From Volume 13, Issue 3, July 2020 | Pages 102-107
This paper explores past natural disasters such as Hurricane Katrina (USA), the Great East Japan and Christchurch (New Zealand) Earthquakes as well as the HIV and SARS pandemics and the impact they had on providing orthodontic services at the time of the crisis. It also addresses the lessons learnt during the process of recovery and the long-term changes made as a result to the provision of care.
A crisis is ‘a decisive moment, a time of danger or great difficulty, the turning point especially of a disease.’1
The world has endured several recent crises and will certainly experience more in the future. Crises include the events related to natural disasters and uncontrollable spread of a disease, which have not only impacted on daily life in general, but also on the ability to deliver orthodontic services. Although previous disaster reports relating to dentistry have largely focused on forensic and emergency dental services, there is limited reporting on the impact on orthodontic services. However, recent natural disaster reports that have commented on orthodontics are Hurricane Katrina (USA), the Great East Japan and Christchurch (New Zealand) Earthquakes, as well as the HIV and SARS pandemics.
Part 1, of this two part article, will discuss the management of the above crises with an emphasis on the impact on the delivery of orthodontic services, the lessons learnt and the long-term changes made as a result. In Part 2, the new disease, COVID-19, will be discussed, the changes that should be made to clinical practice and what the future may entail for orthodontics.
Orthodontics is unique within dentistry as it involves extended courses of active treatment with numerous intervening monitoring and/or adjustment episodes. These are staged to ensure that efficient and effective tooth movements are delivered with minimal side-effects and maximal beneficial outcomes. The effects of the abrupt cessation in the ability to provide ongoing monitoring/adjustments on orthodontic services in times of crisis require careful consideration and planning, not only by the individual providing that care, but also professional bodies and national regulatory authorities. This planning should extend beyond the immediate crisis and include intervening transitional periods, as well as the services provided under ‘new’ normal conditions. Examination of the experiences of orthodontic colleagues in recent national disasters highlight certain planning shortcomings, as well as providing some insights into the beneficial changes that have occurred.
On 29 August 2005, Hurricane Katrina, a category 3 hurricane, hit the states of Louisiana and Mississippi, resulting in over 1,600 fatalities and displacing over 750,000 residents2,3 (Figure 1). It caused widespread severe damage to health infrastructure, including 14 hospitals in Mississippi and 11 hospitals in neighbouring Louisiana.4 Power and telephone lines were destroyed, making land-based communication challenging.4
In the immediate aftermath, although medical care was co-ordinated by the US Department of Health and Human Services Secretary's Emergency Response Teams and FEMA Disaster Medical Assistance Teams, there was no provision for emergency dental treatment. Out of state dentists volunteered their services. However, state legislation in the USA initially delayed the deployment of these volunteers until they obtained temporary dental licensure. Urgent procedures were initially limited to extractions and temporary dressings for the relief of pain. Treatment was carried out in mobile dental vans and tents, with supplies for this service being donated by dental practices and dental supply companies.4 The American Dental Association (ADA) helped with all aspects of the response efforts after the disaster, varying from providing financial aid to supporting re-housing of dentists, sending mobile units and helping to connect people that needed urgent care with details of where they could get treatment.5
Hurricane Katrina severely damaged The Louisiana State University School of Dentistry (LSUSD), making it unusable. LSUSD plays a significant role in training over 80% of Louisiana's dental professionals, with 8 orthodontic residents normally undertaking a 2-year programme.6,7 Storms are common to this region and, as a result, LSUSD had pre-existing contingency plans to accommodate for temporary interruptions. However, there was no plan in place for a major flood that would keep the dental school and all of its programmes (pre-doctoral, hygiene, lab technology and post-doctoral) from the school for 2 years. A task force was quickly set up to oversee the logistics of making alternative arrangements, which resulted in a temporary dental school, albeit smaller in size, being set up 75 miles away. The school was equipped with free equipment from vendors and opened in December 2005. All training programmes had to be modified to accommodate for the smaller space.6 Orthodontic programmes from around the country offered to take the residents for a short period of time or longer, if necessary. The residents decided to stay and were relocated to several different locations, including the private facilities of part-time teaching staff and temporary campus-based clinics, until repaired dental school facilities were re-opened. Many of their original patients eventually returned for treatment, but around 15% of the patient base was lost, with roughly a 6−16 weeks'0 interruption in care. Screening re-opened in February 2006 to replace the patients that had been lost to relocation, and to prepare for the class of residents starting in July 2006. The training period was extended by 2 months for the affected residents.7 Wellbeing support was offered through referral by the LSU Campus Assistance Programme.
The dental school required extensive renovation, which allowed the installation of fibre optics, high-speed internet, digital radiography, electronic appointment scheduling and clinical notes.7 This allowed for more efficient and robust communication pathways and secure storage and retrieval of electronic clinical information.
