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Research Article

Cientific Dental Research Journal (CDRJ)

Volume 1 Issue 2 - 2019
Received: July 26, 2019; Published: July 29, 2019

Dental Emergency Interventions

Sinisa Franjic*
Faculty of Law, International University of Brcko District, Brcko, Bosnia and Herzegovina
*Corresponding Author: Sinisa Franjic, Faculty of Law, International University of Brcko District, Brcko, Bosnia and Herzegovina.

Abstract
Emergency interventions may be required in dental practice. Some urgency may not endanger the life of the patient directly, but
in time it may disturb general health. As a result of insufficient concern about oral health, many diseases of the teeth and mouth
develop gradually so that the patients are not even aware of it. Sometimes sudden pains that require urgent dental intervention may
also occur. It is often very difficult for a patient to differentiate the source of pain as well as to know what to do in such situations.
Keywords: Emergencies; Oral Medicine; Patients; Physicians

Introduction incidents, through emergency medical services (EMS), and in haz-

ardous material and bioterrorism situations.
An emergency is commonly defined as any condition perceived
by the prudent layperson-or someone on his or her behalf as re-
In healthcare delivery, we attempt to meet the health and medi-
quiring immediate medical or surgical evaluation and treatment
cal needs of the community by providing a place for individuals to
[1]. Based on this definition, the American College of Emergency
seek preventative medicine, care for chronic medical conditions,
Physicians states that the practice of emergency medicine has the
emergency medical treatment, and rehabilitation from injury or
primary mission of evaluating, managing, and providing treatment
illness [2]. While a healthcare institution serves the community,
to these patients with unexpected injury and illness.
this responsibility occurs at the level of the individual. Everyone
expects a thorough assessment and treatment if needed, regardless
So, what does an Emergency Physician (EP) do He or she rou-
of the needs of others. This approach is different than that prac-
tinely provides care and makes medical treatment decisions based
ticed by emergency managers, whose goal is to assist the largest
on real-time evaluation of a patient’s history; physical findings;
number of people with the limited resources that are available. As
and many diagnostic studies, including multiple imaging modali-
such, emergency management principles are focused on the needs
ties, laboratory tests, and electrocardiograms. The EP needs an
of the population rather than the individual. When either planning
amalgam of skills to treat a wide variety of injuries and illnesses,
for a disaster or operating in a disaster response mode, the hospi-
ranging from the diagnosis of an upper respiratory infection or
tal should be prepared at some point to change its focus from the
dermatologic condition to resuscitation and stabilization of the
individual to the community it serves and to begin weighing the
multiple trauma patient. Furthermore, these physicians must be
needs of any individual patient versus the most good for the most
able to practice emergency medicine on patients of all ages. It
patients with scarce resources. Moving from the notion of doing
has been said that EPs are masters and mistresses of negotiation,
the most for everyone to doing the best for the many is a critical
creativity, and disposition. Clinical emergency medicine may be
shift in thinking for healthcare institutions considering a program
practiced in Emergency Departments (EDs), both rural and urban;
of comprehensive emergency management. While the initial plan-
urgent care clinics; and other settings such as at mass gathering

Sinisa Franjic. "Dental Emergency Interventions". Cientific Dental Research Journal 1.2 (2019): 12-17.
 © 2019 Cientific Dental Research Journal (CDRJ), Published by Cientific Group. All rights reserved.

