Introduction
A significant public health problem, oral diseases and conditions burden billions of people with a negative impact on their quality of life. Reference Sheiham, Williams and Weyant1,Reference Bernabe, Marcenes and Hernandez2 Individuals who suffer oral diseases and conditions are at risk of pain, tooth loss, and masticatory dysfunction, thereby affecting their nutrition, quality of life, and self-esteem. Reference Fejerskov3–Reference Tonetti, Jepsen, Jin and Otomo-Corgel6
Several contextual factors may influence oral health care services. Among these, natural disasters (ND) are unpredictable events produced by nature, which are outside human control. They may cause loss of life, other health impacts, property damage, and loss of livelihoods and services. Reference Mohamed Shaluf7–Reference Parker and Tapsell9 This disruption of the normal functioning of the community generally provokes an alteration of the normal habits of the population, such as hygiene, shelter, and proper nutrition, and it is common to have major structural losses in homes, workplaces, and health centers. Reference Noji10–Reference Vos, Rodriguez, Below and Guha-Sapir12 This context can trigger a significant impact on lives and health, Reference Satoh, Ohira and Hosoya13,Reference Ohira, Hosoya and Yasumura14 as well as deterioration of oral health in the population, with an over-demand for health services and a shortage of oral health care. Reference Psoter, Park, Boylan, Morse and Glotzer15
In the context of natural disasters, dental professionals form an integral part of the health care community through different roles. They help with oral health promotion in shelters, temporary housing, and disaster recovery public housing; they also provide airway management, general first aid, surgical assistance, and cavity-prevention efforts for disaster-affected children; as well as prevent disaster-related death by aspiration pneumonia, and ultimately, help to identify corpses by tooth and dental treatment information. Reference Psoter, Park, Boylan, Morse and Glotzer15–Reference Nakakuki19
To appropriately fulfill these roles, all members of the dental office staff should be trained to promptly recognize and efficiently manage emergencies. Reference Glotzer, Psoter and Rekow20 Preparedness requires that many areas should be addressed: risk analysis, prevention and surveillance planning, response efforts, as well as training, storing additional equipment and supplies, and increasing the medical/ dental manpower available to meet the demands of these events. A surge capacity must be built by drawing on, and training other professionals to complement the traditional medical and public health workforce. Reference David21 Dentists, with their health training and clinical skills, are an ideal group of professionals with these requirements for a standby public health/ medical group in the context of natural disasters. Reference Dutta, Singh, Passi, Varghese and Sharma17,Reference David21
However, our understanding and knowledge of oral diseases and dental care reality during a natural disaster is still incomplete. This study therefore aims to identify, appraise, as well as summarize existing knowledge about oral health interventions in the context of natural disasters, and verify the main research gaps.
Methods
We performed a scoping review with the aim to describe and map the current available literature regarding oral health care interventions in the context of natural disasters. This article adheres to PRISMA-ScR guidelines. Reference Tricco, Lillie and Zarin22
Eligibility criteria
We based our eligibility criteria based on the PICo (Population, Phenomena of Interest, Context) framework.
Population
We considered as eligible any population receiving an oral health intervention in a natural disaster context. We did not restrict by age, geographic location, or any other variable.
Phenomena of interest
Our areas of interest were oral health interventions, defined as any promotional, preventive, or therapeutic intervention comprehending oral health, made by any health worker, with or without other co-interventions. We excluded forensic studies.
Context
We considered oral health interventions in the context of natural disasters; defined as any catastrophic event linked to geophysical, hydrological, meteorological, or climatological natural hazards, according to a prespecified framework. Reference Vos, Rodriguez, Below and Guha-Sapir12,23 These include widespread fires, floods, storms, earthquakes, and drought, among others, with the potential of causing significant damage. We excluded biological and extra-terrestrial natural hazards, as well as non-natural hazards.
Study design
We considered eligible primary studies (descriptive, observational, or experimental designs) with at least 10 patients receiving an oral health intervention, or systematic reviews. We excluded case reports, case series, non-systematic reviews, and clinical guidelines. We included only studies published in peer-review journals in English, Spanish, or Japanese. We did not apply any publication date restriction.
