The Incidence of Dental Disease Nonbattle Injuries in Deployed U.S. Army Personnel

ABSTRACT Background: In the past, the U.S. Army Reserve (USAR) and Army National Guard (ARNG) have exhibited lower levels of medical and dental readiness than active duty (AD) Soldiers when activated for deployment. Objective: The objective was to compare dental disease and nonbattle injury (D-DNBI) incidence rates and describe the most common D-DNBI diagnoses in Army AD, ARNG, and USAR Soldiers deployed to Iraq (Operation Iraqi Freedom/Operation New Dawn) and Afghanistan or Kuwait (Operation Enduring Freedom). Methods: Data from the Center for AMEDD Strategic Studies (CASS) were used to determine D-DNBI encounter rates and diagnoses for deployed Army Soldiers. Results: "Dental Caries" was the leading diagnosis (10.00%) for Soldiers in both theaters. For Operation Iraqi Freedom, D-DNBI rates were highest in 2010 at 144.05 per 1,000 Soldiers per year (AD 135.77, ARNG 151.39 and USAR 183.76). In comparison, D-DNBI rates in Operation Enduring Freedom were highest in 2012 with an overall rate of 85.77 per 1,000 Soldiers per year (AD 72.48, ARNG 129.38 and USAR 129.52). Conclusions: In both campaigns, the data suggest that ARNG and USAR Soldiers had higher D-DNBI rates when compared to AD Soldiers. Further investigation is needed to decrease D-DNBI rates and to determine risk factors that may influence D-DNBI rates among Army components during deployments.

INTRODUCTION

Despite two decades of discussion about "the new military" for modern times, fighting and winning our nation's wars remains the fundamental role of the U.S. Military. A military force that is well trained and equipped may not be as effective if the medical and dental readiness of the fighting force is not at an optimal level. Ensuring a healthy and fit-to-fight Soldier is paramount to the success of any military.

Several publications describe the incidence of dental emergencies (DE) in military personnel assigned to combat environments (Afghanistan, Bosnia, Iraq, Kuwait, Oman, Saudi Arabia) between 1992 and 2011.1-9 These studies of DEs, also known as Dental Disease and NonBattle Injuries (D-DNBI), in combat environments were based on the observation of personnel of each of the U.S. Service branches, the U.K. Royal Navy/Marines, U.K. Army, French armed forces, and Army personnel from Canada. The range of reported D-DNBI rates for personnel in combat environments ranged from 111 to 437 per 1,000 personnel per year (PPY) with a mean rate of 187.2 per 1,000 PPY. Annual D-DNBI rates per 1,000 Soldiers (PPY) were calculated by dividing the total number of dental encounters for a given year by the population at risk (PAR) represented in Soldier-days and multiplied by total days in the year per 1,000 Soldiers. Of three studies that describe the incidence of D-DNBI in U.S. Army personnel deployed to Bosnia, a mean rate of 254.3 per 1,000 PPY was reported with a range of 156 to 437 per 1,000 PPY.1-3 McKee et al1 reported a weekly rate of 0.84 D-DNBI per 100 Soldiers (annualized rate of 437 per 1,000 PPY) during Operation Joint Guard during 1997. Chaffin2 reported a rate of 156 D-DNBI per 1,000 PPY for Stabilization Force VII (SFOR VII) in the year 2000, whereas Moss3 reported an incidence of 170 D-DNBI per 1,000 PPY a year later for SFOR VIII forces in Bosnia.

The U.S. Army Reserve (USAR), the Army National Guard (ARNG), and Army Active Duty (AD) are the components that comprise the U.S. Army. USAR and ARNG personnel are often activated for combat and stability operations to serve alongside AD members. The Department of Defense (DoD) established a minimum goal of at least 75% of the total military force being medically ready for deployment based on six specific medical measures that identify individual medical readiness (IMR).

