Emergency conditions in Dental Clinics

Hypoadrenalism - Usually the patient is known to have Addison's disease or to be taking steroids long term and has forgotten to take the tablets.

Signs and symptoms

• Pallor
• Confusion
• Rapid weak pulse.

Treatment:

Give oxygen
Give 200 mg hydrocortisone sodium succinate by slow i.v. injection.
 Give steroid replacement
 Determining and managing underlying cause once the crisis over.

If required:

• Transfer to Emergeny hostpital
• Fluids and further hydrocortisone, both i.v.

Acute asthma - Exposure to antigen but precipitated by many factors including anxiety.

Signs and symptoms

• Persistent shortness of breath poorly relieved by bronchodilators
• Restlessness and exhaustion
• Tachycardia greater than 110 beats/min and low peak expiratory flow
• Respirations may be so shallow in severe cases that wheezing is absent.

Treatment
Excluded respiratory obstruction
Sit the patient up
Give oxygen

Salbutamol (Ventolin) via a nebuliser (2.5-5 mg of 1 mg/ml nebuliser solution) or via a large-volume spacer (two puffs of a metered dose inhaler 10-20 times: one puff every 30 seconds up to 10 puffs for a child)
Reassure and allow home if recovered.

• Bronchodilatation.

If Major Problem recommend to hospital Emergeny

• Hydrocortisone sodium succinate i.v.: adults 200 mg; child 100 mg
• Add ipratropium 0.5 mg to nebulised salbutamol
• Aminophylline slow i.v. injection of 250 mg in 10 ml over at least 20 minutes: monitor or keep finger on pulse during injection.

Caution in epilepsy: rapid injection of aminophylline may cause arrhythmias and convulsions.

Caution in patients already receiving theophylline: arrhythmias or convulsions may occur.

Anaphylactic shock

Signs and symptoms

• Paraesthesia, flushing and swelling of face, especially eyelids and lips (Fig. 13)
• generalised urticaria, especially hands and feet
• wheezing and difficulty in breathing
• rapid weak pulse.

These may develop over 15 to 30 minutes following the oral administration of a drug or rapidly over a few minutes following i.v. drug administration.

Treatment

Lay patient flat and raise feet
Give oxygen
Give 0.5 ml epinephrine (adrenaline) 1 mg/ml (1 in
1000) intramuscular
— 0.25 ml for 6-12 years
— 0.12 ml for 6 months to 6 years
repeated every 10 min until improvement.

Requires prompt energetic treatment of

• laryngeal oedema
• bronchospasm
• hypotension.

• Chlorphenamine (chlorpheniramine) 10 mg in 1 ml intramuscular or slow i.v. injection
• Hydrocortisone sodium succinate 200 mg by slow i.v. injection: valuable as action persists after that of adrenaline has worn off
• Fluids i.v. (colloids) infused rapidly if shock not responding quickly to adrenaline.

Stroke - Stroke results from either cerebral haemorrhage or cerebral ischaemia.

Signs and symptoms

• Confusion followed by signs and symptoms of focal brain damage
• Hemiplegia or quadriplegia
• Sensory loss
• Dysphasia
• Locked-in syndrome (aware, but unable to respond).

Treatment

Maintain and transfer for further investigation.

Benzodiazepine overdose - Overdose can result from a large or a fast dose of benzodiazepine or can occur in a sensitive patient.

Signs and symptoms

• Deeply sedated
• Severe respiratory depression.

Treatment

Flumazenil (Annexate) 200 mg over 15 seconds as 100 mg/ml i.v. followed by 100 mg every 1 minute up to maximum of 1 mg Maintain airway with head tilt/chin lift 
Give oxygen.

Treatment

The action of the benzodiazepine is reversed with the specific antagonist.

Angina and myocardial infarction

Signs and symptoms

• Sudden onset of severe crushing pain across front of chest, which may radiate towards the shoulder and down the left arm or into the neck and jaw; pain from angina usually radiates down left arm
Skin pale and clammy
Shallow respirations
Nausea
Weak pulse and hypotension
If the pain not relieved by glyceryl trinitrate (GTN) then cause is myocardial infarction rather than angina.

