The Evolving Role of Dental Responders on Interprofessional Emergency Response Teams

The Evolving Role of Dental Responders on Interprofessional Emergency Response Teams

Dental Clinics of North America, 2016-10-01, Volume 60, Issue 4, Pages 907-920, Copyright © 2016 Elsevier Inc.

Disaster and pandemic response events require an interprofessional team of health care responders to organize and work together in high-pressure, time-critical situations. Civilian oral health care professionals have traditionally been limited to forensic identification of human remains. However, after the bombing of the Twin Towers in New York, federal agencies realized that dentists can play significant roles in disaster and immunization response, especially on interprofessional responder teams. Several states have begun to incorporate dentists into the first responder community. This article discusses the roles of dental responders and highlights legislative advancements and advocacy efforts supporting the dental responder.

Key points

  • Oral health care professionals can serve as responders and should be actively involved in all stages of disaster and pandemic planning within their local communities.

  • Through emerging state and federal laws, dental responders can legally provide triage, immunization/vaccination, and infrastructure support during declared pandemics and disasters.

  • Dentists can serve a critical role as triage coordinators and “medic” members of tactical emergency medical support and forensic investigative teams.

  • The dental profession needs to continue to advocate for dentists and hygienists to be included as key members of the response team.

  • Oral health care providers must be paramount in educating their medical colleagues on the importance of dental skills in catastrophic events and pandemic response.

Introduction

The number of natural, pandemic, man-made (anthropogenic), and terrorism-related events are increasing worldwide. These events are multifactorial, but are heavily influenced by increased population growth, increasing urbanization of populations, and global climate disruptions and their influence on societal well-being. Because economic and health consequences impact climate-related events, deleterious events to humanity are only expected to increase in the future, and significant international health concerns can arise from these events. Examples of recent events include Hurricane Katrina (2005), the Joplin, Missouri, tornado (2011), Hurricane Sandy (2012), the Ebola virus outbreak (2014), and the Zika virus outbreak (2015).

During Hurricane Katrina, 11 hospitals and numerous dental offices in New Orleans, LA, were flooded. In Mississippi, the storm damaged another 14 hospitals and 3 federal medical facilities and caused partial or complete damage to more than 60% of dental practices in the affected counties. The storm affected dentists on a personal level as well; a reported 44 dentists in Mississippi lost their homes as a result of the hurricane. As such, these problems can be magnified when dental and medical personnel and facilities are situated in the area of the disaster.

Although disasters and pandemics are becoming more prominent in recent years, the concept of using medics and disaster response teams to respond to military and large-scale disaster events can be traced back to the early Greeks and the Roman legions. This is not surprising; first responder duties have always had a strong association with military conflicts and disasters. During the Middle Ages, the Order of St. John of Jerusalem (later known as the Order of Malta International) was created and charged with providing military defense of the sick and security of medical centers and main roads, and later filled a crucial medical role during the Crusades in Europe. This set the foundation for modern traumatology and a military system of prehospital emergency medical services based on the triage and transport of casualties; the creation of this modern system is widely credited to Baron Dominique Jean Larrey (1766–1842). This example of military medic duties from the 18th century, along with the continuous efforts of the various Catholic Orders providing medical and first responder care, continues to this day and serves as a model for the emergence of modern first responder entities such as the American Red Cross and the world-wide civilian emergency medical technician and paramedic response systems. This article reviews the history of first responders, their roles and important legislation as it relates to dental responders—specifically the role of dentists on an interprofessional response team, and with a particular focus on dentists providing immunizations.

Etymology of “responders” and evolution of interprofessional response teams

Today the term “emergency response providers” is legally defined in Section 2 of the US Homeland Security Act of 2002. This act defines the term as inclusive of “Federal, State, and local emergency public safety, law enforcement, emergency response, emergency medical (including hospital emergency facilities), and related personnel, agencies, and authorities.” This definition makes no distinction between responders arriving immediately upon the onset of a disaster and those arriving many hours or days after the initial “surge” period (eg, responders who aid in identification and recovery efforts), even though the skills and personnel needed at different time intervals after the onset of an emergency event may be vastly different.

The initial response to an event is particularly critical to effectively contain and mitigate a disaster or pandemic; as such, it is necessary to identify and define “first responders” separately from other responders. President George W. Bush provided a definition for first responder in the 2003 Homeland Security Presidential Directive HSPD-8 as follows : “individuals who in the early stages of an incident are responsible for the protection and preservation of life, property, evidence, and the environment.” According to HSPD-8, these individuals include the emergency response providers defined in the US Homeland Security Act of 2002 and “emergency management, public health, clinical care, public works, and other skilled support personnel (such as equipment operators) that provide immediate support services during prevention, response, and recovery operations.”

The US Department of Health and Human Services released the first National Health Security Strategy in 2009, which was designed to lay out a baseline strategy to minimize the health consequences of large-scale disasters. The subsequent National Health Security Review 2010 to 2014 and the National Health Security Strategy and Implementation Plan 2015 to 2018 describe the progress made toward this goal and updated strategies to improve response. These and other comprehensive response plans incorporate a broad array of interdisciplinary health professionals from different professional backgrounds and organizations, including all levels of government (local, regional, state, and federal), corporations, community organizations, the nonprofit sector, academia, and the scientific community ( Fig. 1 ). The dentist, serving as a dental responder, and as a participating member in the interprofessional first responder team, is included in all of these plans. As these response plans become more collaborative in nature in the future, the further interprofessional development of oral health professionals on a disaster response team will be critical ( Fig. 2 ).