13

ning for emergencies by hospitals is focused on maintaining opera- what the patient wants. In such a situation they would not do what
tions and handling the care needs of actual or potential increased they think is best for the patient but what they know the patient
numbers of patients and/or different presentations of illness or wants.
injury than is traditionally seen, there is also the need to recog-
nize that at some point during a disaster, act of terrorism, or public It is important to note that the emergency exception that allows
health emergency there may be an imbalance of need versus avail- physicians to do what they think is best for the patient without ob-
able resources. At this point the approach to delivering healthcare taining informed consent from the patient or proxy has one ma-
will need to switch from a focus on the individual to a focus on the jor restriction; namely, they cannot do what they think is best if
population. This paradigm shift is one of the core unique aspects of it is otherwise than what they know the patient or proxy wants.
hospital emergency management that allows the hospital to pre- Sometimes, for example, emergency department personnel might
pare to maximize resources in disasters and then to know when know from previous admissions that a particular patient from a lo-
to switch to a pure disaster mode of utilizing its limited and often cal nursing home desires only palliative care. If that patient arrives
scant resources to help the most people with the greatest chance by ambulance at the same emergency department, it is hard to see
of survival. how it would be morally reasonable for physicians to take aggres-
sive measures to keep the patient alive when, even though there is
The healthcare delivery system is vast and comprised of mul- no time to obtain consent for orders not to attempt resuscitation or
tiple entry points at primary care providers, clinics, urgent care not to intubate, they know he or she or a proxy has decided not to
centres, hospitals, rehabilitation facilities, and long-term care have aggressive life-sustaining measures performed.
facilities. The point of entry for many individuals into the acute
healthcare system is through the Emergency Department (ED). Patients accessing emergency care services can present with
Since the late 1970’s, the emergency medical services (EMS) sys- complaints that are extremely diverse, and the way doctors, nurses
tem has allowed victims of acute illness and injury to receive initial and paramedics elicit information from patients predominantly fo-
stabilization of life-threatening medical conditions on the way to cusses on obtaining biomedical details [4]. In some cases, this ap-
the emergency department. Among the many strengths of the ED proach is warranted, as the urgent need to identify signs and symp-
is the ability to integrate two major components of the healthcare toms of life-threatening illness or injury is paramount. Yet, 90% of
system: prehospital and definitive care. The emergency depart- patients accessing emergency services are not critically ill or in-
ment maintains constant communications with the EMS system jured but seek help and advice. In addition to seeking advice, pa-
and serves as the direct point of entry for prehospital providers tients may also be anxious, frightened, intoxicated, misusing drugs
into the hospital or trauma centre. Emergency physicians repre- or have unhealthy lifestyles. They may have psychosocial reaction
sent a critical link in this process by anticipating the resources to physical disease or vice versa - physical illness such as irritable
that ill and injured patients will need upon arrival at the ED and bowel syndrome, asthma, tension headache can be triggered by
initiating appropriate life-saving medical care until specialty re- psychosocial factors. The effects and interpretation of illness will
sources become available. In this context, the healthcare system is trigger a different response to the individual depending on their
an emergency response entity. view and experiences. All these factors will have different needs
and concerns and it is important to elicit these concerns within a
Patient Conditions consultation. However, it has been found that nurses working in
In most emergencies there is no time to disclose the necessary emergency care disregard the potential for anxiety and the need
information for an informed consent [3]. Here the providers sim- for support and reassurance in patients who are not severely ill or
ply act according to what they think will be in the best interests of injured. In addition, where communication skills of junior doctors
the patient. These situations frequently happen in hospital emer- working in emergency departments have been researched, they are
gency rooms and when emergency medical personnel arrive on found to use approaches considered to be more physician/illness
the scene of an accident or sudden illness. orientated than patient centred. By way of similarities of patient
presentations in the pre-hospital setting, this could equally be as-
The emergency exception to informed consent is often obvious, sumed for paramedic practice.
but this is not always so. It does not apply, for example, when per-
sonnel taking care of somebody in an emergency happen to know

Sinisa Franjic. "Dental Emergency Interventions". Cientific Dental Research Journal 1.2 (2019): 12-17.
 © 2019 Cientific Dental Research Journal (CDRJ), Published by Cientific Group. All rights reserved.

