Australian Dental Journal 1997;42:(2):103-8

Medical emergencies in dental practice and choice of

emergency drugs and equipment: A survey of
Australian dentists
P. J. Chapman, MB BS, MDSc*

Abstract
This is a report of a postal questionnaire survey of
1250 general dental practitioners regarding occurrence of medical emergencies and their choice of
emergency drugs and equipment. The response
rate was 65 per cent and the results showed that
about one in seven practitioners had had to
resuscitate a patient. The most common medical
emergencies were adverse reactions to local
anaesthetics, grand mal seizures, angina pectoris
and hypoglycaemia (insulin shock). Nearly all
respondents (96 per cent) believed that dentists
need to be competent in cardiopulmonary resuscitation, just over a half (55 per cent) felt they were
competent in CPR on graduation and a similar
figure (57 per cent) felt they could perform effective
single person CPR for five minutes. Almost twothirds (64 per cent) had undertaken CPR courses
since graduation. Additionally, the most commonly
kept emergency drugs were oxygen (63 per cent)
and adrenaline (22 per cent), while the most
commonly kept emergency equipment was a
manual resuscitator (recoil bag-valve-mask type)
which was kept by 27 per cent of the practitioners.
Key words: Dentists, perceived competence in resuscitation, occurrence rates of medical emergencies, choice of
emergency drugs and equipment.
(Received for publication March 1996.
November 1996. Accepted December 1996.)

Revised

Introduction
Little information has been published on the
competence of dentists in resuscitation or the occurrence of medical emergencies in dental practice.1 A
recently published Australian report by this author
was the first study of this type done in Australia.1
The main results were: almost half of the
*Senior Lecturer (Oral and Maxillofacial Surgery) and Emergencies
Officer, University of Queensland Dental School; Hospital
Consultant; Representative, Australian Resuscitation Council.
Australian Dental Journal 1997;42:2.

respondents felt they were competent in cardiopulmonary resuscitation (CPR) on graduation;

almost two-thirds had undertaken CPR training since
graduation; almost two-thirds felt they would be able
to perform CPR effectively; just over three-quarters
felt they could perform expired air resuscitation
(EAR) effectively, and about one in seven had had to
resuscitate a patient using either EAR or CPR. The
present project was developed from that initial study
but involved a much larger sample size and
additionally was directed to obtaining details of
medical emergencies and what emergency items are
kept by Australian dentists.
Research methods
A confidential postal survey of general dental
practitioners was designed to obtain relevant
information on their perceived competence in resuscitation, what emergency drugs and equipment each
felt the typical general practitioner should have,
what emergency drugs and equipment each actually
had in their surgery, and details of any medical
emergencies encountered. The survey was conducted
in 1995. To ensure accuracy of recall, the time frame
for occurrence of medical emergencies was limited
to the period in practice from January 1980 to
December 1994, and the range of each individuals
full time period in practice relevant to the survey
therefore extended from 1 to 15 years. A specific
question was directed to this aspect. Other questions
concerned the occurrence of the following medical
emergencies: angina pectoris, myocardial infarction,
grand mal seizures, severe asthma, insulin shock,
stroke, adverse reactions to local anaesthetics, other
adverse drug reactions and resuscitation events.
A sample of 1250 general dental practitioners was
randomly selected by computer from the Australian
Dental Associations national registry of approximately
7500.
Any emergency equipment or drug mentioned by
respondents which was obviously related to safety
protocols for administration of general anaesthesia
or intravenous sedation was not included, nor were
103

any emergencies which were related to general

anaesthesia.
Data were analysed as frequency distributions of
relevant variables, and as cross classifications as
required. As the distribution of time since graduation was significantly skewed (p<0.001), the median
rather than mean values are used wherever averages
are reported, and the range instead of the standard
deviation.
The incidence of resuscitation and other medical
emergency events is expressed as the number of
emergencies per 40 years of practice, this time span
being used to represent a lifetime career in dentistry,
and is based on the total time in practice for the
period of the survey of all respondents which was
10 011 years.