Search methods for identification of studies
We searched PubMed (National Library of Medicine, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands) and Epistemonikos (Epistemonikos Foundation, Santiago, Chile) from inception until February 2021. Appendix 1 provides the full search strategy. We also asked experts in the field for relevant studies. We conducted a forward and backward citation-chasing strategy, starting from the included studies. Reference Abbas, Abbasi, Ghous, Ahmad, Ahmad and Ayu24–Reference Yamamoto42
Selection of studies
2 authors (among KS-B, AT, JS-Ch) performed an independent title and abstract screening of the results obtained from the search, solving any discrepancy by consensus. Also, 2 reviewers (among KS-B, AT, JS-Ch) screened studies in full-text, solving any discrepancy by consensus. For the screening process, we used Covidence.
Data extraction
1 of the authors extracted the following data from each included study using a previously piloted data extraction sheet: methodological design, year, country and population, as well as type of natural disaster, and type of interventions, according to predefined criteria. Reference Vos, Rodriguez, Below and Guha-Sapir12,23,43 A second author cross-checked this process. Appendix 2 provides the data extraction sheet.
Data management and synthesis
We narratively described all the included studies in terms of their included population, type of intervention, and natural disaster context. We created matrices of evidence as grids. The rows corresponded with the type of natural disaster according to the following classification defined by the Centre for Research on the Epidemiology of Disasters (CRED) Reference Vos, Rodriguez, Below and Guha-Sapir12,23 :
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Geophysical: Hazard caused by solid earth. Examples: earthquake; mass movement (dry); volcanic activity.
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Hydrological: Hazard caused by occurrence, movement, or distribution of water. Examples: flood; landslide; wave action.
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Meteorological: Hazard produced by short-term extreme weather and atmospheric conditions. Examples: extreme temperature; fog; storm.
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Climatological: A hazard originating from a long-term, macro-scale atmospheric process. Examples: drought; glacial lake outburst; wildfire.
The columns contained the interventions classified according to Cochrane EPOC’s categories. 43 Appendix 3 provides EPOC categories.
Results
Our initial search strategy yielded a total of 5605 references. After title and abstract screening, we assessed a total of 109 studies by full text. We excluded 90 references for the following reasons: wrong interventions (n = 54), wrong study design (n = 31), no natural disaster (n = 3), different language (n = 1), and wrong outcomes (n = 1). Appendix 4 provides the list of the excluded studies with reasons. A total of 19 studies met our eligibility criteria and were included in the scoping review Reference Abbas, Abbasi, Ghous, Ahmad, Ahmad and Ayu24–Reference Yamamoto42 (Figure 1).
Figure 1. PRISMA flowchart.
Most of the included studies (n = 8) were conducted in Japan. Reference Kishi, Aizawa and Matsui29,Reference Matsuyama, Tsuboya, Bessho, Aida and Osaka32,Reference Sato, Kishi and Suda33,Reference Tsuchiya, Aida and Watanabe35,Reference Sato, Aida and Takeuchi39–Reference Yamamoto42 6 studies were conducted in China, Reference Guo, Guo and Li26,Reference Li, Wang and Guo30,Reference Li, Wang and Xiao31,Reference Tang, Zhu and Zhou34,Reference Wang, Wei and He36,Reference Liu, Hu, Li and Ma37 2 in Pakistan, Reference Abbas, Abbasi, Ghous, Ahmad, Ahmad and Ayu24,Reference Karim, Wager and Khan28 1 in Haiti, Reference DeGennaro, DeGennaro and Kochhar25 as well as 1 in Nepal, Reference Rokaya, Suttagul, Karki, Rokaya, Seriwatanachai and Humagain38 and another 1 in Japan and Haiti. Reference Hosokawa, Taura, Ito and Koseki27 The studies were performed in the context of an earthquake (n = 10) or mixed natural disasters (n = 9) (earthquake and tsunami: Great East Japan Earthquake of 2011) (Table 1).
Table 1. Matrix of evidence and general characteristics of included studies
Regarding specific interventions, 12 studies reported a promotional/ preventive intervention, mainly referring to clinical oral examinations performed after the natural disaster. Reference Guo, Guo and Li26,Reference Hosokawa, Taura, Ito and Koseki27,Reference Kishi, Aizawa and Matsui29,Reference Matsuyama, Tsuboya, Bessho, Aida and Osaka32,Reference Sato, Kishi and Suda33,Reference Tsuchiya, Aida and Watanabe35,Reference Liu, Hu, Li and Ma37–Reference Yamamoto42 Moreover, 7 studies reported therapeutic interventions, and mostly, emergency management of fractures and injuries was performed (Table 1). Reference Abbas, Abbasi, Ghous, Ahmad, Ahmad and Ayu24,Reference DeGennaro, DeGennaro and Kochhar25,Reference Karim, Wager and Khan28,Reference Li, Wang and Guo30,Reference Li, Wang and Xiao31,Reference Tang, Zhu and Zhou34,Reference Wang, Wei and He36 According to the EPOC taxonomy, we considered by consensus that natural disasters implied a change to the healthcare environment; for this reason, all the included studies fall into this category. Thus, the set of reported interventions was grouped mainly in the category of ‘coordination of care and management of care processes’ and ‘how and when the care is delivered’ (Table 2). Table 3 provides the matrix of evidence concerning the type of natural disaster and EPOC taxonomy.
