1. 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

2. 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

3. 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

4. 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 95-03. 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. 2003 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

5. 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 2003. 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 E11345.6%19,6284.0% E239116.3%30,2486.1% E332313.5%62,17912.6% E451621.5%119,24224.2% E540016.7%74,55315.1% E62209.2%56,64411.5% E71124.7%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% TOTAL2400100%493,563100% GENDERSAMPLE POPULATION SAMPLE PERCENT ARMY POPULATION ARMY PERCENT MALE208787.0%418,54184.8% FEMALE31313.0%75,02215.2% TOTAL2400100%493,563100% Table 2 Table 1 3 Methods

6. 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 2003. 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% E21174.9%12,1243.3% E338015.8%57,96315.6% E42289.5%52,57114.2% E551121.3%75,80620.4% E629212.2%46,00012.4% E72179.0%30,3628.2% E8321.3%5,7181.5% E9200.8%2,8570.8% O1723.0%10,5352.8% O2893.7%9,5612.6% O31948.1%22,6426.1% O41054.4%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% TOTAL2399100%370,945100% GENDERSAMPLE POPULATION SAMPLE PERCENT AIR FORCE POPULATION AIR FORCE PERCENT MALE187878.3%298,24080.3% FEMALE52121.7%72,70519.6% TOTAL2399100%370,945100% Table 4 Table 3 4 Methods

7. 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 1994. 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 1994. [ ] 95% CI 5

8. None1 to 34 to 67+Mean E1-E448.929.713.57.91.880 E5-E658.927.210.43.51.274 E7-E972.122.64.21.10.652 O1-O376.516.56.10.90.622 O4-O872.716.93.96.51.048 ALL56.926.310.36.51.404 95% CI [54.9-58.9][24.5-28.1][9.1-11.5][5.5-7.5][1.442-1.646] None1 to 34 to 67+Mean E1-E437.040.813.88.42.164 E5-E640.944.610.44.21.589 E7-E947.445.55.31.71.103 O1-O354.438.05.71.90.992 O4-O861.635.31.81.20.794 ALL41.142.111.05.81.767 95% CI [39.6-42.6][40.6-43.6][10.1-11.9][5.1-6.5][1.695-1.839] Table 5: Army Restorative Treatment Needs (Fillings) in 1994 and 2003 (Percent Distribution and Mean) 2003 1994 6

9. None1 to 34 to 67+Mean E1-E478.714.84.71.70.615 E5-E684.713.61.30.40.309 E7-E988.310.71.10.00.184 O1-O392.46.30.7 0.181 O4-O892.76.90.50.00.127 ALL84.612.32.30.80.367 95% CI [83.2-86.0][11.0-13.6][1.7-2.9][0.4-1.2][0.317-0.417] None1 to 34 to 67+Mean E1-E454.333.78.43.51.288 E5-E656.432.67.83.21.188 E7-E954.932.28.84.01.278 O1-O376.719.42.61.30.506 O4-O868.425.25.11.20.739 ALL59.230.67.23.01.105 95% CI [57.8-60.6][29.3-31.9][6.5-7.9][2.5-3.5][1.050-1.160] Table 6: Air Force Restorative Treatment Needs (Fillings) in 1994 and 2003 (Percent Distribution and Mean) 2003 1994 7

10. None1 to 34 to 67+Mean E1-E470.220.07.62.10.759 E5-E679.615.24.20.90.448 E7-E979.315.64.20.90.443 O1-O385.411.72.50.40.277 O4-O886.811.21.80.30.237 ALL76.217.05.51.40.561 None1 to 34 to 67+Mean E1-E463.228.46.02.40.953 E5-E669.327.32.60.80.601 E7-E967.329.02.31.40.634 O1-O380.319.20.50.00.264 O4-O886.912.70.20.10.180 ALL67.527.04.01.50.725 95% CI [66.0-69.0][25.6-28.4][3.4-4.6][1.1-1.9][0.670-0.780] 2003 1994 Table 7: Navy/Marine Corps Restorative Treatment Needs (Fillings) in 1994 and 2003 (Percent Distribution and Mean) 8

11. [ ] 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 2003. 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.

