New Zealand Oral Health Practitioners Preparedness

New Zealand Oral Health Practitioners Preparedness Title: An update on New Zealand oral health practitioners preparedness for medical emergencies Running title: Medical emergencies Authors: C L Hong, A W Lamb, J M Broadbent, H L De Silva, W M Thomson Corresponding author: C L Hong, Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. Abstract Background and objectives: To update information on the preparedness of New Zealand general dental practitioners (GDPs) and other oral health practitioners (OHPs) for medical emergencies. Methods: Electronic and paper survey of a sample of 889 OHPs (comprising GDPs, specialists, hygienists, therapists and clinical dental technicians) randomly selected from the Dental Register. Results: The response rate was 39.7%. About half of the respondents (43.3%) reported encountering at least one emergency event during the last ten years. Vaso-vagal syncope was the most commonly reported emergency event, followed by hyperventilation. The mean ten-year incidence of emergency events (excluding vaso-vagal syncope and hyperventilation) was 2.6 events (SD, 7). Dentists were 6.8 times more likely to experience emergency events than other OHPs (p Conclusion: The majority of New Zealand OHPs were equipped in training, and equipment for medical emergencies, and New Zealand appears better than many other countries in this respect. However, some OHPs still lacked some of the required emergency equipment, drugs, and training. Introduction The New Zealand population (as with other developed countries) is ageing (Statistics New Zealand, 2015). This means that oral health practitioners (OHPs) are (and will continue to be) providing care for an increasing proportion of elderly patients. This demographic shift towards a greying population is not without its dental implications. Ageing is accompanied by chronic diseases, disabilities and poly-pharmacy (Hung et al., 2011), all of which are risk factors for the occurrence of medical emergencies in dental practices. Thus, the risk of medical emergency events is likely to be increasing. Most medical emergencies can be anticipated, and all OHPs should be well-versed in their prevention and management. Training in the provision of basic life support is considered an essential and fundamental component of dentistry. Despite this, studies have shown general dental practitioners (GDPs) to be inadequately trained for medical emergencies (Alhamad et al., 2015; Arsati et al., 2010; Chapman, 1997; Muller et al., 2008). Only about half of German GDPs were able to provide basic life support (Muller et al., 2008). About two in five Belgian dentists had never had adult basic life support training following graduation, and four in five never had pediatric basic life support training (Marks et al., 2013). Some years ago, only half of New Zealand GDPs had a current CPR or first-aid certificate, and one in five lacked an emergency equipment kit (Broadbent and Thomson, 2001). Overseas studies have indicated that the incidence of medical emergencies in dental practice (excluding syncope) is between 3.3 and 7.0 emergency events per practitioner during a ten-year practice period (Arsati et al., 2010; Atherton et al., 1999; Atherton et al., 2000; Chapman, 1997; Girdler and Smith, 1999). A 2001 study of 314 New Zealand GDPs reported a mean 4.5 emergency events per dentist during a ten-year practice period (Broadbent and Thomson, 2001). While this falls within the reported range, most of those studies are dated, and there is a need for more contemporary information, particularly in light of the ageing population (and its greater tooth retention). Published studies also tended to focus on GDPs. There is a lack of published data on the preparedness of other OHPs for medical emergencies. Only one study investigated the incidence of medical emergencies among both dentists and dental auxiliaries. Atherton et al. (2000) noted that dentists experienced more emergency events than dental auxiliaries (nursing staff, hygienists and radiographers). This suggests that other OHPs also encounter medical emergencies, but evidence for this within the New Zealand dental workforce remains unknown. Moreover, in September 2014, the Dental Council of New Zealand (DCNZ) updated its Codes of Practice for Medical Emergencies in Dental Practice (Dental Council of New Zealand, 2014). In this updated standard, the New Zealand Resuscitation Council Certificate of Resuscitation and Emergency Care (CORE) certification level required of OHPs was updated, along with the period of recertification. Little is known about the adherence of OHPs to this updated practice standard. Accordingly, this study investigated the preparedness of New Zealand GDPs and other OHPs for medical emergencies in dental practice. Methods This study was approved by the University of Otago Ethics Committee. Data were collected between March and July 2016. OHPs were