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.

Oral Health Status and Treatment Needs of Army Reserve

Component SoldiersDavid L. Moss, LTC, USA, DC

Andrew K. York, CAPT, DC, USNSusan W. Mongeau, Lt Col, USAF, DC

Tri-Service Center for Oral Health StudiesUniformed Services University of the Health Sciences

Bethesda, MDFebruary 2003

Table of Contents

Background 1

Methods 1

Study Sample 2

Oral Health Status by DoD Dental Classification 2

Operative Treatment Needs 3-6

Oral Surgery (extraction) Treatment Needs 7-8

Endodontic Treatment Needs 9-10

Prosthodontic Treatment Needs 11-12

Periodontic Treatment Needs 13-14

Treatment Needs Expressed as Dental Weighted Values 15-17

DOD Oral Health and Readiness Standards (Appendix A) 18-19

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 / AnalysisTSCOHS 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.

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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 1 Class 2 Class 3

Pe

rce

nt

[ ] 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.

Figure 2. Number of Teeth Requiring Restoration per 1000 RC Soldiers

1934[1771-2091]

0

500

1000

1500

2000

2500

Class 2 Class 3 Total

3

Operative Treatment Needs

237[184-290]

2171[1993-2349]

[ ] 95% confidence interval

Figure 3. Number of Surfaces Requiring Restoration per 1000 RC Soldiers

0

500

1000

1500

2000

2500

3000

3500

4000

Class 2 Class 3 Total

4

Operative Treatment Needs

3131[2866-3396]

509[393-625]

3640[3327-3953]

[ ] 95% confidence interval

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

None 1 to 3 4 to 6 7 or more

Per

cen

t

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

None 1 to 3 4 to 6 7 or more

Per

cen

t

0.4[0.6]

Teeth

Teeth

Operative Treatment Needs

[ ] Margin of Error = 1.96*SE

Figure 6. Restorations Required by Number of Surfaces

1 Surface49%

2 Surface38%

3 Surface9%

4 or More Surfaces

4%

Operative Treatment Needs

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

6

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 2 Class 3 Total

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

None 1 to 2 3 to 4 5 or more

Per

cen

t

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

1.31.7[0.8]

7.8[1.6]

89.2[1.8]

0

2040

6080

100

none 1 to 2 3 to 4 5 or more

Per

cen

t

[ ] Margin of Error = 1.96*SE

[0.6]

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

Anterior Premolar Molar Total

Endodontic Treatment Needs

All endodontic need is considered class 3 need.

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[ ] 95% confidence interval

Figure 11. Distribution of Endodontic Treatment Needs

00.4[0.4]

1.0[0.6]

4.4[1.2]

94.2[1.3]

0

20

40

60

80

100

None 1 2 3 >3

Per

cen

tEndodontic Treatment Needs

1.4% of reservists require more than one endodontic treatment, figure 11.

[ ] Margin of Error = 1.96*SE

10

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 Units RPDs

Prosthodontic Treatment Needs

11

[ ] 95% confidence interval

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

None 1 to 2 3 to 4 5 or more

Pe

rce

ntProsthodontic Treatment Needs

The requirement for fixed prosthodontic care is confined to less than 10% of reservists, Figure 13.

[ ] Margin of Error = 1.96*SE

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Figure 14. Distribution of Periodontal Screening and Recording (PSR) Score

8.7[1.6]

23.1[2.4]

42.1[2.9]

16.8[2.2]9.3

[1.7]

0

20

40

60

80

100

PSR 0 PSR 1 PSR 2 PSR 3 PSR 4

Pe

rce

nt

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

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 Tech RDH Total

Pe

rce

nt

Periodontic Treatment Needs

[ ] Margin of Error = 1.96*SE

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For 30% of reservists oral prophylaxis was the only treatment needed.

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).

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Table 1. DWVs Associated With Providing Required Treatment by Procedure Type

(Per 1000 Mobilized Reservists) Procedure Type Class 2 DWVs Class 3 DWVs Total DWVs

Exam/Bitewings

(Class 4s only)

n/a 316 316

Operative 1766 242 2008

Oral Surgery

(Extractions)

537 254 791

Endodontics n/a 404 404

Prosthodontics 1355 81 1436

Periodontics 3219 358 3944

TOTAL DWVs

(Civilian Cost)

6877

($687,700)

1655

($165,500)

8532

($853,200)

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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

25.5

14.6

9.17

2.6 2 2.3 1.6 0.5

5.1

3.1

2.1

2.1

2.6 3 1.81.6

6.2

0.81.20.4

0.6

0

5

10

15

20

25

30

<200 200-399 400-599 600-799 800-999 1000-1199

1200-1399

1400-1599

1699-1799

1800-1999

>2000

Dollars

Pe

rce

nt

of

So

ldie

rs

Class 3

Class 2

17

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

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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.

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