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Table of Contents
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 111-117

Medical emergencies during exodontia in a referral dental center in Saudi Arabia: A cross-sectional study

1 Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran, Kingdom of Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
3 Department of Preventive Dentistry, Faculty of Dentistry, Najran University, Najran, Saudi Arabia
4 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
5 New Najran General Hospital, Najran, Kingdom of Saudi Arabia

Date of Submission05-May-2022
Date of Decision17-Aug-2022
Date of Acceptance29-Aug-2022
Date of Web Publication15-Nov-2022

Correspondence Address:
Ramat Oyebunmi Braimah
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_25_22

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Background: Medical emergencies such as vasovagal attack, hypoglycemia, and asthmatic attacks that are not related to dentoalveolar procedures, such as bleeding and airway obstruction, etc., do occur in dental clinics; among these emergencies, about 90% are mild, while 8% are severe. Objectives: In this study, the prevalence and management of medical emergencies that occurred during simple and complex exodontia were reported. Methods: Herein, a 2-year prospective cross-sectional study was conducted on patients who were referred to an oral and maxillofacial surgery clinic for dental extractions between January 2019 and December 2020. Patient data including socio-demographic information, pre-existing medical conditions, modality of tooth extraction, types of emergencies encountered, and management protocols were collected. Results: Of 3706 patients, 105 patients had medical emergencies with a prevalence rate of 2.8%. In all, 44 (41.9%) male and 61 (58.1%) female patients aged between 18 and 69 years with a mean (±SD) of 36.9 (11.7) were identified. The reported medical emergencies included vasovagal syncope (38 (36.1%)), hypoglycemia (27 (25.7%)), orthostatic hypotension (26 (24.8%)), asthmatic attacks (5 (4.8%)), hyperventilation syndrome (5 (4.8%)), and seizures (4 (3.8%)). The reported pre-existing medical conditions in these patients included Type II diabetes (DM) + hypertension (HTN) + coronary artery surgery (CAS) (4 (3.8%)), asthma (5 (4.8%)), and seizure disorders (4 (3.8%)). The majority of patients did not exhibit any medical conditions (92 (87.6%)), and most of them recovered spontaneously (47 (44.7%) patients). Conclusion: The majority of patients did not have medical conditions. Vasovagal syncope was the most common medical emergency, followed by hypoglycemia. Asthmatic attacks, hyperventilation syndrome, and seizures were the least reported medical emergencies. Cardiac emergency cases were not reported.

Keywords: Dental center, medical emergencies, oral and maxillofacial surgery, tooth extraction

How to cite this article:
Braimah RO, Ali-Alsuliman D, Taiwo AO, Alyami B, Ibikunle AA, Alwalah AS, Almunajjim HF, Alalharith AS. Medical emergencies during exodontia in a referral dental center in Saudi Arabia: A cross-sectional study. Sci Dent J 2022;6:111-7

How to cite this URL:
Braimah RO, Ali-Alsuliman D, Taiwo AO, Alyami B, Ibikunle AA, Alwalah AS, Almunajjim HF, Alalharith AS. Medical emergencies during exodontia in a referral dental center in Saudi Arabia: A cross-sectional study. Sci Dent J [serial online] 2022 [cited 2023 Mar 20];6:111-7. Available from: https://www.scidentj.com/text.asp?2022/6/3/111/361153

  Background Top

Of the mild and life-threatening medical emergencies that occur in dental clinics, ~90% are mild, while only 8% are severe.[1],[2] To reduce morbidity and mortality rates during such events, dentists must detect such cases early and must initiate primary emergency management.[3],[4] Studies reported that ~35% of patients with pre-existing medical conditions are more prone to emergency conditions during dental treatment; of this percentage, 33% of patients exhibited cardiovascular conditions.[5],[6]

The medical conditions observed during dental treatment include vasovagal attack (syncope) (43.8%), orthostatic hypotension (36.1%), asthmatic attacks (22.5%), hypoglycemia (18.9%), epileptic fits (11.6%), choking (10.1%), anaphylaxis reactions (7.9%), and angina pectoris and cardiac arrest (10.9%).[4],[7],[8] Therefore, dental practitioners must acknowledge the fact that dental patients can have a medical emergency during dental treatment. The detection of “at risk” patients and the appropriate knowledge to manage such episodes when they arise are vital in reducing morbidity and mortality.[9] Hence, medical history of patients should be updated for decreasing the risk of medical emergencies occurring during dental treatment.[9],[10]

Few studies reported the prevalence of medical emergencies in dental practice in the Kingdom of Saudi Arabia.[6] Therefore, in this study, the prevalence rate of medical emergencies that occur in an oral and maxillofacial surgery clinic in a government hospital in Najran, Southern Province of the Kingdom of Saudi Arabia would be reported.

