Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2018; 63: 455–466

doi: 10.1111/adj.12649

Medical emergencies in dental practice – management

requirements and international practitioner proficiency. A
scoping review
M Vaughan,* A Park,* A Sholapurkar,* A Esterman†‡
*Faculty of Dentistry, College of Medicine and Dentistry, James Cook University, Smithfield, Queensland, Australia.
†School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia.
‡Australian Institute of Tropical Health and Medicine, James Cook University, Smithfield, Queensland, Australia.

ABSTRACT
The management of medical emergencies is widely considered a requisite skill for all dentists. Timely intervention of an
emergency can significantly alter the outcome for a patient’s morbidity and possible mortality. This scoping review
examines the prevalence of medical emergencies in dental practice, as well as dentists’ attitude, confidence, and compe-
tence, of medical emergency management within a dental setting. Key findings include a lack of preparedness towards
medical emergencies, despite a universal recognition of the importance and desire to improve key medical skills.
Keywords: Attitude, competence, confidence, dentist, emergencies, medical management.
Abbreviations and acronyms: ALS = Advanced Life Support; BDS = Bachelor of Dental Surgery; BLS = Basic Life Support; CPR = Car-
diopulmonary Resuscitation; U/Grad = Undergraduate.
(Accepted for publication 27 August 2018.)

decades there has been a significant increase in the fre-

INTRODUCTION
Although medical emergencies do not occur com-
monly in dental practice, their incidence is not
insignificant and dental practitioners are expected to
be adept in their initial management.1 When presented
with an emergency, it is not uncommon for a first
responder to be affected by panic or indecision, poten-
tially delaying the response time for critical care, and
thereby resulting in increased morbidity or mortality
for the patient.2 Should such a situation arise in their
clinic, dental practitioners and their teams need to be
confident and up to date with their medical emergency
management skills in order to provide quality initial
treatment of an emergency. Australia, like many other
developed countries, is facing an ageing population.3
With this comes the suggestion that medical emergen-
cies are increasing4 due to both an associated increase
in comorbidities such as hypertension, diabetes, or
heart disease,5–8 as well as an increase in the number
of dentate elderly patients requiring more dental treat-
ment than in years past.9,10 Furthermore, over past
[Correction added on 31 October 2018, after first online publi-
cation: ‘A Sholapurkar’ has been added in the author list.]
© 2018 Australian Dental Association
quency with which members of the public visit the
dentist.5
Despite the formal incorporation of emergency
medical training into undergraduate dental curricula
within the United States nearly 40 years ago,11 den-
tists worldwide still demonstrate an adequate to poor
ability to manage many types of medical emergen-
cies.6,12 In recent years, there has been a dramatic
shift in the method of teaching medical emergency
management to undergraduate students in many
developed countries, in an attempt to improve their
management outcomes.5,13–15 This has seen courses
move away from both didactic only instruction and
inappropriate methods of drug delivery or equipment
usage,4 and incorporate regular simulation train-
ing14,15 or flipped classroom approaches13 into the
delivery of education. However, developing countries
do not appear to have followed this trend, with one
Indian study commenting that many domestic institu-
tions fail to routinely implement emergency manage-
ment training.16 Although dental curricula varies
around the world, a common theme recognized is that
despite geographical differences, practitioners from
multiple countries have expressed a desire to improve
their specific emergency management skill set.12,17
455

M Vaughan et al.
In Australia, the Australian Dental Board do not
currently require Australian dental practitioners to
adhere to medical emergency guidelines, nor undergo
mandatory medical emergency training,18 contrasting
to other developed countries.19,20 Research examining
the incidence of medical emergencies at dental prac-
tices in Australia is lacking, however, a study from
the late 1990s suggested that although medical emer-
gencies can occur as infrequently as once every forty
practice-years, approximately one-in-seven dentists
would be required to resuscitate a patient throughout
their career.21
All Australian schools of dentistry currently require
their students to be certified in first aid and basic life
support prior to treating patients. However, limited
research exists as to Australian students’ knowledge
and proficiency, confidence and attitudes, towards the
topic.13
Notably, to our knowledge, no systematic reviews on
medical emergencies in dental practice have ever been
performed despite significant variation in reported out-
comes. A review of the literature is therefore indicated
to qualify the current published evidence.
Given there is a potentially increasing incidence of
medical emergency, and little research to support the
overall improvement of medical emergency manage-
ment in a dental setting, the aim of this research is to
review what is known about a dentists’ confidence,
knowledge and application and attitudes, towards
medical emergency management in the dental setting.
METHODS
The literature related to this topic is likely to be
diverse, especially with respect to study designs. A sys-
tematic review was therefore unlikely to be suitable,
and a scoping review of the literature was determined
to be the best approach. Notably, a scoping review is
still undertaken in a systematic and rigorous manner,
but is much more appropriately tailored to this
research topic. The protocol was developed using the
scoping review methodological framework proposed
by the Joanna Briggs Institute,22 and was registered at
the web-based Open Science Framework database
prior to undertaking the review. The protocol is avail-
able upon request from the corresponding author. The
scoping review follows five stages: (1) identifying the
research question; (2) identify studies; (3) study selec-
tion; (4) charting the data5; summarising the results.
Stage 1 – identifying the research question
What are dentists’ confidence, knowledge and applica-
tion and attitudes, towards medical emergency man-
agement in a dental setting, and the relevance of the
findings to an Australian setting?
456
18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Stage 2 – identify studies
A three-step search strategy was implemented, starting
with a limited search of OVID, Cumulative Index to
Nursing and Allied Health Literature (CINAHL),
SCOPUS, and MEDLINE (Pubmed) over the course
of January 2018. Following this initial search, an
analysis of key words within titles of relevant papers
was performed in conjunction with an expert librarian
attached to the university. Subsequently, in addition
to relevant key words, a comprehensive search was
performed using the Medical Subject Headings
(MESH) terms Dentists, Emergencies, Attitude of
Health Personnel and Emergency Medical Services.
All identified reports were then analysed for further
relevant papers within their reference list, and study
authors were contacted for further information where
relevant. All articles identified for possible inclusion
were obtained. See Appendix 1 for an attached full
search strategy for CINAHL.
Stage 3 – study selection
The inclusion criteria were papers: (a) in the English
language; (b) published in a peer-reviewed journal; (c)
published since 2012, following the publication of the
latest version of the Australian Therapeutic Guidelines
Oral and Dental; (d) had the full-text available for
review or purchase; and (e) examined student or grad-
uate dentists’ real or perceived proficiency of manage-
ment in a medical emergency; or (f) examined
prevalence, frequency, or outcomes of medical emer-
gencies in a dental setting. The definition of a medical
emergency was that defined by the Australian Thera-
peutic Guidelines Oral and Dental Version 2.23 All
published literature was eligible, including study
designs utilising quantitative or qualitative methods,
case reports, editorials, or expert commentary. No
grey literature was examined, nor geographical restric-
tions placed upon the search criteria.
Search results were imported into a shared EndNote
X8â library, where all articles were duplicated into
two identical sets to facilitate independent review. A
second reviewer was then used for assessing one of
these sets to select citations for inclusion. If consensus
between the two sets of articles was achieved, the
selected articles progressed to assessment of abstract
via the same method. Assessment of full-text articles
was then undertaken by the same two reviewers. If
there were disagreements between the reviewers, the
paper in question was discussed until a consensus was
achieved.
Stage 4 – charting the data
Charting of the data refers to summarising each
included study in a table. A draft checklist was
© 2018 Australian Dental Association

