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Abstract
Background: Only a few data exist about the occurrence of emergencies in dental practice and the training experience of dental practice teams in life support. This study evaluates the incidence of emergencies in dental practices, the attitude of dentists towards emergency management and their training experience.
Methods: Anonymous questionnaires were sent to all 2998 dentists listed in the Saxony State Dental Council Register in January 2005.
Results: 620 questionnaires were returned. 77% of the responders expressed an interest in emergency management and 84% stated that they owned an emergency bag. In the 12-month study period, 57% of the dentists reported up to 3 emergencies and 36% of the dentists reported up to 10 emergencies. Vasovagal syncope was the most frequent emergency (1238 cases). As two cardiac arrests occurred, it is estimated that one sudden cardiac arrest occurs per 638 960 patients in dental practice. 42 severe life-threatening events were reported in all 1 277 920 treated patients. 567 dentists (92%) took part in emergency training following graduation (23% participated once and 68% more than once).
Conclusion: Medical emergencies are not rare in dental practice, although most of them are not life-threatening. Improvement of competence in emergency management should include repeated participation in life support courses, standardisation of courses and offering courses designed to meet the needs of dentists.
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Effective training is widely accepted to result in a positive outcome in early life support, as documented for cardiac arrest over 30 years ago by Copley et al.1 Since then, cardiopulmonary resuscitation (CPR) training and even defibrillation by lay rescuers has become an essential part of international guidelines.2 Nevertheless, it has been shown that even physicians are not sufficiently trained in these basic skills.3
As part of the reform curriculum for undergraduate medical education4 in our institution, students in dentistry are required to take part in a mandatory 4-week emergency medicine course with their fellow medical students.5 Our department developed a 1-day course on emergency management in collaboration with the state dental board for dentists to further improve skills needed in life-threatening emergencies in private dental practice. The mean age of patients and the number of coexisting diseases is increasing, not only in hospital patients but also in dental patients. Furthermore, a significant number of dentists treat children and/or perform procedures under sedation. In previous surveys,6 7 64% and 96% of dentists claimed to have taken part in emergency training. The question of special advanced life support courses designed for the special needs of a dentist has been raised.8
During our emergency management courses for dentists, participants repeatedly stated that they had purchased expensive emergency medical equipment. For example, a special “dentist emergency bag” is available in Germany containing a high-quality laryngoscope and other equipment for advanced life support (ALS). However, an initial assessment of the participants quickly revealed large deficits in practical skills in ALS.
We have therefore evaluated dentists’ self-estimation of knowledge and skills as well as training experience in emergency medicine. In addition, the incidence and type of emergencies in dental practice and the equipment used by dentists to treat emergencies and their expenses for emergency management were assessed.
METHODS
A questionnaire was designed and sent to all 2998 dentists registered at the Dental Medical Association of the state of Saxony, Germany. Post hoc approval was received by the institutional ethics board (EK158072007). The questionnaire was anonymous which did not allow us to recontact non-responders. It contained six sections:
Demographic data regarding the dental practice. This included the area in which the practice is located (rural, town, city) and whether it is a single practice or part of a dispensary. The number of patients per quarter, the proportion of children (<8 years) and elderly patients was evaluated as well as treatment under sedation.
Attitude towards emergency management and self-estimation of skills needed in emergency management. The dentists were asked about their attitude towards emergency equipment (“equipment to treat emergencies has to be available in every dental practice”, “I am not interested in emergency management”). They were also asked whether emergency equipment should be stored but remain visible to the patients. To evaluate emergency skills the dentists were asked whether they are able to perform a given skill correctly using a 6-point Likert scale (“I am able to perform the following skill …”). The following skills were evaluated: taking blood pressure, applying oxygen via mask, bag/mask ventilation, insertion of pharyngeal tubes, establishing intravenous access, preparing infusions, preparing syringes, measuring blood glucose, pulse check, rhythm check with ECG, defibrillation, chest compressions, basic life support (BLS) algorithm, ALS algorithm.