First-line treatment of angina and myocardial infarction

Allow patient to rest in position that feels most comfortable:

• in presence of breathlessness this is likely to be the sitting position, whereas syncopal patients will want to lie flat
• often an intermediate position will be most appropriate.

Angina - 

Angina results from reduced coronary artery lumen diameter because of atheromatous plaques
Myocardial infarction is usually the result of thrombosis in a coronary artery.

Angina is relieved by rest and nitrates:
 
• Glyceryl trinitrate spray 400 mg metered dose (sprayed on oral mucosa or under tongue and mouth then closed)
• Give oxygen
• Allow home if attack is mild and the patient recovers rapidly.

Myocardial infarction

If a myocardial infarction is suspected:

• give oxygen
• aspirin tablet 300 mg chewed.

• Pain control
• Vasodilatation of blood vessels to reduce load on heart.

Further management for severe angina or myocardial infarction

• Transfer to Emergency
• Diamorphine 5 mg (2.5 mg in older people) by slow i.v. injection (1 mg/min)
• Early thrombolytic therapy reduces mortality.

Cardiac arrest

• Most cardiac arrests result from arrhythmias associated with acute myocardial infarction or chronic ischaemic heart disease
• The heart arrests in one of three rhythms 
— VF (ventricular fibrillation) or pulseless VT (ventricular tachycardia)
— asystole
— PEA (pulseless electrical activity) or EMD (electromechanical dissociation).

Signs and symptoms

• Unconscious
• No breathing
• Absent carotid pulse.

Treatment

• Circulation failure for 4 minutes, or less if the patient is already hypoxaemic, will lead to irreversible brain damage
• Institute early basic life support  as holding procedure until early advanced life support is available.

• Transfer to Emergency
• Advanced life support.

Advanced life support for cardiac arrest

Advanced airway management techniques and specific treatment of the underlying cause of cardiac arrest constitute advanced life support (ALS).

Actinomycosis is a rare but serious bacterial infection that typically affects the face, neck, and thoracic and abdominal areas. It is caused by Actinomyces israelii, which are anaerobic, filamentous bacteria that are part of the normal oral and gastrointestinal flora. The infection usually occurs when these bacteria invade tissues through breaks in the mucosal barrier, often following dental procedures, oral infections, or surgery. It is not contagious and does not spread from person to person.

Actinomycosis is a relatively rare, chronic bacterial infection caused by Actinomyces, a genus of Gram-positive, anaerobic, or microaerophilic bacteria that are part of the normal oral flora. The most common species involved in oral infections are Actinomyces israelii, Actinomyces naeslundii, and Actinomyces viscosus.

Features of Actinomycosis in Oral Medicine:

1. Presentation: Oral actinomycosis typically presents as a slowly progressive, indurated, and painless mass with a firm consistency. The lesion may appear as a nodule, a swelling, or a diffuse infiltration of the tissue.
2. Sulfur granules: A characteristic feature of actinomycosis is the presence of sulfur granules, which are microscopic collections of bacteria surrounded by a dense, eosinophilic material.
3. Microscopic appearance: Under the microscope, the bacteria form filamentous structures called "radiating clubs" or "ray fungi" due to their branching pattern.
4. Predisposing factors: The infection often occurs in individuals with poor oral hygiene, dental caries, periodontal disease, or following oral surgery or trauma, which can disrupt the mucosal barrier and allow the bacteria to invade deeper tissues.
5. Clinical forms: There are three main forms of oral actinomycosis: cervicofacial, which affects the neck and face; actinomycetoma, which is a chronic, localized infection of the jaw or other bone; and systemic actinomycosis, which is less common but can disseminate to the lungs, liver, and other organs.

The disease manifests in different forms based on the site of infection:

1. Cervicofacial actinomycosis: This is the most common form, accounting for 60% of cases, and often enters through the mouth or throat. It may appear as a slowly growing, painful mass in the neck or face, with possible drainage of pus through the skin.

2. Thoracic actinomycosis: This type occurs when the bacteria spread to the lungs, often following aspiration from the oral cavity. It can mimic pneumonia at first but may progress to form abscesses and damage surrounding structures such as ribs and vertebrae.

