Life-threatening emergencies are not uncommon

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1 Awareness of Dental Office Medical Emergencies Among Dental Interns in Southern India: An Analytical Study S. Elanchezhiyan, M.D.S.; Sugumari Elavarasu, M.D.S.; K. Vennila, B.D.S.; R. Renukadevi, M.D.S.; M. Nazargi Mahabob, M.D.S.; B. Sentilkumar, M.D.S.; S. Raja, M.D.S. Abstract: Medical emergencies in dental practices are common, and specific training and skills are needed to manage the situations. Dental curricula provide training in basic life support in medical emergency management. In India, the internship is the final stage before graduation, and the interns are future practitioners. Managing emergency situations increases the confidence level among new graduates. Training and skill improvement through various training programs on medical emergencies will improve the quality of dental practice, and it is beneficial to the patients. Knowledge of medical emergencies by dental interns is important since they go for practice without supervision. This study was conducted to assess the awareness and knowledge of medical emergencies among dental interns in the southern part of India. Based on the results, dental curricula need to include more rigorous training in emergency management. Dr. Elanchezhiyan is Reader, Department of Periodontia, Vivekanandha Dental College for Women, Tiruchengode, TamilNadu, India; Dr. Elavarasu is Professor and HOD, Department of Periodontia, JKK Nataraja Dental College, Komarapalayam, TamilNadu, India; Dr. Vennila is a postgraduate student, Department of Periodontia, JKK Nataraja Dental College, Komarapalayam, TamilNadu, India; Dr. Renukadevi is Reader, Department of Periodontia, KSR Institute of Dental Science and Research, Tiruchengode, TamilNadu, India; Dr. Mahabob is Reader, Department of Oral Medicine, Radiology, and Diagnosis, KSR Institute of Dental Science and Research, Tiruchengode, TamilNadu, India; Dr. Sentilkumar is Reader, Department of Oral Medicine, Radiology, and Diagnosis, KSR Institute of Dental Science and Research, Tiruchengode, TamilNadu, India; and Dr. Raja is Lecturer, Department of Orthodontia, KSR Institute of Dental Science and Research, Tiruchengode, TamilNadu, India. Direct correspondence and requests for reprints to Dr. S. Elanchezhiyan, 65A, Iyan Kadu, Devasthanam Pudur, Namagiripet, Namakkal, TamilNadu, India ; elanidr@gmail.com. Keywords: medical emergencies, medicine in dentistry, dental students, India Submitted for publication 3/8/12; accepted 5/25/12 Life-threatening emergencies are not uncommon in dental practice. 1 Invasive procedures in the dental office might result in medical emergencies. Dental surgeons must have good knowledge and awareness of medical emergencies, and they should be prepared to manage such situations. 2 The most common medical emergencies are syncope, adverse reactions to LA, grand mal seizures, angina pectoris, and hypoglycemia. 3,4 One study conducted in Australia found that approximately 15 percent of dental surgeons had resuscitated patients in their dental offices in one year. 5 The extent of treatment by dentists requires preparation for and prevention and management of medical emergencies. To alter the treatment plan, a complete medical history is required. The important aspects of medical emergencies in dental practice are to prevent or to correct the insufficient oxygenation of brain and heart tissues. 6 For ensuring the delivery of oxygenated blood to critical organs, the dentist must be competent in basic cardiopulmonary resuscitation. 2 All health professionals, including dentists, must be well prepared to attend to medical emergencies. The dental surgeon s ability to initiate the primary management in emergencies will be the key to minimize the risk of morbidity or mortality. After the ABCs (airway, breathing, circulation), emergency drugs should be the primary consideration of dental surgeons in medical emergency management. Since training in emergency management for dental graduates is essential, the dental curricula in many countries include training models for medical emergency management. The Indian dental curriculum is also modeled with training for the graduates on emergency management. The dental internship takes place in the fifth year of the B.D.S. curriculum and is the period of getting opportunities to manage patients with the students own skills. The knowledge of interns about medical emergencies and their management will be the important aspect since the interns will be starting their own practice setup. This study is aimed to assess the knowledge and awareness of medical emergencies among interns of dental schools in southern India. Its specific aims are to assess the 364 Journal of Dental Education Volume 77, Number 3