Local, regional, state, and federal organizations contributing to all-hazards and pandemic preparedness and response.
Fig. 1
Local, regional, state, and federal organizations contributing to all-hazards and pandemic preparedness and response.
Interprofessional and collaborative evolution of organizations involved in pandemic and all-hazard planning and response.
Fig. 2
Interprofessional and collaborative evolution of organizations involved in pandemic and all-hazard planning and response.

Traditional first responder activities have typically been performed by public health professionals such as physicians, nurses, physician assistants, and emergency medical technicians. Dental professionals, however, have long served in civilian and military first responder capacities during natural disasters, anthropogenic disasters, and pandemic events, assisting various investigative and law enforcement agencies when processing missing people and identifying anthropological remains. The nature of this work is typically conducted during the recovery efforts in the day(s) after a disaster; therefore, dentists have not traditionally been included as part of the interdisciplinary first responder teams initially called to a disaster scene.

In addition to being trained in forensic identification and biometric informatics, oral health providers have the capacity to respond to disasters, provide immunizations, and provide triage care. Over the past decade, selected states and the US Congress have passed legislation that has defined the dental responder and has expanded the legal authority of oral health care providers to serve in such first responder activities.

Dental responder legislation

Commissioned dentists in the US National Guard services, all branches of the Active Duty and Reserved Armed Forces of the United States, and the majority of international military forces, have a long history of providing military mass casualty and triage support as part of military medical and humanitarian response teams. These dentists provide anesthesia care and management, triage care and management, immunization care and management, and attend to the oral and maxillofacial care and trauma of military forces in battlefield and home station conditions. Military dentists also have a long tradition of providing forensic identification support after battlefield events and military accidents. In the United States and international civilian communities, dentists have traditionally provided first responder care for the forensic identification of casualties from mass disasters, as integral members on disaster mortuary operational teams. However, the idea of a civilian dentist acting as a full-spectrum first responder (ie, practicing care as a military dentist or disaster mortuary operational team dentist) within civilian first response teams—in concert with traditional health care professionals such as physicians, nurses, and emergency medical technicians—was not introduced into the scientific literature until 1996 by Morlang.

The September 11, 2001, terrorist attacks in the United States further served to increase awareness of the potential benefit of dental first responders. After those attacks, numerous medical and dental strategy, theory, and policy experts and clinicians, at the federal and state levels, suggested that the American dental profession needed to define and describe a cohesive vision to establish membership protocols and outline clinical duties for civilian dentists to become members of medical disaster response teams. This vision had to be synergistic with the current standard operation procedures used by the emergency response community and one that could be translated into actual changes in the state dental practice acts for each state in the United States.

State Legislation

Illinois has been at the forefront to advance legislation incorporating dental professionals as first responders on disaster response and immunization teams. This effort to define a cohesive vision and policy for the dentist to serve as a civilian first responder was reported by Colvard and coworkers in 2006. Policy and strategy work by the authors leading up to the release of this paper, in concert with state and national professional support (including the Illinois State Dental Society, American Dental Association, and numerous other organizations), resulted in Illinois Public Act 49 to 409, which was signed into law in 2005. Through this legislation Illinois defined the “dental emergency responder” and became the first state to amend their state dental practice act to introduce the concept of the civilian dental responder providing emergency medical care, triage, and immunizations during a disaster event. The Illinois Dental Practice Act defined a dental emergency responder as a licensed dentist or dental hygienist “who is appropriately certified in emergency medical response, as defined by the Department of Public Health.” Dentists and dental hygienists are described as “acting within the bounds of his or her license when providing care during a declared local, state or national emergency.”

In 2015, the Illinois Dental Practice Act was amended via Public Act 99-0025 to change “dental emergency responder” to “dental responder.” The “dental responder” is defined as “a dentist or dental hygienist who is appropriately certified in disaster preparedness, immunizations, and dental humanitarian medical response consistent with the Society of Disaster Medicine and Public Health and training certified by the National Incident Management System or the National Disaster Life Support Foundation.”

California has also made notable strides to support the dental responder. In contrast with Illinois, California did not directly alter its dental practice act, but rather introduced additional legislation that was designed to reduce the barriers confronting dentists who wished to participate as first responders. The California Dental Association sponsored AB 2210 in 2008. This bill, which was signed into law in 2008 and became effective January 1, 2009, “allows the California Dental Board to suspend compliance with any provision of the Dental Practice Act that would adversely affect a licensee’s ability to provide emergency medical care that is consistent with his/her training.” Through this law, California dental professionals who provide emergency care voluntarily and without compensation during declared disasters are provided indemnity. Several other states have expanded their public health and “good Samaritan” laws to include dentists among potential responders supporting a state or national declared disaster response.