  Materials and Methods Top

This 2-year cross-sectional study was conducted on patients who had tooth extractions at the Department of Oral and Maxillofacial Surgery in a government hospital in Najran between January 2019 and December 2020. This study was approved by the Research and Ethical Committee of the General Directorate of Health Affairs in the Najran region, and informed consent was obtained from all subjects. Pediatric patients were excluded. Patients’ socio-demographic data, modalities of tooth extraction (i.e., simple, and complex extraction requiring osteotomy), comorbid medical conditions, medical emergencies, and employed management protocols were recorded.

Statistical analysis

Statistical analyses were conducted using the Statistical Package for Social Sciences version 20 (IBM SPSS Statistics for MacOS, Version 20.0. Armonk, NY: IBM Corp.). Descriptive analyses and cross tabulations of variables were conducted. Correlation and linear regression analyses were conducted to examine the relationship between the type of tooth extraction and medical emergencies. Statistical significance was set at P < 0.05.

  Results Top

Of a total of 3706 patients that were referred for dental extractions during the study period, 105 medical emergencies were recorded, with a prevalence rate of 2.8%. In all, 44 (41.9%) males and 61 (58.1%) females in the range of 18–69 years were identified, with a mean (±SD) of 36.9 (11.7). The age group of 21–30 and 31–40 years constituted the majority (48 (45.7) and 24 (22.9)) respectively [Table 1].
Table 1: Distributions of age group, pre-existing medical conditions, and medical emergencies according to gender of patients

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The observed medical emergencies were categorized into vasovagal syncope (38 (36.1%)), hypoglycemia (27 (25.7%)), seizures (4 (3.8%)), asthmatic attacks (5 (4.8%)), orthostatic hypotension (26 (24.8%)), and hyperventilation syndrome (5 (4.8%)).

The reported medical conditions of the patients included Type II diabetes (DM) + hypertension (HTN) + coronary artery surgery (CAS) (4 (3.8%)), asthma (5 (4.8%)), and seizure disorders (4 (3.8%)). The majority of the patients did not exhibit any medical conditions (92 (87.6%)) [Table 2].
Table 2: Distribution of medical emergencies according to medical conditions of patients

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Most of the patients recovered spontaneously (47 (44.7%) patients), which was significant when identified with pre-existing medical conditions (P < 0.001). Other management protocols included oxygen supplementation (7 (6.7%)), ambulance requirement (2 (1.9%)), glucose drink (27 (25.7%)), salbutamol inhaler + oxygen (5 (4.8%)), and reclining chair (17 (16.2%)) [Table 3].
Table 3: Distribution of age-group and management of according to types of medical emergencies

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A statistically significant correlation between the modalities of tooth extraction (intra-alveolar or trans-alveolar extraction) and medical emergencies was not observed [Table 4].
Table 4: Distribution of modality of exodontia according to the medical emergencies

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  Discussion Top

Dental health practitioners must first acknowledge the fact that emergency medical situations could arise for any patient during dental procedures.[3] To prevent such adverse events in dental clinics, dental health practitioners must be able to recognize “at risk” patients, identify early signs of an adverse medical event, and swiftly initiate appropriate management.[2],[3] The General Dental Council has recommended that all dental practitioners must have a minimum of 10 hours of medical emergency and cardiopulmonary resuscitation (CPR) training every 5 years with at least 2 hours of training every year to keep dentists abreast with CPR.[11]

