The greatest blow to the welfare of the patient has been the recent tendency, in the last fifty odd years, to demarcate health care systems into different specialties. Time was when a doctor, a good doctor at that, used to deal with most human ills. When special technical expertise was needed, he, of course, could get assistance from specially trained colleagues. This has completely changed now. Even among the dental surgeons there are people who only deal with straightening crooked teeth, or operating on the teeth and the jaws. Although, this kind of sub-specialisation is very fashionable, and useful from the business and monitory point of view, it has been a great blow to the welfare of the patient.



If one were to view health care in its totality, it is not the aching tooth that consults the doctor; the owner of the aching tooth might have other concomitant or cosequent problems. He, in addition, would have his worries, his anxieties, his tensions, his family problems, his economic problems, his social problems and, what have you. If you want to deal with any situation in the practice of dentistry, nay of medicine, it is imperative that you get to know your patient very well. To get to know the patient, one has to have time to listen to the patient, many of us talk to the patient but rarely ever do we talk with the patient or listen to the patient. If one were to listen to the patient carefully, the patient would tell the doctor what is wrong with him/her. This has been proved right even in the present day modern high-tech medical scenario.



Medical emergencies do occur, although luckily very rarely, in dental practice, for the simple reason that the aching tooth has around it a human being having other systemic problems. The first and the foremost that comes to mind is the shock reaction or the vaso-vagal attack.



Vaso-Vagal Attack:



This is due purely to fear. Many people, even today, with very sophisticated gadgetry around the dental chair, still are mortally afraid of the dental chair and the dental surgeon. This might bring on autonomic imbalance at the crucial time when the dental surgeon starts to do his procedure on the patient. The patient’s blood pressure would suddenly drop because of vasodilation and this, coupled with an inappropriate response of the sympathetic system, might result in a temporary syncopal attack. If this occurs even before the procedure has started, the diagnosis is very simple. After you start the procedure, confusion about diagnosis might arise. Luckily, the present day dental chairs are so convenient for diagnosis cum management of this very simple abnormality. You just have to tilt the chair in such a way that the patient’s head becomes lower than his feet. Within no time does the cerebral blood flow get restored and the patient comes back to normalcy very fast. Of course, one would need a lot of psychological reassurance to be in the chair again for the procedure.



After having listened to the patient, if the dental surgeon finds that the patient has a neurotic personality, it is advisable to defer the procedure to a later date; using the interval profitably to reassure him; may be more than once. One of the very useful methods of reassurance in a situation like this, the latter is akin to the panic reaction, is to expose the patient to the real situation repeatedly. In my opinion it may not be a bad idea to have the patient to see similar or even more ominous procedures done on other patients so that he/ she gets reassured.



Anaphylactic reaction:



Drugs used in anaesthetic practice, whether local or general, just like any other drugs, could produce allergic or anaphylactic reactions. This could be an immediate anaphylactic reaction of collapse where the patient’s blood pressure becomes unrecordable, the pulse becomes very fast and thready and, possibly the patient comes out with a rash and, in very occasional cases, he might even get choked because of the oedema in the larynx. Very rarely patients find it very difficult to breathe because of broncho-spasm, which is predominately expiratory, and the patient feels the wheeze coming on when he tries to breathe out. The latter response is more common in known asthmatics. Due care should be taken in such situations to see that his/her asthma is properly controlled before the procedure. I wish to reiterate the added significance of listening to the patient’s past and his other problems in avoiding situations like this. Almost all local anaesthetic drugs could have some effect on the cardio-vascular system. Infact, lignocane is a drug, which we used very commonly, almost as a routine, in acute heart attack situations in coronary care units. Although the scientific data on the usefulness of lignocaine, given intravenously, in the treatment of acute cardiac abnormal rhythms is not very strong, people have been using lignocane routinely for a very long time in practice. It was only recently that a new study, the CAST study or Coronary Arrhythmia Suppression Trial, for the first time showed, that most antiarrythmic drugs, if not all, do not decrease mortality in acute coronary care set up; if anything, some of them might increase mortality. With this background, one has to be very careful in giving local anaesthetic to dental patients. Any history of his having had anaphylactic reaction in the past could be a guide but, sometimes, even that may not help. However, the risks involved with giving lignocane intravenously are much more than giving lignocane sub-mucosally or sub cutaneously. However, care should be taken to see that the drug is not advertantly injected directly intravenously.



If the reaction is not due to shock to be corrected by simple manovure of just putting the head end down, usual anti-anaphylactic drugs like steroids, adrenaline and, in a situation where a patient has difficulty in breathing, one might have to take recourse to artificial breathing through an Ambu bag.



Abnormal bleeding:



There are a host of medical conditions where the bleeding-clotting mechanism, the basic response of the human organism to the dangers of bleeding in his wild and hostile atmosphere, could be deranged under many situations of both disease and drug use. It is very important to take a very detailed drug history of the patient. Many, even in our country, with the western influence, take aspirin routinely in the fond hope of preventing heart attacks. Although controversy still dogs the scientific data in this field – the latest being that the routine aspirin use does substantially increase the haemoragic stroke incidence if people took it for prevention of heart attacks. The report also says that it does decrease the statistically expected number of heart attacks in the population. There are one or two snags in the whole story. The prediction of number of heart attacks in the future in a given population is a highly statistical calculation which, in retrospect, has not been found to be very accurate.