Table 2. Classification of each intervention according to the EPOC taxonomy
Table 3. Matrix of evidence comprehending the type of natural disaster and EPOC taxonomy
As a post-hoc analysis, we also considered studies describing oral health status among people in the context of a natural disaster, without reporting a specific intervention. We found 5 studies, Reference Liang, Tang and Luo44–Reference Funakubo, Tsuboi and Eguchi48 of which the reported outcomes were maxillofacial injuries, tooth loss, periodontal diseases, and temporomandibular disorders. Overall, most studies found that the changes caused by an earthquake such as deteriorating socioeconomic circumstances (for example, housing damage or temporary housing) appeared to impair oral health care practice, oral hygiene habits, and nutritional intake, among others. Appendix 5 provides an overall description of these studies.
Discussion
Our scoping review identified 19 studies with providing an oral intervention in the context of a natural disaster. All of them were performed in the context of an earthquake or mixed natural disasters (earthquake and tsunami) and most of the included studies (n = 8) were conducted in Japan, with oral examination as the intervention most reported. It is important to note that there were only 5 countries included (Japan, China, Pakistan, Nepal, and Haiti), and the types of natural disasters researched were only earthquakes, and earthquakes followed by tsunamis. According to this, there is a critical evidence gap regarding the context of the studies with the absence of other types of natural disasters in other countries.
1 of the possible reasons why most of the included studies were conducted in Japan, is the geography of the country. Since Japan is an island, the flatlands where many people live are on the side of rivers and the sea. As a result, many places are vulnerable to flood damage and earthquakes, making Japan a country with a high incidence of natural disasters like tsunamis, typhoons, heavy rains, and windstorms. Reference Eng and Tan49 Since 20% of the world’s earthquakes with magnitude 6 or higher occur in Japan, there is a high awareness of natural disasters. Reference Shoko, Naho and Keiko50 After the Great Hanshin-Awaji Earthquake in 1995, there was a need for disaster emergency assistance in Japan, so DMAT (Disaster Medical Assistance Team) was established, and research started under the name of ‘Health Crisis Management.’ 51 In 2011, after the Great East Japan Earthquake, people became more conscious of the importance of disaster medicine, hence the Japanese government allocated budgets for research, education and training (e.g., team building). Reference Shoko, Naho and Keiko50 Part of this budget is also used in dentistry for ‘Disaster dental health system training’ and “Disaster dental health advanced training’ by the Ministry of Health, Labor and Welfare through the subsidized Disaster Medical Team Training Support Project. 52 Moreover, the Japanese Society for Disaster Public Health Dentistry (DPHD), 53 was founded as a private organization that aims to provide concrete and practical support to deliver the necessary dental and oral support during a natural disaster. Reference Dilley11
We can hypothesize that other countries with a high incidence of natural disasters have not established emergency assistance and budgets for research, education, and training for disaster emergencies. However, the reason why such countries with a high incidence of natural disasters have not published studies in this regard, requires a deeper analysis. We based our eligibility criteria on oral health interventions. Some studies may approach health care during natural disasters without reporting oral health care interventions specifically, thus, they may not have been included in our review. Moreover, most of the evidence found in the context of natural disasters were reports and comments which were excluded for not meeting our eligibility criteria regarding study design.