3. Abdominal actinomycosis: This form typically begins in the gastrointestinal tract, often the appendix or cecum. It can spread to the liver and other abdominal organs, causing pain, swelling, and the formation of abscesses.

4. Pelvic actinomycosis: Associated with the use of intrauterine contraceptive devices (IUCDs), this infection occurs in the female reproductive system and may cause pelvic inflammatory disease-like symptoms or infertility.

The diagnosis of actinomycosis is often challenging due to its nonspecific symptoms and the difficulty in culturing the bacteria, which require anaerobic conditions. Microscopically, the characteristic 'sulfur granules' can be identified in pus or biopsy samples, which consist of clumps of bacteria surrounded by neutrophils and a fibrin network. These granules can be visualized with specific stains such as Gomori methenamine silver (GMS).

Treatment for actinomycosis involves the administration of high doses of antibiotics for an extended period, typically penicillins (such as penicillin G or amoxicillin) or, if penicillin-allergic, alternatives like clindamycin, erythromycin, or tetracyclines. The duration of treatment can range from several months to over a year, depending on the severity and location of the infection.

Surgical intervention may be necessary in some cases to drain abscesses, remove infected tissue, or correct an underlying condition that facilitated the infection. For example, in pelvic actinomycosis, removal of the IUCD is often a critical step in treatment.

Prevention includes maintaining good oral hygiene and regular dental care, as well as careful monitoring and management of any breaks in mucosal barriers.

Actinomycosis, while not common, requires early and aggressive treatment to prevent complications and ensure the best possible outcome for patients. It is important for medical professionals to consider actinomycosis in the differential diagnosis of chronic suppurative infections, especially in immunocompromised individuals or those with a history of recent surgery or trauma to the affected areas.

Treatment of Actinomycosis in Oral Medicine:

The treatment of actinomycosis involves a combination of surgical and medical interventions:

1. Antibiotics: The cornerstone of treatment is the administration of antibiotics that are effective against anaerobic bacteria, such as penicillins (penicillin G or amoxicillin), particularly penicillin V, for several months to ensure eradication of the infection. In penicillin-allergic patients, alternatives like clindamycin, erythromycin, or tetracyclines may be used.
2. Surgical drainage: If the infection has caused abscesses, surgical drainage may be necessary to release the pus and reduce swelling.
3. Incision and curettage: For localized infections, surgical removal of the affected tissue and curettage of the bone may be performed to remove the necrotic material and allow for healing.
4. Debridement: Removing the devitalized tissue can help in reducing the bacterial load and facilitate the antibiotic treatment.
5. Maintaining oral hygiene: Good oral hygiene practices are crucial to prevent recurrence of the infection. This includes regular brushing, flossing, and professional dental cleanings.
6. Treatment of underlying conditions: Addressing any predisposing factors such as dental caries or periodontal disease is essential to prevent reinfection.
7. Monitoring and follow-up: Patients should be monitored for signs of recurrence, and any persistent symptoms should be evaluated with imaging and biopsy if necessary.

The prognosis of oral actinomycosis is generally good with appropriate treatment. However, the infection can be challenging to diagnose due to its rarity and the similarity of its clinical presentation to other oral diseases. A high index of suspicion, combined with a thorough medical and dental history, clinical examination, and microbiological and histopathological confirmation, is essential for accurate diagnosis and effective management.

Oral medicine is the specialty of dentistry concerned with the oral health care of patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.

Oral medicine acts a focus for specialist interdisciplinary care of patients with symptoms arising from the mouth that do not relate directly to teeth.

These symptoms are often chronic and may have a significant psychological, as well as physical impact on the patient’s quality of life. In some instances, symptoms and signs reflect local problems restricted to the mouth. However, symptoms and signs can represent oral manifestations of more widespread disease.

Oral medicine practice depends on good diagnostic ability, in depth knowledge in identifying and removing the underlying cause from local, systemic ,genetic and environmental factors.

Oral physicians should adapt the demographic changes andmedical advancements with academic and research orientation for expansion of oral medicine and radiology andshoulder the responsibility of being part of patient's overall health care team.