I have the privilege of working with the dental students at the University of Toronto. One of my responsibilities is to discuss with them the management of medically compromised patients. I am often pleasantly surprised with the students’ knowledge pertaining to a myriad of medical emergencies. However, I can say that I consistently take additional time to educate on the management of an acute stroke in a dental office. Specifically, some students indicate that they would give these patients aspirin when they SHOULD NOT GIVE ASPIRIN TO A PATIENT EXPERIENCING AN ACUTE STROKE. (Please forgive the caps lock, bold, and underline…but it’s important to know!)
The path to this learning for these students can look like the following:
Q: What are the signs/symptoms of an acute stroke that a patient is likely to experience?
A: Unilateral facial drooping, weakness of the (most often upper) extremities, and slurred speech/confusion.
Q: What is happening on a molecular level that causes these signs/symptoms?
A: The brain is not getting enough oxygen.
Q: Why is the brain not getting enough oxygen?
A: A portion of the brain is not receiving its usual blood supply.
Q: What is causing the deficit of the cerebral perfusion/lack of blood to part of the brain?
A: Either a blot clot is impeding blood flow to the brain (ischemic stroke) or there was a hemorrhage of a blood vessel supplying part of the brain (hemorrhagic stroke).
Q: How do you know which of the two types of stroke (ischemic vs hemorrhagic) is happening to a patient who is sitting in your dental office?
A: You cannot determine what type of acute stroke a patient is experiencing in your dental office! The patient requires advanced imaging of the brain to determine which type of stroke is causing these signs/symptoms.
Important information: Clinicians have tried again and again to develop chairside clinical scoring systems to differentiate the type of stroke without using advanced imaging (e.g. Greek score vs. Allen Score vs. Siriraj Stroke Score vs. Guys Hospital score). At this time, clinical stroke scores are not accurate enough for use in a resource-poor clinical setting1 such as a dental office. The brain must be imaged to determine the type of stroke for the corresponding treatment that will ensue.
Appropriate management of acute stroke in the dental office includes the following steps:
- Activate the emergency medical system (these patients need advanced assessment as soon as possible).
- Check circulation, airway, and breathing (C-A-B); action as necessary.
- Consider administering oxygen only (and no other drugs/medications).
- Continually monitor the patient (C-A-B) until paramedics arrive. NOTE: Blood glucose should be assessed during this monitoring via a chairside glucometer reading as hypoglycemia can mimic signs of stroke.
Takeaway: DO NOT GIVE ASPIRIN (or any other medications other than perhaps oxygen) TO A PATIENT EXPERIENCING AN ACUTE STROKE.
References
- Mwita CC, Kajia D, Gwer S, Etyang A, Newton CR. Accuracy of clinical stroke scores for distinguishing stroke subtypes in resource poor settings: A systematic review of diagnostic test accuracy. J Neurosci Rural Pract. 2014;5(4):330-339. doi:10.4103/0976-3147.139966
About the Author
Dr. Derek Decloux completed his DMD at the University of British Columbia, his MSc in Dental Anesthesia at the University of Toronto, and he is completing a MSc in Pharmacology and Toxicology at Michigan State University. He served as a Canadian Armed Forces dental officer and continues to serve as a reservist dental officer. He practices dental anesthesia in offices in Southern Ontario, is a staff dentist anesthesiologist at Toronto’s Mount Sinai Hospital’s Department of Dentistry, and is a clinical dental anesthesia instructor at the University of Toronto’s Faculty of Dentistry.