Table 1. Recommendations for a basic

emergency kit suitable for a typical general
dental practitioner*

Results
There were 811 returns from the 1250 mailed
questionnaires, a response rate of 65 per cent which
equates to approximately one in ten Australian
dentists. The year of graduation among the respondents ranged from 1922 to 1994, with quartiles of
the distribution at 1968, 1976 and 1982. Most
graduated from the University of Sydney (34 per
cent) with 21 per cent graduating from the
University of Queensland, 17 per cent from the
University of Melbourne and 11 and 8 per cent from
the Universities of Adelaide and Western Australia,
respectively. Additionally 4 per cent had graduated
from a university in the UK, with 5 per cent
graduating from universities in other countries. The
median time since graduation was 19 years, with a
range from 1 to 56 years.

*Items suggested by less than 1 per cent of practitioners are not listed.

Perceived competence in resuscitation

Apart from four respondents who disagreed and
20 who were unsure, nearly all (96 per cent) believed
that dentists should be competent in CPR.
Over half (55 per cent) of all respondents felt they
were competent in CPR when they graduated, and
overall 64 per cent had undertaken CPR courses
since graduation, comprising 53 per cent of those
who felt competent on graduation, and 77 per cent
of those who did not feel competent on graduation.
For those who graduated after 1980, the proportion who felt competent in CPR on graduation was
substantially higher than for those who graduated
before 1980 (81 per cent compared with 39 per cent;
p<0.001).
Just over half of all respondents (57 per cent) felt
they would be capable of doing effective single person CPR for five minutes, while just over two-thirds
(68 per cent) reported they would be capable of
doing effective artificial ventilation using EAR for
five minutes. Of the latter group, 78 per cent also felt
they were proficient at CPR.
Most respondents considered two-yearly (31 per
cent) or five-yearly intervals (32 per cent) between
refresher (revision) courses to be adequate to
104

Emergency item
Oxygen
Adrenaline 1:1000
Manual resuscitator
Oral glucose
Bronchodilator spray
Glyceryl trinitrate
tablets/spray
Hydrocortisone injection
Antihistamine injection
Pocket mask
Diazepam injection
First aid kit
Atropine injection
Sphygmomanometer
CPR wall poster

Percentage of practitioners who

recommended each item
70
34
27
13
13
12
7
7
4
3
3
2
2
1

maintain proficiency in CPR while only 16 per cent

correctly believed that yearly refresher courses are
recommended. Cumulatively, of the 64 per cent who
had undertaken CPR courses since graduation, 20
per cent had undertaken courses within the previous
year, 42 per cent in the preceding two years, and 70
per cent in the preceding five years. Of those who
had correctly specified that yearly courses were
needed to maintain proficiency, only 38 per cent had
attended one in the preceding year.
Recommendations for a basic emergency kit
There were 40 suggestions for the minimum
requirement of emergency drugs and equipment that
should be kept by a typical general practitioner. Six
items were suggested by more than 10 per cent of
practitioners. The three most commonly suggested
items in descending order were: an oxygen source, by
70 per cent; adrenaline, by 34 per cent; and a manual
resuscitator (recoil bag-valve-mask type), by 27 per
cent (Table 1). Ten per cent did not list any emergency
drugs or equipment as being necessary in a typical
dental practice.
Emergency items kept by practitioners
These results are recorded in Table 2. Five items
were kept by more than 10 per cent of practitioners.
Oxygen, again by far the commonest item, was
kept by 63 per cent of respondents which included
oxygen-powered resuscitators and oxygen capability
on relative analgesia units. Significantly more
respondents who had attended resuscitation courses
since graduation had oxygen in their surgery
(p<0.002).
The second most commonly kept item was a
manual resuscitator (27 per cent). Again, significantly
more respondents who had attended resuscitation
courses kept this item in their surgery (p<0.01).
The third most commonly kept item was
adrenaline (22 per cent). Once again, significantly
Australian Dental Journal 1997;42:2.

