943 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000/2025.943 http://dentistry3000.pitt.edu Gaps in Medical Emergency Preparedness Among Iraqi Dentists: A Na- tionwide Cross-Sectional Analysis Awf Sh. Mahmood1, Meena Muneeb2 1College of Den*stry, Al-Iraqia University, Baghdad, Iraq 2Dijlah University College, Baghdad, Iraq Abstract Objec5ve: To evaluate the preparedness of Iraqi dental practitioners in managing medical emergencies by assessing self-reported confidence, theoretical knowledge, prior clinical ex- posure, and formal training in Basic Life Support (BLS) and emergency management proto- cols. Material and Methods: A nationwide cross-sectional study was conducted from Novem- ber 2024 to March 2025 using a validated, self-administered electronic questionnaire distrib- uted to licensed Iraqi dentists. The survey assessed demographic characteristics, knowledge of emergency protocols, prior exposure to emergencies, and participation in BLS or related training. Data were analyzed using SPSS version 22 to explore associations between prepar- edness and professional or demographic variables. Results: A total of 531 dentists partici- pated; 58.9% were female, and 86% were general practitioners. Only 47.2% reported confi- dence in managing medical emergencies. Furthermore, 86.4% demonstrated moderate to low knowledge, and most had limited clinical exposure. Formal BLS/CPR training was re- ported by 35.2%, and 31.7% had attended structured emergency management courses. Prior training was significantly associated with greater confidence and preparedness (p < 0.05). Conclusion: Substantial deficiencies were identified in the emergency preparedness of Iraqi dentists, particularly in clinical exposure and formal training. These findings highlight the urgent need to incorporate mandatory BLS certification, simulation-based in- struction, and continuous professional development into dental education and licensure frameworks, aligning national practice with international standards and enhancing patient safety. Open Access Cita%on: Mahmood AS, et al. (2025) Gaps in Medical Emergency Preparedness Among Iraqi Den%sts: A Na- %onwide Cross-Sec%onal Analysis. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.943 Received: May 16, 2025 Accepted: July 6, 2025 Published: August 11, 2025 Copyright: ©2025 Mahmood AS, et al. This is an open access ar%cle licensed under a Crea%ve Commons AUrib- u%on Work 4.0 United States License. Email: Awf.sh.mahmood@aliraqia.edu.iq Introduc)on Although medical emergencies are relatively rare in dental settings, their occurrence can be life-threatening and demand immediate, competent intervention. Beyond performing routine procedures, dental practitioners are responsible for recognizing and managing acute medical events that may arise due to patients' underlying systemic conditions, anxiety, procedural stress, or adverse drug interactions [1-3]. Common emergencies encountered in dental clinics include vasovagal syncope, angina, hypoglycemia, seizures, airway obstruction, asthma exacerbations, anaphylaxis, and, in severe cases, cardiac arrest [4-6]. With the growing prevalence of chronic diseases, the likelihood of encountering such scenarios is increasing, underscoring the need for pre- paredness to mitigate preventable morbid- ity, mortality, and medicolegal conse- quences. Despite the existence of international guide- lines emphasizing the importance of emer- gency readiness, evidence suggests that many dental practitioners lack adequate training in medical emergency management [1,7]. Competence in this area requires for- mal instruction in Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), familiarity with emergency pharma- cology, and proficiency in the use of emergency equipment. Nevertheless, global studies continue to reveal deficiencies in preparedness, often attributed to limited training opportunities, insufficient regula- tory mandates, and variability in emergency protocols across clinical settings [8-10]. Fur- thermore, many dental professionals report low confidence in managing emergencies, re- flecting a discrepancy between theoretical knowledge and clinical performance [11]. Compounding this issue, the availability of emergency medications and essential equip- ment in dental clinics is frequently inade- quate, particularly in private practice set- tings. Such deficiencies can delay life-saving interventions, especially in cases where Gaps in Medical Emergency Preparedness Among Iraqi Den`sts: A Na`onwide Cross-Sec`onal Analysis Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.943 