2 knowledge of medical emergencies in dental office among dental interns; to evaluate the awareness about medical emergency management among dental interns; to identify the preparedness of interns towards emergency situations; and to evaluate the knowledge of managing various medically compromised/systemic diseased patients among dental interns. Methods A questionnaire consisting of forty-five multiple-choice questions was prepared for the study. The questionnaire included the following topics: basic life support (BLS) training, commonest medical emergencies in the dental office, CPR, sedation, anesthetic agents, systemically compromised condi- tions and their management, and emergency drugs. The questionnaires were distributed to all 188 current dental interns from various colleges in the southern part of India. The answers were compiled, and the data were entered into Microsoft Excel software for accurate data reproduction. The results were analyzed statistically using SPSS software. Results Out of 188 interns, 182 completed the questionnaire and returned it with answers. Among these 182 participants, only 34 percent (sixty-two) said they had encountered at least one medical emergency in their practice (Figure 1). Even though 96 percent (175) reported that the BLS course is mandatory for dentists, Figure 1. Responses by dental interns in study regarding medical emergencies March 2013 Journal of Dental Education 365

3 only 56 percent said they had trained in BLS. Nearly 96 percent responded that dental office helping staff must have knowledge of medical emergencies. About 43 percent of these respondents reported that syncope is the commonest medical emergency in dental office, and about 95 percent agreed that testing vital signs before starting the dental procedures is important. Around 75 percent (136) responded that patient anxiety is the common cause for dental office medical emergencies. Anxiety was reported to be the commonest reason for increased HT or BP in the dental office by 90 percent of the respondents and hyperventilation by 68 percent. Nearly 79 percent responded that premedication will help in reducing the anxiety, but only 30 percent strongly agreed and around 15 percent disagreed. All respondents (100 percent) agreed that medical history plays a vital role in emergency management; 80 percent agreed strongly. Around 90 percent of the respondents agreed that previous dental treatment exposure will help in reducing the incidence of emergency, while 69 percent agreed it is helpful to some extent. Nearly 65 percent said they believed psycosedation will be beneficial. Short, intermittent treatment procedures for anxiety were preferred by 65 percent of the respondents. Of these respondents, 94 percent reported feeling that CPR has a high success rate in cardiac rate management; of those, only 25 percent strongly agreed. Nearly 91 percent strongly agreed that emergency drugs in the dental office are a must. Regarding drug administration, only 3 percent agreed that sublingual is fastest, while 71 percent agreed that intravenous is fast in onset. Sixty-three percent of the respondents reported feeling they are competent in management of unconsciousness, while the remaining said they were not. Nearly 87 percent of the respondents responded correctly about the effects of glucocorticoids, and around 77 percent advocated using these drugs in their prescription sometimes/if definitely needed. Around 87 percent advocated premedication to asthmatic patients, with three-quarters advocating use only if needed. Eighty percent reported knowing there is an aerosol inhaler in the emergency kit for asthmatic patients. Local anesthetic without vasopressor was preferred for asthmatic patients by 48 percent, while 37 percent preferred LA with vasopressor. Around 95 percent of the respondents advocated RBS before every procedure. In management of diabetic patients, 50 percent agreed with taking a blood glucose level during a procedure, while 35 percent preferred it only if the patient feels hypoglycemia. Glucose supplement to diabetic patients during procedures only when the patient feels hypoglycemia was preferred by 80 percent of the respondents. Short-duration procedures were preferred by 68 percent, while 23 percent felt that duration should be based upon an individual s cooperation and treatment procedure. While 70 percent of the respondents reported that they have some or little knowledge of epilepsy, around 71 percent said they preferred procedures with short duration to minimize anxiety in epileptic patients. Nearly 24 percent said they preferred premedication in epileptic patients. About drugs used in practice, nearly 7 percent of the respondents said they were not sure of any encounter with allergic reaction during practice, while 12 percent had experienced it. Around 80 percent reported intending to change the drug prescription only if the regular drug is not effective. In anesthetic