Dental Treatment Needs of Active Duty Military Personnel 1994 and 2003 Andrew K. York, CAPT, DC, USN Susan W. Mongeau, Lt Col, USAF, DC David L. Moss, LTC, USA, DC Tri-Service Center for Oral Health Studies Uniformed Services University of the Health Sciences Bethesda, MD August 2004

Background1 Methods2 Study Sample3-4 Operative Treatment Needs5-8 Oral Surgery (extraction) Treatment Needs9-12 Endodontic Treatment Needs13-16 Fixed Prosthodontic Treatment Needs17-20 Periodontic Treatment Needs (PSR Distributions)21-24 Executive Summary25 Table of Contents

Background The 1994 Tri-Service Comprehensive Oral Health Survey was the military’s first effort to document the dental treatment needs of Army, Navy, and Air Force active duty personnel employing a standardized methodology across all services. The study report (NDRI-PR 95-03) provides detailed treatment requirement information, however, it is reported at the overall military level and does not provide service specific information. In October 2001, Navy Dentistry began using the Dental Common Access System (DENCAS) to electronically maintain patient treatment needs information in a web-based environment. DENCAS provides immediate access to this information in real time, and eliminates the need to conduct studies to assess treatment needs. The Army and Air Force dental computer systems do not contain patient treatment needs information. The Tri-Service Center for Oral Health Studies (TSCOHS) designed and conducted the 2003 Army and Air Force Dental Treatment Requirements Study to assess the dental treatment needs of Army and Air Force active duty service members. For conciseness, the 1994 Tri-Service Comprehensive Oral Health Survey and the 2003 Army and Air Force Dental Treatment Requirements Study will be referred to as the 1994 and 2003 studies. This report combines information from the original databases associated with the 1994 and 2003 studies with the current DENCAS database. Service specific dental treatment needs are reported from both studies and changes over the past decade are evaluated. 1

Methods 1. Data Collection The 1994 study utilized calibrated examiners to conduct full dental examinations on a random sample of 13,050 Army, Navy, and Air Force active duty members at 26 military clinics. Data were collected from April 1994 to January 1995 using notebook computers and a custom designed input program. A detailed discussion of the purpose, design, and scope of the survey is presented in government study report NDRI-PR TSCOHS dental officers collected the data for the 2003 study by extracting the treatment needs from the military dental records of 4,800 randomly selected active duty service members, located at 8 Army bases (21 clinics) and 8 Air Force bases (12 clinics). Bases were randomly selected from all bases with a probability of selection equal to the size of the patient population supported. At each selected base, 300 dental records were randomly selected. Data were collected from October 2002 to August 2003 by entry into a custom designed Microsoft Access® 2000 input screen Navy dental treatment needs data were extracted from DENCAS in November 2003 to coincide with the 2003 Army and Air Force study data collection. All data collected and contained in the databases is anonymous. Military rank, gender, and location were collected for sample validation. No other demographic information was recorded. All data were then converted to SPSS ® 11.0 databases for statistical analysis. 2

2. Study Sample Tables 1 and 2 show the 2003 Army sample distribution compared to the actual Army population by military paygrade and gender. The all Army numbers are from the Defense Manpower Data Center for September The general sample distribution is very similar to the target population indicating successful sample randomization. Some over-sampling of the E2 group and under-sampling of senior officers occurred. Prior to data analysis the sample was weighted to reflect the exact service population shown. RANK CATEGORY SAMPLE POPULATION SAMPLE PERCENT ARMY POPULATION ARMY PERCENT E %19,6284.0% E %30,2486.1% E %62, % E %119, % E %74, % E %56, % E %37,0807.5% E8421.8%10,9142.2% E9130.5%3,2090.7% WO492.1%11,9132.4% O1451.9%8,7981.8% O2401.7%6,9661.4% O3662.8%25,2665.1% O4311.3%14,0472.8% O5150.6%8,8401.8% O630.1%3,7170.8% O700%158<0.0% O800%111<0.0% O900%41<0.0% O1000%9<0.0% TOTAL %493,563100% GENDERSAMPLE POPULATION SAMPLE PERCENT ARMY POPULATION ARMY PERCENT MALE %418, % FEMALE %75, % TOTAL %493,563100% Table 2 Table 1 3 Methods

