and should be used in the context of a complete respiratory protection program. This program should include training and fit testing to ensure an adequate seal between the edges of the respirator and the wearer's face.

Goggles with side shields provide barrier protection for the eyes and should fit snugly over and around the eyes or personal prescription lenses. Personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. If goggles or face shields are reusable, they must be placed in a designated receptacle for subsequent reprocessing. If they are not reusable, they may be discarded in a designated waste receptacle.

Face shields extending from chin to crown provide better face and eye protection from splashes and sprays than goggles. Shields that wrap around the sides may reduce splashes around the edge. Removal of a face shield, goggles, and mask can be performed safely after gloves have been removed and hand hygiene performed. The ties, ear pieces, or headband used to secure the equipment to the head are considered clean and therefore safe to touch with bare hands. The front of the face shield is considered contaminated [19].

6. ENVIRONMENTAL CONTROL MEASURES

As discussed, contaminated surfaces and objects can serve as the means of transmission for potential pathogens. The transfer of a micro-organism from an environmental surface to a patient is largely via hand contact with the surface. Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of infections [20].

ENVIRONMENTAL CLEANING

All work areas, including contact surfaces and barriers, must be maintained in a clean and sanitary condition. Employers are required to determine and implement a written schedule for cleaning and disinfection based on the location, type of surface to be cleaned, type of soil present, and tasks or procedures being performed. All equipment and environmental and working surfaces must be properly cleaned and disinfected after contact with blood or other potentially infectious material.

If items or surfaces likely to be contaminated are difficult to clean and disinfect, they must be protected with disposable impervious barriers. Clean and disinfect all clinical contact surfaces that are not protected by impervious barriers using an Environmental Protection Agency (EPA)-registered, hospital grade low- to intermediate-level disinfectant after each patient. The low-level disinfectants used must be labeled effective against hepatitis B virus and HIV. Use disinfectants in accordance with the manufacturer's instructions. Clean all housekeeping surfaces (e.g., floors, walls, sinks) with a detergent and water or an EPA-registered, hospital-grade disinfectant. Chemical-resistant utility gloves should be worn when handling hazardous chemicals.

MEDICAL WASTE MANAGEMENT

Federal, state, and local guidelines and regulations specify the categories of medical waste subject to regulation and outline the requirements associated with treatment and disposal. Regulated medical waste is defined as [10]:

- Liquid or semi-liquid blood or other potentially infectious materials

- Contaminated items that would release blood or other potentially infectious material in a liquid or semi-liquid state if compressed

- Items that are caked with dried blood or other potentially infectious material capable of releasing these materials during handling

- Contaminated sharps (e.g., needles, burs, scalpel blades, endodontic files)

- Pathologic and microbiologic wastes containing blood or other potentially infectious material

Regulated medical waste accounts for only 9% to 15% of total waste in hospitals and 1% to 2% of total waste in dental offices [10]. Examples of regulated waste found in dental practice settings are solid waste soaked or saturated with blood or saliva (e.g., gauze saturated with blood after surgery), extracted teeth, surgically removed hard and soft tissues, and contaminated sharp items such as needles, scalpel blades, and wires [10].

Medical waste requires careful disposal and containment before collection and consolidation for treatment. A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. Contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal.

Medical waste requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well-ventilated and inaccessible to pests. Any facility that generates regulated medical waste should have a regulated medical waste management plan to ensure health and environmental safety in accordance with federal, state, and local regulations [20].

DENTAL UNIT WATERLINES, BIOFILM, AND WATER QUALITY

The following information is taken from the Centers for Disease Control and Prevention publication Guidelines for Infection Control in Dental Health-Care Settings.

Studies have shown that dental unit waterlines, such as narrow-bore plastic tubing that carries water to high-speed handpieces, air/water syringes, and ultrasonic scalers, can become colonized with micro-organisms, including bacteria, fungi, and protozoa. Protected by a polysaccharide layer known as a glycocalyx, these micro-organisms colonize and replicate on the interior surfaces of the tubing and form a biofilm. This biofilm serves as a reservoir that can increase the number of micro-organisms in the water used during dental treatment.

In 1993, the CDC recommended that dental waterlines be flushed at the beginning of the clinic day to reduce the microbial load. Dental unit water that remains untreated or unfiltered is unlikely to meet drinking water standards.

Commercial devices and procedures shown to improve the quality of water used in dental treatment include self-contained water systems with chemical treatment, in-line microfilters, and combinations of these treatments. Simply using tap, distilled, or sterile water will not eliminate bacterial contamination in treatment water if biofilms in the system are not controlled. Removal or inactivation of dental waterline biofilms requires use of chemical germicides.

Patient material, such as oral micro-organisms, blood, and saliva, can enter the dental water system during treatment. Devices connected to the dental water system that enter the patient's mouth should be flushed to discharge water and air for a minimum of 20 to 30 seconds after each patient to remove patient material that might have entered the turbine, air, or waterlines.

Manufactured dental units are now engineered to prevent retraction of oral fluids, but some older units are equipped with antiretraction valves that require periodic maintenance. Users should consult the owner's manual or contact the manufacturer to determine whether testing or maintenance of antiretraction valves or other devices is required. Even with antiretraction valves, flushing devices for a minimum of 20 to 30 seconds after each patient is recommended. The DBC standards require that, at the beginning of each work day, dental lines and devices must be purged with air or flushed with water for at least two minutes prior to attaching handpieces, scales, air/water syringe tips, or other devices [2].

7. ENGINEERING AND WORK PRACTICE CONTROLS

The following information is taken from the OSHA Bloodborne Pathogens Standard, 1910.1030.

Engineering controls such as sharps disposal containers, self-sheathing needles, and safer medical devices (e.g., sharps with engineered sharps injury protections and needleless systems) isolate or remove the bloodborne pathogens hazard from the workplace. On the other hand, work practice controls reduce the likelihood of exposure by specifying the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Engineering and work practice controls are intended to work synergistically to eliminate or minimize employee exposure. These controls must be examined and maintained or replaced on a regular basis to ensure their effectiveness. To maintain a safe workplace, employers must provide handwashing facilities that are readily accessible to employees.

Contaminated needles and other contaminated sharps should not be bent, recapped, or removed unless the employer can demonstrate that there is no alternative or that such action is required by a specific procedure. Necessary bending, recapping, or needle removal must be accomplished through the use of a mechanical device or a one-handed scoop technique. Shearing or breaking of contaminated needles is prohibited. Immediately, or as soon as possible after use, contaminated reusable sharps (e.g., scalpels, dental knives) must be placed in appropriate containers until properly reprocessed. These containers must be:

- Puncture resistant

- Labeled or color-coded

- Leak-proof on the sides and bottom

- Maintained in accordance with OSHA requirements for reusable sharps

- Designed so personnel are not required to reach by hand into the container

- Located as close as possible to the point of use

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink should not be kept in refrigerators, freezers, shelves, or cabinets or on countertops where blood or other potentially infectious material is present.

All procedures involving blood or other potentially infectious material must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. Splatter shields should be used on medical equipment associated with risk-prone procedures.

Equipment that may become contaminated with blood or other potentially infectious material must be examined before servicing or shipping and should be decontaminated as necessary, unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible. A readily observable label should be attached to the equipment stating which portions remain contaminated. The employer must ensure that this information is conveyed to all affected employees, the servicing representative, and the manufacturer before handling, servicing, or shipping, so appropriate precautions may be taken.

CLEANING, DISINFECTION, AND STERILIZATION

Application of accepted infection control principles helps maintain a safe environment for both patients and dental care workers. This includes proper use of Standard Precautions and application of approved techniques for cleaning, disinfection, sterilization, and reprocessing of dental equipment. Healthcare policies must identify—primarily on the basis of an item's intended use—whether cleaning and disinfection or sterilization is indicated (Table 2) [21].

Table 2: METHODS FOR STERILIZING AND DISINFECTING PATIENT-CARE ITEMS AND ENVIRONMENTAL SURFACES

Process

Result

Method

Examples

Patient Care Items

Environmental Surfaces

Sterilization

Destroys all micro-organisms, including bacterial spores.

Heat-automated, high temperature

Steam, dry heat, unsaturated chemical vapor

Heat-tolerant critical and semicritical

NA

Heat-automated, low temperature

Ethylene oxide gas, plasma sterilization

Heat-sensitive critical and semicritical

Liquid immersiona

Glutaraldehyde, glutaraldehydes with phenols, hydrogen peroxide, hydrogen peroxide with peracetic acid, peracetic acid

High-level disinfection

Destroys all micro-organisms, but not necessarily high numbers of bacterial spores.

Heat-automated

Washer disinfector

Heat-sensitive semicritical

NA

Liquid immersiona

Glutaraldehyde, glutaraldehydes with phenols, hydrogen peroxide, hydrogen peroxide with peracetic acid, ortho-phthalaldehyde

Intermediate-level disinfection

Destroys vegetative bacteria and most fungi and viruses. Inactivates Mycobacterium bovisb. Not necessarily capable of killing bacterial spores.

Liquid contact

EPA-registered hospital disinfectant with label claim of tuberculocidal activity (e.g., chlorine-containing products, quaternary ammonium compounds with alcohol, phenolics, bromides, iodophors, EPA-registered chlorine-based product)

Noncritical with visible blood

Clinical contact surfaces, blood spills on housekeeping surfaces

Low-level disinfection

Destroys most vegetative bacteria and certain fungi and viruses. Does not inactivate Mycobacterium bovis.

Liquid contact

EPA-registered hospital disinfectant with no label claim regarding tuberculocidal activity. OSHA also requires label claim of HIV and HBV potency for use of low-level disinfectant for use on clinical contact surfaces (e.g., quaternary ammonium compounds, some phenolics, some iodophors)

Noncritical without visible blood

Clinical contact surfaces, housekeeping surfaces

aContact time is the single critical variable distinguishing the sterilization process from high-level disinfection with FDA-cleared liquid chemical sterilants. High-level disinfection uses shorter submersion times.

bInactivation of the more resistant Mycobacterium bovis is used as a benchmark to measure germicidal potency.