Dental readiness is one of the six reportable metrics that determine IMR mandated by DoD Instruction 6025.19.10 The dental readiness classification is as follows: dental readiness 1 patients have a current dental examination, do not require dental treatment or re-evaluation, and are worldwide deployable. Dental readiness 2 patients have a current dental examination, require nonurgent dental treatment or re-evaluation for oral conditions that are unlikely to result in DE within 12 months, and are worldwide deployable. Dental readiness 3 patients have urgent or emergent dental treatment and are considered not to be worldwide deployable. Dental readiness 4 patients require a dental exam because their dental status is unknown. These patients normally are not considered to be worldwide deployable. In 2006, the Assistant Secretary of Defense (Health Affairs) established that at least 95% of both active and reserve forces meet dental class 1 or 2 status and at least 65% meet class 1.11 The findings of a RAND Corporation study suggested that reserve components (RC) were not achieving the targeted goal for medical readiness set by DoD.12 The 2012 RAND Corporation study found that 56% of activated ARNG in Fiscal Year (FY) 2006 were classified as being dentally ready (class 1 or 2). However, through changes and improvements in examination and treatment, the ARNG improved to 85% dental class 1 and 2 by FY 2010. In contrast, activated USAR dental readiness was much lower at 36% in FY 2006, but improved to 64% during the same 4-year period.13 In spite of great improvements in dental readiness initiatives and programs by the Army RC, they still lagged behind their AD counterparts, who had an average dental readiness rate of 90%.12

The objectives of this study were to present the first Army population D-DNBI rates using a comprehensive electronic data capture system utilized in a deployed environment. D-DNBI rates were calculated for U.S. Army personnel deployed to Iraq in support of Operation Iraqi Freedom/Operation New Dawn (OIF/OND), and personnel deployed to Kuwait and Afghanistan in support of Operation Enduring Freedom (OEF). D-DNBI incidence rates were compared among three Army component groups (AD, USAR, and ARNG) in both theaters. Additionally, this study aimed to describe the most frequently occurring types of D-DNBI diagnoses for deployed US Army Soldiers.

METHODS AND MATERIALS

Data Description

D-DNBI information on U.S. Army Soldiers deployed to OIF/OND and OEF were documented electronically at the point of service by Army dental officers using the Army Dental Command Corporate Dental Application (CDA) within Army dental clinics located in Iraq, Afghanistan, and Kuwait. D-DNBI was defined as a condition for which the dental officer documented either the treatment code A0199 (DE) or Current Dental Terminology reference code D0140 (problem focused dental exam). The Dental Emergency Encounter Entry (DEEE) module is a separate feature within the CDA that allows for easy entry of clinical descriptions of D-DNBI using seven major etiology groups and 48 diagnostic categories. A history of the CDA and the methodology utilized to document D-DNBI ensuring the quality of the data entry process are fully described elsewhere by Eikenberg et al.14 A DE, or alternatively referred to as a D-DNBI, was defined as any oral or craniofacial issue perceived by the Soldier to be a problem that caused them to seek the help or advice of a dental officer.15 For example, gingivitis, although not a life-threatening issue, can qualify as a D-DNBI because of the Soldier's perception of having a serious problem as manifested by having gingival bleeding.

Data from the CDA DEEE is forwarded to the CASS where the data undergo quality assurance procedures, are analyzed, and compiled into summary reports available on the CASS Dental Encounters Report System Web site.16 Reports can be stratified by type of operation, gender, component, transport mode, disposition status, and self-reported months on deployment. Four types of reports can be provided: frequency analysis with 16 possible modules, longitudinal analysis, and analyses of rates and ratios.