Although Illinois and California have addressed the inclusion of the dental responders through changes in legislation, other states continue to advocate on the behalf of the dental responder through nonlegislative actions. For example, a number of academics, physicians, and state organizations in New York have provided support over the past decade to include and properly train dentists for first responder activities. In Texas, the Texas Military Forces annually conducts Operation Lone Star, a training event for state and local partners to train for disaster response; this event includes dentists, dental assistants, and dental students.

A number of civilian and military health care professionals and response organizations (such as the American Red Cross) operating at state and local levels continue to support dentists to become first responders and to be actively involved in responder research and training exercises. Notably, the United States Assistant Secretary for Preparedness and Response, responsible for overseeing the US Medical Reserve Corps (MRC), has specifically named dentists and dental assistants as possible “front line” health providers capable of providing “surge” capacity during the first 12 to 72 hours of an emergency. The MRC network currently consists of nearly 1000 community-based response units throughout the United States and US territories.

Federal Legislation

While individual states debate legislative actions to incorporate dental responder activities into each state’s dental scope of practice, important federal legislation was recently passed to support disaster response activities of oral health care providers. The 2013 reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA) gives dentists and dental hygienists the legal authority to support national emergency, disaster, and forensic needs by providing clinical care and infrastructure for “walking well” care, pandemic vaccination support, biometric information, and forensic dentistry.

Three key changes were introduced in the PAHPA, which defined the inclusion of oral health care providers in public health emergency planning and response :

  • 1.

    Dental health care facilities are incorporated under ambulatory care facilities during public health emergencies;

  • 2.

    Dental health assets (including dentists and dental hygienists) are incorporated after medical assets in medical triage activities during a disaster; and

  • 3.

    Training efforts for dental professionals responding to public health emergencies are supported.

The PAHPA serves as a critical starting point for legally introducing dental responders into pandemic and disaster planning and response activities within the United States, but it does not describe the implementation of oral health care providers into these activities. Dentists and hygienists who wish to serve as dental responders will need to become integrated into interprofessional local, state, and federal disaster response teams.

Immunization capacity of dentists

Initial response to a public health emergency occurs at the local level and, as such, is typically coordinated by local/county response teams. Given that the disasters typically faced by a local health department depend on their geographic location, it is critical that disaster response team training occurs at the local level so that all health responder team members are best prepared for potential location-specific emergencies that may arise. As such, the greatest need for dental responders will likely be as members of local disaster response teams. Many communities already have MRC units, Civilian Emergency Response Teams, and similar teams in place to help coordinate the local health care response during emergency situations.

Only a very limited number of publications defining local-level emergency response planning and training activities designed specifically for dental responders have been reported to date in the scientific literature. This is likely owing to a number of factors, including (1) the federal legislation supporting the inclusion of dental responders was only passed recently, and local organizations may not be aware of the change in legislation; (2) the 2013 reauthorization of the PAHPA does not provide guidance for implementing oral health care professionals onto pandemic and disaster response teams, and local health organizations may not know how to begin this process; and (3) resources to provide training may be limited and are likely to first be allocated to the traditional physician and nurse responders. Although the PAHPA states that training activities for dental responders are supported, it does not say in what capacity this support will occur.

One such immunization training activity has been reported. In late 2013, the Operation Sustained Adaptive Prophylaxis influenza mass vaccination drill was developed and conducted by the DuPage County Health Department in Wheaton, Illinois. The exercise was designed to train potential dental responders in a simulated pandemic immunization response scenario, using just-in-time (JIT) training. The protocol was modified from an H1N1 influenza mass vaccination clinical protocol previously used by certified public health nurses, as provided by the local health department. The main goals of the exercise included validating the use of dentists as an emergency response resource; testing the vaccination throughput using the current plans, protocols, and procedures of the health department; validating that the correct vaccination dispensing protocol were used (drug selection, amount, technique); and validating the use and effectiveness of the JIT training.

Fifteen dental professionals (8 hygienists and 7 dentists) from the local MRC served as dental responders in the 1-hour exercise. JIT training consisted of an approximately 15-minute-long video describing inoculation techniques (watched as a group), a 10-minute group discussion reviewing the specific protocol to be used, and 15 minutes at his or her individual station to review independently the protocol and practice techniques. Community volunteers served as the “patients” for the drill. To replicate realistic operational conditions of a mass vaccination, patients were given simulated vaccine administration records. Patients presented the vaccine records to the dental responder, who was then responsible for the appropriate selection and administration of the vaccine. A porcine model was used to simulate the vaccination injection of patients. Trained nurses and emergency response personnel oversaw the exercise and evaluated the dental responders for medical history documentation, vaccination procedures, and patient throughput and error rates. Fig. 3 shows pictures from the exercise.

The setup of a mass vaccination pandemic immunization response exercise completed by dentists.
Fig. 3
The setup of a mass vaccination pandemic immunization response exercise completed by dentists.