Infact, none of the predictions for the future in a dynamic human system come true. In a very elaborate article in the British Medical Journal, a professor of physics in Strathclyde Glasgow, has very clearly shown that doctors have been predicting the unpredictable. That said, I must add that in a patient who has already had a heart attack, aspirin does a lot of good. Despite all these advances, we still do not know what dose of aspirin to take for prevention of heart attacks. In that scenario doctors give anywhere between 50 milligrams of aspirin a day to 365 mg. per day. Many of these patients, if they are taking aspirin as a routine prophylaxis, may not think that it is a treatment and may not volunteer the information to the dental surgeon. In that background, it is always necessary that a dental surgeon should specifically ask every patient the one question which is very important: is the patient taking aspirin or any other blood thinning drugs? If found to be positive, the patient must be referred back to his physician for advice regarding the feasibility or otherwise of the dental procedure.



In case bleeding does occur, and does not stop, the local packing etc are only of temporary relief. The cause of bleeding, either due to the drugs that the patient is on or, due to the bleeding diathesis the patient is suffering from, the patient requires immediate hospitalisation and emergency medical attention to sort out both the diagnosis and to institute effective management.



Delayed allergic response:



There are a few people who come up with a slightly delayed allergic response to the drugs given, or even to the local anaesthetic. Here the usual presentation would be an itchy red rash with or without swelling of the eyelids and difficulty in breathing because of the swelling in the larynx. This requires emergency use of adrenaline, steroids, and anti-histaminics on a long-term basis, to prevent these recurrences. This must be carefully noted down for future guidance of the patient, his future contact with dental surgeons or, other medical personnel.



Blood pressure response:



We had studied a lot of normal human beings on the dental chair. It has also been studied elsewhere. The results have shown that each time the patient gets frightened and each time the drill works or any time the patient feels unexpected pains, the blood pressure peeks suddenly. However, the body is used to this kind of peeking of blood pressure, which should occur in a normal individual under different stressful situations. The body’s wisdom could deal with the situation without any alarm. However, in a patient who suffers from high blood pressure that is not under control, it is possible, theoretically though, that the pressure might peek unusually high and might result in either a cerebral hemorrhage, dissection of an aneurysmal dilation of the aorta or, push the left ventricle into acute failure, if it is already under distress. Although these are only theoretic possibilities, it is sensible practice, atleast from the point of view of consumerism, to have the patients on anti-hypertensive drugs to get clearance from their physicians.



What level of blood pressure should be cleared is a billion dollar question which nobody could answer scientifically. However, it is safe to see that the clinic blood pressure is below 160 systolic and 100 diastolic, before any procedure is permitted on the patient. This could easily be done. But there are certain drugs, which are preferably avoided in trying to lower the blood pressure pre-operatively, which the physician would know.



Myocardial Infarction (Heart Attack):



Any patient, who has had a recent heart attack or stroke, is not an ideal candidate for manipulative surgery or extraction. That said, I must hasten to add that after a period of three months of having had a heart attack the patient is quite is safe. So a past heart attack is not an absolute contra-indication. One must, however, take care to see that the patient is not on an anticoagulant drugs after the heart attack. If the patient has any reservations about having his dental procedure in view of his having had a heart attack in the distant past, it is better to get him cleared from his physician, more for his satisfaction; lest you should get into trouble later on, not because of the heart attack, but because of the fear in the patient’s mind. Mind is a very important part of the human system. It is now documented that many human ills, if not all, have some component from the mind and, every single human physical problem has its mental reverberations.





Anxiety States:



In the fast pace of life in the present day industrialised society, anxiety is very common, sometimes the anxiety will be so much that the very sight of the procedure, even the very thought of the procedure might produce an enormous tachycardia. These people do not require any drug treatment. They require kindness, empathy, understanding, and reassurance. But a small percentage of these people might need pharmacological assistance, in addition. The best drug would be a small dose of beta-blocker, preferably propranolol, about 10-20 mgs. If you are giving the drug yourself, please find out if the patient has any drug idiosyncrasy or, if the patient has any history of depression. In that case you would do well to avoid beta blocking the patient.



Infections:



It is good practice always to cover patients who have valve disease of the heart with anti-biotics before any procedure. This has now become a routine. Supposing you have forgotten to do that and you have already done the procedure, you need not have any guilt feeling whatsoever. Meta-analysis of recent data shows that the chance of secondary infection on a damaged valve (infective endocarditis) comes very very rarely in those who have an uncovered dental procedure. Infact, it is said to be so rare that probably antibiotic cover may not be needed. Legally it is better that you give the patient an anti-biotic cover, as per the conventional wisdom.



Cardiac arryhthmias:



There are a few patients who have abnormal cardiac rhythms who might have an adverse reaction during a dental procedure. One such group of patients is called the sick sinus syndrome. The others are people who are prone to ventricular tachycardia, and bradyarrythmias, like the various grades of heart block. If the patient has a history of any one of the above problems it is always better to get him cleared from his physician before the procedure. If a patient has a pacemaker put in he is quite safe for the procedure and, of course, some people do cover them with antibiotics around the procedure.



In the above narration, I have tried to cover the common emergencies that a dental surgeon could expect to meet in his daily practice. Having said that, I must give the good news that these are very infrequent. But, to be on the safer side, in the present day atmosphere of consumerism, it is necessary that the doctor takes full precautions before he starts the procedure. It is not enough if you have taken the precautions but they must be documented in the case sheet properly. Should any adverse reaction occur later on during the procedure, if the doctor has recorded all that he has found out from the patient, about his past allergies, his drugs, his medical problems, his usual response to these kind of procedures etc., one is safe from the legal point of view. Again the key word is documentation which is the proof of having taken due precautions. Ultimately complication rates are supposed to be directly proportionate to the type of doctor one deals with. Placebo doctors (who please the patient) have comparatively fewer emergency problems compared to the nocebo doctors ( who frighten their patients). One must try to be a placebo doctor. The best drug in this world is a good doctor. It is not the drug or the injection that cures the patient , it is his own immune system that eventually repairs the damage done to the system. But the immune system gets stimulated better when the doctor works as a placebo.