On 22 February 2011, at 12.51 pm, a magnitude 6.3 earthquake struck central Christchurch, New Zealand.8 Due to the time of day, the strength of the earthquake and the subsequent collapse of buildings, 6,659 people were injured, and 182 people killed. Christchurch Hospital, the only acute hospital in that region, along with other health facilities, suffered damage as well as flooding and power loss8 (Figures 2 and 3).
As this was a business day, orthodontic practices were open and treating patients. When the earthquake occurred, these practices were quickly evacuated and, in the moment of haste, some practices did not retrieve IT back-up discs. There were delays lasting several weeks before recovery teams could enter damaged buildings to retrieve these discs safely. Practices that had remote IT back-up or access to servers still operating could communicate with staff and patients via email, as well as website postings, within days of the earthquake once power and internet services had been re-established. Those with paper-based records also had issues retrieving these from damaged premises and, once retrieved, relied upon texting/phoning individual patients or simply waiting for patients to contact them. Many practices established temporary offices in their homes for administration, while establishing temporary clinics in undamaged premises, which included general dental practices where there was spare clinical capacity (after hours, weekends). The use of laptops to connect remotely to a central server for electronic records and appointment scheduling enabled continuation of care, with priority given to those in active treatment.
Following the earthquake, many patients left the province; some never returned. The New Zealand Association of Orthodontists (NZAO) membership outside the province collectively agreed to treat any earthquake transfer patients for free. The NZAO members also arranged for spare instruments and equipment to be sent to those whose practices were inaccessible. Hand instruments and equipment, as well as materials, were transported between the various practice locations, and long delays were experienced in accessing new patient starts, recalls and retainer checks. As practices re-established in new or temporary premises, a complete switch to electronic records was undertaken, including intra-oral scanning, with the discontinuation of plaster models and paper-based clinical notes.
Although many orthodontists held business premises and continuity insurance, there were considerable delays in processing their claims and, as orthodontic care in NZ is essentially privately funded, considerable financial strain was experienced, with continued outgoings while experiencing a substantial reduction in income.9
On 11 March 2011, a devastating magnitude 9.0 earthquake struck the Tohuku and Kanto regions of eastern Japan and generated tsunami waves in excess of 10 metres, with a run up height of up to 40 metres. Fatalities in excess of 15,500 where reported.10 Devastation of buildings, including health facilities, as well as infrastructure, was widespread and included damage to the Fukushima Daiichi Nuclear Plant. This damage triggered substantial releases of radioactive material, resulting in nearby residents being forced into prolonged evacuation.
Disaster emergency relief providing oral health services, including the distribution of oral care products, was undertaken within designated shelters. Shortages of electricity, water, dental supplies and instruments hampered relief efforts.11 A joint taskforce, involving the Japanese Orthodontic Society, Tohuku Orthodontic Society, Tokyo Orthodontic Society, The Japanese Association of Orthodontists and Orthodontic Suppliers Association of Japan, was initiated with the aim to co-ordinate logistic support activities related to orthodontics.10 This included not only private orthodontic facilities, but also the re-opening of university-based postgraduate orthodontic programmes in the affected regions. Most orthodontic clinics re-opened a few months after the earthquake, except those in the coastal region which were washed away by the tsunami. There was also a reduction in patient databases due to patients evacuating never to return, or deciding to discontinue treatment due to other priorities. The Japanese Association of Orthodontists still offer financial assistance to orthodontic patients affected by the 2011 Great East Japan Earthquake and Tsunami.12
Psychiatric support was also provided to the disaster areas for victims, as well as recovery workers, which included dentists who were tasked with identifying the deceased.13
One of Dentsply GAC's major manufacturing partners for orthodontic brackets was within the Fukushima region and ceased operations due to their proximity to the damaged nuclear facility. This closure had a dramatic and prolonged impact on their supply of orthodontic products.14 Although there were some individuals attempting to profit from Denstply GAC's misfortune, others confirmed their loyalty to the brand as well as offering temporary supply arrangements until Dentsply production returned to normal.14
The first case of Human Immunodeficiency Virus (HIV) was reported in 1981.15 HIV targets the immune system, weakening people's defence system against infections,16 with the most advanced stage of HIV infection known as Acquired Immunodeficiency Syndrome (AIDS). Globally, there were 37.9 million people living with HIV at the end of 2018.17 The virus is transmitted by the exchange of body fluids, such as blood, breast milk, semen and vaginal secretions from infected people. HIV is treated with antiretroviral drugs to suppress the replication of the virus, allowing the person's immune system to regain its ability to defend against infections.16
The HIV epidemic changed the practice of orthodontics and our cross-infection practices, which arose when one dentist allegedly infected several of his patients with the HIV virus.18 Despite clinicians being aware of other blood-borne viruses, such as Hepatitis, many dentists did not routinely wear gloves, as it was felt it would affect manual dexterity, especially in orthodontics during wire bending. However, infection control practice guidelines produced by the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis recommended the routine use of gloves and stricter cross-infection practices, even though the perceived risks from orthodontics were considered, by some, to be less than other forms of dentistry.18,19 These guidelines still form the backbone of current guidelines, including BDA A1220 and HTM-01-05.21
