1. Oral Health Status and Treatment Needs of Military Personnel Supported by the Pentagon Dental Clinic Andrew K. York, CAPT, DC, USN David L. Moss, LTC, USA, DC Susan W. Mongeau, Lt Col, USAF, DC Tri-Service Center for Oral Health Studies Uniformed Services University of the Health Sciences Bethesda, MD September 2003

2. Table of Contents Background2 Methods2-3 Study Sample3 Oral Health Status (DoD Dental Classification)4 Operative Treatment Needs5 Oral Surgery (extraction) Treatment Needs6 Endodontic Treatment Needs7 Prosthodontic Treatment Needs8 Periodontic Treatment Needs9-10 Treatment Needs Expressed as Dental Weighted Values11-12 Clinical Mix of Treatment Provided13 Gross Estimation of Population Supported by the Pentagon Dental Clinic 14 Summary of Findings15 1

3. Background In July 2003 the Pentagon Dental Clinic Dental Advisory Board (DAB) requested the Tri-Service Center for Oral Health Studies (TSCOHS) conduct a study to assess the oral health status and treatment needs of the military active duty personnel supported by the clinic. The Pentagon Dental Clinic is uniquely staffed by equal numbers of Air Force, Army, and Navy dental providers. The clinics patient base is comprised of a higher percentage of senior personnel and officers compared to most military dental clinics. This difference in population demographics may result in a mix of patient dental treatment needs and consequently treatment provided that is unlike other military dental clinics. Methods 1. Treatment Needs Assessment The total treatment requirement by a population equals the treatment provided (met treatment need) plus the unmet treatment need. The treatment provided is obtained from each services centralized computer database, DENCAS (Navy), DDS (Air Force), and CDA (Army). Unmet treatment need is that need which has been diagnosed but not yet treated, as found in the patient dental record. 2. Data Collection and Analysis TSCOHS dental officers extracted all oral health status and unmet treatment needs data from a systematic random sample of 442 patient dental records of Navy/Marine, Air Force, and Army personnel supported by the Pentagon Dental Clinic. Data were entered via a customized computer data entry screen designed using Microsoft Access® 2000. These data were then converted into an SPSS ® 11.5 database for statistical analysis. 2

4. 3. Study Sample The sampling frame for this study was the 10,166 dental patient records available at the Pentagon Dental Clinic on 3 September 2003. This analysis reasonably assumes that these records were representative of all patients supported by the clinic. A target sample size of 450 was chosen to provide population estimates no worse than plus or minus 4%. Unmet treatment needs data from a systematic random sample comprised of every 23 rd patient dental record was collected resulting in a final sample size of 442. The sample breakouts by service and paygrade are shown in Tables 1 and 2, respectively. PAYGRADE# in SAMPLE O-82 O-76 O-634 O-5 120 O-4117 O-335 O-24 O-18 WO-42 WO-54 E-93 E-83 E-716 E-6 31 E-5 28 E-4 23 E-3 2 E-2 2 E-1 2 TOTAL 442 # SAMPLED % of SAMPLE Air Force11325.6 Army18642.1 Navy/Marine Corps14332.3 Total442100.0 Table 2 Table 1 3 Methods

5. Oral Health Status (DoD Dental Classification) Figure 1 compares the DoD dental classification distribution between active duty service members supported by the Pentagon Dental Clinic and those supported by all DoD dental clinics. A significantly higher Class 4 rate and correspondingly lower Class 2 rate are found among active duty service members supported by the Pentagon Clinic. 4

6. Unmet Operative Treatment Need Figures 2 and 3 show significantly less unmet operative treatment need among active duty service members supported by the Pentagon Clinic compared to the DoD-wide unmet need. 5

7. Unmet Oral Surgery (Extraction) Treatment Need Figure 4 shows significantly less unmet tooth extraction need among active duty service members supported by the Pentagon Clinic compared to the DoD-wide unmet need. 6

8. Unmet Endodontic Treatment Need Active duty service members supported by the Pentagon Dental Clinic have significantly more diagnosed and untreated endodontics compared to all DoD clinics combined. 7

9. Unmet Prosthodontic Treatment Need Figure 6 shows significantly greater unmet fixed prosthodontic need among active duty service members supported by the Pentagon Clinic compared to the DoD-wide unmet need. Unmet removable prosthodontic treatment need is statistically the same. 8

10. Periodontic Treatment Needs The periodontal condition of each active duty 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). Figure 7 shows no significant difference in PSR score distribution between patients supported by the Pentagon Dental Clinic and those supported by all DoD dental clinics. 9

11. Unmet Prophylaxis Need The Pentagon Dental Clinic is providing a higher percentage of treatment planned prophylaxis, compared to all DoD clinics combined. 10

12. 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 dental treatment needs of military personnel into the dollar cost to provide the required dental care in the civilian community. Table 3 provides the DWV associated with unmet treatment need, by treatment type, and the overall civilian cost estimate for service. Information is provided for treatment necessary to achieve military operational readiness (DoD Class 1 or 2), and treatment necessary to achieve full dental health (DoD Class 1). Dental examination and bitewing radiographs for those who have not been examined for more than 12 months are included in the Class 3 cost, since this is required treatment. 11

