Managing a medical emergency in the dental chair

The semester had just begun. It was the second week of school, and we were about to have our first clinic session. I was excited and nervous at the same time. Excited, because after a monthly break I was returning to school to do what I love to do and nervous, because I was scheduled a 90 year old patient with medical issues. The day prior to the appointment I pulled out my patient’s chart and read about her last appointment. She was seen by one of my classmates 4 months ago, and the appointment had gone very well.

The day of the appointment the patient arrived in time, and I welcomed her to my cubicle. She was feeling well and was very excited about getting her teeth cleaned. I reviewed the medical history with the patient and nothing had changed from her previous appointment. She had an ICD (Implantable Cardioverter Defibrillator), also called Pacemaker, implanted. The patient was also taking hypertensive and hyperlipidemia medications. Her vital signs were normal, and she was feeling good. Extra/Intra oral exam was Within Normal Limits. The patient had generalized PMF (Porcelain fused to metal crowns) in all her posterior teeth, and she only had her third molars missing. Generalized mild marginal inflammation was present. She experienced minimal bleeding upon probing with probing depth ranging from 1 to 3 mm and localized 4 and 5 mm on the posterior teeth. The patient had no attachment loss, no furcation involvement and no tooth mobility. Localized recession was noted on tooth # 29.  The patient’s radiographs were reviewed and no bone loss was detected. Localized moderate calculus deposit on the lower anterior teeth was noted. Consider her age; I was very surprised by most of the assessment’s findings. OHI were given to the patient. Since the patient showed good dexterity, the use of a soft power tooth brush was demonstrated and recommended.

After all the findings were discussed with the faculty and the patient, I started the scaling procedure. The use of the hand instruments instead of the ultra-sonic device was appropriate for this patient. Everything was going well until the end of the scaling procedure when the patient started to experience heart palpitations. Palpitations are feelings or sensations that your heart is pounding or racing.  The heart’s rhythm may be normal or abnormal when a patient is experiencing palpitations. They usually aren’t serious or harmful, and often go away on their own, but if the patient is medically compromised and has Cardiovascular Diseases, the palpitations could be signs of a very serious condition such as Congestive Heart Failure. If the palpitations are accompanied by chest discomfort or pain, fainting, severe shortness of breath and severe dizziness, emergency medical attention is immediately required.

As soon as the patient informed me about her palpitation, I reached to my blood pressure kit and measure her blood pressure. It was rising. From 106/65 that was in the beginning of the appointment to 138/99.  After I measured the patient blood pressure, I asked her if she had any other symptoms. She did not, but her palpitations were making her feel very uncomfortable. Without leaving my cubicle, I called for the faculty and they arrived immediately. They were monitoring the patients pulse and asking her how was she filling. Her condition was stable but her palpitations were not going away. The faculty asked for her physician’s phone number and they were able to reach him. The patient physician advised the faculty to call the EMS if the patient did not feel any better. And if she felt better he wanted to see her in his office the following day. We also had the patient talk to her physician, and he advised her to take a pill that he prescribed. The patient always carried the pill with her, but she did not want to take it because she never took it before. After 10 min of having palpitation that did not worsen and without having other symptoms, the patient started to feel better.  The blood pressure and the heart rate were going down. While I was staying all the time with the patient, I called her daughter and ask her if she can pick the patient up because we did not want her to leave by herself. Her daughter came in about an hour later and they left shortly because the patient was feeling much better.

Having a patient that experience medical complications in the dental chair can be very frightening, but remaining calm is the most important thing in these types of situation. From this experience I learned that, never predict what might happened with patients. Be always prepare, alert and knowledgeable in your field.

Ten days after the incident, the patient had come to the office and left a thank you card and a small gift for me. I was very happy to know that the patient appreciated my help.