Dentistry has valuable assets, both in personnel and facilities, to bring to the initial response to a mass casualty event when the local traditional medical system is overwhelmed. This article describes the services dentists can provide to allow physicians to provide the services only they can provide. The education and training of dentists that is required for preparation and the need to develop an integrated emergency response plan are discussed.
It is evident from recent catastrophic events that the traditional medical care system may be overwhelmed because many medical centers operate close to capacity on a daily basis. Add the generation of mass casualties by a major incident or a significant bioterrorism attack into the equation, and a basic life-saving response by the existing medical care system becomes nearly impossible. Unfortunately, the current world geopolitical environment makes such a scenario entirely possible—some say inevitable. There is a need to marshal all available resources in response to a disaster of great magnitude if losses and disruption of everyday life are to be minimized and recovery facilitated.
Professionals who plan and manage emergency responses must reach out to groups that have assets to contribute to the response effort but are not intrinsically tied to the medical response (eg, hospital personnel). Dentists and dental staff are examples of such groups. For a long time, dentistry has played a well-acknowledged role in participating in the recovery from mass casualty events, such as natural disasters, bombings, and transportation accidents, primarily in the forensic identification of victims when identities cannot be established by conventional means. Some individual dentists also have participated in victim rescue and treatment.
For the most part, the dental profession is a loosely organized network of individual practitioners. There are approximately 175,000 professionally active dentists in the United States, and they are distributed in a manner much like that of the general population . They own, equip, and supply the office facilities in which they provide oral health care. Approximately 85% of dental practices in the United States are solo practices, and 11% are made up of two dentists . The consolidation that has characterized many industries and businesses in the United States, including medicine, has not occurred in dentistry. Only a small proportion of dental care is provided in a hospital setting. In contrast to medicine, most dental care is provided to patients by one primary care dentist in one facility. The average dental office is essentially a mini-hospital or an outpatient clinic. It is equipped with radiographic capability, sterilization equipment, central suction, medical gasses and various anesthesia capabilities, suites with surgical lighting, some surgical equipment and supplies, laboratory space, and administrative areas for records and patient reception. Trained and experienced office staff are present to operate in these areas. Dental offices are dispersed throughout the community.
Dentists are exposed to information in many general medical areas during their predoctoral education that can be useful in disaster response situations. They also routinely perform many tasks that emergency responders may be required to do, such as perform minor surgery, dispense drugs, give injections, and administer anesthesia. It should be apparent from this description that dentistry has much to contribute to the response to a major disaster in terms of personnel and facilities when the traditional medical care system in an area is overwhelmed. This article describes how dentists and allied dental staff can help respond to major disasters.
After the seminal events that occurred in the fall 2001, particularly the deliberate attempts to spread weapons-grade Bacillus anthracis spores through the US mail system , the American Dental Association convened two workshops to determine how dentistry could contribute to the response to mass casualty disasters and how dentistry could become better prepared to respond: (1) a workshop on the role of dentistry in bioterrorism , cosponsored by the US Public Health Service, and (2) a workshop on terrorism and mass casualty curriculum development , cosponsored by the American Dental Education Association. A wide variety of emergency response experts and stakeholders in dentistry attended these workshops. Consensus was reached at these workshops on both subjects, including plans for implementing the suggestions that were developed. Because responses to these disasters are directed by local emergency response agencies, it was determined that the responsibility for dental participation in the response effort must lie with the local dental societies. They were promised to receive assistance and advice from the American Dental Association in developing and organizing dentistry’s response. They also were advised that any plans they develop must be done with the participation of the local emergency response community so that the dental response plan can be fully integrated into the local plan.
It is generally thought that dentistry can be of greatest assistance immediately after the occurrence of a mass disaster before the full force of federal assistance can be mobilized effectively. During recent disasters, this mobilization time varied from a few days to a week. Many victims of disasters cannot wait that long for help. When local medical resources are unable to cope adequately with a huge number of victims, dentists can be recruited to provide certain services that will allow physicians to do things only they can do. Dentists can enhance the surge capacity of the local medical system until additional physicians arrive or the demand for immediate care decreases.
How dentists can help
The prime purpose of recruiting the assistance of dentists in responding to mass casualty incidents is to enable crisis managers to use scarce physician resources in the most effective manner possible by having some services they would ordinarily provide be successfully provided by dentists where possible. Local circumstances (ie, the medical needs and resources of the community after a disaster and the nature of the disaster) determine how dentists can be of assistance. Some assigned duties do not tax the dentist’s knowledge or experience (eg, dispensing medications or immunizations), whereas others may require additional training or some supervision (eg, providing basic medical care in quarantine situations). There are several general areas of response activity in which dentists can be helpful .