developed at the protocol stage to record all key
information, which was then further refined
throughout the process of full-text assessment, to
capture all relevant results. The additional reviewer
was again utilised to extract data from five papers
for comparison with the initial reviewer. The same
checklist was used by the additional reviewer and
perceived relevant results were extracted. This was
performed to ensure consistency of data extraction
throughout the review process. If an initial and
absolute consensus was not reached between the
reviewer and the author, then the data in question
was discussed, and the process repeated on alternate
papers, until such time the data extraction was
deemed to be uniform.
Notably, no formal appraisal of methodological qual-
ity was performed, as is consistent with the guidance on
scoping reviews.22 However, a narrative appraisal is
provided in the Comments column in Table 1.
Stage 5 – summarising the results
The included studies were summarised by themes and
conclusions drawn.
RESULTS
The literature search resulted in 126 full titles (Fig. 1).
After duplicates were removed, 112 titles remained, of
which 68 were excluded for not being related to a
dentists’ perception or ability regarding the manage-
ment of a medical emergency, their attitude regarding
training towards the same, or the incidence of medical
emergencies. The remaining 44 papers had their
abstracts screened, resulting in 25 papers included for
full-text assessment. Screening of full-texts resulted in
the exclusion of only one paper, due to a lack details
on research subjects, culminating in 24 articles for
final inclusion. No additional papers were identified
in reference scanning which were not captured by the
literature search. Notably, no current Australian stud-
ies were found.
Table 1 provides a chart of the results. Two thirds
of the studies (16/24) were from Asia, with 9/24
involving 101–200 participants.
PREVALENCE AND INCIDENCE OF MEDICAL
EMERGENCIES IN THE DENTAL SETTING
11 papers asked respondents’ to detail some aspect of
prevalence or frequency which related to the occur-
rence of a medical emergency.9,14,17,24–31 Of these 11
studies, three appeared to have been well con-
ducted,9,14,25 two to have some strength in their find-
ings,26,28 and six to have questionable
evidence.17,24,27,29–31 As such, only papers with a
© 2018 Australian Dental Association
18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Dentist, emergencies, medical management
methodology deemed adequately robust are summa-
rized below.
This review found that more than half of all dental
practitioners will be required to perform some form
of medical emergency management throughout their
career, with 43.6%,25 68.7%,28 and 75%14 of den-
tists reporting experiences in which they have pro-
vided emergency care to a patient.
Regarding the prevalence of diagnosable medical
emergencies, syncope was demonstrated to be the most
common, representing 34.3%25 and 83.6%28 of all
emergencies attended by a practitioner. Following syn-
cope, the most common diagnosed conditions were
reported to be epileptic episodes, representing 16.1%
of practitioners’ experiences of emergency care,25 and
hypoglycaemia, experienced by 8.4% of dentists.25
Notably, many practitioners faced medical emergencies
in which they were unable to diagnose a condition,
representing 9.3%25 and 20.5%28 of all emergencies
examined.
Relative consensus within these studies showed
approximately 10%–16% of dentists have been
required to provide urgent care for a serious cardiac
event,9,26,28 typically involving either direct patient
resuscitation or the calling of an ambulance for criti-
cal patient transport to a hospital.9,26 Only Marks
et al. reported a diminutive cardiac arrest rate of
0.8% in their study of Belgian dentists.25 Addition-
ally, 77% of the respondents out of the United States
have been faced with a patient exhibiting at least one
sign of a cardiac emergency,9 with demonstrably
higher rates of unresponsive patients in recent years
than have been seen in the past.9
CONFIDENCE OF MEDICAL EMERGENCY
MANAGEMENT
Ten papers examined respondents’ confidence in fac-
tors surrounding medical emergency manage-
ment.14,24–28,30–33 Of these, two studies were
conducted well,14,25 two had some strength to their
findings,26,28 and six provided questionable evidence.
As such, only papers with a methodology deemed ade-
quately robust are summarised below.
Not surprisingly, the results show that a dentist’s con-
fidence in medical emergency management is directly
proportional to the amount of training they have had in
emergency management,25,28 with simulation training
providing more confidence than didactic learning.14
However, exceptions were noted across different stud-
ies, with training not shown to be proportional to a con-
fidence in diagnosing hypertension,25 diagnosing and
treating syncope,28 or diagnosing of angina.28
Of the four reasonably undertaken studies, only one
examined practitioner confidence in drug administra-
tion in an emergency situation. Cukovic-Bagic et al.28
457
 18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
M Vaughan et al.

