Brazilian Dentists Attitudes About Medical Emergencies During Dental Treatment

International Dental Education Brazilian Dentists Attitudes About Medical Emergencies During Dental Treatment Franco Arsati, D.D.S., M.S., Ph.D.; Victor Ângelo Montalli, D.D.S.; Flavia Martão Flório, D.D.S., M.S., Ph.D.; Juliana Cama Ramacciato, D.D.S., M.S., Ph.D.; Fernanda Lopes da Cunha, D.D.S., M.S., Ph.D.; Rodrigo Cecanho, D.D.S., M.S., Ph.D.; Eduardo Dias de Andrade, D.D.S., M.S., Ph.D.; Rogério Heládio Lopes Motta, D.D.S., M.S., Ph.D. Abstract: The main objective of this study was to evaluate the prevalence of emergencies in dental practices and the preparedness and the training experience in cardiopulmonary resuscitation (CPR) of Brazilian dentists in dealing with emergencies. The volunteer participants in the study were 498 Brazilian dentists who were present at the 27th International Congress of Dentistry in São Paulo. The most prevalent emergency was presyncope (reported by 54.20 percent of respondents), followed by orthostatic hypotension (44.37 percent), moderate allergic reactions (16.86 percent), hypertensive crisis (15.06 percent), asthma (15.06 percent), syncope (12.65 percent), angina (6.82 percent), convulsion (6.22 percent), hypoglycemia (5.62 percent), hyperventilation crisis (5.22 percent), choking (2.20 percent), and cerebrovascular accident (0.8 percent). Anaphylaxis, myocardial infarction, and cardiac arrest were the rarest emergencies, reported by only 0.4, 0.2, and 0.2 percent of dentists, respectively. Only 41 percent of the dentists judged themselves capable to diagnose the cause of an emergency during a dental visit. The majority responded that they would be capable of performing initial treatment of presyncope, syncope, orthostatic hypotension, convulsion, and choking. However, most of them felt unable to treat anaphylaxis, myocardial infarction, or cardiac arrest. Further, the majority felt unable to perform CPR or undertake an intravenous injection. It was concluded that the most prevalent medical emergencies in dental practice of Brazilian dentists are presyncope and orthostatic hypotension. The occurrence of life-threatening medical emergencies like anaphylaxis, myocardial infarction, cardiac arrest, and cerebrovascular accident is rare. Brazilian dentists are not fully prepared to manage medical emergencies and have insufficient experience training in CPR. Dr. Arsati is Professor, Department of Oral Pathology, São Leopoldo Mandic Dental Research Center; Dr. Montalli is a Postgraduate Student, Department of Oral Pathology, São Leopoldo Mandic Dental Research Center; Dr. Flório is Professor, Department of Preventive Dentistry, São Leopoldo Mandic Dental Research Center; Dr. Ramacciato is Professor, Department of Physiological Sciences, São Leopoldo Mandic Dental Research Center; Dr. da Cunha is Professor, Department of Physiological Sciences, São Leopoldo Mandic Dental Research Center; Dr. Cecanho is Professor, Department of Physiological Sciences, São Leopoldo Mandic Dental Research Center; Dr. de Andrade is Professor, Department of Physiological Sciences, Faculty of Dentistry of Piracicaba, State University of Campinas (UNICAMP); and Dr. Motta is Professor, Department of Physiological Sciences, São Leopoldo Mandic Dental Research Center. Direct correspondence and requests for reprints to Dr. Rogério Heládio Lopes Motta, Department of Physiological Sciences, São Leopoldo Mandic Dental Research Center, Rua José Rocha Junqueira 13, Ponte Preta, Campinas, São Paulo, Cep: 13045-610, Brazil; 55-19-3211-3600 phone/fax; motta@sedcare.com.br. Keywords: dental education, cardiopulmonary resuscitation, emergency treatment Submitted for publication 6/28/09; accepted 2/27/10 Although uncommon, medical emergencies can happen in dental practice. 1 When an emergency occurs, it can be life-threatening. 2 As health care providers, dentists must be prepared to recognize and properly manage patients who experience medical emergencies in the dental office. 3 Therefore, studies about the types and prevalence of medical emergencies occurring in dental offices, as well as about the preparedness and experience of dentists in dealing with emergencies, have been conducted in various countries. 