Anesthetic

complications and
office emergencies

GROUP 4
ANESTHETIC COMPLICATIONS
AND OFFICE EMERGENCIES
Louise Miclat
 ANESTHETIC COMPLICATIONS AND OFFICE
EMERGENCIES

• anesthetic complication
– Any deviation from the normally expected pattern
during or after the securing of regional analgesia
– These complications may be classified as:
• Primary or secondary
• Mild or severe
• Transient or permanent
Primary complication
• One that is caused and
manifested at the time
of anesthesia
Secondary complication
• One that is manifested
later, even though it
may be caused at the
time of insertion of the
needle and injection of
the solution
 Severe complication
• Manifests itself by a
pronounced deviation
from the normally
expected pattern and
Mild complication requires a definite plan
• One that exhibits a of treatment
slight change from the
normally expected
pattern and reverses
itself without any
specific treatment
Transient complication
• One that although
severe at the time of
occurrence, leaves no
residual effect
Permanent complication
• Leaves a residual effect
even though mild in
nature
Complications may be further be divided into 2
groups:

1. Those attributed to the solutions used

2. Those attributed to the insertion of the
needle
 Complications resulting from the
absorption of the anesthetic solution:

1. Toxicity
2. Idiosyncrasy
3. Allergy
4. Anaphylactoid reactions
5. Infections due to contaminated solutions
6. Local irritations or tissue reactions due to the
solution
Complications attributed to the insertion of the needle:
1. Syncope (fainting)
2. Muscle trismus
3. Pain or hyperalgesia
4. Edema
5. Infections
6. Broken needles
7. Prolonged anesthesia other than from the anesthetic solution
8. Hematoma
9. Sloughing
10. Bizarre neurological symptoms
Complications Caused by Wrong Technique
1. Needle breakage
Cause
1. Primary cause: sudden
unexpected movement
by patient
2. Smaller needles are
more likely to break
3. Previously been bent
are weakened and
more likely to break
Problem
O Needle breakage is not
a significant problem
O If a broken needle can
be a retrieved with out
surgical intervention
• Prevention
• Use of long needle injection for injection requiring
penetration of significant depths
• Don’t insert a needle into the tissue to its hub, unless its
absolutely essential for the success of the technique
• Don’t redirect needle once it is inserted into the tissues
o Management
When a needle breaks:
a) Remain calm
b) Instruct the patient not to move don’t remove your
hand from the patients mouth. Keep patients mouth
open
c) if the fragments is visible, try to remove it with a small
haemostat or a magil incubation forceps
• If needle is lost( not visible )
a) Don’t proceed with an incision or
probing
b) Calmly inform the patient
c) Note the incident in the patients chart
and then inform your insurance carrier
immediately
d) Refer the patient to an oral and
maxillofacial surgeon for consultation
 Cause
2. Pain on injection - Careless injection technique
and callous attitude
- A needle deposition can
become dull from multiple
injections
- rapid deposition it may cause
tissue damage
- Needles with barbs may
produce pain as they are
withdrawn from the tissue
Problem
1. Pain on injection
increases patients
anxiety and may lead to
sudden unexpected
movement , increasing
the risk of the needle
breakage.
Prevention
1.Adhere to proper technique
2.Use sharp needles
3.Use topical anesthetic prior to injection
4.Use sterile local anesthetics solution
5.Inject local anesthetics slowly
Management
- No management required
3. Persistent anesthesia or parasthesia
- On occasion a patient will report feeling numb for many hours or
days after a local anesthetic injection
Cause
1.Trauma to any nerve may lead
2.Anesthetic solution contaminated by alcohol
3.Hemorrhage into or around the neural sheath is another cause
Problem
4.self inflicted injury
5.When lingual nerve involved, the sense of taste may also be
impaired
Prevention
1.Strict adherence to injection protocol
and proper care and handling of dental
cartridges help minimize the risk of
parasthesia
2.Most parasthesis resolve within
approximately 8 weeks without
treatment
3.Only damaged nerve will be permanent
 4. Trismus
- Disturbance of the trigeminal nerve,
especially spasm of the masticatory
muscle, with the difficulty on opening
the mouth.
- Also known as “fals ankylosis”
Cause
1.local anesthetics into which alcohol
or other cold sterilizing solutions have
diffused that produced irritation of
tissue leading potentially into trismus
2.HENORRHAGE, large volume of blood
can produce tissue infection, which
leads to muscle dysfunction as blood
slowly resorbed.
3.Over LARGE AMOUNT OF LOCAL
ANESTHETICS solution deposited into
restricted are produced distention of
tissue, may lead to trismus.
Prevention
1.Use sharp sterile disposable gloves
2.Proper care and handle of dental
anesthetic cartridges
3.CLEAN the site of injection with antiseptic
solution prior to needle penetration
4.Practice ATRAUMATIC INSERTION and
injection technique
5.Use minimal effective volume of local
anesthetic solutions
Management
1.If the treatment should depend on the cause of
trauma, slight exercises and drug therapy may be
necessary to relieve pain, if sufficiently sever.
2.Centrally acting muscle such as Diazepam
(Valium), 2.5-5mg 4x per day or Meprobamate
(Milrown) 1200-1600 mg per dayin 3 or 4 doses
coupled with application of warm moist
compress for 15-20 mins. Per hour will usually
relieve the sympotms in several days.
3.Mild analgesics may also be used for discomfort
of the patient
 - Effusion of blood into extra
vascular spaces
- A common complication of
5. Hematoma intraoral regional analgesia
Cause
- Inadvent nicking of blood vessels,
either an artery or vein during
injection of local anesthetic

Prevention
1. KNOW the anatomy involved in
the proposed injection
2. MODIFY the injection as
indicated by the patients
anatomy
3. MINIMIZE the number of
needle penetrations of tissue
 6. Edema

