International Journal of

Environmental Research
and Public Health

Article
Measuring the Level of Medical-Emergency-Related
Knowledge among Senior Dental Students and
Clinical Trainers
Giath Gazal 1, *, Hamzah Aljohani 1 , Khalid H Al-Samadani 2 and Mohammad Zakaria Nassani 3

1 Department of Oral and Maxillofacial Surgery, Taibah University,

Al Madinah Al Munawwarah 41311, Saudi Arabia; [email protected]
2 Department of Restorative Dental Science, College of Dentistry, Taibah University,
Al Madinah Al Munawwarah 41311, Saudi Arabia; [email protected]
3 Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, Dar Al Uloom University,
Riyadh 11512, Saudi Arabia; [email protected]
* Correspondence: [email protected]

Abstract: Objectives: This study aimed to measure the level of medical-emergency-related knowledge
among senior dental students and clinical trainers in Saudi Arabia. Methods: This cross-sectional
pilot survey was conducted at Taibah Dental College, Madina, Saudi Arabia between March 2017
and November 2018. Two hundred and seventy-five self-administered anonymous questionnaires
on the management of common medical emergencies were distributed to all senior dental students
and clinical trainers at Taibah Dental College. Results: There was a serious lack of knowledge
!"#!$%&'(!
!"#$%&' regarding the management of medical emergency scenarios among the participants. Only 54% of
Citation: Gazal, G.; Aljohani, H.; participants knew the correct management for some frequent and life-threating conditions such
Al-Samadani, K.H.; Nassani, M.Z. as “crushed chest pain”, and only 30–35% of participants knew the correct management of deeply
Measuring the Level of sedated patients with benzodiazepine overdose and crisis of hypoadrenalism. Moderate-quality
Medical-Emergency-Related knowledge (50–74% of participants responded correctly) was noted for the following conditions:
Knowledge among Senior Dental sudden onset of brain stroke, psychiatric patient, unconscious patient with hypoglycemia, patient
Students and Clinical Trainers. Int. J. with postural hypotension, and patient with hyperventilation. Based on the scale of knowledge,
Environ. Res. Public Health 2021, 18, there were significant differences in the level of knowledge between clinical trainers, senior dental
6889. https://doi.org/10.3390/
students, and junior dental students (p  0.01). Almost all students and 90% of trainers declared the
ijerph18136889
need for further training. Conclusions: The overall knowledge regarding the management of medical
emergency crises in the dental chair was moderate. However, the scale of knowledge regarding
Academic Editor: Chethan Sampath
the management of medical emergency crises has gradually increased with the number of years of
Received: 22 May 2021
experience. Most participants recognize the need for further training.
Accepted: 23 June 2021
Published: 27 June 2021 Keywords: knowledge; management; medical emergencies; dental chair

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in
published maps and institutional affil- 1. Advances in Knowledge
iations. This study provides an informative platform for dental practitioners, enabling them
to eliminate the uncertainty and confusion that they encounter when they are involved in a
medical emergency case in the dental chair.

Copyright: © 2021 by the authors. 2. Application to Patient Care

Licensee MDPI, Basel, Switzerland. This article aims to improve the quality of dental care provided to diabetic/heart
This article is an open access article disease patients in the dental office.
distributed under the terms and
conditions of the Creative Commons 3. Introduction
Attribution (CC BY) license (https:// Understanding emergency measures for life-threatening conditions that occur in the
creativecommons.org/licenses/by/
dental office enhance the self-confidence of dental practitioners and give them the ability
4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 6889. https://doi.org/10.3390/ijerph18136889 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 6889 2 of 10

