1. Oral Health Status and Treatment Needs of Army Reserve Component Soldiers David L. Moss, LTC, USA, DC Andrew K. York, CAPT, DC, USN Susan W. Mongeau, Lt Col, USAF, DC Tri-Service Center for Oral Health Studies Uniformed Services University of the Health Sciences Bethesda, MD February 2003

2. Table of Contents Background1 Methods1 Study Sample2 Oral Health Status by DoD Dental Classification2 Operative Treatment Needs3-6 Oral Surgery (extraction) Treatment Needs7-8 Endodontic Treatment Needs9-10 Prosthodontic Treatment Needs11-12 Periodontic Treatment Needs13-14 Treatment Needs Expressed as Dental Weighted Values15-17 DOD Oral Health and Readiness Standards (Appendix A)18-19

3. Background Prior to this study, the dental treatment need among Army Reserve Component soldiers was largely unknown. Anecdotal accounts from Operation Desert Storm (1991) reported poor dental health and large amounts of dental treatment need. In October 2001, the largest reserve component mobilization in a decade began with the onset of Operation Noble Eagle/Enduring Freedom. This presented a unique opportunity to assess the dental condition of this group. The Tri-Service Center for Oral Health Studies (TSCOHS) was tasked and funded by the DoD Health Affairs, TRICARE Management Activity (TMA) to develop and implement a scientific protocol to assess and document the oral health status and treatment needs of these mobilized reservists. In January 2002 Army Dental Command tasked all dental treatment facilities to collect and submit data, according to the protocol provided by TSCOHS, for all reservists mobilizing through their command. Methods 1. Data Collection Reservist dental records are reviewed by Army dental personnel as part of the mobilization process. This review determines whether or not a dental examination is required, based upon the individual’s DoD Dental Classification, Appendix A. Patient dental exams are recorded using the Standard Form 603. All dental facilities were tasked to send TSCOHS a copy of the most recent SF603 from the dental record of each reservist mobilizing through their facility. If a new dental examination was performed, a copy of that new SF603 was collected. If a new dental examination was not required, a copy of the most recent SF603 in the patient’s record was collected. All data was received by TSCOHS via US mail in postage paid, pre-address envelopes. 2. Computer Data Entry / Analysis TSCOHS dental personnel manually transferred the treatment needs for over 1,141 Army reservists into a customized computer data entry screen designed using Microsoft Access® 2000. This data was then converted into a SPSS ® 11.0 database for statistical analysis. 1

4. 3. Study Sample The six month data collection period ran from January through August 2002. TSCOHS received 1,141 records from 24 Army dental treatment facilities (DTF). This represented an estimated 9% of all Army reservists mobilized during the study period. The representative strength of this sample is bolstered by the natural randomization resulting from data collection at many geographically disbursed data collection sites. No indications of systematic bias were found. 2 Figure 1. Dental Class Distribution After Inprocessing Exam 24.8 [2.5] 69.8 [2.7] 5.4 [1.3] 0 20 40 60 80 100 Class 1Class 2Class 3 Percent [ ] Margin of Error = 1.96*SE Oral Health Status by DoD Dental Classification Figure 1 shows the DoD dental classification distribution of Army reservists. There are no Class 4 reservists since those who had not received a dental examination within 12 months were reexamined at inprocessing.

5. Figure 2. Number of Teeth Requiring Restoration per 1000 RC Soldiers 1934 [1771-2091] 0 500 1000 1500 2000 2500 Class 2Class 3Total 3 Operative Treatment Needs 237 [184-290] 2171 [1993-2349] [ ] 95% confidence interval

6. Figure 3. Number of Surfaces Requiring Restoration per 1000 RC Soldiers 0 500 1000 1500 2000 2500 3000 3500 4000 Class 2Class 3Total 4 Operative Treatment Needs 3131 [2866-3396] 509 [393-625] 3640 [3327-3953] [ ] 95% confidence interval