Table 2. Emergency items kept by

practitioners*
Emergency item
Oxygen
Manual resuscitator
Adrenaline 1:1000
Bronchodilator spray
Oral glucose
Glyceryl trinitrate
tablets/spray
Hydrocortisone injection
Antihistamine injection
Diazepam injection
Atropine injection
Glucose injection
Pocket mask
First aid kit
Sphygmomanometer
CPR wall poster
Aromatic ammonia

Table 3. Incidence of medical emergencies in

a practising lifetime*

Percentage of practitioners
who have each item
63
27
22
13
11
9
9
9
5
5
4
4
3
2
1
1

*Items kept by less than 1 per cent of practitioners are not listed.

more respondents who had attended resuscitation

courses kept this item in their surgery (p<0.001).
Approximately 14 per cent (114 respondents)
indicated that they did not keep any emergency
drugs or equipment in their surgery. Of these
respondents almost two-thirds had listed at least one
emergency item as being a minimum requirement
for a typical general dental practitioner, although
this group included 30 of the 75 practitioners who
practised close to a medical facility.
Incidence of medical emergencies and
resuscitation events
As in any such study the following results represent
an estimate of the various occurrences, based on the
unverified information provided.
Most respondents (94 per cent) mentioned at
least one medical emergency and the most common
was adverse reactions to local anaesthetics, estimated
as occurring at a rate of seven in one practising lifetime (Table 3). This included four anaphylactic
reactions. Grand mal seizures, angina and insulin
shock were the next most common emergencies,
using the same time span. Only one case of insulin
shock required parenteral therapy, the others
responding to oral glucose.
Twenty CPR emergencies were reported and 75
per cent survived. Although the aetiology was
unknown or not specified in 11 cases, the commonest
known cause was myocardial infarction.
Fifteen emergencies requiring artificial ventilation
(AV) were reported and all survived. Four occurred
during IV sedation with methohexitone, while
another three occurred during IV sedation with an
unspecified drug.
The overall incidence of resuscitation events was
estimated as affecting about one dentist in seven.
Four instances of anaphylactic reactions to local
anaesthetics were reported, three of which developed
Australian Dental Journal 1997;42:2.

Emergency
Adverse
reaction to LA
Grand mal
seizure
Angina
Insulin shock
Severe asthma
All resuscitations
CPR
AV
Myocardial infarct
Stroke
Anaphylactic
reaction to
penicillin
Anaphylactic
reaction to LA

Number of
events
1753
381
252
160
88
35
20
15
19
12

Incidence in a practising lifetime

7.00
1.52
1.01
0.64 or about 1 in 2 dentists
0.35 or about 1 in 3 dentists
0.14 or about 1 in 7 dentists
0.08 or about 1 in 13 dentists
0.06 or about 1 in 17 dentists
0.08 or about 1 in 13 dentists
0.05 or about 1 in 20 dentists

0.016 or about 1 in 60 dentists

0.016 or about 1 in 60 dentists

*A 40-year period is used to represent a life-time career in these

calculations.
Extrapolated figure based on subsample of 661 responses (82% of
total).
Artificial ventilation, including EAR and use of resuscitators.

into cardiac arrest while the other one responded to

adrenaline and hydrocortisone injections. All
survived. Also four cases of anaphylaxis resulting
from the use of the penicillin group of antibiotics
were reported three were associated with oral
administration, the other not being stated. None
required resuscitation.
Other significant adverse drug reactions were
reported: five were associated with use of IV methohexitone and another with use of IV diazepam;
another four were associated with use of a topical
anaesthetic; and another was reported each for
codeine, aspirin and an endodontic filling material.
All of these cases also had a successful outcome.
Additionally respondents mentioned instances
when they had had to resuscitate someone outside
the surgery, 24 instances using CPR and six using
AV.
Personal comments were recorded by 16 per cent of
respondents and the most frequently cited can be
summarized as follows:
Dental practitioners should be competent in CPR,
as a professional and community responsibility.
CPR training at university should be a certificate
course run by qualified instructors.
CPR competence is far more important for
dentists compared with use of injectable emergency
drugs.
The early arrival of medical aid is far more
important than the risk of dentists mis-using potent
injectable drugs that they are not properly trained to
use.
More CPR and medical emergency courses
should be offered by the university dental schools
and the Australian Dental Association (ADA),
especially for country practitioners.

