Michelle Dawn Mooney: Hello, and welcome to the Healthfirst podcast, where clinical insight meets real-world practice to help you deliver safer, smarter patient care. I’m your host, Michelle Dawn Mooney, and today’s episode brings together two leading experts from different corners of healthcare to tackle a critical but often overlooked topic in dentistry: medical emergency readiness. Joining us is Dr. Dustin Calhoun, an emergency medicine specialist with first-hand experience managing high-stakes, life-threatening situations. Alongside him is Dr. Stanley Malamed, a renowned dentist, anesthesiologist, educator, and author of the definitive text on medical emergencies in the dental office. Together, they’ll explore how dental professionals can better identify risk, monitor patients, and respond confidently when seconds matter most. So thank you both for being here today. Great to have you.
Dr. Dustin Calhoun: Thanks for having us on.
Michelle Dawn Mooney: Before we dive into the Q&A here, I’d love to get a brief bio if you wouldn’t mind, starting with you, Dr. Malamed.
Dr. Stanley Malamed: Okay. Well, I am, as you said, a dentist anesthesiologist. Anesthesiology is the most recent recognized specialty in dentistry, going back to 2019. From New York — all my training was done in New York. Dental school, NYU. Then I went to Montefiore Hospital in the Bronx and did a dental residency, but then I did a one-year medical anesthesiology residency. Came out to USC, University of Southern California in 1973, and I’m still here.
Michelle Dawn Mooney: Dr. Calhoun.
Dr. Dustin Calhoun: So I’m an emergency physician and an EMS physician. I did medical school in Georgia and then trained in emergency medicine residency in North Carolina. Came up to where I am now in Cincinnati to do an EMS fellowship, and currently work for the University of Cincinnati. A large portion of my practice is EMS, so in a pre-hospital setting, but obviously I still work plenty of time in the emergency department.
Michelle Dawn Mooney: Great to have you share that. Thank you again for being here. And clearly, we have the right two people for this conversation. So, Dr. Malamed, you’ve spent decades educating clinicians. How common is undiagnosed hypertension among dental patients, and why does it often go unnoticed?
Dr. Stanley Malamed: Well, first of all, it’s undiagnosed amongst people, period. The numbers show between 30% and 50% of people who have high blood pressure are not diagnosed, and many of those who are diagnosed are not managing it properly. So high blood pressure, from our perspective in dentistry — and I’m sure Dr. Calhoun sees a lot of acute problems in the emergency room that are probably related to high blood pressure — it is a major problem.
Michelle Dawn Mooney: And Dr. Calhoun, from an emergency medicine perspective, what are the real risks when elevated blood pressure is missed before a procedure?
Dr. Dustin Calhoun: Well, as Dr. Malamed said, it is a leading cause. Cardiovascular disease is one of the, if not the, leading cause of death in the United States amongst adults. And high blood pressure, particularly untreated high blood pressure, is one of the most significant causes of coronary artery disease. So you’re looking at somewhere around 80 million people in the United States that have this disease. And you could see a lot of different varieties of consequences — the problem is that almost anything you can think of could potentially be tied back to it, and at times you have no symptoms at all. So you get a huge spectrum of patients, some of whom see no consequences immediately. It’s not like a lot of other things. You break a leg, you have an immediate consequence and you want to get it fixed. Whereas you go to your doctor or your dentist, you get a blood pressure check, they tell you some numbers are high and that you really should follow up. You go, “I don’t really have any symptoms from that right now, so I do nothing about it.” And then five, ten, twenty years later, you’re suffering the consequences when it’s too late.
Dr. Stanley Malamed: So back in the 1970s and ’80s, I was involved with what was called the Citizens for the Treatment of High Blood Pressure. And back then, it was called the silent killer. And exactly what Dustin just said — it’s asymptomatic until you have a stroke, until you have a myocardial infarction, a heart attack. It’s asymptomatic until then, and then it may be too late.
Michelle Dawn Mooney: So let me ask you, based on that, what specific blood pressure thresholds should prompt a dentist to delay or modify treatment?