Source: [10]

Cleaning is defined as the removal of visible soil (organic and inorganic material) from objects and surfaces; normally, it is accomplished manually or mechanically using water with detergents or enzymatic products. Decontamination reduces the number of pathogenic micro-organisms on objects, usually with a 0.5% chlorine solution [21]. Thorough cleaning and decontamination are essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes.

Disinfection is a process that eliminates many or all pathogenic micro-organisms, except bacterial spores, on inanimate objects. In healthcare settings, objects are usually disinfected using liquid chemicals or wet pasteurization (i.e., the use of hot water to destroy micro-organisms). There are three levels of disinfection:

- High-level disinfection: Used to disinfect patient-care equipment that touches mucous membranes or blood.

- Intermediate-level disinfection: Used mainly to disinfect items that have contact with intact skin, but is appropriate for certain semicritical items (e.g., chair arms).

- Low-level disinfection: Used to disinfect the healthcare environment or items that touch intact skin.

Surface disinfection is an important part of environmental cleaning. Most bacteria and mycobacteria (e.g., TB) survive for months on dry surfaces [32]. Respiratory viruses, such as coxsackie or influenza, can persist on surfaces for a few days. Hepatitis viruses and HIV can persist for more than one week, and herpes viruses have been shown to persist from only a few hours up to seven days [32]. All surfaces in patient care areas should be cleaned then disinfected according to the manufacturer's instructions and allowed to dry completely.

Sterilization is a process that destroys or eliminates all forms of microbial life and is carried out in healthcare facilities by physical or chemical methods. Sterile and nonsterile are absolute concepts. If a sterile item is touched by anything nonsterile, the formerly sterile item is contaminated.

The sterilization area should be separate from any patient care or staff break areas. The sterilization section of the processing area should include the sterilizers and related supplies, with adequate space for loading, unloading, and cool down [10]. The area can also include incubators for analyzing spore tests and enclosed storage for sterile items and single-use items. Manufacturer and local building code specifications will determine placement and room ventilation requirements.

According to the CDC guideline, heat-tolerant dental instruments usually are sterilized by steam under pressure (autoclaving), dry heat, or unsaturated chemical vapor [10]. All sterilization should be performed by using medical sterilization equipment cleared by the FDA. The sterilization times, temperatures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed [10]. Sterilization most often fails due to overloading.

Devices being sterilized should first be cleaned, as debris interferes with the sterilization process. If an ultrasonic unit is utilized, it should be covered while actively in use. Instruments should be fully dry prior to packaging and storage.

Storage practices for wrapped sterilized instruments can be either date- or event-related. Packages containing sterile supplies should be inspected before use to verify barrier integrity and dryness. Although some facilities continue to date every sterilized package and use shelf-life practices, other facilities have switched to event-related practices [10]. This approach recognizes that the product should remain sterile indefinitely, unless an event causes it to become contaminated (e.g., torn or wet packaging). Even for event-related packaging, the date of sterilization should be placed on the package, and if multiple sterilizers are used in the facility, the sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure [10]. If packaging is compromised, the instruments should be re-cleaned, sterilized again, and packaged in new wrap.

Categorizing Patient-Care Items

Patient-care items (e.g., dental instruments, devices, and equipment) are categorized using the Spaulding classification system as critical, semicritical, or noncritical, depending on the potential risk for infection associated with their intended use. Critical items are those items that enter sterile spaces, such as soft tissue or bone. These items pose the greatest risk of transmitting infection and require sterilization.

Semicritical items touch intact mucous membranes and have a lower risk of transmission. Because the majority of semicritical items in dentistry are heat-tolerant, they should be sterilized using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection, which kills all microbial life except spores [10,21].

Noncritical items pose the least risk of transmission of infection, contacting only intact skin, an effective barrier to most micro-organisms. In the majority of cases, cleaning and disinfection with an EPA-registered hospital disinfectant is adequate. When the item is visibly contaminated with blood or other potentially infectious material, an EPA-registered hospital disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant) should be used [10].

High-speed dental hand pieces, low-speed hand piece components used intraorally, and other dental unit attachments (e.g., reusable air or water syringe tips and ultrasonic scaler tips) must be heat-sterilized between patients. Single-use disposable instruments such as prophylaxis angles, cups, brushes, tips for high-speed evacuators, saliva ejectors, and air and water syringe tips must be used for one patient only and discarded. Proper functioning of the sterilization cycle must be verified through the use of a biologic indicator (such as a spore test). Studies have demonstrated variability among dental practices in meeting sterilization standards. In one study, 49% of respondents did not challenge autoclaves with biological indicators. Other studies using biologic indicators found a high proportion (15% to 65%) of positive spore tests after assessing the efficacy of sterilizers used in dental offices [21].

Dental unit water lines must be anti-retractive. At the beginning of each workday, dental unit lines should be purged with air or flushed with water for at least two minutes prior to attaching handpieces, scalers, and other devices. The dental unit line must be flushed between each patient for a minimum of 20 seconds [2]. Single-use barriers may be used on those environmental surfaces that are difficult to clean and disinfect.

Laboratory Areas

Splash shields and equipment guards should be used on dental laboratory lathes. Fresh pumice and a disinfected, sterilized, or new ragwheel should be used for each patient. Devices used to polish, trim, or adjust contaminated intraoral devices must be disinfected or sterilized [2].

Intraoral items, such as impressions, bite registrations, and prosthetic or orthodontic appliances, must be cleaned and disinfected with an intermediate-level disinfectant before manipulation in the laboratory and before placement in the patient's mouth. Such items should be thoroughly rinsed prior to placement in the patient's mouth [2].

Reprocessing Reusable Medical Equipment

Reusable instruments, medical devices, and equipment should be managed and reprocessed according to recommended and appropriate methods. Industry guidelines as well as equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions should be available for each instrument, medical device, and equipment reprocessed. The FDA has issued guidance on ensuring the safety of reusable medical devices [38].

Single-Use Devices

A single-use device is a device that is intended for use on a single patient during a single procedure. An unused single-use device is referred to as an original device. A reprocessed single-use device is an original device that has previously been used on a patient and has been subjected to additional processing and manufacturing for the purpose of an additional single use on a patient [22].

8. PROTECTING DENTAL HEALTHCARE WORKERS

Protecting dental professionals is an integral part of every dental organization's general program for infection prevention and control. The objectives usually include [23,24]:

- Educating personnel about the principles of infection control and emphasizing individual responsibility

- Providing care to personnel for work-related illnesses or exposures

- Identifying work-related infection risks and implementing appropriate preventive measures

- Containing costs by preventing infectious diseases that result in absenteeism and disability

OCCUPATIONAL EXPOSURES

An occupational exposure is defined as a percutaneous injury or contact of mucous membrane or nonintact skin with blood, tissue, or other potentially infectious material, most commonly a needlestick injury. The risk of infection depends on several factors, including:

- Whether the exposure was from a hollow-bore needle or other sharp instrument

- Whether the exposure was to nonintact skin or mucous membranes

- The amount of blood involved

- The amount of contagion present in the source person's blood

If a sharps injury occurs, wash the exposed area with soap and water. Do not "milk" or squeeze the wound. There is no evidence that using antiseptics will reduce the risk of transmission for any bloodborne pathogens; however, the use of antiseptics is not contraindicated. In the event that the wound needs suturing, emergency treatment should be obtained. The risk of contracting HIV from this type of exposure is extremely rare. Only 58 cases of confirmed occupational HIV transmission to healthcare personnel have been reported in the United States, with an additional 150 possible transmissions reported to the CDC [39]. There are no documented cases of a dental healthcare professional contracting HIV from an occupational exposure.

OSHA's final rule for occupational exposure to bloodborne pathogens requires dental employers to arrange a confidential medical evaluation and follow-up for any employee reporting an exposure incident [3]. An exposure incident is any eye, mouth, mucous membrane, nonintact skin, or other parenteral contact with blood or other potentially infectious material. Saliva in dental procedures is treated as potentially infectious material.

Following an exposure, the dental employer must refer the exposed employee to a licensed healthcare professional who can provide information and counseling and discuss how to prevent further spread of a potential infection. The exposed employee is entitled to appropriate follow-up and evaluation of any reported illness to determine if the symptoms may be related to HIV or hepatitis B infection.

Prompt response is necessary whenever an occupational exposure occurs. If possible, the patient should be interviewed to determine if any risk factors or bloodborne pathogens not previously disclosed are present. The patient may be tested along with the employee, if he or she agrees, in order to obtain the most information possible. Testing and postexposure prophylaxis may be conducted at an occupational injury clinic. All events leading up to and after the exposure should be documented in a written report.

Postexposure Prophylaxis

Postexposure prophylaxis (PEP) involves the provision of medications to someone who has had a substantial exposure, usually to blood, in order to reduce the likelihood of infection. PEP is available for HIV and hepatitis B virus. Although there is no PEP recommended for hepatitis C virus, limited data indicate that antiviral therapy might be beneficial when started early in the course of infection [36]. For employees who have not received the hepatitis B vaccine series, the vaccine (and in some circumstances hepatitis B immunoglobulin) should be offered as soon as possible (within seven days) after the exposure incident. The effectiveness of hepatitis B immunoglobulin administered more than seven days after exposure is unknown. PEP has been the standard of care for healthcare providers with substantial occupational exposures since 1996 and must be provided in accordance with the recommendations of the U.S. Public Health Service [36].