.
.
.
.

105

. All dental staff should be competent in CPR,

and know where the oxygen is, and how to change
cylinders.
There should be a stated policy on a basic
emergency kit which dentists should have.
CPR competence and having an adequate
emergency kit are especially important if not close to
medical aid, especially in country areas.
Dentists should establish good rapport with
medical practitioners who could be called in an
emergency.
The importance of a good medical history cannot be overstated, and regular review is essential.

.
.
.

Discussion
The aim of initiating CPR for a cardiac arrest
victim is, besides the possibility of spontaneous
recovery of vital functions, to maintain an adequate
level of tissue oxygenation until emergency facilities
become available, especially defibrillation. 2,3 That is,
CPR by itself has only a limited chance of a successful
outcome but, integrated with early defibrillation and
advanced life support it plays a critical role in greatly
improving survival chances.4,5 Therefore, Emergency
Medical Services (EMS) should be called early.
The outcome of a resuscitation incident is directly
dependent, amongst other things, on the rescuers
competence in resuscitation and the delay before
resuscitation is commenced.2 However, external
cardiac compression (ECC) only provides about a
third of the normal cardiac output and therefore
cerebral perfusion. Although this level of cerebral
perfusion is sufficient in the short term, any errors
made when performing ECC may have a deleterious
effect on the outcome.6,7 Also delays in initiating
resuscitation must be minimized as irreversible
neuronal damage occurs after oxygen deprivation of
only about 3-4 minutes.8 Ideally all dental staff
should be competent in CPR. Obviously, the worst
case scenario for a resuscitation emergency is where
incorrect and possibly dangerous techniques are
used. Resuscitation skills are initially acquired by
supervised training and testing on manikins, followed by refresher courses (preferably annually) to
maintain the skills at an effective level.1 It has been
shown that strategically placed CPR wall posters
markedly improve retention of both resuscitation
knowledge and practical skills.9 It is therefore recommended that such posters could be well utilized
in the dental suite.
There is no doubt that dentists, as health care
professionals, should be competent in basic
resuscitation (EAR and CPR) when they graduate.1
Further, trends in the USA in this regard are
interesting as more States now require CPR
competence for registration. That is, currently 18
State dental boards require certification in CPR for
initial registration as a dentist, while 22 also require
that certification be maintained for renewal of
registration, most commonly on an annual or biennial
basis.4
106

Before discussing the results it should be recalled

that not all dentists registered in Australia are
members of the Australian Dental Association from
whose national membership registry the sample of
practitioners was randomly selected, although the
great majority are.
In the present survey, 96 per cent of respondents
believed that dentists should be competent in CPR.
This compares with 99 per cent in the previous
Australian survey.1 However, only just over half (55
per cent) felt they were competent in CPR on
graduation, although this figure was substantially
higher for the more recent graduates (81 per cent).
The only way of achieving competence is with a
structured CPR course using qualified instructors.
At the University of Queensland a formal CPR
course was introduced by the author in 1975, and
the resuscitation curriculum now involves initial
training and testing in third year, with retesting in
both fourth and fifth years. Students graduate with a
certificate of competence in CPR, pocket mask
ventilation and use of supplemental (low pressure)
oxygen.
The suggestions for a basic emergency kit for a
typical general practitioner showed an oxygen source
was suggested by most (70 per cent). There is no
debate that oxygen should be available in a dental
surgery.1,10,11 Oxygen is indicated in all emergencies
except anxiety-induced (primary) hyperventilation.12
The simplest way of administering increased oxygen
levels to a non-breathing victim is by using pocket
mask ventilation (mouth-to-mask ventilation) with
low pressure supplemental oxygen at a flow rate of
10 litres per minute this provides approximately 50
per cent oxygen in the ventilated air.13,14 This
compares to about 17 per cent in a persons expired
air, that is, during normal EAR.
With the pocket mask technique there is little
possibility of gastric distension causing reflux of
gastric contents, with the inherent serious risks of
airway blockage and pulmonary aspiration. This is a
significant problem with use of resuscitat o rs ,
especially the oxygen-powered type. Further, the
technique requires minimal training compared with
using resuscitators, and is the recommended method
of ventilation for a single operator.13,14 Insertion of an
oropharyngeal airway will facilitate pocket mask
ventilation although an airway should only be used
by persons familiar with their use.13,14 Head tilt and
jaw support will still be necessary after insertion of
an airway as their use does not by itself guarantee the
patency of the upper airway.15
In the present study, only 4 per cent had a pocket
mask. Standard anaesthetic facemasks can of course
also be used for mouth-to-mask ventilation.
Alternatively, use of a manual resuscitator with a
competent two-person technique, either as an
atmospheric air resuscitator or more preferably with
supplemental oxygen, is of course another option.
Use of high pressure (resuscitation) oxygen for
ventilation is an Advanced Life Support technique,
Australian Dental Journal 1997;42:2.

