Comparison of Dental Emergencies Among U.S. Military and Civilian Personnel During Combat Operations in 2007-2009.

INTRODUCTION: Information from published studies describing dental treatment of nonmilitary personnel in a military theater of operations is sparse. The primary objective of this study is to determine the number of dental emergencies (DEs) and the types of dental treatment rendered on non-U.S. military (civilian) personnel treated by Navy dentists in 2007-2008 in Iraq and 2009 in Afghanistan. The second objective is to compare the type of DE treatment procedures provided to civilian personnel to the type of DE treatment procedures performed on U.S. military personnel. MATERIALS AND METHODS: Navy Dental Officers documented the diagnoses of unscheduled DEs. All treatment provided was described at the time of treatment using the Current Dental Terminology codes of the American Dental Association. Current Dental Terminology Code A0145 (2007 and earlier) and A0199 (2008 onward) in the patient encounter indicated a DE. This study is limited to DE occurring in (1) patient categories: U.S. civilian employees, other beneficiaries of the U.S. Government, foreign national civilian/dependents, and civilian, no government connection and (2) U.S. military service members. Chi-square analysis was performed to compare the proportion of dental treatment category procedures on civilian patients compared to those on U.S. military patients. RESULTS: During the reporting period, 308 patients were treated for DE in Afghanistan. Civilians treated accounted for 18.5% (n = 57) of all DEs. Nearly 93.0% of civilians who were treated were U.S. (DoD) civilian employees. Of the 57 civilian patients treated for DE, 61.4% of patients (n = 35) received oral surgery. There were 251 U.S. military patient encounters (81.5% of all DEs). Restorative dentistry was the most common dental procedure for military personnel DE. When comparing civilian and military patients, civilian patients are statistically more likely than military patients to receive oral surgery treatment for DE (P < .00001). In Iraq, 3,198 patients were treated for DE during the reporting period. Civilians treated accounted for 18.8% (n = 601) of all DEs. About 56.9% (n = 342) of civilians who were treated were U.S. contract employees. Of the 601 civilian patients treated for DE, 37.1% (n = 223) received oral surgery. There were 2,597 U.S. military patient DE encounters, and restorative dentistry was the most common dental procedure. When comparing civilian and U.S. military patients in Iraq, civilians are statistically less likely to have their DE treated by restorative dentistry (P < .00001) and are more likely have it treated by oral surgery/extractions (P < .00001). It is significantly more likely for civilians to have multiple categories of DE that must be treated (P< .00001). CONCLUSIONS: The primary group of civilians treated for DE in Afghanistan was U.S. civilian employees. The primary group of civilians treated for DE in Iraq were contract employees of the U.S. Government. The primary dental treatment of civilian beneficiaries in both the theaters of operation was oral surgery. This brings into question what dental fitness standards are there for primarily U.S. civilian and contract employees.

Causes of Oral-Maxillofacial Injury of U.S. Military Personnel in Iraq and Afghanistan, 2001-2014.

Background: Few studies have examined the causes or mechanisms of oral-maxillofacial (OMF) injury among deployed military populations. This study reports causes of OMF injuries to U.S. Department of Defense personnel deployed to Afghanistan in Operation Enduring Freedom (OEF) or to Iraq in Operation Iraqi Freedom (OIF) and Operation New Dawn (OND). This study provides follow-on analysis of a previous report of OMF injury rates among U.S. military personnel in Iraq and Afghanistan from 2001 to 2014. Methods: The populations studied were military personnel deployed to Afghanistan in OEF or Iraq in OIF and OND, who sought care at a level III military treatment facility for one or more OMF injuries. Injuries were identified in the Department of Defense Trauma Registry using diagnosis codes associated with OMF battle and non-battle injuries. Causes associated with these injuries were identified by evaluation of the data field "dominant injury mechanism." All OMF injuries incurred from October 19, 2001, to June 30, 2014, were included. Findings/Results: Approximately 89% of all OMF battle injuries in both OIF/OND and OEF were due to explosives or explosive devices. The three leading causes of OMF non-battle injuries for both OIF/OND and OEF were motor vehicle crashes/accidents (MVCs), falls, and "other blunt" trauma. MVCs as well as other blunt trauma accounted for a greater percentage of OMF non-battle injuries in OIF/OND than in OEF (p < 0.01). OMF non-battle injuries due to falls were more likely to occur in OEF (p = 0.05). Helicopter/plane crashes were responsible for a significantly higher percentage of OMF non-battle injuries in OEF compared with OIF/OND (p < 0.01). Discussion/Impact/Recommendations: Across both theaters of war, Iraq and Afghanistan, the main causes of OMF battle and non-battle injuries were consistent. Battle injuries were primarily due to explosives or explosive devices and the three main causes of non-battle injuries were MVCs, falls, and other blunt trauma. However, the distribution of causes differed by war theater. Future studies should focus on potential reasons for cause distribution disparities in MVCs and helicopter/plane crashes as they can only be partially explained by topography and infrastructure differences between Iraq and Afghanistan. Further surveillance is needed to understand the scope of OMF injuries in military-armed conflicts and operations.