In this study, a medical emergency prevalence rate of 2.8% was observed in the oral and maxillofacial surgery clinic. This study could not be compared with other studies as most of them reported medical emergencies encountered by general practitioners in different dental clinics. These studies reported high prevalence rates among dentists. In the UK, a study reported a prevalence rate of 70.2%,[12] while that of 74.4% in France,[13] where dentists had experienced medical emergencies in their clinics. A local study reported a prevalence rate of 67%,[6] while another reported a prevalence rate of 74.8%,[14] where dentists had experienced at least one medical emergency in dental clinics. These wide variations between this study and previous studies are mainly related to the different study designs and sample selection. Moreover, the low prevalence rate in this study is thought to be related to the fact that the study is conducted in a specialized dental center with only specialists carrying out extractions and who have received adequate training in CPR by the Saudi Heart Association. Furthermore, all of the dental nurses and assistants were equally trained in basic life support (BLS) and CPR. In addition, our clinic was well equipped with emergency medications, first aid kit, and a central oxygen pipeline to provide first aid in case of such emergencies.

Complex extractions requiring osteotomy are expected to be associated with more emergencies because of difficulties, long operation times, and high patient anxiety associated with such procedures. On the contrary, a significant correlation between the recorded emergency and modality of tooth extraction was observed in this study. Adequate preparations with respect to psychological and physical aspects of trans-alveolar extraction, including strict instructions to eat before the procedure, were thought to prevent such emergencies. Most of the time, patients were already prepared physically, psychologically, and emotionally before trans-alveolar tooth extraction. Furthermore, all the dental procedures carried out in the oral surgery clinic were performed by specialists oral and maxillofacial surgeons experienced in dentoalveolar surgery, thereby limiting surgical trauma and time.

Previous studies[4],[6],[8],[12],[15] reported that vasovagal syncope accounts for the majority of the medical emergencies, i.e., 38 (36.1%) cases. Syncope is described as a temporary loss of consciousness caused by a drop in the volume of blood that flows to the brain.[1] Studies reported that females are most likely prone to syncope.[15] This study has validated this report as the majority of the syncope cases were observed in females.[16],[17] On the contrary, other studies reported male pre-ponderance.[18] Psychogenic factors were the major risk factors identified with syncope during dental treatment.[15] Fear of dentists and the dental environment significantly increase the risk of syncope.[15],[19] This fear worsens in the oral and maxillofacial surgery clinic due to the fear of blood.[15] This finding is in agreement with previously reported studies that psychogenic factors are responsible for the risk of developing syncope in dental clinics.[15] In a systematic review of the etiology of syncope, studies have not reported any correlation between syncope and age.[15] However, Romme et al.[17] concluded that typical clinical features of reflex syncope are more common in younger patients below 40 years and in females. On the other hand, in this study, syncope more commonly occurred in the age group of 21–40 years, which corroborated this previously reported result. Syncope is prevented by generally reducing stress in dental clinics together with minimal display of instruments. When too many instruments are displayed in front of patients, this can lead to severe anxiety that can trigger syncope. Immediate raising of the legs to increase blood flow to the brain reverses syncope. In this study, patients recovered after this maneuver, and they were discharged from the clinic with stable vital signs.

In this study, hypoglycemia was identified as the second most common medical condition after vasovagal attacks, as observed in 27 (25.7%) patients. This finding is in agreement with that reported in some previous studies;[6],[8] however, it is not in agreement with those reported in other studies that identified epilepsy and orthostatic hypotension as the second most common medical emergency in dental practice.[14],[20],[21] Hypoglycemia occurs when the blood sugar falls below 3 mmol/L, with clinical features of fatigue, sweating, and dizziness; it is commonly observed as an acute complication of diabetes, but it is also observed in non-diabetics.[2] In this study, all cases of hypoglycemia were observed in non-diabetic patients. Most of them had skipped their breakfast before coming to the dental clinic. Strict questioning about whether patients had their breakfast should be enforced as a precautionary measure. In all the cases of hypoglycemia in this study, none of the patients became unconscious but were only dizzy; therefore, they are provided a glucose drink and an oxygen face mask support. When patients become unconscious, intramuscular glucagon should be administered, and an ambulance should be called for immediately.[2]

