Every dentist should realize that medical emergencies can, do and will happen during the course of practice.
Here is a suggested list of the core 8 emergency drugs needed for each dental office along with suggested other emergency medications for those doing advanced anesthesia. Emergency drugs should be available in all dental offices ready to address the medical emergency that they would be used for.
Glucagon (GlucoGen)—Antihypoglycemic: causes a rise in blood glucose levels by promoting hepatic glycogenolysis and gluconeogenesis. Atropine—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an antisialagogue effect. Hydrocortisone (Solu-Cortef)—Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, mineralocorticord activity and stimulates gluconeogenesis. Dexamethasone – Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, glucocorticord activity, and stimulates gluconeogenesis. Esmolol—Beta-antagonist: is a cardioselective beta1 receptor blocker with rapid onset and a very short duration of action, with no significant intrinsic sympathomimetic or membrane stabilizing activity at therapeutic dosages. NOTE: Practitioners may vary on what they carry in their office with these medications as well as the dosing dependent upon the training they received related to advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS). Adenosine (Adenocard)—Antiarrhythmic: used for treatment of paroxysmal supraventricular tachycardia by slowing conduction time through the atrioventricular (AV) node as well as interrupting the re-entry pathways through the AV node. Amiodarone (Cordarone)—Antiarrhythmic: a Class III agent that inhibits adrenergic stimulation which prolongs the action potential, decreases AV conduction and sinus node function which is used for life-threatening recurrent ventricular fibrillation or hemdynamically-unstable ventricular tachycardia. Atropine (Atropine)—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an anti-sialagogue effect. Lidocaine—Antiarrhythmic: is a Class IB antiarrhythmic drug which is used intravenously for the treatment of ventricular arrhythmias. Third, place these emergency medications in ziploc bags or smaller plastic containers with color coded labels for easy identification. Finally, develop an emergency drug logbook and keep up with your drugs and their expiration dates. At monthly staff meetings, encourage emergency medications as a regular topic so that area is covered each month and you can prevent your drugs from being expired. The next several pages of downloadable documents illustrate a suggested source for dentists to use to develop a checklist of emergency drugs they need in their office depending on if they use local anesthesia or a specific type of advanced anesthesia. DOWNLOADABLE DOCUMENT #4: PREPARATION CHECKLISTS ON EACH MEDICAL EMERGENCY THAT COULD ARISE IN A DENTAL OFFICE. None of us know when our patient’s life may depend on our readiness as well as having the proper emergency drugs.
INTRODUCTION Every so often, we have a patient who presents with clinical challenges that need to be handled outside of the usual protocol. Fosamax Issues Patients who have resorptive bone diseases such as osteoporosis (often women) can benefit from the use of oral bisphosphonates (BPs).
Because BPs can be given to many cancer patients who also have a need for invasive dental care involving bone, it should be noted that ONJ cannot be effectively treated with debridement and antibiotics or even hyperbaric oxygen exposure.
CLOSING COMMENTS During a dental career, we are sometimes presented with opportunities to be creative, offering the chance for a better outcome for a patient than his or her condition might normally warrant. In April 2007, the ADA and its Council on Scientific Affairs published a position paper that provides newly revised guidelines for the prevention of infective endocarditis (IE).1 These guidelines, endorsed by the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Heart Association (AHA), among others, reflected current research assessing dental procedure related bacteremia, endocarditis prevention, and the most common pathogens associated with the condition. Multiple studies suggest that procedures such as tooth extraction, periodontal surgery, tooth cleaning and scaling, rubber dam placement, and root canal therapy can cause a bacteremia.?3-5 Even though there is evidence that bacteremia follows dental treatment and dental hygiene procedures, because of potential allergy, resistance, and cost-effectiveness, among other factors, the counsel restricted the classes of patients for whom short-term antibiotic prophylaxis before dental procedures are recommended. To control the risk of IE in patients for whom antibiotic prophylaxis is no longer recommended, the ADA recommends that individuals simply maintain good oral hygiene and avail themselves of professional dental care. Assuming, as has been suggested by the AHA’s report, that it might be helpful to reduce the oral bacterial burden prior to dental procedures in individuals where antibiotic prophylaxis is not recommended, the literature regarding xylitol, a sugar substitute that occurs widely in nature which can be delivered topically in the mouth, offers a potential means for achieving this end. Presently, xylitol is primarily delivered via chewing gum.15,27-29 but it has also been incorporated into lozenges and syrup. Xylitol has also recently been incorporated into a time-release adhering disc called XyliMelts (OraHealth Corporation) that can be adhered to the teeth or adjoining gingiva to time-release 500 mg of xylitol. These emergencies could be related to dental treatment, patient risk factors or they could occur unexpectedly in the dental environment. Dentists realize and know that adverse events can occur before, during or after administration of local anesthesia. Emergency drugs, along with their actions and dosages, should be known by the dentist and his or her team. Here is an acronym that could assist you in trying to remember the many emergencies along with the emergency drugs that could potentially be used to treat them. Check with your state dental board for the mandatory emergency medications you must have in your office. You can enter each of your emergency drugs along with their expiration dates so a reminder is sent to you before the actual expired date.