TUBERCULOSIS PREVENTION

To prevent the transmission of Mycobacterium tuberculosis in dental care settings, infection-control policies should be developed based on the community TB risk assessment and reviewed annually. The policies should include appropriate screening for latent or active TB disease in dental care providers, education about the risk for TB transmission, and provisions for detection and management of patients who have suspected or confirmed TB disease.

The CDC recommends that all dental care providers be screened for TB upon hire, using either a tuberculin skin test or blood test [25]. Patients with symptoms of TB should be identified by screening; dental treatment should be deferred until active TB has been ruled out or the patient is no longer infectious following treatment. The potentially active TB patient should be promptly referred to an appropriate medical setting for evaluation of possible infectiousness and should be kept in the dental care setting only long enough to arrange for referral. Standard Precautions are not sufficient to prevent transmission of active TB.

A diagnosis of active respiratory TB should be considered for any patient with the following symptoms:

- Coughing for more than three weeks

- Loss of appetite

- Unexplained weight loss

- Night sweats

- Bloody sputum or hemoptysis

- Hoarseness

- Fever

- Fatigue

- Chest pain

A person with latent TB (positive skin test and no symptoms) can be treated in a dental office using standard infection control precautions [26]. This person has no symptoms and cannot transmit TB to others as there are no spores in his or her sputum.

The American Dental Association recommends that all patients be asked about any history of TB or exposure to TB, including signs and symptoms and medical conditions that increase their risk for TB disease. The Health History Form, developed by the U.S. Department of Health and Human Services, can be used to ask these questions.

If a patient with suspected or confirmed infectious TB disease requires urgent dental care, that care should be provided in a setting that meets the requirements for airborne infection isolation. Respiratory protection (with a fitted N95 disposable respirator) should be used while performing procedures on such patients. Standard surgical masks are not designed to protect against TB transmission [26].

VACCINATION

Hepatitis B

The hepatitis B vaccine is given in a series of three injections at 0, 1, and 6 months. If one of the injections is missed, the series does not need to be restarted. The CDC recommends if the series is interrupted, the second or third dose should be administered as soon as possible; the second and third doses should be separated by an interval of at least eight weeks [33]. No booster is necessary. Follow-up serologic testing two months after vaccination (to ensure efficacy) is recommended. The provision of employer-supplied hepatitis B vaccination may be delayed until after probable exposure for employees whose sole exposure risk is the provision of first aid.

The high risk of hepatitis B virus exposure among healthcare personnel makes it imperative that clinical dental personnel be vaccinated. Vaccination can protect both workers and patients from hepatitis B virus infection and, whenever possible, should be completed when dentists or other dental care personnel are in training [10].

Influenza

Influenza is primarily transmitted from person to person via large, virus-laden droplets generated when infected persons cough or sneeze. These large droplets can settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are within 3 feet of infected persons. Transmission may also occur through direct contact or indirect contact with respiratory secretions, such as when touching surfaces contaminated with influenza virus and then touching the eyes, nose, or mouth. The CDC strongly recommends that all healthcare personnel, especially those who have contact with patients at high risk, who have high-risk medical conditions, or who are older than 50 years of age, receive an annual (seasonal) influenza vaccination [5].

TRAINING AND EDUCATION

Dental professionals should also fulfill all federal and state requirements for infection control training. New employees, or employees being transferred into jobs involving tasks or activities with potential exposure to blood or other potentially infectious material, must receive bloodborne pathogen training before assignment to tasks in which an occupational exposure may occur. Retraining is required annually or when changes in procedures or tasks affecting occupational exposure occur. Employees should be provided access to a qualified trainer to answer questions during the training session.

9. CONCLUSION

Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Engineering controls help to make the workplace safer, while administrative controls ensure that written protocols are in place and followed. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

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14. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337(21):1485-1490.

15. California Department of Public Health. Cal/OSHA's Aerosol Transmissible Disease Standards and Local Health Departments. Available at https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/OHB/CDPH%20Document%20Library/ATD-Guidance.pdf. Last accessed January 18, 2022.

16. Occupational Safety and Health Administration. Frequently Asked Questions: Needlestick. Available at http://www.osha.gov/needlesticks/needlefaq.html. Last accessed January 18, 2022.

17. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis. 2001;7(2):1818-1865.

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21. Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Available at https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf. Last accessed October 21, 2021.

22. U.S. Food and Drug Administration. Reprocessing of Single-Use Devices. Available at https://www.fda.gov/medical-devices/products-and-medical-procedures/reprocessing-reusable-medical-devices. Last accessed January 18, 2022.

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29. Hübner NO, Handrup S, Meyer G, Kramer A. Impact of the "Guidelines for infection prevention in dentistry" (2006) by the Commission of Hospital Hygiene and Infection Prevention at the Robert Koch-Institute (KRINKO) on hygiene management in dental practices—analysis of a survey from 2009. GMS Krankenhhyg Interdiszip. 2012;7(1):Doc14.

30. Simmons College. Press Release: Superbug Transmitted by Textiles: Research Cites Clothing as Key Link in Spread of Infection. Available at http://www.hospitalinfection.org/PDF/Dr.%20Liz%20Scott%20PR.pdf. Last accessed January 18, 2022.

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32. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.BMC Infectious Diseases. 2006;6:130.

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54354 • Medical Emergencies in the Dental Setting

Mark J. Szarejko, DDS, FAGD

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Numerous dental procedures are completed annually, many with the use of local anesthesia. The individual health of the dental patients can span the spectrum of issues. Some patients will have no current medical problems, while others can have one or more chronic health issues, some for which prescribed medications are taken. Any of these patients can develop a life-threatening medical problem during any phase of dental treatment. Even patients without past or current medical problems can become involved in an acute medical crisis for which immediate medical assistance performed by trained staff members is required. A thorough awareness of the patient's current and past medical history is required before the initiation of any dental treatment, as it can identify issues that may predispose a patient to a medical emergency. This course will review the most common medical emergencies that arise during dental treatment and their underlying cause(s), pathophysiology, and treatment. Staff preparation and the appropriate medications used for emergency medical treatment will be reviewed.

Table of Contents

54354 • Medical Emergencies in the Dental Setting

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. PATIENT ASSESSMENT AND MEDICAL HISTORY

3. COMMON MEDICAL EMERGENCIES IN THE DENTAL SETTING

SYNCOPE (FAINTING)

CARDIOVASCULAR EMERGENCIES IN THE DENTAL SETTING

SEIZURES

DIABETIC EMERGENCIES

ASTHMA ATTACK

4. ALLERGIC REACTIONS DURING DENTAL TREATMENT

ANAPHYLAXIS

LOCAL ANESTHETIC REACTIONS

5. ASPIRATED AND INGESTED OBJECTS DURING DENTAL TREATMENT

6. STAFF PREPARATION AND TRAINING FOR MEDICAL EMERGENCIES

STAFF TRAINING

AVAILABLE MEDICATIONS

OXYGEN

CIRCULATION AND AEDs

7. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

54354 • Medical Emergencies in the Dental Setting

Education Category. Infection Control / Internal Medicine

Release Date. 02/01/2023

Expiration Date. 01/31/2026

Course Overview

Numerous dental procedures are completed annually, many with the use of local anesthesia. The individual health of the dental patients can span the spectrum of issues. Some patients will have no current medical problems, while others can have one or more chronic health issues, some for which prescribed medications are taken. Any of these patients can develop a life-threatening medical problem during any phase of dental treatment. Even patients without past or current medical problems can become involved in an acute medical crisis for which immediate medical assistance performed by trained staff members is required. A thorough awareness of the patient's current and past medical history is required before the initiation of any dental treatment, as it can identify issues that may predispose a patient to a medical emergency. This course will review the most common medical emergencies that arise during dental treatment and their underlying cause(s), pathophysiology, and treatment. Staff preparation and the appropriate medications used for emergency medical treatment will be reviewed.

Audience

This course is designed for all members of the dental profession, including dentists, dental hygienists, and dental assistants.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this activity for 5 continuing education credits. AGD Subject Code 142. This course meets the Dental Board of California's requirements for 5 unit(s) of continuing education. Dental Board of California course #05-3841-24380. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

Course Objective

Patients, those who accompany them, or members of the dental staff can be stricken suddenly and without warning by any of a variety of medical emergency issues. The purpose of this course is to provide all members of the dental staff with the training necessary to provide immediate assistance to a patient that experiences any problem that constitutes a medical emergency.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline the importance of the medical history as a means to decrease the occurrence of medical emergencies.

2. Review the most common medical emergencies in the dental setting and how to identify patients who may be at risk.

3. Identify causes of allergic reactions during dental treatment and describe acute care interventions.

4. Discuss methods to prevent aspiration and the protocol to treat patients who have aspirated an object.

5. Outline the role and responsibilities of the dental staff during a medical emergency.

Faculty

Mark J. Szarejko, DDS, FAGD, received his dental degree from the State University of New York at Buffalo in 1985. He received fellowship from the Academy of General Dentistry in 1994.

Faculty Disclosure

Contributing faculty, Mark J. Szarejko, DDS, FAGD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Dental treatment is usually not associated with the development of acute medical emergencies. However, exacerbations of medical conditions or the emergence of previously asymptomatic medical problems, inadequate pain control, and stress and anxiety associated with dental treatment can occur at any time [1]. Studies have found that acute medical emergencies occur in less than 0.5% of dental treatments but account for approximately 3% of all dental malpractice litigation [29,47]. While medical emergencies cannot be prevented completely, a staff that can render appropriate assistance to a stricken patient can increase the chances for the patient's survival.

A comprehensive review of the patient's medical history that includes any current medications and any problems or issues that a patient has had with past dental treatment is an essential component of determining a patient's ability to withstand dental treatment. Incorporation of these findings before dental treatment may not eliminate the risk of a medical emergency developing during dental treatment, but it can minimize its occurrence.