7. Figure 4. Distribution of Operative Treatment Needs 39.3 [2.8] 39.4 [2.8] 12.3 [1.9] 9.0 [1.7] 0 20 40 60 80 100 None1 to 34 to 67 or more Percent Figures 4 and 5 provide the distribution of all operative treatment needs and Class 3 operative treatment needs, respectively. [ ] Margin of Error = 1.96*SE 5 Figure 5. Distribution of Class 3 Operative Treatment Needs 88.6 [1.8] 9.8 [1.7] 1.2 [0.6] 0 20 40 60 80 100 None1 to 34 to 67 or more Percent 0.4 [0.6] Teeth Operative Treatment Needs [ ] Margin of Error = 1.96*SE

8. Operative Treatment Needs Approximately half of all restorations required are one surface, and more than one-third are two surface restorations, figure 6. 6

9. Figure 7. Number of Required Tooth Extractions by Dental Class for 1000 RC Soldiers. Oral Surgery (Extraction) Treatment Needs [ ] 95% confidence interval 7 445 [380-512] 250 [191-313] 695 [605-785] 0 100 200 300 400 500 600 700 800 Class 2Class 3Total

10. Figure 8. Distribution of all Tooth Extraction Needs 74.4 [2.5] 14.7 [2.1] 8.5 [ 1.6] 2.4 [0.9] 0 20 40 60 80 100 None1 to 23 to 45 or more Percent Oral Surgery (Extraction) Treatment Needs 25.6% of Reservists require at least one tooth extracted, Figure 8. 10.8% of reservists require at least one class 3 extraction and 3% will need 3 or more, Figure 9. [ ] Margin of Error = 1.96*SE 8 Figure 9. Distribution of Class 3 Extraction Needs 1.3 1.7 [0.8] 7.8 [1.6] 89.2 [1.8] 0 20 40 60 80 100 none1 to 23 to 45 or more Percent [ ] Margin of Error = 1.96*SE [0.6]

11. Figure 10. Number of Teeth Requiring Endodontic Procedures per 1000 RC Soldiers. 23 [12-34] 18 [15-20] 36 [24-48] 77 [56-96] 0 10 20 30 40 50 60 70 80 AnteriorPremolarMolarTotal Endodontic Treatment Needs All endodontic need is considered class 3 need. 9 [ ] 95% confidence interval

12. Figure 11. Distribution of Endodontic Treatment Needs 0 0.4 [0.4] 1.0 [0.6] 4.4 [1.2] 94.2 [1.3] 0 20 40 60 80 100 None123>3 Percent Endodontic Treatment Needs 1.4% of reservists require more than one endodontic treatment, figure 11. [ ] Margin of Error = 1.96*SE 10

13. Figure 12. Number of Required Prosthodontic Procedures per 1000 RC Soldiers. 26 [14-38] 144 [112-176] 0 25 50 75 100 125 150 Fixed UnitsRPDs Prosthodontic Treatment Needs 11 [ ] 95% confidence interval

14. Figure 13. Distribution of Fixed Prosthetic Units Required 0.3 [0.3] 1.3 [0.7] 7.6 [1.5] 90.9 [1.7] 0 20 40 60 80 100 None1 to 23 to 45 or more Percent Prosthodontic Treatment Needs The requirement for fixed prosthodontic care is confined to less than 10% of reservists, Figure 13. [ ] Margin of Error = 1.96*SE 12

15. Periodontic Treatment Needs The periodontal condition of each reservist is indicated by the Periodontal Screening and Recording (PSR) score. PSR scores are defined as PSR 0 (maximum probing depth less than 3.5mm, no calculus or defective margins, gingival tissues are healthy with no bleeding on probing); PSR 1 (maximum probing depth less than 3.5mm, no calculus or defective margins, bleeding on probing); PSR 2 (maximum probing depth less than 3.5mm, calculus or defective margins present); PSR 3 (probing depth 3.5mm to 5.5mm); PSR 4 (probing depth greater than 5.5mm). [ ] Margin of Error = 1.96*SE 13

16. Figure 15. Percent of Reservists Requiring a Dental Cleaning 65.9 [2.8] 21.8 [2.4] 88.7 [1.8] 0 20 40 60 80 100 Dental TechRDHTotal Percent Periodontic Treatment Needs [ ] Margin of Error = 1.96*SE 14 For 30% of reservists oral prophylaxis was the only treatment needed.