Overall, the results of the dental responders were found to be similar to those documented by the DuPage County Health Department in mass influenza clinics previously conducted by certified public health nurses. A total of 335 patients were treated during the hour-long exercise, corresponding to an average throughput rate of 22.3 patients per dentists per hour. Among the 335 patients, 7 medical errors (incorrect vaccine dosage administered and/or incorrectly documented vaccine administration records) were documented, corresponding with a medical error rate of 2.1%. These results were found despite noting the 15 dental responders had vastly different backgrounds and professional experiences. This suggests validation of the use of the JIT training methodology and validation of the dental profession in general as a valuable immunization resource. It was further noted that 3 of the vaccinators did not possess the necessary vaccine administration skills to competently conduct the drill, thereby emphasizing the importance of local responder teams to regularly conduct training exercises such as this to ensure their team members are adequately prepared to respond to a pandemic or disaster.

Summary

Although dentists have traditionally served on civilian interprofessional disaster response teams, their role has typically been limited to the forensic identification of remains. Oral health care professionals diagnose and treat medical conditions in their daily activities, just like their colleagues from other health care disciplines. Such activities include surgical care, anesthesia care, administering immunizations, providing appropriate (triage and tactical) support care during emergency response and triage interventions, following up with patients, and referring patients to other medical experts. These same skills and infrastructure assets are used during pandemic and disaster response activities. Dentists also possess a unique diagnostic skill set for forensic dental, oral, and facial data gathering and analysis—additional skills that are important during first responder activities. As such, dental professionals are uniquely positioned at the forefront of emerging biometric and forensic standards and technologies, and therefore can play a critical role in first responder and health security efforts.

Recent work has sought to drastically expand the purview of dentists and hygienists in disaster and pandemic planning and response. Toward this goal, work over the past decade has focused primarily on:

  • 1.

    Policy advancements to legally expand the role of the civilian dental responder, and

  • 2.

    Educating other health care professionals and the public to better understand the dentists’ and hygienists’ skill sets, and how these unique skills can be incorporated into interprofessional disaster response teams to enhance the overall quality and efficacy of emergency response efforts.

Policy advancements during the past decade, on both the state and federal levels, have resulted in significant progress in expanding the role of the dental responder beyond traditional forensic identification activities. Illinois has made the most legislative progress on the state level, through amendments made to the Illinois Dental Practice Act that define and include dental responder activities in the dentist’s regular scope of practice. The 2013 reauthorization of the Pandemic and All-Hazard Preparation Act introduced dental professionals into federal legislation overseeing public health emergency response. This was a crucial achievement for the dental profession, but significant work remains to further implement the changes outlined in the act.

To this end, efforts to educate other disaster responders, other health care professionals, and the public as to the value of including dental responders are on-going. Training exercises such as the immunization drill conducted by the DuPage County Health Department (Wheaton, IL) provide documented evidence of the capacity and capability of dental professionals to participate in pandemic and disaster planning and response. As dentists become more involved in first responder activities in the future, it is critical that similar training drills continue to be developed and executed.

Although advocacy efforts have increased in recent years, to date, only a relatively small number of local, state, and federal response teams actively recruit and incorporate dentists in their first responder efforts. As such, the dental community needs to continue educating other health care professionals and the public. Disaster response requires the integrated response of health professionals, and interprofessional communication is critical among members of a response team. As such, all stakeholders, regardless of their health care profession, need to work together in the strategic planning, hands-on preparation drills, and active response situations to ensure the health consequences of such hazards are minimized and the response efforts can be completed as quickly and efficiently as possible. Oral health care professionals should be actively involved in all stages of disaster and pandemic planning and response within their local communities.

Now that federal legislation is in place recognizing the dental profession as responders, work must focus on solidifying collaborations among the health professions. The dental community as a whole needs to continue to advocate for dentists and hygienists to be included as key members of the response team and must educate other health professions and the public as to the critical role oral health professionals can play in disaster and pandemic response. Likewise, consensus building among various government agencies, professional organizations, and the public must continue, and fundamental changes to the dental curriculum that require oral health professionals to receive disaster and pandemic response training should be implemented. Strategy sessions and hands-on training drills can serve as important interprofessional educational tools, allowing dentists and dental students to learn pandemic and disaster response techniques alongside other health care providers, while also enabling current and future dental professionals to provide valuable input into response activities. One suggested method to provide real-world interprofessional relations training to oral health care providers is to include dentists and hygienists as vaccinators during seasonal flu vaccination clinics commonly hosted by county health departments, hospitals, and universities.

Dentists and hygienists interested in training to become dental responders are urged to actively participate in their local communities through units such as the MRCs and Civilian Emergency Response Teams. Additionally, appropriately qualified dentists could serve as members on local tactical emergency medical support teams. There are also several nongovernmental organizations and religious organizations that sponsor responder teams and seek dentists for the unique skill sets oral health care professionals can provide during all-hazard and pandemic events. Additionally, interested individuals should contact their local county health departments, county coroner’s offices, and/or the various federal responder teams (such as disaster medical assistance teams and disaster mortuary operational teams) for participation opportunities. All teams listed require active licensure, advanced training and education, and experience for participation. Finally, the various levels of National Guard, Reserves Armed Forces, and Active Duty military train and staff responder teams able to respond to the full spectrum of chemical, biological, radiologic, nuclear, and explosive events that could potentially occur around the world. The dentist and oral health care community can make significant contributions to the intraprofessional and interprofessional collaborations among health care providers by serving on response teams within their communities.