3-13 Unfortunaly, these countries have dental education programs different from those in Brazil, so the results of such reports are not applicable to Brazilian dental practice. Previous studies on medical emergencies occurring in Brazil have addressed only dentists of the state of Santa Catarina 14 or focused exclusively on the ability of dentists to perform cardiopulmonary resuscitation (CPR). 15 Law 5081 of August 24, 1966, 16 which regulates dental practice in Brazil, states that Brazilian dentists have the responsibility to initiate primary management in patients who develop any systemic complications related to the dental treatment or coincident with it. Further, if necessary, Brazilian dentists may June 2010 Journal of Dental Education 661

perform intramuscular or intravenous emergency drug injections. The main objective of this study was to evaluate the prevalence of medical emergencies in dental practices and the preparedness and training experience in cardiopulmonary resuscitation of Brazilian dentists to deal with these situations. Methods This study was approved by the Ethics Committee of the São Leopoldo Mandic Dental School (#2008/323), and a total of 498 Brazilian dentists volunteered to take part in the study. A nonprobabilistic sample was constituted of Brazilian dentists who were present at the 27th International Congress of Dentistry in São Paulo. This is the most important congress frequented by clinical dentists throughout Brazil. Between January 24 and 28, 2009, more than 50,000 Brazilian dentists visited this event. These dentists were invited to participate in the study by eight dental professionals who explained its objectives. To be included in the study (inclusion criteria), the volunteers must have graduated from a Brazilian dental school and have more than one year of practice. A total of 498 volunteers signed a term of free and informed consent before filling out a confidential, anonymous, self-administered questionnaire. The questionnaire consisted of mainly objective questions, requiring a simple yes or no reply, in addition to asking the number of emergencies that occurred in the dentists practice over the previous twelve months. Questions 1 through 6 were directed towards obtaining the following information with respect to the volunteer: gender, year of graduation, location of the dental practice according to state in Brazil, whether he or she attended at a private clinic or public service, and the number of patients attended during the course of the last year. Questions 7 through 9 investigated the number of occurrences of specific medical emergencies over the previous twelve months and the type of help asked for by the dentists. The aim of questions 10 through 12 was to obtain information about training in CPR. Questions 13 through 15 evaluated the dentists knowledge and skills in managing specific medical emergencies. Finally, in the last question, the dentists were given the opportunity to explain why they thought themselves incapable of performing certain procedures for managing medical emergencies. Data were entered into a computer database, and a descriptive statistical analysis was performed. Results The mean age of the responding dentists and time since primary dental qualification were 35.6 (±SD 9.6) and 13.8 (±9.1) years, respectively. The total number of patients attended by the dentists over the previous twelve months was 482.784. The mean number of patients treated by each dentist was 1371.5 (±71.7). Of all the dentists, 67.3 percent were from the state of São Paulo, 7.2 percent from Minas Gerais, 6.8 percent from Rio de Janeiro, 3.2 percent from Bahia, and 2.8 percent from Rio Grande do Sul. The remaining 12.6 percent practiced their profession in the other twelve Brazilian states. It was verified that 50.8 percent of the dentists worked exclusively in private clinics, 12.0 percent in public service, and 33.5 percent in both. Most respondents (75 percent) mentioned at least one medical emergency during the previous twelve months. Table 1 shows the number of dentists reporting specific emergencies, the total number of