Medical emergencies in dental o ffi ces in Slovenia and readiness of dentists to handle them

Introduction. Dentists, and all other dental healthcare workers, can expect to face a medical emergency directly or indirectly related to dental treatment. This study evaluates the incidence of medical emergencies in dental offices in Slovenia, the readiness of dentists and possession of specific medical equipment. Methods. An anonymous online based questionnaire was sent through the Medical Chamber of Slovenia via email to all 1503 active dentists in Slovenia. The questionnaire was pilot-tested on 25 dentists and improved accordingly. Thirty closedended questions were answered by 289 (19.2 %) dentists. Results. 93.4 % (n=267) of dentists reported a medical emergency in their dental office. The most prevalent diagnosis was syncope (1.88-2.44/dentist/year) followed by hypoglycaemia (0.20-0.25/dentist/year), hypertensive crisis (0.4/dentists/year) and anaphylaxis (0.3/dentists/year). There were no cardiac arrests reported in the dentists’ entire careers. 85.1 % (n=239) of dentists underwent postgraduate BLS training, 87.4 % (n=209) of them in the last 5 years. Responding dentists estimated that they are most capable of dealing with syncope and least proficient in dealing with stroke, cardiac arrest and a hypertensive crisis. They felt generally more prepared to manage than diagnose a medical emergency. Only 58.1 % (n=161) of dentists have access to a self-inflating bag with a reservoir, and 54.9 % (n=152) to an oxygen mask. Only 4.0 % (n=11) of them have a full set of equipment recommended by Medical Chamber of Slovenia. Conclusions. Results support modification of the undergraduate and postgraduate curriculum for dental students to address specific medical emergencies and the usage of limited equipment. They support more rigorous regulations concerning postgraduate education and specific equipment for dealing with medical emergencies in dental offices in Slovenia.


INTRODUCTION
Dentists, and all other dental healthcare workers, can expect to face a medical emergency, directly or indirectly related to dental treatment.In the developed world, life expectancy is rising, and consequently, dentists are increasingly confronted with an older population with peculiar predispositions, such as a high burden of chronic diseases, greater need and intake of medications and an increased risk of drug interactions and adverse effects.(1) In addition, dental procedures themselves, which commonly involve the use of local anaesthetics, delicate surgical processes, as well as intense patient anxiety, can increase the chances of medical emergencies.(2) The most commonly reported medical emergencies in dental practice include vasovagal syncope, hypoglycaemia, angina, convulsions, asthmatic attack and anaphylactic reaction.Myocardial infarction and sudden cardiac death are fortunately very rare.(3) Earlier reports noted that medical emergencies in dental practice were relatively rare, with an average of one emergency per 3-4 years.(4) However, subsequent research in Europe revealed that 57 % of dentists faced at least 3 medical emergencies per year and 36 % of dentists reported more than 10 emergencies during the previous year.(5) Accordingly, dentists are expected to possess both the requisite core competencies and adequate equipment capacity to di-agnose and appropriately intervene and manage potentially life-threatening medical emergencies that may commonly arise in their practice.Unfortunately, however, Girdler showed that only 12.9 % of dentists consider themselves competent to make the correct diagnosis of a medical emergency, and more than 50 % of UK dentists do not provide appropriate treatment when a medical emergency occurs.(6) As part of the curricular reform for undergraduate medical education in Slovenia, dental students are required to take part in two mandatory 60-hour long Emergency Medical Care training courses with their fellow medical students and a 30-hour course in Geriatric Dentistry, where they learn specific medical emergencies they may face during dental practice.(7) After that, no formal education in emergency medical care is legally required during dentist's postgraduate education in Slovenia.In addition to diagnostic and therapeutic capacities in medical emergencies, preventive strategies during dental treatment are equally imperative.Primary prevention can be achieved by carefully and comprehensively obtaining and updating patient medical histories, with emphasis on known allergies, adverse reactions to medications, chronic illnesses and chronic therapy, and accordingly observing precautionary actions with respect to findings.(8) The aims of this study were to assess the incidence of medical emergencies in dental offices in Slovenia; to determine the confidence perception of dentists in Slovenia with regard to dealing with medical emergencies; to evaluate whether dental offices are properly equipped for adequately responding to medical emergencies; and to ascertain whether dentists are participating in postgraduate courses in emergency medical care and if this reflects on their self-confidence.

METHODS
An online questionnaire developed with the online tool Survey Monkey (Survey-Monkey Inc, Palo Alto, California, USA) was distributed via email to all 1503 active dentists registered with the Medical Chamber of Slovenia.tists were asked about their frequency of participation in BLS (basic life support) courses, the interval since the last course, and their knowledge of the use of AED (automatic external defibrillators).4. Self-perception of competencies in recognising and managing medical emergencies.To estimate their emergency response proficiency, dentists were asked whether they are able to perform specific basic skills correctly (BLS algorithm, establishing intravenous access, chest compressions) using a 6-point Likert scale from 1 ("completely disagree") to 6 ("completely agree").We also evaluated whether dentists agree with the following statements: "I am able to diagnose my patient with the following medical emergency…" and "I am able to treat my patient with the following medical emergency …".The questionnaire was pilot-tested on 25 dentists before the study, to evaluate the relevance of questions, response format and phrasing.Inclusion criterion was: fully completed sections on demographic data and incidence of medical emergencies.The questionnaire was anonymous which did not allow us to identify and track responders and non-responders.Demographic data about the population of dentists in Slovenia was obtained from Medical Chamber of Slovenia and was used to evaluate the representativeness of the sample.