Oral-Maxillofacial Injury Surveillance of U.S. Military Personnel in Iraq and Afghanistan, 2001 to 2014.

BACKGROUND: Cranial and oral-maxillofacial injuries accounted for 33% of military visits to in-theater (Level III) military treatment facilities for battle injuries during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Even after years of conflict, the size and scope of oral-maxillofacial injuries in military armed conflict is still not fully understood. This study reports U.S. Department of Defense (DoD) rates of oral-maxillofacial injuries that can be used for further surveillance and research. METHODS: The populations studied were military personnel deployed to Afghanistan in OEF or Iraq in OIF and Operation New Dawn (OND), who sought care at a Level III military treatment facility for one or more oral-maxillofacial injuries. Injuries were identified in the DoD Trauma Registry (DoDTR) using diagnosis codes associated with oral-maxillofacial battle and nonbattle injuries. All oral-maxillofacial injuries incurred from October 19, 2001, to June 30, 2014, were included. The Defense Manpower Data Center provided DoD troop strength numbers to serve as the study denominators. RESULTS: Battle injuries accounted for 80% of oral-maxillofacial injuries in OEF. There were 2,504 oral-maxillofacial injuries in OEF. The Army accounted for 1,820 (72.7%), the Marines 535 (21.3%), the Air Force 75 (3.0%), and the Navy 74 (3.0%). The oral-maxillofacial injury rates in OEF for the Army ranged from 1.10 to 4.90/1,000 person years (PY), for the Marines from 0.57 to 9.39/1,000 PY, for the Navy from 0 to 3.29/1,000 PY, and for the Air Force from 0 to 3.38/1,000 PY. The Army tended to have the highest incidence of all services in the early and latter part of the conflict, whereas Marines tended to have the highest incidence in the middle years. The Marines, Army, and Navy all had their individual highest incidences in 2009, the first year of the 2009 to 2011 OEF troop surge. Battle injuries accounted for 75% of oral-maxillofacial injuries in OIF/OND. There were 3,676 oral-maxillofacial injuries in OIF/OND. The Army accounted for 2,798 (76.1%), the Marines 731 (19.9%), the Navy 91 (2.5%), and the Air Force 56 (1.5%). The injury rates in OIF/OND for the Army ranged from 0.66 to 8.69/1,000 PY, for the Marines from 0.88 to 42.7/1,000 PY, for the Navy from 0.35 to 19.16/1,000 PY, and for the Air Force from 0.24 to 1.13/1,000 PY. In OIF/OND, the Marines had the highest overall oral-maxillofacial injury rate (42.70/1,000 PY) in 2003. The other services had their individual peak incidences in either 2003 or 2004. DISCUSSION/IMPACT/RECOMMENDATIONS: This is the first study, which quantified the incidence of oral-maxillofacial injury in theaters of conflict over prolonged periods. The Army has the highest number of injuries. The Marines had the highest incidences during the initial stages of OIF and the OEF troop surge. Intensity of the conflict could account for the upswing in rates. These increases in injury rates highlight the need for additional health care personnel to be deployed near the battlefield to treat these injuries.

Risk of dental disease non-battle injuries and severity of dental disease in deployed U.S. Army personnel.