randomly selected from the 2015-2016 Dental Register, obtained from the DCNZ. The 896 randomly selected OHPs represented 20% of the source population for each OHP type (GDPs, dental specialists, hygienists, therapists, and clinical dental technicians). A small number (7) who did not have a clinical role or were not practising in New Zealand were considered ineligible and were excluded from the sample, leaving 889 eligible participants. The electronic survey used Qualtrics TM software. A link to the online questionnaire was emailed to each participant in March 2016. Participants who failed to respond within two weeks were sent a reminder email. Those who did not respond to the electronic survey were then sent a questionnaire with a cover letter and reply-paid envelope. Questionnaire The questionnaire sought information on the respondents socio-demographic characteristics (specifically gender, age, ethnicity, year of primary dental qualification, and practice location), experience and preparedness for medical emergencies. The frequency of specific medical emergencies was also assessed. To maximise the accuracy of recall, the question on the incidence of vaso-vagal syncope and hyperventilation was limited to the past practising year, while other medical emergencies events to the past ten practising years, or as long as the practitioner had been practising if less than ten years. Information on the availability of emergency equipment and drugs (and confidence in administering these) was also sought. The list of emergency equipment and drugs was derived from the DCNZs practice standard (Dental Council of New Zealand, 2014) . Statistical analysis Data were entered electronically and analyzed using version 21 of the Statistical Package for Social Sciences (for Windows) (IBM).The level of statistical significance was set at p Results Responses were received from 353 of the 889 invited practitioners giving a response rate of 39.7%. Dentists (GDPs and dental specialists) represented 65.7% of respondents, while the remainder were other OHPs. Comparison with the 2011-2012 Workforce Analysis suggested an over-representation of New Zealand qualified dentists and dentists aged above 50 years within the sample (Table 1). For analysis purposes, the respondent age was dichotomized to less than 50 years old and 50 years or older. Similarly, the year in which practitioners obtained their primary qualification was also divided into two groups for analytical purposes: before 1990 and after 1990. More than half of the respondents (64.4%) listed their ethnicity as New Zealand European. The mean number of patients seen by a dentist in a week was 49 (SD, 26), and 44 (SD, 23) for other OHPs. Most dentists (96.6%) reported treating patients with local analgesia (mean, 49 per week; SD, 26); 36.2% reported using intravenous sedation (IV), oral sedation (OS) or relative analgesia (RA) (IV: mean, 0.6; SD, 3, OS: mean, 0.3; SD, 1, RA: mean, 0.2; SD, 1); and 8.0% reported treating patients under general anesthesia. The use of local analgesia during dental procedures was reported by 74.4% (n=90) of other OHPs (mean, 19; SD, 14). Almost half (48.7%) of OHPs reported updating each patients medical history at every visit; 45.8% did it at every new treatment plan/check-up, and the remaining 5.4% updated the medical history only occasionally. Vaso-vagal syncope was the most commonly reported emergency, followed by hyperventilation. Excluding hyperventilation and vaso-vagal events, there were 828 emergency events reported, corresponding to a mean of 2.4 events per respondent during the ten-year period (range, 0-62; SD, 7). Nearly half of respondents (43.3%) reported encountering at least one medical emergency during the last ten years. Dentists experienced a mean of 3.4 events (range, 0-62; SD, 8) and other OHPs a mean of 0.5 events (range, 0-11; SD, 1). Dentists were significantly more likely to experience more emergency events. Other significant emergency events reported were 78 episodes of tachycardia, five episodes of allergic reaction to latex, four episodes of Bells palsy, four episodes of vomiting and three episodes of bleeding (Table 2). Most respondents (96.9%) reported having a medical emergency kit available. Only 38.1% reported checking their medical emergency kit more than twice annually. Details of the emergency equipment and drugs kept by respondents are shown in Table 3. Most respondents reported having an ambubag and airway (82.1%), breathing apparatus for oxygen delivery (82.9%), an oxygen cylinder and regulator (82.3%) and a basic airway adjunct (77.2%) available. Among those who reported keeping these items, fewer than three in four were confident in using them. Dentists were further asked to provide information on the availability of a spacer device to deliver salbutamol and disposable hypodermic syringe and/or needles. Of the 70.1% who reported having a spacer device to deliver salbutamol, 82.6% were confident