Study Design

This retrospective cohort epidemiology study was designed to assess the frequencies of 48 diagnoses associated with D-DNBI occurring within U.S. Army components: AD, USAR, and ARNG. Data analysis for this study was performed using data from the CDA DEEE separately for the two most recent theaters of operation, one in Iraq (OIF/OND), and the other in Afghanistan including its staging area in Kuwait (OEF). D-DNBI encounter data were available for OIF/OND from 1 May 2009 to 31 December 2011 and for OEF from 1 July 2010 to 31 December 2012. There were identified inconsistencies in the early periods of implementation of the CDA DEEE module within both campaigns resulting in a limited number of documented encounters at the onset of data collection within each theater. As a result, early periods of data capture were not included in the D-DNBI rates estimates. For OIF/OND, only the most stable data from the last 5 months were used to extrapolate annual 2009 D-DNBI rates. In OEF, D-DNBI encounter data were first captured in July 2010, however, the collection process was not fully operational until 2011; therefore, 2010 annual rates were not calculated. However, encounter data for this period in OEF are included in all other descriptive tables.

Descriptive analysis of the study population included frequency distributions of D-DNBI encounters, most frequent diagnoses, and analysis of average encounters per patient and average diagnoses per encounter across the U.S. Army components. Analysis of variance (ANOVA) was performed to test for differences in the average number of encounters per Soldier and mean number of diagnoses per encounter among U.S. Army components. Additionally, the Tukey-Kramer multiple comparisons test was utilized for pair-wise comparisons of means. As mentioned, the annual (PPY) D-DNBI rates were calculated by dividing the total number of dental encounters for a given year by the PAR represented in Soldier-days and multiplied by total days in the year per 1,000 Soldiers. The univariate Poisson regression was used to compare D-DNBI rates between components. Soldier population data were obtained from the Defense Manpower Data Center from the Contingency Tracking System, and were used to identify deployed U.S. Army Soldiers according to their dates of arrival and departure. Fluctuation ratios were calculated by dividing the maximum annual D-DNBI rate by the minimum annual D-DNBI rate for each component within each theater. All data analyses were performed using SAS version 9.2 software. In all analyses, p values less than 0.01 were considered significant.

This study was conducted under a protocol (USAISR Protocol no.: H-11-037) that was reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol office. CASS receives dental data on a regular basis in accordance with an established data use agreement. Data used by CASS were obtained and analyzed following strict data governance rules approved by the Army Human Research Protection Office: records were limited in scope to variables needed for the stated purposes and de-identified. All personally identifiable information was removed to ensure investigators could not identify individuals and could not rematch protected health information data back to individual patients. All datasets were protected on secure DoD servers.

RESULTS

During the overall data collection period, a total of 31,659 Soldiers were seen by Army Dental Officers in Iraq during OIF/OND, or in Afghanistan and the staging treatment facilities in Kuwait during OEF: 21,626 of those Soldiers were deployed to OIF/OND and 10,033 Soldiers were in OEF. The majority of D-DNBI patients seen were AD Soldiers, over 60% for both campaigns. The total of 31,659 Soldiers that were seen for a D-DNBI was distributed across the three component forces as follows: AD constituted 64.3%, ARNG constituted 23.6%, and USAR constituted 12.1%. A total of 40,026 D-DNBI (1.3 encounters per Soldier), and 47,495 diagnoses were documented (1.2 diagnoses per encounter). The distribution of patients, encounters, and diagnoses by component status is described in Table I for OIF/OND and OEF.

There were a total of 27,838 D-DNBI encounters in OIF/ OND and 12,188 D-DNBI encounters in OEF. The number of encounters per Soldier ranged from 1 to 9 in both theaters (median was 1.0 for both operations) with the majority of Soldiers, over 75%, in all components having one dental encounter (Table II). There was no statistically significant difference in the mean number of encounters per patient across the three U.S. Army components in OEF (AD, ARNG, and USAR). On the contrary, when analyzing the number of D-DNBI encounters in OIF/OND, a one-way ANOVA test followed by the Tukey-Kramer test showed a difference in mean number of encounters between AD and USAR component groups and a difference in means between ARNG and USAR in OIF/OND. Although statistically significant, differences do not seem to be clinically relevant (Table II).