Emergencies during the 12-month study period. The number of cases in 10 categories was evaluated: syncope, heart attack, hypertensive crisis (elevated blood pressure and symptoms), choking emergency, anaphylactic reaction, hypoglycaemia, asthma, stroke, convulsions and death. One additional field was added for emergencies which did not fit into the categories. For each emergency, the study participants were asked for the treatment which was necessary regarding the case (“I had nothing to do, patient got well without treatment”, “I treated the patient in my practice”, “the patient had to be treated by a general practitioner or even in the hospital” or “I had to call an ambulance”).
Emergency equipment available in own dental practice. The following six categories were evaluated: emergency bag, bag/mask, oxygen, blood pressure meter, infusions and ECG/defibrillator. For each category the dentists were also asked whether they own the respective equipment or whether they intend to buy it.
Expenses for emergency equipment and for emergency training. In each category participants were asked about the costs during the past 12 months, 2 and 5 years as well as their plans for the following year.
Participation in courses on emergency medicine. The dentists were asked how often they had participated in an emergency medicine course during the past 5 years and how long since the last training course. They were also questioned about the content of the emergency training course (“Was practical training of basic life support/advanced life support part of the course?”).
Statistical analysis
Statistical analysis was performed using SPSS V.12.0 for Windows (SPSS Inc, Chicago, Illinois, USA). Data regarding self-estimation of diagnostic and therapeutic competence were analysed dependent on previous training. The Kolmogorow-Smirnow test was used to test the data of the groups for Gaussian distribution. Data which were not normally distributed were tested for differences between the groups using the Kruskal-Wallis test.
RESULTS
A total of 620 questionnaires were returned, representing a response rate of 21%. Of the respondents, 71% had their own private practice, 17% shared a private practice and 12% were working in co-operative practices. Nearly half of all the practices (43%) were in small towns, one-third (34%) in larger cities and a one-fifth (23%) in rural areas. Only a few of these practices (17%) were housed in poly-clinics or medical buildings.
Most participants had long professional careers; 45% had been practising dentistry for 20–29 years, 20% for >30 years, 25% for 10–19 years and only 10% for <10 years. The number of patients treated per quarter varied considerably from <250 (3%) to >1000 (5%); the majority of participants (83%) treated 250–749 patients per quarter. One-fifth (21%) of the dentists stated that they occasionally performed sedation procedures.
Attitude towards emergency management
In general the attitude of the dentists towards emergency management can be considered positive. Most dentists were interested in emergency management but 54 of 611 dentists stated that they were not interested (50 not interested at all) in this issue (table 1). In addition, 94% supported the idea that each dental practice should be equipped with an emergency medical kit; 79% were in total agreement. Only 6% did not deem it necessary. The majority of the respondents (78%) thought that it was unnecessary to place the emergency equipment in full view of patients.
Equipment to treat emergencies
Of the dentists who responded, 84% stated that they have an emergency bag ready in their practice and only 5% do not store any equipment to treat emergencies. 88% of the dentists own a ventilation bag, 73% have basic airway equipment and 72% keep oxygen. 70% of those questioned stated that they have infusions and equipment to establish intravenous access. Only 2% of the dentists own a defibrillator.
Incidence of emergencies
The questionnaires clearly indicate that confrontations with medical emergencies in everyday dental practice are quite possible. More than half of those who answered the questionnaire (57%) reported up to three emergencies between 1 January 2004 and 31 December 2004. More than one-third (36%) dealt with up to 10 patients with medical emergencies annually in their own practices. Among these emergency cases, vasovagal syncope was the most frequent occurrence in dental practices (1238 cases per year). Cardiac arrest occurred in two cases and 42 severe life-threatening events (acute coronary syndrome, anaphylaxis, airway obstruction, and stroke) were reported (table 2).