http://dentistry3000.pitt.edu 2 emergency medical services are delayed or unavailable [6,12]. In Iraq, despite the critical nature of this is- sue, there is a notable lack of data on dental practitioners' preparedness for medical emergencies. As such, this study aims to evaluate the knowledge, confidence, prior exposure, and training of Iraqi dentists re- garding emergency management. By identi- fying existing gaps, this research seeks to provide an evidence-based foundation for educational reform and policy development within a developing healthcare system. Material and Methods Study Design This descriptive cross-sectional study was conducted between December 2024 and March 2025 to assess the preparedness of Iraqi dental practitioners in managing medi- cal emergencies. The study adhered to the STROBE guidelines for cross-sectional re- search. Survey Design & Development of Ques- tionnaire A structured, self-developed questionnaire was designed by the authors based on a com- prehensive review of the literature on emer- gency management in dental settings. Con- tent validity was established through evalu- ation by five independent experts in oral and maxillofacial surgery and oral medicine, who assessed each item for clarity, relevance, and completeness. A pilot study involving 30 li- censed practicing dentists was conducted to evaluate validity and internal consistency, with refinements made accordingly before [inal distribution. The final questionnaire consisted of three core domains: 1. Demographic and professional profile, including gender, academic qualifi- cation, specialty, and years of clinical experi- ence. 2. Knowledge assessment, compris- ing 14 multiple-choice items focused on emergency recognition, pharmacologic pro- tocols, and clinical response. Each correct re- sponse was awarded one point. Total knowledge scores were categorized as high (11–14), moderate (7–10), or low (0–6). 3. Training and preparedness, cap- turing self-reported confidence in handling medical emergencies, prior exposure to such events, and previous participation in Basic Life Support (BLS), Cardiopulmonary Resus- citation (CPR), and Advanced Cardiovascular Life Support (ACLS) training courses. The complete questionnaire is available in Table 1 to support transparency and repro- ducibility. Data Collection The questionnaire was distributed electron- ically through official mailing lists of dental associations, academic platforms, and pro- fessional social media groups. Eligible partic- ipants were licensed Iraqi general dentists and dental specialists actively engaged in clinical practice. Dental students and non- practicing individuals were excluded to en- sure the accuracy and relevance of the sam- ple. A convenience sampling approach was used. Sample Size Determination The required sample size was calculated us- ing Slovin's formula, assuming a target pop- ulation of 19,000 Iraqi dentists, a 95% confi- dence level, and a 5% margin of error. The minimum calculated sample was 392. A total of 531 valid responses were collected, ex- ceeding the requirement and enhancing the generalizability of the results. Ethical Considerations Ethical approval was obtained from the Fac- ulty of Dentistry, Dijlah University (Ref No.29 on 16 October 2024). All participants were informed of the voluntary and anony- mous nature of the study, and electronic in- formed consent was obtained prior to partic- ipation and completion of the survey. Statical Analysis Data was analyzed using SPSS version 25 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequencies and percent- ages, were used to summarize categorical and continuous variables. Inferential statis- tics were applied to examine associations be- tween knowledge levels and participant characteristics. Pearson chi-square tests and post hoc analyses were used to evaluate group differences. The contingency coeffi- cient (C.C.) was calculated to determine the strength of associations among categorical variables. A p-value of 0.05 or less was con- sidered statistically significant, and out- comes were classified as non-significant, sig- nificant, or highly significant. No subgroup or sensitivity analyses were conducted beyond the descriptive and comparative statistics reported, as the primary objective was to as- sess preparedness levels and associated fac- tors within the overall study sample con- sistent with the cross-sectional design. Results A total of 531 licensed dental practitioners from across Iraq participated in this study. Of these, 313 (58.9%) were female and 218 (41.1%) were male. Most respondents (81.7%) reported less