Study Sample (cont.) Tables 3 and 4 show the 2003 Air Force sample distribution compared to the actual Air Force population by military paygrade and gender. The all Air Force numbers are from the Defense Manpower Data Center for September The general sample distribution is very similar to the target population indicating successful sample randomization. Some under-sampling of the E1 and E4 groups occurred. Prior to data analysis the sample was weighted to reflect the exact service population shown. RANK CATEGORY SAMPLE POPULATION SAMPLE PERCENT AIR FORCE POPULATION AIR FORCE PERCENT E1140.6%13,9013.7% E %12,1243.3% E %57, % E %52, % E %75, % E %46, % E %30,3628.2% E8321.3%5,7181.5% E9200.8%2,8570.8% O1723.0%10,5352.8% O2893.7%9,5612.6% O %22,6426.1% O %16,0954.3% O5903.8%10,7282.9% O6341.4%3,8051.0% O720.1%140<0.0% O820.1%85<0.0% O900%39<0.0% O1000%13<0.0% TOTAL %370,945100% GENDERSAMPLE POPULATION SAMPLE PERCENT AIR FORCE POPULATION AIR FORCE PERCENT MALE %298, % FEMALE %72, % TOTAL %370,945100% Table 4 Table 3 4 Methods

Operative Treatment Needs For all services, the number of teeth per thousand active duty service members that require operative restoration is significantly less in 2003 compared to 1994, Figure 1. The mean number of operative restorations required by Air Force active duty service members has declined by 67% since On average, Army active duty (AD) have approximately 4 times more unmet restorative need compared Air Force AD and almost 3 times more compared to Navy/Marine Corps AD. Tables 5-7 show the distribution of restorative needs among the Army, Air Force, and Navy/Marine Corps personnel respectively. For all services, the percentage of AD personnel with no restorative needs has significantly increased since [ ] 95% CI 5

None1 to 34 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] None1 to 34 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 5: Army Restorative Treatment Needs (Fillings) in 1994 and 2003 (Percent Distribution and Mean)

None1 to 34 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] None1 to 34 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 6: Air Force Restorative Treatment Needs (Fillings) in 1994 and 2003 (Percent Distribution and Mean)

None1 to 34 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL None1 to 34 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 7: Navy/Marine Corps Restorative Treatment Needs (Fillings) in 1994 and 2003 (Percent Distribution and Mean) 8

[ ] 95% CI 9 Extraction Treatment Needs For all services, the number of teeth per thousand active duty service members that require extraction is less in 2003 compared to 1994, Figure 2. Among Air Force AD personnel, there was a significant 60% decline in the number of teeth per thousand active duty service members that require extraction, between 1994 and On average, Army active duty (AD) have approximately 4 times more unmet extraction need compared Air Force AD and over 2 times more compared to Navy/Marine Corps AD. Tables 8-10 show the distribution of extraction need among the Army, Air Force, and Navy/Marine Corps personnel respectively. For all services, the percentage of AD personnel with no extraction needs has increased since 1994, however, the Navy increase is not statistically significant in our study.

None1 or 23 or 45+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] None1 or 23 or 45+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 8: Army Extraction Treatment Needs in 1994 and 2003 (Percent Distribution and Mean) 10

None1 or 23 or 45+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] None1 or 23 or 45+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 9: Air Force Extraction Treatment Needs in 1994 and 2003 (Percent Distribution and Mean) 11

None1 or 23 or 45+Mean E1-E E5-E E7-E O1-O O4-O ALL None1 or 23 or 45+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 10: Navy/Marine Corps Extraction Treatment Needs in 1994 and 2003 (Percent Distribution and Mean) 12

[ ] 95% CI 13 Endodontic Treatment Needs For all services, the number of teeth per thousand active duty service members that require endodontics is significantly less in 2003 compared to 1994, Figure 3. This decline is in keeping with the decline in operative and extraction needs. However, during the 1994 study, examiners were instructed to record endodontic treatment need for all teeth with a deep carious lesion that in their best judgment would require endodontics following removal of the carious lesion. It is reasonable to assume that some portion of these teeth were successfully restored without endodontics, and therefore, the 1994 study likely overestimated the endodontic needs. The endodontic need captured in the 2003 study was only those teeth actually treatment planned for endodontic treatment. Tables show the distribution of endodontic need among the Army, Air Force, and Navy/Marine Corps personnel respectively.

AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ][ ][ ] AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ][ ][ ] Table 11: Army Endodontic Treatment Needs (Percent Needing Endodontics and Mean Number Needed) % Needing at Least OneMean Endodontics Needed % Needing at Least OneMean Endodontics Needed 14

AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ][ ][ ] AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ][ ][ ] Table 12: Air Force Endodontic Treatment Needs (Percent Needing Endo. and Mean Number Needed) % Needing at Least OneMean Endodontics Needed % Needing at Least OneMean Endodontics Needed 15

AnteriorPosteriorAnteriorPremolarMolarTotal E1-E E5-E E7-E O1-O O4-O ALL AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E E5-E E7-E O1-O O4-O ALL % CI [ ] [ ][ ][ ][ ][ ] Table 13: Navy / Marine Corps Endodontic Treatment Needs (Percent Needing Endo. and Mean Number Needed) % Needing at Least OneMean Endodontics Needed % Needing at Least OneMean Endodontics Needed 16

Fixed Prosthodontic Treatment Needs For all services, the number of units of fixed prosthodontics required per thousand active duty service members is significantly less in 2003 compared to 1994, Figure 4. This decline is in keeping with the decline in operative, endodontic, and extraction needs. However, methodological differences between the 1994 and 2003 studies may account for a portion of this difference. During the 1994 study, examiners were instructed to record fixed prosthodontic treatment need for all teeth where, in their best judgment, the patient would benefit from the treatment, regardless of the patient’s access to that care. The 2003 study simply recorded the treatment needs found in the patient’s military dental record. In the event that military dentists failed to treatment plan fixed prosthodontic care because access to that care was not readily available, we would expect an underestimation of true treatment need which would account for a portion of the differences shown in Figure 4. Tables show the distribution of the number of fixed prosthodontic units needed among the Army, Air Force, and Navy/Marine Corps personnel respectively. For all services, the percentage of AD personnel with no fixed prosthodontic needs has increased since [ ] 95% CI 17

None1 or 23 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] None1 or 23 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 14: Army Fixed Prosthodontic Treatment Needs (Units) (Percent Distribution and Mean)

None1 or 23 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] None1 or 23 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 15: Air Force Fixed Prosthodontic Treatment Needs (Units) (Percent Distribution and Mean)

None1 or 23 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL None1 or 23 to 67+Mean E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 16: Navy / Marine Corps Fixed Prosthodontic Treatment Needs (Units) (Percent Distribution and Mean)

Periodontal Treatment Needs The periodontal condition of each AD service member 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). The current PSR distributions, taken from the 2003 study and DENCAS, are shown in Figure 5. Tables show the distribution of PSR scores among the Army, Air Force, and Navy/Marine Corps personnel respectively. For all services, the percentage of AD personnel with severe periodontal disease (PSR 4) has decreased since This decrease is statistically significant for Army and Navy/Marine Corps, but failed to reach statistical significance for Air Force personnel in our study. 21

CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 17: Army Periodontal Screening and Recording (PSR) Distribution 22

CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] Table 18: Air Force Periodontal Screening and Recording (PSR) Distribution 23

CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E E5-E E7-E O1-O O4-O ALL CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E E5-E E7-E O1-O O4-O ALL % CI [ ][ ][ ][ ][ ] : Navy / Marine Corps Periodontal Screening and Recording (PSR) Distribution 24

Executive Summary  Data from the 1994 Tri-Service Comprehensive Oral Health Survey, the 2003 Army and Air Force Dental Treatment Needs Study, and the Navy Dental Common Access System (DENCAS) were combined to determine Service specific dental treatment needs, and changes over the past decade were evaluated.  The oral health of Army, Air Force, and Navy/Marine Corps active duty service members significantly improved between 1994 and Improvement occurred in all clinical disciplines of dentistry examined (i.e. operative, extraction, endodontic, fixed prosthodontic, and periodontic need).  Methodological differences between the 1994 and 2003 studies may account for an unknown portion of the observed endodontic and fixed prosthodontic improvement.  Despite significant improvement since 1994, on average, Army active duty service members have approximately 4 times more unmet restorative need compared to Air Force active duty and almost 3 times the need compared to Navy/Marine Corps active duty.  Despite significant improvement since 1994, Army active duty service members have approximately 3 times more unmet extraction need compared to Air Force active duty and over 2 times the need compared to Navy/Marine Corps active duty.  On average, Air Force active duty service members enjoyed the highest level of oral health in the 2003 study, with a 67% reduction in restorative need and a 60% reduction in extraction need between 1994 and  Navy/Marine Corps active duty service members enjoyed significantly less restorative and extraction need in 1994, compared to other services, and demonstrated significant improvement in