- Swelling of tissues
Cause
1. Trauma during
injection
2. Infection
3. Allergy,
angiodema
4. Hemorrhage
Problem
1.Edema is a seldome intense enough to prduce
significant problems such as airway obstruction
that results in pain and dysfunction of the region
and in personal embarrassment for the patient
2.Swelling produced by angioneuretic edema in
an allergic individual in response to an allergen
is capable leading to a comprpmise airway
3.Edema of the tongue, pharynx or larynx may
develop, this represents a potential life
threatening that requires vigorous management
Prevention
1.Properly care for and handle the local anesthetic armamentarium
2.Use atraumatic injection technique
3.Complete an adequate medical evalutation of the patient prior to drug
administration
Management
4.Reduction of the swelling
5.When produced by traumatic injection or introduction of irritating solutions,
the degree of edema is usually minimal and will resolve in 1-3 days without
formal therapy , it may be necessary to prescribe analgesics for pain
6.Following hemorrhage, edema will resolve slowly over 7-14 days as extra-
vasated blood elements are resorbed into the vascular system .
7.Edema produced by infection will not resolve spontaneously but may, infact ,
become progressively more intense. If signs and symptomsdo not appear to
resolve in 3 days, institute antibiotic therapy.
5. Edema is produced by allergy is the most
potentially life threatening. The degree of edema
and its location are highly significant. If swelling
develops in buccal soft tissues and there is
absolutely no airway involvement, treatment
consists of intra muscular and oral antihistamine
admistration and medical consultation with an
allergy to determine precise of edema.
6. When edema occurs in ay area where it
compromises breathing treatment consists of the
following
• Epinephrine 3mg
• Antihistamine
• corticosteroids
7. Medical assistance summoned patient
in supine position, if unconscious, use
basic cardiac life support
8. Thorough evaluation of the patient
prior to next appointment to
determine the cause of the reaction
7. Sloughing of tissues
- Prolonged irritation of ginigival soft tissues may lead to a
number of unpleasant complications, including epithelial
desquamation and sterile abscess
Cause
– Epithelial desquamation
1. Application of topical anesthtic agent to ginigival tissues for a
prolonged period of time
2. Heightened sensitivity of tissues to chemical agents
3. Reaction in area where topical anesthetic is required
– Sterile abscess
1. Secondary to prolonged ischemia resulting ischemia resulting
from the use of local anesthetic agent with vasoconstrictors
2. Almost always occurs in the firm soft tissues of the hard
palate
Problem
1.pain., quite sever
2.There is remote possibility of infection developing on the said areas
Prevention
3.Use topical anesthetics as recommended
4.When using vasonstrictors for hemostasis, do not employ overly
concentrated solutions
Management
5.No formal management is required
6.Management may be symptomatic, for pain, such as analgesic or aspirin
or codeine and a topically applied ointment such as orabase to minimize
irritation to the area as recommended
7.Epithelial desquamation will resolve within a few days
8.Record date on patients chart
 8. Lip Chewing
- Trauma to the lips and tongue of the patient
caused by unintentionally biting or chewing
these structures while still anesthetized.
- Occurs most frequently in children and in
mentally handicapped children and adults

- CAUSE:
- Use of long acting local anesthetic in patients
undergoing short dental procedures
PROBLEM:
-Trauma that will lead to swelling and
significant pain when the anesthetic
action dissipate

PREVENTION:
-If dental procedures are brief, the
appropriate local anesthetic solution
should be selected
-Cotton roll can be placed between the
lips of the patient if they are still
anesthetized at the time of discharge,
tie it in position with dental floss
wrapped around the teeth
-Tell the patient and adult guardian MANAGEMENT: (symptomatic)
against eating, drinking hot fluids and -Analgesics for pain
biting on the lips or tongue while still -Antibiotics for infection
anesthetized.
-Lukewarm saline rinse to help decrease
swelling present
-Petroleum Jelly or other lubricant to cover the
lesion and minimize irritation
 9. Facial Nerve Paralysis
• Local anesthetic agent is introduced deep into
the parotid gland which terminal portions of
the facial nerve runs

• CAUSE:
– Directing a needle toward or its unintended
deflection in a posterior direction during an inferior
alveolar nerve block that may place the needle tip
within the substance of the parotid gland.
PROBLEM:
Loss of motor function to
the muscles of facial
expression by local
anesthetic solution is
transitory. It can last from
1 to several hours,
depending on the agent
employed, the volume
injected and the proximity
to the facial nerve
Unilateral
Cosmetic appearance; no
treatment
Patient may be unable to
voluntary close the eye.
Winking and blinking
become impossible to
perform, however, corneal
reflex is intact.
• PREVENTION:
– Know your anatomic
landmarks
– If the needle deflects
posterior during inferior
alveolar nerve block, it
should be withdrawn
entirely, the barrel of the
syringe brought
posterior and the needle
advance until it contacts
the bone
• MANAGEMENT:
– Reassure the patient
– Advise the patient to
periodically close the upper
eyelid manually to keep the
cornea lubricated
– Contact lenses should be
removed until muscular
movement returns
– Note the incident on the
patient’s chart
– Although there is no
contraindication in re-
anesthetizing the patient to
achieve mandible anesthesia, it
may be careful to forego further
dental therapy
 10. Syncope (fainting)
• Most frequent complication associated with
local anesthesia
• Form of neurogenic shock

• CAUSE:
– Cerebral ischemia secondary to a vasodilatation or
an increase in the peripheral vascular bed, with a
corresponding drop in blood pressure
 • MANAGEMENT
PREVENTION:
-Detect early stage of fainting by the change
in the patient’s appearance, such as pallor
-Patient should be placed in a semi reclining
position before a local anesthetic solution is
introduced
– Reassure and re-evaluate the
patient before continuing with
the procedure
– Lower chair back while the
patient’s legs are slightly
elevated
– If the patient is conscious, he
should be instructed to take a
few deep breaths. This will
assist venous return while
providing adequate
oxygenation
– If a patient loses
consciousness, the pulse,
respiration and color should be
checked to determine the
severity of the condition
 11. Infection
• CAUSE:
– Contamination of the needle
– Improper technique in handling of the anesthetic agent
– Improper tissue preparation for injection

• PROBLEM:
- Low grade infection
- May lead to trismus if not recognized and proper
treatment initiated
PREVENTION
• Use disposable needles
• Proper care and handling of
needles
– Recap the needle when not in
use to avoid contamination
through contact with non sterile
surfaces
– avoid multiple injections with
the same needle
• Proper care and handling of
dental cartridges of local
anesthetic solution
– Single use only
– Store aseptically in original
container, covered at all times
– Cleanse the diaphragm with
sterile, disposable alcohol wipes
 MANAGEMENT
• Low grade infection
• Record the progress of
– Seldom recognized the patient on the
immediately dental chart
– Patient will report post
injection pain and
dysfunction 1 or more
days, following dental
therapy. Rarely will there
be any overt signs &
symptoms of infection
present
• Immediate treatment
– Heart analgesic
– Muscle relaxant &
physiotherapy
12. Bizarre Neurological Symptoms
• A rare condition that may occur following the insertion of a needle
and the injection of a solution in a given area

• CAUSE:
– Inadvertent anesthesia to nerves in approximating the area

• PROBLEM:
– Patients may exhibit facial paralysis, crossed eyes, muscular weakness,
temporary blindness, and many other unexpected complications
• PREVENTION:
– To follow closely accepted techniques and to
adhere to all the basic concepts of accepted
procedures

• MANAGEMENT:
– Patients should be diagnosed according to the
symptoms manifested, and, regardless of how
thoroughly the literature is followed, someone
somewhere will describe a seemingly impossible
neurological complication
Complications caused by anesthetic solutions
 Local reactions caused by
anesthetic solutions
• Infections due to contaminated solutions are
rare at the present time. This is primarily
because of the high standards of asepsis
practiced by the manufacturers of various
local anesthetics. It is important for the dentist
to purchase anesthetic cartridges from reliable
manufacturers.
 Cartridges
• Should be only used once, any attempt to use a
portion on one patient and the remaining amount on
a subsequent may induce possibility of cross
infection
• Stored aseptically as possible
• Rubber or metal endings should be protected from
contamination
• Anesthetic cartridges stored in an alcohol solution
– All cartridges leak to some degree and in time alcohol will
seep into the anesthetic solution
– Injection of alcohol-contaminated anesthetic may result
to prolonged anesthesia or local irritation
• Holding solutions
– Capable of sustaining the growth of various
microorganisms leading to contamination of the
cartridge and anesthetic solutions
– Once the original container is opened, cartridges
should be stored DRY in their original container or
in another suitable sterile container that is kept
covered at all times
• The operator should handle cartridges only by
the way of the stoppered end after thoroughly
washing the hands.
• The rubber diaphragm should be wiped with a
sterile, disposable alcohol sponge prior to
insertion into the syringe and affixing the
needle.
 1. Burning of injection
• CAUSE:
– pH of the solution being deposited into the soft
tissue
– Rapid injection of local anesthetic
– Contamination

