‘Red flags’ to prevent medical emergencies
by JoAnn R. Gurenlian, RDH, PhD, and Frieda Atherton Pickett, RDH, MS
This article continues the discussion concerning effective means to prevent medical emergencies in oral health settings. (See the July 2010 issue of RDH for part one of this two-part series.) The focus of this article will be on substance abuse, diabetes mellitus, cardiovascular disease, and seizure disorder. The 2007 American Dental Association health history form is used as the prototype for identifying questions that can elicit red flag responses.
“Do you use controlled substances (drugs)?”
In 2008, 8% of the U.S. population suffered from chemical dependence, alcohol abuse, or both. Substance abuse affects all age groups.1 Significant issues are related to substance abuse (including prescribed narcotics):
● The deleterious oral effects of drug abuse
● Medical problems related to drug abuse
● Participation in a recovery program or a history of being in a recovery program
● Interactions between some controlled substances and drugs used as part of oral care; illegal drugs and agents used commonly in dentistry
● Appointment-control issues such as missed appointments or excessive complaints during the appointment
Oral complications of substance abuse include xerostomia, mucosal injury, rampant caries, and aggressive periodontal disease.2 Systemic effects that need to be considered include cardiovascular disease (CVD), myocardial infarction (MI), infective endocarditis, blood-borne communicable disease, liver dysfunction, and immunosuppression. Follow-up questions are recommended to determine the degree of organ involvement.
Clients may be at risk for or demonstrate hypertension, increased bleeding, and poor metabolism of drugs. Products containing epinephrine (local anesthetics or gingival retraction cords) may enhance tachycardia and increase blood pressure, placing the client at risk for a medical emergency.
A variety of strategies can be used to prevent medical emergencies related to substance abuse from occurring:3
■ Review the medical history and consult the client’s physician to determine the relationship of substance abuse history to systemic disease or communicable diseases, reduced liver function, poor wound healing, and appropriate analgesics to prescribe for oral pain.
■ Use standard precautions to avoid disease transmission.
■ Determine the functional capacity of the client prior to continuing with oral care when CVD is reported.
■ Instruct the client to refrain from using any drugs before the dental or dental hygiene appointment.
■ Advise cocaine users to refrain from using for at least 18 hours prior to a dental appointment in which use of a vasoconstrictor is planned due to a potential drug-drug interaction.
■ Advise heavy marijuana users to discontinue use for at least one week before dental care.
■ Caution methamphetamine users to refrain from using for 24 hours prior to their appointment when local anesthesia with a vasoconstrictor is planned.
■ Advise those clients with a history of alcohol use and liver disease to abstain from alcohol intake for at least five days for clotting factors to develop.4
■ Monitor vital signs during each appointment and defer treatment if blood pressure is ≥ 180/110 or if pulse rate is over 120 beats per minute.
■ Use a local anesthetic with a low concentration of vasoconstrictor (1:100,000 or 1:200,000) or one without a vasoconstrictor for short procedures.
■ Monitor bleeding during treatment and use digital pressure to establish clotting. If the client has a history of alcohol abuse, recommend an INR be performed prior to procedures involving bleeding. Avoid prescribing aspirin for oral pain to prevent GI bleeding.
■ Avoid using narcotic analgesics for pain control. If the client is currently abusing other substances, additional depression of the central nervous system can occur, causing a potential medical emergency.
“Please (X) a response to indicate if you have or have not had any of the following diseases or problems: diabetes. If yes, specify below: type 1 or type 2?”
Diabetes mellitus (DM) is a group of metabolic diseases characterized by increased levels of blood glucose that results from defects in insulin secretion or how insulin is used in the body. The Centers for Disease Control and Prevention estimate that nearly 24 million Americans have diabetes, about 57 million have prediabetes and are at an increased risk of developing DM, and one-quarter of these cases are undiagnosed with the individuals unaware they have the disease.5
For those individuals who respond positively to medical questions about diabetes, conduct follow-up questioning related to disease control:
▲ What have your recent blood sugar levels been?
▲ How often do you check your blood glucose levels?
▲ How often does your health-care provider check your blood glucose levels?
▲ What is your most current A1C level?
▲ Do you heal slowly or have frequent infections?
The most common medical emergency to occur when treating a client with DM is hypoglycemia. This emergency condition typically occurs when the client takes insulin or oral sulfonylureas and fails to eat food. When food is not eaten, the dose of insulin or oral medication becomes an overdose and hypoglycemia results. Blood glucose values less than 70mg/dL define hypoglycemia.6 The clinician must be able to recognize signs of hypoglycemia, which appear in Table 1. Questioning related to the risk for hypoglycemia include:
▼ When was your last meal and what did you eat?