agents, liver metabolizing agent was the prime choice (88 percent), with nearly three-quarters of the respondents preferring conscious sedation in managing anxious patients. While 48 percent indicated preferring plain LA without vasoconstrictor in treating all hypertensive patients, 45 percent said they preferred regular LA with vasoconstrictor in well-controlled BP patients. Nitrous oxide was said to be the preferred inhalation anesthesia by 78 percent, while 46 percent said they were not sure of the sulfating agent in anesthesia. Only 2 percent of the respondents said they had encountered angioedema in practice. Around 90 percent suggested that dental office must be equipped with oxygen supply. Around 85 percent reported that antibiotic premedication to cardiac patient is must, and 65 percent reported it is needed before any selective invasive procedure. Nearly 11 percent said they preferred physician instruction to do so in antibiotic premedication. While treating cardiac patients, morning appointments without specific time duration were preferred by 48 percent, while 32 percent preferred regular appointments. About 5 percent said they had experienced angina in their prior practice. For management of angina during dental procedures, around 21 percent advocated stopping the procedure, beginning sublingual nitroglycerine administration, monitoring the conditions, and then continuing the procedure if patient condition is stable; however, 63 percent advocated nitroglycerin administration and monitoring and then seeking physician help and 15 percent preferred to stop the procedure and seek 366 Journal of Dental Education Volume 77, Number 3

4 physician help. Around 30 percent said they preferred stopping antiplatelet therapy before any procedure; 32 percent preferred stopping before any invasive procedure with the remaining preferring to stop if indicated by a physician. Discussion Basic life support includes ABC, the maintaining of airway, and supporting breathing and circulation. Training is required to perform CPR in any medical emergency. 7 The occurrence of medical emergencies in the dental office is quite common, and with the increasing rate of elderly and medically compromised patients, the frequency of medical emergencies in the dental office is increasing. 8 Dental surgeons should be capable of managing emergencies effectively, which needs proper training. 5,9 Basic life support is the dental surgeon s responsibility if any medical emergency occurs in the dental office. The BLS course trains participants in management of various emergencies. 10,11 Providing BLS is the prime contribution of the dentist towards managing medical emergencies. Performing CPR in emergencies is providing BLS, but not all dental surgeons around the world are capable of performing proper CPR. To help dentists handle emergency situations, the dental curriculum in many countries includes BLS training, so acquiring knowledge of and training in BLS is important for dental students. 12,13 In India, the dental curriculum includes all basic medical sciences, which would provide better knowledge of handling medical emergencies. The dental interns are treating patients under the supervision of the faculty, and they depend on the faculty if an emergency occurs. BLS courses are regularly conducted for the interns in various institutions. 14 The dental interns will soon be graduates entering into practice. Their knowledge of medical emergencies should be assessed to identify their level of ability and to perform any modifications needed in the training system. Our study of 182 interns found that only 56 percent reported having received BLS training. Around 34 percent said they had encountered some emergency situations in practice. The results showed a strong need and desire for medical emergency management education for dental interns as advocated in another study. 3 Dental students should be trained in identifying the medical emergency and effectively managing it. Diagnosing the cause of the emergency and having knowledge to manage it are the most important in dental practice. Unfortunately, many practitioners are not aware of the cause and are unable to manage when an emergency occurs. 5 The level of knowledge about medical emergencies found in our study is at the same level of other dental practitioners found in other studies. 