In India and abroad, dentists are subjected to medical and surgical training during their pre-doctoral education that makes them useful in disaster management situations. They are also trained for handling medical emergencies in dental clinics and hospitals such as performing minor surgery, dispensing of drugs, giving injections and administration of anaesthesia [2]. Specialized dental surgeons or oral and maxillofacial surgeons (OMFS) are also capable of administering anaesthetic and surgical services to patients with many types of injuries. OMFS apart from treating dentoalveolar injuries and facial fractures are also efficient in handling trauma patients and can provide first aid, including endotracheal intubation and cardiopulmonary resuscitation [4].
The initial training obtained by the dental professionals during their graduate degree makes them important in terms of catastrophic events in the following ways [5]:
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Well trained in sterilization techniques and infection control methods
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Trained in drug delivery methods including injection
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Expert in suturing techniques and bleeding controlling methods
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Proficient in participating in interdisciplinary professional groups, and
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Trained in handling uncomfortable patients
However, these services can also be provided by other health professionals like the physicians, pharmacists and nursing professionals. But in a mass disaster scenario, when there is shortage of physicians the role of dentist becomes more important as only dentists have the standard training for carrying out these services both at undergraduate and at postgraduate level and can be a best substitute. No other profession has undergraduate training that so closely parallels that of the physician as does the training of the dentist.
By virtue of training and practical experience, dentists possess a high degree of manual dexterity together with excellent hand and eye coordination in the treatment of patients, frequently under extreme conditions of pain and infection.
Moreover, the primary role played by dentists in disasters has been in the form of forensic odontology [6, 7] and the assistance of dental members in Disaster Mortuary Operational Response Teams [7]. Dentists are also employed in the armed forces sector for their valuable services [8]. Instead, an additional training is required in medical and nursing education for performing these functions [9]. Thus, to incorporate the participation of other non-physician and nurse healthcare groups such as dental hygienists, pharmacists, podiatrists, and mental health workers in such services, particular areas of surge manpower need to be identified and the underlying training required by healthcare professionals including dentists; thus, surge roles can be addressed and the necessary skill sets can be incorporated into the education of these professionals.
The services rendered by dental professionals during a major public health disaster are described in detail as follows:
Dental Surveillance
Bioterrorism attacks and pandemics often have relatively indistinguishable beginnings and ends and unpredictable effects on a population. Surveillance is important in conditions when there is increased influx of patients with symptoms of paralysis or neurology, or infection, which is non-traumatic. The presence of dental offices in nearly every community makes it very important in a catastrophic disaster. Thus, dentists can be a part of effective surveillance network by getting updated on the information on unusual syndromes in the community as well as unusual clinical presentations [10]. For example, dentists can notify the public health authorities about the presence of patients with intra-oral or cutaneous lesions or both, thus facilitating the early detection of a bioterrorism attack or spread of a pandemic infection. In this way, an early detection of an infectious agent in a population can lead to reduction in mass casualties by prompt prevention and therapeutic methods. This criterion also makes dentists unique amongst all other health professionals.
Dental Offices Acting as Medical Sites
Dental offices are equipped with potentially useful equipment and supplies that prepare it to serve as decentralized auxiliary hospitals in case the need arises [6]. Availability of air and suction lines, X-ray equipment and sterilizing techniques in dental offices can be used as self-contained alternate medical sites if hospitals are under attack or are unsafe because of widespread infection associated with biological weapons [10]. No other health professional has such well-equipped clinic to provide as alternative medical site for use during an event of catastrophic disaster.
Distribution of Medication
During medical emergency situations, it may be possible that physicians, nurses and pharmacists are not able to effectively prescribe or dispense the medication necessary in the critical and appropriate time. This calls for a dentist who can prescribe and dispense the required medications, after the outbreak of the disease has been determined by the physician and public health officials managing it. Patients can be monitored by dentists for adverse reaction and side effects, and if necessary, they are also referred to physicians for treatment of untoward effects from the medications [6, 7]. Dentists can also be a source of information about the medication and its proper use, side effects and the need for compliance for the patient [11].
Immunization
In major metropolitan areas, where the spread of communicable disease is facilitated, this effort may involve millions of people. The number of physicians and nurses available may not be able to implement immunization program in limited time. In urgent programs, trained dentists can participate in mass immunization programs. Dental clinics can also be considered as immunization sites to minimize the concentration of potentially infected patients [7, 12].