to act properly in such circumstances [1]. Therefore, a great responsibility rests on the
faculties of dentistry to provide an adequate curriculum and the necessary training in order
to graduate dentists with the required level of understanding and training [2,3]. Knowledge
of how to deal with patients who need dental treatments and who have life-threatening
medical problems such as acute asthma, ischemic heart disease, uncontrolled diabetes, etc.,
enhance dentists’ ability to make clinical decisions with great confidence [1–4]. As a result,
the patient feels that he/she is in expert, safe, and professional hands. Dentists have to
recognize that medical emergencies can take place at any time in the daily dental practice.
They should expect to encounter and manage at least one or two life-threatening medical
emergencies over their clinical life [1]. Possession of adequate knowledge and competency
to deal with medical emergencies will provide the dentist with greater confidence to
manage one of the most critical aspects of his/her profession. The best approach to
deal with an emergency situation is to adequately prepare yourself for such a critical
moment [2]. Generally, an emergency plan should include training of the dental staff to
manage emergencies, publication of emergency-related guidelines, and training on the
immediate use of emergency kit or “crash cart” [3].
Despite the efforts made by dental schools to deliver the necessary knowledge about
the management of medical emergency in the dental chair, there is still a number of dental
graduates and dentists suffering from a deficit of knowledge in this regards [4]. This defect
in knowledge was recognized by many studies; as an example, Jodalli and Ankola [4] re-
ported a shallow level of knowledge in medical emergencies, related drugs, and equipment
amongst dental graduates in Belgaum city of India. The participants in that study indicated
that medical emergencies should be an essential topic of the dental study plan. Further-
more, most of the participating dental graduates expressed a will for more training in
utilizing practical courses in medical emergencies [4]. Another study by de Bedout et al. [5]
underlined apparent confusion among dental residents and practicing periodontists in
handling of several medical emergency cases and varying degrees of incorrect diagnoses.
It was also concluded that further training about case specific features is needed for the
Indiana dental faculty members and residents [5–8]. In a survey among Saudi dental
students and interns, the authors concluded that the availability of medications and basic
emergency equipment in the dental settings coupled with well-trained dental staff on the
management of basic life support have a major role in the reduction in mortality risk related
to medical emergencies in the dental chair [3]. Additionally, Paquette et al. emphasized
that dentists need to enhance their professional skills to positively contribute to the overall
health management of their patients [8].
It is redundant to say that dentists should be effectively trained to handle medical
emergencies. On the level of designing a dental curriculum, it is necessary to improve
the quality of training in medical emergencies so as to enhance dental students’ ability to
diagnose and deal with medical emergency cases in a professional manner [8,9]. While
medical emergencies are wide in range, severe asthmatic attack, acute hypoglycemia,
anaphylactic attack, and epilepsy attack are examples of the medical emergencies that
dentists and students could encounter in the dental chair and require careful immediate
management and adequate training to deal with.
In Saudi Arabia, it is a precondition for healthcare professionals to attend a training
course and pass an assessment exam in cardiopulmonary resuscitation to obtain a work
license [3]. Such a measure is a sign of good practice. It comes under the welfare of patients
and clinicians, as it saves patients’ lives and protects health professionals from litigation.
Despite the importance of being adequately qualified in the management of medical
emergencies, little is known about the knowledge and experience on the management of
common dental-office-related medical emergencies among dental students and trainers in
Saudi Arabia.
The aim of this pilot survey was (a) to measure the level of medical-emergency-related
knowledge and its relationship to the expertise and (b) to measure the awareness and the
Int. J. Environ. Res. Public Health 2021, 18, 6889 3 of 10

need for training on the management of medical emergencies among senior dental students
and trainers at Taibah Dental College, Medina, Saudi Arabia.

4. Materials and Methods

This cross-sectional study was conducted at Taibah Dental College, Madina, Saudi
Arabia between March 2017 and November 2018. The protocol was approved by the Ethics
and Research Committee at Taibah Dental College (Study Reference No. TUCDREC-2l6l2l8-
Juhani). The target population was 4th, 5th, internship dental students, and clinical trainers
working as teaching staff members at Taibah Dental College. Lists of senior dental students
and clinical trainers were obtained from the examination office at Taibah Dental College.
This identified 275 subjects who were eligible to take part in this study (210 students and
65 clinical trainers). The study instrument was a self-administered questionnaire that
was developed using the textbook of Master Dentistry (Guidance on the management of
common medical emergencies; Coulthard et al. [6]). The questionnaire was presented in
English. In the first stage, it was piloted among 15 dental students and 10 clinical trainers
to ensure the clarity and feasibility of its contents.
In the first part of this questionnaire, participants were required to record their demo-
graphical information including age, gender, and nationality in addition to their years of
experience. In the second part, participants were presented with 20 medical emergency
cases that frequently take place in the dental chair [6] (Table 1).