12. None1 or 23 or 45+Mean E1-E467.212.520.00.30.978 E5-E684.77.67.40.30.424 E7-E990.15.84.20.00.253 O1-O391.23.55.30.00.241 O4-O894.71.33.90.00.194 ALL78.49.012.40.20.630 95% CI [76.8-80.0][7.9-10.1][11.1-13.7][0.0-0.4][0.560-0.700] None1 or 23 or 45+Mean E1-E462.018.119.60.31.034 E5-E680.911.87.10.20.437 E7-E984.512.22.30.90.341 O1-O378.811.99.30.00.520 O4-O895.93.60.60.00.586 ALL71.715.013.00.30.731 95% CI [70.4-73.0][13.9-16.1][12.0-14.0][0.1-0.5][0.690-0.772] 2003 1994 Table 8: Army Extraction Treatment Needs in 1994 and 2003 (Percent Distribution and Mean) 10

13. None1 or 23 or 45+Mean E1-E489.62.37.60.50.349 E5-E698.40.80.90.00.044 E7-E999.30.70.0 0.012 O1-O397.31.01.70.00.080 O4-O8100.00.0 0.000 ALL95.61.23.00.20.143 95% CI [94.8-96.4][0.8-1.6][2.3-3.7][0.0-0.4][0.115-0.171] None1 or 23 or 45+Mean E1-E478.07.114.50.30.680 E5-E692.04.63.40.10.196 E7-E994.44.21.30.00.097 O1-O393.42.54.10.00.192 O4-O896.72.30.60.40.085 ALL87.65.07.20.20.358 95% CI [86.7-88.5][4.4-5.6][6.5-7.9][0.1-0.3][0.329-0.387] 2003 1994 Table 9: Air Force Extraction Treatment Needs in 1994 and 2003 (Percent Distribution and Mean) 11

14. None1 or 23 or 45+Mean E1-E484.17.97.70.20.435 E5-E694.03.82.20.10.142 E7-E991.64.24.10.10.227 O1-O394.82.82.40.00.141 O4-O897.71.70.60.00.047 ALL89.65.54.80.10.275 None1 or 23 or 45+Mean E1-E479.412.58.00.10.500 E5-E691.96.51.50.10.146 E7-E997.22.20.60.00.049 O1-O396.33.50.20.00.054 O4-O897.62.40.0 0.024 ALL87.08.64.30.10.292 95% CI [85.9-88.1][7.7-9.5][3.7-4.9][0.0-0.2][0.267-0.317] 2003 1994 Table 10: Navy/Marine Corps Extraction Treatment Needs in 1994 and 2003 (Percent Distribution and Mean) 12

15. [ ] 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 11-13 show the distribution of endodontic need among the Army, Air Force, and Navy/Marine Corps personnel respectively.

16. AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E40.30.20.80.0030.0010.0100.014 E5-E60.50.3 0.0100.0020.0030.015 E7-E90.0 0.50.000 0.003 O1-O30.0 0.90.000 0.005 O4-O80.60.0 0.0210.000 0.021 ALL0.40.10.60.0050.0010.0060.012 95% CI [0.1-0.7][0.0-0.2][0.3-0.9][0.000-0.011][0.000-0.003][0.001-0.011][0.004-0.020] AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E41.60.82.10.0190.0100.0300.059 E5-E61.30.92.40.0150.0100.0270.052 E7-E92.00.62.10.0240.0060.0260.056 O1-O30.60.02.50.0060.0000.0330.039 O4-O80.70.00.30.0070.0000.0030.010 ALL1.50.72.50.0170.0080.0290.054 95% CI [1.1-1.9][0.5-0.9][2.0-3.0][0.012-0.022][0.005-0.011][0.023-0.035][0.046-0.062] Table 11: Army Endodontic Treatment Needs (Percent Needing Endodontics and Mean Number Needed) 2003 1994 % Needing at Least OneMean Endodontics Needed % Needing at Least OneMean Endodontics Needed 14

17. AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E40.60.00.50.0090.0000.0040.013 E5-E60.00.10.20.0000.0010.0030.004 E7-E90.0 0.40.000 0.004 O1-O30.30.00.30.0030.0000.0030.006 O4-O80.00.9 0.0000.0080.0160.024 ALL0.20.10.40.0030.0010.0040.008 95% CI [0.0-0.4][0.0-0.2][0.1-0.7][0.000-0.006][0.000-0.002][0.001-0.007][0.003-0.013] AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E40.3 1.20.0050.0030.0160.024 E5-E60.60.91.60.0090.0060.0190.034 E7-E90.6 1.60.0080.0060.0200.034 O1-O30.30.00.50.0030.0000.0050.008 O4-O80.0 1.20.000 0.012 ALL0.40.31.20.0060.0030.0150.024 95% CI [0.2-0.6][0.1-0.5][0.9-1.5][0.003-0.009][0.001-0.005][0.010-0.020][0.018-0.030] Table 12: Air Force Endodontic Treatment Needs (Percent Needing Endo. and Mean Number Needed) 2003 1994 % Needing at Least OneMean Endodontics Needed % Needing at Least OneMean Endodontics Needed 15

18. AnteriorPosteriorAnteriorPremolarMolarTotal E1-E40.50.70.0060.0020.0060.014 E5-E60.60.80.0070.0020.0080.017 E7-E90.60.90.0080.0020.0090.019 O1-O30.40.50.0050.0010.0050.011 O4-O80.40.80.0050.0020.0080.015 ALL0.50.80.0060.0020.0070.015 AnteriorPremolarMolarAnteriorPremolarMolarTotal E1-E40.30.61.90.0040.0060.0210.031 E5-E60.80.42.10.0100.0040.0250.039 E7-E90.90.74.10.0130.0070.0410.061 O1-O30.00.3 0.0000.003 0.006 O4-O80.00.20.10.0000.0020.0010.003 ALL0.5 2.00.0070.0050.0230.035 95% CI [0.3-0.7] [1.6-2.4][0.004-0.010][0.002-0.008][0.018-0.028][0.027-0.043] Table 13: Navy / Marine Corps Endodontic Treatment Needs (Percent Needing Endo. and Mean Number Needed) 2003 1994 % Needing at Least OneMean Endodontics Needed % Needing at Least OneMean Endodontics Needed 16

19. 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 14-16 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 1994. [ ] 95% CI 17

20. None1 or 23 to 67+Mean E1-E491.66.31.40.60.194 E5-E685.39.05.20.50.370 E7-E980.511.66.81.10.549 O1-O388.68.82.60.00.207 O4-O881.811.76.50.00.392 ALL87.78.23.50.60.301 95% CI [86.4-89.0][7.1-9.3][2.8-4.2][0.3-0.9][0.237-0.365] None1 or 23 to 67+Mean E1-E479.816.04.00.20.374 E5-E666.924.68.10.40.664 E7-E966.524.28.60.80.728 O1-O384.813.71.10.30.220 O4-O877.418.43.50.70.440 ALL75.019.25.40.30.485 95% CI [73.7-76.3][18.0-20.4][4.7-6.1][0.1-0.5][0.452-0.518] Table 14: Army Fixed Prosthodontic Treatment Needs (Units) (Percent Distribution and Mean) 2003 1994 18