No practitioner is able to determine when he or she will be faced with a medical emergency that will require the use of emergency drugs. So it was with Lucinda, who presented with caries in 2 specific teeth that would normally have been treated by doing extractions. For the last 11 years, a number of studies have been published that have documented the condition of osteonecrosis of the jaw (ONJ) that is associated with the use of oral BPs; thus called bisphosphonate-related osteonecrosis of the jaw, or BRONJ. To prevent negative outcomes, the clinician must recognize that there are no effective treatments for ONJ.
Triad VLC Bonding Agent (DENTSPLY Trubyte) placed on lower partial denture for male ZAAG attachment. Triad DuaLine dual-cure (self- and light-cured) reline composite material (DENTSPLY Trubyte). Having written extensively about and practiced minimally invasive dentistry, this case where the patient presented with a history of BP use for treating osteoporosis required that kind of approach. Bisphosphonate-related osteonecrosis of jaw (BRONJ) in Japanese population: a case series of 13 patients at our clinic.
Bisphosphonate-related osteonecrosis of the jaw: position paper from the Allied Task Force Committee of Japanese Society for Bone and Mineral Research, Japan Osteoporosis Society, Japanese Society of Periodontology, Japanese Society for Oral and Maxillofacial Radiology, and Japanese Society of Oral and Maxillofacial Surgeons. Bisphosphonate-associated osteonecrosis of the jaw, with healing after teriparatide: a review of the literature and a case report.
A retrospective clinical and radiographic study on healing of periradicular lesions in patients taking oral bisphosphonates.
Whitehouse is a founding member and past president (2003 to 2005) of the World Congress of Minimally Invasive Dentistry (MID).
The new guidelines reduce the classes of patients for whom antibiotic prophylaxis is recommended because the risk of morbidity resulting from antibiotic use outweighs its probable benefits. Prevention via systemic antibiotic application is generally discouraged because, in addition to the above, there is a lack of viable supportive research and further, there are contradictory results.
The underlying assumption is that good oral hygiene will reduce overall bacterial counts leading in turn to a reduction in the number of bacteria introduced during dental or hygiene procedures.
To date, there have been no prospective, controlled, randomized studies to assess these issues.
In a study assessing the effect of xylitol on hunger, xylitol has been put into yogurt,30 and it is also found in other food products.31 However, one of the problems with its incorporation into foods is whether an adequate concentration can be maintained over a long enough time in the mouth to effectively reduce oral bacteria. Xylitol delivered in this manner is very likely to be present in the mouth for longer periods of time (30 to 120 minutes—based on reports from subjects in a pilot study) and may be more tolerated by patients unwilling or unable to chew gum (eg, the edentulous, those with temporomandibular joint disorder or disabilities). One would expect the required dosage for an equal effect to be significantly lower and the effect of an equal dosage to be significantly greater. A medical emergency could evolve into a life-threatening emergency without proper treatment. It is particularly important that the dentist be knowledgeable about the indications, contraindications, dosages and methods of delivery for all items included in the emergency kit.
Package insert of all local anesthetics clearly illustrates the importance of the dental practitioner having the proper equipment and resuscitative drugs prior to administering any local anesthetic. The ADA states that all dentists should have an emergency drug kit, equipment and knowledge to properly use all items. It is for that reason alone, dental healthcare practitioners should stay up-to-date on medical emergencies as well as the drugs used to treat them. He performed his residency in Oral & Maxillofacial Surgery at University Hospital at the University of Cincinnati. However, the health history showed Fosamax use and, upon further questioning, it was found that she had a history of heavy use of this prescription drug within the last 5 years. From the studies, one can learn how these jaw necroses are tied to the use of BPs (such as Fosamax, risedronate, or alendronate).1 A clinical study important to the dental profession2 documented the healing issue faced when extracting teeth or bone work, namely slow or nonhealing of sockets.