Table 1. Twenty medical emergency cases that frequently take place in the dental chair.

Medical Emergency Scenario Proposed Management

1- First-line treatment of fainting patient in dental chair Lay flat +/ give oxygen!expect prompt recovery
2- First-line treatment of patient with hyperventilation Ask patient to re-breath from cupped hands or reservoir bag
3- First-line treatment of patient with postural hypotension in dental
chair Lay flat, give oxygen, and sit up very slowly
4- First-line treatment of conscious patient with hypoglycemia Give glucose with a little water or glucose oral gel
5- First-line treatment of unconscious patient with hypoglycemia 1 mg Glucagon injection

6- First-line treatment of patient with epileptic seizure Place the patient in recovery position and check airway after convulsive
movements have subsided
7- First-line treatment of patient has a crisis of hypoadrenalism
(Addison’s disease or long-term steroids) in dental chair Lay flat + give oxygen + 200 mg hydrocortisone IV
8- First-line treatment of patient has acute asthmatic attack in dental
chair Sit up + give oxygen + salbutamol
9- First-line treatment of patient has anaphylactic shock 1 mL adrenaline (1 mg/mL) for IM
10- First-line treatment of patient has been deeply sedated with
benzodiazepine overdose and suffered from severe respiratory Reverse of conscious sedation by giving 0.2 mg Flumazenil IV over 15 s
depression in dental chair
11- First-line treatment of patient has sudden onset of brain stroke
(hemiplegia or quadriplegia) in dental chair Reassure the patient and transfer to hospital
12- First-line treatment of psychiatric patient has
unusual/bizarre/agitated/violent behaviour in dental chair Transfer to hospital
13- First-line treatment of patient has crushed chest pain in dental 400 mcg nitroglycerin spray + 300 mg aspirin chewable tablets + 50%
chair oxygen with 50% nitrous oxide
14- Further management of patient who has episode of chest pain
relieved by rest and nitrates Give oxygen and allow home if mild and rapidly recovered
15- Further management of patient who has severe chest pain (severe
angina or myocardial infarction) not relieved by rest and nitrates Hospital for giving: IV diamorphine + thrombolytic therapy (heparin)
16- First-line treatment of patient who has sudden heart arrest in
dental chair Immediate cardiopulmonary resuscitation (CPR)
17- Cardiopulmonary resuscitation (CRP) consists of: After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
18- First-line management of patient with chronic liver disease needs Arrangement for a coagulation screen and liver function tests prior to
dental extraction under LA surgery
19- First-line treatment of patient with known diabetes who becomes
sweaty, with nausea and tachycardia in dental chair Check if patient has eaten and give him some glucose
20- First-line management of patient with renal failure, needs dental Dental extraction must be done the day following dialysis because there
extraction under LA is no active heparin in circulation
Int. J. Environ. Res. Public Health 2021, 18, 6889 4 of 10

Participants were asked to indicate on a 3-point scale their level of agreement with
proposed management for each emergency situation. Scale categories were agree, disagree,
I do not know. If the respondent agrees on the suggested management of the emergency
case, that means a correct response. On the contrary, a disagreement indicates a wrong
response. As well, “I do not know” indicates no/wrong response. A scale of knowledge
was created by summing the number of correct answers.
In the last part of the questionnaire, each participant was required to self-evaluate his/her
training, knowledge, and clinical competency in the management of medical emergencies.
Questionnaire envelopes were distributed to students by class leaders and by heads of
departments to clinical trainers. Participants were ensured that participation was voluntary,
anonymous, and the collected data would be confidential.