Dental Disease and Non-Battle Injuries (D-DNBI) continue to be a problem among U.S. Army active duty (AD), U.S. Army National Guard (ARNG), and U.S. Army Reserve (USAR) deployed soldiers to Operation Iraqi Freedom/Operation New Dawn in Iraq and Operation Enduring Freedom in Afghanistan. A previous study reported the annual rates to be 136 D-DNBI per 1,000 personnel for AD, 152 for ARNG, and 184 for USAR. The objectives of this study were to describe D-DNBI incidence and to determine risk factors for dental encounters and high severity diagnoses for deployed soldiers. The 78 diagnoses were classified into three categories based on severity. Poisson regression was used to compare D-DNBI rates and logistic regression was used to analyze the risk of high severity D-DNBI. In both campaigns, Reserve had a higher risk of D-DNBI than active duty. For Afghanistan, ARNG and USAR demonstrated over 50% increased risk of D-DNBI compared to AD. In Iraq, USAR had a 17% increased risk over AD. Females had a higher risk of D-DNBI (>50%) compared to males in both campaigns. High severity D-DNBI made up 2.77% of all diagnoses. Within Afghanistan, there was a 4.6% increased risk of high severity D-DNBI for each additional deployment month.

The incidence of dental disease nonbattle injuries in deployed U.S. Army personnel.

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.

Operational cost analysis of dental emergencies for deployed US Army personnel during operation Iraqi freedom.

The documentation of dental emergency (DE) rates in past global conflicts has been well established; however, little is known about wartime DE costs on the battlefield. Using DEs as an example for decreased combat effectiveness, this article analyzes the cost of treating DEs in theater, both in terms of fixed and variable costs, and also highlighted the difficulties that military units experience when faced with degradation of combat manpower because of DEs. The study found that Dental-Disease and Non-Battle Injury cost the U.S. Army a total of $21.4M between July 1, 2009 and June 30, 2010, and $21.9M between July 1, 2010 and June 30, 2011. The results also revealed that approximately 32% of DE required follow-up treatment over the 2-year period, which increased the costs associated with a DE over time. Understanding the etiology and cost of DE cases, military dental practitioners will be better equipped to provide oral health instructions and preventive measures before worldwide deployments.

Use of the dental disease nonbattle injury encounter module to assess the emergency rate on an Army military installation within the United States.

The objectives of this study are (1) to establish a baseline rate for dental emergencies (DE) occurring within a Brigade Combat Team (BCT) garrisoned on a military installation located in the continental United States (CONUS), and (2) to determine if differences in risk of DE are observed in soldiers of different Dental Fitness Classifications (DFC). Data concerning DE were documented by Army Dental Corps providers using CONUS Dental Disease Nonbattle Injury Emergency Encounter module of the Corporate Dental Application (CDA). The data were collected from September 1, 2011 to December 15, 2011. The number of soldiers at risk, the BCT dental readiness, the DFC of each soldier who experienced a DE, and the date of the dental visit that preceded the DE were documented from CDA. The estimated rate of 221 DE per 1,000 soldiers per year was observed. The risk of DE for DFC 3 soldiers was five times that of soldiers who were DFC 1 or 2. Assessing the DE rate of a BCT in garrison is useful for stakeholders and policymakers who must accommodate the impact of DE on mission readiness.

The severity of oral/facial problems treated in Iraq March 2008 to February 2009.

BACKGROUND: The objective of this study was to describe the severity of oral/facial problems occurring in Navy and Marine Corps personnel deployed to Iraq. METHODS: Data documented by Navy Dental Officers deployed to Iraq were used to determine the number and type of oral/facial problems treated and to determine the percentages of severe, moderately severe, and pain/loss of function oral/facial problems treated in Iraq from March 2008 through February 2009. RESULTS: During the year of data collection, a total of 13,933 dental visits were documented for Navy and Marine Corps personnel. Of these, 1,641 were encounters to treat an oral/facial problem in Navy and Marine Corps personnel. In all, 37 (2.2%) of the 1,641 encounters for oral/facial problems were considered severe, 266 (16.2%) moderately severe, and 1,338 (81.5%) were for pain/loss of function. CONCLUSIONS: Although the majority of military personnel with oral/facial problems experience mild to moderate pain or loss of dental function, approximately 20% are of sufficient severity to cause the warfighter to experience a limitation of their operational capability.

An evaluation of U.S. Navy Dental Corps classification guidelines.