14

Dental Emergency Clinic Oral Medicine

The Dental Emergency Clinic (DEC) is an important part of the Oral medicine and oral surgery are specialised branches of den-
service provided to patients [5]. It is a demanding environment tistry that deal with a wide range of disorders affecting the mouth,
in which to work for main two reasons. First, many patients who face and jaws and which normally require medical or surgical in-
attend such departments have a general tendency to avoid dental tervention [7]. There is considerable overlap in the range of condi-
treatment and view attending such a department as a last resort. tions that present to medical and surgical specialists, but several
Second, from the point of view of the clinicians who work in such very important clinical conditions can present acutely to dental
clinics, the clinical spectrum is wide, and although there is no re- practitioners.
mit to provide a specialist service, the boundaries of knowledge
and experience for clinicians in certain areas are approaching this. An acute condition may be defined as a suddenly presenting
Clinical staff working in these departments need a wide skill mix. disorder, usually with only a short history of symptoms, but with a
degree of severity that causes significant disruption to the patient.
For maximum efficiency in any department that deals with They include traumatic injuries, facial pain, swellings arising both
emergencies, a system of triage is immensely valuable. Triage is es- intra-orally and around the face, jaws and neck, blistering and ul-
sentially the process of determining the priority of patients’ treat- cerative disorders of the oral mucosa, disturbed orofacial sensory
ment based on severity of their condition. Triage should result in or motor function and haemorrhage.
determining the order and priority of a patient’s emergency treat-
ment and occasionally their onward transport. In the DEC, emer- Emergencies
gency situations include those where the airway may be compro- The commonest medical emergencies seen in the dental
mised due to infection or trauma. Such patients must be assessed emergency clinic are faints [8]. Hypoglycaemia, asthma, anaphy-
promptly and referred quickly for onward management. Other laxis, angina and seizures may also be seen but are less common.
patients, who may have sustained trauma, need to be assessed ex- All members of the dental team need to be aware of what their
peditiously, particularly from the point of view of airway and vital role would be in the event of a medical emergency and should be
signs, and possible head injury and concomitant injuries, which in trained appropriately with regular practise sessions.
some cases may take priority over the facial or dental injuries.
A thorough history is always important. If a medical condition
Injuries to the head, face, and neck in the multiply injured pa- is identified and medication is normally taken, a check should
tient need to be prioritized [6]. Injuries resulting in airway com- always be made to ensure that the medication has been taken as
promise, significant and ongoing bleeding, and possible loss of vi- usual and its usual level of efficacy.
sion are a high priority. But they are uncommon. When multiple
coexisting injuries are present, it is important not to be distracted Therapists and hygienists treat patients of all ages and it is in-
by the obvious facial injuries. A systematic approach beginning evitable that some of these patients will have significant medical
with the rapid assessment and management of all life-threatening conditions and take medication, both of which may necessitate a
injuries is required. This is followed by a head-to-toe secondary modification to dental treatment [9]. In addition, many patients
evaluation and investigations. This will provide information on the will experience anxiety associated with their treatment. It is to be
full extent of all injuries and help establish priorities. Once airway expected that acute medical conditions will occur in a dental prac-
compromise, significant bleeding, and possible loss of vision have tice, albeit rarely. It is worth remembering that friends or family
been addressed, all other facial injuries can wait for at least a short who often accompany patients, other visitors to the practice and
while, during which time the entire patient can be assessed. The staff may become unwell and require urgent attention. Medical
initial priority is to treat any immediate life-threatening condi- emergencies can therefore occur anywhere on the premises, not
tions first. The most widely adopted approach is that developed by just in the surgery. It is essential that all dental healthcare work-
the American College of Surgeons and known as Advanced Trauma ers should have the knowledge and skills to recognise and provide
Life Support or ATLS. It consists of an initial rapid primary sur- appropriate immediate medical care for emergencies that might
vey to identify and treat immediately life-threatening conditions present in dental practice. In some instances, this will require the
(the ABCDE approach). Once the patient is stable, a more detailed provision of life-saving measures prior to the arrival of specialist
head-to-toe examination (secondary survey) can be performed. help.

Sinisa Franjic. "Dental Emergency Interventions". Cientific Dental Research Journal 1.2 (2019): 12-17.
 © 2019 Cientific Dental Research Journal (CDRJ), Published by Cientific Group. All rights reserved.