Dr. Stanley Malamed: Well, being the dentist — number one, most dentists don’t record blood pressure. At every lecture I give, and I give a lot of CE programs, I ask, “If I went to your dental office and pulled out a chart, would I find a blood pressure reading on every chart?” And except for oral maxillofacial surgeons and dentists who are doing sedation, most general dentists do not record blood pressure. I was looking at an article this morning — it was a survey of 230-something dentists. 51% of them said they rarely or never record blood pressure. And the reasons they gave were, number one, a lack of time, which is interesting, and number two, a feeling that the patient didn’t care — which both of these things are scary.
So I ask these doctors who don’t record blood pressure: “Is there a blood pressure in your mind that if you took it, you would say to your patient, ‘I’m sorry, but you have a problem — not dental, a medical problem. Take care of it.'” And they always give me a number. They’ll say a systolic of 150 or 160. Okay. If you don’t record blood pressure on all your patients, you’ve probably treated a patient with a systolic above 200. You just didn’t know it.
And that’s what’s frightening, because people don’t like dentists. They’re afraid to go to the dentist, which elevates blood pressure. We do things that can hurt. We give injections and do surgeries. And then you throw in white coat hypertension — just having your blood pressure checked by a physician or a dentist is enough to raise it. So combine all these things together, and if you’re not recording blood pressure, we’re playing with dynamite. There has to be a number at which you, the doctor, have to become really uncomfortable and say, “I’m sorry, not today.”
Dr. Dustin Calhoun: That’s an interesting question. I think we each have a number in our head. Numbers are tricky, though. So if you look at just what’s the diagnosis of hypertension — the purpose of that question is, when should a primary care doctor start treating you to prevent a long-term consequence like heart failure, heart attack, or stroke, versus what’s a number that’s scary enough that the dentist should consider not doing a procedure? Well, the first number — a lot of people will use 140 over 90 as that typical definition for when to start treating. Whereas I think a number that’s moderately established based on common practice is about 180 over 110. If you have that and you’re in my office, we’re probably not going to do anything but the most absolutely necessary procedure on you.
Whereas when you come to me in an emergency department, that’s a whole different story. Numbers mean very little to me until they get crazy. If your blood pressure is 250 over 150, then I worry, period. But below those kinds of numbers, it’s much more about symptoms. And that’s where it gets frustrating for patients, because there are times when a provider will see those numbers and do the right thing — they got a blood pressure, which is fantastic, they alerted to the concern — but then the next step was, “We need to send you to the emergency department,” without that intervening discussion of, “Are you having symptoms from this?” In which case, off to the emergency department with you. Or, “You just have a number that is a long-term problem — if I’m your primary care doctor, I am the plan. If I’m your dentist, it’s making sure you’re moving toward a primary care doctor to make that plan.” But those are very different things.
And I think, just to add onto what Dr. Malamed was saying about the dentist — this applies to primary care doctors as well. There’s a lot of time limitation. Blood pressure has lots of technological tools, but they can be misused like anything else. One of the really common ones we see in primary care applications — and my dentist used — is wrist cuffs. The traditional upper-arm cuff works because, unless you’re doing something unusual, that arm is about the same level as your heart most of the time, which is where you’re trying to get a blood pressure. Whereas my wrist — I can easily put it in my lap, up in the air, wherever — and that can have massive differences. Because we’re talking about millimeters of mercury when we talk about blood pressure numbers. Just a few movements up and down makes a big difference.
As does what the patient was doing beforehand. If you look at how you’re supposed to take a blood pressure — seated in a relaxed, comfortable environment, feet uncrossed, hands in your lap, not talking. Versus most of the time in a dental office, we’ve got a temperature probe in the patient’s mouth, they’re afraid about the painful thing the dentist is about to do, and their legs are crossed and half elevated. All of those things mess up the blood pressure. But from a safety perspective, they mess it up in an upward direction, so at least they make it more sensitive — I’m more likely to make you look like you have hypertension, not less likely. It explains why it looks bad there, but then doesn’t when the blood pressure is taken at your primary care doctor’s office.