OBJECTIVES: The aims of this research were to evaluate the effectiveness of two different sets of dental classification guidelines to differentiate dental emergency (DE) rates between deployable and nondeployable personnel. METHODS: A retrospective study of the dental records of two cohorts of Marine Corps recruits examined and treated using different classification guidelines was completed. RESULTS: Both classification systems showed significant differences between DE rates of nondeployable and deployable personnel. No statistical difference was observed when comparing the adjusted HRs of the two cohorts. CONCLUSIONS: Results of this study suggest that both guidelines are able to distinguish between deployable and nondeployable personnel and give reasonable assurance that class 1 and 2 patients will not experience a DE for a 6-month period. Incorporating factors such as caries risk, number of missing and filled teeth, and number of third molars may improve the ability of the dental classification systems in predicting DE.

An evaluation of replacement rates for posterior resin-based composite and amalgam restorations in U.S. Navy and marine corps recruits.

BACKGROUND: Restoration replacement is a clinical concern that has not been studied among military personnel. The authors determined the prevalence of placement of posterior amalgam and resin-based composite restorations and the incidence of replacement among U.S. Navy and Marine Corps personnel. METHODS: The authors analyzed dental records from 2,780 personnel to determine the relative risk of replacement for initially sound restorations during subjects' first years of military service. RESULTS: At the initial examination, 964 (15.2 percent) of amalgam restorations and 199 (17.4 percent) of resin-based composite restorations required re-treatment. Of those judged clinically acceptable, 14.2 percent of amalgam and 16.7 percent of resin-based composite restorations required replacement during the observation period. The authors found significant increases in replacement rates for resin-based composite restorations compared with amalgam restorations for replacement due to all causes (adjusted hazard ratio, 1.28; P < .05), as well as for replacement due to restoration failure (adjusted hazard ratio, 1.64; P < .01). CONCLUSIONS: About 30 percent of posterior restorations required replacement, either at the initial examination or during the subjects' first years of military service. In a young military population, significantly more resin-based composite restorations in place at the initial examination will require replacement than will amalgam restorations. Multi-surface restorations had higher rates of replacement than did one-surface restorations, and subjects at high caries risk experienced significantly higher replacement rates than did those at low caries risk. CLINICAL IMPLICATIONS: The number of surfaces restored and subjects' caries risk status may influence the longevity of resin-based composite and amalgam restorations.

Estimation of nonpreventable dental emergencies in U.S. Marine Corps personnel.

Previous studies of military personnel have reported that 26% to 75% of dental emergencies cannot be prevented. The aims of this study were (1) to estimate the percentage of dental emergencies for which causative conditions were not indicated for urgent treatment on the previous annual dental examination (nonpreventable dental emergency) and (2) to estimate the rate of dental emergencies that can be expected if all urgent treatment is completed. This retrospective cohort study of Marine Corps recruits revealed that 58.4% to 70.3% of conditions resulting in dental emergencies were nonpreventable. Therefore, the estimated range of dental emergencies that can be expected if all urgent treatment indicated on the previous dental examination is completed is 77 to 92 dental emergencies per 1,000 personnel per year. The rate of nonpreventable dental emergencies should be considered when staffing for level I care.

A statistical method to evaluate dental classification systems used by military dental services.

UNLABELLED: The aim of this research project was to develop a systematic approach to evaluate the effectiveness of dental classifications used by military dental services to predict dental emergencies. DESIGN: A retrospective cohort study of U.S. Navy recruits were followed for an average of 3.5 years. Dental records of 1,114 recruits who had their initial dental examination during the calendar year 1997 were collected in 2001. Four hundred sixty-two dental emergencies (DE) were recorded, of which 50 were class 3 patients. The incidence density ratio (IDR) of DE was 2.2 (p < 0.001; class 3 compared to class 1 or 2 patients). The mean times to DE in patients who experienced DE were 92 days (class 3 patients) and 418 days (class 1 and 2 patients; p < 0.001), while the median times to DE were 59 days and 295 days (p < 0.001) for class 3 and class 1 or 2, respectively. The adjusted hazard ratio for DE in class 3 versus class 1 and 2 patients was 1.519 (p = 0.0149). We have concluded that examination of the following statistics is necessary to assess the effectiveness of military dental classification systems: (1) the percentage of DE that occur in class 3 patients, (2) the IDR of DE, (3) the mean time to DE, (4) the median time to DE, and (5) the hazard ratio of DE.

Dental classification and risk assessment prevention of dental morbidity in deployed military personnel. Consensus statements.

Because of the differences in definitions among authors as to what constitutes a "dental emergency", the attendees at the workshop discussed these definitions and arrived at a consensus.