15

Medical emergencies are unexpected and infrequent, but den- When assessing the patient, undertake a complete initial as-
tists are expected to have the ability to diagnose and treat medi- sessment, identifying and treating life-threatening problems first,
cal emergencies [10]. Dentists are often held legally responsible before moving on to the next part of assessment. The effectiveness
for any unfavourable outcomes resulting from mismanagement of treatment/intervention should be evaluated, and regular reas-
of those medical emergencies. The ability and preparation of the sessment undertaken. The need to call for an ambulance should
clinician and staff to respond to an emergency play a key role in be recognised, and other members of the multidisciplinary team
potential outcomes. Therefore, strategic planning for the manage- should be utilised as appropriate so that patient assessment, insti-
ment of medical emergencies in the dental office should be fore- gation of appropriate monitoring and interventions can be under-
front in the mind of professionals starting a new office. In addi- taken simultaneously.
tion, established practitioners must ensure that the office remains
Sedation
ready to respond promptly and efficiently to such events.
Sedation in dentistry has an excellent safety record. If intrave-
Considering that dentists treat numerous patients who are tak- nous (IV), inhalation or oral sedation is administered correctly to
ing multiple medications for underlying medical conditions and carefully selected patients, by trained dental clinicians, with appro-
the fact that the dental office can be a stressful environment for priate facilities and support, then the incidence of untoward prob-
some patients, it is not surprising that medical emergencies may lems should be very low [12]. However, complications can and do
arise. Some of the commonly encountered medical emergencies occur and it is essential that all members of the dental team practis-
in the dental office include adverse drug reactions, altered mental ing sedation be trained and regularly updated in the management
status, shortness of breath, chest pain, diabetic complications, and of sedation-related complications and medical emergencies. Where
seizures. sedation is being carried out, it is essential that the appropriate
emergency equipment and drugs are available, ready for immedi-
ate use should the need arise.
Clinical Signs
The clinical signs of acute illness and deterioration are usually
By definition, a true emergency is one which occurs without
similar regardless of the underlying cause, because they reflect
warning and which could not reasonably have been foreseen.
compromise of the respiratory, cardiovascular and neurological
Medical emergencies can affect anyone, at any time, irrespective of
functions [11]. These clinical signs are commonly
whether they are at home, at work, walking down the street or in
• Tachypnoea (respiratory rate > 20/min): a particularly a dental surgery.
important indicator of an at-risk patient and is the most
common abnormality found in acute illness; Many sedation-related complications are predictable and thus
• Tachycardia (heart rate > 100 beats per minute) emergencies should be avoidable by good planning and skilful
• Hypotension (usually a systolic blood pressure < 90mmHg) technique. The need for careful and thorough presedation patient
• Altered consciousness level (e.g. lethargy, confusion, rest- assessment cannot be over-emphasised. The fitness of each patient
lessness or falling level of consciousness). to undergo treatment under sedation, and thus the risk which se-
• The identification of the clinical signs of acute illness (to- dation presents to the patient, must be individually assessed. If any
gether with the patient’s history, examination and appro- aspect of the medical history suggests a potential problem, then
priate investigations) is central to objectively identifying expert advice should be sought, either from the patient’s medical
patients who are acutely ill or deteriorating. However, practitioner or by referral to a hospital specialist. Dental treatment
these clinical signs of deterioration are often subtle and requiring sedation is never so urgent as to put the patient’s life at
can go unnoticed. It is therefore important to assess the risk from inadequate assessment and planning.
patient following the systematic ABCDE approach. ABCDE
approach include Adherence to the principles of good sedation practice should
• Airway minimise the incidence of problems. However, despite careful
• Breathing preparation and technique, complications and emergencies can
• Circulation still arise.
• Disability
• Exposure.

Sinisa Franjic. "Dental Emergency Interventions". Cientific Dental Research Journal 1.2 (2019): 12-17.
 © 2019 Cientific Dental Research Journal (CDRJ), Published by Cientific Group. All rights reserved.