than five years of clin- ical experience, while 7.7% had practiced for 5–10 years, 4.9% for 11–19 years, and 5.6% for 20 years or more. Regarding qualifica- tions, general practitioners represented 86% of the sample (n = 457), while special- ists comprised 14% (n = 74). The sociodem- ographic characteristics of the participants are summarized in Table 2. Emergency preparedness is detailed in Table 3. Notably, 47.3% of respondents (n = 251) reported confidence in managing medical emergencies, whereas 52.7% (n = 280) did not; this difference was not statistically sig- nificant (P = 0.557). A history of encounter- ing a medical emergency was reported by 45.0% (n = 239), compared to 55.0% (n = 292) who had not (P = 0.275). In contrast, only 35.2% (n = 187) had received formal Basic Life Support (BLS) or Cardiopulmo- nary Resuscitation (CPR) training, a statisti- cally significant difference compared to the 64.8% (n = 344) who had not (P = 0.001). Furthermore, 31.7% of participants (n = 168) attended structured emergency man- agement courses, while 68.3% (n = 363) had not—a highly significant finding (P < 0.001). Knowledge was assessed using a 14-point scale covering core emergency management concepts. Overall, 13.3% of respondents demonstrated high knowledge (mean score: 11.79), 47.1% had moderate knowledge (mean score: 8.55), and 39.4% exhibited low knowledge (mean score: 4.63), as demon- strated in Table 4. Statistical analysis revealed several signifi- cant associations. Emergency exposure was significantly associated with gender [Corre- lation Coefficient (CC) = 0.179, P = 0.03] and professional qualification (CC = 0.239, P = 0.013). Confidence in managing emergencies was strongly associated with prior exposure (CC = 0.242, P = 0.003) and significantly re- lated to attendance at emergency manage- ment courses (CC = 0.201, P = 0.014). Prior exposure to emergencies was also highly as- sociated with having received BLS training (CC = 0.270, P = 0.001) and with participa- tion in emergency courses (CC = 0.256, P = 0.002). These correlations are detailed in Ta- ble 5. Discussion This study reveals significant deficiencies in the medical emergency preparedness of Iraqi dental practitioners in terms of clinical Gaps in Medical Emergency Preparedness Among Iraqi Den`sts: A Na`onwide Cross-Sec`onal Analysis Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.943 http://dentistry3000.pitt.edu 3 exposure, confidence, and formal training. Only 47.2% of respondents reported confi- dence in managing medical emergencies. This alarming figure aligns with interna- tional literature that links limited practical exposure and inadequate training to dimin- ished self-efficacy in emergency response. These findings highlight a compelling need to integrate structured, simulation-based emergency training within both undergrad- uate and postgraduate dental education in Iraq to ensure baseline competence and en- hance clinical responsiveness. The lack of clinical exposure emerged as a significant concern, with 55% of participants indicating they had never encountered a medical emergency in practice. Additionally, only 35.2% had received formal Basic Life Support (BLS) or Cardiopulmonary Resusci- tation (CPR) training, and just 31.7% had at- tended structured emergency management courses—both statistically significant gaps (P = 0.001 and P < 0.001, respectively). These deficiencies directly threaten patient safety and hinder effective emergency manage- ment. Prior research, including those by Wu et al. and Manton et al, has consistently demonstrated that repeated exposure to simulation-based scenarios significantly en- hances readiness and decision-making in acute clinical situations. [13,14]. Similarly, Anwar et al. emphasized the importance of systematic, curriculum-based emergency in- struction in bridging the knowledge-practice gap among dental professionals [15]. Comparable inadequacies have been docu- mented in regional studies. A national survey by Alotaibi et al. on BLS certi[ication rates among Saudi dentists, while Ilyas et al. and Tar Binti Midzi et al. found that the absence of formal emergency education in Malaysia and Saudi Arabia similarly compromised preparedness [16-18]. In contrast, regula- tory frameworks in the United States and the United Kingdom mandate BLS/CPR certifica- tion for licensure, with periodic recertifica- tion ensuring sustained competency. Iraq currently lacks such regulatory enforcement, exacerbating the systemic vulnerability in emergency management. Substantial inter- national evidence affirms that mandatory training and revalidation