Catastrophic preparedness should be incorporated into the dental school curriculum. The experience at New York University College of Dentistry is that a combination of catastrophic preparedness elements integrated within existing courses with a short, meaningful capstone course dedicated to all hazards preparedness can be accomplished successfully and meet proposed competencies for training in the dental curriculum. The roles and responsibilities in catastrophic response preparedness and response of dentists are actively being discussed by the dental profession. An element of that discussion has to include the “what” and “how” of education and training for dentists at the predoctoral level and after dental school graduation. The concepts presented in this article should be debated at all levels of the profession.
The events of September 11, 2001 and the subsequent anthrax scare triggered an unprecedented concern for public health preparedness and uneasiness about the nation’s capacity to defend itself against and respond to another terrorist attack. This awareness prompted the public health community to focus on ways to increase surge capacity by increasing the number of available and trained personnel to respond to mass casualty events. In early 2002, the leadership of the New York University College of Dentistry (NYUCD) sought to define a role for the dental profession in response to the new threats of terrorism the United States was facing. One initiative proposed expanding the dental school curriculum to include bioterrorism studies and training across the 4 years of dental education to prepare dentists to respond and contribute to a public health disaster.
In parallel, the American Dental Association began to focus on defining the role of dentists in responding to a bioterrorism attack. The specific areas of concern were (1) what preparation was required to respond to an attack, including the appropriate role of dental schools in training dentists to respond and (2) to what extent, if any, training should be mandated. The outcome of a consensus meeting was that bioterrorism training should occur within the dental school predoctoral curriculum and that all dentists should receive at least a basic level of bioterrorism training, including training that would enable them to recognize diseases and provide treatment and preventive measures under the direction of a responsible emergency response agency .
The American Dental Association and the American Dental Education Association then cosponsored a workshop entitled “Terrorism and Mass Casualty Curriculum Development.” Participants recommended that core competencies be taught to all dental students to familiarize them with the potential agents that might be used in an attack, prepare them to respond to a significant attack, and create a cadre of aware health care professionals who could serve as a source of surveillance information in the event of an attack. The workshop participants concluded that although the addition of new courses related to bioterrorism to the curriculum would allow for more extensive training, the already crowded predoctoral curriculum leaves little room for the addition of entirely new courses. A more realistic approach would be to incorporate materials to address the core competencies into existing courses .
Proposed updated American Dental Education Association guidelines for competencies of graduate dentists also include the ability to “develop a catastrophic preparedness plan for the dental office,” a component of best practices that addresses the personal professional level response to a catastrophic event . To achieve this goal, a minimal understanding of disaster agents/consequences/responses must be learned either through dental school training or continuing education. The knowledge and skills to meet this American Dental Education Association competency are immediately transferable to the dentists’ and staffs’ homes and families. With this new skill, dentists—respected community members—are positioned to positively influence the local response planning at the governmental, agency, and local organizational levels.
Private dental practice and dental educational institutions provide a community health care resource that has the potential to provide assistance to prevent, prepare, respond, and recover during a catastrophic event. A survey of dental and medical school deans and state dental society presidents demonstrated that key professional and educational leadership consider dentists to have skills that can be part of a disaster response; in fact, they have an ethical obligation to provide assistance during the response to such an event. To be effective, however, they agreed that some type of significant additional training and integration into an organized response system is needed . Through existing, formal opportunities in advanced training and participation in organized responder systems, hospital-based and public health dentists are a particularly valuable potential pool of skilled persons who can fill important roles during a response.
Catastrophic preparedness education and training for dentists and dental personnel is based on predoctoral initial basic competencies, postdoctoral training competencies, elective continuing education, and special, advanced programs for some dentists. Table 1 outlines a concept of this training and educational spectrum. This article presents (1) how faculty become trained in catastrophe preparedness, (2) proposed predoctoral dental competencies, (3) an approach to integrating catastrophic event basic science issues into the dental school curriculum, (4) a description of the capstone catastrophe preparedness course, and (5) suggestions on postdoctoral training components, continuing education recommendations, and advanced responder opportunities for dentists.
|Predoctoral||Postdoctoral||Continuing education||Advanced responder|
|Basic science integration||Basic medicine principles a||Basic science aspects||Community emergency response team|
|Office management||Basic surgical principles a||Office management||Medical reserve corps|
|Basics in catastrophic events||Basic trauma principles a||Basics in catastrophic events||National disaster medical systems|
|Core disaster life support||Principles of triage||Principles of triage|
|Advanced cardiac life support||Advanced cardiac life support|
|Basic disaster life support||Basic disaster life support|
|Institution disaster plan||National incident command system|
|National incident command system|
One of the most important issues related to introducing catastrophic preparedness into the dental school curriculum was the necessary preparation and training of the dental faculty. New York City remains on one continuous post-9/11 alert; every day the people of New York City see heightened subway security with National Guard soldiers at the major train stations and heavily armed police at the bridges and tunnels. Add to the mix potential natural disasters and threats such as avian flu, and the concept of having to do more to prepare is never out of mind of a responsible health care professional.
In response to the NYUCD dean’s vision to define a role for the dental profession in the months after 9/11, faculty with varied backgrounds stepped forward. This group shared the willingness and a sense of duty to contribute in this national emergency. They were dentists who had backgrounds in microbiology, epidemiology, oral pathology, oral medicine, or general dentistry, and some—but not all—had military experience. The interested faculty developed their individual skills and knowledge as essential components toward achieving the goal of improved expertise within the college on matters related to bioterrorism. The development of the individual faculty members and the success and enthusiasm of the new program were linked together .