▼ Did you take your medication today? What did you take? If taking insulin, when is the peak activity?
▼ Have you experienced hypoglycemia recently?
▼ How many episodes of hypoglycemia have you had this week?
▼ Have you had any problems during dental or dental hygiene treatment?
Hypoglycemia can be prevented by measuring blood glucose prior to treatment, ensuring the client has eaten a healthy meal after taking his/her medication, and observing the client for signs of hypoglycemia. Question the clients who take insulin about the peak effect of the insulin preparation being used. The peak effect, or activity, is the time when hypoglycemia is most likely to occur. Avoid scheduling the appointment around that time. In addition, avoid lengthy dental appointments that extend into the client’s next meal or snack time. If this is unavoidable, advise the client to bring a healthy snack to the appointment, and schedule additional time for the client to have this meal. Keep a sugar food in the operatory to reverse the signs and symptoms of hypoglycemia should it develop.
“Please (X) a response to indicate if you have or have not had any of the following diseases or problems: cardiovascular disease. If yes, specify below type of condition: angina, arteriosclerosis, coronary artery disease, chest pain upon exertion.”
“Please (X) a response to indicate if you have or have not had any of the following diseases or problems: heart attack.”
Cardiovascular disease (CVD) includes abnormal function of blood vessels and disease of the heart muscle that can be congenital or acquired. Clients who report risk factors for CVD (see Table 2) are at an increased risk for cardiac-related emergencies. CVD includes a variety of conditions ranging from hypertension to stroke to heart attack. Cardiac disease may be present without the client being aware of any problems. Hypertension is often referred to as “the silent killer” leading to a heart attack, and many adults are unaware of the warning signs of a myocardial infarction (MI). Vital sign measurements are the best clinical tool in the dental office setting to identify undiagnosed CVD and to identify potential complications for those clients who report a history of CVD.
Another essential evaluation method used to determine cardiac risk is based on the client’s ability to perform basic daily activities and is referred to as “functional capacity.” According to the American College of Cardiology (ACC) and the American Heart Association (AHA), adequate functional capacity is defined as being able to perform activities that meet a 4 metabolic level of endurance or 4 metabolic equivalents (METS).7 Table 3 highlights these MET levels. The ACC/AHA has proposed that the risk for occurrence of a serious cardiac event, such as an MI or heart failure, is increased when the client is unable to meet a 4 MET demand during normal daily activity.
Question clients who present with a history of CVD and/or MI as follows:
- Can you walk on the treadmill at 4 mph?
- Can you run a short distance?
- Can you climb a flight of stairs carrying groceries?
- Can you do housework and move furniture?
- Can you play sports such as golf, bowling, tennis, etc.?
If the answer is “yes,” the client meets the minimum 4 MET level of endurance and is at low risk for a cardiac emergency. However, the client who cannot walk up a flight of stairs without shortness of breath, fatigue, chest tightness, or pain is at an increased risk for cardiac problems during oral procedures.
For those clients who present with a history of MI, pose these additional follow-up questions:
- How long has it been since your last heart attack?
- How is your health now?
- What medications are you taking?
When a client reports a history of MI, the heart muscle is left damaged. A recurrent MI is more likely to occur within one month. For this reason, oral care is contraindicated for the first month after a heart attack to allow the condition to stabilize.8 Obtain a medical clearance to determine if adequate functional capacity has been regained and if there are any other contraindications for oral treatment. Monitor vital signs before and after the dental or dental hygiene appointment. Defer treatment when blood pressure values are excessive (≥ 180/110). Carefully review medications with the client to determine side effects that may influence planned treatment. A stress-reduction protocol with short appointments is advised. Pain control will help reduce stress; however, the clinician must use the cardiac dose of vasoconstrictor in local anesthesia (no more than two cartridges of 1:100,000 vasoconstrictor). Further, observe the client for signs of a heart attack. If signs occur, stop treatment and call 911 immediately.
“Please (X) a response to indicate if you have or have not had any of the following diseases or problems: neurologic disorders, epilepsy, fainting spells, or seizures. Specify condition.”
Medical emergencies can occur in clients with a history of seizures. A seizure is not a disease in itself. It is a sign of a neurological disease that manifests as a disturbance of movement, feeling, or consciousness.9 Seizures tend to be sudden and result from excessive electrical discharges in the brain that override normal brain function or loss of inhibitory function. Epilepsy is also referred to as a seizure disorder. It is characterized by sudden surges of disorganized electrical impulses in the brain. These seizures can be mild or severe, focal or generalized.
