The Incidence of Dental Disease Nonbattle Injuries in Deployed U.S. Army Personnel
By DeNicolo, Philip | |
Proquest LLC |
ABSTRACT Background: In the past, the
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 (
The
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
The objectives of this study were to present the first
METHODS AND MATERIALS
Data Description
D-DNBI information on
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
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
This study was conducted under a protocol (USAISR Protocol no.: H-11-037) that was reviewed and approved by the
RESULTS
During the overall data collection period, a total of 31,659 Soldiers were seen by Army Dental Officers in
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
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
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
D-DNBI Rates
The annual D-DNBI encounter rates for Soldiers deployed to
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
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,
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
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
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
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.
This study was funded and conducted under a protocol (USAISR Protocol no.: H-11-037) that was reviewed and approved by the
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*Naval Medical Research Unit San Antonio, 3650
[dagger]Dental and Trauma Research Detachment,
[double dagger]
§Army Medical Department (AMEDD) Center and School,
doi: 10.7205/MILMED-D-13-00511
Copyright: | (c) 2014 Association of Military Surgeons of the United States |
Wordcount: | 4672 |
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