patients affected, the incidence of each emergency according to the number of patients affected per million, and the number of cases experienced per dentist per year. Of the total of 374 respondents who reported having experienced any type of medical emergency in the dental office over the previous twelve months, 66.8 percent (n=250) said they asked for some type of help during the occurrence of the emergency, 24.3 percent (n= 91) did not ask, and 8.8 percent (n=33) did not answer the question. Most consulted a doctor (29 percent; n=36) or another dentist (25.4 percent; n=19). Fewer sent for an emergency ambulance (10.5 percent; n=13) or rescue service (1.6 percent; n=13) or sought the advice of a nurse (1.6 percent; n=2). With regard to CPR training, 59.6 percent (n=297) of the respondents had undergone some type of training, while 40.0 percent (n=199) had never been trained in this procedure. Among those who had some training, half (50.2 percent; n=149) received training during their undergraduate course; 21.2 percent (n= 63) during some postgraduate programs; and 36.1 percent (n=107) and 16.2 percent (n=48) during training in institutions, such as the fire brigade, armed forces, and military police, or during their diving and civil pilot s courses. With regard to the frequency of CPR training, 8.4 percent reported that they trained once a year, 3 percent once every two years, and 2.7 percent once every three years. The majority (70 percent) had undergone training only once since graduation. 662 Journal of Dental Education Volume 74, Number 6

Table 1. Medical emergencies reported by dentists and number of patients affected over a twelve-month period, plus number of patients affected per million and cases per dentist for the medical emergencies per year Dentists Reporting Emergency Number of Patients Affected Cases/Dentist/ Emergency n (%) Patients Affected (million/year) Year Presyncope 270 (54.20%) 785 1626 1.58 Orthostatic hypotension 221 (44.37%) 891 1845.6 1.79 Moderate allergic reaction 84 (16.86%) 183 379.1 0.37 Hypertension crisis 75 (15.06%) 255 528.2 0.51 Asthma 75 (15.06%) 65 134.6 0.13 Syncope 63 (12.65%) 85 176.1 0.17 Angina 34 (6.82%) 73 151.2 0.15 Convulsion 31 (6.22%) 24 49.7 0.05 Hypoglycemia 28 (5.62%) 52 107.7 0.10 Hyperventilation crisis 26 (5.22%) 215 445.3 0.43 Choking 11 (2.20%) 34 70.4 0.07 Cerebrovascular accident 4 (0.80%) 5 10.4 0.01 Anaphylaxis 2 (0.40%) 2 4.1 0.004 Myocardial infarction 1 (0.20%) 1 2.1 0.002 Cardiac arrest 1 (0.20%) 1 2.1 0.002 Unspecified collapse 8 (1.60%) 9 18.6 0.02 With regard to the dentists ability to diagnose the cause of a medical emergency, 41 percent of the respondents judged themselves capable of doing so, and 50.2 percent did not. The self-assessed capability of these dentists to initiate emergency treatment of the most frequent medical emergencies is illustrated in Table 2. Of the respondents, 79.7, 72.9, and 85.7 percent did not judge themselves capable of rescuing victims of acute myocardial infarction, anaphylactic shock, and cerebrovascular accident, respectively. The dentists capacity to perform specific procedures in emergencies is illustrated in Table 3. Among the respondents, 54.4 and 61.4 percent did not judge themselves competent to perform CPR and apply a drug intravenously, respectively. The dentists most frequent justifications with regard to the lack of preparation to deal with medical emergencies were the lack of updating courses after graduation (51 percent), lack of learning during undergraduate course (19.1 percent), and disinterest (4.6 percent). Thirty-seven percent of the respondents reported having no difficulty in dealing with medical emergencies in dentistry. Discussion This study investigated the prevalence of medical emergencies in dental practices and the preparedness and the training experience in CPR of Brazilian dentists. In this study, the occurrence of specific medical emergencies was investigated only over the past twelve months because it would be easier for the clinicians to remember the events that had occurred. 