|
| A) | should not involve the patient when it is reviewed. | ||
| B) | does not need to be updated for each patient encounter. | ||
| C) | need not include information about current medications taken by the patient. | ||
| D) | is a document whose review with the patient should be completed by the dentist. |
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.
| A) | seizures. | ||
| B) | syncope. | ||
| C) | anaphylactic shock. | ||
| D) | myocardial infarction. |
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.
| A) | may be stable or unstable. | ||
| B) | can be precipitated by stress. | ||
| C) | is a form of ischemic heart disease. | ||
| D) | All of the above |
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.
| A) | 3 months | ||
| B) | 6 months | ||
| C) | 9 months | ||
| D) | 12 months |
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.
| A) | insulin. | ||
| B) | aspirin. | ||
| C) | epinephrine. | ||
| D) | nitroglycerin. |
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.
| A) | Oxygen | ||
| B) | Morphine | ||
| C) | Nitroglycerin | ||
| D) | Acetaminophen |
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.
| A) | Strokes are always preceded by warning signs. | ||
| B) | Dental treatment may be completed two weeks after the initial stroke. | ||
| C) | Strokes are not generally associated with risk factors such as hypertension. | ||
| D) | There is an elevated level of recurrence during the first six months after the initial stroke. |
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.
| A) | Seizures can occur subsequent to drug or alcohol withdrawal. | ||
| B) | Status epilepticus is not generally considered a medical emergency. | ||
| C) | To protect the patient, cotton rolls or bite blocks should be placed in the patient's mouth after a seizure begins. | ||
| D) | Dental treatment should be cautiously started if the patient has not been compliant with his or her seizure-related medications. |
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.
| A) | insulin-dependent diabetes. | ||
| B) | a disease usually beginning in childhood. | ||
| C) | the classification of diabetes that affects 95% of patients with diabetes. | ||
| D) | a condition in which the body does not produce adequate amounts of insulin. |
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.
| A) | Tremors | ||
| B) | Confusion | ||
| C) | Difficulty in speaking | ||
| D) | Skin that is hot and dry |
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) | cold air. | ||
| B) | stress and anxiety. | ||
| C) | medications such as salicylates and nonsteroidal anti-inflammatory drugs. | ||
| D) | All of the above |
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.
| A) | 2 million | ||
| B) | 15 million | ||
| C) | 53 million | ||
| D) | 75 million |
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].
| A) | lidocaine. | ||
| B) | penicillin. | ||
| C) | epinephrine. | ||
| D) | nitroglycerin. |
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.
| A) | Anaphylactic reaction may be of immune or nonimmune origin. | ||
| B) | Initial symptoms of anaphylactic reaction often involve localized hives on the torso. | ||
| C) | Anaphylactic reaction is fairly common and less serious than other types of allergic response. | ||
| D) | An anaphylactic reaction is characterized by a set of symptoms that involves various organs and systems and only occur independently. |
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.
| A) | aspirin. | ||
| B) | oxygen. | ||
| C) | glucose gel. | ||
| D) | epinephrine. |
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].
| A) | 0.3 mg every 3 to 5 minutes until stabilized | ||
| B) | 0.3 mg every 5 to 15 minutes until stabilized | ||
| C) | 0.5 mg every 3 to 5 minutes until stabilized | ||
| D) | 0.5 mg every 5 to 15 minutes until stabilized |
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].
| A) | A poor injection technique | ||
| B) | Diseases that alter the metabolism of local anesthetics | ||
| C) | An overdose of the local anesthetic relative to the patient's age and weight | ||
| D) | All of the above |
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.
| A) | Objects aspirated into the bronchus will always cause labored breathing. | ||
| B) | Chest or abdominal x-rays need not be taken if the object cannot be found. | ||
| C) | Patients with neuromuscular control problems have a decreased risk of aspirating an object. | ||
| D) | Using barriers such as rubber dams or gauze squares can decrease the chance of aspiration. |
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.
| A) | certification in CPR. | ||
| B) | ability to use emergency medications and equipment. | ||
| C) | clearly defined role assignments for each staff member. | ||
| D) | All of the above |
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.
| A) | Morphine | ||
| B) | Flumazenil | ||
| C) | Lorazepam | ||
| D) | Desipramine |
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.