Dr. Stanley Malamed: So let me throw this out. We’re very unlikely to see 250/150 in a dental environment, but we are going to see numbers approaching 200, or a diastolic above 100. From my perspective as a dentist, systolic is more important to us than diastolic. Diastolic elevations tend to lead to chronic problems like heart failure. A sudden elevation of an already elevated systolic can lead to an acute problem — hemorrhagic stroke and things along that line. So yeah, they’re both important, but from dentistry’s perspective, if you hurt somebody, systolic’s going to go up a lot higher than diastolic.
Dr. Dustin Calhoun: Great point, because diastolic is a much more chronic kind of concern. Now, as you mentioned, part of the reason lots of folks do blood pressures now is that more public health aspect — you should be aware of this, we’re benefiting your health overall. So having an elevated diastolic may not preclude the procedure today, but it’s probably something we should make the patient aware of to get follow-up. The systolic is much more prone to the things we’re actually trying to avoid in an acute setting.
Michelle, I think there’s one important caveat we should draw attention to, and that’s pregnancy. Pregnancy has a lot of very specific physiology and very specific guidelines. We talk about numbers being less important than symptoms — that’s sort of our mantra in the emergency department. That isn’t always the case with pregnancy. When we see hypertension in pregnancy, the threshold is lower — we get very concerned when we see a pregnant patient with a blood pressure of 140 over 90 or above. Later in pregnancy, we start calling it things like pre-eclampsia. But even early in pregnancy, gestational hypertension is very concerning. If a practitioner finds that, it’s a patient they really should very rapidly refer to their gynecologist or obstetrician. If the patient has any symptoms at all, or if their blood pressure is starting to exceed 160 over 100 or 110, those are patients that — symptoms or not — really should be referred straight to an emergency department.
Dr. Stanley Malamed: One more thing. We have never, in 40 years at USC School of Dentistry, had a patient who said, “Why are you doing this?” Nobody has ever questioned the dentist, “Why is a dentist taking my blood pressure?” They appreciate it.
Michelle Dawn Mooney: I want to ask you this — there are a lot of variables in play. What are some of the early warning signs that dental teams should be trained to recognize that could indicate a patient is heading toward a medical emergency?
Dr. Dustin Calhoun: When we see patients in the emergency department, we’re concerned about the combination of a number and a symptom. Those really are what we refer to as red flag symptoms — things that tell me that either your brain or your heart are struggling and don’t like the pressure they’re seeing. It may be very obvious concerning stroke-like symptoms: facial droop, slurred speech, blurring of vision, one-sided weakness, tingling. Chest pain, shortness of breath. Strangely, shoulder pain and back pain can also be referred symptoms from those sorts of problems. Lightheadedness, headache — those are some of the really big ones. Some of the harder ones to figure out are things like nausea and vomiting. That can be a sign of too much pressure inside the head, but it can also unfortunately be a sign of countless other things that are less concerning and shouldn’t necessarily preclude a procedure. But those are the things we think of as red flags.
Dr. Stanley Malamed: Right. And if a patient is in my chair with any of those things you mentioned, we’re stopping. We’re going to evaluate and, in some cases, make that phone call for 911. When it comes to nausea and vomiting, as you said, it’s so vague, it could be anything. Probably they don’t like going to the dentist — that could be one of them.
Look, syncope — fainting — is absolutely the number one most common medical emergency in dentistry. In every survey that’s been done worldwide, people don’t like going to the dentist. Out comes that syringe and the patient is unconscious. But that’s not cardiovascular, right there.
Dr. Dustin Calhoun: Yeah. And syncope without associated things like seizure-like activity, bad persistent visual changes, or persistent headache is probably much less concerning. It’s more likely related to a low blood pressure, potentially.
Michelle Dawn Mooney: Dr. Malamed, you talked about taking blood pressure in the beginning and how no patient has ever complained about it, but I want to ask about the importance of continuous patient monitoring during procedures, and what tools or technologies practices should consider implementing.