This course will highlight the most frequently occurring medical emergencies that develop during the course of dental treatment and give an overview of management and prevention. Dental professionals should consult their individual state laws regarding the level of training required of dental staff, the type of emergency medications that must be available, and the necessity of certain resuscitation equipment. This is especially true when varying levels of sedation are used. When a practice is prepared to immediately respond to a patient that has been stricken with an acute medical problem, a life can be saved.

2. PATIENT ASSESSMENT AND MEDICAL HISTORY

Dental treatment cannot begin unless a current and accurate medical history is obtained from the patient. Dental professionals should involve the patient in an active discussion as to any active health issue(s) and medications being taken. All medications, whether prescribed or over-the-counter, must be disclosed. In addition, herbal and dietary supplements should be disclosed in order to reduce the risk of herb-drug interactions. Ample time should be allowed for this exchange of information between the dentist and patient. A medical history form may be used and should feature a comprehensive analysis of the myriad of medical conditions that can afflict a patient. The review of the medical history before dental treatment is not a task that the dentist should delegate to a staff member. Once completed, this form should be signed by the dentist and patient. For patients who have not attained the age of majority (usually 18 years of age) or who have a cognitive disability that precludes them from giving consent, a parent or legal guardian should sign the form. This document should be updated each time a patient returns for any dental treatment. Some patients may consider the disclosure of this information an invasion of privacy and/or refuse to complete certain sections. If a patient remains adamant and refuses to provide medical information even when its necessity for dental treatment is made known, the patient should not be treated.

According to the 2018 National Health Interview Survey (NHIS), 27.2% of adults 18 years of age and older have multiple chronic conditions [2]. The rate increases with age. Chronic illness affects an estimated 80% of people 65 years of age or older; 68% of individuals in this age group have two or more chronic illnesses [3]. A 2017 white paper published by the American Association of Dental Boards noted that "medical emergencies during dental treatment are increasing in frequency, intensity, and diversity" due to increases in the older population, medically complex patients, invasive dental treatment, and in-office sedation [46]. Consultation with the patient's physician should be sought when one or more chronic illnesses may compromise the patient's ability to withstand dental treatment, especially dental surgery or invasive procedures. The dentist should also determine if the patient is compliant with any prescribed medication regimen(s). Non-compliance with prescription medications can increase the morbidity associated with systemic disease(s) and increase the potential for an exacerbation of the condition as a medical emergency during dental treatment.

The age of the patient is a consideration in dental treatment, especially when local anesthetics, sedatives, analgesics, and antibiotics are used in any combination. Children and adolescents usually require smaller doses of these medications as compared to adults, and the elderly may also require lower doses due to an increased sensitivity and lower body weight. Diseases that affect renal and/or hepatic metabolism can result in a toxic accumulation of any of these medications and require an adjustment of medication dosages and frequency. Caution should be taken to avoid using or prescribing medications in dental treatment that could adversely interact with those prescribed for chronic illnesses. If there is any doubt about a patient's ability to tolerate a medication used for dental treatment, the patient's physician should be consulted. Effects of medications used to treat varying medical conditions that can manifest as a medical emergency during dental treatment will be discussed in detail later in this course, as will potential interactions and adverse events. The dentist should consider these potential issues before any medication is used in any capacity for dental treatment.

3. COMMON MEDICAL EMERGENCIES IN THE DENTAL SETTING

SYNCOPE (FAINTING)

The most common emergency seen in the dental setting is vasovagal syncope [7]. This condition features a sudden and temporary loss of consciousness and can affect approximately 3% of men and 3.5% of women at some time in their lives [4]. There is a 6% incidence of syncope in patients who are older than 75 years of age [4]. Patients who have fainted maintain their pulse and their ability to breathe. However, because the nature of the loss of consciousness cannot be determined by visual means, the basics of airway patency, breathing, and circulation must be assessed to distinguish between syncope and a life-threatening condition such as a myocardial infarction.

The recovery from an episode of syncope is usually rapid, but the etiologies of this disorder can vary. Vasovagal syncope (or cardioneurogenic syncope) occurs when an acute decrease in blood pressure reduces the blood flow and subsequent oxygen perfusion to the brain. One source of this type of syncope is a condition called orthostatic hypotension. In patients with orthostatic hypotension, blood vessels in the legs do not constrict normally in the standing position, which results in pooling of blood in the legs and decreased blood flow to the brain. In a similar fashion, postural syncope (also referred to as postural hypotension) may occur when there is an abrupt change in a patient's position. This can occur after dental treatment when a patient has been in a supine position for an extended interval and abruptly changes to a standing position without allowing enough time for the cardiac output and blood pressure to properly equilibrate. Situational syncope is physiologically a variant of vasovagal syncope caused by the anxiety and stress that some patients experience during dental treatment.

Although patients recover quickly from an episode of syncope, all patients who faint in a dental office should be referred to their physician to determine the underlying cause and the appropriate treatment. Patients may emerge from syncope in a state of confusion and may experience emotional distress. Dental treatment should be terminated and not resumed until the cause of their syncope is determined and treated. Patients who have experienced previous episodes of syncope can usually determine the symptoms that occur just prior to their actual loss of consciousness. These may include sudden-onset dizziness, lightheadedness, weakness in the legs, and loss of peripheral vision ("tunnel vision"), among many others. If a patient can communicate these signs, the staff may be able to assist the patient to prevent a fall from a standing position and potential bodily injury.

After it is determined that the patient has maintained respiration and cardiac output and that cardiopulmonary resuscitation (CPR) is not necessary, the use of aromatic ammonia to facilitate the return to consciousness can be used. After regaining consciousness, the patient may be too distraught to drive, and arrangements should be made for transportation, preferably to a physician's office.

While syncope cannot be eliminated as a medical emergency, some practices can be instituted to minimize its occurrence. Patients who have experienced situational syncope during dental treatment may benefit from sedation for the duration of procedures. Repositioning a patient in gradual increments from a supine position to a sitting position after the completion of dental treatment can decrease the likelihood of postural syncope. It is important that patients be urged to remain seated until they feel stable and clear-headed.

CARDIOVASCULAR EMERGENCIES IN THE DENTAL SETTING

Approximately 126.9 million adults in the United States have some form of cardiovascular disease, and almost one of every three deaths is attributed to this problem [6]. The American Heart Association indicates that 805,000 adults experience a myocardial infarction each year. In addition, more than 7 million adults in the United States have ever experienced a stroke [6]. With so many patients afflicted with various forms of cardiovascular disease, dental practices will invariably treat patients with diagnosed and undiagnosed cardiovascular conditions. Thus, it is critical that each dental practice can respond appropriately to a medical emergency that is of cardiovascular origin.

Ischemic Heart Disease

An impediment to the flow of blood, as in the case of an artery that has become constricted, will decrease the perfusion of oxygenated blood to tissue or organs. When the reduction of perfusion to the myocardium of the heart is sufficient enough that the myocardial cells weaken but do not die, a condition known as angina occurs. When the supply of oxygenated blood to the myocardium is further reduced and the myocardial cells become necrotic, a myocardial infarction ("heart attack") occurs. Either of these conditions can occur spontaneously, without any previous symptoms or chest pain. The dental staff should have an established protocol in place to treat the emergency manifestations of these cardiovascular conditions.

Acute chest pain that occurs during dental treatment may be an infrequent event, but the underlying pathophysiology can be the source of dire consequences, especially if immediate action is not taken. Angina pectoris and acute myocardial infarction are the two most likely cardiovascular sources of chest pain that develop in a conscious patient while undergoing dental treatment [7]. Anxiety and panic are also potential causes of chest pain, although the seriousness of possible myocardial infarction requires that any report of pain be considered a medical emergency.

Angina pectoris may be classified as stable or unstable. Patients with stable angina experience chest pain when physical activity and/or emotional stress cause a metabolic demand on the myocardium that the existing supply of oxygenated blood cannot meet. For these patients, a sublingual tablet or a sublingual metered spray of nitroglycerin will relieve the pain within a few minutes. Patients with unstable angina experience cardiac-related chest pain even while at rest. Because these patients are at increased risk for adverse cardiac events, such as an acute myocardial infarction, ventricular tachycardia and fibrillation, and arrhythmias, they should not receive dental treatment until their unstable angina is treated. Emergency dental treatment of patients with unstable angina should only be done in an environment in which all vital signs can be monitored and in which emergency medical assistance is immediately available. A hospital setting, whether inpatient or outpatient, may be necessary.

Treatment of angina pectoris begins with a thorough review of the medical history. Patients who have been diagnosed with stable angina pectoris usually are aware of the events that will precipitate an angina attack. The stress and anxiety that some patients experience during dental treatment can be one such factor. These patients usually have a prescription for nitroglycerin, either as a sublingual metered 0.4-mg spray or a 0.3-mg sublingual tablet that dissolves quickly. Therefore, patients with a known history of angina pectoris should be asked to bring their own nitroglycerin tablets to the dental office. Dentists who have nitroglycerin included in their emergency kits should label the initial date the container was opened. After nitroglycerin tablets are exposed to air or light when their container is opened, the shelf-life is only three months [7,45]. If three months have expired, a new supply must be purchased. Sublingual nitroglycerin spray may be used until the expiration date listed on its original container.

If a patient with a history of angina experiences chest pain, the dental procedure should be stopped immediately and the patient should be placed in a comfortable position. Administration of 0.3-mg tablet or 0.4-mg metered spray nitroglycerin sublingually is the initial treatment of choice. This dose should provide relief of the angina-related pain in just a few minutes. If needed, this same dose can be administered twice more at intervals of five minutes. If the pain is not relieved after the repeated doses of nitroglycerin, the dentist should consider that a myocardial infarction is developing and use the emergency protocol for this serious cardiac event.