• PROBLEM
– Tissue irritation
• If caused by pH of the solution = rapidly disappear
• If caused by rapid injection or contaminated solution =
damage to the tissue
• PREVENTION: • MANAGEMENT:
Slow rate of injection – Since most instances of
– Ideal rate is 1ml/min burning on injection are
transient and do not
– Don’t exceed the
lead to prolonged tissue
recommended rate of
involvement, formal
1.8ml/min
treatment is not usually
– Cartridge of anesthetic indicated.
should be stored at
room temperature
 2. Post Anesthetic Intraoral Lesion
• Patients occasionally report to a dentist that
approximately 2 days following intraoral
injection of local anesthetic, the mouth
developed ulceration, primarily around the
site(s) of the injection
• The primary presenting symptom is pain,
usually of a relatively intense nature
 Recurrent Aphtous Stomatitis
• Intraoral
manifestation
• It develops on
gingival tissues that
are not attached to
underlying bone such
as the buccal
vestibule
• Not viral but thought
to be either an auto
immune process or
an L-form bacterial
infection
 Herpes simplex
• Develop intraoral but most commonly
observed extra oral
• It is viral and develops intraoral on
tissues that are attached to underlying
bone such as soft tissue of hard palate
• Trauma to tissue by needle, local
anesthetic solution, cotton swab or
any other instrument that may
reactivate the latent form of the
disease process that has been present
in tissues prior to the injection
• PROBLEM:
– Acute sensitivity in • PREVENTION:
ulcerated area Extraoral herpes simplex
– Risk of developing - May be effectively treated if
a secondary it is in its prodromal stage
infection is small in - Prodrome consists of a mild
both these burning or itching sensation
at the site where the virus
situation
is present, either applied
topically with a cotton swab
3-4 times daily.
- Effectively minimizes the
acute phase process
- Not effective intraoral
 Management:
• Topical anesthetic • Orabase, a protective
solutions, such as paste, without kenalog,
viscous lidocaine, can a cortocosteroid, is not
be applied as needed to recommended because
the painful areas its anti-inflammatory
• A mixture of amounts of actions provide an
diphenhydramine, and increased risk if either
milk of magnesia, rinsed viral or bacterial
in the mouth, involvement
effectively coats the • Duration of ulcerations
ulcerations and provide is approximately 7-10
relief from pain days with or without
• Negatol, a chemical cauterizing agent, is often used to
provide dramatic effect on tissues. However, its use in
the management of herpetic or aphtous lesions can not
be recommended
• Keep adequate records in the patient’s chart
• Symptomatic
– Pain : major presenting symptom
– Reassure patient that the situation is not due to a bacterial
infection secondary to the local anesthetic injection but in
fact is an exacerbation of a process that has been present, in
latent form, in the tissues prior to injection.
– the objective of the treatment is to keep the ulcerated areas
covered and/or anesthetized
COMPLICATION
S DUE TO
ANESTHETIC
SOLUTION
GROUP 4
TOXICITY

GROUP
Naral, 4
Pauline
UE DENTAL MEDICINE
 TOXICITY
- “Toxic overdose”
- Symptoms manifested as the result of over dosage or excessive
administration of a drug.
• Central Nervous System
• Respiratory System
• Circulatory System
- The concentration of the local anesthetic in the plasma should be
at an equilibrium so that there is a favorable relationship
between the amounts being absorbed into and diffusing out of
the plasma.
- Ester type of local Anesthesia, a sufficient amount of plasma
cholinesterase should be enough to hydrolyze the drug.
 TOXICITY
Causes:
• Amount of the drug
• Unusually rapid absorption or intravascular injection
• Unusually slow biotransformation
• Slow distribution
• Slow elimination

Factors:
• Patient’s general physical condition
• Rapidity of injection
• Route of administration
• Amount of the drug
• Age
**the more the vascular the area, the more rapid the absorption, and the greater
the possibility of a toxic reaction**
 TOXICITY

Vasodilators VS Vasoconstrictors
• Vasodilators - enhances the absorption of the
drug therefore less dosage is needed
• Vasoconstrictor – slows down the absorption
thus causes longer duration of the effect of
the drug
 TOXICITY

TOXIC EFFECTS ON THE CNS

• Amygdala
• Biphasic effect: AFTER CNS STIMULATON, A
PROPORTIONATE PERIOD OF CNS DEPRESSION
OCCURS
• Subtoxic doses produces anticonvulsant
effects.
• Procaine and Lidocaine.
 TOXICITY
Mild Degree Toxicity
CORTICAL REGION STIMULATION
• Talkativeness, slurred speech, apprehension, localized
muscular twitching, tremor of the hands and feet.
• Light headedness, tinnitus, difficulty focusing the eyes,
disorientation, drowsiness and numbness of the
tongue.
• Generalized numbness of the tongue due to its highly
vascularized tissue of the oral cavity.
MEDULLARY STIMULATION
• Increased heart rate
• Increased blood pressure
 TOXICITY
• And increase respiratory rate
Pharmacological Management of CNS Stimulation
• 50 to 100 mg of Barbiturates, Pentobarbital;
intravenously administered to prevent
development of seizure. Not indicated for
seizure control lest excessive postictal
depression be produced. For moderate toxicity
• 5 to 10 mg Diazepam; intravenously
administered to prevent and control a seizure.
 TOXICITY
Mild Degree Toxicity
CORTICAL REGION DEPRESSION
• Lethargy, unresponsiveness, lack of movement of the extremities,
sleepiness, drowsiness, and muscular weakness.
MEDULLARY DEPRESSION
• Slight fall in heart rate and blood pressure
• Mild depression of the respiratory rate
Pharmacological Management of CNS Depression-mild to moderate
• Airway-by extending the head maximally
• Respiration- by providing artificial ventilation
• Circulation- position the patient that allows gravity to alter the
venous return.
• Pharmacological support is not really necessary.
 TOXICITY
SEVERE TOXICITY-Generalized tonic-clonic seizure
• 7.5 to 10.0 µg/ml of the local anesthetic agent
• Due to continues redistribution and biotransformation of the local
anesthesia while seizure is occurring.
• Muscle contraction of respiration-rapid consumption of O2 –
Cyanosis
• Increased metabolic rate and ineffective respiratory elimination-
increased CO2- metabolic and respiratory acidosis –increased
duration of the seizure
Pharmacological Management of CNS Stimulation(SEVERE)
• 20 to 40 mg of Succinylcholine -intravenously administered to
control the seizure.(or double the dose for intramuscular)Paralyzes
all voluntary muscle for a period of 5 to 7 mins. Artificial ventilation
is a must.
 TOXICITY
SEVERE TOXICITY-Postictal Depression
• Occurs after a tonic/ clonic seizure
• Severe cortical depression manifested by:
unresponsiveness, unconsciousness, stupor,
and coma.
• Severe medullary depression manifested by:
depression of cardiovascular function,
respiratory depression and hypoxia.
 TOXICTY
Pharmacological Management of CNS Depression- Severe
• A combination of mechanical and pharmacological support is
needed.
• Mechanical support for consciousness and respiration
• Pharmacological support for circulation,
• Hypovolemia and Bradycardia must be considered and treated.
• Hypovolemia -can be corrected by a combination of positional
changes and the infusion of 250 to 500ml of 5% dextrose in water
or 5% dextrose in lactated Ringer’s solution that is intravenously
administered.Conservative dose of Phenylephrine if further support
is needed.
• Bradycardia -0.5 mg atropine or 0.2 mg glycopyrrolate,
intravenously or intramuscularly administered.0.4 mg of atropine
sublingual tablets v
 TOXICTY
Toxic Effects on the Cardiovascular System
• Depression effect only.
• Direct depression of the myocardium- slow the rate of
impulse of conduction-prolong the refractory period
*direct relationship between the dose and effect*
• 1.5 to 5µg/ml of lidocaine- low dose and is used as
antiarrythmic (Anticonvulsants on the CNS)
• More than 5µg/ml- severe depression of the cardiac
function (slowed conduction,bradycardia, decrease cardiac
output)
• More than 10µg/ml- massive cardiovascular collapse
*Therefore, close observation after injection is a must.*
 TOXICTY
Management of Toxic Reactions

