10th anniversary of 9/11

Looking back and moving forward

by Winnie Furnari, RDH, MS, FAADH

When our 35th president was killed by an assassin's bullet as his motorcade wound through Dallas in 1963, we were told we would always remember where we were when we heard the news. To this day, those of us who witnessed the event can say, "I remember."

The same holds true for the terrorist attacks of Sept. 11, 2001. Those of us who witnessed this event will remember the exact moment in time, where we were, and many things after that. This is called episodic memory, and is not fully developed until around four years of age. It is different from other types of memory because it is accompanied by a feeling of remembering and attachment, as opposed to factual remembering.1 Like many of you that morning, I was scaling teeth, a procedure integral to our existence and a familiar start to that horrific episodic memory.

Does time change our memories? Not as much in this modern age, because we have videos and pictures to remind us of exactly how events unfolded. As we age, many people claim that short-term memory starts to fade, but we can recall events that occurred years and years ago quite clearly. In this instance, it is good to know that in our lifetime we will never forget. What about those in this country who were babies, and those born after Sept. 11, 2001? Their knowledge is not a memory, but what they have been told and what they have seen. It may have been a good thing that fate spared them from witnessing the horror, yet they should not be spared the stories we have to tell. This is the goal of the Sept. 11th Education Program, a curriculum designed for schools about teaching 9/11. Students are asked to interview family and friends about the event, and are assigned to get firsthand accounts. The program has developed a curriculum and website where teachers can discuss plans and successes on incorporating 9/11 into lesson plans or as a separate learning experience.2 Learn more about the 9/11 Education Foundation and Education Program at www.LearnAbout911.org.

Many events in history are kept alive through memorials, statues, holidays, and site tours. The Sept. 11, 2001, event also has memorials, movies, articles, books, and new onsite memorials in New York, on the grounds of the Pentagon, and in Shanksville, Pa. These provide a means for closure, for easing our hurt, and certainly as a way to help deal with the loss. Dealing with these tragedies has not been easy for many people. Statistics show that incidents of posttraumatic stress disorder (PTSD) increased dramatically after Sept. 11th.3 It is recognized as a real illness. People can experience PTSD after living through or seeing a traumatic event. People become stressed and afraid after danger is over and the lives of the victims and people around them are affected. Psychological and physical symptoms can be mild to severe, and can occur years after an event.4 For those seeking comfort, active participation in commemorations can provide an avenue for healing.

There is a little known memorial in New York City called Memorial Park, which is on the same street as the Office of the Chief Medical Examiner. In this refrigerated building lie the unidentified remains of the victims of that day. They will be entombed in the World Trade Center (WTC) Memorial at ground zero. This country has a unique culture toward our dead. Enormous energy is exerted to do everything possible to give a name to a decedent and a burial of respect. Our government works daily on repatriating remains of men and women of service who have died for peace. A visit to the Joint POW/MIA Accounting Command (JPAC) in Hawaii proved to me how much effort and respect is given to the task of identifying men and women of service.

The same is true for the New York City Medical Examiner, Dr. Charles Hirsch, who has proclaimed that the city will never stop trying to identify the remains found in the World Trade Center attack. Technology advances every year, and someday there will be new technology to be applied to the remains for identification. During the effort to help the families receive the remains of their loved ones, the dental community was an instrumental and viable aspect of the medical examiner's enormous contingency of professionals.

Many articles have been written about the contributions of dentistry in the effort to identify remains from the tragedy. On this anniversary, it is worth repeating that I witnessed firsthand the untiring work that our community put into the goal of identification. Thousands of hours were contributed. There were 24-hour shifts for months. There were phone calls to treating dentists for records, antemortem charts created, and data entry recorded in a computer program. There were schedules to set up and monitor, supplies to secure, verifications of licenses, and incoming phone calls and faxes to be addressed. There were remains to clean and chart, paperwork to complete, volunteers to train, and protocols to create and respect. National and international agencies were all involved with the dental team.

Anyone who is a member of the dental community can stand proud to know that colleagues were integral in the effort. Colleagues exhibited the highest level of professionalism, ethics, and respect for one another and the task at hand. We can also be proud that this was indeed the greatest exhibit of offering for help from dentistry ever to occur.

Dentists, dental hygienists, and assistants worked side by side, day and night, for months on end applying their dental knowledge and expertise to all the aspects of dental identification. We worked with various radiographs and numbering systems. We worked with poorly written narratives and poorly copied radiographs. We worked with a multitude of partial remains, and with the heavy burden of the horror of the event. After all of this, dentistry can stand tall because the work was perfect and the contribution can never be erased, even from fading memories. The record speaks for itself in history.