STATISTICAL ANALYSIS
The data obtained were systematically collected and missing data noted.For descriptive analysis of variables, as well as calculating significant differences, SPSS v.12.0 for Windows (SPSS inc., Chicago, Illinois, USA) was used.The Shapiro-Wilk test was used to evaluate the data of groups for Gaussian distribution, while the Mann-Whitney U test or Kruskal-Wallis test was used to assess for differences between groups for data which were not normally distributed.Representativeness of the sample was evaluated using Chi-Square test.A statistically significant difference was determined at P = 0.05.

Demographic data
A total of 332 questionnaires were returned.Of these, 43 did not meet the inclusion criteria and were consequently excluded from the analysis.1 and 2.
Out of 255 dentists that responded to this section, only 50.6 % (n=129) completely or mainly agreed with the statement: "I am able to perform CPR (cardiopulmonary resuscitation) correctly and efficiently" and 60.4 % (n=154) completely or mainly disagreed with the statement: "I am able to establish venous access".

Equipment to manage medical emergencies
Out of the 277 dentists that responded to

DISCUSSION
The present study aimed primarily to determine the incidence of medical emergencies in dental offices in Slovenia.The preparedness of dentists in terms of selfconfidence to diagnose and manage medical emergencies, as well as the availability of basic medical equipment to manage medical emergencies were also evaluated.
Being an anonymous questionnaire-based study conducted on the whole population of active dentists in Slovenia, the limitations of potential response and selection bias were taken into account.To minimise these, we designed a questionnaire with clear-cut closed-ended questions and ordinal answering scales.The questionnaire reached dentists of all ages from all Slovenian geographic health regions.Our sample consists of 289 respondents; thus our paper describes a sample of 19.2% of 1503 Slovenian dentist population at the time of study.Accordingly, we cannot assume that the returned questionnaires are representative of the whole active dentist population in Slovenia.Since the studied population as a whole is relatively small, the absolute number of responding dentists is lower than those of similar surveys conducted in other countries.(5,6,9) To compensate for the low absolute number, we analysed all questionnaires that met the minimal inclusion criteria, unconstrained by considerations of sample representativeness.
Our results show that medical emergencies in dental practices are not infrequent.About two thirds of dentists faced at least one medical emergency during the previous twelve months, and the majority of them (93.4 %) had already experienced medical emergency situations in the course of their career.This clearly indicates that dentists should expect to be crucially involved in the diagnosis and management of medical emergencies.(5,10) The most common of these emergencies was syncope, followed by hypoglycaemia, hypertensive crisis, anaphylaxis and seizures; however, in most cases the emergencies were not life-threatening.Our reported relative incidence of medical emergencies is gen-  It is known that a thorough medical history can help to reduce the risk of medical emergencies.(10) We showed that among Slovenian dentists, a general medical history is taken and written down in the medical

Figure 1 .
Figure 1.Estimation of competence for dentists who had never participated in BLS (basic life support) training before (■) 38) and dentists who had already participated in BLS training at least once (•) (n=217).Data shown represent mean values; *P<0.05versus dentists that had never participated in BLS training (Mann-Whitney U test).
Practice of obtaining and recording a medical historyEighty-one (29.4 %) of 277 dentists that responded to this section, reported taking and writing down a general medical history only at the patient's first visit.The

Table 3 .
Estimation of competence (n=255).Data shown represent a mean value; *P<0.05versus I am able to treat (Mann-Whitney U test).

Table 4 .
Practice of obtaining and recording a medical history (n=277).Based on our study, dentists can expect to face a medical emergency, other than syncope, every two to three years.Cardiac arrest was the medical emergency with the lowest incidence.No responding dentist encountered a cardiac arrest patient in their dental office over their entire career; paradoxically, this is the prime focus of BLS and ALS (advanced life support) training.Thus, it could be beneficial to modify the undergraduate and postgraduate curriculum for dental students to address these specific medical states and highlight the use of available equipment in dental offices.
(14,15)idence of cardiac arrest in dental offices is very low and the cost effectiveness of AED in primary care is considered poor.(11)Weestimate, that AED placement in yet obligatory.Three quarters of responding dentists were also trained to use the AED.It is worth noting that only a minority of responding dentists were trained in establishing venous access and the majority of them do not feel competent to perform this, hence it is probably not appropriate for dentists to attempt to provide ALS with the use of intravenous drugs.(14,15)