Table 1. Chart of included papers

Author, year, Research design Sample Dependent variable Key findings Comment on study
country of origin size

Ahamed & Cross-sectional 100 Self-perceived aptitude in 80% of respondents were Study poorly
Kumar, 2016, BLS by final year U/Grad confident in the autonomous
India students and interns treatment of most medical
emergencies
40% of respondents confident in
providing treatment of all
emergencies
80%–90% of students had
knowledge about airway
obstruction, CPR, anaphylaxis
medications, anginal pain, and
epilepsy management
Al-Shamiri et al., Cross-sectional 212 Knowledge of BLS in U/ >50% of respondents correctly Study has moderate
2017, Saudi Grad dental students and answered <50% questions
Arabia interns Overall inadequate knowledge
on BLS
Albelaihi et al., Cross-sectional 153 Self-perceived aptitude in 37% of respondents were Study poorly
2017, Saudi U/Grad students and confident in their management
Arabia interns of any potential medical
emergency
40% of respondents believed
antihistamines are primary drug
of choice in anaphylaxis
71% knew correct chest location
for CPR
Alhamad et al., Cross-sectional 145 Frequency of medical 1/3 of dentists were not confident Study poorly
2018, Saudi emergencies encountered using drugs or medical
Arabia by graduate dentists emergency equipment
44.8% of dentists confident with
providing CPR
Alotaibi et al., Cross-sectional 464 Knowledge of CPR in U/ 93.6% of respondents agreed BLS Study has moderate
2016, Saudi Grad students and dental should be in curriculum
Arabia faculty staff Some students reported lack of
BLS knowledge due to lack of
interest, or an incomprehension
of the need for BLS
1/3 of respondents were
concerned about performing
CPR on a stranger out of fear of
causing harm
>50% participants able to
identify correct compression:
breath ratio, rate and depth of
compression
Higher knowledge of CPR
equated with higher confidence
in performance
Baduni et al., Cross-sectional 104 Knowledge of BLS in 48% of respondents knew Study poorly
2014, India undergraduate students compression rate for CPR
and graduate dentists 36% knew compression:breath
ratio for CPR
Highest score achieved by
dentists 1–5 years out, lowest
score by students
undertaken. No details
given on basis of
questions, nor
randomization. No
validity or reliability
testing. Study
limitations not
addressed.
strength.
Utilised previously
used, validated,
questionnaire. Pilot
tested, response rate
of 81%. No reliability
testing, some study
limitations addressed.
undertaken. No details
given on basis of
questions. No validity
or reliability testing.
Response rate of 57%,
study limitations not
addressed.
undertaken. Questions
based on faculty staff
opinion. No validity
or reliability testing.
Response rate of 73%,
study limitations not
addressed.
strength. Utilised
previously used,
validated
questionnaire. No
validity or reliability
testing. Response rate
of 78%, study
limitations addressed.
undertaken. No details
on basis of questions.
No validity or
reliability testing.
Sampling bias evident,
no response rate
disclosed. Study
limitations not
addressed.

(continued)

458 © 2018 Australian Dental Association

 18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Dentist, emergencies, medical management

Table 1 continued
Author, year, Research design Sample Dependent variable Key findings Comment on study
country of origin size

Bell et al., 2014, Cross-sectional 69 Confidence of final-year >95% of students were confident Study poorly
England BDS students in the in the management of most undertaken. No details
handling of a medical medical emergencies Over 80% on basis of questions.
emergency. confident in the administration No reliability testing,
of emergency drugs validity testing
20% couldn’t use a pocket mask inadequate. Response
and oxygen port rate of 78%, some
Mental health was area of study limitations
greatest concern, with the fewest addressed.
number of respondents able to
assess
Breuer et al., Cross-sectional 30 Aptitude of BLS 93% of respondents incorrectly Good study. Details
2016, Germany procedural performance utilised oxygen 46% performed given on basis and
in U/Grad students incorrect CPR validity of simulation
47% did not use an AED in BLS testing. Study
procedure limitations addressed.
Cukovic-Bagic Cross-sectional 498 Attitudes and confidence 52% of respondents were not Study has moderate
et al., 2017, held by graduate dentists’ confident with adrenaline usage strength. Utilised
Croatia towards medical 43% were not confident with previously used,
emergencies in paediatric oxygen usage validated, and reliable
patients 45%–65% did not feel confident questionnaire, on a
with some aspect of commonly comparative
faced emergencies population. Although
38.8% of respondents believe the authors had a
BLS training is needed once- stated aim of
yearly measuring the dentists’
33.5% believe it is needed once knowledge, no results
every 2 years for this topic were
reported. Response
rate of 95%. Study
limitations not
addressed.
Ehigiator et al., Cross-sectional 124 Education Status of U/ 8% of respondents felt inclusion Study poorly
2014, Nigeria Grad dental students of medical emergency undertaken. No details
management training was not given on basis of
necessary questions. No validity
41.9% report not receiving any or reliability testing.
sort of medical emergency No response rate
training given. Study
limitations not
addressed.
Elanchezhiyan Cross-sectional 182 Attitudes held by interns 96% of interns believed BLS Study poorly
et al. 2013, towards medical training should be mandatory undertaken. No details
India emergency management 37% of respondents were not given on basis of
training, and knowledge confident in the management of questions. No validity
of BLS and associative an unconscious patient or reliability testing.
drugs 56% of interns have trained in Response rate of 97%.
BLS, but their quality of medical Study limitations not
emergency management and addressed.
knowledge is very poor
Jamalpour et al., Cross-sectional 80 Knowledge of CPR in 35% of respondents scored 0% Study poorly
2015, Iran graduate dentists on written assessment of medical undertaken. No details
determined via simulation emergencies, whilst only 6% given on basis of
and theoretical exam scored 100% questions. No validity
3.75% of practitioners were able or reliability testing.
to perform CPR correctly Sampling bias evident.
16% of practitioners performed Response rate of 89%.
no correct actions in CPR Study limitations not
administration addressed.