The first cases of Severe Acute Respiratory Syndrome (SARS) emerged in mid-November 2002 in Guangdong Province, China.22 Although SARS was initially thought to be related to poultry, new evidence points to Himalayan palm civet cats as the source of infection.23 The initial infection was transmitted from Guangdong Province to Hong Kong (Kowloon) in late February 2003 by a medical doctor and from there it spread rapidly, with outbreaks in Hanoi, Singapore and Toronto.22 Transmission was via respiratory droplets and/or fomites and the resulting infection comprised pneumonia with resultant irreversible pulmonary fibrosis.24
As no vaccine was available, containment was achieved through isolation and quarantine measures between 2002 and 2004. Nevertheless, there were 9098 reported cases of SARS and 747 deaths.25 Although in Hong Kong, at the Prince Philip Dental School, strict infection control procedures and the routine use of personal protective equipment (PPE) had been in place following avian flu pandemic strategic planning undertaken in 2000, some health workers contracted SARS through not wearing protective eye equipment.26
During the period of uncertainty, the combined paedodontic/orthodontic clinics, along with other disciplines, were instructed to reduce procedures that generated aerosols and to use pre-procedural antibacterial mouthrinses (0.12% chlorhexidine). However a paper by Dawson et al showed that use of preprocedural rinse at debond increased the bacterial count.27 In March, all clinics and teaching was stopped. This allowed for structural changes to be made to the open clinics to allow one-way patient flow, restricted access from the waiting room and segregated triaging areas. Only limited emergency clinics remained open, with all patients undergoing a careful medical history, including screening questions and temperature check. It was not until late April that clinics re-opened, with a heightened awareness amongst all staff of infection control. Interestingly, the use of CAD-CAM technology to obviate conventional impression taking was recommended to reduce the risk of gagging, and eliminate the need for disinfection of impressions prior to dispensing to the laboratory.28
The abrupt cessation in the ability to provide orthodontic treatment for extended periods of time presents unique challenges for patient care and practice management (Table 1). Although crises have been experienced by some colleagues, it has never been on such a worldwide scale as has been imposed by the current COVID-19 crisis.
| Natural Disasters |
|
| Pandemics |
|
Natural disasters normally result in physical damage to orthodontic premises, materials and equipment, a disrupted communication infrastructure, loss of physical and sometimes digital records followed by the need to relocate or rebuild and establish communications with staff and patients. The loss or damage to homes and personal effects may add to the financial and mental stress of patients, their families, and to the orthodontic practice owners and staff.
In the case of the Christchurch earthquake, those practices that used electronic practice management systems and digital patient records with offsite back-up were at a distinct advantage in the immediate post crisis period. They were more able to re-establish patient communication, retrieve clinical records and continue orthodontic care of their patients, even when there was limited capacity due to improvised or temporary practice facilities. As a result, the use of electronic patient records, including digital X-rays, and intra-oral scanning, has since widely been adopted in all dental practices.
Those crises related to pandemics such as SARS have resulted in national regulatory authorities aligning cross-infection protocols and the use of PPE to revised best practice standards to protect both the public and clinicians. The routine use of gloves in orthodontics was hastened when the risks of HIV infection via saliva and blood became known, along with the introduction of more stringent instrument sterilization procedures. The routine use of face masks and eye protection increased during the height of the risk of the SARS pandemic due to its known aerosol transmission.
The important supportive role of national and regional orthodontic associations has also been highlighted in times of crisis. The ability to help co-ordinate various logistics and offer donations was demonstrated in Japan, New Orleans and New Zealand.
The lack of dental involvement in national emergency response planning, as illustrated by Hurricane Katrina, and in pandemic planning, should be addressed. Monaghan suggested that public health organizations should consider appointing someone who is responsible for producing guidance, particularly on any new emerging infection and how this might affect dentistry.25 This would ensure that the dental profession would receive early, appropriate advice. Some states in America, such as Illinois, have started to integrate dentists into these responder teams.29
Interestingly, with each natural disaster and pandemic there are common themes to the challenges experienced, as well as lessons learnt. Feedback from the contributors directly affected by these disasters have shown that, with resilience, patience and time, those affected do overcome the trials faced. It is also important to note that decisions were made that, in hindsight, may not have been the best. However, it is also important to remember that these decisions would have been made using the information at hand and without the benefit of a crystal ball. In all, the crises explored in this paper have highlighted how orthodontists have subsequently used the opportunity to improve services. In Part 2 we will discuss the current COVID-19 crisis and how the orthodontic specialty might navigate its way through it.
