During the anthrax incidents, access to accurate information about symptoms and treatment of anthrax exposure was in high demand. Several government agencies and private organizations provided needed information about anthrax to the poorly informed medical community and public. In the absence of good information, there was a demand for drugs to treat and prevent anthrax, even among those for whom these drugs were unnecessary and inappropriate. In some instances, patients exerted pressure on their family dentists to prescribe the preferred antibiotic for treating anthrax infections when their family physicians refused to do so. Some local dental societies and individual members contacted the American Dental Association for information about identifying anthrax in patients, about anthrax symptoms and treatment protocols and about how to protect the staff in dental offices from anthrax infection.

The nature of the questions received by the ADA indicated a dearth of basic knowledge on the part of the public and the profession in regard to even the rudimentary facts about anthrax, including the fact that it is not a contagious disease.

Given the chaotic response to this limited event, there is a clear need for the development of a prepared response to the deliberate infection of civilians with a virulent contagious agent. The government and the local health care community must be prepared to respond if they are to effectively limit transmission of the disease and its associated morbidity and mortality, as well as to prevent confusion and panic.

Since the beginning of this year, there has been a massive amount of national, state and local activity across the country to prepare for another such attack, and a substantial amount of resources has been dedicated to that preparation. Activities have extended from the local level to the highest tiers of the federal government.

As a critical component of the health care system, dentistry most likely will be called on to play an important role in the initial response to a future significant bioterrorist attack in the United States. Dentistry has played an important and effective role in other types of mass disasters, such as transportation accidents, bombings and natural disasters. This role has involved primarily dental forensic activities, although individual dental care providers may offer a variety of skills in times of crisis. Little is known about the role dentistry can play in significant bioterrorist attacks, although it is expected to be a very different role than that it has played in responding to more common types of disasters.

Dental offices are equipped with potentially useful equipment and supplies and should be prepared to serve as decentralized auxiliary hospitals in case the need arises.

	THE WORKSHOP

TOP ABSTRACT THE WORKSHOP DENTISTRY’S ROLE IN A... A HOST OF KEY... CONCLUSION

 
To help determine a potential role for dentistry, and the scope of such a role, in a response to a significant bioterrorism attack, the American Dental Association convened a meeting, "Workshop on the Role of Dentistry in Bioterrorism," in June. Experts on this issue and representatives from organizations that will be involved in dentistry’s response met to forge a consensus on dentistry’s role in that response. People representing organized dentistry, government, the military and academia attended.

The workshop presentations included several solicited papers on various aspects of bioterrorism, as well as response plans already developed, and speakers proposed a range of potential roles for dentists’ involvement. After discussing these topics in work groups, the participants developed a consensus on several key roles for dentistry, including some of the specific preparatory steps that need to be taken.

	DENTISTRY’S ROLE IN A RESPONSE

TOP ABSTRACT THE WORKSHOP DENTISTRY’S ROLE IN A... A HOST OF KEY... CONCLUSION

 
Dentistry can contribute valuable assets, both in personnel and in facilities, to the preparation for and in the immediate response to a bioterrorist attack and its aftermath. These assets can make a significant difference in the outcome.

In a major bioterrorist attack, the local needs could be massive and immediate. The traditional medical resources—both personnel and facilities—of a community under attack will be overwhelmed, especially in the first few days after the determination that the community has been deliberately subjected to an infectious agent. It will fall to nonphysicians to provide many services ordinarily supplied by physicians (such as performing triage, dispensing medications and providing general medical support). As hospitals become filled, alternate sites for the provision of health care may be required, and dental offices could fill that need.

Variations in detecting that an attack has occurred will happen as a result of the different agents that may be used. For example, if pathogens are the vehicles used in the attack, various intervals between the time of the actual attack and the identification of an index case will occur because of various pathogens’ differing incubation times. Chemical or radiation attacks usually will be immediately identifiable, except for, perhaps, chemical attacks on the public water supply.