(continued)

© 2018 Australian Dental Association 459

 18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
M Vaughan et al.

Table 1 continued
Author, year, Research design Sample Dependent variable Key findings Comment on study
country of origin size

Khami et al., Cross-sectional 177 Graduate dentists <60% of respondents were Good study. Details
2014, Iran knowledge of medical knowledgeable about given on basis of
emergencies and BLS hypoglycaemia characteristics, survey. Survey valid
chest pains of cardiac origin, and reliable.
and correct CPR Respondent sample
<33% could diagnose adrenal population criteria
crisis or hyperventilation well defined. Response
rate of 84%. Study
limitations not
addressed.
Kishimoto et al., Cross-sectional 50 Aptitude of ‘dental 100% of respondents agreed Good study. No details
2017, Japan provider’ management on training useful for future clinical on basis of training
simulated syncope and work course. Subject matter
anaphylaxis following 86% of respondents preferred to experts involved in
implementation of learn via simulation over training delivery.
training didactic Respondent sample
Diagnosis and treatment skills population criteria
for anaphylaxis and syncope well defined. Response
dramatically increased following rate of 98%. Study
training programme limitations addressed.
implementation
Marks et al., Cross-sectional 548 Self-perception of dentists’ Confidence in handling medical Good study. No details
2013, Belgium medical emergency emergencies increased with given on respondent
management further medical emergency sampling criteria.
competencies. management training, with the Survey valid and
exception of diagnosing reliable. Pilot testing
hypertension performed. No
response rate given,
but sample
represented 7% of all
registered dentists in
the country. Study
limitations addressed.
Narayan et al., Cross sectional 201 Attitudes and Knowledge Interns Attitudes – 67.6% Study poorly
2015, India of interns and ‘positive’ and 32.4% ‘negative’ undertaken. No details
postgraduate students Postgraduate Attitudes – 52% given on basis of
towards medical positive, 48% negative questions. No validity
emergency management Interns knowledge - 17.6% or reliability testing.
training poor, 62.7% average, 19.6% No definitions given
Postgraduate knowledge - 13% for key terms. No
poor, 75% average, 12% good response rate given.
No significant difference Study limitations not
between interns and p/grad addressed.
Cumulatively, 68.8% had
average knowledge
Nogami et al., Cross-sectional 35 Correlation between time- Time elapsed since training was Study has moderate
2016, Japan elapsed since BLS training not correlated with skill quality strength. Details given
and aptitude of CPR in CPR skills deteriorate rapidly, on basis of aptitude
graduate dentists but no clear critical time interval measurements, and
Two years is possibly too long outcomes were
between refresher training objectively measured.
No participation rate
given. Some study
limitations addressed.
Pieran et al., Cross-Sectional 823 Attitudes of dentists and 16% of respondents had a patient Good study. Details
2013, USA hygienists towards undergo a cardiac event given on basis of
automated external 77% of respondents had a survey. Sampling
defibrillator usage patient exhibiting symptoms of method, sampling size,
cardiac event randomization method
12% of respondents had clearly defined. Valid
performed CPR outside of clinic and reliable survey.
Response rate of 24%.
Study limitations
comprehensively
addressed.

(continued)

460 © 2018 Australian Dental Association

 18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Dentist, emergencies, medical management

Table 1 continued
Author, year, Research design Sample Dependent variable Key findings Comment on study
country of origin size

Roy et al., 2017, Cross-sectional 84 Aptitude of U/Grad After examination, students in
France students following
medical emergency
simulation training
Sangamesh Cross-sectional 192 Attitudes held by U/Grad Students felt BLS inclusion in
et al., 2018, students towards medical
India emergency management
training
Singh et al., Cross-sectional 147 U/Grad and P/Grad dental 90% of respondents agreed
2018, India students self-perceived
knowledge, attitudes, and
competence towards
medical emergency
management
Somaraj et al., Cross-sectional 183 Aptitude of BLS skills 100% of respondents believe BLS
2017, India relative to anxiety in
dental interns
Stafuzza et al., Cross-sectional 100 Attitudes held by graduate 100% of participants showed
2013, Brazil dentists’ towards post-
graduate medical
emergency training, and
their knowledge of BLS
Good study. Details
simulation group rated their given on basis of
ability to manage medical simulation testing,
emergency significantly higher outcome
than control group measurement, and
95% of respondents valued evaluation
simulation training and standardization. Some
recommended for all future sampling bias present,
students study limitations
Significant improvement comprehensively
measured in group with addressed.
simulation training compared to
control
Study poorly
curriculum is important undertaken. No details
given on basis of
questions. No validity
or reliability testing.
No response rate
given. Study
limitations not
addressed.
Study poorly
dentists should be well-versed undertaken. No details
with knowledge of handling given on basis of
medical emergencies questions. No validity
>96% of all respondents believe or reliability testing.
every clinic should have a full Some sampling bias
suite of emergency equipment present. No response
73% of interns, and 79% of rate given. Study
postgraduate students felt they limitations not
had inadequate training in addressed.
medical emergency management
91% of interns and 88% of
postgraduate students felt they
could ‘diagnose a medical
emergency’
Study poorly
should be part of U/Grad undertaken. Details
curriculum, however 81% given on basis of
believe BLS should not be questions. No validity
performed in private practice, in or reliability testing.
lieu of hospital-only No definitions given
90% had a ‘positive attitude’ for key terms. No
40% had below average response rate given.
knowledge of BLS procedures Study limitations not
addressed.
Study poorly
interest in attending post- undertaken. No details
graduate BLS courses given on basis of
49% of respondents were questions. No validity
satisfied with previous post- or reliability testing.
graduate medical emergency Response rate of 79%.
training, whilst 42% were Study limitations not
dissatisfied addressed.
87% of respondents trained in
BLS, but only 43% felt
themselves capable in
performing BLS
28% knew how to use
emergency equipment
66% knew how to diagnose
medical urgency/emergency
67% knew how to perform CPR

(continued)

© 2018 Australian Dental Association 461

 18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
M Vaughan et al.

