1. Oral Health Status and Treatment Needs of the Air Force Reserve Component Susan W. Mongeau, Lt Col, USAF, DC Andrew K. York, CAPT, DC, USN David L. Moss, LTC, USA, DC Gary C. Martin, 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 Background2 Methods2 Study Sample3 Oral Health Status by DoD Dental Classification3 Operative Treatment Needs4-6 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 Department of Defense Oral Health and Readiness Standards18-19 (Appendix A) 1

3. Background Prior to this study, the dental treatment need among Air Force Reserve Component (RC) airmen 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, Air Force Office of the Assistant Surgeon General for Dental Services 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 Upon initial access to Air Force dental treatment facilities reservist dental records are reviewed. This review determines whether or not a dental examination is required, based upon the individual’s DoD Dental Classification, Appendix A. The results of the patient dental examination is recorded using the Standard Form 603/603A. All dental facilities were tasked to send TSCOHS a copy of the most recent SF603/603A from the dental record of each reservist receiving care at their facility. If a new dental examination was performed, a copy of that new SF603/603A was collected. If a new dental examination was not required, a copy of the most recent SF603/603A in the patient’s record was collected. All data was received by TSCOHS via US mail in postage paid, pre-addressed envelopes. 2. Computer Data Entry / Analysis TSCOHS dental personnel manually transferred the treatment needs for over 2,000 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. 2

4. 3. Study Sample The six month data collection period ran from January through August 2002. TSCOHS received 2,135 records from 44 Air Force dental treatment facilities (DTF). Following exclusion of 69 incomplete records, the remaining sample size was 2,066 records. This represented an estimated 16% of all Air Force reservists mobilized during the study period. The representative strength of this large 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. 3 [ ] Margin of Error = 1.96*SE Oral Health Status by DoD Dental Classification Figure 1 shows the DoD dental classification distribution of Air Force reservists. There are no Class 4 reservists since those who had not received a dental examination within 12 months were reexamined at inprocessing.

5. Operative Treatment Needs Air Force reservists require 1020 operative restorations per 1000 reservists, 10% of which are class 3, Figure 2. A comparison of figure 3 with figure 2 shows that the average class 3 restoration involves 2.7 surfaces. [ ] 95% CI 4

6. Operative Treatment Needs Less than one-half of Air Force reservists require operative treatment. 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

7. Operative Treatment Needs Nearly half of all restorations required are one surface, and more than one-third are two surface restorations, Figures 6. 6

8. Oral Surgery (Extraction) Treatment Needs Figure 7 shows extraction needs by dental classification. Approximately 45% of all extractions are Class 3. [ ] 95% CI 7

9. Oral Surgery (Extraction) Treatment Needs Only 8.1% of Air Force reservists require a tooth extraction, Figure 8. Class 3 extraction needs are limited to 3.9% of Air Force reservists, Figure 9. [ ] Margin of Error = 1.96*SE 8

10. Endodontic Treatment Needs Approximately two-thirds of endodontic treatment required is on molar teeth, Figure 10. [ ] 95% CI 9

11. Endodontic Treatment Needs Only 0.6% of Air Force reservists require more than one endodontic treatment, Figure 11. [ ] Margin of Error = 1.96*SE 10

12. Prosthodontic Treatment Needs [ ] 95% CI 11

13. Prosthodontic Treatment Needs The requirement for fixed prosthodontic care is confined to less than 5% of Air Force reservists, Figure 13. [ ] Margin of Error = 1.96*SE 12

14. 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). Figure 14 shows approximately 30% of Air Force reservists had higher levels of periodontal disease as indicated by PSR scores of 3 and 4. [ ] Margin of Error = 1.96*SE 13

15. Periodontic Treatment Needs [ ] Margin of Error = 1.96*SE 14 Nearly 85% of Air Force reservists required a dental cleaning and of those, less than 8% required the expertise of a hygienist or periodontal therapist, Figure 15. Among Class 2 Air Force reservists almost half (46%) required a dental prophylaxis as their only dental treatment need.

16. 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 Air Force reservists 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 a 1000 airmen reserve component mobilization. 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), Appendix A. Over 72% of RC airmen mobilized had not had a dental examination in 12 months (did not have a current exam and bitewing radiographs) and since this is required treatment, it is included in the Class 3 costs. This study did not capture the number of panoramic radiographs required. Data from a simultaneous sub-study of 300 reservists mobilized at Navy Dental Center (NDC) Great Lakes found 75% needed a new panoramic radiograph to be in compliance with dental and forensic requirements. Therefore, if the Air Force reservists are similar, for every 1000 reservists mobilized 750 would require a panoramic radiograph (0.70 DWV). This would add 750 x 0.70 x $100 = $52,500 to the cost estimates provided in Table 1. Based on the mean number of DWV needed, the civilian cost to move a Class 3 reservist to Class 2 is $467. Another $1,005 worth of care would be required to move this reservist to Class 1(oral health). For the average Class 2 reservist, a mean of $476 worth of care would be needed to reach Class 1. Only 2.7% of Air Force reservists required no dental treatment. 15

17. Table 1. DWV Associated With Providing Required Treatment by Procedure Type (Per 1000 Mobilized Air Force Reservists) Procedure TypeClass 2 DWVsClass 3 DWVsTotal DWVs Exam/Bitewings (Class 4s only) n/a404 Operative860120980 Oral Surgery (Extractions) 150110260 Endodonticsn/a250 Prosthodontics58075655 Periodontics31003403440 TOTAL DWVs (Civilian Cost) 4690 ($469,000) 1299 ($129,900) 5989 ($598,900) 16

18. Dental Treatment Needs Expressed As Dental Weighted Values (DWV) Nearly half of Air Force Class 2 reservists and nearly four percent of Air Force Class 3 reservists require less than $200 of dental treatment, while approximately five percent of Air Force Class 2 reservists and almost one-quarter of Air Force Class 3 reservists require more than $2,000 of dental care. * Based on Dental Weighted Values 17

19. 18 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

20. 3.Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months. a)Acute gingivitis or pericoronitis. 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