Preparation before an attack. Education of the dental profession regarding the medical and oral manifestations of diseases that may result from a bioterrorist attack will be important, as well as similar education of the public. Formal plans for an organized response by dental personnel in case of an attack must be developed, integrated into each community’s response plan and practiced periodically. Dental auxiliary personnel also should be involved and trained appropriately. Dental offices are equipped with potentially useful equipment and supplies and should be prepared to serve as decentralized auxiliary hospitals in case the need arises.

Educational programs that provide information about potential biological weapons should be developed and made available to dentists through continuing education courses and to dental students as a part of the dental school curriculum.

Biological weapons that may be used in a terrorist attack fall into three main categories: bacterial agents, viral agents and biological toxins. Generally, dentists have little knowledge of or experience with these entities or the human pathology related to them. It is not practical, however, to expect that dentists will retain an adequate level of knowledge of this subject for them to be able to respond effectively to an attack if it occurs months or years after training. The ADA should develop up-to-date sources of information that can be accessed quickly during an attack and reference materials that can be distributed for use as needed. These quick references should be able to provide dentists with a sufficient level of information concerning the particular agent used in an attack to enable them to respond effectively.

Armed with knowledge and connected to scientifically based information sources about agents that may be used in bioterrorism, dentists can educate their patients and correct misinformation that may be circulating throughout the general public.

Dentists have contact with the general public on a regular basis. Armed with knowledge and connected to scientifically based information sources about agents that may be used in bioterrorism, dentists can educate their patients and correct misinformation that may be circulating throughout the general public. Special training may be needed for risk communication.

Dental office auxiliary personnel also can provide services in the event of a major attack, so they too should participate in bioterrorism educational programs and receive training.

Dental offices are located throughout any given community and have many of the resources that hospital facilities have: sterilization equipment, air and gas lines, suction equipment, radiology capabilities, instruments, needles. They may be called on to serve as local "minihospitals" when local hospital facilities become overwhelmed or when the concentration of patients is to be avoided, as in attacks involving contagious agents. Concentrations of patients and health care providers also may present tempting secondary targets to attackers. In some scenarios, decentralization of medical care may be the most appropriate response.

Predesignated dental offices may act as stockpiling sites for materials and supplies to be distributed in the event of an attack.

The key to successful preparation for an effective response to a major bioterrorism attack is development of a response plan that is integrated into each community’s disaster response plan and testing it by conducting mock attacks.

Assistance during an attack. The assistance dentists and other dental personnel can provide during the first few days of a significant bioterrorist attack will vary according to the needs of the community and the resources available. These may run the gamut from the packaging of medications in individual doses to providing a major portion of primary medical care in a quarantined area if physicians are unavailable because they have become disabled or have died.

Surveillance and notification. Since there is an incubation period before the clinical manifestations of diseases that have been used as weapons in bioterrorist attacks become apparent, the initial recognition that an attack has been perpetrated may be difficult. Because dental offices are distributed across the community, dentists can serve as an excellent surveillance resource. They can detect characteristic intraoral or cutaneous lesions if they are present and report them to public health authorities. They also may be able to detect unusual patterns of employee absences or patients’ canceling or missing appointments that are not explainable by recognizable local circumstances. These occurrences may well be a harbinger of serious events about to happen.

Diagnosis and monitoring. Besides assisting in the early identification of the disease or diseases introduced in a bioterrorist attack, dentists can provide individual patient diagnosis by observing the physical and behavioral signs people manifest when the nature of the attack has been determined. Salivary and/or nasal swabs may yield important diagnostic or treatment information and can be collected by dentists for laboratory testing to determine diagnoses when necessary or to monitor treatment progress.

Referral. Dentists can refer suspicious cases to the appropriate specialists for confirmation, treatment or both.

