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MyView: EpiPens: dental necessity or extravagance?

October 03, 2016

By Larry J. Sangrik, D.D.S.

Larry J. Sangrik, D.D.S.
As someone who has lectured nationally on medical emergency preparedness for many years, it is disheartening to see that some of our dental colleagues have become swept up in the recent EpiPen cost crisis.

An EpiPen is an auto-injection device intended for use during an acute, severe allergic reaction (i.e. anaphylaxis). It was designed for lay use by nonhealth care providers such as a parent or teacher. Additionally, it can be self-administered by an individual experiencing an episode. Sadly, various events have occurred recently which have caused the cost of these devices to explode. Reports circulated that a kit of two pens can easily exceed $500. This is tragic for families that need to stock these devices both at home and at school for their children.

While EpiPens were never intended for use in health care facilities such as dental offices, when I lecture, I am surprised at the number of dentists that report keeping them in the medical emergency armamentarium. This trend has become so pervasive that some dental boards have actually mandated dental offices keep them in stock.

While stocking epinephrine is a key component in any dentist's medical emergency kit, stocking it as an EpiPen is both unnecessary and inappropriate. Patients would be far better served if dentists stocked ampules of epinephrine; spent a few minutes to learn and practice loading a medical syringe; and learned to administer a sublingual injection using a 1 cubic centimeter tuberculin syringe.

I have two faults with the EpiPen in a dental setting.

First, the device is all or nothing. It will either deliver 0.3 or 0.15 mg depending on the adult or pediatric dose. This is fine for a layperson in an unsupervised situation facing anaphylaxis.

However, the situation is different in a dental office. First, the dentist should be responding to the medical emergency from a written emergency plan (i.e. response manual) that includes algorithms for a wide variety of medical scenarios. These algorithms should include detailed response directives, including dosages.

The dentist should find that a well-written medical emergency response manual will show epinephrine is indicated in three different situations, each requiring differing dosages.

Yes, epinephrine is indicated in 0.3 or 0.15 mg dosages for anaphylaxis. In this capacity, the EpiPen is equal (but not superior) to an equivalent dose of epinephrine delivered via a conventional syringe.

However, a lower dose of 0.1 mg would be appropriate for both children and adult patients that are experiencing an asthma attack that is refractory to conventional treatment such as multiple attempts with an albuterol inhaler.

Finally, during full cardiac arrest, Advanced Cardiac Life Support calls for the recurrent administration of 1.0 mg of epinephrine every five minutes during CPR. While most dentists are not Advanced Cardiac Life Support-compliant, it is absurd that dentists would have access to epinephrine in their office during basic life support and not utilize it.

Unfortunately, despite the cost, two adult pens and two pediatric pens is an insufficient initial dose. Clearly, ampules and syringes are not only far more affordable, but they also offer dentists far more flexibility in the use of epinephrine.

Secondly, EpiPens are an unnecessary financial burden on a dental practice.

Various risk factors within the general population predict medical emergencies during dental care will increase in frequency, diversity and intensity, in my opinion. Having lectured over much of the country for many years, it is my belief that many, if not most, dental offices need improvement in their level of medical emergency readiness. In many offices, the financial savings of epinephrine ampules versus EpiPens should be directed elsewhere.

Two areas are critically deficient. While many dentists are equipped to provide supplemental oxygen to a nonbreathing patient, a disturbingly high percentage of offices are incapable of providing supplemental oxygen to a breathing patient. Secondly, with Type 2 diabetes reaching epidemic proportions, all dental offices should maintain a glucose meter and strips for assessment of hyper and hypoglycemia.

Although less critical than the above, the typical dental office would also benefit more from maintaining a pulse oximeter on the premises than having EpiPens rather than ampules.

That fact is, if a dental office is truly prepared for a medical emergency with a thorough response manual, oxygen in various delivery systems and various emergency equipment, then the dentist is probably comfortable loading a medical syringe from an ampule or vial.

If your dental office is comprehensively prepared to address a medical emergency but money is just burning a hole in your pocket to buy an EpiPen, then do so. But do not do it because you believe it is a superior technique or you fear loading a conventional syringe. Instead donate it to a school or a family in need. Given the cost crisis, far too many people, especially children, who truly need one, are living without.

Dr. Sangrik practices in Chardon, Ohio, and lectures nationally on preparing for medical emergencies in the dental office, the science of dental fear, patient monitoring and nitrous oxide sedation.