Table 1 continued
Author, year, Research design Sample Dependent variable Key findings Comment on study
country of origin size

Tanzawa et al., Cross-sectional 98 Aptitude of U/Grad 78% of respondents valued the Study has moderate
2013, Japan students during robotic simulation training strength. No details
simulation of medical 32% of respondents could not given on basis of
emergency take radial pulse simulation testing or
78% of respondents could not outcome
correctly use pulse oximeter measurement. Details
given on
standardization of
evaluation.
Respondent sample
population criteria
defined. Participation
rate of 100%.
Limitations of study
not addressed.

Fig. 1 Study flow.

reported that approximately 50% of Croatian dentists
were not confident in the usage of adrenaline or oxy-
gen in a paediatric scope of medical emergencies.28
No study examined overall practitioner confidence
in adult medical emergency management. Cukovic-
Bagic et al. examined dentists’ confidence for a paedi-
atric medical emergency, and found that only 35%–
55% of respondents felt confident with managing all
aspects of ‘common’ medical emergencies.28
Only one paper examined student confidence in
medical emergency management, and reported
approximately one-third of Saudi Arabian dental
462
students were concerned about performing CPR on a
stranger due to fear of causing additional harm.26 Stu-
dents with a higher knowledge of CPR had more con-
fidence in its implementation.26
KNOWLEDGE OF MEDICAL EMERGENCY
MANAGEMENT PROCEDURES
17 papers examined respondents’ knowledge or profi-
ciency in medical emergency management procedures.
Of these 17 studies, four appear to have been well
conducted, four to have some strength in their
© 2018 Australian Dental Association

findings, and nine to have questionable evidence. Only
the eight reasonably well-conducted papers are sum-
marized below.
Studies of German dentistry students in a simulated
environment found that 93% of respondents could
not correctly use oxygen, 46% could not correctly
perform CPR, and 47% did not use an Automated
External Defibrillator (AED) in a situation when it
was indicated.34 This poor knowledge and practice
was mirrored by senior dentistry students in Saudi
Arabia, where more than half of respondents correctly
answered less than half of the questions on a theoreti-
cal examination of Basic Life Support (BLS) and asso-
ciated procedures, despite more than half being able
to correctly identify technical considerations of Car-
diopulmonary Resuscitation (CPR).35 Furthermore,
less than one-third of students from another Saudi
Arabian university were able to identify the correct
way to manage a choking adult.26
Studies of dentistry students in Japan found that
approximately one-third of respondents could not cor-
rectly take a radial pulse, nor could 22% of respon-
dents correctly use a pulse oximeter. As little as 8%
of students could correctly diagnose adrenaline hyper-
sensitivity.15
In studies of Iranian general dentists, <60% of
respondents were adequately knowledgeable about
characteristics of hypoglycaemia, chest pains of a car-
diac origin and the correct method of CPR.36 Addi-
tionally, less than one-third could correctly diagnose
adrenal crisis or hyperventilation.36
Simulation training dramatically increased practi-
tioners’ knowledge and procedural proficiency in med-
ical emergency management. Studies in this review
examined both specific procedural proficiency, such as
anaphylaxis or syncope,37 and BLS procedures in gen-
eral.14 A dramatic increase in practitioner proficiency
was reported following the implementation of a simu-
lation training programme.
Interestingly, one study examined the relationship
between the time since BLS course completion and dete-
rioration of emergency management skills, the results of
which demonstrated that elapsed time was not corre-
lated with skill quality.38 Contrastingly, they went on to
report that emergency management skills deteriorated
rapidly following training, however, no critical time
interval was stated before a practitioner returned to a
base level of proficiency. Subsequently, it was suggested
dentists consider undertaking a periodic refreshing of
emergency skills more frequently than every 2 years.38
ATTITUDES TOWARDS MEDICAL EMERGENCY
MANAGEMENT TRAINING
Here, 12 studies examined respondents’ attitudes
towards medical emergency management training. Of
© 2018 Australian Dental Association
18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Dentist, emergencies, medical management
these 12 papers, two were well-designed and under-
taken studies, three were reasonably undertaken, and
seven reported questionable evidence. As such, only
papers with a methodology deemed adequately robust
will be reported on.
Regarding the addition of BLS training in an under-
graduate curriculum, 93.6% of BDS students agreed
that formal BLS training should be a compulsory
component of their studies.26 Cited reasons for unfa-
vourable responses towards BLS training included a
lack of interest, a belief that medical emergencies are
not commonly encountered in dental practice, or an
incomprehension of the need for BLS services.
Studies examining the incorporation of simulation
training into medical emergency training showed both
dentists and students alike felt the addition to be
highly valuable. Kishimoto et al. reported 100% of
respondents to believe simulation training useful in
future clinical work, and 86% subsequently preferred
to learn via simulation over traditional didactic learn-
ing methods.37 This feeling of value is consistent with
other studies in this review, with 78-95% of students
reporting the same,14,15 and recommending simulation
training for all future students.14
Only one study examined respondents’ attitudes
towards the frequency of medical emergency training,
finding 72.3% of dentists believe BLS refreshing train-
ing should occur at least once every 2 years.28
DISCUSSION
Across the included studies, few examined factors sur-
rounding medical emergencies with significant rigour,
thereby warranting further exploration. Those studies
which reported higher quality evidence generally
found a significant portion of dentists or dental stu-
dents wanting, or needing more training in factors
surrounding medical emergencies.
Prevalence
Recent literature suggests that the frequency of medi-
cal emergencies in the dental surgery is increasing.4
Possible reasons may be an older population with an
increase in chronic medical conditions,10 increased
usage of long-term medication, a trend towards longer
dental appointments, or an increased use of drugs in
clinical dentistry.17
Previously, research has shown that UK dentists
may see one medical emergency every 3.6–4.5 years,39
two medical emergencies for every 10 000 patients
treated under local anaesthesia,12 or 0.7 emergencies
per dentist per year.40 Few prevalence studies have
been published in recent years, however, data exists
suggesting a higher occurrence, with 57% of dentists
facing up to three or more emergencies per year.41
463
 18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
M Vaughan et al.