Immunizations. In the event that rapid inoculation or vaccination of the public is required to prevent the spread of infection by a biological agent, dentists may be recruited to assist in a mass inoculation program. Physicians and nurses will be unable to fulfill the requirements of such a program in the urgent time frame that will be essential for successful prevention of the spread of disease.

Medications. If the mass population requires treatment, preventive medication or both, pharmacies’ capabilities may become overpowered quickly. Dentists could be called on to prescribe and dispense chemotherapeutic or chemoprophylactic medications for the public. When drugs are stockpiled in bulk, dental personnel could help repackage them for individual use before dispensing them. Dentists also will serve as sources of information for patients concerning the appropriate use of the medications they have distributed, and they must monitor patients for adverse reactions and side effects.

Because of their training and experience, many dentists may be able to augment and assist medical and surgical personnel in providing definitive treatment for victims of bioterrorist attacks.

Triage. Whenever there is a greater number of casualties than the medical care system can accommodate relatively quickly, or whenever medical care resources are overwhelmed, some system for establishing priorities for treatment must be established. Appropriately trained dentists can fulfill this function, thus freeing up medical professionals to provide definitive care for the greatest number of patients. This system should be established now, in preparation for potential future attacks.

Medical care augmentation. Because of their training and experience, many dentists may be able to augment and assist medical and surgical personnel in providing definitive treatment for victims of bioterrorist attacks. Some of the services dentists may provide include

– treatment of cranial and facial injuries;

– providing or assisting in administration of anesthetic;

– starting intravenous lines;

– performing appropriate surgery and suturing;

– assisting in shock management;

– assisting in stabilizing patients;

– collecting preantibiotic blood samples;

– taking medical histories;

– providing cardiopulmonary resuscitation.

In instances in which a communicable disease has been detected, an area including and surrounding the geographic area in which the disease is centered may be quarantined for a length of time, depending on the disease’s incubation period. In some instances, physicians may be infected with the pathogen via exposure to patients seeking treatment before the disease is recognized and the quarantine is established. Dentists may not be similarly infected. If a sufficient number of physicians is not available because they have become disabled by or have died of the disease, dentists may be called on to provide primary health care for the people contained in the quarantine area.

Decontamination and infection control. Dentists and dental auxiliaries are well-versed in infection control procedures and can apply their knowledge in reducing the spread of infections—between patients and between patients and caregivers—in mass disasters. The decontamination of casualties, when appropriate, can be accomplished effectively by dental personnel.

Dentists who have experience in practicing in a hospital setting may be especially valuable and may be particularly equipped to provide services that require a close working relationship with physicians.

After the initial attack. As the community’s medical systems become able to accommodate the medical needs of the public following the initial massive need for medical assistance, the roles dentists and other dental personnel play will change.

The traditional forensic services that dentists have provided in other mass disasters will be available as needed. Dentists trained in forensic odontology will work closely with local Disaster Mortuary Operational Response Teams, known as DMORTs.

Dentists also may provide local surveillance to detect any spreading of disease beyond the original area of attack or re-emergence of infections in the original attack area.

	A HOST OF KEY ISSUES

TOP ABSTRACT THE WORKSHOP DENTISTRY’S ROLE IN A... A HOST OF KEY... CONCLUSION

 
In discussing the full range of potential roles for dentistry and their implications, the workshop participants raised a number of key issues.

Dentists in urban vs. rural settings. Dentistry’s role in responding to a bioterrorism attack may differ significantly for dentists who are located in an urban vs. a rural area because of differences in the demographic characteristics of the professionals in these areas, the availability of medical facilities and the general environmental differences between urban and rural settings.

Notable characteristics of an urban environment vs. a rural environment:

– densely concentrated population, facilitating the spread of contagious pathogens;

– large amount of medical facilities and resources;

– greater availability of dental specialists;

– better potential for connection to public health agencies;

– greater likelihood of becoming a target;

– potential for some population subsets’ being unconnected to the health care system;

– potential for cultural issues and concerns.