Dr. Stanley Malamed: Okay, so let’s talk about the typical dentist doing restorative work — fillings — using nothing other than local anesthetic containing epinephrine, lidocaine, articaine, whatever. Pre-op vital signs: pre-operative blood pressure, heart rate, and rhythm. Respiratory rate — to my way of looking at it, it’s yes or no. We can see hyperventilation, which is a patient breathing super rapidly because they’re scared. But during the procedure, if all you’re doing is local anesthesia and restorative work, we don’t normally monitor continuously. There’s no real reason for it, assuming the patient’s vital signs are within normal limits when we start.
Now, any dentist who is doing any kind of sedation — whether it’s oral sedation, intravenous sedation, or even nitrous — we’re required to record vital signs, essentially as in the operating room, every five minutes. But for most dentists who don’t do those things — which is the majority of dentists in the United States — pre-operative vital signs would be the way to go. Because that’s going to give you a clue, in addition to reviewing a medical history, whether or not that patient is at risk for cardiovascular problems or fear-related problems in dentistry. And then you can modify your dental treatment appropriately.
Michelle Dawn Mooney: Dr. Calhoun, can you share a real-world case from the emergency department that highlights how quickly a routine situation can escalate, and what dental professionals can learn from it?
Dr. Dustin Calhoun: Absolutely. So, very generalized — I don’t want to share any private information. But we very commonly do somewhat high-stakes procedures in the emergency department, oftentimes procedures that you can’t delay based on the patient having recently eaten, or regardless of what their blood pressure or other vital signs might be prior to the procedure. So we use a lot of monitoring techniques, and there’s one aspect of monitoring we use frequently that’s probably much less used in dentistry. And I would say it is not used at all in general restorative dentistry, Dr. Malamed — correct me if I’m wrong — though I assume it’s much more common in dental surgical procedures.
What I’m referencing is end-tidal CO2. Capnography was a game changer when it became commonplace in medicine. It essentially measures the CO2 as you breathe out, so it’s a breath-to-breath metric of not only whether you’re breathing, but whether the metabolic processes in your body are functioning — whether your blood pressure is pushing enough blood to your cells to make them do what they’re supposed to be doing. End-Tidal CO2 is at this point an absolute requirement in a place like an emergency department. If you do not have it, the likelihood of you doing anything but the most absolutely emergent procedure is pretty low.
And you can watch patients change very rapidly with that tool. A patient who only moments ago was wide awake, or sedated to the level you wanted them to be, can be not breathing at all two or three breaths later. And very possibly — based on how focused you are on the procedure you’re doing, other things going on, patient body habitus, and the environment — that two or three breaths could very easily expand into a minute or two before it’s noted if you’re relying purely on blood pressure or pulse oximetry the way we historically did. Stories abound of patients having very rapid turns and providers being able to intervene almost immediately based on good monitoring techniques.
Dr. Stanley Malamed: A little bit of history, if you don’t mind. When I did my anesthesia residency in the early 1970s, we didn’t have pulse oximetry. Capnography wasn’t even a word anyone had heard of. We did blood pressure. And the comment was, “If a patient is blue — cyanotic — you’re not in trouble, you’ve been in trouble for a long time.” And then along came pulse oximetry, which gave us a reading five or ten seconds after an incident occurred, from a clip on your finger. And I think during the pandemic, almost worldwide, everybody bought a pulse oximeter.
Now, capnography, as you said, is a game changer because we breathe to get rid of CO2. Getting oxygen is good, but we want to get rid of CO2. And capnography in dentistry is not used a lot in general practice, but it is required in most provinces in Canada and states in the United States if a dentist is doing parenteral sedation — intravenous sedation, intramuscular sedation, or general anesthesia. Capnography is now the standard of care. It’s a requirement in every state and province.