Self-estimation of competence in treatment and diagnosis
The dentists estimated their competence to diagnose the respective emergency on a scale from 1 (“I am not able to perform skill at all”) to 6 (“I am able to perform skill correctly”). The mean value for cardiac arrest was 4.2 (dentists who had not taken part in emergency training) with a non-significant increase for dentists who had had one emergency training session (4.4) and for dentists who had had several training sessions (4.9) (fig 1). The dentists also felt quite confident in diagnosing acute coronary syndrome (3.6 no training, 3.7 one training session, 4.1 several training sessions) and anaphylaxis (3.4 no training, 3.5 one training session, 4.0 several training sessions). The scores for dentists who had no prior training and dentists who had attended one emergency management course did not differ significantly for all emergencies. However, the score was significantly higher for dentists who attended several courses than for those who had had no training in all categories except for cardiac arrest.
The item “I am able to treat the following emergencies” was rated worse than the competence in diagnosis. The values are shown in fig 2. The mean value for dentists who had never taken part in an emergency training course and for dentists who had attended one course revealed significant differences only regarding the treatment of acute asthma. However, dentists who had attended several courses had significantly better values regarding asthma, convulsions, cardiac arrest, acute coronary syndrome, hypertensive crisis, anaphylaxis and stroke.
Confidence in special skills
The self-estimation of competence regarding specific skills needed in emergencies is shown in table 3. Only about half the responding dentists believed that they are able to perform bag/mask ventilation (57%) and BLS (49%). Basic airway management was rated even worse (16%), and only a few dentists felt able to defibrillate (3%) or perform ALS (9%). The motivation to learn the skills was quite high with half the dentists expressing a desire to be trained in defibrillation (46%) and the ALS algorithm (49%) in the future.
Training
A total of 567 dentists (92%) had undergone emergency training, 146 (23%) once in their career and 421 (68%) several times. Participation in an emergency training programme occurred more than 12 months previously in 32% of the dentists and more than 24 months previously for 28% of them. Fifty-one of the responding dentists (8%) had never taken part in any emergency training; 33 had taken part in emergency training without practical exercises in BLS. The dentists stated that the following emergencies had been part of the curriculum: cardiac arrest (n = 484, 85%), acute coronary syndrome (n = 391, 69%), anaphylaxis (n = 299, 53%), asthma (n = 287, 51%), airway obstruction (n = 282, 50%), hypoglycaemia (n = 259, 46%), convulsions (n = 246, 43%), hypertensive crisis (n = 198, 35%), stroke (n = 137, 24%).
Expenses for emergency management
Two hundred and twenty dentists had spent a mean (SD) of €196 (310) on emergency equipment in the previous 12 months and 141 planned to buy equipment for €224 (335) in the following year. One hundred and thirty-two dentists spent €227 (189) on training during the study period and 313 dentists planned to spend €313 (214) in the following year. Four hundred and fifty-nine dentists had not invested in training in the previous 12 months and 469 did not plan to spend money on training in the following year.
DISCUSSION
This survey evaluates medical emergencies and emergency management in dental practices in the German state of Saxonia. Questionnaire studies are always limited as the results may be biased by under- or over-reporting. Furthermore, selective retention of facts such as the incidence of emergencies can influence the responses of participants. To minimise these effects, we aimed to construct precise questions with a small scope of interpretation such as closed questions and ordinal answering scales. We cannot assume that the data obtained by self-estimation of competence is equal to external evaluation. Nadel and colleagues9 showed that self-estimation of competence in skills needed for paediatric life support is higher than actual performance. It is therefore likely that actual skills are inferior to self-assessed evaluation.
The results clearly show that emergencies are not rare in dental practice, as nearly two-thirds of the responding dentists experienced at least one emergency during the 12-month study period. However, serious life-threatening events are much less frequent. The 620 dentists who responded to the questionnaire treated 1 277 920 patients during the study period. As two cardiac arrests occurred, we might estimate that in dental practice one sudden cardiac arrest occurs every 638 960 patients. Implementation of public access defibrillator (PAD) programmes has been recommended when the probability of use is one cardiac arrest in 5 years.10 Although the incidence is far lower in dental practice and the cost effectiveness in primary care practices has been described as poor,11 patients who are aware of the effectiveness of PAD programmes from the public press might expect standards in dental practice to be equal to those in airports and casinos.