• Mild reaction- requires no specific treatment

and will generally subside in a few minutes.
Dental procedure may be carried out as planned.
• Severe reaction- requires immediate and specific
attention. All dental procedures must be stopped
and must concentrate on protecting the patient
from any accidental injury.
 TOXICITY
PREVENTION

• Adequate evaluation prior to regional anesthesia

• Proper anesthetic drug
• Least possible amount of drug
• Least possible concentration
• Slow deposition
• Aspiration
• Vasoconstrcitor
• Proper technique
 ALLERGY AND
ANAPHYLACTOI
D REACTIONS

GROUP
Naral, 4
Pauline
UE DENTAL MEDICINE
ALLERGY AND ANAPHYLACTOID REACTIONS

• A specific hypersensitivity to a drug or chemical agent brought

about by an alteration in the body’s reaction to an antigenic
substance that may be acquired or familial.
• The skin, mucous membrane and blood vessels are the common
shock organs.
• Asthma, rhinitis, angioneurotic edema, urticaria and other skin
rashes are just some of the reactions.
• Respiratory, cardiovascular system as well as the smooth muscle
of the gastrointestinal tract are only occasionally involve.
• Antigen-(destroyed/neutralize)-antibody=NR
• Antigen-(binds)- antibody= histamine or histamine like
substance.
ALLERGY AND ANAPHYLACTOID REACTIONS

Histamine or the histamine like substance:

• Capillaries becomes more permeable-
extravasation of plasma- urticaria/
angioneurotic edema
• spasm of smooth muscles-asthma
• vasodilation of the microcirculation-pooling of
blood
ALLERGY AND ANAPHYLACTOID REACTIONS

Methyl Paraben
• The preservative content of the cartridge to
prevent contamination of the solution caused by
multiple punctures of the rubber diaphragm with
the needle and solution withdrawal.
• Responsible for allergic reactions provoked by
injection of pharmaceutical agents containing
them.
• Mepivacaine(Carbocaine)
ALLERGY AND ANAPHYLACTOID REACTIONS

Immediate Reactions
• Develop within seconds to hours of exposure
• Cytotoxic Reactions- transfusion reactions,
autoimmune hemolysis, hemolytic anemia, and
membranous glumerulonephritis
• Immune complex reactions- serum sickness, lupus
nephritis, and acute viral hepatitis.
• Anaphylactic reactions- affects the skin. Mucous
membrane, respiratory system, GIT, and cardiovascular
system. most common in dentistry
ALLERGY AND ANAPHYLACTOID REACTIONS

Localized Immediate Reactions

Most Common
• Urticaria- production of smooth, elevated patches of skin,
wheals which are accompanied by intense itching.
• Angioedema- localized swelling of the soft tissues of the hands,
face , lips, tongue, pharynx, and larynx.
Common
• Asthma- respiratory distress of the expiratory type including
prolonged expiration accompanied by audible wheezing.Involves
the lower tracheobronchial tree.
• Angioedema of the tongue, pharynx, and larynx are involved
when the upper tracheobranchial tree is
involved.OBSTRUCTION.
ALLERGY AND ANAPHYLACTOID REACTIONS

Management of Localized Immediate Reactions

IMMEDIATE MILD AND LOCALIZED REACTION
• -50 mg of diphenhydramine every 3 to 4 hrs a day that is
administered orally.
• EXTREMELY MILD CASES- no treatment necessary but rather
acknowledgement.
SEVERE LOCALIZED REACTION
• 25 to 50 mg of diphenhydramine IV or IM administered.
• 0.3 to 0.5 mg of epinephrine;administered subcutaneously or
IM. To decrease upper airway edema and prevent respiratory
malfunction.
ALLERGY AND ANAPHYLACTOID REACTIONS

EMERGENCY
• Administration of 100% Oxygen and antihistamines.
• Delay the dismissal of patient for atleast an hour for further
observations and be under the care of an adult.
• Severe upper airway edema- mechanical measures in addition
to pharmacotherapy is used.
Cricothyrotomy
• Creation of an opening into the airway through the
cricothyroid membrane.
• Only done when there is any slightest suspicion of life-
threatening airway obstruction may it caused by foreign
object or edema..
 Cricothyrotomy
Procedure
1. Palpation of the thyroid eminence or “ Adam’s apple” with the head
extended.
2. The palpating fingers moves inferiorly down the midline of the thyroid
cartilage until a small depression is felt with the tip of the finger until
the cricoid cartilage.
3. The depression or cricothyroid membrane marks the proposed point of
entrance into the airway.
4. At this point, an opening may be created in the airway by inserting a
suitable device that will not only enter the airway but maintain
patency of the newly created opening.
5. A vertical incison may be made with a scalpel that is then rotated
perpendicularly to maintanin patency.
6. Large gauge intravenous needles( 14 to 16 gauge) may be inserted into
the airway: a scalpel is not required.
ALLERGY AND ANAPHYLACTOID REACTIONS