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The Evolving Role of Dental Responders on Interprofessional Emergency Response Teams Michael D. Colvard DDS, PhD, MTS, MS , Benjamin J. Vesper PhD, MBA , Linda M. Kaste DDS, MS, PhD , Jeremy L. Hirst MS, MBA , David E. Peters JD , James James MD, DrPH, MHA , Rodrigo Villalobos DDS, MSc, MS and E. John Wipfler MD Dental Clinics of North America, 2016-10-01, Volume 60, Issue 4, Pages 907-920, Copyright © 2016 Elsevier Inc. Disaster and pandemic response events require an interprofessional team of health care responders to organize and work together in high-pressure, time-critical situations. Civilian oral health care professionals have traditionally been limited to forensic identification of human remains. However, after the bombing of the Twin Towers in New York, federal agencies realized that dentists can play significant roles in disaster and immunization response, especially on interprofessional responder teams. Several states have begun to incorporate dentists into the first responder community. This article discusses the roles of dental responders and highlights legislative advancements and advocacy efforts supporting the dental responder. Key points Oral health care professionals can serve as responders and should be actively involved in all stages of disaster and pandemic planning within their local communities. Through emerging state and federal laws, dental responders can legally provide triage, immunization/vaccination, and infrastructure support during declared pandemics and disasters. Dentists can serve a critical role as triage coordinators and “medic” members of tactical emergency medical support and forensic investigative teams. The dental profession needs to continue to advocate for dentists and hygienists to be included as key members of the response team. Oral health care providers must be paramount in educating their medical colleagues on the importance of dental skills in catastrophic events and pandemic response. Introduction The number of natural, pandemic, man-made (anthropogenic), and terrorism-related events are increasing worldwide. These events are multifactorial, but are heavily influenced by increased population growth, increasing urbanization of populations, and global climate disruptions and their influence on societal well-being. Because economic and health consequences impact climate-related events, deleterious events to humanity are only expected to increase in the future, and significant international health concerns can arise from these events. Examples of recent events include Hurricane Katrina (2005), the Joplin, Missouri, tornado (2011), Hurricane Sandy (2012), the Ebola virus outbreak (2014), and the Zika virus outbreak (2015). During Hurricane Katrina, 11 hospitals and numerous dental offices in New Orleans, LA, were flooded. In Mississippi, the storm damaged another 14 hospitals and 3 federal medical facilities and caused partial or complete damage to more than 60% of dental practices in the affected counties. The storm affected dentists on a personal level as well; a reported 44 dentists in Mississippi lost their homes as a result of the hurricane. As such, these problems can be magnified when dental and medical personnel and facilities are situated in the area of the disaster. Although disasters and pandemics are becoming more prominent in recent years, the concept of using medics and disaster response teams to respond to military and large-scale disaster events can be traced back to the early Greeks and the Roman legions. This is not surprising; first responder duties have always had a strong association with military conflicts and disasters. During the Middle Ages, the Order of St. John of Jerusalem (later known as the Order of Malta International) was created and charged with providing military defense of the sick and security of medical centers and main roads, and later filled a crucial medical role during the Crusades in Europe. This set the foundation for modern traumatology and a military system of prehospital emergency medical services based on the triage and transport of casualties; the creation of this modern system is widely credited to Baron Dominique Jean Larrey (1766–1842). This example of military medic duties from the 18th century, along with the continuous efforts of the various Catholic Orders providing medical and first responder care, continues to this day and serves as a model for the emergence of modern first responder entities such as the American Red Cross and the world-wide civilian emergency medical technician and paramedic response systems. This article reviews the history of first responders, their roles and important legislation as it relates to dental responders—specifically the role of dentists on an interprofessional response team, and with a particular focus on dentists providing immunizations. Etymology of “responders” and evolution of interprofessional response teams Today the term “emergency response providers” is legally defined in Section 2 of the US Homeland Security Act of 2002. This act defines the term as inclusive of “Federal, State, and local emergency public safety, law enforcement, emergency response, emergency medical (including hospital emergency facilities), and related personnel, agencies, and authorities.” This definition makes no distinction between responders arriving immediately upon the onset of a disaster and those arriving many hours or days after the initial “surge” period (eg, responders who aid in identification and recovery efforts), even though the skills and personnel needed at different time intervals after the onset of an emergency event may be vastly different. The initial response to an event is particularly critical to effectively contain and mitigate a disaster or pandemic; as such, it is necessary to identify and define “first responders” separately from other responders. President George W. Bush provided a definition for first responder in the 2003 Homeland Security Presidential Directive HSPD-8 as follows : “individuals who in the early stages of an incident are responsible for the protection and preservation of life, property, evidence, and the environment.” According to HSPD-8, these individuals include the emergency response providers defined in the US Homeland Security Act of 2002 and “emergency management, public health, clinical care, public works, and other skilled support personnel (such as equipment operators) that provide immediate support services during prevention, response, and recovery operations.” The US Department of Health and Human Services released the first National Health Security Strategy in 2009, which was designed to lay out a baseline strategy to minimize the health consequences of large-scale disasters. The subsequent National Health Security Review 2010 to 2014 and the National Health Security Strategy and Implementation Plan 2015 to 2018 describe the progress made toward this goal and updated strategies to improve response. These and other comprehensive response plans incorporate a broad array of interdisciplinary health professionals from different professional backgrounds and organizations, including all levels of government (local, regional, state, and