Since a protocol is essential during a natural disaster, the Pan American Health Organization has worked to build a post-disaster guideline for oral health, Reference Estupiñán and Scharfen54 and the Association of State and Territorial Dental Directors in the United States developed a manual for Emergency Preparedness and Response for State Oral Health Programs. Reference Kepler Cofano, Finn and Joskow55 However, even in Japan where there is an established budget for disaster emergencies, there is no detailed protocol for dental care in times of disaster at the national level. The Japan Dental Association, 52 and the Japan Dental Hygienists Association have proposed such a system. An industrial organization called the ‘Japan Disaster Dental Health Liaison Council,’ Reference Tsukinoki, Segawa, Nakakuki, Oka and Adachi56 is working to establish a nationwide system. 57 Additionally, it is included in the core curriculum for dental students and dentists in Japan to learn ‘the ability to explain the need for dental care in times of disaster.’ 58
From the clinical point of view, most of the included studies demonstrate the importance of oral clinical examinations and initial emergency management. Reference Abbas, Abbasi, Ghous, Ahmad, Ahmad and Ayu24,Reference Guo, Guo and Li26–Reference Li, Wang and Xiao31,Reference Sato, Kishi and Suda33–Reference Tsuboi, Matsui and Shiraishi40 Some of them have a special focus on maxillofacial trauma management, Reference Abbas, Abbasi, Ghous, Ahmad, Ahmad and Ayu24,Reference Guo, Guo and Li26,Reference Li, Wang and Guo30,Reference Li, Wang and Xiao31,Reference Tang, Zhu and Zhou34,Reference Wang, Wei and He36 emphasizing the importance of dental and maxillofacial trauma knowledge of the entire multidisciplinary team. Also the included studies demonstrate the relevance of preventive care through providing oral care products, and education in orphanages, elementary schools, and shelters with elderly survivors, as the first approach to the survivors. Reference Hosokawa, Taura, Ito and Koseki27 This approach from the evacuation centers, welfare shelters, temporary housing, or even afterward when people move to reconstructed houses, should be long-term to maintain good oral health and prevent oral diseases. Reference Nakakuki59 On the other hand, the proposal of a partnership between universities, hospitals and local governments from different countries (developed and developing countries for example) offer a new model and an interesting initiative for reducing the burden of access to care, and also improving the education and training of the professionals. Reference DeGennaro, DeGennaro and Kochhar25 In the case of Japan, it was suggested to categorize the victims into 3 groups: those who have been victims, those who are currently in trouble, and those who are not currently in trouble. Reference Adachi, Tanaka, Fukushima, Fuji and Nakakuki60 For the first group, those who have been victims, dental records can be useful for the body’s identification. For the second group, those who are currently with dental pain or oral disease need immediate access to oral care, so it is necessary to establish a system for emergency dental treatment, as well as mobile clinics and temporary clinics to treat the patients. The third group is people who don’t have dental problems now but are likely to have problems in the future; for this group it is necessary to take action to prevent problems. In the Great Hanshin-Awaji Earthquake and the Great East Japan Earthquake, pneumonia accounted for about a fourth of all disaster-related deaths, and many of them were suspected to be aspiration pneumonia, Reference Shibata, Ojima and Tomata61 with the elderly and children being the highest risk groups. In this sense, the role of dental professionals must constantly change to meet the needs of the community during natural disasters. Reference Kato, Morita and Tsuzuki18
Our study has some limitations. We included only studies published in peer-review journals in English, Spanish, or Japanese, therefore, studies in other languages may not have been included. Among the strengths of our study, our broad eligibility criteria concerning the phenomena of interest allowed us to probably identify most of the relevant evidence. Also, we performed an exhaustive search strategy, and we conducted a screening and data extraction process by two authors. Furthermore, from our knowledge, this is the first scoping review of oral health in the context of natural disasters.
Further research is needed in areas in which we found scarce evidence, including the diversification and comparison of the types of intervention in oral health, the types of natural disasters, and the countries where the studies are carried out. The studies included in our review emphasize that the effective management of natural disaster survivors requires a multidisciplinary team with a focus on oral health preventive and therapeutic approaches. Moreover, a protocol to address oral health care should be established and implemented with an immediate and comprehensive approach during a natural disaster context. With all this information, we consider that we have comprehensively described the current body of evidence regarding oral health interventions during natural disasters. The evidence accessed in our study was limited, highlighting the need for further research to focus on different oral health care outcomes in the context of different natural disasters, thus enhancing the formulation and implementation of recommendations and protocols worldwide.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/dmp.2023.62
Author contributions
KS-B designed the scoping review, analyzed, and interpreted the data, as well as drafted and revised the paper. AT analyzed and interpreted the data, drafted and revised the paper. JS-Ch analyzed the data, drafted, and revised the paper. KN drafted and revised the paper. JB designed the scoping review, wrote the search strategy, interpreted the data, drafted, and revised the paper.
Competing interest
None declared.
Abbreviations
CRED, Centre for Research on the Epidemiology of Disasters; DMAT, Disaster Medical Assistance Team; DPHD, Japanese Society for Disaster Public Health Dentistry; EPOC, Effective Practice and Organisation of Care; ND, Natural Disasters; PICo, Population, Phenomena of Interest, Context.
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