If treatment (such as extraction) is absolutely needed with a patient taking a BP, the treating medical doctor should be contacted about his or her BP delivery.5 A study concerning implant placement for those who were actively taking BPs showed no discernable healing issues. This compromised situation and the research supporting caution led to the alternate treatment shown. However, the guidelines also suggest that dental manipulation of any type may result in the introduction of potentially pathogenic bacteria into the bloodstream. Good oral hygiene includes daily tooth brushing, flossing, and minimizing sugars that feed resident bacteria. XyliMelts can also be used while sleeping, when saliva flow is lowest, potentially increasing the effectiveness of the overall antibacterial action. A preliminary study (which cannot be cited because of proprietary issues) has apparently shown that only one gram per day delivered over time by XyliMelts can significantly reduce S mutans counts. Until studies are completed to determine whether this usage is sufficient to obtain optimal reduction of pathogenic bacteria, to be conservative, based on prior chewing gum studies, one could increase the usage to 4 g per day (8 discs). Dentists are also urged to perform continual emergency kit maintenance by replacing soon-to-be-outdated drugs before their expiration.

Dentists should be thoroughly knowledgeable on the emergency drugs they have in their office.
Develop a regular protocol to where you and your staff are able to rehearse various emergencies using your emergency drugs. When patients have taken BPs for the treatment of osteoporosis, the ability for bone to heal after surgery can be limited.
He continues to practice 2 days per week after having sold his dental practice in Castro Valley, Calif. This raises an important question whether less risky approaches to controlling oral bacteria prior to dental procedures and general oral care might be a useful preventative strategy for individuals previously defined as at-risk for IE and where antibiotics are not now recommended. While this proposal makes eminent sense, from a public health standpoint it is not all that clear that the majority of people will follow good preventative practices and present for routine dental care.
However, xylitol released from gum is dissipated in about 15 minutes,34 new 32 which requires that it be used 5 times or more per day to be effective and be used in larger quantities than desired. A similar oral adhering disc called Oramoist (Quantum) designed to adhere to the roof of the mouth and release flavor to stimulate saliva also contains xylitol but the amount of xylitol in each disc is not published by the manufacturer and is likely insignificant. Roberson has dual Board Certifications by the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology.
Should nonhealing take place, the patient’s life is affected, which can be a significant issue for the clinician too. ONJ is a serious but infrequent condition that has been recently associated with nitrogen-containing bisphosphonate therapy.
3 were calcified, the root was sealed with a glass ionomer (GC Fuji II [GC America]) (Figure 3). He can be reached at (510) 881-1924 or via email at This email address is being protected from spambots.
In fact, based on the US Surgeon General’s Report in 2000,10,11 there remains a substantial discrepancy between American children, young adults, and older adults in terms of access to preventative and other dental care services based on ethnicity, income, education, and special needs status. 3 and 18 because of potential healing problems in the bony socket sites due to the use of Fosamax. The study observed 7 patients who had taken BPs and had extractions, with 6 of the patients having had sequestration during nearly a year of observation, and only 3 had experienced healing.
Since this tooth was without symptoms or swelling, it was determined that the roots could be left at this point. Assign a staff member the role of reviewing your emergency drugs each month to prevent expiration of these drugs. It should be noted that the current standard treatment for BRONJ does not always provide good results.3 BPs have been widely, efficiently, and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers, and multiple myeloma bone diseases. Hsiao et al9 found that the results of this preliminary short-term study suggest that patients taking long-term oral BPs can expect a satisfactory outcome with evidence of periradicular healing after conventional root canal treatment. If any symptomology would appear at a later time, that could be dealt with by prescribing antibiotics.
Thus, many people in the US will not receive the preventative training and skills development necessary to satisfy the ADA’s basic requirements for prevention of IE associated with routine home care. Thus, root canal treatment may be considered a safe and realistic alternative to extraction in patients on bisphosphonate therapy. The issue facing all dental clinicians is to extract or not to extract a tooth when the patient has been or is taking BPs. Even if the potential for osteonecrosis is small for any given patient, no dentist wants to be responsible for the patient getting this condition, and therefore, hesitancy on the decision to proceed with an extraction would be reasonable.
Since the patient would now need a removable partial denture, a unilateral type was offered with tooth No.
18 had a temporary restoration after the root canal, because the occlusal height above to No.
15 was limited due to super eruption, and because crown lengthening was ruled out due to the BP issue; the tooth was restored with composite down into the pulp chamber. This restoration allowed for preparation for the ZAAG female attachment placement (Figure 7) using the ZAAG drill (Figure 8) and the actual attachment. The ZAAG female attachment was cemented into the preparation (Figure 9) using SEcure Cement (Parkell). The unilateral partial denture was primed with Triad VLC Bonding Agent (DENTSPLY Trubyte) (Figure 11), so that the male ZAAG could be “picked up” with Triad DuaLine (DENTSPLY Trubyte) dual-cure reline material (Figure 12).
The result was giving the patient a firmly fitting unilateral partial denture, using a tooth that normally would have been extracted. Figure 13 shows the unilateral partial denture with the ZAAG attachment bonded in using Triad DuaLine.

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