Management of Asthmatic Attacks

1.Mechanical Means
2.Inhalation of Aerosols that contain
isoproterenol or epinephrine- produce
profound and instantaneous relaxation of
bronchiole smooth muscle.
3.IV 250 to 500 mg of aminophylline that relxes
vascular and bronchiole smooth muscle.
Hypotension must be observed.
ALLERGY AND ANAPHYLACTOID REACTIONS

Generalized Immediate Reaction

• Occurs minutes after exposure to the agent.
• Sudden cardiovascular collapse, severe respiratory distress,
pruritis and appearance of erythema and severe urticaria.
• Gastrointestinal involvement
• Management of Generalized Immediate Reactions:
• PROMPT ACTION is necessary
• Mechanical means of support to respiration and circulation.
Administer intravenous fluids, vasopressors and corticosteroids.
• 15 mg of ephedrine followed by 4 to 12 mg of dexamethasone
administered IV for rapid absorption.
• O.3 to 0.5 mg Epinephrine- drug of choice
• External cardiac compression
ALLERGY AND ANAPHYLACTOID REACTIONS

DELAYED REACTION
• Occurs more than 48 hours after exposure to the allergen.
• More annoying than serious
• Manifested by localized edema in the are of injection, joint
pain, tenderness, and malaise.

Allergy Testing
• It is not within the scope of the dentist’s to attempt to
approve or disapprove the accuracy of a patient’s statement
of a previous allergic reaction. This should be the
responsibility of the allergists.
ALLERGY AND ANAPHYLACTOID REACTIONS

Prevention
• Adequate preanesthetic evaluation
• No drug or drugs should be used if the patient
gives a history of previous allergic reaction to
them.
• No patient should be tested to attempt to
disprove his allergic history.
 LOCAL
REACTIONS
CAUSED BY
ANESTHETIC
SOLUTION
GROUP
Naral, 4
Pauline
UE DENTAL MEDICINE
 Infection Caused by Contaminated Solution and
Local Irritation Caused by the Solution-LOCAL
REACTION
INFECTION CAUSED BY CONTAMINATED SOLUTION
• Primarily rare due to high standards of asepsis of the
manufacturer. Reliable manufacturer is therefore the best
protection of the dentist.
• The cartridge should only be used once and specially on one
patient only.
• The cartridge should be stored as aseptically as possible. Once
the container is opened, cartridges should be stored dry in any
suitable container that is kept covered at all times..
• A sterile, disposable sponge is wiped on the rubber diaphragm
prior to insertion to the syringe and affixation of the needle.
 Infection Caused by Contaminated Solution and
Local Irritation Caused by the Solution-LOCAL
REACTION

LOCAL IRRITATION CAUSED BY THE SOLUTION

• Prolonged anesthesia may be a complication
resulting from the injection of solution other
than the local anesthetic agent, such as alcohol,
sterilizing solution or others.
• If the injection is injected too rapidly on
confined areas, excessive pressure and
excessive volume,a local tissue damage may
result.
 Idiosyncrasy
• Refers to any reaction to a local anesthetic or drug that
cannot be classified as toxic or allergic
• Reaction shows no relation to the pharmacology of the drug
and may vary in degree from day to day
• Can occur as the result of emotional interplay causing an
array of unusual symptoms
• Treatment is almost impossible to outline in advanced
• Patient’s airway must still be maintained and adequate
oxygenation should be assured
• It is important that the dentist observe all patients closely and
try to diagnose an untoward situation as accurately as
possible so that proper treatment can be instituted
 Epinephrine Overdose
• Optimal concentration Clinical manifestations:
for prolonged pain 1. Dizziness
control: 1:250,000 2. Fear and anxiety
3. Pallor
• Employed to control
4. Palpitation
bleeding when applied 5. Perspiration
directly to the area 6. Restlessness
• Overdose reaction is 7. Respiratory Difficulty
quite rare 8. Tenseness
9. Throbbing headache
10. Tremor
11. Weakness
 Epinephrine Overdose
• Signs
– Sharp elevation in blood pressure (primarily
systolic)
– Elevated heart rate
– Premature ventricular contractions, ventricular
tachycardia, ventricular fibrillation
– possible cardiac arrythmias
 Epinephrine Overdose
• Management:
– Short duration: no formal management required
– Terminate dental procedure
– Remove source of epinephrine
– Conscious patient: position in a comfortable position; supine
position should not be done because of its accentuation of
cardiovascular effects
– Semi-sitting or erect position minimizes the elevation in cerebral
blood pressure
– Reassure patient that effects will subside
– Monitor blood pressure & heart rate every 5 minutes and
administer oxygen
– If patient is hyperventilating, is not indicated
– Permit patient to remain in the dental chair as long as necessary
– If there is doubt about the ability for self-care, do not discharge the
patient
 MEDICAL
EMERGENCIES
IN THE DENTAL
OFFICE
 Dentists need not accurately diagnose the cause
of the emergency but should give essential
medical treatment until the services of a
physician can be secured
 Dentists are expected to be able to safeguard the
life and welfare of patients during an emergency
 Pre-treatment physical evaluations should
forewarn the dentist of those patients most likely
to present emergency problems
CARDIOVASCULA
R CONDITIONS

ONG, Kathryn Macy

UE DENTAL MEDICINE
 Cardiovascular Conditions
 Mostly results from a combination of
preexisting pathologies and increased work
requirement of the heart
 Brought about not only by physical exertion
but also by catecholamine release following
emotional stress or pain
 Dentist’s concern: Welfare and comfort of
the patient
 Cardiovascular Conditions
1. Angina Pectoris
Signs/ Symptoms:
– primary characteristic: sudden onset of pain localized or
radiated to the arms, shouler or neck
– Patients complains of subsequent discomfort or a feeling of
fullness or pressure
Management:
– Patient should be comforted, reassured and put at rest
– Give 1 or 2 Nitroglycerin tablets (0.6mg) sublingually
– Patient should be asked to inhale a broken ampule of amyl
nitrate
– If relief is not obtained, oxygen and IM or IV meperidine
(Demerol) or morphine can be given to ease the pani and
anxiety
 Cardiovascular Conditions
2. Coronary Artery Occlusion
May vary from mild to very severe
Signs / Symptoms:
– Most common: substernal pain (mild to severe)
– Severe: Patient may feel that his head is about to burst
– Mild: pain is manifested as “digestive crisis” or heart burn
Management:
– Administer oxygen to alleviate any myocardial ischemia and
may help relieve the pain
– Patient should be placed in a supine position with head and
thorax elevated
– Give Morphine (8 to 15 mg) or meperidine (50 to 100 mg,
depending on severity) via IM or slowly via IV
 Cardiovascular Conditions
3. Congestive Heart Failure
• More often a chronic than an acute condition
• Patient gives a history of some cardiac disease
Signs / Symptoms:
– Patient becomes anxious, has severe dyspnea, moist cough, produces
pink-tinged sputum and rapid pulse
Management:
– Discontinue all procedures
– Patient kept at semisitting position
– Oxygen should be administered
– Give small doses of Morphine (8 to 10mg) or Meperidine (50 to
75mg) via IM for relief
– Rapid digitalization should not be attempted by the dentist and
movement only done after consultation with a physician
 Cardiovascular Conditions
4. Cardiac Arrythmias, Hypertension,
Hypotension
Signs/ Symptoms:
– Minor alterations in cardiac activity will show no demonstrable
symptoms
– Usually unobserved unless accompanied by obvious symptoms
such as pain, shortness of breath, headache, dizziness, or
syncope
Management:
– Patients are treated with oxygen, proper positioning or
administration of narcotic analgesics
– Medical consultations should be sought if indicated
 Cardiovascular Conditions
5. Shock
Management:
– Resulting from a hypotensive episode  patient is placed in a
semireclining, supine postion but with legs and thorax slightly
elevated
– Patient is adequately breathing  oxygen is administered with
a face mask (note the vital signs)
– Persistent hypotension with signs of cold and clammy skin
intravenous infusion of 5% dextrose in water or lactated
ringer’s solution
– To elevate blood pressure  give Mephentermine sulfate
(Wyamine) or Phenylephrine (Neo-Synephrine)
– Provide adequate spontaneous ventilation or artificial
ventilation
 Respiratory Conditions
 Usually results from a pre-existing condition
plus an exaggerating factor (emotion or
introduction of allergen)
 Dentist’s first concern: determine whether
respiratory exchange is adequate
RESPIRATORY
CONDITIONS