The curriculum goal was all hazards training: incorporating a multidisciplinary mindset into the dental school curriculum to enhance medical and public health capabilities during time of crisis when current response resources at the national and local level would likely be overwhelmed. The faculty members involved with the catastrophic preparedness development participated in a diverse set of activities to bring themselves and the group to a satisfactory level for curriculum development in all-hazards training. Several notable activities assisted in the process for training and curriculum development. First, an expert panel was established to standardize and certify faculty instructors for preparedness and disaster response training. The expert panel included eight dental faculty members, two oral and maxillofacial surgeons, two pediatric dentists, one oral medicine specialist, one general practitioner, and two additional with military command and chemical, biologic, radiologic, nuclear, and explosive expertise. Their objective was to set the standards.
Dental and medical school and nursing faculty attended comprehensive 5-day training courses at Fort Sam Houston in San Antonio, Texas. These courses were designed by the US Army’s Nuclear, Biological and Chemical Sciences Division of the Army’s Health Sciences School. The purpose of this training was to enhance the knowledge base regarding bioterrorism and weapons of mass destruction, including chemical, biologic, radiologic, nuclear, and explosive devices. The course also outlined the role of military dentists as triage officers on the battlefield, delineated the role of the government agencies in the chain of command, and engaged the participants in case seminars and a field exercise designed to enable the participants to experience setting up a decontamination station and effectively treating casualties in a simulated terrorist attack .
Three faculty pioneered and completed didactic and clinical training in mass casualties/biologic and chemical triage by participating in a series of courses conducted by the American Medical Association (AMA) on disaster life support from core through basic and advanced levels (core disaster life support [CDLS], basic disaster life support [BDLS], and advanced disaster life support [ADLS], respectively). These courses stressed a comprehensive all-hazards approach to help physicians and other health professionals deal with catastrophic emergencies from man-made acts and explosions, fires, natural disasters, and the outbreak of infectious diseases . These faculty members are certified trainers able to conduct the CDLS and BDLS courses.
Under the direction of the New York City Department of Health, points of distribution (POD) exercises have been conducted at the NYUCD. In the case of a natural epidemic or bioterrorist attack, mass prophylaxis or vaccinations may be required. To dispense antibiotics or vaccine to the public, PODs would be set up, requiring thousands of health professionals as staff. In these PODs, clinic roles are assigned to each health professional based on his or her skills and licensure. Hundreds of NYUCD faculty and students participated, expanding the trained reserve .
Three faculty members participated in six disaster response seminars developed by NYU Medical School’s emergency medicine faculty and participated in a mini-internship in the emergency medicine department at Bellevue Hospital where, under the direction of emergency room physicians, they were exposed to the skills of rapid patient evaluation and the search for underlying systemic disease . Nine faculty members were trained by the New York Department of Health and Mental Hygiene in telephone triage for an avian flu outbreak. Five of these participants are currently part of New York City’s Medical Reserve Corps (MRC) specifically assigned to the health department for telephone triage duties.
These dental faculty members became the core group of faculty instructors who currently teach undergraduate and postgraduate students and conduct continuing education courses that have enabled NYUCD to become a recognizable and accredited center for basic and advanced level of training in CDLS and BDLS.
Dental student competencies
There are predictable challenges to be addressed when developing curriculum for predoctoral students. One challenge is to accept that dental curricula are overcrowded with clock hours. Curriculum committees usually demand that something be cut when faculty propose new subjects. How do we add content that is viewed as essential within the context of the dental curriculum? A second challenge is to determine what content is appropriate to add. A third challenge is constructing content that is carefully integrated into curriculum. Developing competencies early in the process served as a template to develop specific content material that meets the needs of entry-level dentists regardless of where they practice.
A few assumptions guided us as we developed competencies for our predoctoral students: (1) Catastrophic events take different forms, none of which is predictable. (2) Most dentists are less likely to be first responders and more likely to be community resources in an integrated response. (3) Dentists, by virtue of their overall education, have skills that can be applied directly or adapted easily when needed. Integration within current instruction had to be the hallmark of any new education programs. (4) Dentists who were willing to be first responders would need additional education beyond their predoctoral education. (5) Dentists, as members of their community, would be accountable for developing personal protection plans to ensure their safety and survival so that they would remain community resources. (6) Dentists, regardless of their education, faced the ethical dilemma of deciding whether to join in their community’s response or stand aside.
Based on these assumptions, we developed the following competencies for dental graduates :
Competency 1: Describe the potential role of dentists in the first/early response in a range of catastrophic events.
Competency 2: Describe the chain of command in the national, state, and/or local response to a catastrophic event.
Competency 3: Demonstrate the likely role of a dentist in an emergency response and participate in a simulation/drill.
Competency 4: Demonstrate the possible role of a dentist in all communications at the level of a response team, the media, to the general public, and to patient and family.
Competency 5: Identify personal limits as a potential responder and sources that are available for referral.
Competency 6: Apply problem solving and flexible thinking to unusual challenges within the dentist’s functional ability and evaluate the effectiveness of the actions that are taken.
Competency 7: Recognize deviations from the norm, such as unusual cancellation patterns, symptoms of seasonal illnesses that occur out the normal season, and employee absences, that may indicate an emergency and describe appropriate action.