Periodontal health status in a cohort of young US Navy personnel.

OBJECTIVES: Neither the prevalence of periodontal disease nor long-term trends in periodontal health among US military personnel has been well studied. The authors analyzed dental records to assess the prevalence and severity of periodontal disease, characterize changes in periodontal health, and determine the associations of age, race, gender, and tobacco use with periodontal status among US Navy personnel. METHODS: Dental records from 1,107 personnel who entered military service in 1997 were gathered from eight US Navy dental treatment facilities. Demographic information, tobacco use status, and periodontal health status, as reflected by the Periodontal Screening and Recording (PSR) information recorded at each required dental examination during the 4-year observational period (1997 to 2001), were collected. To improve sensitivity in measuring the extent of periodontal disease, the standard five-point PSR scale was reexpressed as a "PSR grade." RESULTS: Over 98 percent of Navy recruits exhibited some level of periodontal disease at initial examination. Most (76 percent) exhibited gingivitis of varying severity. Over a mean observational period of 3.4 years, 91 percent of subjects received at least one oral prophylaxis, and over 60 percent received two to four prophylaxes. Subjects with severe periodontal conditions received as many as 22 appointments for prophylaxis or periodontal therapy. From initial to final examination, periodontal status improved for 29.2 percent of subjects, deteriorated for 31.3 percent, and remained unchanged for 39.5 percent. Subjects presenting initially with healthy periodontia, or gingivitis without evidence of periodontitis, tended to deteriorate or remain unchanged, while those exhibiting periodontitis tended to improve with periodontal therapy. Race (non-White) and greater age at entry were significantly associated with increased risk for poorer periodontal health at both initial and final examination. CONCLUSIONS: Although a needs-based dental care model appears effective in managing periodontal disease among those receiving active therapy, patients who receive sporadic care may deteriorate over time. To maintain periodontal health in this population, appropriate preventive and periodontal therapies should be provided soon after entry and repeated at intervals specific to individual patient need.

Dental sealant longevity in a cohort of young U.S. naval personnel.

BACKGROUND: The U.S. Navy emphasizes caries prevention and encourages the placement of dental sealants on the caries-susceptible teeth of patients at risk of developing caries. The authors analyzed dental records to assess the longevity of dental sealants placed in naval personnel. METHODS: A cluster sample of dental records from 1,123 personnel who entered naval service in 1997 was drawn from eight Navy dental treatment facilities. The authors determined the number of sealants provided, the number of sealants that failed over the observation period (1997-2001), the dates of sealant failure and the longevity of sealants placed during and after recruit training. RESULTS: A total of 319 personnel received sealants during their first two years of service. The authors evaluated 1,467 sealed teeth. They followed the sealants for an average of 35 months. They noted 179 sealant failures in 102 subjects; 69 previously sealed teeth required sealant replacement, and 110 sealed teeth required restoration of the occlusal surface. Among those sealants that failed, the mean length of time from placement to failure was 26 months. Sealant failure rates were significantly higher among subjects at moderate risk or high risk of developing caries than among subjects at low risk. CONCLUSIONS: After an average of 35 months, 87.8 percent of the sealants placed in this population were retained and functional. Subjects who were at moderate or high risk of developing caries demonstrated significantly higher sealant failure rates than those at low risk of developing caries. CLINICAL IMPLICATIONS: Dental sealants can be retained successfully in adults. They should be considered a viable treatment alternative for adult patients who are susceptible to caries; however, patients at elevated risk of developing caries may require more frequent re-evaluation and maintenance to achieve maximum benefit.

Waterline biofilm and the dental treatment facility: a review.

Biofilms are well-organized communities of cooperating microorganisms that can include bacteria, protozoa, diatoms, and fungi. Surveys of dental unit waterlines (DUWLs) indicate that biofilm formation is a universal problem and that environmental and human-derived opportunistic pathogens can be cultured consistently from biofilms retrieved from DUWLs and other dental devices. Although the health risks presented by waterline bacterial colonization have yet to be adequately addressed, professional and ethical considerations indicate that steps should be taken to improve the quality of DUWLs. To address these concerns, the Council on Scientific Affairs of the ADA recently published a list of products cleared by the FDA to control dental waterline contamination. The goal of this article is to increase the awareness of potential health risks posed by biofilm formation and provide information on techniques and devices designed to control the microbial contamination of DUWLs.