5,6 Our results demonstrated that the most prevalent emergencies are not necessarily those that presented the highest rate of incidence (patients affected per million per year) (Table 3). The explanation for these results is that some dentists reported several occurrences for the same event. For example, at least ten respondents reported ten orthostatic hypotension events in the past twelve months. Presyncope, orthostatic hypotension, moderate allergic reactions, hypertension crisis, asthma, and syncope were, in order, the most common emergencies seen by dentists. Previous studies have found that vasovagal syncope (common faint) is the commonest emergency related to dental practice. 4,6,8,13,14,17 It is important to point out that our study evaluated the occurrence of presyncope and syncope separately. Presyncope and vasovagal syncope are precipitated mainly by the patient s fear and anxiety. However, the first is associated with incipient loss of consciousness, while the second is associated with an actual state of unconsciousness. 11 However, in our study, it was not possible to identify the causes of the syncopes reported by the dentists. The incidence of cardiac emergencies was the lowest among all of the possible medical emergencies. The incidence of cardiac arrest was 0.002 June 2010 Journal of Dental Education 663

Table 2. Dentists self-perceived competence to provide initial management for medical emergencies, by absolute (n) and relative frequency (%) Dentists giving a: Negative Response Positive Response NA Emergency n % n % n % Presyncope 58 11.6% 433 86.9% 7 1.4% Syncope 108 21.7% 384 77.1% 6 1.2% Moderate allergic reaction 243 48.8% 249 50.0% 6 1.2% Angina 323 64.9% 160 32.1% 15 3.0% Orthostatic hypotension 95 19.1% 394 79.1% 9 1.8% Convulsion 227 45.6% 259 52.0% 12 2.4% Asthma 341 68.5% 148 29.7% 9 1.8% Hyperventilation crisis 257 51.6% 226 45.4% 15 3.0% Hypoglycemia 242 48.6% 245 49.2% 11 2.2% Cardiac arrest 342 68.7% 148 29.7% 8 1.6% Myocardial infaction 397 79.7% 95 19.1% 6 1.2% Cerebrovascular accident 427 85.7% 61 12.2% 10 2.0% Hypertension crisis 313 62.9% 180 36.1% 5 1.0% Anaphylaxis 363 72.9% 127 25.5% 8 1.6% Choking 222 44.6% 268 53.8% 8 1.6% NA=not answered Table 3. Absolute (n) and relative frequencies (%) of dentists self-perceived competence to undertake specific practical emergency skills Dentists giving a: Negative Response Positive Response NA Skill n % n % n % Perform cardiopulmonary resuscitation 271 54.4% 214 43.0% 13 2.6% Give an intramuscular injection 113 22.7% 375 75.3% 10 2.0% Give a subcutaneous injection 140 28.1% 346 69.5% 12 2.4% Give an intravenous injection 306 61.4% 179 35.9% 13 2.6% Check the carotid pulse 51 10.2% 437 87.8% 10 2.0% Assess breathing 23 4.6% 464 93.2% 11 2.2% Take a blood pressure 28 5.6% 458 92.0% 12 2.4% Perform abdominal thrust (choking) 185 37.1% 299 60.0% 14 2.8% NA=not answered cases/dentist/year. This finding is consistent with the research of Girdler and Smith conducted in England, where the same annual incidence was observed for this emergency. 6 However, in the United States, the incidence of cardiac arrest was five times higher (0.011). 4 For acute myocardial infarction, the results of our study (0.002) were also close to those found by Girdler and Smith. 6 The incidence of anaphylaxis was 0.004 cases/dentist/year, three times lower than that found in the British research (0.013). 6 As in previous studies, 4,6,17 the results of our study confirm that the most critical clinical situations for the patient, such as acute myocardial infarction, cardiac arrest, and anaphylaxis, are the most uncommon. Nevertheless, the morbidity and mortality of these emergencies in comparison with the others are significant, so that dentists must be adequately prepared to face such critical situations. 18 Our study found that 40 percent of the responding dentists had never undergone training in CPR. 664 Journal of Dental Education Volume 74, Number 6