3,15-21 These interns are future dental practitioners, so it seems they might not acquire any knowledge of emergency management in practice before graduation. Effective training should be based on the need of the interns and be targeted towards the areas where they are not strong. Intense and repeated training will help to attain the desired effect. The training should be started when the students start working on patients. We propose one triangular representation of effective clinical dentistry (Figure 2). The basic dental and medical training should be given simultaneously to make dental students effective in managing all kinds of patients. Knowledge and training in medical conditions will make the dental practice complete, while insufficient training restrains the dentist from attempting some treatments in clinical practice. Based on this study, the knowledge of medical emergencies among dental interns in southern India is superficial. This superficial knowledge makes the interns insecure, which acts as hindrance in performing BLS that will lead to improper management of medical emergencies in the dental office, which could have fatal consequences. 8 Our study found that the dental interns are not completely aware of and are not being trained in effective management of all emergency situations. Conclusions In this study, we found a lack of knowledge of medical emergency conditions among these interns in southern India dental schools; that a large percentage of the interns had not received any BLS training during their coursework; that almost all the respondents agreed BLS is mandatory; and that only one-third of the respondents had experience with any of the medical emergencies. These findings point to the need for intense training in BLS to help them develop deeper knowledge about medical emergencies and the addition of periodical assessment and upgrading training for dental professionals regarding medical emergencies. For an effective dental practice, these are necessary improvements to be made in the dental March 2013 Journal of Dental Education 367

5 Dental training BLS training Knowledge of oral diseases Knowledge of systemic conditions and emergencies Skills in clinical Skills in managing medically dental procedures compromised patients Complete clinical dental practice Note: The whole body conditions should be focused while performing dental practice instead of only oral conditions. The knowledge of systemic conditions and medical emergencies will make a dental surgeon attempt treatment of any patient without hesitation, which makes the dental practice a complete one. Figure 2. Triangular representation to complete clinical dental practice curricula of these schools by those responsible for dental education. REFERENCES 1. Matsuura H. Analysis of systemic complications and deaths during dental treatment in Japan. Anesth Prog 1989;36: 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;156(2): Fast TB, Martin MD, Ellis TM. Emergency preparedness: a survey of dental practitioners. J Am Dent Assoc 1986;112: Malamed SF. Medical emergencies in the dental office. 5th ed. St Louis: Mosby, 2000: Chapman PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J 1997;42(2): Hass DA. Management of medical emergencies in dental office: conditions in each country, the extent of treatment by the dentist. Anesth Prog 2006;53: Handley AJ. Basic life support. Br J Anaesth 1997;79: Carvalho RM, Costa LR, Marcelo VC. Brazilian dental students perceptions about medical emergencies: a qualitative explorative study. J Dent Educ 2008;72(11): Malamed SF. Emergency medicine in pediatric dentistry: preparedness and management. J Calif Dent Assoc 2003;31(10): ADA Council on Scientific Affairs. Office emergencies and emergency kits. J Am Dent Assoc 2002;133: Hussain I, Mathews RW, Scully C. Cardiopulmonary resuscitation skills of dental personnel. Br Dent J 1992;173(5): Gonzaga HFS, Buso L, Jorge MA, Gonzaga LHS, Chaves MD, Amidia OP. Evaluation of knowledge and experience of dentists of Sao Paula state, Brazil about cardiopulmonary resuscitation. Braz Dent J 2003;14(3): Champan PA. A questionnaire survey of dentists regarding knowledge and perceived competence in resuscitation and occurrence of resuscitation emergencies. Aust Dent J 1995;40(2): Dental Council of India. B.D.S. course syllabus. At: www. dciindia.org/bds-syl.pdf. Accessed: May 10, Morse Z, Murthi VK. Medical emergencies in dental practice in the Fiji islands. Pac Health Dialog 2004;11(1): Gupta T, Aradhga MR, Nagaraj A. Preparedness for management of medical emergencies among dentists in Udupi and Manglore. India J Contemp Dent Pract 2008;9(5): Peskin RM, Siegelman LI. Emergency cardiac care: moral, legal, ethical considerations. Dent Clin North Am 1995;39(3): Journal of Dental Education Volume 77, Number 3

6 18. Kaeppler G, Dandlander M, Hinkelcin R, Lipp M. Quality of CPR by dentists in dental emergency care. Mund Kiefer Gesichtschir 1998;2(2): Jordan T, Brandly P. A survey of basic life support training in various undergraduate health care professions. Resuscitation 2000;47(3): Miller MP, Hansel M, Stehr SN, Weber S, Koch T. A state wide survey of medical emergency management in dental practice: incidence of emergency and training experience. Emerg Med J 2008;25: Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J 2001;97(429):82-6. March 2013 Journal of Dental Education 369