Definitive Treatment
Dentists have training and experience in many areas that may be a part of casualty care in mass casualty events. As mentioned earlier, OMFS are appropriately trained to provide first aid, endotracheal intubation, cardiopulmonary resuscitation as well as anaesthetic and surgical services to patients with different injuries [4]. Dentists can identify the infectious disease that causes mass casualties and can recognize the sign and symptoms of that disease which may help to identify the afflicted patients [8]. Dentists regularly collect salivary samples, nasal swabs, or other specimens for laboratory processing, leading to proper diagnosis, information about progress of the treatment and the status of the infection of patient [13]. Thus, it is suggested that civilian dentists should be trained along with dental personnel in armed services to form a good team with their medical counterparts and augment the emergency care to large number of causalities that may be generated in severe disaster including major earthquake [9, 14].
Triage Services
Triage is derived from French word ‘trier’, which means to sort out. It is applied to various situations ranging from everyday triage of emergency department patients to large-scale disasters [12]. During a mass casualty event when there may be deficiency of personnel, facilities, and medical supplies, it may not be possible to give immediate treatment for all casualties. In such situations, triage must be done to prioritize treatment plan. Dentists can provide assistance in these treatment procedures without further training. This provides additional help to physicians providing definitive care for patients most urgently in need rather than screening casualties. Dental offices could serve as triage centres if needed [15].
Triage consists of rapid classification of the injured on the basis of the severity of their injuries and the likelihood of their survival [3].
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Red colour indicates high priority treatment or transfer.
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Yellow colour signals medium priority.
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Green colour indicates ambulatory patients.
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Black colour is for dead or moribund patients.
Forensic Assistance
Forensic odontology continues to be a crucial element in nearly all mass disasters irrespective of its incidence, viz. natural or accidental. This is one area which makes the dental professionals unique and far more important than others, especially in catastrophic events. The multiple functions of this unique discipline can range from the identification of human remains to mass disaster management, including the assessment of bite marks and patterned skin injuries along with the use of dental materials in the examination of evidence [16]. Dental identifications have always played a key role in victim identification during natural and manmade disaster events, particularly mass casualty events normally associated with aviation disasters [17]. A dental record is a well-structured document recording the details related to the history of the illness, physical examination, diagnosis, treatment, and management of a patient. The legislation compels dental professionals to produce and maintain adequate patient records. Dental records can also find their use in forensic cases, teaching and research, as well as in legal matters. Comprehensive and accurate records are a vital part of dental practice. However, primarily dental records are maintained to deliver quality treatment and care to patients and for follow-up.
Supporting Other Health Professionals
It is the responsibility of the private practitioners and local dental societies to make the local emergency response planners aware of the services rendered by the dental profession at the time of disaster [8]. As already discussed, in response to a declared medical emergency, the role of medical professionals can be augmented by dentists and their dental auxiliaries. Dentists can be recruited to provide certain services that only physicians can do when there is inadequate local medical resources to cope adequately with increasing number of patients. Dentists can enhance the surge capacity of the local medical system until another team of physicians can arrive or the demand for immediate care decreases [2]. Nurses or other healthcare professionals lack such training as required for disaster response.
Infection Control
Dentists and dental auxiliaries practice appropriate methods of infection control in their clinic on a daily basis. They are well versed and well practiced in infection control methods and can bring their expertise to mass casualty situations, particularly related to control of infectious agents, thereby limiting the spread of infection through patients and responders who are rendering assistance. Dentists can help to prevent decontamination casualties from certain bioterrorism attacks in which contact with patients’ clothing or skin surfaces may also lead to the spread of infection to caregivers. Dentists already familiarized with the disaster mortuary activities can be useful in managing the remains of victims whose death is a result of the event, particularly infectious events [18].
Quarantine
During a pandemic or after bioterrorism attack with a communicable agent, the spread of the disease can be controlled or prevented by imposing strict quarantine restrictions on the geographic area contaminated and its environment. The duration of quarantine depends upon the incubation time of the agent and other factors. Before the existence of the quarantine area, wide contamination is already established which can infect the primary care providers directly or through contact with patients under care. This could lead to disability or even death. Dentists may not be similarly infected by patients because dental appointments are not given to infected patients. Dentist may also provide primary health care for people in the quarantined area [19].
In Japan, dentists were employed for the examination of the teeth of thousands of bodies who died in the March 11, 2011 earthquake and tsunami in an effort to help identify them. Immediately after the great disaster the JDA’s Earthquake Disaster Response Headquarters was set up by the Japan Dental Association (JDA). Under the presidentship of Dr. Mitsuo Okubo, JDA performed various activities like dispatch of dentist teams to the affected areas for identification of disaster victims, keeping a check on the safety of JDA members and their families, survey of the status of dental offices as well as hospitals and related oral health facilities, making plans to send mobile clinics to deliver oral health care at shelters and making the shipment (using trucks arranged by the government) of oral health care products, hand instruments, devices and dental materials to be delivered to the dentists already under progress [20, 21].