Debriefing and lessons learned are a regular part of teams and event protocol. Some important lessons have been that it is monumentally important to keep accurate documentation and recordkeeping. We can never know how important our documentation will be to the identification of the unknown. Dentistry has also learned that hygienists can be vital contributors to the team with hard work, ethics, and dedication.

Nationally and worldwide we witness changes. We are much more alert to our surroundings. We comply with long lines at airports, dutifully remove our shoes, and allow ourselves to be X-rayed and scanned. The face of a terrorist is the same as the face of a child abuser. In other words, there is no uniform face, race, nationality, religion, or culture that defines terrorist or abuser. We accept these changes in the name of safety and protection. We now have a government agency called Homeland Security, and we know it has thwarted more threats than we will ever hear about.

In New York City, radiographs are now digital and new programs are in place to manage any new multiple fatality incident. Dentists are cautioned about visiting disaster sites for their safety. Hazardous materials teams train regularly for numerous possible terrorist and accidental events that would endanger the public and first responders.

Before Sept. 11, 2001, there was no standard or uniform data set for antemortem records. For the past four years I have served as the American Dental Hygienists' Association liaison to The American Dental Association Standards Committee on Dental Informatics (SCDI) Joint Working Group 10.12 on Forensic Odontology Informatics for Specification No. 1058. The standard is designed to fill that void. The goal was uniform nomenclature for all of the information gathered during the course of dental evaluation. It was also created to make it possible for these codes to be transferred in a standardized electronic format. By standardizing the descriptors used to code this information, the likelihood of identifying human remains or a living amnesiac increases.

On Nov. 2, 2010,5 the American National Standards Institute (ANSI) approved ADA Specification No. 1058 as an American National Standard. During the past 10 years, many forward-thinking hygienists have pursued their interests by taking formal forensic dentistry training. They have joined national and local forensic societies, the Government Disaster Mortuary Operational Team (D-MORT), and are contributing their energies and knowledge to this field in growing numbers. My studies have expanded into learning all the possible biological chemical, nuclear, and explosive threats to the world, and government readiness for professionals and communities, through a master's degree in Biosecurity and Disaster Preparedness. Now I inform our community that there is a place for dentistry in disaster preparedness and response.

In 2005, the State of Illinois amended its dental practice act to include dentists and dental hygienists specifically as dental emergency responders (DER).6 The American Dental Association and the American Dental Hygienists' Association are part of a coalition supporting Federal Legislation for the inclusion of dental personnel and facilities in the National Health Security strategy known as the Dental Emergency Responder Act of 2011. The bill will be considered by the full House shortly. 7

As Sept. 11th is a day of service and remembrance, we must continue to keep this respect yet also move forward. Those of us with episodic memory will pass on and the event must remain in the minds of the living, and every dental professional past and to come who can make a difference in forensic dentistry. On Sept. 11th, we look back to give us the impetus to continue forward.

On this tenth anniversary, I acknowledge the dental hygienists who volunteered in New York City 10 years ago. A few came one or two times, a few gave hundreds of hours, and a few gave more than 1,000 hours. There were also a few hygienists deployed to the city through D-MORT. Whether they came for one day or one year, they made an impact on forensic odontology, dental hygiene, and humanity.

Winnie Furnari, RDH, MS, FAADH, is a past president of the New Jersey Dental Hygienists' Association and the Dental Hygienists' Association of the State of New York. She is an assistant clinical professor at New York University College of Dentistry and teaches Forensic Dentistry/Bioterrorism Preparedness for dental hygienists in the baccalaureate program and through continuing education presentations. She was awarded the Pfizer/ADHA Award of Excellence, the ADHA Distinguished Service Award, and both national and international recognition for her forensic work. As a member of the New York City Dental Identification Team, she has participated in several multiple fatality responses.

References

1. Clayton N, et al. Episodic Memory. University of California, Los Angeles. Available at http://www.bec.ucla.edu/papers/Clayton_4.25.07b.pdf.
2. 911 Education Program Available at www.LearnAbout9-11.org.
3. DiGrande L, Perrin M, Thorpe L, et al. Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2-3 years after the September 11, 2001 terrorist attacks. Journal of Traumatic Stress, 2008;21(3):264-73. Available at http://www.mph.ufl.edu/events/seminar/PTSD_Sept11_DiGrande2008.pdf.
4. Medline Plus: Post-Traumatic Stress Disorder. Available at http://www.nlm.nih.gov/medlineplus/posttraumaticstressdisorder.html.
5. Garvin J. Forensic data standards set. ADA News. December 13, 2010. Available at http://www.ada.org/news/5123.aspx.
6. Colvard M, Lampiris L, Cordell G, et al. The dental emergency responder: expanding the scope of dental practice. Journal of the American Dental Association, 2006;137:468-473.
7. Disaster preparedness and response. American Dental Association. Available at http://www.ada.org/2390.aspx.