Medical emergencies can and do present in primary care dental practices; in fact, around 60% of dentists experience at least one emergency every 12 months (Müller et al, 2008). Consequently, the dental regulator, the General Dental Council (GDC), identifies the importance of maintaining knowledge and skills in this area. It recommends that all dental professionals carry out at least 10 hours of medical emergency training as part of continuing professional development (CPD) every cycle, of which 2 hours must be completed annually (GDC, 2018). The maintenance of knowledge, skills and teamwork is paramount, as real-life learning moments to consolidate experience are rare.
The development of the dental team has given rise to multiple dental care professionals (DCPs) and team members that may be involved in the management of a medical emergency. DCPs include dental nurses, dental hygienists and dental therapists. The GDC's ‘Standards for the dental team’ recommend that at least two people are available to deal with medical emergencies when treatment is taking place, that all members of staff – whether GDC registered or not – know their role in a medical emergency, that any members of staff that may be involved are trained and prepared, and crucially that they practice in a team regularly in simulated clinical scenarios (GDC, 2013a).
It is important to acknowledge Schedule 19 of the Human Medicine Regulations 2012, that in an emergency, anyone can administer adrenaline 1:1000 up to 1 mg for intramuscular (IM) use in anaphylaxis and glucagon injections. This covers all staff that may be present in a dental practice during a medical emergency.
In addition, all DCPs can administer non-injectable medical emergency drugs, including aspirin, oral glucose, glyceryl trinitrate (GTN) spray, oxygen and salbutamol, for the purpose of saving a life. They must be competent in the use of the drugs (Scottish Dental Clinical Effectiveness Programme (SDCEP) (2023). DCPs cannot administer the controlled drug, midazolam.
A medical emergency in a dental practice may require the response of paramedics. As such, the aims of this article are to enhance paramedics’ knowledge of dental team members that may be present at a medical emergency, their scope of practice, what qualifications they may have, what equipment is available, what drugs can be administered, and what medical emergencies present most frequently in primary dental care – the overall aim being to enhance patient care.
Members of the dental team
Because of the busy nature of a primary dental practice, staff members can vary day to day. Consequently, the roles that individuals assume in a medical emergency can and do change.
Administration staff
Receptionists and practice managers are not registered with a professional body and have limited medical training. They are not able to administer any prescription-only medicines (POMs) but are trained in basic life support (BLS), can administer cardiopulmonary resuscitation (CPR) and oxygen if appropriately trained, as well as operate an automated external defibrillator (AED). Typically, these staff members will ring emergency services, communicate crucial information to call handlers and guide attending emergency services to the patient. It is not uncommon for these staff to also be trained dental nurses.
Dental nurses
Dental nurses are registered with the GDC, with typical training being between 12 and 24 months, depending on programme structure, which includes a mix of theoretical learning and practice experience within a dental practice or dental hospital (GDC, 2024). The focus of a dental nurse is supporting dentists in providing oral healthcare, unlike an adult nurse registered with the Nursing and Midwifery Council (NMC), who focuses on providing general healthcare.
They must ‘support the patient and their colleagues if there is a medical emergency’ (GDC, 2013b). They are unable to administer POMs, but can administer injectable adrenaline, glucagon and non-injectable medical emergency drugs found in a dental practice, excluding midazolam. They are trained in BLS, can administer CPR, oxygen and operate an AED. Usually, dental nurses will be responsible for gathering the necessary medical emergency kit and drugs, as well as for record- and time-keeping. Senior dental nurses may also assess and manage the patient according to agreed emergency clinical procedures and training (SDCEP, 2014). Additionally, dental nurses can monitor blood pressure, blood glucose and oxygen saturation, as well as assume the role of team leader.
Dental hygienists and therapists
Dental hygienists and therapists are also registered with the GDC. They will possess a diploma or Bachelor of Science in either one or both subjects (GDC, 2023a). They are trained in BLS, can administer CPR, oxygen and operate an AED.
They can administer all drugs required in a medical emergency (except midazolam) that are included in the British National Formulary (BNF) ‘guidelines for medical emergencies – prescribing in dental practice’ from the National Institute for Health and Care Excellence (NICE) (2023). Midazolam is a controlled drug and, at the time of publication, cannot be administered by a dental therapist or hygienist, unless under the directive and supervision of a dentist, or if the medication is listed on a patient-specific directive (PSD) in the patients notes. It is worth noting that dental therapists and hygienists may perform the role of team leader.
Dentists
Dentists are registered with the GDC and will be in possession of a Bachelor of Dental Surgery (BDS) or equivalent (GDC, 2023b). They can fulfil all duties in a medical emergency including BLS, CPR, AED and administer all medical emergency drugs found in a dental practice. Dentists tend to assume the role of team leader in a medical emergency, but as mentioned, this is not always the case.
If a dental practice undertakes sedation, DCPs and dentists will also be required to undergo annual immediate life support (ILS) training (SDCEP, 2017).
History of prescribing and administering POM for dental hygienists and dental therapists
From 12th June 2024, amendments to the Human Medicines Regulations 2012 came into effect, allowing suitably trained dental therapists and hygienists to supply and administer specified medicines without the need for a PSD or patient-group direction (PGD) from a dentist (England 2024).
Previously, owing to an omission during the update to the Dentists Act 1984, dental hygienists and therapists were required to have either a PSD or PGD from a dentist or doctor to administer or supply POMs. A PSD is individually tailored to the needs of a patient to enable the safe supply and/or administration of medicines and to manage identified risks. A PSD requires a dentist or doctor to act as a prescriber for POMs, and would be required to be written in the individual patient clinical notes, covering name, form, strength of medicine, route of administration, dose, frequency, dates of treatment, number of doses and signature of the prescriber. A PGD is a written instruction that allows listed health professionals to sell, supply or administer named medicines in an identified clinical situation. The Human Medicines Regulations 2012 required that a PGD must be signed by a dentist and a pharmacist. In addition, for practices providing NHS primary dental services, the PGD must also be signed on behalf of the commissioning body (Evans, 2014).