5. Statistical Analysis
Descriptive statistics were used to present characteristics of participants, and frequency
tables were generated to illustrate the response of participants to questionnaire items; continuous
data were expressed by mean ± standard deviation. Participants’ responses to questionnaire
items were regrouped to either a correct or incorrect response; then, the scale of knowledge
was calculated by summing the correct response (scale ranged from 0 to 20). Students were
grouped according to their year in the faculty (4th year, 5th year, and internship), and trainers
were grouped according to their years of clinical experience (<=10 years, between 11–20 years,
>20 years). We used a Chi-square for trend to compare the responses for questionnaire items
between the different groups of participants. The significance level was set at p  0.01. All
statistical analyses were undertaken with SPSS software (IBM SPSS Statistics for Windows,
Version 20.0, Released 2011, IBM Corp, Armonk, NY, USA).

6. Results
By the end of this survey, 202 out of 210 eligible students and 41 out of 65 eligible
trainers completed and returned the study questionnaire. The final response rate was,
therefore, 96% among dental students and 63% among clinical trainers. Characteristics of
the study population are illustrated in Table 2.

Table 2. Characteristics of participants.

Characteristics of Participants Students (n = 202) Trainers (n = 41)

Female 56.4% (114) 70.7% (29)
Gender
Male 43.6% (88) 29.3% (12)
Saudi 100% (202) 22% (9)
Nationality
Non-Saudi 0% (0) 78% (32)
4th year 70.8% (143) -
Year of study (Students) 5th year 17.3% (35) -
Internship 11.9% (24) -
Trainer <= 10 years - 22%(9)
Experience (Trainers) Trainer 11–20 years - 43.9% (18)
Trainer > 20 years - 34.1% (14)
Bachelor - 2.4% (1)
MSc - 12.2% (5)
Qualification (Trainers)
Board - 14.6% (6)
PhD - 70.7% (29)
Mean ± SD Mean (SD)
Age 22.9 ± 1.3 43.8 ± 8.2
Clinical experience in years (Trainers) - 18.8 ± 8.7

All students were Saudi, compared to only 22% of trainers. The majority of dental
students were 4th year students (70.8%). Trainers had a wide range of experience from
Int. J. Environ. Res. Public Health 2021, 18, 6889 5 of 10

less than 10 years (22%) to more than twenty years (34%). Many participants (students
and trainers) showed a moderate level of knowledge in the management of medical
emergencies, so for some frequent and life-threating conditions, such as “crushed chest
pain”, only 54% responded correctly. The range of knowledge for this condition increased
from 48% among 4th year students to 78% among trainers. The knowledge for the treatment
of other conditions was even worse, so only 32% know the correct management of “deeply
sedated patient with benzodiazepine overdose”. Details of responses for all conditions
among study participants are presented in Table 3. Moderate-quality knowledge (50–74%
of participants responded correctly) was present in the following conditions: crushed
chest pain, sudden onset of brain stroke, psychiatric patient, unconscious patient with
hypoglycemia, patient with postural hypotension, and patient with hyperventilation.

Table 3. Percentages of correct answers of participating dental students and clinical trainers to the management of 20 medical
emergency cases that frequently take place in the dental chair.