with restricted out-of-hospital application. Finally,

delays should not occur in commencing ventilation
whilst equipment is being located and brought to
hand if not immediately available mouth-to-mouth
ventilation should be started. The fear of crossinfection, especially with the HIV virus, may cause
reluctance to use this technique. Although it is
impossible to give an absolute guarantee, the risk is
almost negligible and up till recently no cases of transmission of HBV or HIV infection have been reported
following mouth-to-mouth resuscitation.16-18 Of
course, blood or saliva should always be washed off
or wiped away before starting and hepatitis B vaccination is recommended for all health care personnel,
as a general precaution. 17
The second most suggested item was adrenaline
which was suggested by just over a third of the
respondents (34 per cent). Adrenaline is the
emergency drug of choice in managing the three types
of severe allergic drug reactions: bronchospasm,
laryngeal oedema, and anaphylaxis, which are
extremely rare but potentially life-threatening
emergencies.19-21 This is because of the antihistamic,
bronchodilator and vasopressor actions of adrenaline.21 In anaphylaxis, if cardiovascular collapse
occurs, the term anaphylactic shock is often used.
Intramuscular adrenaline is the drug of choice to
use in these situations. Subcutaneous administration
could also be used although this has a slower
absorption rate. There is however a prerequisite for
a practitioner to consider before adding adrenaline,
or any injectable drug, to an emergency kit. That is,
in the successful management of medical emergencies,
it is far more important (in fact, essential) that a
dentist is competent in basic resuscitation skills
rather than possessing a potent injectable drug but
lacking such skills. Competence in resuscitation is
the base-line for handling all emergencies.1,22
Once a practitioner satisfies this criterion then
selection of adrenaline as an emergency drug
becomes a safe option. In the present study about
one in five dentists had adrenaline available. It is
obviously essential that the practitioner also knows
the correct dosage of adrenaline and contraindications
for its use.1,10 In the allergic reactions previously
mentioned, for an adult, 0.3-0.5 mg (0.3 mL-0.5
mL of a 1:1000 solution) is administered immediately
by IM injection preferably into the tongue or floor of
mouth where absorption occurs within minutes.23-25
Alternatively, other IM sites could be used, for
example, the lateral aspect of the thigh or the deltoid
region. Adrenaline is available in a preloaded syringe
as a 1 mL 1:1000 solution (containing 1.0 mg) for
immediate use and this is the preferred presentation
of the drug. Two such preloaded syringes should be
kept, as the injection may need to be repeated after
three to five minutes, and perhaps even subsequently
until the symptoms subside.1,21,23 For treating allergyinduced bronchospasm, an adrenaline aerosol is an
alternative.26 The dosage is one inhalation at onset of
wheezing which can be repeated in three minutes.
Antihistamines and corticosteroids are second line
Australian Dental Journal 1997;42:2.