in using the device. A higher proportion of dentists reported having a disposable hypodermic syringe and/or needle available (82.5%), and 76.7% of dentists were confident in using it. A majority of dentists reported having adrenaline (91.3%), glyceryl trinitrate spray or tablets (86.9%), aspirin tablets (82.1%) or a salbutamol inhaler (79.0%) available in their emergency kit. Most respondents (92.9%) reported holding a current NZRC certificate. The majority (97.2%) of dentists who did not use sedation reported holding a NZRC certificate of level 4 or above. Three dentists did not provide information on their NZRC certificate level and one dentist reported having NZRC certificate level 3. For dentists who reported using any form of sedation excluding RA, 76.1% had a NZRC level 5 certificate or above, 22.5% reported having a NZRC level of 4, and 1.4% did not provide information on their certificate level. Most other OHPs (90.2%) had a NZRC level of 4 and above. Four other practitioners had a NZRC level of 3 and two reported having a NZRC level of 2. Five other OHPs did not provide information on their certification level. Data on the emergency items available among dentists who uses any form of sedation (including no sedation) are presented in Table 4. Just over one in four dentists using sedation (excluding RA) reported having an opioid antagonist. Excluding opioid antagonists, dentists who reported not using IV sedation were significantly more likely to have these emergency items than dentist not practicing sedation. The mean number of emergency events reported by dentists over the past ten years by the use of varying modes of sedation (including no sedation) are presented in Table 5. A statistically significant difference was observed in the frequency of angina pectoris, respiratory depression, allergic reaction to a drug, acute asthma and prolonged epileptic seizures between dentists who reported using sedation and those who did not practice sedation. Dentists using GA sedation reported significantly higher occurrence of angina pectoris than dentists used other form of sedation or did not use sedation, and those using RA reported more episodes of acute asthma than those who did not use sedation. Discussion This survey aimed to investigate the preparedness of New Zealand GDPs and other OHPs for medical emergencies. It was found that dentists were significantly more likely to encounter emergency events than other OHPs and that the majority of New Zealand OHPs were adequately prepared to manage a medical emergency. The response rate of 39.7% was higher than that reported by Muller et al. (2008) but lower than other studies (Atherton et al., 2000; Broadbent and Thomson, 2001).This may be attributed to the use of an online survey, which are less likely to achieve responses rates as high as surveys administered on paper (Shih and Xitao Fan, 2008). As with other self-administered survey, there is a tendency to under- or over-report the incidence of medical emergencies. Certain characteristics of the study respondents and differed significantly from the wider New Zealand dental workforce (Table 1). Dentists aged under 50 years and those who qualified overseas were under-represented. Such a difference may affect the generalizability of the findings. Despite these limitations, this is the first cross-sectional survey study which attempts to evaluate the incidence and preparedness of all New Zealand OHPs for medical emergencies in dental practices. Vaso-vagal syncope is the most commonly reported emergency by OHPs, followed by hyperventilation. This is in accordance with previously published studies (Alhamad et al., 2015; Marks et al., 2013; Muller et al., 2008) with the exception of Broadbent and Thomson (2001) who reported hyperventilation as the most common emergency event. Comparison of the findings of the current study in respect of GDPs to those of Broadbent and Thomson (2001) found that while the percentage of GDPs reporting vaso-vagal syncope and hyperventilation was lower than the 2001 study, the overall mean number of events per reporting participant in this study was higher. The incidence of respiratory depression reported by GDPs was 1.5 times lower than in the 2001 study (Broadbent and Thomson, 2001). This may be due to greater awareness and preparedness among GDPs, combined with stricter regulations imposed by the DCNZ. The use of sedation in dentistry has a positive influence on patients, but while it reduces anxiety and fear, it also increases the risk of respiratory depression. This was reflected in this study. Dentists using IV sedation reported a significantly greater incidence of respiratory depression than those who did not. This is, perhaps, unsurprising, as airway complications are the greatest threat to the safety of sedated patients (Tobias and Leder, 2011). However, the overall incidence of hypoglycemia reported by OHPs in our study was higher than that reported by Arsati