4th Year (N = 143) 5th Year (N = 35) Internship (24) Trainer (41)
Medical Emergency Scenario p
% (95% CI) % (95% CI) % (95% CI) % (95% CI)
72.7% 60% 83.3% 92.7%
Fainting patient in dental chair 0.01 *
(64.7–79.8%) (42.1–76.1%) (62.6–95.3%) (80.1–98.5%)
65.7% 62.9% 91.7% 70.7%
Patient with hyperventilation 0.17
(57.3–73.5%) (44.9–78.5%) (73–99%) (54.5–83.9%)
Patient with postural 65.7% 74.3% 79.2% 90.2%
0.001 *
hypotension (57.3–73.5%) (56.7–87.5%) (57.8–92.9%) (76.9–97.3%)
Conscious patient with 96.5% 100% 100% 92.7%
0.49
hypoglycemia (92–98.9%) (90–100%) (85.8–100%) (80.1–98.5%)
Unconscious patient with 75.5% 65.7% 75% 63.4%
0.16
hypoglycemia (67.6–82.3%) (47.8–80.9%) (53.3–90.2%) (46.9–77.9%)
73.4% 80% 87.5% 85.4%
Epileptic seizure 0.05 *
(65.4–80.5%) (63.1–91.6%) (67.6–97.3%) (70.8–94.4%)
30.1% 45.7% 50% 61%
Crisis of hypoadrenalism <0.001 *
(22.7–38.3%) (28.8–63.4%) (29.1–70.9%) (44.5–75.8%)
68.5% 85.7% 91.7% 90.2%
Acute asthmatic attack 0.001 *
(60.2–76%) (69.7–95.2%) (73–99%) (76.9–97.3%)
50.3% 71.4% 79.2% 70.7%
Anaphylactic shock 0.002 *
(41.9–58.8%) (53.7–85.4%) (57.8–92.9%) (54.5–83.9%)
Deeply sedated with 24.5% 54.3% 41.7% 34.1%
0.08
benzodiazepine overdose (17.7–32.4%) (36.6–71.2%) (22.1–63.4%) (20.1–50.6%)
67.1% 68.6% 70.8% 68.3%
Sudden onset of brain stroke 0.8
(58.8–74.8%) (50.7–83.1%) (48.9–87.4%) (51.9–81.9%)
60.8% 65.7% 62.5% 56.1%
Psychiatric patient 0.69
(52.3–68.9%) (47.8–80.9%) (40.6–81.2%) (39.7–71.5%)
47.6% 37.1% 70.8% 78%
Crushed chest pain <0.001 *
(39.1–56.1%) (21.5–55.1%) (48.9–87.4%) (62.4–89.4%)
Episode of chest pain relieved 50.3% 51.4% 50% 73.2%
0.03 *
by rest and nitrates (41.9–58.8%) (34–68.6%) (29.1–70.9%) (57.1–85.8%)
Severe chest pain not relieved 51.7% 37.1% 54.2% 68.3%
0.11
by rest and nitrates (43.2–60.2%) (21.5–55.1%) (32.8–74.4%) (51.9–81.9%)
81.8% 74.3% 87.5% 97.6%
Sudden heart arrest 0.02 *
(74.5–87.8%) (56.7–87.5%) (67.6–97.3%) (87.1–99.9%)
Cardiopulmonary resuscitation 71.3% 82.9% 70.8% 85.4%
0.1
steps (63.2–78.6%) (66.4–93.4%) (48.9–87.4%) (70.8–94.4%)
Chronic liver disease needs 69.2% 74.3% 91.7% 85.4%
0.008
dental extraction (61–76.7%) (56.7–87.5%) (73–99%) (70.8–94.4%)
Known diabetes who becomes
73.4% 91.4% 75% 85.4%
sweaty, with nausea and 0.11
(65.4–80.5%) (76.9–98.2%) (53.3–90.2%) (70.8–94.4%)
tachycardia
Renal failure needs dental 71.3% 80% 70.7%
79.2% (57.8–92.9%) 0.79
extraction (63.2–78.6%) (63.1–91.6%) (54.5–83.9%)
* Significant difference in percentages of correct answers of participating dental students and clinical trainers to the management of
20 medical emergency cases that frequently take place in the dental chair (p < 0.001, Student’s t-test).

The scale of knowledge was, as expected, the lowest among the 4th year students
(scale 12.7, 95% confidence interval 12.2–13.2), increasing to 13.6 (95% confidence interval
12.3–15) among the 5th year students. Among internship students and trainers with less
than 20 years of experience, the scale was about 14.7. Among trainers with more than
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 7 of 11
Int. J. Environ. Res. Public Health 2021, 18, 6889 6 of 10

was declared by almost all students (only one student declares no need for further train-
20 and
ing), years of experience,
even the scale
among trainers, increased
more than 90%to 16.2 (95% declared
of them confidence
theinterval:
need for14.6–17.9).
further train-
Figure 1 shows the scale of knowledge for the different
ing. The details of these results are summarized in Table 4. groups of participants.

Figure 1. Knowledge
Figure scale
1. Knowledge forfor
scale thethe
different
differentgroups
groups of participants.
participants.Knowledge
Knowledge scale
scale ranges
ranges between
between 0 and020.
and 20.