Among those who had undergone training (59.6 percent), the majority (70 percent) had done so only once. Half of the dentists received CPR training during their undergraduate program and the other half in postgraduate programs. Taking into consideration that in this study, the mean time of clinical practice of the respondents since they graduated was 13.8 years and that the majority of individuals who had received CPR training lost the skills acquired after eighteen months, 19 our results suggest that the majority of Brazilian dentists would not be capable of adequately undertake cardiopulmonary resuscitation. In contrast with our results, Atherton et al. 8 found that, among dentists from Great Britain, the majority had received CPR training in the undergraduate program (93.9 percent) and postgraduate training (98.9 percent). However, an investigation performed in India found similar results with ours, since less than half of the Indian dentists received practical training in management of medical emergencies during their undergraduate and postgraduate education. 12 Only 41 percent of the respondents in our study judged themselves capable of diagnosing the cause of an emergency during a dental attendance. Similar results were reported in the study conducted by Girdler and Smith, 6 who found that the minority of dentists (20.8 percent) believed they could diagnose the cause of a collapse. In our study, the majority of responding dentists judged themselves able to initiate the management of patients only in presyncope, syncope, orthostatic hypotension, convulsion, and choking. Over twothirds of the respondents did not judge themselves capable of initiating attendance of acute myocardial infarction, cardiac arrest, and anaphylaxis. These last results are cause for concern considering that these emergencies could easily lead to the patient s death. 18,20 With regard to the dentists skills in the management of medical emergencies, 43 percent of respondents judged themselves competent to perform cardiopulmonary resuscitation. However, this result is inconsistent with the fact that only 29.7 percent judged themselves capable of initiating emergency attendance in a case of cardiac arrest. These results are similar to those obtained by Laurent et al., 3 who found that final-year dental students were not capable of competently managing a cardiac arrest although more than half of these students considered themselves totally or sufficiently capable of carrying out cardiopulmonary resuscitation emergencies. Our results were also similar to those obtained by Girdler and Smith, who found that British dentists in their study were more prepared to undertake cardiopulmonary resuscitation than to manage a cardiac arrest. 6 Similar with our results, Indian dentists also self-assessed they were not prepared to undertake cardiopulmonary resuscitation. 12 The majority of responding dentists in our study judged themselves capable of applying an intramuscular or subcutaneous injection, checking the carotid pulse or a patient s breathing, checking blood pressure, and performing abdominal compressions for dealing with obstructed airways. Nevertheless, the majority (62.4 percent) did not judge themselves competent to apply an intravenous injection. Similar results were found in the research conducted in England with regard to the skills to apply injections and check arterial blood pressure. 6 The most common justifications the respondents in our study gave for their lack of knowledge and skills as regards medical emergencies were the lack of training and update since primary qualification and lack of learning and training during the undergraduate program. Broadbent and Thomson found that dentists in New Zealand were dissatisfied with the training they had received for medical emergencies as undergraduate students and that 14.1 percent currently felt inadequately prepared for an emergency in practice. 9 Unfortunately, in the undergraduate programs in dentistry in Brazil, there is no compulsory discipline for teaching medical emergencies. When the undergraduate student receives this knowledge, it is due to the individual efforts of professors in the areas of physiology, pharmacology, or surgery, which briefly include the subject in their disciplines, although frequently without practical basic life support training. Carvalho et al. found that Brazilian undergraduate students in dentistry developed only superficial knowledge about medical emergencies. 