17. Dental Treatment Needs Expressed As Dental Weighted Values (DWV) American Dental Association Current Dental Terminology (CDT3) is a list of dental procedures and nomenclature used by civilian and military dentistry to record dental treatment provided. Dental Weighted Values (DWV) are weights assigned by military dentistry to each CDT3 dental procedure. These weights (DWV) are based on the fee charged by civilian dentists for each procedure (DWV = Civilian Fee /100). The use of dental weighted values allowed us to convert the treatment needs of RC soldiers into the dollar cost to provide the required dental care. Table 1 provides the DWV, by treatment type, and the overall civilian cost estimate for treatment necessary to achieve military operational readiness (DoD Class 1 or 2), and treatment necessary to achieve full dental health (DoD Class 1) for a 1,000 soldier RC mobilization. 56.4% of RC soldiers mobilized were class 4 (did not have a current exam and bitewing radiographs). This study did not capture the number of panoramic radiographs required. Data from prior mobilizations indicate that only 41% of reservists had a current panoramic radiograph. Assuming 590 new panoramic radiographs will be required for every 1000 RC soldiers activated would add 413 DWV’s and $41,300 to the required class 3 treatment. Based on the mean number of DWV’s needed, the civilian cost to move a class 3 (not deployable) RC soldier to class 2 is $449. Another $1088 worth of care would be required to move this soldier to class 1 (oral health). For the average class 2 soldier, a mean of $638 worth of care would be needed to reach class 1 (oral health). 15

18. Table 1. DWVs Associated With Providing Required Treatment by Procedure Type (Per 1000 Mobilized Reservists) Procedure TypeClass 2 DWVsClass 3 DWVsTotal DWVs Exam/Bitewings (Class 4s only) n/a316 Operative17662422008 Oral Surgery (Extractions) 537254791 Endodonticsn/a404 Prosthodontics1355811436 Periodontics32193583944 TOTAL DWVs (Civilian Cost) 6877 ($687,700) 1655 ($165,500) 8532 ($853,200) 16

19. The distribution of treatment need is shown in figure 15. Among those with need, forty percent required less than $400 of dental treatment, while approximately eleven percent required more than $2,000 of dental care. Among all reservists, 2.8% did not require any treatment. Figure 16. Dental Treatment Needs Expressed in Dollars 17

20. Department of Defense Oral Health and Readiness Standards The oral health status of uniformed personnel shall be classified as follows: a. Class 1. (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable. b. Class 2. Patients with a current dental examination, who require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following: 1.Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient. 2.Interim restorations or prostheses that can be maintained for a 12 ‑ month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated. c. Class 3. Patients who require urgent or emergent dental treatment. Class 3 patients are not normally considered to be worldwide deployable. 1.Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient. 2.Interim restorations or prostheses that cannot be maintained for a 12 ‑ month period. Appendix A 18

21. 3.Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months. a)Acute gingivitis or pericornitis. b)Active progressive moderate or advanced periodontitis. c)Periodontal abscess. d)Progressive mucogingival condition. e)Periodontal manifestations of systemic disease or hormonal disturbances. f)Heavy subgingival calculus. 4.Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication, or acceptable esthetics. 5.Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal. 6.Chronic oral infections or other pathologic lesions including: a)Pulpal, periapical, or resorptive pathology requiring treatment. b)Lesions requiring biopsy or awaiting biopsy report. 7.Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections, or provide timely follow-up care (e.g., drain or suture removal) until resolved. 8.Acute temporomandibular disorders requiring active treatment that may interfere with duties. d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients are normally not considered to be worldwide deployable. 19