Table 4. Participants’ self-evaluationTable 4 shows

of their some
training, variationsand
knowledge, among study
clinical groups in
competency in the
the self-evaluation
management of of their
medical
emergencies. training, knowledge, and clinical competency in the management of medical emergencies
and the need for further training. It is clear that 61.7% of participants received training
in the
4th Yearmanagement of medical emergencies during an undergraduate dental program
5th Year
Internship Trainer Trainer Trainer
(range
Dental from 53.3% for
Dental 4th year dental students to 94.4% among trainers with 10–20 years of
experience). Most
Student students evaluated their training as fair, while most trainersYears
Student
Dental <=10 Years 11–20 Years >20 evaluated p
Student
their training as good. Satisfaction (24)the knowledge
with (9) (18)
about medical (14) was in
emergencies
(143) (35)
general moderate with no specific difference between groups. The need for further training
Received training in the in the management of emergency cases was very high in general (97.9%). This need was
management of medical declared by almost all students (only one student declares no need for further training),
emergencies during and even
53.8% (77)among71.4%trainers,
(25) more
58.3%than 90% of88.9%
(14) them declared
(8) the need
94.4% (17)for further
64.3% training.
(9) 0.004 *
Undergraduate dental The details of these results are summarized in Table 4.
program 7. Discussion
Quality of training -Lack of knowledge
- - - - -
and training on the management of dental chair medical emergency
Poor 15.6% (12)is considered
problems 4% (1) a main14.3%
source(2) 0%affecting
of anxiety (0) 11.8%
not (2)
only patient’s 0% (0) but
perception
Fair also all(26)
33.8% junior and
52%senior
(13) dental
50%practitioners
(7) [7–11].(3)
37.5% Therefore,
11.8%a successful
(2) dental
22.2% (2)school
0.07
Good is the one
37.7% (29) that has competent
36% (9) clinical
35.7% (5) trainers who
50% (4) contribute to students’
41.2% (7) 77.8% (7)profes-
relevant
Very good sional(7)
9.1% development [8–12]. By establishing
8% (2) 0% (0) such
12.5%an action,
(1) a29.4%
competent
(5) dental0%student
(0) and
trainer will be able to treat and safely handle any dental chair medical emergency condition
Excellent 3.9% (3) 0% (0) 0% (0) 0% (0) 5.9% (1) 0% (0)
with a minimal level of anxiety [7]. The findings of this pilot survey show a serious lack of
Satisfaction level with knowledge regarding management of medical emergency scenarios among dental students
knowledge about medical and -even among trainers.
- - is reflected-by high proportions
This deficit - -
of participants who -
emergencies have a lack of information or incorrect knowledge on managing these conditions. This
Not at all satisfied lack is(29)
20.3% recognized by (5)
14.3% 97.9% of25%
participants
(6) who declared
11.1% (1) the5.6%need(1)
for additional
0% (0)training.
Slightly satisfied 40.6% (58) 42.9% (15) 45.8% (11) 11.1% (1) 5.6% (1) 7.1% (1)
Moderately satisfied 30.8% (44) 42.9% (15) 25% (6) 55.6% (5) 50.% (9) 64.3% (9) <0.001 *
Very satisfied 7% (10) 0% (0) 4.2% (1) 22.2% (2) 27.8% (5) 28.6% (4)
Extremely satisfied 1.4% (2) 0% (0) 0% (0) 0% (0) 11.1% (2) 0% (0)
Int. J. Environ. Res. Public Health 2021, 18, 6889 7 of 10

Such a lack must be addressed by medical education departments and educators in Saudi
dental schools.

Table 4. Participants’ self-evaluation of their training, knowledge, and clinical competency in the management of medi-
cal emergencies.

