Author: Nathan MOREAU (DDS, MSc, PhD)
Associate Professor, Department of Oral Medicine and Oral Surgery, Bretonneau Hospital, AP-HP, Paris, France
INTRODUCTION
In the midst of one of the greatest health crises the modern world has had to face, each healthcare professional can only ponder his personal implication in such a catastrophe. Are we doing enough? Where are we the most useful? What will happen if too many of us get contaminated and sick?
These questions resonate even more for dentists at a time when the National Dental Council has asked that all non-urgent clinical activities be postponed, leaving the motivated dentists with a feeling of helplessness and the wanting to do more.
Quite unfortunately, it seems as if such questions haven’t been given much thought in the heat of the COVID-19 pandemic. As a profession, we hold the sole responsibility to think (or rethink) our role within this crisis, echoing a more global reflection on the dentist as a medical health professional who is (or should be) concerned -as much as his medical colleagues- with the promotion and maintenance of public health.
HISTORICAL PERSPECTIVES
It is difficult to pinpoint the first time that dentists have taken part in major health crises but there have been numerous historical examples of their implication in such events.
Few people remember Charles Valadier, a French-born American citizen, who was a pioneer in the treatment of jaw injuries incurred during the First World War.1 In 1914, after the beginning of the hostilities, he began to look for ways to help the war effort. As the French authorities were reticent to accept him as he was not a French national, he offered his services to the British Red Cross Society in Paris, and thus became the first dental surgeon to provide treatment for the British troops in France. In this period, he worked with Harold Gillies and developed an expertise in the treatment of jaw fractures, treating the numerous soldiers wounded during the Great War. He developed principles and appliances, some of which are still currently in application, thus becoming a forgotten pioneer of maxillofacial surgery as this new surgical specialty emerged.
More recently, with the emergence of the Human Immunodeficiency Virus (HIV) pandemic in the 1980s, there has been a resurgence of tuberculosis infections throughout the world, especially in underdeveloped countries.2 As about one-fourth of the whole human population is estimated to be infected with Mycobacterium tuberculosis (World Health Organization data, 2020), dental practitioners from around the world will -at some point- be confronted to patients with tuberculosis. Although quite rare (at least in the developed countries), there are several oro-facial manifestations of tuberculosis such as isolated oral ulcers (of the dorsum of the tongue, palate, gums, floor of the mouth and lips), tuberculous osteomyelitis of the jaw, tuberculous parotitis and tuberculous cervical lymphadenitis that can sometimes lead to the diagnosis of tuberculosis in otherwise undiagnosed patients. In that respect, dentists thus have a role to play both in the prevention of the spread of the disease (by limiting the production of aerosols from rotary instruments, wearing face masks and providing adequate ventilation of the dental office) but also in its early diagnosis so as to initiate the appropriate antibiotic regimen as soon as possible.2
In that same vein, the HIV pandemic in itself has been an opportunity to assess the implication of the dental profession against a new emerging health threat. Indeed, in a similar and more potent fashion than with tuberculosis, oral manifestations of HIV such as oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma or necrotizing ulcerative gingivitis/periodontitis have been surrogate markers of CD4 lymphocyte-mediated immune deficiency and thus highly useful in suspecting HIV infection, especially in cases where serological testing is difficult or not accessible.3 During the 1980s, the oral health community actively responded to the HIV epidemic: researchers pursued studies on the oral manifestations of HIV and on new possible means of diagnosis (using saliva or gingival cervical fluid for example); educators addressed the pandemic in the dental curriculum and finally practitioners responded to infection control procedures and occupational transmission issues as edicted by the collaboration between the International Dental Federation (FDI) and the World Health Organization.3
Other examples of dentists’ implication in global health issues include the Swine Flu,4 the opioid crisis,5 antibiotic resistance6,7 and the current COVID-19 pandemic.8
LEGAL PERSPECTIVES
Several articles from the French Code of Public Health can be drawn from to consider the dentist’s role in a global health crisis. These are presented here in their original French wording so as not to risk any error in translation.
Article R. 4127-202:
“Le chirurgien-dentiste, au service de l’individu et de la santé publique, exercice sa mission dans le respect de la vie et de la personne humaine.
Il est de son devoir de prêter son concours aux actions entreprises par les autorités compétentes en vue de la protection de la santé.”
In one of the first articles of what composes the Dentist’s Deontology Code, it is explicitly stated that the dentist must serve the public health, and as such must help protect Health in collaboration with the relevant authorities.