Nitroglycerin is a vasodilator and causes the relaxation of smooth muscle of the vasculature; dilation occurs in venous and arterial beds and the coronary arteries. The ultimate effect is a reduction in systemic vascular resistance and left ventricular pressure, which reduces the myocardial demand for oxygen [8]. However, this vasodilation effect can interact synergistically with other medications and cause untoward effects. For example, male patients who are currently taking medications for erectile dysfunction, such as sildenafil, tadalafil, or vardenafil, can experience a significant decrease in blood pressure when these medications and nitroglycerin are combined. Unconsciousness and even death can occur from the resulting profound hypotension. The serious drop in blood pressure that can occur when these medications are combined may not readily be reversible with vasopressor medications. In these cases, supplemental oxygen may be helpful. While some patients may be reluctant to list these medications on their medical history, it is mandatory that the medical history of any male patient who is administered nitroglycerin is reviewed to determine if they are concurrently using medications for erectile dysfunction.

If a patient responds favorably to the nitroglycerin, it should be determined if the frequency and intensity of the attacks are progressing toward unstable angina. This diagnosis can only be made by the patient's physician or cardiologist, to which a referral should be made if angina-related chest pain has occurred during dental treatment.

If the repeated administration of nitroglycerin has not succeeded in the alleviation of the chest pain, the emergency protocol for the treatment of an acute myocardial infarction must be started. Emergency medical services (EMS) should be contacted immediately by one staff member while other staff members assist the patient.

The dentist should also suspect the occurrence of a myocardial infarction in all patients with acute chest pain, whether they have a history of myocardial infarction or have no history of cardiovascular pathology. Treatment should commence immediately while waiting for EMS to arrive.

A conscious patient should be placed in a comfortable position that is easily accessible by EMS personnel. The medications used to provide initial life-sustaining treatment for a conscious patient may be remembered by the acronym MONA: morphine, oxygen, nitroglycerin, and aspirin [9]. Morphine given by intramuscular or intravenous means provides relief from the acute, crushing pain that accompanies a myocardial infarction. Because many dental offices do not utilize this medication, the inhalation of a 50:50 ratio of nitrous oxide and oxygen can also be used for acute pain relief [10]. The inhaled concentration of oxygen in this mixture is more than ambient air concentrations. In offices that are not equipped with a nitrous oxide delivery system, oxygen from a portable tank through a nasal cannula or a nasal hood at a flow rate of 4–6 liters per minute is used. Nitroglycerin, as a sublingual tablet or a metered sublingual spray, will act as a vasodilator and ultimately reduce the oxygen requirements of the myocardium. In a conscious patient, a dose of 325 mg of aspirin, which provides antiplatelet activity, should be chewed and swallowed.

When a patient suspected of having an acute myocardial infarction becomes unconscious, then he or she should be positioned to assess the airway, breathing, and circulation. When neither a pulse nor breathing can be detected, CPR should be started.

Additionally, the use of an automated external defibrillator (AED) can be indispensable in saving the life of a patient experiencing a cardiac emergency. Every dental office should have an AED, even if it is not required by state law. When used with the basic life support techniques of CPR, defibrillation can significantly increase the chance of surviving a myocardial infarction. Each minute that elapses before the heart is successfully defibrillated results in a 7% to 10% decrease in the chance for survival [11]. Instructions on the use of this device should be incorporated into the office training for all staff members. Because the response time for EMS can vary, the dental staff should be prepared to provide medical support for the patient until EMS personnel can provide further assistance and transport the patient to the hospital.

Cerebrovascular Accidents (Strokes)

As noted, approximately 7 million adults in the United States have a history of stroke; of those, nearly 75% are older than 65 years of age [6,12]. As the American population ages, the number of patients with a history of stroke who continue to seek dental care is considerable. Risk factors that were likely instrumental in the development of the initial stroke, such as hypertension, can remain as precipitating factors for another event.

There are two basic categories of stroke: hemorrhagic and ischemic. Hemorrhagic strokes occur when a blood vessel in the brain ruptures. Ischemic strokes occur when the partial or complete occlusion of a blood vessel by an emboli or atherosclerotic plaque diminishes or eliminates the perfusion of oxygenated blood to a section of the brain. Sudden confusion, weakness on one side of the body, visual disturbances, and a struggle to speak are common symptoms of a stroke. A patient who demonstrates any of these symptoms should be administered oxygen and EMS should be summoned immediately. If the patient lapses into unconsciousness, the basics of monitoring the airway, breathing, and circulation must be maintained.

Similar to a cardiac emergency, a stroke can occur without any prior symptoms and in patients with no medical history of cardiovascular disease. However, if the medical history is positive for stroke, the chance for a recurrent stroke and related morbidity and mortality is increased. Approximately 3% to 10% of strokes recur within one month, with an elevated risk of recurrence within the first six months [42]. With the passage of time, there is a decreased risk of another stroke. However, 33% of stroke survivors have a recurrence within two years [42]. When possible, dental treatment should be deferred during this interval. Patients who develop odontogenic pain or infection or who have experienced oral or maxillofacial trauma during this initial period may require treatment that cannot be postponed for six months. In these cases, the patient's physician should be consulted prior to any procedures, and treatment should be as conservative as the situation allows. Invasive treatment, such as oral surgery, may need to be completed in a hospital setting, so all vital signs can be monitored. Many post-stroke patients take anticoagulant medications, which can cause problems with hemostasis postsurgically.

Stroke survivors who seek dental care should be carefully assessed before any dental treatment, especially when the stroke has occurred within the last year. Vital signs should be taken as a baseline and monitored throughout the procedure. Stress should be minimized during any dental procedure, and pain control must be optimal. Sedation with a combination of nitrous oxide and oxygen can be beneficial in the reduction of anxiety and as a mild analgesic. Vasoconstrictors such as epinephrine should be avoided if at all possible. These steps are designed to decrease the chance of a recurrent stroke, but do not eliminate it. Quick response and knowledge of each patient's risk will allow for the best possible outcome.

SEIZURES

Seizures are a rare occurrence in the dental setting but can occur, and the characteristic convulsive movements of the limbs may endanger the patient. Epilepsy is a neurologic disease associated with recurrent, spontaneous seizure activity. However, seizures can occur in patients without a history of epilepsy for a variety of reasons, including brain tumors and withdrawal from alcohol, narcotics, or benzodiazepines.

The most serious manifestation of seizure activity is the tonic-clonic seizure (formerly grand mal seizure). These seizures, which are probably the best known, consist of two phases. The tonic phase features generalized muscle rigidity, dilation of the pupils, eyes that roll upward, and a loss of consciousness. The clonic phase includes uncoordinated movements of the limbs and head, often with the jaws tightly clenched. This clonic activity usually lasts less than two minutes, after which muscular relaxation and a return to consciousness occur.

The absence seizure was formerly referred to as a petit mal seizure. Absence seizures are rare in adulthood and almost always begin in children between 4 and 12 years of age [39]. This seizure is characterized by a brief period of altered consciousness, often described as a staring spell. The duration of the seizure is generally 5 to 30 seconds. The absence seizure may occur up to 100 times per day or only rarely [39]. The child is often described as having a blank stare that interrupts motor and mental activity, which begins and ends suddenly. The patient will have no loss of postural tone but may experience a mild increase or decrease in muscular tone. Occasionally, the child will exhibit minimal myoclonic movements around the eyelids or mouth. The patient may have automatisms associated with the seizure, including chewing or rapid blinking. During the seizure there is a loss of awareness [39]. There is usually no postictal period, and the individual may continue activities with full awareness after the seizure has subsided.

When patients do not enter the recovery phase and have repeated seizures, the condition is known as status epilepticus. This is a medical emergency, and EMS must be summoned as soon as possible, as patients can become hypoxic. If possible, supplemental oxygen should be administered.

Before any dental treatment is begun, the dentist should have a clear history of each patient's seizure activity and compliance with prescribed medications. Dental appointments should only proceed if a patient has been compliant with prescribed medications. Even when the precautions are followed, seizures can still occur. Many patients with a history of seizures have a prodromal phase or an aura prior to the tonic phase of seizure activity, allowing for some warning of the event. This provides an opportunity to remove any objects from the mouth that were placed for dental treatment to prevent aspiration or injury. This phase can also provide time to administer anticonvulsant medications. Attempting intramuscular injections or the placement of an intravenous line to administer anticonvulsant medications can be difficult and dangerous while the patient is seizing. Nothing, including a bite block or cotton rolls, should be placed in the mouth after the seizing activity has begun. The patient should remain in a supine position in the dental chair, and any dental instruments in the field of operation should be moved away to protect the patient from injury. Breathing is usually unaffected by seizure activity, but recording vital signs may not be possible. However, upon conclusion of the seizure, some patients will be unconscious and must have an evaluation of their airway, breathing, and circulation. Dental treatment should not be resumed but should be rescheduled to another time.

Because patients can emerge from seizures in a confused and exhausted state, they should not attempt to drive; transportation home may be provided by a responsible adult. If the seizure was a first-time occurrence for the patient, a referral to a physician is necessary in order to discover the underlying cause.

DIABETIC EMERGENCIES

In the United States, approximately 11.3% of the population, or 37.3 million children and adults, have diabetes [17]. Type 1 diabetes, in which the body does not produce adequate amounts of insulin, accounts for about 5% of these cases and usually has an onset in childhood, adolescence, or young adulthood. These patients require insulin injections to manage the disease. The remaining 95% of patients have type 2 diabetes, caused by the body's impaired glucose metabolism. These patients usually develop diabetes at 40 years of age or older, and oral hypoglycemic medications with occasional supplementation with insulin are utilized by these patients [18,44]. Most dental practices will treat patients with diabetes and should be prepared for emergency situations that can develop before, during, or after dental treatment.

Dentists should discuss the type of diabetes, compliance with prescribed medications and dietary recommendations, problems with glycemic control, and acute and chronic complications of the disease with all patients with diabetes before dental treatment begins. Consulting a patient's physician before initiation of dental treatment can decrease the chance of a diabetic emergency. Diabetes-related emergencies in the dental setting usually involve hypoglycemia (low blood glucose) or, less frequently, hyperglycemia (elevated blood glucose).