21. None1 or 23 to 67+Mean E1-E497.81.50.70.00.039 E5-E697.71.60.50.10.048 E7-E995.42.81.80.00.111 O1-O396.72.70.70.00.052 O4-O895.03.21.80.00.090 ALL97.22.00.80.00.056 95% CI [96.5-97.9][1.4-2.6][0.4-1.2][0.0-0.0][0.040-0.072] None1 or 23 to 67+Mean E1-E483.412.13.60.90.391 E5-E678.513.55.92.00.656 E7-E973.414.58.83.30.878 O1-O392.26.11.50.20.148 O4-O883.512.02.61.90.521 ALL82.111.94.51.50.498 95% CI [81.0-83.2][11.0-12.8][3.9-5.1][1.2-1.8][0.453-0.543] Table 15: Air Force Fixed Prosthodontic Treatment Needs (Units) (Percent Distribution and Mean) 2003 1994 19

22. None1 or 23 to 67+Mean E1-E493.05.91.10.10.118 E5-E690.67.71.60.10.161 E7-E988.69.32.00.10.198 O1-O394.54.80.70.10.086 O4-O889.88.71.40.10.167 ALL91.67.01.40.10.143 None1 or 23 to 67+Mean E1-E484.313.81.60.30.265 E5-E678.016.64.80.50.454 E7-E968.120.69.32.00.797 O1-O391.58.10.40.00.117 O4-O882.515.91.60.10.254 ALL81.115.13.40.50.369 95% CI [79.9-82.3][14.0-16.2][2.8-4.0][0.3-0.7][0.332-0.406] Table 16: Navy / Marine Corps Fixed Prosthodontic Treatment Needs (Units) (Percent Distribution and Mean) 2003 1994 20

23. 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 17-19 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 1994. 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

24. CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E43.823.454.614.93.3 E5-E64.323.851.415.15.4 E7-E91.332.541.320.05.0 O1-O31.832.148.212.55.4 O4-O80.018.260.615.26.1 ALL3.324.952.115.44.3 95% CI [2.6-4.0][23.2-26.6][50.1-54.1][14.0-16.8][3.5-5.1] CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E48.24.334.945.96.7 E5-E66.82.125.248.517.3 E7-E911.91.522.538.725.3 O1-O315.77.541.032.73.1 O4-O812.72.826.753.83.9 ALL8.93.631.144.811.5 95% CI [8.1-9.7][3.0-4.2][29.7-32.5][43.3-46.3][10.6-12.4] 2003 1994 Table 17: Army Periodontal Screening and Recording (PSR) Distribution 22

25. CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E40.915.471.411.50.9 E5-E60.517.658.515.67.8 E7-E90.018.535.227.818.5 O1-O34.426.558.87.42.9 O4-O85.318.457.913.25.3 ALL1.417.961.314.05.4 95% CI [0.9-1.9][16.4-19.4][59.4-63.2][12.6-15.4][4.5-6.3] CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E47.811.535.642.52.7 E5-E66.27.527.349.29.8 E7-E99.55.720.448.815.7 O1-O313.012.937.534.61.9 O4-O810.74.729.449.85.4 ALL8.49.431.244.56.4 95% CI [7.6-9.2][8.6-10.2][29.9-32.5][43.1-45.9][5.7-7.1] 2003 1994 Table 18: Air Force Periodontal Screening and Recording (PSR) Distribution 23

26. CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E419.714.044.319.82.3 E5-E622.211.836.823.45.7 E7-E918.811.836.525.17.6 O1-O320.819.641.815.91.9 O4-O815.715.542.621.64.6 ALL20.313.440.621.54.2 CODE 0CODE 1CODE 2CODE 3CODE 4 E1-E47.07.533.247.34.9 E5-E610.65.518.851.014.2 E7-E910.56.216.242.524.6 O1-O322.36.335.832.63.1 O4-O820.66.324.943.94.3 ALL10.06.626.647.09.8 95% CI [9.0-11.0][5.8-7.4][25.2-28.0][45.4-48.6][8.9-10.7] 2003 1994 19: Navy / Marine Corps Periodontal Screening and Recording (PSR) Distribution 24

27. 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 2003. 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 2003.  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 2003. 25