To determine the complexity of treatment required for D-DNBI, the number of diagnoses per encounter was calculated for each of the RCs within each theater of operations. Army Soldiers had 33,084 diagnoses summed across all dental encounters in OIF/OND (Table I) with an overall average of 1.19 diagnoses per encounter (range 1-6). The average number of diagnoses per encounter in OIF/OND varied minimally across component groups, and the differences were not statistically significant (Table III). The average number of diagnoses per D-DNBI encounter in OEF was 1.18 diagnoses per D-DNBI encounter with a total of 14,411 diagnoses documented. Most dental encounters in both theaters and across all three U.S. Army components, (over 70%) resulted in one diagnosis (Table III). There were small differences in the averages of diagnoses per encounter across component groups in OEF; 1.19 AD, 1.17 ARNG and 1.14 USAR. However, in both theaters, ANOVA testing revealed nonstatistically significant differences in the mean number of diagnoses per encounter when comparing AD with USAR in OEF (Table III).

Analysis of the most frequent diagnoses associated with D-DNBI encounters revealed "Dental Caries" as the leading diagnosis overall (10.00%), as well as being the most frequent diagnosis in the OIF/OND theater (Tables IV and V). The diagnosis "Fractured Tooth-No Caries-not related to trauma" was ranked second overall (9.81%), as shown in Table IV, but was the most frequent diagnosis in the OEF theater at 10.60% (Table VI) and for each component group in OEF. Interestingly, though gingivitis was ranked as the fifth overall diagnosis (6.40%), it was more prevalent in the USAR components (8.41%) compared to AD (5.8%) and ARNG (6.97%), and ended as the third most frequently observed diagnoses for USAR. Among USAR in Iraq (OIF/OND), gingivitis was ranked as the second most common diagnosis. Results for combined theaters are presented in Table IV and results for OIF/OND and OEF are presented in Tables V and VI, respectively.

D-DNBI Rates

The annual D-DNBI encounter rates for Soldiers deployed to Iraq varied over the time data were collected with the peak rates of D-DNBI in 2010 as follows: 183.76 per 1,000 Soldiers per year for USAR, 151.39 for ARNG, 135.77 for AD and 144.05 overall (Table VII). The 2011 OIF/OND rates included encounters during the withdrawal period from Iraq. Subsequently, D-DNBI rates were lower in 2011 as expected. The USAR had the highest D-DNBI rates among components for the entire study period (Table VII). Results of the unadjusted Poisson regression analysis showed that the unadjusted D-DNBI encounter rates of ARNG and USAR personnel in OIF/OND were significantly higher when compared to the D-DNBI rates of AD (p < 0.001 for both comparisons). The fluctuation ratio for D-DNBI annual rates in OIF/OND between 2009 and 2011 was 1.3 for AD, 1.5 for ARNG, 1.3 for USAR, and 1.3 for U.S. Army overall.

In OEF, D-DNBI rates were considerably lower than OIF/ OND with yearly averages for the duration of the study as follows: 70.69 versus 118.20 for AD, 129.98 versus 161.93 for USAR, and 83.61 versus 124.51 for Army total (all rates per 1,000 Soldiers per year). The ARNG was the only group with a higher average D-DNBI rate in OEF than OIF/OND, 130.42 versus 126.21. Army Reserve (USAR) groups had consistently higher D-DNBI annual rates compared to AD in both campaigns and in all years, however, differences were more pronounced in OEF. D-DNBI rates for both reserve component groups (ARNG and USAR) were almost twice as high as AD rates in OEF. In 2011, USAR and ARNG had 131.46 and 130.43 D-DNBI encounters per 1,000 Soldiers per year respectively, versus 68.89 for AD. In 2012, USAR and ARNG had D-DNBI rates of 129.38 and 129.52 per 1,000 Soldiers per year versus 72.48 in AD (Table VII). Results of the unadjusted Poisson regression demonstrated that in Afghanistan the ARNG and USAR had significantly higher rates for D-DBNI encounters than the AD component (p = 0.001 for ARNG versus AD, and p < 0.001 for USAR versus AD). Within OEF, fluctuation rate ratios were 1.1 for AD, 1.0 for ARNG, 1.0 for USAR, and 1.1 for the total Army population in Afghanistan.