policies signifi- cantly improve preparedness and clinical outcomes [19]. Notably, years of clinical experience were not significantly associated with prepared- ness (P > 0.05), a finding consistent with Bhagat et al. [20]. This suggests that clinical tenure alone does not ensure competence re- inforces the necessity of structured, recur- rent training. However, male practitioners and dental specialists were significantly more likely to have encountered medical emergencies (P = 0.030 and P = 0.013, re- spectively), likely due to greater clinical ex- posure levels and practice environments. These patterns are consistent with observa- tions by Varoni et al., who identified clinical settings and patient caseload as critical de- terminants of preparedness [21]. Further multivariate analysis revealed that confidence in managing emergencies was significantly associated with previous clini- cal exposure (P = 0.003), participation in emergency training courses (P = 0.014), and receipt of BLS/CPR instruction (P = 0.002). These associations confirm that structured training improves theoretical knowledge, practical confidence, and operational agility. Accordingly, integrating emergency prepar- edness training into continuing professional development (CPD) frameworks and licen- sure requirements is essential for a resilient and competent dental workforce. The overall preparedness score in this study reflects a moderate to poor level of readi- ness, echoing findings from Jaber et al. and other regional studies. Given the well-docu- mented decline in emergency skills, periodic re-evaluation and refresher training are im- perative. Sustainable preparedness hinges on initial educational interventions and lon- gitudinal reinforcement through validated assessments and mandatory workshops [6,22]. Conclusions The findings reveal a substantial deficiency in medical emergency preparedness among Iraqi dental practitioners. Bridging the gap necessitates the urgent need for comprehen- sive, well-structured practical training pro- grams. Incorporating mandatory BLS/CPR certification, simulation-based training, and continuous professional development (CPD) into dental education and licensure require- ments is essential. These interventions will reinforce practitioner competence, enhance patient safety, and align emergency response protocols in Iraq with international stand- ards of care. Conflicts of Interest The authors state that there are no con[licts of interest. Financial Support This research was not supported by any grants or external funding sources. References 1. 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Medical emergencies in den- tal practice: A nationwide web-based survey of Italian dentists. Heliyon. 2023 Mar 1;9(3):e13910. Table 1. The questionnaire of the study Part (1): Sociodemographic Part Q1 Gender □ Male □ Female Q2 Years of Experience □ Less than 5 years □ 5–10 years □ 10–19 years □ More than 20 years Q3 Qualification □ General practi- tioner □ Specialist Part (2): Knowledge-Based Assessment Q4 What is the most frequently encountered medical emergency in dental practice? A. Syncope B. Hypoglycemia C. Allergic Reaction D. Seizure Q5 A 25-year-old asthmatic patient begins wheezing and has difficulty breathing during a dental procedure. What should be done initially? A. Administer Oxy- gen B. Administer an ep- inephrine IM injec- tion C. Administer albut- erol D. Call emergency medical as- sistance Q6 A diabetic patient, during a dental proce- dure, feels sweaty, tired, disoriented, and has a headache. The condition is most likely: A. Hyperglycemia B. Hypoglycemia C. Angina D. Anaphylaxis Q7 During a dental procedure, a young adult patient loses consciousness, followed by generalized tonic-clonic movements; af- ter 2 minutes, the seizure subsides, but the patient remains unconscious. What is the next immediate step in managing this con- dition? A. Administer 5 mg midazolam B. Activate emer- gency medical ser- vices C. Place the patient in a recovery position and maintain the air- way D. Monitor vital signs and wait for the patient to regain con- sciousness Q8 An adult male patient feels dizzy and sweaty and experiences crushing pain ra- diating down the left arm, neck, and man- dible, associated with nausea and vomit- ing. The condition is most likely: A. Angina B. Insulin shock C. Asthmatic attack D. Myocardial infarction Q9 When do most medical emergencies oc- cur in dental practice? A. During treatment B. Immediately after treatment C. 2–3 hours after treatment D. During or shortly after local anesthesia injection Q10 What is the