federal), corporations, community organizations, the nonprofit sector, academia, and the scientific community ( Fig. 1 ). The dentist, serving as a dental responder, and as a participating member in the interprofessional first responder team, is included in all of these plans. As these response plans become more collaborative in nature in the future, the further interprofessional development of oral health professionals on a disaster response team will be critical ( Fig. 2 ). Fig. 1 Local, regional, state, and federal organizations contributing to all-hazards and pandemic preparedness and response. Fig. 2 Interprofessional and collaborative evolution of organizations involved in pandemic and all-hazard planning and response. Traditional first responder activities have typically been performed by public health professionals such as physicians, nurses, physician assistants, and emergency medical technicians. Dental professionals, however, have long served in civilian and military first responder capacities during natural disasters, anthropogenic disasters, and pandemic events, assisting various investigative and law enforcement agencies when processing missing people and identifying anthropological remains. The nature of this work is typically conducted during the recovery efforts in the day(s) after a disaster; therefore, dentists have not traditionally been included as part of the interdisciplinary first responder teams initially called to a disaster scene. In addition to being trained in forensic identification and biometric informatics, oral health providers have the capacity to respond to disasters, provide immunizations, and provide triage care. Over the past decade, selected states and the US Congress have passed legislation that has defined the dental responder and has expanded the legal authority of oral health care providers to serve in such first responder activities. Dental responder legislation Commissioned dentists in the US National Guard services, all branches of the Active Duty and Reserved Armed Forces of the United States, and the majority of international military forces, have a long history of providing military mass casualty and triage support as part of military medical and humanitarian response teams. These dentists provide anesthesia care and management, triage care and management, immunization care and management, and attend to the oral and maxillofacial care and trauma of military forces in battlefield and home station conditions. Military dentists also have a long tradition of providing forensic identification support after battlefield events and military accidents. In the United States and international civilian communities, dentists have traditionally provided first responder care for the forensic identification of casualties from mass disasters, as integral members on disaster mortuary operational teams. However, the idea of a civilian dentist acting as a full-spectrum first responder (ie, practicing care as a military dentist or disaster mortuary operational team dentist) within civilian first response teams—in concert with traditional health care professionals such as physicians, nurses, and emergency medical technicians—was not introduced into the scientific literature until 1996 by Morlang. The September 11, 2001, terrorist attacks in the United States further served to increase awareness of the potential benefit of dental first responders. After those attacks, numerous medical and dental strategy, theory, and policy experts and clinicians, at the federal and state levels, suggested that the American dental profession needed to define and describe a cohesive vision to establish membership protocols and outline clinical duties for civilian dentists to become members of medical disaster response teams. This vision had to be synergistic with the current standard operation procedures used by the emergency response community and one that could be translated into actual changes in the state dental practice acts for each state in the United States. State Legislation Illinois has been at the forefront to advance legislation incorporating dental professionals as first responders on disaster response and immunization teams. This effort to define a cohesive vision and policy for the dentist to serve as a civilian first responder was reported by Colvard and coworkers in 2006. Policy and strategy work by the authors leading up to the release of this paper, in concert with state and national professional support (including the Illinois State Dental Society, American Dental Association, and numerous other organizations), resulted in Illinois Public Act 49 to 409, which was signed into law in 2005. Through this legislation Illinois defined the “dental emergency responder” and became the first state to amend their state dental practice act to introduce the concept of the civilian dental responder providing emergency medical care, triage, and immunizations during a disaster event. The Illinois Dental Practice Act defined a dental emergency responder as a licensed dentist or dental hygienist “who is appropriately certified in emergency medical response, as defined by the Department of Public Health.” Dentists and dental hygienists are described as “acting within the bounds of his or her license when providing care during a declared local, state or national emergency.” In 2015, the Illinois Dental Practice Act was amended via Public Act 99-0025 to change “dental emergency responder” to “dental responder.” The “dental responder” is defined as “a dentist or dental hygienist who is appropriately certified in disaster preparedness, immunizations, and dental humanitarian medical response consistent with the Society of Disaster Medicine and Public Health and training certified by the National Incident Management System or the National Disaster Life Support Foundation.” California has also made notable strides to support the dental responder. In contrast with Illinois, California did not directly alter its dental practice act, but rather introduced additional legislation that was designed to reduce the barriers confronting dentists who wished to participate as first responders. The California Dental Association sponsored AB 2210 in 2008. This bill, which was signed into law in 2008 and became effective January 1, 2009, “allows the California Dental Board to suspend compliance with any provision of the Dental Practice Act that would adversely affect a licensee’s ability to provide emergency medical care that is consistent with his/her training.” Through this law, California dental professionals who provide emergency care voluntarily and without compensation during declared disasters are provided indemnity. Several other states have expanded their public health and “good Samaritan” laws to include dentists among potential responders supporting a state or national declared disaster response. Although Illinois and California have addressed the inclusion of the dental responders through changes in legislation, other states continue to advocate on the behalf of the dental responder through nonlegislative actions. For example, a number of academics, physicians, and state organizations in New York have provided support over the past decade to include and properly train