Prevalence studies are often subject to the limitations Knowledge/proficiency of emergency management
of recall and sampling bias, and their findings should
With previously discussed evidence suggesting a possi-
be considered with appropriate discretion. Retrospec-
bly increasing frequency of overall medical emergen-
tive studies of documented medical emergencies report
cies, and a stable frequency of severe medical
the incidence of such emergencies to be lower than
emergencies, dentists’ knowledge and proficiency of
reported elsewhere in the literature.10 It appears likely
medical emergency management are arguably at a
that the majority of dental practitioners will be
greater need than ever in the past. Therefore, it is
required to perform some form of medical emergency
worrying that significant gaps in proficiency and edu-
management throughout their career.
cation for both dentists and dental students alike were
Overall, our review found that simple emergencies
recognized in studies across multiple developed coun-
such as syncope remain the most commonly encoun-
tries.
tered. Furthermore, reviewed evidence suggests the
Oxygen administration is a vital process in basic life
incidence of severe medical emergencies, including
support, and given its relative ease of use, an inability
possible cardiac arrest, are occurring with significant
to correctly administer it in an emergency situation is
frequency,9,26,28 and remain consistent with Chap-
a profound failing on behalf of a dentist’s training.
man’s findings from 1997, reporting that approxi-
With 93% of German dental students failing to cor-
mately 14% of dentists will be involved in the
rectly administer oxygen in a simulated environ-
resuscitation of a patient.21 This evidence suggests
ment,34 further investigations are warranted as to why
that the teaching of the management skills for both
such an event has occurred, and whether it is consis-
basic life support and CPR should remain a priority.
tent with the proficiency of dentists in the workforce.
Further research in Australia is needed to qualify the
Furthermore, with nearly half of evaluated students
outcomes of any medical emergencies in an Australian
failing to either correctly perform CPR, or use an
population, and any potential implications of a man-
AED in an indicated situation,34 questions on a sys-
dated requirement for medical emergency training for
temic failing of medical emergency education are
dentists.
raised. Correct CPR technique and early use of a
defibrillator has been shown vital in a patient’s chain
Confidence in managing an emergency of survival,42 and a failure to do so can directly lead
to a loss of life. Poor student knowledge on basic pro-
Little research has been undertaken in recent years on
cesses of medical emergency management was mir-
dentists’ confidence in aspects of managing a medical
rored in both Japan and Saudi Arabia, suggesting that
emergency, however, what evidence exists is unsup-
insufficient weighting is placed on these skillsets by
portive of proficiency in an emergency situation.
the profession. Further research is indicated in an
Reviewed findings from a national survey of Croatian
Australian population to determine the state of stu-
dentists showed a direct association between confi-
dent knowledge and proficiency in medical emergency
dence in medical management and the level of train-
management.
ing they have previously received.28 It further stands
Although research has been conducted on dentists’
to reason that previous exposure to a medical emer-
proficiency of medical emergency management, this
gency increases practitioner confidence in its manage-
was in a single population of Iranian dentists.36 Sub-
ment, as in the case of simulation training. Although
sequently, drawing conclusions for an Australian pop-
medical emergencies in children are rare, basic princi-
ulation is likely to be erroneous.
ples of both emergency drug administration, and basic
No conclusion could be made regarding the rate by
life support procedures, remain consistent across age
which medical emergency skills degrade, however, it
groups. Therefore, it can be concluded that any lack
was suggested that the refreshing of any skills should
of confidence reflects poorly on practitioner training,
be within 2 years of education date. This is consistent
and suggests a need for further practitioner education.
with other published evidence, suggesting that a high
With only one moderate-sized study based out of
frequency of skill refreshing is required, even in popu-
Saudi Arabia examining student confidence in emer-
lations who maintain an advanced level of medical
gency management,26 assumptions of external validity
emergency knowledge.43
for an Australian population and educational curricu-
Data from this review strongly suggests the imple-
lum may be erroneous and should be interpreted with
mentation of simulation training alongside didactic
caution. Nonetheless, with one-third of these respon-
learning dramatically increases a participant’s confi-
dents being concerned about performing CPR on a
dence, knowledge and proficiency of medical emergency
stranger for fear of causing harm, the simple reinforc-
management.14,15,37 This is in-line with existing
ing of CPR fundamentals to students remains an inex-
research 13,44 and given the history of this model being
pensive and potentially valuable lesson for students
utilised in both medicine and other high risk
worldwide.
464 © 2018 Australian Dental Association

