Some of the most important lessons may be about doing less—but doing it exceptionally well.
By Duane Tinker – The Toothcop
Dental Compliance Consultant | Former Investigator | NREMT
I started in EMS more than 30 years ago.
One thing emergency medicine has taught me is that what we were taught years ago isn’t necessarily what we’re doing today.
Protocols change.
Equipment changes.
Procedures change.
Sometimes something we considered “advanced” turns out not to improve outcomes simply because it is more advanced.
That’s what evidence-based medicine is supposed to do.
So as dentistry begins taking medical emergency preparedness more seriously, maybe we should ask:
What has EMS already learned that dentistry should be paying attention to?
I’d start with the airway.
1. BVM First. Advanced Airway Later—Maybe.
If a patient isn’t breathing adequately, do we immediately need an advanced airway?
No.
Current American Heart Association guidance says airway management during adult cardiac arrest generally begins with a basic strategy such as bag-mask ventilation. Either bag-mask ventilation or an advanced airway strategy may be considered depending on the circumstances and the skill of the healthcare provider.
The pediatric evidence is even more interesting.
For infants and children experiencing out-of-hospital cardiac arrest, the 2025 AHA/AAP guidelines say it is reasonable to use bag-mask ventilation rather than an advanced airway intervention such as endotracheal intubation or a supraglottic airway.
Think about what that could mean for dentistry.
Maybe we should spend less time worrying about whether every sedation dentist can intubate and considerably more time making sure the clinical team can perform really good BVM ventilation.
Good positioning.
Good mask seal.
Open airway.
Visible chest rise.
Appropriate ventilation.
And preferably the ability to perform a coordinated two-person technique when personnel are available.
That sounds basic.
It isn’t.
2. OPA, NPA, or Supraglottic Airway?
This really isn’t an either/or question.
An oropharyngeal airway or nasopharyngeal airway helps maintain an open airway.
A supraglottic airway—such as an i-gel or LMA-type device—provides a more advanced means of establishing and maintaining ventilation.
They’re not interchangeable.
And neither eliminates the need to know how to ventilate.
The federal evidence-based guideline for prehospital airway management recognizes bag-mask ventilation, supraglottic airways, and endotracheal intubation as different airway-management strategies rather than assuming everyone needs an endotracheal tube.
AHA takes a similar approach. When an advanced airway is used during adult cardiac arrest, either a supraglottic airway or endotracheal tube may be used depending in part on the system and the provider’s ability to maintain successful intubation performance.
That last part matters.
Can you actually do it?
Not:
Were you trained to do it?
Not:
Did you demonstrate it five years ago?
Can you successfully perform that procedure today, under pressure, on a real patient?
That’s a very different question.
3. Advanced Doesn’t Automatically Mean Better
This may be the biggest lesson dentistry can take from evidence-based EMS.
Endotracheal intubation sounds more sophisticated than holding a mask on somebody’s face and squeezing a bag.
It is.
But more sophisticated doesn’t automatically mean better for every patient, provider, or environment.
AHA specifically recognizes potential complications associated with advanced airway placement, including interruption of compressions and failed or misplaced airways. It also recommends frequent experience or frequent retraining for healthcare professionals performing endotracheal intubation during cardiac arrest.
That should get our attention.
How many dentists performing sedation have frequent experience with emergency endotracheal intubation?
Some absolutely do.
Others don’t.
So perhaps the question shouldn’t be:
“What’s the most advanced airway this dentist was trained to place?”
Maybe it should be:
“What’s the least invasive intervention we can perform reliably that effectively oxygenates and ventilates this patient?”
That’s a very different way of thinking about emergency preparedness.
4. Pediatrics May Teach Us the Most
This gets particularly important with children.
Pediatric cardiac arrest commonly develops following progressive respiratory failure or shock rather than beginning as a primary cardiac event. That’s one reason ventilation and oxygenation play such an important role in pediatric resuscitation.
Now think about the sedated pediatric dental patient.
Respirations become inadequate.
Then slower.
Maybe the airway obstructs.
Oxygen saturation falls.
Hypoxemia worsens.
Bradycardia develops.
Eventually, the child arrests.
Where do we want the dental team to intervene?
Way up here.
Before the cardiac arrest.
Recognize respiratory depression.
Open the airway.
Reposition.
Ventilate.
Support oxygenation.
Reverse the cause when appropriate.
Get help moving.
That’s rescue.
And it may be far more important than proving someone can remember the pediatric cardiac-arrest algorithm after the child becomes pulseless.
So Where Should Dentistry Start?
If we were going to build an evidence-based dental emergency model from the ground up, I wouldn’t start by buying more equipment.
I’d start with three questions:
1. Can we recognize deterioration early?
2. Can we effectively oxygenate and ventilate the patient?
3. Can we perform exceptional BLS while getting EMS to the patient quickly?
Then we build from there.
Airway positioning.
Suction.
BVM.
OPA/NPA when appropriate.
Supraglottic airway when indicated and when the provider has been trained and remains competent to use it.
Advanced airway management when appropriate to the provider, environment, patient, and actual current competency.
Notice the progression.
We’re not choosing equipment because one device is more advanced than another.
We’re solving a problem.
· Is the airway open?
· Is the patient breathing adequately?
· Can we ventilate them?
If yes, don’t complicate things just to demonstrate a more advanced skill.
If no, escalate.
The Toothcop’s Take
Maybe dentistry has spent too much time asking what emergency equipment should be in the office and not enough time asking what emergency skills the team can/should actually perform.
Having a BVM doesn’t mean your team can ventilate a patient.
Having an OPA doesn’t mean anyone knows when or how to use it.
Having an i-gel doesn’t mean someone can place it under pressure.
And having an ACLS or PALS card doesn’t necessarily mean the provider should attempt every advanced intervention taught in those courses.
Evidence-based emergency care asks a better question:
What does this patient need right now—and can this team perform it competently?
That’s one of the lessons I think dentistry should take from EMS.
Sometimes the best intervention isn’t the most advanced one.
It’s the intervention that works.
And if we’re serious about improving medical emergency preparedness in dentistry, I think airway management and effective ventilation are very good places to start.
Duane Tinker – The Toothcop
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