DISCUSSION

Dental readiness is not only an important issue for medical and dental staffers and planners, but it is of utmost importance to combatant commanders. In their study of the medical readiness of the USAR component, RAND Corporation authors state, "a dental emergency can require three convoy vehicles with up to nine personnel for security in-theater for the sole purpose of medical evacuation".12 The result is a net loss of that Soldier from their unit in addition to the number of personnel required to transport the Soldier to a dental treatment facility, especially if they are not colocated on a forward operating base with dental support. Gunepin et al9 reported that 65% of the DE patients among French military personnel in Afghanistan required medical evacuation to receive care.

Even with adequate predeployment oral care, Mahoney and Coombs17 concluded that a well-prepared, dentally fit force can expect 150 to 200 dental casualties per 1,000 personnel per year. Results presented here suggest low overall rates (average overall rate in OIF/OND was 124.5 per 1,000 Soldiers per year and 83.6 in OEF), when compared to previously reported rates reported for military personnel in combat environments (111 to 437 per 1,000 Soldiers per year).1-9

The occurrence of D-DNBI in the war zone presents a very challenging situation with respect to logistical support, transportation, and accessibility to a dental treatment facility. Our findings suggest that "Dental Caries" and "Fractured Tooth-No Caries-not related to trauma" are the most prevalent oral problems faced by all three components of the Army. The findings further suggest that "Defective Restoration-With Caries/and Without Caries", which account for two of the five most prevalent tooth morbidities, could be considered an opportunity lost at predeployment screening. Military dental providers strive to mitigate the probability of D-DNBI by conducting a predeployment dental examination that includes visual inspection, selective pulpal tests, periodontal assessment, and acquisition of indicated oral radiographs to identify moderate to severe dental lesions and possible foci of infection before deployment of Soldiers. Though widely used, the traditional oral examination is usually inadequate to fully recognize the presence of cracks, fractures, and secondary or recurrent caries under existing restorations. Fractured teeth without caries or fractured restorative materials may not be preventable; however, restoration failure and tooth fracture because of caries may well have been prevented with more precise examination procedures and new caries detection methodologies.

The 2008 DoD recruit study summarized the oral health status of service component recruits, including AD members, and reported only small differences in the oral health status and dental classifications among AD, USAR, and ARNG.18 When reviewing three clinical findings that may influence the rate of D-DNBI, the only difference was a higher mean number of restorations needed in AD personnel. AD had a greater mean number of teeth requiring restorations (3.9), compared to both USAR (3.3) and ARNG (3.6). The mean number of teeth requiring extractions was similar, 2.1 for AD and 2.0 for both USAR and ARNG, and the mean number of teeth requiring endodontics was 0.1 for all groups. The 2008 DoD recruit study results suggest no clinical difference in the dental treatment needs among the three categories of Soldiers at the recruit phase, however, according to the results of this study differences in the D-DNBI rates among component groups are observed. In the most recent campaign, OEF, USAR, and ARNG had D-DNBI rates approximately twice as high as AD Soldiers. In OIF/OND, USAR (and in most of cases ARNG) also had higher D-DNBI annual rates than AD Soldiers, although the disparity was not as great as in OEF. In addition, the reserve components (ARNG and USAR) had higher percentages of gingivitis diagnoses than AD Soldiers.

USAR Soldiers have different access to dental services before deployment than AD Soldiers, possibly explaining differences in gingivitis, as gingivitis is associated with lack of preventive care. Although most ARNG and USAR soldiers have civilian full-time or part-time employment, it is unknown whether they have sufficient private dental insurance to cover preventive dental procedures. AD Soldiers can see a dentist at any time a problem arises, which bears no financial cost to that Soldier. In contrast, when an ARNG or USAR Soldier visits a civilian dentist, the Soldier is responsible for all costs especially if they lack dental insurance. Additionally, if ARNG and USAR Soldiers have prior knowledge of future military activation and deployment, they may be more likely to wait to receive their dental care while on AD. This may explain the likelihood of developing a greater need for dental services by the ARNG and USAR when activated to full-time status, which puts an increasing strain on dental workload both in the predeployment and deployment environment.