professions,45 it is surprising to note a slow uptake of
incorporation into an undergraduate dental curriculum.
As such, the established body of evidence for the
benefits of simulation training support its routine
implementation and utilization in the delivery and
maintenance of medical emergency management skills
for all dental practitioners.
Attitudes towards medical emergency management
Given the available evidence suggesting dentists and
dental students are generally poor at medical emer-
gency management, their attitude to it may serve as a
valuable indicator for a future direction of training
and skills development. In this review, it was found
that more than 90% of students felt there was signifi-
cant value in BLS training, and it should be a compul-
sory component of their dental education.26 This is
noteworthy given that despite a self-reported assess-
ment of value, students could not undertake emer-
gency management processes with skill proportional
to the value they place on the role. This suggests that
education processes are failing to properly equip stu-
dents, an argument that is supported by existing
research reporting 55% of New Zealand dentists
being unhappy with their undergraduate medical
emergency training.12 Judicious consideration should
be given to existing medical emergency training pro-
cesses in order to determine their suitability for best
meeting the needs of future practitioners.
Dentists’ perceptions on the frequency with which
they feel refresher training should be undertaken may
also be taken as an indicator for the future direction of
education. With nearly three-quarters of surveyed den-
tists believing medical emergency refresher training
should be undertaken at least every 2 years,28 it is sup-
portive of the notion that practitioners believe skillsets
for handling medical emergencies retain a high impor-
tance throughout their careers. This desire for continu-
ing education should be met with vigour in an attempt
to build upon knowledge which may have been inade-
quately developed in a dentist’s formative education.
With previously discussed evidence highlighting the
value in simulation training, it is not surprising that
results of this review found a great majority of stu-
dents felt there was increased value in simulation
training against traditional didactic learning meth-
ods.14,15,37 It is therefore our conclusion that simula-
tion training is a vital requirement for future
education in emergency management.
CONCLUSION
The prevalence of medical emergencies is increasing in
dental practice, and data analysed in this review sug-
gests that dental practitioners may be unprepared for
© 2018 Australian Dental Association
18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Dentist, emergencies, medical management
their emergency management skills, despite having
universally positive attitudes towards the concept.
Further, research into the prevalence of medical emer-
gencies, practitioner confidence and attitudes and
practitioner knowledge and proficiency, is required in
Australia to consolidate these findings.
CONFLICT OF INTEREST
The authors declare there are no potential sources of
conflict of interest.
REFERENCES
1. Haas DA. Management of medical emergencies in the dental
office: conditions in each country, the extent of treatment by
the dentist. Anesth Prog 2006;53:20–24.
2. Lawson L. Medical emergency preparedness in dental practice.
RDH 2017;37:47–59.
3. Australian Institute of Health and Welfare. Older Australia at a
Glance. 2017.
4. Greenwood M. Medical emergencies in dental practice. Prim
Dent J 2014;3:4–5.
5. Wald DA, Wang A, Carroll G, Trager J, Cripe J, Curtis M. An
office-based emergencies course for third-year dental students. J
Dent Educ 2013;77:1033–1041.
6. Kufta K, Saraghi M, Giannakopoulos H. Cardiovascular consid-
erations for the dental practitioner. 2. Management of cardiac
emergencies. Gen Dent 2018;66:49–53.
7. Carvalho RM, Costa LR, Marcelo VC. Brazilian dental stu-
dents’ perceptions about medical emergencies: a qualitative
exploratory study. J Dent Educ 2008;72:1343–1349.
8. Clark MS, Wall BE, Tholstr€ om TC, Christensen EH, Payne BC.
A twenty-year follow-up survey of medical emergency education
in U.S. dental schools. J Dent Educ 2006;70:1316–1319.
9. Pieren JA, Gadbury-Amyot CC, Kandray DP, Van Ness CJ,
Mitchell TV. The attitudes of Ohio dentists and dental hygien-
ists regarding the use of automated external defibrillators in the
dental setting–a follow-up study. J Dent Hyg 2013;87:158–168.
10. Anders PL, Comeau RL, Hatton M, Neiders ME. The nature
and frequency of medical emergencies among patients in a den-
tal school setting. J Dent Educ 2010;74:392.
11. Fast T, Graham W. Curricular guidelines for management of
medical emergency in dental education. J Dent Educ
1981;45:379–831.
12. Broadbent JM, Thomson WM. The readiness of New Zealand
general dental practitioners for medical emergencies. NZ Dent J
2001;97:82–86.
13. Newby JP, Keast J, Adam WR. Simulation of medical emergen-
cies in dental practice: development and evaluation of an under-
graduate training programme. Aust Dent J 2010;55:399–404.
14. Roy E, Quinsat VE, Bazin O, Lesclous P, Lejus-Bourdeau C.
High-fidelity simulation in training dental students for medical
life-threatening emergency. Eur J Dent Educ 2018;22:e261–e268.
15. Tanzawa T, Futaki K, Kurabayashi H, et al. Medical emer-
gency education using a robot patient in a dental setting. Eur J
Dent Educ 2013;17:e114–e119.
16. Sangamesh NC, Vidya KC, Pathi J, Singh A. Awareness, atti-
tude, and knowledge of basic life support among medical, den-
tal, and nursing faculties and students in the University
hospital. J Int Soc Prev Community Dent 2017;7:161–167.
17. Stafuzza TC, Carrara CFC, Oliveira FV, Santos CF, Oliveira
TM. Evaluation of the dentists’ knowledge on medical urgency
and emergency. Braz Oral Res 2014;28:1–5.
465

M Vaughan et al.
18. Dental Board of Australia. Registration Standards 2018 [Avail-
able from: http://www.dentalboard.gov.au/Registration-Standard
s.aspx.
19. New Zealand Dental Council. Medical Emergencies in Dental
Practice - Practice Standard 2016.
20. U.K. General Dental Council. Standards for the dental team.
2018.
21. Chapman PJ. Medical emergencies in dental practice and choice
of emergency drugs and equipment: a survey of Australian den-
tists. Aust Dent J 1997;42:103–108.
22. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D,
Soares CB. Guidance for conducting systematic scoping reviews.
Int J Evid Based Healthcare 2015;13:141–146.
23. Oral and Dental Expert Group. Therapeutic guidelines: oral
and dental. Version 2. Melbourne: Therapeutic Guidelines Lim-
ited, 2012.
24. Elanchezhiyan S, Elavarasu S, Vennila K, et al. Awareness of
dental office medical emergencies among dental interns in south-
ern India: an analytical study. J Dent Educ 2013;77:364–369.
25. Marks LA, Van Parys C, Coppens M, Herregods L. Awareness
of dental practitioners to cope with a medical emergency: a sur-
vey in Belgium. Int Dent J 2013;63:312–316.
26. Alotaibi O, Alamri F, Almufleh L, Alsougi W. Basic life sup-
port: knowledge and attitude among dental students and Staff
in the College of Dentistry, King Saud University. Saudi J Dent
Res 2016;7:51–56.
27. Bell G, James H, Kreczak H, Greenwood M. Final-year dental
students’ opinions of their training in medical emergency man-
agement. Prim Dent J 2014;3:46–51.

