Visual observation of the patient can provide the doctor with additional information about the patient’s physical status and degree of anxiety. Observation of a person’s posture, body movements, speech, and skin may help the doctor detect disorders that may previously have gone unnoticed.13 Persons with chronic pulmonary disorders often must sit more upright in the dental chair than other patients because of severe orthopnea. Arthritic patients with a rigid neck need to rotate their entire trunk when turning toward the doctor or when viewing an object from the side. In addition, involuntary body movements occurring in conscious patients may indicate significant disorders. Tremors may be noted in disorders such as fatigue, multiple sclerosis, parkinsonism, and hyperthyroidism, as well as hysteria and nervous tension.

The dentist reviews the completed form with the patient and asks additional questions about any medical problems that the patient has reported. Through this dialogue, the dentist seeks to determine the significance of any reported medical disorder to the proposed dental treatment plan. 13

The recognition of ‘at-risk’ patients and subsequent appropriate management is paramount in reducing the probability of an adverse event. Acknowledgement that any dental patient may have a medical emergency during dental treatment is a key start point. A thorough medical and drug history is mandatory and should be undertaken by the dentist in person. Patient-completed health questionnaires should be confirmed by a verbal history. Identification of at-risk patients will allow modifications to be made to treatment planning and may highlight those patients whose treatment may be more appropriately conducted at specific times or in specialist centres. Medical and drug records should be updated annually, and any changes highlighted during on-going treatment plans should be re-assessed and recorded at every visit. This is more important now than ever as we are treating an ageing population who may have substantial co-morbidities and who are undergoing complex and frequently changing medical therapies. 14

Many apprehensive patients report that their fear of dentistry or surgery is so great that they are unable to sleep well the night before their appointment. Fatigued the next day, they are less able to tolerate any stress placed on them during treatment. The dentist may prescribe a sedative-hypnotic drug, such as diazepam, triazolam, flurazepam, zaleplon or zolpidem, for administration one hour before the patient goes to bed.

Apprehensive or medically compromised patients are better able to tolerate stress when rested. Consequently, for most of these patients, including children, the ideal time to schedule dental treatment is early in the day.

Once in the dental office, an apprehensive patient should not have to wait in the reception area or dental chair for extended periods before treatment begins. Anticipation of a procedure can induce more fear than the actual procedure.

Should additionally stress reduction procedures be required, the dentist may consider using any available sedation technique or general anesthesia. Nondrug techniques include iatrosedation (including music and video) and hypnosis; the more commonly used pharmacosedative procedures include oral, inhalational, intramuscular, intranasal and intravenous (minimum or moderate) sedation. 15, 16

For stress reduction to be successful, the patient’s pain must be controlled. Successful pain management is of greater importance in medically compromised patients.

In many instances, a healthy but fearful patient may wish to have as few dental appointments as possible, regardless of their length. However, satisfying a patient’s (or parents’ or guardians’) desire for longer appointments is inadvisable if the dentist believes there are appropriate reasons for shorter appointments.

The emergency drugs are of two categories 17:

Essential emergency drugs and Additional emergency drugs (Figure 1).

If conscious, the patient should sit in any position that is comfortable. If unconscious, the patient should be supine with the legs elevated slightly to about 10˚ to 15˚. This position facilitates blood flow to the brain, thus helping to correct any deficient oxygen delivery. Medical emergencies can often be prevented by early recognition. 18 An abnormal patient color, pulse rate or breathing can signal some impending emergencies. It is important to have a systematic approach to an acutely ill patient and to remain calm. The principles are summarized in the ‘ABCDE’ approach. 19

Airway obstruction is a medical emergency and must be managed quickly and effectively. Usually, a simple method of clearing the airway is all that is needed. A head tilt, chin lift or jaw thrust will open the airway. 19 Patients who are unable to speak are to be feared and establishing a patent airway is vital. 19 It is important to remove any visible foreign bodies, blood or debris and the use of suction may be beneficial.

Opening Airway Technique 19: The rescuer must stand behind the victim’s head to perform this procedure.

Head tilt 19: Place one hand on patient’s forehead and apply backward pressure with the palm to rotate the head upward and backward.

Chin lift 19: Place the tips of middle and index fingers on the symphysis of the mandible to lift the mandible.

Jaw thrust technique 19: Place the fingers on the angle of the mandible and displace the mandible forward.

The dentist and staff members should consider the second step—breathing— immediately after taking care of the patient’s airway. If he or she is conscious, this usually is not a problem, and the team can move on quickly to circulation. If the patient is talking, then he or she is breathing, but in cases of asthma or allergy, the dentist must rule out wheezing (bronchospasm). He or she also needs to consider whether the patient is breathing too slowly or rapidly. Any team member can monitor the respiratory rate and adequacy of respiration. In adults, the normal respiratory rate is 12 to 15 breaths per minute. In children, the rate is higher, with an 8-year-old averaging 18 breaths per minute and a 3-year-old averaging 22 breaths per minute.9 Bradypnea is any respiratory rate significantly below the normal rate; it may result in hypoventilation and inadequate oxygenation. Tachypnea, often a sign of anxiety, is any respiratory rate significantly above the normal rate; it may lead to hyperventilation syndrome. For offices in which the clinician induces moderate or deep sedation or administers a general anesthetic, a pulse oximeter should be available and can be used to assess the adequacy of oxyhemoglobin saturation.

Circulatory assessment should never delay the start of CPR. By far the most common cause of a collapse that is essentially circulatory in origin is the simple faint (vaso-vagal syncope). A rapid recovery can be expected in these cases if the patient is laid flat and the legs rose. Prompt management is required as cerebral hypoxia has devastating consequences if prolonged. Causes other than a faint must be considered if recovery does not happen quickly. Checking the carotid pulse to diagnose cardiac arrest can be unreliable, even when attempted by some health care professionals. Checking the carotid pulse should only be carried out by those proficient in doing this. The latest guidelines highlight the need to identify agonal gasps (as well as the absence of breathing) as a sign to commence CPR and lay no particular emphasis on checking the carotid pulse. 1

Disability is the term which refers to an assessment of the neurological status of the patient. In this context, primarily, it refers to the level of consciousness (in trauma patients a more widespread neurological examination is required). Hypoxia or hypercapnia (increased blood levels of carbon dioxide) is possible causes, together with certain sedative or analgesic drugs. It is important to exclude hypoxia or hypotension and attention to the airway, giving supplemental oxygen and supporting the patient’s circulation (by lying them supine and raising their legs) will in many cases solve the problem. All unconscious patients who are breathing and have a pulse should be placed in the recovery position if they are unable to maintain their own airway. 20

A rapid gross assessment can be made of a patient’s level of consciousness using the AVPU method 20:

Are they Alert?

Do they respond to Vocal stimuli?

Do they respond to Painful stimuli? or

Are they Unresponsive?

A lapse into unconsciousness may be due to hypoglycaemia – if the blood glucose level is less than 3mmol/litre as checked by a glucose measuring device.

Exposure refers to loosening or removal of some of the patient’s clothes. For example, for the application of defibrillator paddles (in dental practice), or if the patient has been involved in a traumatic incident (usually in hospital), for examination purposes. It is important to bear in mind the patient’s dignity as well as the potential for clinically significant heat loss. 20