dentists for first responder activities. In Texas, the Texas Military Forces annually conducts Operation Lone Star, a training event for state and local partners to train for disaster response; this event includes dentists, dental assistants, and dental students. A number of civilian and military health care professionals and response organizations (such as the American Red Cross) operating at state and local levels continue to support dentists to become first responders and to be actively involved in responder research and training exercises. Notably, the United States Assistant Secretary for Preparedness and Response, responsible for overseeing the US Medical Reserve Corps (MRC), has specifically named dentists and dental assistants as possible “front line” health providers capable of providing “surge” capacity during the first 12 to 72 hours of an emergency. The MRC network currently consists of nearly 1000 community-based response units throughout the United States and US territories. Federal Legislation While individual states debate legislative actions to incorporate dental responder activities into each state’s dental scope of practice, important federal legislation was recently passed to support disaster response activities of oral health care providers. The 2013 reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA) gives dentists and dental hygienists the legal authority to support national emergency, disaster, and forensic needs by providing clinical care and infrastructure for “walking well” care, pandemic vaccination support, biometric information, and forensic dentistry. Three key changes were introduced in the PAHPA, which defined the inclusion of oral health care providers in public health emergency planning and response : 1. Dental health care facilities are incorporated under ambulatory care facilities during public health emergencies; 2. Dental health assets (including dentists and dental hygienists) are incorporated after medical assets in medical triage activities during a disaster; and 3. Training efforts for dental professionals responding to public health emergencies are supported. The PAHPA serves as a critical starting point for legally introducing dental responders into pandemic and disaster planning and response activities within the United States, but it does not describe the implementation of oral health care providers into these activities. Dentists and hygienists who wish to serve as dental responders will need to become integrated into interprofessional local, state, and federal disaster response teams. Immunization capacity of dentists Initial response to a public health emergency occurs at the local level and, as such, is typically coordinated by local/county response teams. Given that the disasters typically faced by a local health department depend on their geographic location, it is critical that disaster response team training occurs at the local level so that all health responder team members are best prepared for potential location-specific emergencies that may arise. As such, the greatest need for dental responders will likely be as members of local disaster response teams. Many communities already have MRC units, Civilian Emergency Response Teams, and similar teams in place to help coordinate the local health care response during emergency situations. Only a very limited number of publications defining local-level emergency response planning and training activities designed specifically for dental responders have been reported to date in the scientific literature. This is likely owing to a number of factors, including (1) the federal legislation supporting the inclusion of dental responders was only passed recently, and local organizations may not be aware of the change in legislation; (2) the 2013 reauthorization of the PAHPA does not provide guidance for implementing oral health care professionals onto pandemic and disaster response teams, and local health organizations may not know how to begin this process; and (3) resources to provide training may be limited and are likely to first be allocated to the traditional physician and nurse responders. Although the PAHPA states that training activities for dental responders are supported, it does not say in what capacity this support will occur. One such immunization training activity has been reported. In late 2013, the Operation Sustained Adaptive Prophylaxis influenza mass vaccination drill was developed and conducted by the DuPage County Health Department in Wheaton, Illinois. The exercise was designed to train potential dental responders in a simulated pandemic immunization response scenario, using just-in-time (JIT) training. The protocol was modified from an H1N1 influenza mass vaccination clinical protocol previously used by certified public health nurses, as provided by the local health department. The main goals of the exercise included validating the use of dentists as an emergency response resource; testing the vaccination throughput using the current plans, protocols, and procedures of the health department; validating that the correct vaccination dispensing protocol were used (drug selection, amount, technique); and validating the use and effectiveness of the JIT training. Fifteen dental professionals (8 hygienists and 7 dentists) from the local MRC served as dental responders in the 1-hour exercise. JIT training consisted of an approximately 15-minute-long video describing inoculation techniques (watched as a group), a 10-minute group discussion reviewing the specific protocol to be used, and 15 minutes at his or her individual station to review independently the protocol and practice techniques. Community volunteers served as the “patients” for the drill. To replicate realistic operational conditions of a mass vaccination, patients were given simulated vaccine administration records. Patients presented the vaccine records to the dental responder, who was then responsible for the appropriate selection and administration of the vaccine. A porcine model was used to simulate the vaccination injection of patients. Trained nurses and emergency response personnel oversaw the exercise and evaluated the dental responders for medical history documentation, vaccination procedures, and patient throughput and error rates. Fig. 3 shows pictures from the exercise. Fig. 3 The setup of a mass vaccination pandemic immunization response exercise completed by dentists. Overall, the results of the dental responders were found to be similar to those documented by the DuPage County Health Department in mass influenza clinics previously conducted by certified public health nurses. A total of 335 patients were treated during the hour-long exercise, corresponding to an average throughput rate of 22.3 patients per dentists per hour. Among the 335 patients, 7 medical errors (incorrect vaccine dosage administered and/or incorrectly documented vaccine administration records) were documented, corresponding with a medical error rate of 2.1%. These results were found despite noting the 15 dental responders had vastly different backgrounds and professional experiences. This suggests validation of the use of the JIT training methodology and validation of the dental profession in