It’s amazing how much the old techniques like pulse oximetry — still extremely valuable, and it tells us things that End-Tidal CO2 doesn’t tell us as clearly — but there are still providers that rely on pulse oximetry too much. A fun game to play is to put a pulse oximeter on and hold your breath. I’m not all that young anymore, and I can hold my breath for about a minute and a half before it changes at all. I can’t even imagine allowing a patient to go without breathing for a minute and a half without noticing it during a procedure. That really drives home the value of the newer technology with End-Tidal.
Michelle Dawn Mooney: We’ve established the need to be proactive here. So Dr. Malamed, I want to ask you — what practical step-by-step protocols can dental practices put in place today to improve emergency preparedness?
Dr. Stanley Malamed: Well, the whole goal here is not to have any emergencies, period. So we start out with a patient history — a piece of paper with 10, 20, 30, 40, 50 questions on it. We review the history, and then any positive response, we do what is called a dialogue history. So if the patient says, “I had a heart attack” — I have a problem with that term because “heart attack” is used for both cardiac arrest and MI, which are very different things — but if they say they had a heart attack, the dialogue history asks: When did it happen? What medications are you on? What residual effects, if any, are there? If the patient says, “Yes, I’m diabetic,” you ask: Type 1 or type 2? How well in control are you?
So number one, we have the medical history. Number two, we have vital signs. Blood pressure should be taken on every patient, every time they come in. Now, when I go to the dentist, I go mainly for hygiene appointments. Every hygienist I’ve been to in the last 30 or 40 years routinely takes a blood pressure. Hygienists are a lot better at doing this than doctors. In fact, I’ve had some unfortunate situations where a hygienist told me: “I was taking the blood pressure on a patient, and the doctor came by and said, ‘We don’t do that here.'” Really. It gets down to the doctor not caring about blood pressure. It takes too much time, and time is money.
So there are some barriers here. Going back to my informal surveys — raising your hand in a lecture of mine — how many of you on a regular basis record blood pressure on every patient? The answer is most of them don’t. The vast majority. I’m talking way under 50%, probably closer to 25%. They simply don’t do it.
Michelle Dawn Mooney: Dr. Malamed, do you think that some of it is a concern for liability? That the dentist is worried that ignorance is bliss — “If I don’t know about it, I’m not liable for dealing with it” — which obviously is not accurate, right? If it is the standard of care, just because you didn’t check it doesn’t mean you’re not liable for it. But I wonder if that’s the thought process — oh, stick your head in the sand.
Dr. Stanley Malamed: Absolutely. No, I’ve been involved, unfortunately, over the years with too many cases — I do defense work 99% of the time. I like to believe that whether it’s a physician or a dentist, they were trying to do the right thing, and stuff happens. But I’ve been involved with cases where blood pressures were way, way high and the doctor went ahead and treated anyway, and the end result was a stroke or an MI and the patient died.
You are a healthcare professional. We are dental doctors. We have an obligation: do no harm — whether it’s medical or dental. And I have a problem with my profession in that too many of the older doctors are thinking like tooth doctors. The mouth is not attached to the rest of the body? We know that is not true. And the younger doctors — the ones who graduated within the last 20 years or so — they’re more inclined to do these things because I think we turned a corner on being healthcare providers, not just tooth doctors. Everything we do can involve systemic consequences. Bacterial endocarditis is one good example. We can produce problems, and we don’t want to. We want to prevent bad things from happening if we possibly can — and in most cases, we can.
Michelle Dawn Mooney: So as we wrap up here, looking ahead, how can dentistry continue to evolve in prioritizing patient safety and integrating more medical screening into everyday practice?
Dr. Stanley Malamed: They need education, seriously. So now we go to these big dental meetings, which by the way are starting to not be there anymore because younger doctors want to sit like we’re doing right now and do a Zoom. They don’t want to go to these big dental conferences anymore. The attention spans — where I used to give lectures that were three hours in the morning and three in the afternoon — now everything is no more than three hours, if not an hour and a half. The attention span is gone. As an old fuddy-duddy, I’m complaining about this right now. But it’s hard. It’s all about education.