ONG, Kathryn Macy

UE DENTAL MEDICINE
 Respiratory Conditions
1. Asthma
• Almost 50% results form allergy to external allergens  exposure to
a specific allergen, unusual excitement, emotional stress or infection
• Ingested food and drugs may produce the condition
• May range from mild to severe
Signs/ Symptoms:
– Manifested by wheezing type of respiration with expirations much more
affected than inspiration
Management:
– For severe conditions where breathing is problem, oxygen should be
administered but cautiously so as not to trap air
– Epinephrine (0.3 to 0.5 ml of a 1:1000 solution) should be given via IM
– Give Aminophylline (0.25 to 0.5 gm) via IV if Epinephrine is not effective
– Bronchodilator sprays with Isoproterenol in a 1:200 solution may be used
(may be repeated in 10 to 20 minutes if necessary)
– Consult a physician if the attack is other than mild
 Respiratory Conditions
2. Emphysema
• May either be acute or chronic
• Characterized by dilation of the alveoli and distal
bronchioles
Signs/ Symptoms:
– Chronic: coughing spell causing an asthma –like attack
Management:
– Most effective: Bronchodilator sprays (with 1:1000
epinephrine or 1:200 isoproterenol)
– Emphysematous type: appointments should be during the
afternoon to give more time to clear the tracheobronchial tree
and reduce possible difficulties
 Respiratory Conditions
3. Mechanical Respiratory Embarrassment
• Rare/ unusaul lodging of foreign bodies in the larynx, trachea, or
tracheobroncheal tree
Management:
– Attempt to retrieve any body while still in the pharynx by instructing the
patient to hold his mouth open and refrain from swallowing or taking a
deep breath
– If object cannot be retrieved: patient should be induced to cough
forcefully  this may release and expel object
– if breathing is sufficient and partial oxygenation is maintained but cannot
dislodge the object, patient must be taken to the hospital
– If effective ventilation is reduced, dentist should not hesitate to perform a
cricothyrotomy (needle or tracheome is inserted in the midline through
the cricothyroid membrane ) given that the obstruction must be at the
level of the vocal cords and superior to the cricothyroid cartilage.
 NERVOUS
SYSTEM
DISORDERS

ONG, Kathryn Macy

UE DENTAL MEDICINE
 Nervous System Disorders
 Usually manifested by a loss of conciousness,
convulsive seizures, severe headaches,
muscle weakness or paralysis of specific
muscles
 Could occur from causes such as: drug
toxicity, hypoxia or hypercarbia
 Nervous System Disorders
1. Epilepsy
• Occurs in about 5% of the population
• Characterized by loss of conciousness, involutnary muscle
movements and disturbances of the autonomic nervous system
• Grand Mal Convulsions
– Characterized by excessive muscular activity, loss of consciousness and
muscle rigidity
– Patient becomes apneic
– May fall into exhaustive sleep or exhibit headache, vomiting, and muscle
soreness after an attack
• Petit Mal Convulsions
– Loss of consciousness is the predominant symptom
– The eyelids and sometimes the head move synchronously
– Seizure lasts only for a short while and usually has no afteraffects
 Nervous System Disorders
Management:
 Maintain patent airway (make sure patient is breathing adequately)
 Prevent any bodily injury form occurring during convulsion
 Dentist should keep a well-padded tongue blade available
- may help establish airway
- prevent severe injury to lips and tongue
- save the patient’s life
 Impending seizure is warned by the patient, IV Pentobarbital
sodium (Nembutal) or Secobarbital sodium (Seconal) is given slowly
to prevent the attack
 Patients should be ventilated when necessary
 Severe convulsions: patient is given 20-40mg of succinylcholine
chloride via IV or double the dose via IM
 Nervous System Disorders
2. Cerebral Vascular Emergencies
Signs/ Symptoms:
– Weakness or paralysis of extremities
– Sudden flaccid paralysis of the side of the face or slurred
speech
– Severe unilateral headache preceding other symptoms
Management:
– Maintenance of patent airway
– Adequate ventilation with oxygen until a physician is
consulted

3. Syncope (fainting)
• Most common medical emergency
METABOLIC
DISEASES

PAHANG, Julius
Martin S.
UE DENTAL MEDICINE
 Diabetes Mellitus
• Common condition affecting 1.5% to 2% of
the population.
• Caused by a disorder of carbohydrate
metabolism resulting from insulin deficiency
and producing hyperglycemia and glycosuria.
 Diabetes Mellitus

2 – types:
a. Insulin dependent Diabetes Mellitus (Type I)
b. Non-Insulin dependent Diabetes Mellitus
(Type II)
 Type I (IDDM)
• This form of diabetes results from a severe,
absolute lack of insulin caused by a reduction
in the beta-cell mass.
Triad for islet cell destruction:
1. Genetic Susceptibility – HLA DQ3.2, HLA DR3
HLA DQ 1.2
2. Auto-immunity
3. Environmental factors
 Environmental factors
• Race:
- Western countries have greater susceptibility
than Asian countries.
• Viruses:
- Measles, Rubella, Coxsackie B virus
• Chemical toxins:
a. Streptozotocin – Antibiotic used for treating
metastatic cancer of pancreatic islets. Has
destructive effect on B-cells.
b. Alloxan - Oxygenated pyrimidine derivative
used to produce purple dye murexide.
c. Pentamdine – Drug used for the treatment of
parasitic infections.
Others:
• Ingestion of Cow’s milk early in life – Has
higher incidence of IDDM and anti-bodies
against Bovine Serum Albumin, initiating
immune-response.
 Pathogenesis
Causative agent

B- Cell Damage (Insulitis)