et al. (2010) and Broadbent and Thomson (2001). Proper diagnosis of hypoglycemia is dependent on the observation of the Whipples triad; elevated plasma glucose concentration, hypoglycemic symptoms and relief of symptoms following carbohydrate administration, (Nelson, 1985). It is possible that any one of these symptoms may be overlooked by the practitioner when making a diagnosis resulting in over-diagnosis. Excluding vaso-vagal syncope and hyperventilation, the overall rate of medical emergency events among OHPs in New Zealand was lower than reported in previous overseas studies (Table 6). Comparison with Broadbent and Thomson (2001) suggests a decrease in the incidence of emergency events reported by GDPs, dipping from 4.5 to 2.9 emergency event per practitioner over a ten-year period in this study, pFigure 1). Dentists were 6.8 times more likely to experience an emergency event than other OHPs. This is consistent with findings of the 2000 United Kingdom survey, which also reported a greater frequency of emergency events by dentists than ancillary staff (Atherton et al., 2000). Several factors could contribute the latter difference. First, dentists are more likely to provide more complicated treatment than other OHPs. Second, patients who have more complex medical problems (or who are more anxious) may be more likely to attend a dentist than other OHPs for dental treatment. Being prepared with the proper equipment and drugs for the management of an emergency event is important, and most OHPs did have access to an emergency kit. With respect to GDPs, an 18.2% increase over 2001 was observed in the proportion of GDPs with an emergency kit (Broadbent and Thomson, 2001). The four basic emergency pieces of equipment meant to be contained within an emergency kit (regardless of practitioner type) are an ambubag and airway, breathing apparatus for oxygen delivery, oxygen cylinder and regulator, and basic airway adjuncts. The majority of GDPs (85%-89%) had these items, which was a marked improvement from the 2001 study where it ranged between 24% and 81%. Other OHPs were lacking in the availability of an ambubag and airways (30.3%) and basic airway adjunct (35.2%). The drugs required by the DCNZ practice standard were available to the majority of GDPs, but a relatively high proportion of specialists lacked some drugs, namely glyceryl trinitrate spray or tablets (21.9%), aspirin tablets (40.6%), and salbutamol inhaler (34.4%). The availability of oxygen was not specifically asked about in this survey, instead, the availability of an oxygen cylinder and regulator was assessed. We did not specifically asked OHPs whether the oxygen cylinder was filled. It was assumed that, if respondents had this equipment, oxygen would available. Dentists using sedative agents would be expected to be best prepared with appropriate medications and equipment. While they were well equipped (>86%) with the four basic pieces of equipment (listed in the previous paragraph), they were not well equipped with the additional equipment required for sedation, especially in the availability of an opioid antagonist (27.6%). This study found that overall, dentists practising sedation were better prepared with these additional items than those who did not. It is likely that some practitioners may be using a form of sedation that negates the use of these equipment. However, regardless of the form of sedation used, the requirement set by the DCNZ should always be followed. Proper training in the management of medical emergencies is important. A majority of dentists not using sedation (97.2%) and other OHPs (90.2%) had the appropriate NZRC CORE Level 4. Comparison with other overseas studies found OHPs in New Zealand to be better equipped in this area. Arsati et al. (2010) showed that only 59.6% of Brazilian dentists had undergone some form of resuscitation training, while only 47.5% of Belgium dentists (Marks et al., 2013) and 64% of Australian GDPs had undertaken basic life support trainings or CPR courses (Chapman, 1997). However, additional reinforcement is necessary to ensure that all OHPs have the appropriate NZRC CORE level, and thus the skills required to manage medical emergencies. For dentists using sedation, NZRC CORE Level 5 as outlined by the DCNZ guideline (implemented in 2014) is mandatory. However, almost one in four dentists using sedation (excluding RA) did not have a NZRC Level 5 or above certificate. This may be a concern because these practitioners are likely to undertake more complex procedures, possibly in patients with complicated medical conditions. We observed that they were more likely to experience emergency events in their practices. Conclusion Most New Zealand OHPs were equipped in training and equipment for medical emergencies, and New Zealand appears better than many other countries in this respect. However, the different groups of OHPs were still lacking some of the required emergency equipment and drugs. Our findings also clearly show that while there has been a marked improvement from the 2001 study, some OHPs still lacked training (NZRC CORE), and so, it is possible that these practitioners may lack competence in treating medical emergencies. References Alhamad M, Alnahwi T, Alshayeb H, Alzayer A, Aldawood O, Almarzouq A, Nazir MA(2015). Medical emergencies encountered in dental clinics: A study from the Eastern Province of Saudi Arabia. J Fam Community Med 22(3):175-179. Arsati F, Montalli VA, Florio FM, Ramacciato JC, da Cunha FL, Cecanho R, de Andrade ED, Motta RHL (2010). Brazilian dentists attitudes about medical emergencies during dental treatment. J Dent Educ 74(6):661-666. Atherton GJ, McCaul JA, Williams SA (1999). Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. BDJ 186(2):72-79. Atherton GJ, Pemberton MN, Thornhill MH (2000). Medical emergencies: the experience of staff of a UK dental teaching hospital. BDJ 188(6):320-324. Broadbent JM, Thomson WM (2001). The readiness of New Zealand general dental practitioners for medical emergencies. NZ Dent J 97(429):82-86. Chapman PJ (1997). Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J 42(2):103-108. Dental Council of New Zealand (2014). Medical Emergencies in Dental Practice Practice Standard. Wellington: Dental Council of New Zealand. Girdler NM, Smith DG (1999). Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 41(2):159-167. Hung WW, Ross JS, Boockvar KS, Siu AL (2011). Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC 11(1):1-12. Marks LA, Van Parys C, Coppens M, Herregods L (2013). Awareness of dental practitioners to cope with a medical emergency: a survey in Belgium. Int Dent J 63(6):312-316. Muller MP, Hansel M, Stehr SN, Weber S, Koch T (2008). A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. EMJ 25(5):296-300. Nelson RL (1985). Hypoglycemia: fact or fiction? Mayo Clin Proc 60(12):844-850. Shih T-H, Xitao Fan (2008). Comparing Response Rates from Web and Mail Surveys: A Meta-Analysis. Field Methods 20(3):249-271. Statistics New Zealand (2015). 2013 Census QuickStats about people aged 65 and over. Wellington: Statistics New Zealand. Tobias J, Leder M (2011). Procedural sedation: A review of sedative agents, monitoring, and management of complications. SJA 5(4):395-410. Author details: C L Hong BDS. Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. A W Lamb BDS. Dental and oral health department, Level 10, Wellington Hospital, Riddiford St, Newton, 6021. J M Broadbent BDS, PGDipComDent, PhD. Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. H L De Silva BDS, MS, FDSRCS, FFDRCSI. Department of Oral Diagnostic and Surgical Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. W M Thomson BSc, BDS, MA, MComDent, PhD. Department of Oral Sciences, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054. Table 1. Comparison of respondents sociodemographic characteristics with those of the New Zealand (NZ) dental profession. Dentist (%) Dentists in NZ dental profession a (%) Other OHPs (%) Other OHPs in NZ dental profession a (%) Sex Male Female 140 (60.6) 91(39.4) 1347 (64.6) 738 (35.4) 9 (7.4) 112 (92.6) 54 (4.3)c 1191 (95.7)c Age Less than 50 50 and over 104 (45.6) b 124 (54.4) b 1220 (58.5)b 865 (41.5) b 68 (56.2) 53 (43.8) 881 (61.1) 561 (38.9) Country of qualification New Zealand Other 184 (81.4) b 42 (18.6) b 1456 (69.8) b 629 (30.2) b 112 (92.6) 9 (7.4) NR NR a Dental Council of New Zealand (Workforce Analysis 2011-2012) b p c Excludes clinical dental technicians NR: not reported Table 2. Incidence of medical emergencies by practitioner type. Emergency event Number of GDPs reporting during a one-year period (%) Number of specialists reporting during a one-year period (%) Number of other practitioners reporting during a one-year period (%) Mean number of events for per reporting practitioners (sd) Total number of events reported (max) Vaso-vagal syncope a 71 (36.0) 10 (37.0) 1.5 (12.8) 3.3 (6.0) 313 (50) Hyperventilation a 40 (20.3) 3 (11.1) 1.2 (10.3) 3.5 (5.1) 185 (25) Angina pectoris (chest pain) 2.4 (12.2) 5.0 (18.5) 1.0 (0.9) 1.7 (1.3) 51 (5) Swallowed foreign body 2.9 (14.7) 3.0 (11.1) 1.2 (10.3) 1.8 (2.2) 79 (12) Epileptic seizures (grand mal) 1.7 (8.6) 4.0 (14.8) 3.0 (2.6) 1.8 (2.0) 43 (10) Hypoglycemia 4.4 (21.3) 7.0 (25.9) 3.0 (2.6) 3.7 (3.7) 192 (15) Myocardial infarction 0.3 (1.5) 1.0 (3.7) 0.0 (0.0) 1.3 (0.5) 5 (2) Respiratory depression 1.0 (5.1) 5.0 (18.5) 0.0 (0.0) 6.0 (6.4) 90 (80) b Allergic reaction to a drug 2.8 (14.2) 5.0 (18.5) 2.0 (1.7) 3.2 (4.6) 112 (20) Anaphylaxis 9.0 (4.6) 4.0 (14.8) 0.0 (0.0) 1.7 (1.4) 5 (5) Overdose (eg of anesthetic) 4.0 (2.0) 2.0 (7.4) 1.0 (0.9) 1.4 (0.8) 10 (3) Circulatory depression or collapse 4.0 (2.0) 2.0 (7.4) 2.0 (1.7) 2.1 (1.6) 17 (5) Stroke (cardiovascular accident) 3.0 (1.5) 1.0 (3.7) 0.0 (0.0) 1(-) 4 (1) Inhaled foreign body 2.0 (1.0) 0.0 (0.0) 1.0 (0.9) 1 (-) 3 (1) Acute asthma 7.0 (3.6) 1.0 (3.7) 2.0 (1.7) 1.8 (1.3) 18 (5) Hyperglycemia