Since 2019, the British Association of Dental Therapists (BADT) and the British Society of Dental Hygiene and Therapy (BSDHT) have advocated for legislative change to allow dental hygienists and therapists to supply and administer POMs under certain exemptions. The recent update to the Human Medicines Regulations 2012 now allows trained dental therapists and hygienists to supply and administer specified medicines without the need for a PSD or PGD from a dentist.
However, it is important to note that the new regulations do not extend to the administration of the controlled drug midazolam. A PSD will still be required for dental hygienists and therapists to administer midazolam in a medical emergency (The Human Medicines Regulations 2024).
For a paramedic attending a medical emergency at a dental practice, understanding the restrictions on dental hygienists and dental therapists regarding the administration of POMs is crucial. In an emergency, if a patient requires midazolam and there is no PSD documented by a dentist or doctor, the dental hygienist or therapist may be unable to administer the medication.
Paramedics need to collaborate with the dental team to verify whether a PSD exists. If not, the paramedic may need to step in to administer midazolam, especially in time-sensitive situations.
Equipment
The GDC advises that all registrants must follow guidance produced by the Resuscitation Council (UK) (RCUK) regarding medical emergencies and training (GDC, 2023c). Table 1 demonstrates the minimum equipment list for primary dental care suggested by the RCUK (2023). If the practice undertakes sedation, however, additional equipment is needed and can be found within the guidance (RCUK, 2023).
| Airway and breathing | Circulation |
|---|---|
| Protective equipment - gloves, aprons, eye protection | Automated external defibrillator (AED) |
| Pocket mask with oxygen port | Adhesive defibrillator pads |
| Portable suction | Razor |
| Oropharyngeal airways sizes 0,1,2,3,4 | Scissors |
| Self-inflating bag with reservoir (adult) | |
| Self-inflating bag with reservoir (child) | |
| Clear face masks for self-inflating bag (sizes 0,1,2,3,4) | |
| Oxygen cylinder | |
| Oxygen masks with reservoir | |
| Oxygen tubing |
Drugs
The GDC advises that dental practices follow the British National Formulary (BNF) guidance (NICE, 2023) regarding what drugs should be contained within an emergency drugs kit (GDC, 2023c). The Human Medicines Regulations 2012 allows dental therapists and hygienists to hold emergency drugs on the premises, but do not allow the medicines to be directly purchased. Dental hygienists and therapists can be practice owners. They would therefore need a prescription from a dentist or doctor for the supply of emergency drugs under a PGD.
Table 2 summarises the drugs and, if appropriately trained, the dental team members that can administer them, recommended by the BNF (NICE, 2023; SDCEP, 2023). If a practice undertakes sedation, there are additional drugs recommended.
| Drug | Admin staff | Dental nurse | Dental hygienist and therapist | Dentist |
|---|---|---|---|---|
| Adrenaline/epinephrine Injection, adrenaline 1 in 1000, (adrenaline 1 mg/1 mL as acid tartrate), 1 ml Ampoules | ✓ | ✓ | ✓ | ✓ |
| Glucagon Injection (as hydrochloride), 1-unit vial (with solvent) | ✓ | ✓ | ✓ | ✓ |
| Oxygen | ✓ | ✓ | ✓ | ✓ |
| Aspirin Dispersible Tablets 300 mg | ✓ | ✓ | ✓ | |
| Glucose (for administration by mouth) | ✓ | ✓ | ✓ | |
| Glyceryl Trinitrate Spray (GTN) | ✓ | ✓ | ✓ | |
| Salbutamol Aerosol Inhalation, salbutamol 100 micrograms/metered inhalation | ✓ | ✓ | ✓ | |
| Midazolam Oromucosal Solution (CD) | ✓ |
Source: NICE (2023); SDCEP (2023)
Frequently presenting medical emergencies
Research demonstrates that the most common medical emergencies seen in practice by dental professionals are syncope, non-specific collapse, hypoglycaemia and seizures. It is reported that these have been encountered every 1.59, 1.64, 8.26 and 10.56 years, respectively (Sin et al, 2023).
Dental professionals express lower confidence in diagnosing and managing medical emergencies such as adrenal crises, anaphylaxis, and seizures (Sin et al, 2023). While formal guidelines for managing adrenal crises in dental settings are under development (Royal College of Surgeons of England, 2023), there is a clear need for advanced training in handling anaphylaxis and seizures to boost practitioners’ confidence.
The GDC (2013a) highlights the importance of regular practice in simulated clinical scenarios and according to Sin et al (2023), in 2019, dental professionals received various forms of medical emergency training, including face-to-face BLS (62%), theoretical training on medical emergencies (50.5%), and role-play exercises (48%). Additionally, most practitioners participated in annual medical emergency training (89.2%) to maintain their competency in handling medical emergencies as a team.
Although there is already structured guidance and regular training recommended, Sin et al (2023) suggests that enhancing training could further improve outcomes. Incorporating training sessions that focus on collaboration with emergency services might be a valuable approach to advancing both confidence and competence in dental practitioners managing medical emergencies
Conclusion
There is limited guidance concerning what drugs DCPs can and cannot administer during a medical emergency. Going forward, additional guidance from regulators is needed.
Medical emergencies are an important aspect of primary dental care, making it essential for emergency services to understand the qualifications and limitations of the dental professionals they may encounter. Future training initiatives could incorporate focused sessions on collaborating with paramedics, which could further improve patient care.