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A state-wide survey of medical emergency

management in dental practices: incidence of
emergencies and training experience
M P Müller, M Hänsel, S N Stehr, S Weber and T Koch

Emerg. Med. J. 2008;25;296-300

doi:10.1136/emj.2007.052936

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Prehospital care
Department of Anaesthesiology
and Intensive Care Medicine,
University Hospital Carl Gustav
Carus, University of Technology,
Dresden, Germany
Correspondence to:
Dr M P Müller, Department of
Anaesthesiology and Intensive
Care Medicine, Carl Gustav
Carus University Hospital,
University of Technology, 01307
Dresden, Germany;
mp-mueller@web.de
Accepted 18 November 2007
296
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A state-wide survey of medical emergency
management in dental practices: incidence of
emergencies and training experience
M P Müller, M Hänsel, S N Stehr, S Weber, T Koch
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 man-
agement 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.
Effective training is widely accepted to result in a
positive outcome in early life support, as docu-
mented for cardiac arrest over 30 years ago by
Copley et al.1 Since then, cardiopulmonary resusci-
tation (CPR) training and even defibrillation by lay
rescuers has become an essential part of interna-
tional 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 under-
graduate 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 depart-
ment 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 equip-
ment. 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:
1. Demographic data regarding the dental prac-
tice. 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.
2. Attitude towards emergency management
and self-estimation of skills needed in emer-
gency 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 manage-
ment’’). 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,
Emerg Med J 2008;25:296–300. doi:10.1136/emj.2007.052936
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establishing intravenous access, preparing infusions, pre-
paring syringes, measuring blood glucose, pulse check,
rhythm check with ECG, defibrillation, chest compres-
sions, basic life support (BLS) algorithm, ALS algorithm.
3. 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 reac-
tion, 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’’).
4. 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.
5. 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.
6. 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 distrib-
uted 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
Table 1 Attitude towards emergency management
Item
Equipment to treat emergencies has to be available in every dental practice
I am not interested in emergency management
Emergency equipment should be stored visibly for the patients
Absolute number of answers in each category on a 6-point Likert scale from 1 (disagree completely) to 6 (agree completely).
Emerg Med J 2008;25:296–300. doi:10.1136/emj.2007.052936
Prehospital care
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 ques-
tionnaire (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
1 2 3 4 5 6 n
5 7 25 26 65 485 613
333 96 40 38 54 50 611
258 136 83 76 30 28 611
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Table 2 Emergencies reported in the 12-month study period

No of dentists who Incidence of
experienced emergency emergency

Vasovagal syncope 358 1238

Hypertensive crisis 41 72
Seizure 42 46
Hypoglycaemia 22 33
Asthma 24 26
Acute coronary syndrome 22 24
Anaphylaxis 7 9
Airway obstruction 5 5
Stroke 4 4
Cardiac arrest 2 2
Other emergencies 18 26

Figure 1 Self-estimation of competence to diagnose emergencies.

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%).
Answers to the item ‘‘I am able to diagnose …’’ are shown as mean
values on a scale from 1 (disagree completely) to 6 (agree completely);
n = 620, *p,0.05.
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 compe-
tence 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

Expenses for emergency management

Two hundred and twenty dentists had spent a mean (SD) of
J196 (310) on emergency equipment in the previous 12 months
and 141 planned to buy equipment for J224 (335) in the
following year. One hundred and thirty-two dentists spent
J227 (189) on training during the study period and 313 dentists
planned to spend J313 (214) in the following year. Four
Figure 2 Self-estimation of competence to treat emergencies.
Answers to the item ‘‘I am able to treat …’’ are shown as mean values
on a scale from 1 (disagree completely) to 6 (agree completely);
n = 620, *p,0.05.

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Prehospital care

Table 3 Dentists’ self-estimation of skills, training experience and wish to train in the future
I am able to perform I have trained in the I would like to train in
the skill skill in the past the skill in future

Taking blood pressure 98 84 5

Applying oxygen via mask 59 59 32
Bag/mask ventilation 57 62 30
Insertion of pharyngeal tubes 16 36 46
Establishing intravenous access 32 51 48
Preparing infusions 27 37 48
Preparing syringes 23 31 48
Measuring blood glucose 23 21 43
Pulse check 97 75 6
Rhythm check with ECG 3 6 39
Defibrillation 5 9 46
Chest compressions 62 71 25
BLS algorithm 49 58 34
ALS algorithm 9 9 49
BLS, basic life support; ALS, advanced life support.
In the item ‘‘I am able to perform skill’’ the proportion of dentists who answered ‘‘agree completely’’ or ‘‘agree’’ on the 6-point Likert
scale is given. All numbers are percentages of dentists who answered the respective question.

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) pro-
grammes 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 ques-
tionnaire (6 pages). Furthermore, we cannot assume that the
returned questionnaires are representative of the whole study
population. However, the absolute number of returned ques-
tionnaires 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.

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Prehospital care
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 participa-
tion in life support courses as well as standardisation of courses
specially designed for dentists.
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.
Competing interests: None declared.
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Correspondence to: Dr K Sanyal, Clinical Fellow, Department of Medicine, Norfolk
and Norwich University Hospital NHS Trust, Norwich, UK; ksanyal01@doctors.org.uk
Competing interests: None declared.
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