Notable characteristics of a rural environment vs. an urban environment:

– geographically dispersed population that is difficult to concentrate for effective and timely treatment;

– smaller number of dentists than in urban areas, and very few specialists;

– reduced access to definitive treatment because of lesser amount of medical facilities and resources;

– less potential for connection to public health agencies;

– reduced access to federal services;

– less access to relevant information for dentists, who therefore may require additional training;

– easier identification of disease clusters;

– possible extension of time to critical mass of infected people needed to determine that an attack has occurred;

– greater likelihood of dentists’ having a leadership role in the community;

– greater likelihood of dentists’ being viewed as key health care practitioners and having more visibility as experts;

– potential for cultural issues or concerns.

The qualitative demands that will be placed on the health care system in both settings after a bioterrorist attack will be fairly consistent, so the discussions above apply equally to both urban and rural dentists. Because of the limited numbers of health care providers in rural areas, however, health care providers of all disciplines in those areas more than likely will be asked to provide a broader variety of services. Dental offices may be of even greater value as local treatment centers in rural areas than in urban areas. Effective communications may be more difficult to accomplish, but may be more important, in rural areas.

Legal and legislative issues. Significant legal questions come to mind as one contemplates the potential role dentists may play in the response to a massive bioterrorist attack. Dental practice acts, the scope of dental practice and state licensure do not address this radical expansion of services dentists may be called on to provide in an emergency. Liability issues for dentists involved in primary response activities beyond their normal scope of practice are of concern. State "good Samaritan" laws vary greatly from state to state and may not afford adequate protection for dentists in these situations. Competency and the precertification of competency also are issues, not only for dentists but probably for most physicians as well.

These issues must be addressed if dentists are going to participate in immediate-response activities following a significant bioterrorism attack. Federal and state lawmakers should consider legislation that would enable dentists to provide all the valuable assistance they can. In a time of disaster, society must rely on the voluntary assistance of the entire health care community.

Failure to address the legal and legislative issues may severely dampen the voluntary response dentists will make to aid victims at the time of an attack and will hinder dentists’ critical preparation for such assistance.

How dentistry can prepare. It is clear that a great deal of preparation is required if dentistry is to fulfill its maximum potential for assisting in the response to a bioterrorist attack on the United States. That preparation involves individual members of the dental team and local dental societies. When one considers the services dentists may be asked to provide in such an event, it appears that dentists have the basic knowledge and experience to be able to perform those services adequately with a minimum amount of additional training. For example, dentists could easily acquire the knowledge and master the technical skills required to vaccinate people against smallpox, start intravenous lines and prescribe and distribute medications. More extensive training may be required if dentists are to provide patient triage and, certainly, if they are to assume major responsibility for providing primary medical care in quarantined areas.

Local dental societies should begin developing a response plan in which the dental resources of a community can be quickly mobilized and respond effectively when a need for them arises. The plan must be integrated into the local disaster response plan to realize maximum benefits from the assets dentistry can bring to a disaster response. Dentistry should develop, as soon as possible, relationships with the public health community and governmental agencies charged with managing responses to mass disasters so that the profession can be integrated effectively into the plans.

To ensure that dentists can be mobilized quickly in a time of need, a communications system that can reach all dentists should be established. This communications system also could be used to provide education and information to dentists. Dental societies may be helpful in establishing and operating a communications network.

If dentists are to function as a part of the surveillance and monitoring apparatus, an appropriate agency must establish a central reporting site where bits of information from a large number of observers can be gathered. In this manner, any present patterns can be detected, and potential attacks or the spread of diseases can be identified early.

Dentistry has not been included in initial state disaster response plans. The public health community, federal and state agencies, and the hospital-medical communities most likely have not considered the valuable assistance dentistry can provide in mass disaster situations. It is important that the ADA educate these groups regarding the valuable services dentistry can provide in times of great need, when a community’s normal medical capabilities are overwhelmed.