general as a valuable immunization resource. It was further noted that 3 of the vaccinators did not possess the necessary vaccine administration skills to competently conduct the drill, thereby emphasizing the importance of local responder teams to regularly conduct training exercises such as this to ensure their team members are adequately prepared to respond to a pandemic or disaster. Summary Although dentists have traditionally served on civilian interprofessional disaster response teams, their role has typically been limited to the forensic identification of remains. Oral health care professionals diagnose and treat medical conditions in their daily activities, just like their colleagues from other health care disciplines. Such activities include surgical care, anesthesia care, administering immunizations, providing appropriate (triage and tactical) support care during emergency response and triage interventions, following up with patients, and referring patients to other medical experts. These same skills and infrastructure assets are used during pandemic and disaster response activities. Dentists also possess a unique diagnostic skill set for forensic dental, oral, and facial data gathering and analysis—additional skills that are important during first responder activities. As such, dental professionals are uniquely positioned at the forefront of emerging biometric and forensic standards and technologies, and therefore can play a critical role in first responder and health security efforts. Recent work has sought to drastically expand the purview of dentists and hygienists in disaster and pandemic planning and response. Toward this goal, work over the past decade has focused primarily on: 1. Policy advancements to legally expand the role of the civilian dental responder, and 2. Educating other health care professionals and the public to better understand the dentists’ and hygienists’ skill sets, and how these unique skills can be incorporated into interprofessional disaster response teams to enhance the overall quality and efficacy of emergency response efforts. Policy advancements during the past decade, on both the state and federal levels, have resulted in significant progress in expanding the role of the dental responder beyond traditional forensic identification activities. Illinois has made the most legislative progress on the state level, through amendments made to the Illinois Dental Practice Act that define and include dental responder activities in the dentist’s regular scope of practice. The 2013 reauthorization of the Pandemic and All-Hazard Preparation Act introduced dental professionals into federal legislation overseeing public health emergency response. This was a crucial achievement for the dental profession, but significant work remains to further implement the changes outlined in the act. To this end, efforts to educate other disaster responders, other health care professionals, and the public as to the value of including dental responders are on-going. Training exercises such as the immunization drill conducted by the DuPage County Health Department (Wheaton, IL) provide documented evidence of the capacity and capability of dental professionals to participate in pandemic and disaster planning and response. As dentists become more involved in first responder activities in the future, it is critical that similar training drills continue to be developed and executed. Although advocacy efforts have increased in recent years, to date, only a relatively small number of local, state, and federal response teams actively recruit and incorporate dentists in their first responder efforts. As such, the dental community needs to continue educating other health care professionals and the public. Disaster response requires the integrated response of health professionals, and interprofessional communication is critical among members of a response team. As such, all stakeholders, regardless of their health care profession, need to work together in the strategic planning, hands-on preparation drills, and active response situations to ensure the health consequences of such hazards are minimized and the response efforts can be completed as quickly and efficiently as possible. Oral health care professionals should be actively involved in all stages of disaster and pandemic planning and response within their local communities. Now that federal legislation is in place recognizing the dental profession as responders, work must focus on solidifying collaborations among the health professions. The dental community as a whole needs to continue to advocate for dentists and hygienists to be included as key members of the response team and must educate other health professions and the public as to the critical role oral health professionals can play in disaster and pandemic response. Likewise, consensus building among various government agencies, professional organizations, and the public must continue, and fundamental changes to the dental curriculum that require oral health professionals to receive disaster and pandemic response training should be implemented. Strategy sessions and hands-on training drills can serve as important interprofessional educational tools, allowing dentists and dental students to learn pandemic and disaster response techniques alongside other health care providers, while also enabling current and future dental professionals to provide valuable input into response activities. One suggested method to provide real-world interprofessional relations training to oral health care providers is to include dentists and hygienists as vaccinators during seasonal flu vaccination clinics commonly hosted by county health departments, hospitals, and universities. Dentists and hygienists interested in training to become dental responders are urged to actively participate in their local communities through units such as the MRCs and Civilian Emergency Response Teams. Additionally, appropriately qualified dentists could serve as members on local tactical emergency medical support teams. There are also several nongovernmental organizations and religious organizations that sponsor responder teams and seek dentists for the unique skill sets oral health care professionals can provide during all-hazard and pandemic events. Additionally, interested individuals should contact their local county health departments, county coroner’s offices, and/or the various federal responder teams (such as disaster medical assistance teams and disaster mortuary operational teams) for participation opportunities. All teams listed require active licensure, advanced training and education, and experience for participation. Finally, the various levels of National Guard, Reserves Armed Forces, and Active Duty military train and staff responder teams able to respond to the full spectrum of chemical, biological, radiologic, nuclear, and explosive events that could potentially occur around the world. The dentist and oral health care community can make significant contributions to the intraprofessional and interprofessional collaborations among health care providers by serving on response teams within their communities. References 1. 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