21 Recently, the Federal Council of Dentistry mandated that all postgraduate courses must include the discipline of medical emergencies in dentistry in their programs. However, we would argue that it is unacceptable that this discipline is mandatory only for postgraduate programs, since any dentist, whatever his or her level of training, could be faced with a medical emergency during clinical practice. Thus, we believe that undergraduate courses in dentistry must be revised for the mandatory inclusion of this subject in their curricula. Similarly, after graduation, the dentist should regularly take theoretical and practical courses in the area, regulated by the Federal Council of Dentistry. June 2010 Journal of Dental Education 665

Conclusions Our study has found that the most prevalent medical emergencies in the practices of Brazilian dentists are presyncope and orthostatic hypotension, followed by moderate allergic reactions, hypertension crisis, asthma, and syncope. The occurrence of life-threatening medical emergencies, such as anaphylaxis, myocardial infarction, cardiac arrest, and cerebrovascular accident, is rare. Further, the results of our study have demonstrated that Brazilian dentists are not fully prepared to manage medical emergencies and have insufficient experience training in CPR. REFERENCES 1. Le TT, Scheller EL, Pinsky HM, Stefanac SJ, Taichman RS. Ability of dental students to deliver oxygen in a medical emergency. J Dent Educ 2009;73(4):499 508. 2. Malamed SF. Back to basics: emergency medicine in dentistry. J Calif Dent Assoc 1997;25(4):285 6,288 94. 3. Laurent F, Augustin P, Nabet C, Ackers S, Zamaroczy D, Maman L. Managing a cardiac arrest: evaluation of final-year predoctoral dental students. J Dent Educ 2009; 73(2):211 7. 4. Fast TB, Martin MD, Ellis TM. Emergency preparedness: a survey of dental practitioners. J Am Dent Assoc 1986; 112(4):499 501. 5. 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):103 8. 6. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 1999;41(2):159 67. 7. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 3: perceptions of training and competence of GDPs in their management. Br Dent J 1999;186(5):234 7. 8. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff of a UK dental teaching hospital. Br Dent J 2000;188(6):320 4. 9. Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J 2001;97(429):82 6. 10. Alexander RE, McPhillips A. The state of preparedness in Texas dental practices for medical emergency responses: a survey. Tex Dent J 2004;121(12):1122 30. 11. Morse Z, Murthi VK. Medical emergencies in dental practice in the Fiji Islands. Pac Health Dialog 2004;11(1):55 8. 12. Gupta T, Aradhya MR, Nagaraj A. Preparedness for management of medical emergencies among dentists in Udupi and Mangalore, India. J Contemp Dent Pract 2008; 9(5):92 9. 13. Müller MP, Hänsel M, Stehr SN, Weber S, Koch T. A statewide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J 2008;25(5):296 300. 14. Santos JC, Rumel D. Medical emergency in dental practice in the state of Santa Catarina: occurrence, equipments and drugs, professional expertise, and training of the clinicians. Ciên Saúde Coletiva 2006;11(1):183 90. 15. Gonzaga HF, Buso L, Jorge MA, Gonzaga LH, Chaves MD, Almeida OP. Evaluation of knowledge and experience of dentists of Sao Paulo State, Brazil, about cardiopulmonary resuscitation. Braz Dent J 2003;14(3):220 2. 16. Brazil. Law 5081. Regulates the practice of dentistry in Brazil. At: www.cfo.org.br. Accessed: March 20, 2009. 17. Malamed SF. Managing medical emergencies. J Am Dent Assoc 1993;124(8):40 53. 18. Malamed SF. Medical emergencies in the dental office. 5th ed. St. Louis, MO: Mosby, 2000. 19. Chate RA. Evaluation of a dental practice cardiopulmonary resuscitation training scheme. Br Dent J 1996; 181(11 12):416 20. 20. Chapman PJ. A questionnaire survey of dentists regarding knowledge and perceived competence in resuscitation and occurrence of resuscitation emergencies. Aust Dent J 1995;40(2):98 103. 21. Carvalho RM, Costa LR, Marcelo VC. Brazilian dental students perceptions about medical emergencies: a qualitative exploratory study. J Dent Educ 2008;72(11):1343 9. 666 Journal of Dental Education Volume 74, Number 6