drugs in managing severe allergic drug reactions

with no place in the immediate emergency situation.1,27
The concept of a basic emergency kit suitable for a
general practitioner varies considerably between
authorities. However, over recent years the trend has
been to restrict the items to a minimum in the interests
of safety and common sense with which this author
agrees, while the importance of an adequate medical
history, regularly updated, cannot be overemphasized
in the prevention of emergencies.
For a basic emergency kit, McCarthy,10 a foremost
authority recommends:
1) An oxygen source and a positive pressure
ventilation capacity, for example, using a pocket
mask or manual resuscitator.
2) Adrenaline 1:1000.
3) Glyceryl trinitrate spray, for anginal episodes
and suspected myocardial infarction.
Malamed, also a renowned expert in this field,
agrees with this philosophy, but additionally
includes an injectable antihistamine.11 This would be
used in cases of delayed allergic skin reactions, without cardiorespiratory involvement. Both authors also
imply that a source of oral glucose should be readily
available in the surgery (for example, soft drink,
sugar cubes, confectionery bars) for the insulin
dependent diabetic.
Additional items can obviously be added depending
on a practitioners preference, expertise and type of
practice. Also, proximity of medical aid may
influence the selection of emergency drugs. Prepackaged emergency drug kits are available but are
generally overstocked for the needs of a general
dental practitioner and may give a false sense of
security.28
It is imperative for a dentist to be conversant with
the pharmacology of any drugs selected for an
emergency drug kit.1,10 For example, Middlehurst et
al.29 found that only a third of dentists in a survey in
England had confidence in their safe and proper use
of the emergency drugs they kept. Further, in
relation to the use of IV benzodiazepines to control
grand mal seizures as recommended by some
authors, Malamed states that the practitioner must
be capable of managing an apnoeic patient because
of the risk of causing severe respiratory depression. 23
In the present study, about one in twenty dentists
kept diazepam for injection as an emergency drug.
Malamed30 additionally states that naloxone, a
narcotic antagonist, should be included if narcotic
injections are kept in an emergency kit as is sometimes recommended. Additionally, the treatment of
dysrhythmias using intravenous drugs is part of
Advanced Cardiac Life Support requiring specialist
medical skills.31
The incidence of resuscitation emergencies
reported in the previous Australian survey1 showed
very similar results to this study. That is, the
occurrence rate of resuscitation emergencies was
identical in both, that is, estimated as affecting about
one dentist in seven; while for cardiac arrest the
107

occurrence rate was similar, that is, estimated as

affecting about one dentist in eleven in the earlier
study compared with about one in thirteen in this
study.
From the present study it was estimated that
about one dentist in 60 experienced an anaphylactic
reaction to local anaesthetics. The incidence may,
however, become less since the removal of parabens
from dental LA cartridges in 1984.32
Conclusion
From the results, an estimate of the occurrence
rate of cardiac arrest in the dental surgery was
determined, that is, it affected about one dentist in
thirteen. Additionally, the combined incidence of
anaphylactic reactions to both local anaesthetics and
antibiotics affected about one dentist in thirty.
Acknowledgements
The author wishes to sincerely thank the
practitioners who kindly provided the information
necessary for the project; Ms D. Battistutta for
providing statistical services; and the Australian
Dental Research Fund (now the Australian Dental
Research Foundation) for support.
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Op.cit.1993:51.
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Op.cit.:368.

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27. Ibid.:372.

04. Peskin RM, Siegelman LI. Emergency cardiac care moral, legal
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29. Middlehurst RJ, Walton G, Coates D. Teaching resuscitation

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05 Baskett PJF. Resuscitation Handbook. 2nd edn. London: Wolfe,

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Op.cit.:416.

06. Adult advanced life support Guidelines. Med J Aust

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32. Ibid.:351

28. Ibid.:55.

31. Ibid.:418.

07. Baskett PJF. Resuscitation Handbook. Op.cit.:42.

08. Malamed SF. Medical emergencies in the dental office. 4th edn.
St Louis:Mosby, 1993:424.
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Op.cit.:65-8.

108

Address for correspondence/reprints:

Dental School,
The University of Queensland,
Turbot Street,
Brisbane, Queensland 4000,
Australia.

Australian Dental Journal 1997;42:2.