Autoimmunity to B-cells

Immune B- Cell damage

Insulin

Diabetes Mellitus
 Type II NIDDM
• Is a metabolic disorder that is characterized
by high blood glucose in the context of insulin
resistance and relative insulin deficiency.
2 – Metabolic defects:
a. Derangement in insulin secretion
b. Insulin resistance
 Acute metabolic complications of Diabetes
mellitus

A. Diabetic Coma
1. Diabetic Ketoacidosis
2. Non-ketotic hyperosmolar coma
B. Insulin Shock
 Diabetic Coma
1. Diabetic ketoacidosis – stimulated by severe
insulin deficiency coupled w/ absolute or
relative increases of glucagon.
Danger: Ketone body formation, dehydration
Organs affected: Brain, Skeletal muscles, Liver,
Kidneys
Symptoms: Nausea, vomiting, respiratory
difficulties, warm and dry skin, thirst,
xerostomia.
 Diabetic ketoacidosis
Management:
1. Sodium Bicarbonate
2. IV Insulin
 Diabetic Coma
2. Non-ketotic hyperosmolar coma – a syndrome
engendered by the severe dehydration resulting
from sustained hyperglycemic diuresis, w/c is
coupled w/ an inability to drink water.
Danger: severe dehydration and shock.
Organs affected: kidneys and body tissues.
Symptoms: Polyuria, Glycosuria, tremors,
seizures.
 Non-Ketotic hyperosmolar coma
Management:
1. IV fluid
2. Insulin
3. Sodium and potassium
4. Tolbutamide (Orinase) - a first generation potassium
channel blocker, sulfonylurea oral hypoglycemic
drug.
Indication: Type II DM
Contraindication: Type I DM
 Acute metabolic complications of Diabetes
mellitus
B. Insulin Shock (Hypoglycemia)
• Critical decreased in blood sugar level
• Caused by excessive insulin intake or
premedications.
Symptoms:
- Hunger -Mentally confused
- Weakness
- Cold perspiration
- Easily irritated and anger
 Insulin shock
Management:
1. Few lumps of sugar, candy or any sugared
drinks.
2. In extreme cases: Glucagon HCL may be
given via IV or IM.
 Cholinesterase inactivity
• Caused by an inactive or insufficient Plasma
cholinesterase.
Danger:
- Toxicity due to very slow hydrolysis of ester
compounds
- Prolonged paresthesia
- Convulsion
Management: limit the convulsive state by
Barbiturates.
 ENDOCRINE
MALFUNCTIONS

PAHANG, Julius
Martin S.
UE DENTAL MEDICINE
 Hyperthyroidism
(Thyrotoxicosis)
• Hypermetabolic state caused by elevated
levels of free T3 and T4 in the blood.
• More often in women
2- forms:
a. Diffuse toxic goiter (Grave’s Disease)
b. Toxic nodular goiter
 Diffused Toxic Goiter
• Grave’s Disease
• Diffusely enlarged,
highly vascular thyroid
gland
• Common in young
adults
• Disorder of immune-
response
 Toxic Nodular Goiter
• Plummer’s Disease
• Nodules within the
gland while the rest of
the glandular tissue is
atrophied
• Common in older
patients
• Arises from long-
standing nontoxic
goiter
 Clinical signs and Symptoms
• Exopthalmos
• Enlarged thyroid
• Muscle weakness and
Fatigue
• Increased Neuromuscular
and sympathetic activity
• Increased pain sensitivity
• Increased BMR
• Excessive perspiration
• Tachycardia
• Excessive Heat
 Oral Manifestations
• Accelerated tooth
erption
• Marked loss of alveolar
process
• Diffused
demineralization of the
jawbone
• Progressive
periodontal destruction
 Management
• Contraindication of epinephrine
• Higher dosage of local anesthetics, sedatives
and analgesics: Since patient has increased
tolerance to CNS depressants
In case of impending thyroid crisis:
• Sedate the patient
• Application of cold packs to lower body
temperature
• Oxygen mask should be used
 Management
Thyroid Inhibitors
1. Antithyroid drugs – Inhibits the iodination of
tyrosin moities and coupling of Iodotyrosines.
a. Propacil
b. Tapazole
2. Ionic Inhbitors – Block the iodide transport
mechanism.
a. Thiocyanate (SCN-)
b. Perchlorate (Cl0-4)
 Management
Thyroid Inhibitors
3. Iodide – In large doses, inhibits proteolysis of
Thyroglobulin where increasing amounts of
thyroid hormone are confined within the colloid
and not released in the blood.
4. Radioactive Iodine – sequestered by the gland
and results in localized destruction of thyroid
tissues.
 Hypothyroidism
1. Cretinism
- Retardation of both physical and intellectual
growth in children.
- Becomes evident over ensuing weeks to months.
a. Endemic Cretinism – Due to dietary lack of
iodine.
ex. Diffused nontoxic goiter
b. Sporadic Cretinism – Due to congenital
developmental failure in gland formation.
 Clinical Signs and Symptoms
• Dry, rough skin
• Widely set eyes
• Periorbital puffiness
• Flattened, broad nose
• Overly large protuberant
tongue
• Impaired skeletal growth
• Retard development of
brain
 Oral Manifestation
• Teeth are usually poorly
shaped and carious
• Gingiva is inflammed or
pale and enlarged
• Larger maxilla and
Mandibular teeth
 Hypothyroidism
2. Myxedema – Hypothyroidism in older child or
adult
 Clinical Signs and Symptoms
• Slowing physical and
mental activity
• Cold intolerance
• Apathy
• Periorbital edema
• Dry, thickened and
enlarged tongue
 Management
• Hypothyroid patients have difficulty in withstanding
stress and tend to be sensitive to all CNS
depressants (Esp. Narcotics).
• Dosage should be adjusted
• Thyroid Hormone replacement therapy:
a. Levothyroxine Sodium (Synthroid)
b. Liothyronin Sodium (Cytomel)
c. Liotrx (Euthroid)
d. Thyroglobulin (Proloid)
e. Thyroid tablets (thyrar)
 Adrenal Insufficiency
(Hypoadrenalism)
• Caused by any anatomic or metabolic lesion
of the cortex that impairs the output of
cortical steroids.
• Caused by a deficiency of ACTH
1. Primary acute Adrenocortical insufficiency
2. Primary Chronic Adrenocortical
insufficiency
3. Secondary Adrenocortical insufficiency
 Primary Acute Adrenocortical Insufficiency
Danger: Adrenal Crisis
- As a crisis in patients w/ chronic adrenocortical
insufficiency precipitated by any form of stress that
requires an immediate increase in steroid output from
glands incapable of responding.
- From too rapid withdrawal of steroids from patients
whose adrenals have been suppressed by long-term
steroid administration.w
- From Failure to increase the level of administered
steroids during stress in a bilaterally adrenalectomized
patient.
- As a result of some massive destruction of adrenals
 Clinical Signs and symptoms
• Fatigue
• High Fever
• Headache
• Shaking chills
• Tacypnea
• Skin rash
• Rapid Heart rate
• Profound weakness
• Excessive sweating of face and palms
• Darkening of the skin
• Dehydration
 Management
Risk Factor:
• Dehydration
• Premature withdrawal of predisone too early
• Physical stress
Treatment:
- Immediate injection (IV/IM) of hydrocortisone
- IV fluid or vasoconstrictors in case of hypotension
- Monitor patient’s BP every 3 to 5 mins.
Primary Chronic adrenocortical insufficiency