Article R. 4127-204:
“[…] Sauf circonstances exceptionnelles, il ne doit pas effectuer des actes, donner des soins ou formuler des prescriptions dans les domaines qui dépassent sa compétence professionnelle ou les possibilités matérielles dont il dispose.”
Although the legislator does not explicitly define the exceptional circumstances, one can easy construe them as global health crises or other medical/sanitary emergencies. Such an hypothesis is reinforced by the following article.
Article R. 4127-205:
“Hors le seul cas de force majeure, tout chirurgien-dentiste doit porter secours d’extrême urgence à un patient en danger immédiat si d’autres soins ne peuvent lui être assures.”
Indeed, both in an individual medical emergency and in a global sanitary crisis, the dentist must do his best (in adherence with his relevant medical training) to manage the emergency, if no other more adequate assistance can be procured.
Article R. 4127-212:
“ Le chirurgien-dentiste ne doit pas abandonner ses patients en cas de danger public, si ce n’est sur ordre formel et donné par écrit des autorités qualifiées.”
As such, the dentist must provide continuous care for his patients, unless ordered otherwise by the relevant authorities, for instance by participating in local, regional or national on-call duties (as reinforced in other articles such as the following).
Article R. 4127-245:
“Il est du devoir de tout chirurgien-dentiste de prêter son concours aux mesures prises en vue d’assurer la permanence des soins et la protection de la santé. Sa participation au service de garde est obligatoire. […]”
On-call duty is thus essential, even more so in case of a global heath crisis such as the current COVID-19 pandemic. The present article does not preclude the possibility of being implicated in other public health measures to protect Health in a crisis context.
PEDAGOGICAL PERSPECTIVES
As teachers, we have a tremendous opportunity to shape the future of the dental profession by acting as role models and by entrusting a global health perspective and interest in all young dental trainees. Such a perspective should ultimately lead to better, more engaged, dental practitioners who will rapidly and easily engage in the management of global public health issues, such as fighting antibiotic resistance,6.7 mitigating the opioid crisis5 or limiting preventable diseases.
What can we teach our dental students regarding the present pandemic?
The French bylaw of 3 March 2006 created a new basic life support training that had the novel particularity of being common to all health professionals, namely l’Attestation de Formation aux Gestes et Soins d’Urgence (AFGSU). Such a module integrates, quite à propos, a learning module on “collective emergencies and exceptional sanitary events” where are discussed such issues as the seasonal flu epidemic or the possible integration of the dentist in a “plan blanc” (a special crisis plan in case of insufficient hospital means). Dental students usually distance themselves from such issues, often believing that they are of little concern to them. One can only hope that the current events will help reinforce the importance of said issues. Let us not forget our role as teachers, in reminding our students of the reasons for such training in rare sanitary crises. Forewarned is forearmed.
As teachers, we have a tremendous opportunity to shape the future of the dental profession by acting as role models and by entrusting a global health perspective and interest in all young dental trainees. Such a perspective should ultimately lead to better, more engaged, dental practitioners who will rapidly and easily engage in the management of global public health issues, such as fighting antibiotic resistance,6.7 mitigating the opioid crisis5 or limiting preventable diseases.
What can we teach our dental students regarding the present pandemic?
The French bylaw of 3 March 2006 created a new basic life support training that had the novel particularity of being common to all health professionals, namely l’Attestation de Formation aux Gestes et Soins d’Urgence (AFGSU). Such a module integrates, quite à propos, a learning module on “collective emergencies and exceptional sanitary events” where are discussed such issues as the seasonal flu epidemic or the possible integration of the dentist in a “plan blanc” (a special crisis plan in case of insufficient hospital means). Dental students usually distance themselves from such issues, often believing that they are of little concern to them. One can only hope that the current events will help reinforce the importance of said issues. Let us not forget our role as teachers, in reminding our students of the reasons for such training in rare sanitary crises. Forewarned is forearmed.
If, as it is unfortunately predicted, the pandemic reaches a critical point where most of the specialised healthcare professionals (intensivists, infectious disease specialists, emergency doctors, nurses, etc.) are either sick and/or in insufficient numbers, the implication of other healthcare professionals will be mandatory. Ad hoc training, taking into account the dentist’s existent competencies, will allow a global implication of the dental profession in this unprecedented crisis. Such training modules are still to be defined.
If, as it is unfortunately predicted, the pandemic reaches a critical point where most of the specialised healthcare professionals (intensivists, infectious disease specialists, emergency doctors, nurses, etc.) are either sick and/or in insufficient numbers, the implication of other healthcare professionals will be mandatory. Ad hoc training, taking into account the dentist’s existent competencies, will allow a global implication of the dental profession in this unprecedented crisis. Such training modules are still to be defined.