Preventive dental services and oral hygiene instructions are available to all AD Soldiers at least on an annual basis. It is believed that those who have consistent interaction and exposure to preventive services and optimum oral hygiene instructions will have greater awareness of the importance of preventive care than those who have not been exposed to similar services or oral hygiene instructions. Also, further analysis aimed at describing the differences of D-DNBI by specific variables such as, gender, age, and type of units and military grade must be undertaken by military oral epidemiology researchers. We believe that this in-depth analysis will highlight additional information that can be used for the development of a D-DNBI predictive model aimed at mitigating D-DNBI on the battlefield. Given this potential, it may be worthwhile to fund and conduct studies to eliminate differences in emergency-DNBI incidence rates across the aforementioned variables in order to decrease the dental workload in and out of theater. Currently, the dental profession lacks definitive predictive models and tools to assess such potential challenges.

CONCLUSION

Dental care in deployed operations is critical to ensure a healthy fighting force as evidenced by over 40,000 D-DNBI encounters over 4 years and in two campaigns. The use of the DEEE module and availability of timely D-DNBI data allowed for calculation of reliable rate estimates and collection of valuable information on dental care needs. The most common diagnoses indicate a need for a wide range of dental care services from basic dental care (dental caries and gingivitis were in the five most frequently observed diagnoses) as well as restorative dental treatment (fractured teeth and defective restorations) to more complex care (periradicular periodontitis and periradicular abscess in the 15 most frequently observed diagnoses). Soldiers had more D-DNBI encounters in OIF/OND than in OEF. Overall, D-DNBI rates for all three U.S. Army components, as well as total Army rates were highest in OIF/OND theater and in the year 2010 (from a 2009-2011 period). There are differences in component group D-DNBI rates perhaps explaining the fluctuating rates published in the literature as both USAR and ARNG rates of D-DNBI are higher overall compared with AD.

Although, several articles have focused on presenting D-DNBI rates, some of the variability in the estimates could be attributed to the methods used to collect and analyze the data. In the literature many authors observed D-DNBI among Soldiers during short periods of deployment and then extrapolated to produce annual estimates. Additionally, published D-DNBI rates have been based on retrospective information for small cohorts (groups) of military personnel during deployment, which may not represent the true incidence rate of D-DNBI for the entire deployed Soldier population. In contrast, our comprehensive study looked at D-DNBI rates for the total deployed Army population, as well as by component status using timely data collected and analyzed in near real time and observed over long-term deployments.

The data from this study suggest that RC Soldiers have higher rates of D-DNBI when compared to their AD counterparts. However, given the significant differences found in D-DNBI rates between the ARNG, USAR, and AD in both campaigns, future studies should be conducted to identify potential risk factors to determine if the higher rates are due to an inequality in the distribution of personnel at higher risk of D-DNBI within the RCs. Some of the potential variables to include in the future multivariate analysis model would include gender, age, unit category, and rank.

Further research must be conducted to determine risk factors, develop new diagnostic methodologies, and develop D-DNBI predictive models, which can be used to decrease D-DNBI cases and predict the workload expected during deployments.

ACKNOWLEDGMENTS

We would like to thank Dr. Ralph Katz, professor of Epidemiology and Health Promotion from New York University, School of Dentistry for his invaluable insight and assistance on the manuscript.

This study was funded and conducted under a protocol (USAISR Protocol no.: H-11-037) that was reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol office.