Some mass casualty events are distinct entities easily recognized and of easily defined duration and effect on a population (eg, a severe weather event). Other disasters, particularly bioterrorism attacks and pandemics, often have relatively indistinguishable beginnings and ends and unpredictable effects on a population. Because of the variable incubation periods of infectious agents, the time of exposure can be estimated only after the resultant disease has manifested. It also may take up valuable time to determine that a population-wide problem actually exists. Dentists can be part of an effective surveillance network because they are scattered throughout a community much as the general population is and are visited by patients who are generally medically healthy and have not seen a physician. Observation of intraoral or cutaneous lesions or both when they are present and the notification of public health authorities about these observations may facilitate the early detection of a bioterrorism attack or spread of a pandemic infection. Early detection of an infectious agent in a population may allow for reduction in the number of casualties by prompt initiation of preventive and therapeutic intervention.
Sales of over-the-counter medications are often monitored in the epidemiology community as a potential early warning of community-wide infections. Monitoring of unusual and unexplained “no show” patients in dental offices also may help provide an early warning. A reporting network and a real-time analytic mechanism involving other inputs also must be established for this to be of value in early detection.
Referral of patients
Patients who show early signs or symptoms of infectious diseases, have suspicious cutaneous lesions, or are suspected of having such diseases may be referred to a physician for a definitive diagnosis and appropriate treatment, if necessary. This referral may be important because early treatment or early initiation of prophylaxis can have a significant influence on the outcome of the patient’s encounter with the disease. The clinical course of smallpox, for example, can be ameliorated by vaccination even after the patient has been infected.
Diagnosis and monitoring
After an infectious disease that causes mass casualties has been identified, dentists who are able to recognize the signs and symptoms of that disease may be able to identify afflicted patients. Dentists can collect salivary samples, nasal swabs, or other specimens when appropriate for laboratory processing that may yield valuable diagnostic information or indication of the progress of treatment, including the status of the patient’s infectiousness.
In the effective response to any mass casualty event a system must be established to prioritize treatment among casualties, because immediate treatment for all casualties is not possible because of inadequate resources in personnel, facilities, and medical supplies. Dentists are able to assist in this important function with relatively little additional training. This assistance allows physicians to provide definitive care for patients most urgently in need rather than screening casualties. Dental offices could serve as triage centers if needed.
To limit the spread of infectious agents, whether from a natural pandemic, a deliberate bioterrorism attack, or contamination as a result of a local event, rapid immunization of great numbers of individuals may be required in a short amount of time. In major metropolitan areas, where the spread of communicable disease is facilitated, this effort may involve millions of people. Physicians and nurses may be unable to implement such a program in the critical time frame required. Dentists can participate in mass immunization programs with a minimum of additional training and may be the critical factor in the success of urgent programs. Dental offices can be used as immunization sites to minimize the concentration of potentially infected persons.
In mass casualty situations, particularly after a bioterrorism attack or the unfolding of a pandemic infection, the population may require medication to treat or prevent the manifestation of the infection being faced. Physicians, nurses, and pharmacists may not be able to effectively prescribe or dispense the medications necessary in the critical, appropriate time required. Dentists can be called on to prescribe and dispense the medications required after that determination has been made by the physicians and public health officials managing the disease outbreak. Dentists also can monitor patients for adverse reactions and side effects and refer patients who experience untoward effects from the medications to physicians for treatment, if necessary. Dentists also can be used as sources of information for patients concerning the medications they are using by communicating information on proper use, problems that may occur and their manifestation, and the need for compliance. Dentists can monitor the effectiveness of the treatment regimen.
Dentists and dental auxiliaries practice sound infection control procedures in their offices on a daily basis. They are well versed and well practiced in infection control and can bring their expertise to mass casualty situations, particularly situations that involve infectious agents, to limit the spread of infection among individuals and between patients and responders who are rendering assistance. Decontamination of casualties from certain bioterrorism attacks in which contact with patients’ clothing or skin surfaces may spread the agent to caregivers may be accomplished by dentists with some additional training. Dentists who are familiar with disaster mortuary activities can be useful in managing the remains of victims whose death is a result of the event, particularly infectious events. These remains most likely will be contaminated and require careful management to prevent further disease spread.
In addition to providing services that dentists ordinarily do, they may be able to augment or participate in the treatment provided by medical and surgical personnel. Dentists have training and experience in many areas that may be a part of casualty care in mass casualty events:
Treating oral, facial, and cranial injuries
Providing cardiopulmonary resuscitation
Obtaining medical histories
Collecting blood and other samples
Providing or assisting with anesthesia
Starting intravenous lines
Suturing and performing appropriate surgery
Assisting in patient stabilization
Assisting in shock management
During a pandemic or after a bioterrorism attack with a communicable agent, strict quarantine restrictions may be imposed on the geographic area contaminated and its environs to help prevent or control the spread of the disease to other areas. The duration of the quarantine varies according to the incubation time of the agent and other factors. Before the existence of the area-wide contamination is established, primary care providers may become infected directly or through contact with patients seeking care. During the period of quarantine they may become disabled by the disease or even die. Dentists may not be similarly infected by patients because ill patients do not seek care from dentists and, if sufficiently ill, do not keep scheduled dental appointments, which minimizes intimate contact with infected persons. Dentists may be called on to provide some primary health care for people in the quarantined area.