5th Year Dental Internship Trainer Trainer Trainer

4th Year Dental
Student Dental Student <=10 Years 11–20 Years >20 Years p
Student (143)
(35) (24) (9) (18) (14)
Received training in the
management of medical
emergencies during 53.8% (77) 71.4% (25) 58.3% (14) 88.9% (8) 94.4% (17) 64.3% (9) 0.004 *
Undergraduate dental
program
Quality of training - - - - - -
Poor 15.6% (12) 4% (1) 14.3% (2) 0% (0) 11.8% (2) 0% (0)
Fair 33.8% (26) 52% (13) 50% (7) 37.5% (3) 11.8% (2) 22.2% (2)
Good 37.7% (29) 36% (9) 35.7% (5) 50% (4) 41.2% (7) 77.8% (7) 0.07
Very good 9.1% (7) 8% (2) 0% (0) 12.5% (1) 29.4% (5) 0% (0)
Excellent 3.9% (3) 0% (0) 0% (0) 0% (0) 5.9% (1) 0% (0)
Satisfaction level with
knowledge about medical - - - - - - -
emergencies
Not at all satisfied 20.3% (29) 14.3% (5) 25% (6) 11.1% (1) 5.6% (1) 0% (0)
Slightly satisfied 40.6% (58) 42.9% (15) 45.8% (11) 11.1% (1) 5.6% (1) 7.1% (1)
Moderately satisfied 30.8% (44) 42.9% (15) 25% (6) 55.6% (5) 50% (9) 64.3% (9) <0.001 *
Very satisfied 7% (10) 0% (0) 4.2% (1) 22.2% (2) 27.8% (5) 28.6% (4)
Extremely satisfied 1.4% (2) 0% (0) 0% (0) 0% (0) 11.1% (2) 0% (0)
Self-evaluation of the
clinical competency in
- - - - - -
dealing with medical
emergencies
Poor 18.9% (27) 22.9% (8) 25% (6) 11.1% (1) 5.6% (1) 0% (0) <0.001 *
Fair 44.1% (63) 45.7% (16) 50% (12) 33.3% (3) 0% (0) 35.7% (5)
Good 31.5% (45) 28.6% (10) 25% (6) 33.3% (3) 55.6% (10) 35.7% (5)
Very good 4.9% (7) 2.9% (1) 0% (0) 22.2% (2) 22.2% (4) 21.4% (3)
Excellent 0.7% (1) 0% (0) 0% (0) 0% (0) 16.7% (3) 7.1% (1)
Need for further training
in the field of medical 99.3% (142) 100% (35) 100% (24) 88.9% (8) 88.9% (16) 92.9% (13) 0.002 *
emergencies

* denotes significant difference at p  0.01, p was calculated according to Chi-square for trend.

Although the overall knowledge was moderate, we noticed a higher knowledge rate
for some conditions; so, 84% of participants knew the correct management of “sudden
cardiac death”, and 75.3% for the management of “cardiopulmonary resuscitation steps”.
This may be explained by the good training the students received from their trainers,
attending and passing successfully the CPR course, which is considered as a prerequisite
to obtaining a dental license in the KSA, and it is also a part of the dental curriculum.
One of the most interesting findings from this study was the awareness and knowledge
toward the management of a medical emergency in the dental chair has accumulated
over time amongst the participants. The scale of knowledge, which ranges between 0
and 20, scored the lowest (12.7) among the 4th year students, increased to 13.6 among the
5th year students, then 14 among internship students, trainers with less than 20 years of
experience was about 14.7, and the scale increased in trainers with greater than 20 years of
experience to 16.2.
On the other hand, the results indicate that clinical trainers and dental students have a
good level of knowledge and information regarding certain medical emergency scenarios,
for example the treatment of conscious patients with hypoglycemia, epileptic seizures,
acute asthmatic attacks, and chronic liver disease. This might be attributed to the fact
that those conditions are widespread within this particular community [12–18]. Another
interesting result was that students had better knowledge than their clinical trainers in
terms of medical emergency management of conscious and unconscious patients with
hypoglycemia, patients with renal failure who need dental extraction under local anesthesia,
and psychiatric patients. This may be due to the current knowledge they have obtained
from their curriculum.
A study by Dym et al. (2016) [11] indicated that medical emergencies may take place at
any dental practice, and appropriate measures should be planned to enable the healthcare
Int. J. Environ. Res. Public Health 2021, 18, 6889 8 of 10