Orthostatic hypotension was the third most common medical emergency reported. This finding is in agreement with that reported in a study conducted in the Eastern Province of the Kingdom of Saudi Arabia.[6] However, it is different from those reported in other studies in which orthostatic hypotension is identified as the most common medical episode.[14],[22] This medical emergency occurs when an individual stands up from the lying position, such as in a dental chair, and the blood is pushed into the leg vessels as a result of gravity; therefore, the flow of blood to the brain is reduced. Typically, to increase the blood pressure so as to maintain an adequate supply to the brain, a compensatory mechanism occurs via which the heart rate and vasoconstriction of abdominal and leg vessels are increased.[23],[24] In patients with orthostatic hypotension, this mechanism is delayed or does not occur; therefore, blood pressure remains low, resulting in light headedness, headaches, dizziness, nausea, weakness, angina, syncope, stoke, slurred speech and visual disturbances. All these symptom’s eventually results in patients falling down[23],[24] This event can be reduced by slowly changing from the supine position to the upright position.[24] Furthermore, a dental appointment should be scheduled early, about 40–60 min after food, and the procedure should be kept as short as possible.[23],[25] Herein, patients were asked to sit back on the dental chair with their head position lower than the leg to increase the flow of blood to the brain as reported previously.[25]

Asthmatic attacks (5 (4.8%)), hyperventilation syndrome (5 (4.8%)), and seizures (4 (3.8%)) were not common medical emergencies identified. This finding is in agreement with that reported previously in the Kingdom of Saudi Arabia.[6],[14] Moradi-Lakeh et al.[26] reported a low prevalence of asthma in the population of Saudi Arabia; therefore, it is not surprising to have low cases of asthmatic attacks in dental clinics. In all cases in this study, a salbutamol inhaler with intra-nasal oxygen supplementation was provided, and patients made full recovery and were discharged home. Hyperventilation is described as ventilation in excess of that required to maintain adequate blood oxygen and carbon-dioxide levels, which is mainly caused by acute anxiety.[27] Owing to increased ventilation, patients with hyperventilation have excess oxygen; therefore, oxygen supplementation is counterproductive in them.[27] Post-hyperventilation apnea did not develop in any of the five cases in this study; however, these patients were given referral to clinicians for further examination and investigations. Seizure disorders reported in the Kingdom of Saudi Arabia fall within the range reported worldwide.[28] Only 4 (3.8%) cases were encountered herein as most patients visiting the oral and maxillofacial surgery clinic with seizure disorders were well controlled. Adequate preventive measures included avoiding the entry of direct light of the dental chair into patients’ eyes and reducing stress as much as possible.[29] In only two cases in this study, the ambulance had to be called because the patients had seizures that lasted for more than 5 min. Nevertheless, such patients were only kept for observation in the emergency department and were discharged home the same day.

Notably, myocardial infarction, cerebrovascular accidents, and cardiac arrest did not occur in our clinic. Local and international studies also reported the least cases of cardiac emergencies in dental practice.[4],[6],[12] In this study, adequate medical history collected from our patients might have been responsible. In situations in which medical details stated by patients are ambiguous, consultation letters are sent to their physicians. In addition, all cases of medically compromised patients were given morning appointments and never seen for routine dental extractions in the afternoon. Furthermore, staff were provided adequate training in BLS and CPR. The current study is limited as it is conducted only in an oral and maxillofacial surgery clinic and in one city of Saudi Arabia. However, it is a cross-sectional study that generates baseline data for medical emergencies occurring in a dental clinic at only one dental referral center in Najran in the Kingdom of Saudi Arabia.

  Conclusion Top

The prevalence of medical emergencies in an oral and maxillofacial clinic reported in the current study (2.8%) is comparable to that reported locally and in other countries. Vasovagal attacks (syncope) (38 (36.1%)) were the most common medical emergency, followed by hypoglycemia (27 (25.7%)). Orthostatic hypotension (26 (24.8%)) was the third most common one. Asthmatic attacks (5 (4.8%)), hyperventilation syndrome (5 (4.8%)), and seizures (4 (3.8%)) were the least reported medical emergencies. Cardiac emergency cases were not encountered. The majority of the patients had no pre-existing medical conditions. Adequate collection of medical history is the panacea to preventing medical emergencies in dental clinics. Updated training and re-training in BLS and CPR are highly recommended for dentists and nursing staffs to reduce morbidity and prevent mortality when such medical emergencies arise in dental practices.



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Conflict of interest

The authors declare that there is no conflict of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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