13. Table 3. DWVs Associated With Unmet Treatment Needs by Procedure Type (Per 1000 Supported AD Service Members) Procedure TypeClass 2 DWVsClass 3 DWVsTotal DWVs Pentagon Clinic Total DWVs All Military Clinics Exam/Bitewings (Class 4s only) n/a123.1 56.6 Operative266.434.8301.2779.3 Oral Surgery (Extractions) 53.29.562.7682.3 Endodonticsn/a169.6 74.2 Prosthodontics1481.10.01481.11251.5 Periodontics1226.1136.21362.31501.2 TOTAL DWVs (Civilian Cost) 3026.8 ($302,680) 473.2 ($47,320) 3500.0 ($350,000) 4345.1 ($434,510) 12

14. Clinical Mix of Treatment Provided (Met Treatment Need) The ADAs Common Dental Terminology –3 (CDT-3) was utilized across military dentistry to report clinical productivity, during fiscal year 2003. The CDT-3 is set up in a five-digit alphanumeric system that identifies procedures and services. The categories are: 1) Diagnostic D0100-D0999, 2) Preventive D1000-D1999, 3) Restorative D2000-D2999, 4) Endodontics D3000-D3999, 5) Periodontics D4000-D4999, 6) Prosthodontics removable D5000-D5899, 7) Maxillofacial Prosthetics D5900-D5999, 8) Implant Services D6000-D6199, 9) Prosthodontics fixed D6200-D6999, 10) Oral Surgery D7000-D7999, 11) Orthodontics D8000-D8999, and Adjunctive General Services D9000-D9999. In this analysis Prosthodontics removable codes, Maxillofacial Prosthetics codes, Prosthodontics fixed codes and Restorative codes D2410-D2980, were combined into one category, Prosthodontics (Pros). Figure 9 shows the percentage of FY03 DWV production by each of these categories, comparing the productivity mix of personnel assigned to the Pentagon Clinic with that of all DoD dental clinics. Higher percentages of the Pentagon clinic DWVs were for Implants, Prosthodontics, and Periodontics compared to all DoD dental clinics. Lower percentages of the Pentagon clinic DWVs were for Oral Surgery, Orthodontics, and Adjunctive General Services compared to all DoD dental clinics. 13

15. Navy (FY02) Army (FY03) Air Force (FY02) Annual Number of D0120 – Periodic Exams 528,347453,084370,727 Active Duty Population Supported 558,006495,146370,362 Ratio of Periodic Exams to AD Member Supported 0.950.921.00 14 Gross Estimate of Population Receiving Dental Care at the Pentagon Dental Clinic (Based on Treatment Provided) The DAB expressed difficulty in reliably determining the size of the population supported by the Pentagon Dental Clinic (PTDC). Since the military has an annual examination requirement, this gross analysis estimates the population supported based on the number of periodic (annual) exams provided by the Pentagon Dental Clinic during a full year. Table 5 shows the annual number of Periodic Exams (D0120) completed by Navy and Air Force Dentistry during FY02, and Army Dentistry during FY03. Also, shown in Table 5 is the active duty population for each service as of 31 July 2003 taken from the Defense Manpower Data Center website. The ratio of Periodic Exam to active duty service member is approximately one for each service. Due to the consistency of this ratio we can estimate the population supported by the Pentagon Dental Clinic to be roughly 13,236. (11,860 Periodic Exams completed in the past year plus an additional 11.6% to adjust for the difference in Class 4 percentage between the PTDC patients and all DoD active duty patients). We found 10,166 patient records at the PTDC indicating approximately 23% of patient records are missing. We recommend data sources showing approximately this number personnel supported most likely reflect the effective population receiving care at the PTDC. Table 5

16. Summary of Findings Compared to all active duty military personnel, those personnel supported by the Pentagon Dental Clinic (PTDC) are more senior in rank. Records held by the PTDC are 42.1% Army, 32.3% Navy/Marine Corps, and 25.6% Air Force. The DoD Dental Class 4 rate is 21.9% among active duty military supported by the PTDC compared to a 10.3% Class 4 rate among all DoD active duty personnel. Compared to all active duty military personnel, those personnel supported by the Pentagon Dental Clinic (PTDC) have significantly less unmet dental treatment need (i.e. treatment planned but care not yet provided). The PTDC produces approximately 109,000 Dental Weighted Values (DWV) per year. The following can be said about the mix of dental procedures provided: Compared to the mix of treatment provided by all DoD dental clinics combined, the PTDC provides higher percentages of dental implant, prosthodontic, and periodontic treatment. Compared to the mix of treatment provided by all DoD dental clinics combined, the PTDC provides a lower percentage of oral surgery, orthodontic, and adjunctive general services. Based on number of annual exams provided, the PTDC effectively provides dental care to an estimated 13,236 patients, and holds the dental records of approximately 10,166. Supply costs when estimated at $5.69 per DWV per year would equal approximately: 109,000 X $5.69 = $620,210 per year 15