professionals to tackle such emergency cases at their practice place. High awareness
of the dental team and their rapid reaction to any medical emergency situation can be
regarded a crucial factor in the successful management of the emergencies occurring in the
dental office [12]. However, most general dental practitioners lack the knowledge to deal
with medical emergencies affecting pediatric patients and do not have the confidence to
identify and handle emergencies in children [14,19,20]. Therefore, it was recommended
to provide dentists with adequate training and education to overcome this professional
defect [8]. Instant application of the right medical emergency protocol in the dental office
can significantly improve the chance for a positive outcome and save the life of the affected
patient [13]. In light of these findings, planners of dental education in Saudi Arabia should
draw attention to the necessity of planning more lectures, practical sessions, and workshops
to cover topics on the management of medical emergency problems for undergraduate
dental students. This issue was resolved according to some other studies through the
application of constructed sessions and workshops related to the management of medical
emergency cases in the dental chair. For example, Miller and Metz [14] conducted a
study on 120 dental students to evaluate the importance of clinical scenario videos in
improving the perception of dental students of the basic sciences and their ability to apply
content knowledge. Video modules were developed utilizing simulated patients and
custom-designed animations to illustrate ways of management of medical emergencies
in the dental practice. The study findings revealed that the video clips and animation
helped dental students to understand and recognize the causes of medical emergencies and
implement their understanding of physiology to the scenario and significantly improved
their competency to answer various clinical questions. It can be argued that online modules
may be a useful tool to promote students’ perceptions of the basic sciences and increase their
ability to use basic science content to important scenarios in the clinical practice [21,22].
A similar study was carried out among graduating dental students at the University of
British Columbia from 2008 until 2012 to analyze their perceptions regarding the importance
of competency and confidence in their ability associated with each dental educational
statement [15]. The results showed that, overall, students rated all the competencies as
important, but they rated their confidence lower than the perceived importance. The
competencies that were rated as most important by students were correlated with tasks
regularly practiced throughout undergraduate dental education [15]. A survey study
was carried out in Saudi Arabia between 2013 and 2014 to evaluate readiness for medical
emergencies in private dental centers [22]. The outcome of this study revealed a deficiency
in personnel training, drug availability, and emergency equipment among the investigated
dental clinics. More rigorous rules and regulations for medical emergency education must
be implemented to prevent disasters in these dental clinics [22]. Finally, knowledge about
the management of medical emergencies in the dental chair is essential for dental graduates.
A key of success in the field of dentistry depends on the recognition of the severity of
medical conditions and taking the necessary action before and during dental treatment
in order to avoid medical crises in the dental chair [23]. Yearly training can be of help to
enhance students’ preparedness in the management of medical emergencies in the dental
setting [24].
A limitation of this survey is related to the fact that the survey was conducted in
one public university, which may affect the generalizability of the results to the whole
dental students in KSA. First, second, and third year students did not participate in the
study due to their lack of clinical experience. There was no participation of other local and
international dental colleges because this survey is considered a pilot study. In order to
confirm the findings of this study, a nationwide future survey is highly recommended.

8. Conclusions
The overall knowledge regarding the management of medical emergency crises in the
dental chair was moderate. However, the scale of knowledge regarding the management of
medical emergency crises has gradually increased with the number of years of experience.
Int. J. Environ. Res. Public Health 2021, 18, 6889 9 of 10

The need for further training in the management of emergency medical cases in the dental
chair was very high in general. Online modules, clinical courses, and workshops on dental
chair medical emergency management are recommended to improve clinical trainers’ and
students’ basic medical knowledge and enhance their ability to use it in clinical practice.

Author Contributions: Conceptualization, G.G. and H.A.; methodology, G.G. and M.Z.N.; formal
analysis and interpretation, M.Z.N.; data curation, G.G. and H.A.; writing—original draft preparation,
G.G. and K.H.A.-S.; writing—review and editing, M.Z.N.; supervision, G.G.; project administration,
G.G. and K.H.A.-S.; funding acquisition, K.H.A.-S. All authors have read and agreed to the published
version of the manuscript.
Funding: No financial support of this study.
Institutional Review Board Statement: This study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Ethics and Research Committee at Taibah Dental
College (Study Reference No. TUCDREC-2l6l2l8-Juhani).
Informed Consent Statement: Informed consent was not required from all subjects involved in the study.
Data Availability Statement: The data that support findings of this study are available on request
from the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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