Our data show that 84% of the responding dentists own an emergency bag. In the emergency management courses which take place in our institution, many dentists report that they even store equipment for ALS such as a laryngoscope and a broad variety of drugs. Some of them had purchased emergency bags especially designed for dentists. Unfortunately these bags rarely contain equipment which the dentist is trained to use. Furthermore, companies selling these bags do not always fill it with low-priced articles (such as a single-use bag/mask instead of a reusable bag/mask). We believe that, in addition to providing training for dentists who are not experienced with emergencies, we should also give them appropriate advice regarding equipment. Training curricula should focus on skills which improve outcome in case of an emergency such as calling for help, performing BLS, administering oxygen and basic airway management. The emergency bags stored in dental practice should not contain irrelevant equipment such as advanced airway management devices and drugs which with which dentists are unfamiliar. The money saved could be invested in an automated external defibrillator (AED)—a tool which has been proved to save lives.
The fact that only 49% of the responding dentists felt competent in BLS is alarming. A survey study by Morgan and Westmoreland12 showed that 22% of junior doctors who were members of a cardiac arrest team did not feel competent to perform cardiopulmonary resuscitation.
Self-estimation of diagnostic and therapeutic competence did not differ significantly between dentists who had undergone one emergency training session and those who had had no training except for one item. One possible explanation is that only 41% of all dentists had taken part in an emergency training session within the past 12 months. Skills in BLS, airway management and defibrillation have been shown to decline significantly within 6 months of training.13 However, dentists who had undergone more than one training session estimated their diagnostic and therapeutic competence to be significantly better in most categories, which demonstrates the importance of repetitive training.
There are different courses for emergency management for dentists in different curricula in Saxonia. In some courses dentists are instructors while in others emergency physicians serve as the teachers. The content, teaching methods and the proportion of practical training vary between different courses. For example, 15% of the dentists who had taken part in a course stated that cardiac arrest was not addressed. Furthermore, it has been shown that, even in a standardised course, the teaching differs between different instructors.14 It might be helpful to establish a standard course for dentists. The immediate life support course, which is a one-day course with practical training in BLS as well as basic airway management and defibrillation with an AED,15 would perhaps be adequate for this target audience. This course has been shown to be well accepted by participants from different professions working in primary care trusts.13
Our results show that dentists are highly motivated and interested in emergency management. Nearly half of them would like to be trained in defibrillation and even ALS. We as a provider of life support courses should fulfill participants’ requests, but we should work with them as partners and establish standardised concepts with a focus on patient outcome such as BLS and defibrillation.
The findings of this survey are limited because of the low response rate of only 21%, possibly due to the long questionnaire (6 pages). Furthermore, we cannot assume that the returned questionnaires are representative of the whole study population. However, the absolute number of returned questionnaires is higher than in previous studies on emergencies in dental practice.7 This high number of questionnaires gives us an insight into emergency management in dental practice. The long questionnaire was used to evaluate not only the incidence of emergencies but also the attitude, training experience, equipment and self-estimation of knowledge. Self-estimation of competence may be biased by social desirability.16 However, our data clearly show a lack of training experience, so it is unlikely that the competence of dentists to treat emergencies is much higher than they think.
CONCLUSION
Medical emergencies are common in dental practice, although most of them are not life-threatening. Most dentists have purchased emergency medical equipment. There is room for improvement regarding self-estimation of competence in emergency management. This should include regular participation in life support courses as well as standardisation of courses specially designed for dentists.
REFERENCES
Footnotes
Funding: This study was funded by Medtronic GmbH, Düsseldorf/ Germany and by MeetB, Potsdam/ Germany. The funding covered postage costs as well as personnel costs for data acquisition.
Funding: None declared.