primary cause of syncope in the dental office? A. Anxiety B. Hypertension C. Overexertion D. Prolonged treatment Q11 What is the immediate action when a pa- tient experiences syncope during dental treatment? A. Place the patient in the Trendelenburg position B. Ask the patient to sit in an upright posi- tion C. Recline the patient and give oral glucose D. Place the patient on their side Q12 A conscious adult patient complains of difficulty breathing and speaking, holding their neck with one hand. The probable di- agnosis is: A. Asthma – give al- buterol B. Angina – adminis- ter Oxygen C. Aspiration of a foreign body – Heim- lich maneuver D. Respiratory arrest – back blows Gaps in Medical Emergency Preparedness Among Iraqi Den`sts: A Na`onwide Cross-Sec`onal Analysis Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.943 http://dentistry3000.pitt.edu 5 Q13 A diabetic patient shows symptoms of rapid pulse and pale, cold, and clammy skin. What is the first line of treatment? A. Oral glucose B. Glucagon 1 mg in- jection C. Sublingual nitro- glycerine D. Oxygen Q14 A young adult patient suddenly becomes pale with a flushed face and develops shortness of breath and gasping. The best action is: A. Epinephrine 1 mg/mL IM B. GTN 400 mi- crograms C. Salbutamol in- haler 100 mi- crograms D. Dispersible aspirin 300 mg Q15 A young adult patient suddenly becomes pale with a flushed face and develops shortness of breath and gasping. The best action is: A. Epinephrine 1 mg/mL IM B. GTN 400 mi- crograms C. Salbutamol in- haler 100 mi- crograms D. Dispersible aspirin 300 mg Q16 What is the best position for a conscious patient who has developed a myocardial infarction, and which drug would you choose for such a condition? A. Comfortable posi- tion and Aspirin B. Supine position and Aspirin C. Reclined position and Oxygen D. Supine position and Oxygen Q17 What is the best treatment for a patient who has crushing pain extending to the neck and jaw? A. Aspirin B. Sublingual glyc- eryl trinitrate C. IV saline infusion D. Insulin SC Answer Key – Questions 4 to 17 4. A | 5. C | 6. B | 7. C | 8. D | 9. D | 10. A | 11. A | 12. C | 13. A | 14. A | 15. A | 16. A | 17. B Part (3): Training and Preparedness Assessment Q18 Do you feel confident in handling medical emergencies during dental procedures? □ Yes □ No Q19 Have you ever encountered a medical emergency during a dental procedure? □ Yes □ No Q20 Did you receive practical Basic Life Sup- port (BLS) or cardiopulmonary resuscita- tion (CPR) training? □ Yes □ No Q21 Have you attended any courses in the management of medical emergencies? □ Yes □ No Table 2. Sociodemographic characteristics (SDC) of the participants. SDC Groups No. % Gender Male 218 41.1 Female 313 58.9 Years of Experience < 5 yrs. 434 81.7 5 - 10 yrs. 41 7.7 11 - 19 yrs. 26 4.9 ≥ 20 yrs. 30 5.6 Qualification GP 457 86 Specialists 74 14 Gaps in Medical Emergency Preparedness Among Iraqi Den`sts: A Na`onwide Cross-Sec`onal Analysis Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.943 http://dentistry3000.pitt.edu 6 Table 3. Confidence, exposure, and trainingrelated to medical emergency preparedness. Table 4. Knowledge level stratification of participants based on a 14-point assessment scale. Knowledge Score No. of Participants % of Sample Average Score Mini- mum Score High Knowledge (11–14 points) 71 13.3 11.79 11 Moderate Knowledge (7–10 points) 251 47.1 8.55 7 Low Knowledge (0–6 points) 209 39.4 4.63 0 Note: Scores reflect participant responses on a 14-point knowledge assessment scale. Questions Response n % P-value Confident in handling medical emergencies? Yes 251 47.3% 0.557 No 280 52.7% Have you encountered a medical emergency previously? Yes 239 45.0% 0.275 No 292 55.0% Have you received BLS/CPR training? Yes 187 35.2% 0.001 No 344 64.8% Have you attended emergency management courses? Yes 168 31.7% <0.001 No 363 68.3% Gaps in Medical Emergency Preparedness Among Iraqi Den`sts: A Na`onwide Cross-Sec`onal Analysis Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.943 http://dentistry3000.pitt.edu 7 Table 5. Correlation analysis of exposure, confidence, training, gender, and professional qualification. Variables Analyzed Correlation CoefJicient (CC) P-value Gender and Emergency Exposure 0.179 0.03 Quali[ication and Emergency Exposure 0.239 0.013 Con[idence and Prior Exposure 0.242 0.003 Con[idence and Emergency Course Attendance 0.201 0.014 Encountered Emergency and BLS Training 0.270 0.001 Encountered Emergency and Emergency Course Attendance 0.256 0.002 CC: Correlation Coef[icient; HS: Highly Signi[icant (P ≤ 0.01); S: Signi[icant (P ≤ 0.05)