16

Responsibility of the Physicians being replaced by a national standard of care in recognition of im-
The aim is to provide excellence in emergency department (ED) proved information exchange, ease of transportation, and the more
care by cultivating the following desirable habits [13]: widespread use of sophisticated equipment and technology.
• Listen to the patient.
• Exclude the differential diagnoses (‘rule out’) and refine Establishing the standard of care in a given case requires the
the possible diagnosis (‘rule in’) when assessing any pa- testimony of medical experts in most circumstances, unless the
tient, starting with potentially the most life-or limb-threat- breach alleged is sufficiently egregious to be self-evident to the lay
ening conditions, and never trivializing. jury member—for example, amputating the wrong limb or leaving
• Seek advice and avoid getting out of depth by asking for surgical implements in the operative field. A physician specializing
help. in a given field will be held to the standard of other specialists in
• Treat all patients with dignity and compassion. the same field, rather than to the standard of non-specialists.
• Make sure the patient and relatives always know what is
happening and why, and what any apparent waits are for. To be eligible to receive federal funds such as Medicare and
• Maintain a collective sense of teamwork, by considering all Medicaid, hospitals with an emergency department must offer
ED colleagues as equals whether medical, nursing, allied emergency and stabilizing treatment services to the public with-
health, administrative or support services. out bias or discrimination [15]. The Emergency Medical Treatment
• Consistently make exemplary ED medical records. and Active Labour Act is a comprehensive federal law that obligates
• Communicate whenever possible with the general practi- hospitals offering emergency services to do so without consider-
tioner (GP). ation of a patient’s ability to pay. It’s important to note that this ob-
• Know how to break bad news with empathy. ligation does not apply to inpatients or non-emergent conditions.
• Adopt effective risk management techniques. The absence of bias in the delivery of care should not be misunder-
stood to suggest all hospitals must provide all medical services, but
The duty of care is a physician’s obligation to provide treat- rather the services they choose to offer must be delivered without
ment according to an accepted standard of care [14]. This obliga- bias to the individual patient.
tion usually exists in the context of a physician patient relationship
but can extend beyond it in some circumstances. The physician– A hospital and its entire staff owe a duty of care to patients ad-
patient relationship clearly arises when a patient requests treat- mitted for treatment [16]. Following an emergency call, the ambu-
ment and the physician agrees to provide it. However, creation of lance service has a duty to respond and provide care. Accident &
this relationship does not necessarily require mutual assent. An Emergency (A&E) departments have a duty of care to treat anyone
unconscious patient presenting to the ED is presumed to request who present themselves and are liable for negligence if they send
care and the physician assessing such a patient is bound by a duty them away untreated. Hospitals without an A&E facility will dis-
of care. The Emergency Medical Treatment and Active Labor Act play signs stating the location of the nearest A&E department. This
(EMTALA) requires ED physicians to assess and stabilize patients ensures that the hospital could not be held negligent if a patient
coming to the ED before transferring or discharging them. Such an presented and required emergency treatment as the hospital or its
assessment presumably creates the requisite physician-patient re- staff had never assumed a duty of care. Once a patient is handed
lationship. over, a duty of care is created between the patient and the practitio-
ner and this cannot be terminated unless the patient no longer re-
When caring for a patient, a physician is obligated to provide quires the care or the carer is replaced by another equally qualified,
treatment with the knowledge, skill, and care ordinarily used by competent person. It is therefore extremely important that prac-
reasonably well-qualified physicians practicing in similar circum- titioners are aware of their local policies, professional standards
stances. In some jurisdictions, these similar circumstances include and their scope of practice to avoid becoming liable for litigation
the peculiarities of the locality in which the physician practices. by putting a patient at risk, delivering ineffective care or breaching
This locality rule was developed to protect the rural practitioner their duty of care.
who was sometimes deemed to have less access to the amenities of
urban practices or education centres. However, the locality rule is

Sinisa Franjic. "Dental Emergency Interventions". Cientific Dental Research Journal 1.2 (2019): 12-17.
 © 2019 Cientific Dental Research Journal (CDRJ), Published by Cientific Group. All rights reserved.

17

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Sinisa Franjic. "Dental Emergency Interventions". Cientific Dental Research Journal 1.2 (2019): 12-17.