Hypoglycemia

Hypoglycemia occurs most frequently in persons with type 1 diabetes but can also occur in individuals with type 2 diabetes. When a normal dose of insulin or oral hypoglycemic agent is taken prior to dental treatment and the patient eats minimally or not at all, blood glucose levels can plunge rapidly. Signs and symptoms of hypoglycemia can develop rapidly and include anxiety, skin that is cool and moist, sweating, confusion, difficulty speaking, labored breathing, and tremors. Tachycardia can exacerbate the anxiety that can accompany hypoglycemia. Some patients with diabetes will develop a condition known as hypoglycemia unawareness. This is a condition whereby a patient who has experienced many hypoglycemic events will not manifest the early signs and symptoms of hypoglycemia. These patients can progress rapidly to severe hypoglycemia and may have seizures and lose consciousness [19]. When the dental staff is treating a patient with diabetes, they should recognize that the occurrence of these symptoms indicates hypoglycemia and requires immediate treatment.

A glucometer provided by the patient or the dental staff may be used to measure blood glucose. A conscious hypoglycemic patient may take fruit juice, regular soda, or a glucose gel that can be absorbed through the oral mucosa in order to stabilize the blood glucose level. After 15 minutes, the blood glucose should be rechecked. If it has not returned to an acceptable level (i.e., a concentration higher than 60 mg/dL), another dose of glucose should be taken and the levels rechecked in 15 minutes. After the level has reached at least 60 mg/dL, a mixed snack can be provided [20]. Any remaining dental treatment should be rescheduled, and the patient should be referred to their physician for further evaluation.

If a patient with hypoglycemia lapses into unconsciousness, EMS should be summoned and the patient's physician notified immediately. The staff should begin immediate measures to raise the blood glucose level, although no food or beverage that must be chewed and swallowed should be placed into the mouth of an unconscious patient. Glucose gel may be applied onto the oral mucosa, through which systemic absorption occurs. An intramuscular injection of glucagon (1 mg) may be administered, which stimulates the formation of glucose from glycogen stored in the liver. If an intravenous line can be prepared by the dentist, a solution of 50% dextrose in water can be used [21,45]. The patency of the airway, breathing, and circulation should be monitored as with any unconscious patient. The patient should have blood glucose levels monitored every 15 minutes and should be transported to the hospital, where further evaluation and stabilization of the blood glucose can be done.

Prior to any further dental treatment, patients should have their insulin and/or oral hypoglycemic agent regimen and diet re-evaluated by their physician. Patients who have had surgical procedures must be counseled to maintain the dietary and medication regimen as prescribed to avoid the precipitation of another hypoglycemic crisis at home. The physician may recommend a temporary dose adjustment in oral hypoglycemic agents or insulin.

Hyperglycemia

As noted, hyperglycemia is a less frequent emergency issue among patients with diabetes. However, elevation in blood glucose can lead to an altered mental status, the odor of acetone on the breath, blurred vision, excessive thirst and hunger, rapid and deep breathing, cardiac arrhythmias, and in severe cases, coma. The onset of these symptoms is more gradual compared to those associated with an acute hypoglycemic crisis. Most dentists do not have training in the administration and dosage of insulin specific to the patient's glycemic control goals. In cases of hyperglycemic emergencies, a physician should be contacted and EMS summoned for appropriate treatment. Monitoring the airway, breathing, and circulation along with providing supplemental oxygen as needed may be necessary until EMS arrives.

ASTHMA ATTACK

According to the Centers for Disease Control and Prevention, 8% of adults and 5.5% of children are currently diagnosed with asthma [22]. This disease is the most common cause of respiratory distress among dental patients [23]. Asthma features the constriction of the bronchial and bronchiolar muscles and extensive secretion of viscous mucus in the respiratory tract, making breathing difficult to impossible. It is a chronic inflammatory respiratory disease characterized by recurrent episodes of dyspnea, coughing, and wheezing [24]. Asthma attacks occur when the bronchiolar tissue is hyper-responsive to a variety of stimuli, including cold air, smoke, medications (e.g., salicylates and nonsteroidal anti-inflammatory drugs [NSAIDs]), various chemicals, stress, allergens, exercise, and anxiety, among many others.

When a patient's medical history reveals asthma, it is important for the dental professional to determine the severity of the illness, the types of medication(s) prescribed, frequency and the severity of attacks, and known triggers that have stimulated asthma attacks in the past. If a patient is a persistent asthmatic with a high frequency of asthma attacks, his or her physician should be consulted before any treatment is begun, as the stress and anxiety that some patients associate with dental treatment can precipitate an attack.

Dental offices that treat patients with asthma should have short-acting inhalers, such as albuterol, available to rapidly reverse asthma symptoms in the event the patient does not bring one. Albuterol is a bronchodilator that acts by inducing the relaxation of constricted bronchiolar smooth muscles and inhibiting the release of substances from mast cells that cause bronchiolar constriction. Most inhalers are aerosol, although dry powder and nebulizer types are also available. If an asthma attack occurs during dental treatment, the procedure should be stopped, the patient placed in an upright position, and the albuterol inhaler should be used.

Intramuscular injections of 0.3–0.5 mg epinephrine in a 1:1,000 (1 mg/mL) concentration may be used if albuterol is not available. Epinephrine may be used every 20 minutes for two additional doses [5,45]. If necessary, supplemental oxygen and a second administration of the albuterol inhaler may be administered. A pulse oximeter can be used to determine oxygen saturation. Because members of the dental staff generally do not have the experience to discern the severity of an asthma attack, EMS should be summoned if the patient has not responded to the initial use of these medications.

If the anxiety and stress of dental procedures has been a stimulant for an asthma attack in the past, inhalation sedation with nitrous oxide may be helpful. However, nitrous oxide may cause irritation of the airway in sensitive patients. In these patients, nitrous oxide should only be used if it is approved by a physician. Moderate sedation can prove to be dangerous in patients with asthma because of the limited control of the airway. This method should only be used with physician approval and may need to be performed in a hospital environment. Narcotic analgesics should be avoided as they can stimulate histamine release, which can result in bronchospasm [25]. As a class, narcotics also cause respiratory depression.

4. ALLERGIC REACTIONS DURING DENTAL TREATMENT

According to some estimates, more than 53 million Americans have at least one allergy [26]. Furthermore, approximately 5% to 10% of adverse reactions to medications are allergic reactions. The clinical manifestations of these reactions can range from a rash and erythema (in nearly 50% of medication-related reactions) to a 1% incidence of anaphylaxis. In general, when a medication is consumed, there is a 1% to 3% chance of an allergic reaction [43].

Medical emergencies related to allergic reactions are uncommon but possible in the dental office. Prevention of this kind of emergency begins with a review of the medical history as it relates to prior allergic reactions to medications, food, or materials. It is important to note that patients who do not have any past allergic reactions are not guaranteed immunity from future allergic reactions [27].

Today, penicillin is the most common cause of drug-related allergic reactions, and latex is the most common material in the dental environment that causes an allergic reaction [28]. Approximately 1% to 5% of the general population has a latex allergy, but the prevalence is increased in certain populations, including atopic patients and persons who have chronic occupational exposure (e.g., healthcare professionals, rubber industry workers) [33]. There are several different types of latex allergies, but those who experience immediate hypersensitivity after exposure (a type I reaction) are the most likely to develop anaphylaxis. The use of non-latex gloves and rubber dams is the most practical remedy for this problem, but this requires that a latex allergy be communicated to all staff members involved with direct clinical care and contact with the patient before a procedure. A life-threatening allergic reaction can occur if a dentist does not inform other clinical staff about a patient's latex allergy and latex gloves are subsequently used during the patient's treatment.

Allergic responses to medications and materials begin at the cellular level and involve various degrees of hypersensitivity reactions. The ingestion of a medication or exposure to a material such as latex can stimulate an inappropriate immune response in some patients. A type I reaction manifests as an allergic response when a complex is formed between the ingested material (allergen) and an immunoglobulin, such as immunoglobulin E (IgE). This unique biochemical complex then stimulates the release of histamines from mast cells, which increases vascular permeability with fluid from the vasculature extruding into the adjacent tissues. The degree to which this affects the patient can vary from local involvement to a systemic reaction to anaphylaxis and even death.

In the dental setting, many potential allergens are present. Medications (over-the-counter or prescribed), materials such as latex, or even local anesthetics used for dental procedures can all induce allergic reactions. Some allergic reactions develop slowly, while others can progress rapidly and cause systemic collapse. When an allergic reaction is suspected, dental treatment should cease and the emergency treatment protocol should be initiated. Mild allergic reactions in which there is localized rash, hives, or itching and during which the patient remains conscious can be treated with a histamine blocker, such as 25–50 mg diphenhydramine taken orally every six to eight hours [5]. Patients should be referred to a physician or an allergist to determine the source of the allergic response. If there is any doubt about the stability of the patient or the potential for a progressive allergic response that could lead to anaphylaxis, the patient should continue to receive supportive care and the EMS should be summoned.

ANAPHYLAXIS

An anaphylactic reaction represents the most serious degree of an allergic response. It is characterized by a set of symptoms that involves various organs and systems and occurs independently, simultaneously, or subsequently [30]. Initial symptoms often involve widespread hives and progress rapidly to bronchospasm, respiratory arrest, and ultimately, cardiac arrest. Whether the anaphylactic reaction is of immune or nonimmune origin, the stimulation of mast cells and circulating basophils release chemical mediators that begin the anaphylactic process.

The release of histamine and bradykinins causes vasodilation and edema, while the release of prostaglandin D2 and leukotrienes results in bronchoconstriction [31]. These biochemical events can cause a transfer of as much as 50% of intravascular fluids to extracellular spaces [32]. A steep decline in blood pressure and cardiovascular collapse can ensue. Immediate emergency treatment and contact of EMS is mandatory to save the patient's life.