For those clients who respond affirmatively to the health history question related to seizure disorder, further evaluation is warranted. Follow-up questions should include:
- What type of seizure do you have?
- When was your last seizure?
- What medications are you taking for seizures?
- Have you taken your medication today?
- Do you know when a seizure is coming on?
- What usually happens in your seizure?
- Have you had a seizure during dental or dental hygiene treatment?
- Are there special things I should avoid during your treatment which may precipitate a seizure?
These questions help the clinician determine whether the seizures are controlled with medication and if the client is taking the medication regularly. The client should have been seizure-free for several months to be considered controlled. The risk for a seizure during the appointment increases when the client reports having seizures even though he/she is taking anticonvulsant medication. Knowing what happens at the beginning or just before a seizure helps the oral health provider recognize the onset of an episode and institute management procedures quickly. For those clients who report experiencing an aura before the seizure, request that they alert the clinician when they feel an aura. If a seizure develops during treatment, position the client out of the way of the dental equipment to prevent possible injury during the seizure. If the client experiences a seizure during oral procedures, it is important to note in the written record what precipitated the event so those activities can be avoided at subsequent appointments. Include management of the seizure in the written record as well.
This article has reviewed some of the red flags clinicians need to take into consideration when reviewing the medical history. Careful questioning and interviewing will assist the oral health provider in understanding the extent of a client’s condition and the strategies to prevent medical emergencies from occurring in clinical practice settings.
JoAnn R. Gurenlian, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing-education programs to health-care providers. She is a visiting scholar at Capella University and vice president of the International Federation of Dental Hygienists.
Frieda Atherton Pickett, RDH, MS, is a former associate professor at the Caruth School of Dental Hygiene, Baylor College of Dentistry, as well as an author and lecturer.
- Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, Md.
- Rees T. Oral effects of drug abuse. Crit Rev Oral Biol Med 1992; 3:163-184.
- Pickett FA, Gurenlian JR. Preventing medical emergencies: Use of the medical history. 2nd Ed. Philadelphia: Lippincott, Williams & Wilkins, 2010; 89-90, 93-94.
- Glick M. Medical considerations for dental care of patients with alcohol-related liver disease. J Am Dent Assoc 1997; 128:61-69.
- National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007 fact sheet. Bethesda, Md: U.S. Department of Health and Human Services, National Institutes of Health, 2008.
- Hypoglycemia. National Diabetes Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. National Institute of Health. Available at: http://diabetes.niddk.nih.gov/dm/pubs/hypoglycemia/. Accessed Sept. 22, 2009.
- Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation 2007; 116(17):1971-96.
- Little JW, Falace DA, Miller CS, Rhodus ML. Dental Management of the Medically Compromised Patient. 7th ed. St. Louis, Mo., Mosby, 2008; 64.
- Jacobsen PL, Eden O. Epilepsy and the dental management of the epileptic patient. J Contemp Dent Prac 2008; 9(1):1-9.
Table 1 —
Signs of Hypoglycemia
Common signs ...
- Dizziness or lightheadedness
- Difficulty speaking
Signs during sleep ...
- Crying out or having nightmares
- Finding pajamas or sheets damp from perspiration
- Feeling tired, irritable, or confused after waking up
Source: Hypoglycemia. National Diabetes Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. National Institute of Health. Available at: http://diabetes.niddk.nih.gov/dm/pubs/hypoglycemia/. Accessed Sept. 22, 2009.
Table 2 —
Risk Factors for Cardiovascular Disease
Risk factors ...
- Family history of CVD
- Diabetes mellitus
- Increased serum cholesterol levels
- Increased body weight, obesity
- Sedentary lifestyle
- Advancing age
- Male gender
Contributing factors ...
Source: Risk Factors and Coronary Heart Disease. American Heart Association. Available at http://www.americanheart.org/presenter.jhtml?indentifier=235. Accessed Sept. 22, 2009.
Table 3 —
Energy Requirements for
Activities and Metabolic Equivalents (METs)
1 MET ...
- Eat, dress oneself, use toilet
- Walk indoors around house
- Walk a block on level ground at 2 mph to 3 mph
4 METs to 9 METs ...
- Light housework, dusting, washing dishes
- Climb a flight of stairs carrying groceries
- Walk at 4 mph on treadmill
- Run a short distance
- Heavy housework, scrub floors, move furniture
- Participate in moderate activities like golf, bowling, dancing, doubles tennis
10 METs ...
- Participate in strenuous activities, singles tennis, football, skiing, etc.
Source: Adapted from Fleisher et al. ACC/AHA 2007 Perioperative Guidelines. Circulation 2007.