The role of dental schools. Dental schools can provide a great portion of the education of the profession that will be needed. The predoctoral dental school programs should devote adequate curriculum time to the subject of bioterrorism. New dentists should have the basic information required to function effectively in a bioterrorism response, as well as quick-reference materials to use when the need arises. Continuing education programs for established dentists also should be developed.

In addition to providing education for the dental profession, dental schools can serve as valuable assets during the actual response to an attack. Since most schools are associated with academic health centers, whose hospitals may be overwhelmed with demands for care, they may be mobilized to be used as hospital annexes. Dental students and faculty may serve both in the dental school–hospital or in the field as primary responders. Dental schools also can be repositories for prestocked supplies and equipment.

The role of dental auxiliaries. Dental office auxiliaries can provide important assistance in the initial response to a major bioterrorism attack. All are familiar with and can serve in administrative functions, managing medical records and handling patient flow. With additional training, dental hygienists can provide valuable assistance in mass disaster responses by providing assigned clinical services beyond those they ordinarily supply, possibly including administration of inoculations and vaccinations. Dental assistants can continue to aid dentists, even in tasks different from those they usually perform, in the expanded roles dentists may fill in mass disaster responses. Clerical staff can provide an important link in communications between dentists and other clinicians.

Preparation: mandatory or voluntary? The workshop participants discussed the preparation of dentists for participating in the response to a major bioterrorist attack. The figure illustrates the relationship between the education and training dentists will require to become prepared for bioterrorist attacks and the degree of their participation in the response to such attacks. The workshop participants as a group believed that all dentists and dental students should be taught, at a minimum, basic information about bioterrorism, about early recognition of the signs and symptoms of diseases that may be used as bioterrorist weapons and about the preventive measures that can be used.

View larger version (22K): [in this window] [in a new window]   Figure. A schematic representation of dentists’ educational preparation for and participation in responding to a bioterrorism attack, as proposed by participants in the American Dental Association’s Workshop on the Role of Dentistry in Bioterrorism.

Professionals who will be called on to provide specialized services should be certified, as should those who have access to sites that will be used to stockpile equipment and supplies or that will serve as auxiliary treatment facilities. Additional education and training may be required for these professionals and standards developed for the sites, including enforcement by periodic inspection.

In general, the group believed that the basic capabilities described here should be mandatory for all dentists. The education and training required to achieve these capabilities should be required in the curriculum of each dental school and be available to practicing dentists through continuing education. Responding to an event and achieving certification as a professional capable of providing special services or as a storage or auxiliary treatment site should be voluntary. It should be noted that the group had some difficulty in drawing the boundary for "mandatory" preparation on the figure; participants were uncertain about the clinical services dentists may perform during an emergency and about the effective retention of the information previously learned without (one hopes) having applied it.

Medical Reserve Corps. The U.S. Department of Health and Human Services and the USA Freedom Corps is forming local Citizen Corps Councils and the Medical Reserve Corps, or MRC, to assist in responding to mass disasters, including bioterrorist attacks. The MRC will consist of retired health care workers who have maintained adequate levels of competency in their professions and who want to continue to serve their communities, particularly in times of great need. The MRC will be developed, administered and deployed on the local level. Dentists have training and experience that can be of significant value to the MRC in this effort. In addition to preparing for mass disasters, the MRC will address other local public health issues.

	CONCLUSION

TOP ABSTRACT THE WORKSHOP DENTISTRY’S ROLE IN A... A HOST OF KEY... CONCLUSION

 
Dentistry has an important role to play in the response to a significant bioterrorism attack. With adequate preparation, dentistry’s valuable assets in terms of personnel and facilities can help in determining that a bioterrorist attack has occurred and in responding to that attack. The profession should develop a disaster response plan that can be integrated into each community’s disaster response plan.

View larger version (101K): [in this window] [in a new window]   Dr. Guay is chief policy advisor, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail "guaya{at}ada.org". Address reprint requests to Dr. Guay.