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
Table of Contents
Background
2
Methods
2
Study Sample
3
Oral Health Status by DoD Dental Classification
3
Operative Treatment Needs
4-6
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
Department of Defense Oral Health and Readiness Standards
18-19 (Appendix A)
1
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
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.
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.
Figure 1. Dental Class Distribution After Inprocessing Exam
100
77.2
[1.8]
Percent
80
60
40
20
9.0
13.8
[1.2]
[1.5]
0
[ ] Margin of Error = 1.96*SE
Class 1
Class 2
Class 3
3
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.
Figure 2. Number of Teeth Requiring Restoration
(Per 1000 Reservists)
1500
1000
915
1020
[839-991]
[936-1104]
105
500
[81-129]
0
[ ] 95% CI
Class 2
Class 3
Total
Figure 3. Number of Tooth Surfaces Requiring Restoration
(Per 1000 Reservists)
2500
2000
1500
1000
500
0
1880
[1723-2037]
1600
[1468-1732]
280
[219-341]
[ ] 95% CI
Class 2
Class 3
Total
4
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.
Percent
Figure 4. Distribution of Operative Treatment Needs
100
80
60
40
20
0
57.6
[2.1]
34.2
[2.0]
5.8
[1.0]
2.4
[0.7]
[ ] Margin of Error = 1.96*SE
None
1 to 3
4 to 6
7 or more
Figure 5. Distribution of Class 3 Operative Treatment Needs
Percent
93.5
100
80
60
40
20
0
[1.1]
6.2
0.1
[1.0]
[0.1]
0.1
[0.1]
[ ] Margin of Error = 1.96*SE
None
1 to 3
4 to 6
7 or more
5
Operative Treatment Needs
Nearly half of all restorations required are one surface, and more than one-third are two surface
restorations, Figures 6.
Figure 6. Restorations Required by Number of Surfaces
4 or More
Surfaces
8%
3 Surface
12%
1 Surface
44%
2 Surface
36%
6
Oral Surgery (Extraction) Treatment Needs
Figure 7 shows extraction needs by dental classification. Approximately 45% of all extractions are
Class 3.
Figure 7. Number of Required Tooth Extractions by Dental Class
(Per 1000 Reservists)
250
204
[169-239]
200
150
113
[87-139]
91
[68-114]
100
50
0
[ ] 95% CI
Total CL2
Total CL3
Total
7
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.
Figure 8. Distribution of Tooth Extraction Needs
91.9
100
[1.2]
Percent
80
60
40
20
4.9
2.9
0.3
[0.9]
[0.7]
[0.2]
1 to 2
3 to 4
0
[ ] Margin of Error = 1.96*SE
None
5 or more
Figure 9. Distribution of Class 3 Tooth Extraction Needs
96.1
[0.8]
100
Percent
80
60
40
20
2.8
0.9
0.2
[0.7]
[0.4]
[0.2]
0
[ ] Margin of Error = 1.96*SE
None
1 to 2
3 to 4
5 or more
8
Endodontic Treatment Needs
Approximately two-thirds of endodontic treatment required is on molar teeth, Figure 10.
Figure 10. Number of Required Endodontic Procedures
(Per 1000 Reservists)
50
45
40
35
30
25
20
15
10
5
0
44
[33-55]
28
[20-36]
11
5
[6-16]
[2-8]
[ ] 95% CI
Anterior
Premolar
Molar
Total
9
Endodontic Treatment Needs
Only 0.6% of Air Force reservists require more than one endodontic treatment , Figure 11.
Figure 11. Distribution of Endodontic Treatment Needs
96.4
100
[0.8]
Percent
80
60
40
20
3.0
0.5
.1
[0.7]
[0.3]
[.1]
0
0
[ ] Margin of Error = 1.96*SE
None
1
2
3
>3
10
Prosthodontic Treatment Needs
Figure 12. Number of Required Prosthodontic Procedures
(Per 1000 Reservists)
150
100
85
[63-106]
50
5
[2-8]
0
[ ] 95% CI
Fixed Units
RPDs
11
Prosthodontic Treatment Needs
The requirement for fixed prosthodontic care is confined to less than 5% of Air Force reservists,
Figure 13.
Figure 13. Distribution of Fixed Prosthetic Units Required
95.4
100
[0.9]
Percent
80
60
40
20
3.6
0.8
0.2
[0.8]
[0.4]
[0.2]
1 to 2
3 to 4
0
[ ] Margin of Error = 1.96*SE
None
5 or more
12
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.
Figure 14. Distribution of Periodontal Screening and Recording (PSR) Score
100
Percent
80
44.5
60
[2.1]
40
20
19.0
19.9
[1.7]
[1.7]
6.3
10.3
[1.0]
[1.3]
0
[ ] Margin of Error = 1.96*SE
PSR 0
PSR 1
PSR 2
PSR 3
PSR 4
13
Periodontic Treatment Needs
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.
Figure 15. Percent of Air Force Reservists Requiring a Dental Cleaning
100
Percent
80
84.7
78.1
[1.6]
[1.8]
60
40
6.6
20
[1.1]
0
[ ] Margin of Error = 1.96*SE
Dental Tech
RDH
Total
14
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
Table 1. DWV Associated With Providing Required Treatment by Procedure Type
(Per 1000 Mobilized Air Force Reservists)
Procedure Type
Class 2 DWVs
Class 3 DWVs
Total DWVs
Exam/Bitewings
(Class 4s only)
n/a
404
404
Operative
860
120
980
Oral Surgery
(Extractions)
150
110
260
Endodontics
n/a
250
250
Prosthodontics
580
75
655
Periodontics
3100
340
3440
TOTAL DWVs
(Civilian Cost)
4690
($469,000)
1299
($129,900)
5989
($598,900)
16
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.
Figure 16. Distribution of Cost* of Treatment Needed
60
Percent
50
45.5
40
30
23.6
22.5
20
10.9
10
12.2 13.7
5.4
12.3
9.9
4.9
3.4
600-799
800-999
7
2.4
6.3
1.4
0.8
4.9
0.7
3.2
1.6 2.8
4.6
0
<200
200-399
400-599
1000-1199 1200-1399 1400-1599 1600-1799 1800-1999
>2000
Dollars
Air Force Class 2 Reservists
Air Force Class 3 Reservists
* Based on Dental Weighted Values
17
Appendix A
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.
2.
Treatment or follow-up indicated for dental caries or minor defective restorations
that can be maintained by the patient.
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.
18
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