While the patient is conscious, any dental materials in the patient's mouth should be removed to prevent their aspiration and further complication of the efforts to treat the patient. The patient should be placed in a supine position with the legs slightly elevated to facilitate blood flow to the brain. The basics of airway, breathing, and circulation should be constantly monitored.

Evidence Based Practice Recommendation

According to the Australasian Society of Clinical Immunology and Allergy, epinephrine is the first line treatment of anaphylaxis and acts to reduce airway mucosal edema, induce bronchodilation, induce vasoconstriction, and increase strength of cardiac contraction.

https://www.allergy.org.au/images/ASCIA_HP_Guidelines_Acute_Management_Anaphylaxis_2023.pdf

Last Accessed: January 25, 2023

Level of Evidence: Expert Opinion/Consensus Statement

Epinephrine remains the medication of choice to treat anaphylactic shock. Commercially prepared pre-loaded syringes of 0.3 mg of 1:1,000 epinephrine (usually referred to by their brand name, EpiPen) can be injected into the deltoid or vastus lateralis muscles or in the sublingual region. The highly vascular sublingual region can promote rapid absorption of the epinephrine. Subcutaneous administration of epinephrine does not provide as much bioavailability of epinephrine as the intramuscular or sublingual routes [5,45].

Once absorbed, epinephrine targets the alpha and beta receptors of the cardiovascular system, inducing vasoconstriction and increasing the systolic blood pressure. Epinephrine also acts as a bronchodilator and can relieve the respiratory distress associated with anaphylaxis. The dose of 0.3 mg epinephrine can be administered every 5 to 15 minutes until hypotension and respiratory distress are stabilized. An intramuscular injection of a histamine blocker such as diphenhydramine can also help by reducing the effects of the histamine release from the mast cells [5].

Positive pressure oxygen delivered through a mask can provide supplemental oxygen. Some patients will exhibit severe pharyngeal and laryngeal swelling and require intubation for the proper exchange of oxygen. All anaphylactic patients must be transferred to a hospital for further treatment and observation, as some patients have a biphasic response and begin to display symptoms of anaphylaxis even after seemingly effective treatment. Biphasic reactions have been reported to occur in 1% to 20% of anaphylaxis episodes, usually about eight hours after the first reaction, although they can occur up to 72 hours later [16]. After recovery from the anaphylaxis reaction, the patient should consult with his or her physician or allergist to identify which substance(s) caused the event and to prevent recurrence.

LOCAL ANESTHETIC REACTIONS

Local anesthetics provide a means by which restorative, surgical, and endodontic procedures can be completed in a comfortable fashion. Some estimates suggest that approximately 300 million cartridges of local anesthetics are used in the United States annually [34]. These injected medications have an outstanding record of safety, and allergies to local anesthetics are rare. Systemic complications that occur after the injection are also rare but do occur and can progress rapidly. However, the safety record of local anesthetics should not allow a sense of complacency to develop among clinicians regarding their use. Package inserts from the manufacturers contain warnings that those who administer local anesthetics should be prepared to diagnose and treat emergency situations such as dose-related toxicity and acute reactions that may occur after administration. The availability of oxygen and resuscitative equipment and the competence to use this equipment properly is also advised.

As discussed, the medical and dental history of each patient should be reviewed prior to the initiation of treatment and the administration of any medication. When the dental history reveals that a patient has had problems with local anesthetics before, a thorough investigation of the nature the problem, the local anesthetic used, and the required emergency treatment and outcome can provide important information. A consultation with dental clinicians involved in prior treatments and, if applicable, physicians involved in their emergency treatment may help to identify the etiology of the toxicity reaction so it can be avoided in subsequent appointments.

Allergic Reaction

Allergic reactions can occur upon the administration of local anesthetics. Some patients have allergies to the anesthetic itself, but some patients will be allergic to sulfite compounds. Antioxidants such as sodium metabisulfite or potassium metabisulfite are used as stabilizers in local anesthetic solutions that contain vasoconstrictors, such as epinephrine or levonordefrin. The presence of a documented sulfite allergy or a history of an allergic-type asthma attack should prompt the clinician to utilize a local anesthetic without a vasoconstrictor.

Toxicity

Although vasoconstrictors must be avoided in patients with sulfite compound allergy, they usually play an important role in minimizing the rapid systemic dissemination of the local anesthetic. Both epinephrine and levonordefrin constrict blood vessels in the injection area, resulting in a slower systemic absorption and decreasing the chance of systemic toxicity. Aspirating before injecting slowly also minimizes the chance that the local anesthetic will be injected directly into a blood vessel, decreasing the rate of systemic circulation. Direct intravascular injection of an entire cartridge of a local anesthetic can have adverse effects on both cerebral and cardiac tissues.

The prevention of toxicity from local anesthetics involves more than a careful injection technique. A patient's age, weight, medical conditions, and current medications can all influence the metabolism and clearance of local anesthetics. The most common cause of local anesthetic toxicity is an overdose of the medication relative to the age and weight of the patient. This occurs most often in pediatric patients, but excessive doses also occur in adults, particularly elderly individuals [35]. Each local anesthetic has a maximum allowable dosage schedule as a guideline when calculating doses, expressed as the maximum total dose (in mg) of a given anesthetic relative to the weight of the patient. Some local anesthetics, such as bupivacaine, are not recommended for use in patients younger than 12 years of age. Children do not have the capability to metabolize and excrete local anesthetics as well as healthy adults. In addition, the elderly, adults with low body weight, and those with chronic illness(es) may have a diminished capacity to metabolize and excrete local anesthetics. Clinicians should avoid using the same dose on each patient without regard to these factors.

Systemic disease can also affect an individual's ability to metabolize and excrete local anesthetics. The amide type of local anesthetics, which includes lidocaine, mepivacaine, bupivacaine, and prilocaine, undergoes metabolism primarily in the liver and excretion is via the kidneys. The majority of articaine is metabolized in the plasma. It has an amide component but is the only amide with a thiophene ring. Diseases such as hepatitis and cirrhosis can adversely affect hepatic function and decrease the liver's ability to metabolize these anesthetics; a dose that is usually appropriate for the age and weight of a healthy patient can gradually accumulate to toxic levels. Patients with impaired renal function, especially those with end-stage renal disease and those on dialysis, will have difficulty excreting metabolized local anesthetics. These patients' physicians and specialists should be consulted about an appropriate dosing schedule. When multiple quadrants of restorative treatment are performed, full-mouth extractions completed, or multiple doses are administered in the same area in patients who are having difficulty achieving a state of anesthesia, the maximum allowable local anesthetic dose for the patient can be achieved quickly.

The concurrent use of certain medications can also alter the metabolism of local anesthetics. Medications such as phenytoin, meperidine, and desipramine compete with local anesthetics for the same protein binding sites, which can decrease efficacy of both drugs [36]. Cimetidine, which is in common use for the treatment of gastroesophageal reflux disease and ulcers, can decrease the rate at which lidocaine is metabolized in the liver, as both medications compete for the same hepatic enzymes [37]. These instances of competitive drug metabolism can cause a local anesthetic to be retained longer and a toxic accumulation may be reached faster if the dose is not adjusted.

The manifestations of toxicity to local anesthetics and their vasoconstrictors can have different clinical appearances. When a local anesthetic with epinephrine is injected into a blood vessel and distributed systemically, patients may experience tachycardia, heart palpitations, and anxiety. This is usually a transient reaction that subsides in a few minutes. However, patients should be monitored to assure that it is not the beginning of a more progressive toxic reaction. Furthermore, patients should never be left alone after a local anesthetic has been injected.

Local anesthetics can cross the blood-brain barrier and can exert a depressant or excitatory action on both the central nervous system (CNS) and the cardiovascular system. Some toxic reactions to local anesthetics can occur rapidly after the injection, while others may be delayed for several minutes. A clinically evident excitatory phase, featuring excessive talking, apprehension, and excitability, may be present during these reactions. Among the local anesthetics used, the lack of this phase occurs more frequently with lidocaine [38]. Patients can progress to demonstrate signs of slurred speech, diaphoresis, nausea, vomiting, tachycardia, and an increased rate of breathing when the degree of toxicity is minimal to moderate. When higher doses of a local anesthetic cause more severe acute toxicity, the patient may develop seizures, CNS depression, hypotension, bradycardia, and a decreased respiratory rate.

When any sign of local anesthetic toxicity emerges, members of the dental care team should begin with an initial monitoring of the vital signs. Fortunately, most reactions to a local anesthetic toxicity are mild and self-limiting, with only the use of supplemental oxygen needed to assist the patient. More severe reactions occur within one minute of administration of the local anesthetic and can lead to seizures and unconsciousness. When this occurs, one staff member should contact EMS while the dentist and others are monitoring the airway, breathing, and circulation of the patient. If the patient has seizures that do not appear to be decreasing in intensity, a benzodiazepine may be used. The dental staff should stabilize the patient until EMS has arrived. In rare cases, this may involve the administration of CPR and/or the use of an AED. An analysis should be completed to determine the cause of the toxic reaction so recurrence can be prevented.

5. ASPIRATED AND INGESTED OBJECTS DURING DENTAL TREATMENT

The aspiration of an object into the bronchi or lung or the ingestion of an object into the esophagus and ultimately the gastrointestinal tract during a dental procedure is a potentially life-threatening event. Among the objects that have been aspirated or ingested are extracted teeth, crowns, bridges, implant instruments, endodontic instruments, rubber dam clamps, cotton rolls, and parts of teeth or old restorative materials that have fractured during extractions or during instrumentation with a high-speed handpiece. The saliva in the oral environment, limited access and vision, and occasional abrupt movements by the patient can cause the clinician to lose control of an object in his or her grasp. The inability to retrieve an object from the mouth can result in its displacement into the posterior pharynx and the potential to enter the esophagus or bronchi. There are several practices that can be used to decrease the incidence of this problem.