CLINICAL PERSPECTIVES
What clinical competencies can the dentist draw from to assist in the fight against the SARS-CoV-2?
As any other medical healthcare professional, the dentist relies on classical clinical competencies to diagnose, treat and monitor diseases that fall within his scope of practice. Many of those clinical competencies can be used in the COVID-19 pandemic, such as medical interview, clinical examination of the head and neck region, swabbing, vitals monitoring, emergency procedures (oxygenotherapy, cardiopulmonary resuscitation) when necessary and basic nursing.
A non-exhaustive list of possible clinical competencies that the dentist can transfer in the COVID-19 setting are presented in Table 1.
Obviously, there are numerous clinical (and non-clinical) duties that the dentist can be trained to perform in such a health crisis context. Several possible competencies that the dentist can acquire are listed in Table 2.
Other non-listed competencies could be required by our medical colleagues, and it will be our duty to acquire them as fully as possible. Finally, let us not forgot about the current (and future) implication of our colleagues and students in recent telemedicine experiments such as the COVIDOM platform for the follow-up of COVID+ patients and the very recent COVIDENT platform for the management of dental emergencies.
TABLES
Table 1
| Clinical competencies of the French Dentist transferable in the COVID-19 pandemic setting | |
|---|---|
| Medical interview | – Patient history – Medical history – Review of systems |
| Clinical examination | – General inspection – Vitals assessment (pulse, blood pressure, oxygen saturation, temperature) – Oral cavity examination – Oropharynx examination – Nose and throat swabbing – Lymph nodes palpation – Venous blood sampling (when knowledgeable) |
| Treatment | – Injections (subcutaneous, intramuscular…) |
| Emergency procedures | – High-concentration mask inhalation oxygenotherapy – Bag-valve-mask insufflation oxygenotherapy – Basic cardiopulmonary resuscitation (chest compressions, ventilation, defibrillation) |
| Nursing | – Monitoring of vitals – Patient washing – Changing of beds – Instrument and room disinfection – Stewardship |
Table 2
| Clinical competencies that the French Dentist can acquire in the COVID-19 pandemic setting | |
|---|---|
| Nursing | – Venous blood sampling (if necessary) – Injection techniques (if necessary) – Drug preparation and perfusion – Orotracheal intubation assistance – Oral and nasal mucus suctioning |
| Clinical examination | – Basic pulmonary auscultation – Detection of clinical signs of sepsis and/or choc – Detection of clinical signs of respiratory insufficiency |
| Radiographic examinations | – Basic chest X-ray realization |
| Monitoring | – Ventilator monitoring |
| Administrative and management tasks | – Ad hoc electronic health records completion and maintenance – Staff coordination |
CONCLUSION
Our world is currently facing an unprecedented pandemic, the evolution of which is still uncertain. There is no doubt that only a global collaborative interdisciplinary engagement of all healthcare professionals will allow us to tackle this major health crisis. As dentists, we must answer the call made by our medical colleagues to fight a common evil, in adherence with our ethical engagement to promote and protect Health as reminded by our deontology and Hippocratic oath.
REFERENCES
- McAuley JE. Charles Valadier: a forgotten pioneer in the treatment of jaw injuries. Proc Roy Soc Med 1974; 67: 785-789.
- Samaranayake LP. Re-emergence of tuberculosis and its variants: implications for dentistry. Int Dent J 2002; 52: 330-336.
- Kleinman DV. Building the capacity for the response of the dental profession to the global HIV pandemic: a case study in international collaboration. J Pub Health Dent 1994; 54: 234-237.
- Wiwanitkit V. What should the dentist be concerned about in the scenario of emerging swine flu. J Indian Soc Pedod Prev Dent 2009; 27: 263.
- Keith DA, Kulich RJ, Bharel M, et al. Massachusetts dental schools respond to the prescription opioid crisis: a statewide collaboration. J Dent Educ 2017; 81: 1388-1394.
- Teoh L, Stewart K, Marino R, McCullough M. Antibiotic resistance and relevance to general dental practice in Australia. Aust Dent J 2018; 63: 414-421.
- Bansal R, Jain A, Goyal M, et al. Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance. J Fam Med Prim Care 2019; 8: 3518-24.
- Peng X, Xu X, Li Y, et al. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020; 12: 9.
ABOUT THIS PAPER
Manuscript submitted and accepted: March 2020.
Citation MOREAU N. (Re)defining the dentist’s role in major health crises: the COVID-19 pandemic experience. Fr J Dent Med 2020; 2 Article 1.
DOI: https://doi.org/10.36161/FJDM.0003