We have to let them know. This podcast is going to be some help, hopefully, to some people. It’s very easy for a dentist to take a new patient and put them in a chair and treat them. What we have to understand is that there are going to be some patients who shouldn’t be in that chair. And how do you find that out?
First of all, going back to: everybody lies. Patients lie. They leave things off their medical histories. One great example I had many, many years ago was a patient who had an MI about three months prior to the dental appointment. But on the medical history where it said, “Do you have whatever?” — “No.” Because the patient knew that if he told the dentist he had had a myocardial infarction three months ago, they probably wouldn’t treat him at that appointment. And he wanted the treatment done.
Okay — medical history is good. Vital signs are telling you what is happening to that person at that moment. That’s why blood pressure, heart rate, and rhythm are so very important.
Dr. Dustin Calhoun: I think it is somewhat similar to the emergency department, which surprises me. As we’ve had this discussion, I’ve sort of recognized that it’s different than a primary care doctor’s office, because there is, by definition, some responsibility in dentistry for that middle ground — the not emergent, but concerning set of numbers. And it seems to me like there are a couple of answers. One is planning, as we talked about. You have to have staff that are trained to do blood pressures properly. You have to prioritize that as an important thing. There are lots of things I find in the emergency department that are not pertinent to me as an emergency physician, but they are pertinent to the patient. As a healthcare provider, we do want to help people with those when we have the opportunity. So you’ve got to have the staff, the training, and then just have a plan for what you do with it. I think you lose a lot of that concern for liability and the unknown if you have that plan established ahead of time.
I think you break it out into: are we talking about big, scary numbers associated with big, scary red flag symptoms that lead straight to the emergency department? Do we have a number that science and common practice say I shouldn’t do the procedure today? Or do I have a number in the middle, where my responsibility is really just about ensuring the patient either currently has a primary care connection, or I can help them with that connection — even if it’s just a list of primary care doctors. Just the reference: you have high blood pressure. This kills people all over the world, particularly in our country. The answer is just having a primary care doctor. Call your insurance, ask them who they cover, and go there. Those little steps make this process a little less scary than it has to be.
Dr. Stanley Malamed: Can I ask Dustin one last question? This is what I normally tell a doctor who wants to start recording blood pressure but wants to know what to do with it. So if you’re in Iowa — how do I know when not to treat a patient? What I normally tell the doctor is: if there is a local high blood pressure clinic or a hospital that has a department that treats high blood pressure, contact them and tell them, “I am a dentist practicing in this city. I record blood pressure. Please tell me, at what blood pressure would you tell me to not treat that patient today and to refer them to you for an immediate evaluation?”
Dr. Dustin Calhoun: Yeah, I think that’s reasonable. You’ll probably get some varied answers, and just from my quick perusal of the dental literature recently, it does seem like 180 over 110 is relatively well established as a threshold for postponing procedures in the dental community. Your local health department will often have clinics, and emergency departments always have at least a referral process. And if you can build that connection — ask them, “What do you guys do with new patients who don’t have a primary care doctor when you’re trying to hook them up with one? Share that with me so I can do the same for these patients.” Emergency departments, as crowded as they are, will do what they can to help you keep your patients from winding up in the emergency department.
Michelle Dawn Mooney: And a big help for both of you to share your expertise here. We talked about how we want to avoid any medical emergency, and the best way to do that is education. So Dr. Dustin Calhoun, Dr. Stanley Malamed, thank you for taking time out of your busy schedules to be here and educate the audience. Really appreciate you both being here.
Dr. Dustin Calhoun: Thank you for having us on.
Dr. Stanley Malamed: Thank you.
Michelle Dawn Mooney: And I want to thank all of you for tuning in and listening to the Healthfirst podcast. If you enjoyed the conversation today, be sure to subscribe to hear more engaging conversations like the one you heard from Dr. Calhoun and Dr. Malamed. I’m your host, Michelle Dawn Mooney. Thanks again for joining us. We hope to connect with you on another podcast soon.