28. Cukovi c-Bagic I, Hrvatin S, Jelicic J, et al. General dentists’
awareness of how to cope with medical emergencies in paedi-
atric dental patients. Int Dent J 2017;67:238–243.
29. Somaraj V, Shenoy RP, Panchmal GS, Jodalli PS, Sonde L, Kar-
kal R. Knowledge, attitude and anxiety pertaining to basic life
support and medical emergencies among dental interns in Man-
galore City, India. World J Emerg Med 2017;8:131–135.
30. Alhamad M, Alnahwi T, Alshayeb H, et al. Medical emergencies
encountered in dental clinics: a study from the Eastern Province
of Saudi Arabia. J Family Community Med 2015;22:175–179.
31. Singh N, Kachwaha P, Singhal DK. Preparedness of dental stu-
dents to manage medical emergencies in clinical dental set-up: a
cross-sectional questionnaire survey. Indian J Public Health Res
Dev 2018;9:289–294.
32. Ahamed A, Santhosh Kumar MP. Knowledge, attitude and per-
ceived confidence in handling medical emergencies among den-
tal students. J Pharm Sci Res 2016;8:645–649.
33. Albelaihi HF, Alweneen AI, Ettish A, Alshahrani FA. Knowledge,
attitude, and perceived confidence in the management of medical
emergencies in the dental office: a survey among the dental students
and interns. J Int Soc Prev Community Dent 2017;7:364–369.
34. Breuer G, Knipfer C, Huber T, et al. Competency in managing
cardiac arrest: a scenario-based evaluation of dental students.
Acta Odontol Scand 2016;74:241–249.
35. Al-Shamiri HM, Al-Maweri SA, Shugaa-Addin B, Alaizari NA,
Hunaish A. Awareness of basic life support among Saudi dental
students and interns. Eur J Dent 2017;11:521–525.
36. Khami MR, Yazdani R, Afzalimoghaddam M, Razeghi S, Mos-
cowchi A. Medical emergency management among Iranian den-
tists. J Contemp Dent Pract 2014;15:693–698.
37. Kishimoto N, Mukai N, Honda Y, Hirata Y, Tanaka M,
Momota Y. Simulation training for medical emergencies in the
dental setting using an inexpensive software application. Eur J
Dent Educ 2017;09:09.
38. Nogami K, Taniguchi S, Ichiyama T. Rapid deterioration of
basic life support skills in dentists with basic life support
healthcare provider. Anesth Prog 2016;63:62–66.
466
18347819, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/adj.12649 by Nat Prov Indonesia, Wiley Online Library on [06/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
39. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in
general dental practice in Great Britain. Part 1: their prevalence
over a 10-year period. Br Dent J 1999;186:72–79.
40. Girdler NM, Smith DG. Prevalence of emergency events in Bri-
tish dental practice and emergency management skills of British
dentists. Resuscitation 1999;41:159–167.
41. M€ uller MP, H€ansel M, Stehr SN, Weber S, Koch T. A state-
wide survey of medical emergency management in dental prac-
tices: incidence of emergencies and training experience. Emerg
Med J 2008;25:296–300.
42. Holmberg MJ, Vognsen M, Andersen MS, Donnino MW,
Andersen LW. Bystander automated external defibrillator use
and clinical outcomes after out-of-hospital cardiac arrest: a sys-
tematic review and meta-analysis. Resuscitation 2017;120:77–
87.
43. Anderson GS, Gaetz M, Masse J. First aid skill retention of first
responders within the workplace. Scand J Trauma Resusc
Emerg Med 2011;19:11.
44. Balmer MC. A dental undergraduate course for the manage-
ment of medical emergencies in dental practice. Eur J Dent
Educ 2008;12:239–246.
45. Al-Elq AH. Simulation-based medical teaching and learning. J
Family Community Med 2010;17:35–40.
Address for Correspondence
Matthew Vaughan
Faculty of Dentistry
College of Medicine and Dentistry
14-88 McGregor Rd
Smithfield, QLD 4878
Australia
Email: mattvaughan@gmail.com
APPENDIX 1 CINAHL SEARCH STRATEGY
1 Dentists OR Dentist Attitudes (MH and keyword
= dentists)
2 Emergencies OR Emergency service OR Physi-
cians, emergency (MH and keyword = emergen-
cies)
3 First aid (MH and keyword = first aid)
4 Critical care (MH and keyword = critical care)
5 Attitude of health personnel (MH and keyword =
attitude of health personnel)
6 Emergency medical services OR emergency medi-
cal technicians OR emergency service (MH and
keyword = emergency medical services)
7 Emerg* AND (manag* OR med* OR train*)
8 Life support
9 Dent*
10 Skill* OR knowled* OR competen*
11 Confidenc* OR attitude*
12 BLS OR ALS OR CPR
13 S5 OR S10 OR S11
14 S1 OR S9
15 S2 OR S3 OR S4 OR S6 OR S8
16 S7
17 S13 AND S14 AND S15 AND S16
© 2018 Australian Dental Association