Evidence Based Practice Recommendation

According to the Hartford Foundation Center of Geriatric Nursing Excellence, older adults with neurologic conditions such as Parkinson disease can experience dysphagia. These patients may often appear to have excess saliva, but this is usually the result of their inability to retain contents in the oral cavity and swallow adequately. Oral care is most effective when these patients can be in a semi-upright position to avoid choking or aspiration.

http://m4.wyanokecdn.com/6c3b9e6272d6a4834c6dc9b1c2ce3e04.pdf

Last Accessed: January 25, 2023

Level of Evidence: Expert Opinion/Consensus Statement

Patients who have any congenital or acquired diseases that affect neuromuscular control can have difficulty with their gag reflex and swallowing and may experience excessive movements of the tongue, lips, and cheeks. Patients with a history of conditions associated with neuromuscular deficits, such as cerebral palsy, Parkinson disease, and stroke, often require special care and attention. Patients who have a high level of anxiety about dental treatment may move abruptly during the dental procedure, causing the clinician to lose control of instruments or objects (such as crowns) that are being held within the mouth. Various levels of sedation can diminish the fear and anxiety that these patients associate with dental treatment, but it can also decrease protective reflexes such as gagging and coughing.

When patients are anesthetized, especially when multiple quadrants are involved, their ability to detect loose or foreign objects before they enter the posterior pharynx can be compromised. Barriers may be placed to prevent objects that have become dislodged in the mouth from being aspirated or ingested. During most restorative procedures and endodontic procedures, rubber dam isolation of the tooth being treated provides a dry operating field and can prevent pieces of the tooth or old restoration and endodontic instruments from entering the posterior pharynx.

However, the rubber dam clamp itself can become dislodged and mobile within the oral cavity. A small piece of dental floss may be tied around the clamp, with the free ends extending out from the mouth. This can aid in retrieving the clamp should it become dislodged. Isolation during extractions can be accomplished with a 4-inch x 4-inch piece of cotton gauze. These procedure-related practices can diminish the chance of aspirating or ingesting an object.

Despite the best efforts of isolation, objects may enter the posterior pharynx during dental treatment. When this occurs, patients should be placed in an upright position and allowed time to determine if a productive cough will force the object into the mouth, where its retrieval is possible. If the object cannot be found in the mouth, the patency of the patient's airway and his or her ability to breathe should be monitored. If the patient can breathe independently, the airway remains unobstructed. However, objects can be lodged in a bronchus without labored breathing or coughing.

When the object cannot be located, an immediate medical consultation is required. Aspirated objects may have sharp and irregular surfaces that can traumatize tissue. Further, these objects may be laden with bacteria of the oral flora, which can cause complications such as post-obstructive pneumonitis, pulmonary abscesses, and bronchiectasis [41]. Chest radiography including posteroanterior and lateral projections is required to detect the presence of a foreign object in the bronchi or lungs [40]. When located, the object can be removed by surgical procedures such as bronchoscopy.

Radiographs of the abdomen should also be taken, as it is more likely that an object will be swallowed and introduced into the gastrointestinal tract than it will be aspirated into the bronchi or lung [41]. Swallowed objects that are sharp and irregular have the capability of perforating the gastrointestinal mucosa, and medical and surgical consultation with a gastroenterologist is required in these cases. While some objects may require surgical removal from the gastrointestinal tract, others may safely progress through the entire system and be eliminated with solid waste.

In some cases, aspirated objects may become lodged in the trachea and cause partial or complete obstruction of the airway. In the latter case, the Heimlich maneuver, or abdominal or chest thrusts in patients who are pregnant or obese, should be used. The activation of EMS is required if these procedures cannot remove the aspirated object and oxygen via CPR or positive pressure cannot be supplied to the lungs. Even if the object is retrieved and a normal flow of oxygen is resumed, the patient should be referred to a physician or specialist to determine if the lodged object caused any trauma to the area. When an object has been aspirated or swallowed by a patient, it is essential that the dental staff reviews the incident to determine methods by which this incident can be avoided in the future.

6. STAFF PREPARATION AND TRAINING FOR MEDICAL EMERGENCIES

An emergency can be defined as a sudden and unexpected occurrence that requires immediate action. This definition is applicable to the medical emergency situations described in this course as well as many others that can develop during dental treatment, even when measures have been taken to decrease the chance of their occurrence. A meticulous review of each patient's medical and dental history and an awareness of their current medication(s) can help to assess the degree to which patients are at risk for developing a medical emergency during dental treatment. However, because patients with benign medical histories can develop an emergent medical problem, all members of the dental staff should be trained to take immediate action to assist the patient.

STAFF TRAINING

There is no substitute for appropriate staff training for medical emergencies. The occurrence of a medical emergency is not the time to assign specific roles for each staff member, check the emergency medicine kit for drugs that have expired, or make sure that the AED is working properly. The chaos and panic that can ensue among an unprepared dental staff can mean the difference between life and death.

Each staff member should be assigned a specific duty to assume during a medical emergency. Contingency plans should be made for the times when a staff member is absent. New staff members should be assigned their specific role when they join the practice. One person should be the designated leader responsible for directing other staff members and performing the initial assessment of airway, breathing, and circulation. It is important that this person has the demeanor to remain calm amid stressful circumstances. A second team member is responsible for bringing the emergency kit, the portable oxygen tank, and the AED to the patient. This staff member should be trained to assist with CPR. A third staff member is responsible for contacting EMS and providing information about the nature of the emergency situation and the patient's current vital signs. An estimated response time should be obtained [13,45]. Larger practices may have more than one such team, while practices that are just starting may have to divide the duties among just two or three staff members.

These roles should be practiced in medical emergency drills on a quarterly basis and should feature the various emergency situations to which the staff must respond. All staff members should be current with basic CPR training. Some states require a higher level of training, such as advanced cardiac life support, for practices that provide various levels of sedation for their patients.

Medications that are frequently used in medical emergencies have been highlighted in various sections of this course and can be purchased separately or as part of a medical emergency kit. Staff training for medical emergencies should highlight which medications are used for specific emergency situations, their route of administration, and the location of the emergency kit. A staff that is well-trained for medical emergencies during dental treatment can make the difference between the life and death of an afflicted patient.

AVAILABLE MEDICATIONS

Practices that routinely sedate patients with opioids or benzodiazepines should have antidotal drugs readily available to reverse the respiratory depression that can accompany the administration of these medications. Naloxone is an opioid antagonist that can reverse respiratory depression caused by this class of drugs, and flumazenil is capable of reversing the effects of benzodiazepine [14,15]. Flumazenil is given via an intravenous route, so clinicians who utilize it must be capable of establishing an intravenous line. Naloxone can be provided by intramuscular or intravenous means. Because many practices utilize sedation, especially for patients with a high level of anxiety about dental treatment, there should be a means to reverse respiratory depression due to excessive sedation.

The dental staff should have immediate access to medications and equipment used during dental emergencies. These supplies should be kept in a centrally located area, and their location should be known to all staff members. Several manufacturers supply the most commonly used emergency medications as a kit, and some will automatically ship new medications when those previously provided have expired. It remains prudent to have one staff member who periodically reviews the expiration dates of all emergency medications and orders replacements for those that have been used for an emergency situation. The indications and appropriate use for these medications should be communicated to all staff members.

OXYGEN

The use of oxygen is common in many medical emergencies. A portable oxygen cylinder (E-size) with a nasal cannula or nasal hood should be present in each office. The oxygen cylinder(s) should be checked periodically for the appropriate volume of oxygen, as even a small leak can cause loss of the entire volume of oxygen. All staff members should know how to operate these oxygen cylinders. Some offices may have nitrous oxide and oxygen delivery systems for each operatory. However, the tubing for these systems is not long enough to reach a stricken person beyond the operatory itself. Therefore, even offices with these systems should have portable oxygen cylinders available. Replacement tanks should be ordered after a cylinder has been used for an emergency situation.

CIRCULATION AND AEDs

Monitoring vital signs is critical to any emergency situation, so each office should have a stethoscope and a sphygmomanometer to record blood pressure. Several automated devices that record vital signs are available and may be useful when patient movement, such as during a seizure, makes a manual blood pressure assessment difficult.

Some states require that each dental practice have an AED and that staff be trained in its proper use. These devices should be a part of every dental practice even if there is no requirement by law to do so. Most manufacturers can provide training for the entire staff via in-office presentations or training videos. AED training should be incorporated into practice emergency drills so each staff member can use this device in an emergency situation. Voice prompts guide the operator for proper assessment and use of the AED during a cardiac emergency. Because long intervals can pass between uses of this device, its batteries should be checked at regular intervals.

7. CONCLUSION

This course has reviewed some of the most common medical emergencies that can occur during dental treatment, but it is beyond the scope of this course to discuss the exhaustive list of all medical emergencies that can occur. All members of the dental staff should be prepared to act decisively when a patient is stricken with an acute medical problem. This can only happen if the staff has been adequately trained and has actively participated in preparatory medical emergency drills.

As noted, medical emergencies occur in less than 0.5% of dental treatments; however, the American Dental Association has reported that 3% of all litigation against dentists originated from the failure to properly respond to a patient who developed a medical emergency during dental treatment [29,47]. Knowledge of the different kinds of medical emergencies and the corresponding emergency treatment protocols and medications empower the dental staff to act appropriately when a medical emergency arises. These problems may be infrequent in the dental setting, but because the possibility always exists, the dental staff should never be complacent about this issue. There is more than just a moral and ethical obligation to respond appropriately and to stabilize the patient before EMS arrives. A dental staff with proper training and equipment can save a life.

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Evidence-Based Practice Recommendations Citations

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