• Addison’s Disease
- Caused by any chronic destructive process in the adrenal
cortex.
- 90% of the functioning cortical cells have been destroyed.
(+) Whites, Women
Causes:
 Atrophy of adrenal glands
 Destruction of adrenal glands
 Lack of ACTH
 Idiopathic
 Clinical Importance
• Lack of Aldosterone - Dehydration
secretion - Hyperkalemia and acidosis
- Decreased ECF
- Increased RBC
concentration
- Decreased Cardiac output
- Shock

• Increased MSH - Melanin pigmentation of

secretion mucous membrane
 Clinical manifestations
• Weakness
• Hyperpigmentation
• Nausea
• Hypotension
• Weight Loss
• Anorexia
• Hypoglycemia
• Hyperkalemia
 Management
Risk Factor:
• Dehydration
• Acidosis
• Hyperkalemia
• Hypotension
Treatment:
- Immediate injection (IV/IM) of hydrocortisone or Predisone
tablets
- IV fluid or vasoconstrictors in case of hypotension
- Sodium Bicarbonate to neutralize Acidity
- NSAIDS and ACE Inhibitors for Hyperkalemia
- Monitor patient’s BP every 3 to 5 mins.
HEMORRHAGIC
TENDENCIES

PAHANG, Julius
Martin S.
UE DENTAL MEDICINE
 Hemorrhagic Tendencies
- Prolonged clotting or bleeding
Causes:
• Hemopathology: Leukemia, hemophilia
• Thrombocytopenic purpura
• Anti-coagulant therapy
• local pathology
• hypertension
 Management
• The dentist should understand the history of
bleeding tendencies, as well as the existence of
local or systemic conditions that may prolong
bleeding
• Bleeding and coagulation time should be ordered
and evaluated and preventive measures taken
accordingly if any bleeding tendencies exists
• Obtain medical clearance from a physician prior
to any dental procedures
 Management
Anti-Hemorrhagic drugs:
1. Styptics - is a short stick of
medication, usually
anhydrous aluminum
sulfate, potassium alum
(both are types of alum) or
titanium dioxide which is
used for stanching blood by
causing blood vessels to
contract at the site of the
wound.
 Management
Anti-Hemorrhagic drugs:
2. Chitosan - topical
agents composed of
chitosan and its salts.
Chitosan bonds with
platelets and red
blood cells to form a
gel-like clot which
seals a bleeding vessel
 EMERGENCIES
RESULTING FROM
PRESCRIBED
MEDICATIONS
PAHANG, Julius
Martin S.
UE DENTAL MEDICINE
 Emergencies resulting from prescribed
medications

A. Cardiac Glycosides
Pharmacodynamics:
- Increases the force of contraction of the
myocardium on the failing heart
- Increases the cardiac output and stroke
volume
Pharmacokinetics:
- Reduction in heart size
- Decreased heart rate and venous pressure
 Emergencies resulting from prescribed
medications

A. Cardiac Glycosides
• Digoxin
• Digitoxin
• Digitalis leaf
 Emergencies resulting from prescribed
medications
B. Anti-Hyperglycemic drugs
• Insulin (regular, NPH, PZI, Lente)
• Tolbutamide (Orinase)
• Chlorpropamide (Diabenese)
C. Anti-Coagulant
• Warfarin (Coumadin)
D. Thyroid medications
• Thyroid extracts
• Levothyroxin (Synthroid)
• Liothyronin (Cytomel)
 Emergencies resulting from prescribed
medications

E. Psychosedatives (tranquilizers)
• Meprobamate (Equanil)
• Diazepam (Valium)
• Chlordiazepoxide (Librium)
• Chlorpromazine (Thorazine)
• Trifluoperazine (Stelazine)
 Emergencies resulting from prescribed
medications

F. Steroid hormones:
• Prednisone
• Hydrocortisone (Solu-Cortef)
• Dexamethasone (Decadron)
G. Anti-Hypertensives:
• Reserpine (Serpasil)
• Guanethidine (Ismelin)
• Methyldopa (Aldomet)
 Emergencies resulting from prescribed
medications

H. Anti-Convulsants:
• Diphenylhydantoin (Dilantin)
• Phenobarbital
• Primadone (Mysoline)
I. Antiarrhythmics:
• Quinidine
• Procaine amide
 CPR

MEDRANO, KEVIN
UE DENTAL MEDICINE
Cardiopulmonary Resuscitation
( CPR )
-All dentists should understand the
basic rudiments of CPR.
 A = Airway
• The most important aspect of CPR is to establish the
airway of the patient
• All unconscious require that at least this step be carried
out.
• Without airway, controlled ventilation is impossible that
may result in rapid development of hypoxia and
hypercarbia.
• Hypoxia – the body is deprived of adequate oxygen
supply.
 B = Breathing
• Breathing is never attempted in the absence airway
establishment.
• Air or oxygen maybe forced into the patient’s lungs by a
resuscitator such as an Ambu bag or a mouth-to-mouth
or mouth-to-nose breathing.
• In using Ambu bag, the dentist or the assistant should be
certain that there are no leaks around the mask, which
would prevent sufficient air from being forces into the
lungs.
 In mouth-to-mouth ventilation:

1. The head is tilted backward

2. The nose is compressed between the thumb and
forefinger to prevent air leakage.
3. The operator should take a deep inspiration before
each expiration into the patient’s mouth.
4. One cane readily determine if the air is reaching the
patient’s lungs by observing the rise and fall of the
chest wall.
 C = Circulation
• After doing steps A and B, check the status of the
circulation by palpating for the presence of the carotid
pulse in the neck.
• While head extension is maintained with one hand, the
other hand locates the victim’s larynx. The finger are
then moved laterally into the groove between the
trachea and the muscles at the side of the neck where
the carotid pulse can be felt.
• Weak pulse = circulatory depression ( not collapsed )
• No pulse = need to initiate CPR.
 Steps in CPR:
1. The victim must always be on his back on a firm surface in
the horizontal position for external chest compression to be
effective.
2. The clinician should be positioned at the side of the patient,
the lower margin of the rib cage is located with the middle
and index fingers of the hand closest to the victim’s feet.
3. The fingers then run along the rib cage toward midline to
locate the inferior border of the sternum.
4. The heel of the second hand is placed in the midline in the
lower portion of the sternum.
5. The operator’s elbow should be straightened and the
shoulders positioned directly over the hands.
 Steps in CPR:
6. Pressure is then released allowing the heart to refill. The
time allowed for the release should be equal the time
required for compression.
7. The hands should not be allowed to “bounce” free from
the sternum lest the next compression be delivered
forcefully that can cause trauma or harm.
8. If there is still no pulse felt, a ventricular fibrillation
should be done.
9. If possible, continue CPR until help is summoned.