REFERENCES

1. McKee K, Kortepeter M, Ljaamo S: Disease and non-battle injury among United States Soldiers deployed in Bosnia-Herzegovina during 1997: summary primary care statistics for Operation Joint Guard. Mil Med 1998; 163: 733-42.

2. Chaffin J: U.S. Army dental emergency rates in Bosnia. Mil Med 2001; 166: 1074-8.

3. Moss D: Dental emergencies during SFOR 8 in Bosnia. Mil Med 2002; 167: 904-6.

4. Deutsch W, Simecek J: Dental emergencies among Marines ashore in Operations Desert Shield/Storm. Mil Med 1996; 161: 621-3.

5. Dunn W: Dental emergency rates at an expeditionary medical support facility supporting Operation Enduring Freedom. Mil Med 2004; 169: 349-53.

6. Dunn W, Langsten R, Flores S, Fandell JE: Dental emergency rates at two expeditionary medical support facilities supporting Operations Enduring Freedom and Iraqi Freedom. Mil Med 2004; 169: 510-4.

7. Richardson P: Dental morbidity in United Kingdom armed forces, Iraq 2003. Mil Med 2005; 170: 536-41.

8. Groves R: Dental fitness classification in Canadian forces. Mil Med 2008; 173(1 Suppl): 18-22.

9. Gunepin M, Derache F, Ausset I, Berlizot P, Simecek J: The rate of dental emergencies in French armed forces deployed to Afghanistan. Mil Med 2011; 176: 828-32.

10. U.S. Department of Defense, Individual Medical Readiness (IMR): DoD Instruction 6025.19, Washington, DC, Headquarters, 2006. Available at http://www.dtic.mil/whs/directives/corres/pdf/602519p.pdf; accessed October 15, 2013.

11. Policy on Oral Health and Readiness. Available at http://www.health.mil/~/media/MHS/Policy%20Files/Import/06-001.ashx; accessed April 2, 2014.

12. Medical Readiness of the Reserve Component. Available at http://www.rand.org/pubs/monographs/MG1105.html; accessed October 17, 2013.

13. Bodenheim M: Dental readiness of the Army Reserve components: a historical review, part two. U.S. Army Medical Department Journal 2011; January- March 2011: 58-61.

14. Eikenberg S, Keeler R, Green T: Use of the Army Dental Command Corporate Dental Application as an electronic dental record in the Iraq theater of operations. U.S. Army Medical Department Journal January - March 2011: 51-7.

15. Simecek J: Consensus statements. Mil Med 2008; 173(1): 59.

16. The Center for AMEDD Strategic Studies. Portal for Dental Encounter Report System. 2009. Available at https://cass.amedd.army.mil/ako/sas/dnbi/dental; accessed February 5, 2013.

17. Mahoney G, Coombs M: A literature review of dental casualty rates. Mil Med 2000; 165: 751-6.

18. Leiendecker T, Martin G, Moss D: 2008 Department of Defense (DoD) recruit oral health survey. Mil Med 2011; 176 (8 Suppl): 1-44.

John W. Simecek, DDS, MPH*; MAJ Paul Colthirst, DC USA[dagger]; Barbara E. Wojcik, PhD[double dagger]; COL Steven Eikenberg, DC USA§; Alicia C. Guerrero, MPH[double dagger]; Adam Fedorowicz, PhD[double dagger]; Wioletta Szeszel-Fedorowicz, PhD[double dagger]; COL Philip DeNicolo, DC USA[dagger]

*Naval Medical Research Unit San Antonio, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6315.

[dagger]Dental and Trauma Research Detachment, Institute of Surgical Research, 3650 Chambers Pass, Fort Sam Houston, TX 78234-6315.

[double dagger]Center for AMEDD Strategic Studies, 2478 Stanley Road, Suite 47, ATTN: MCCS-FH, Fort Sam Houston, TX 78234.

§Army Medical Department (AMEDD) Center and School, 3599 Winfield Scott Road, Suite 600, Fort Sam Houston, TX 78234-6315.

doi: 10.7205/MILMED-D-13-00511