January – March 2011 

Perspectives 1

MG David A. Rubenstein; COL Mustapha Debboun; Richard Burton 

The US Army Dental Corps: 100 Years Old and Better Than Ever 6

MG M. Ted Wong 

Highlights in the History of Army Dentistry 8

COL Samuel A. Passo; COL (Ret) John E. King 

CAD/CAM Dentistry for Today’s On-The-Go Military 26

COL Jeffrey A. Hodd 

Is the US Army Dental Corps Ready for the Digital Impression? 38 

COL Michael R. Craddock; COL Richard J. Windhorn

Ten-Month In Vitro Leakage Study of a Single-Cone Obturation System 42 

LTC A. John McKissock; COL Pete Mines; COL Mark B. Sweet; Col Steven L. Klyn, USAF 

US Army Dental Command Information Management: 48

Poised to Provide Quality Support for the Next 100 Years

LTC Jeffrey S. Marks; MAJ Thomas E. Strohmeyer 

Use of the Army Dental Command Corporate Dental Application as an 51 

Electronic Dental Record in the Iraq Theater of Operations 

COL Steven Eikenberg; MAJ Robert Keeler; SFC Thomas Green 

Dental Readiness of Army Reserve Components: A Historical Review, Part Two 58 

COL Mark B. Bodenheim 

The 2008 Army Recruit Oral Health Survey Results 62

COL David L. Moss 

The US Army Dental and Trauma Research Detachment: 68 

Now Part of the Army Institute of Surgical Research 

MAJ Davin E. Mellus; Jacqueline Amaya 

Clinical and Electrodiagnostic Abnormalities of the Median Nerve in US Army 70 

Dental Assistants Before and After Training as Preventive Dental Specialists 

David G. Greathouse, PhD; et al 

Palatal Fracture in a Child 82

COL Karen M. Keith; CPT Tyler L. Clark 

Pyogenic Granuloma Occurring in a Postmenopausal Woman on 86 

Hormone Replacement Therapy 

MAJ Thomas M. Johnson; et al 

An Aggressive Benign Cementoblastoma 91

COL (Ret) Richard E. Collins; Rafael Flores Asturias, MD 

Dental Rehabilitation of a Patient with Dentinogensis Imperfecta: A Clinical Report 95

COL David A. Mott; COL Minaxi I. Patel; LTC Dong Soo Park 

Solid Ameloblastoma, Resection to Reconstruction: A Case Report 98

MAJ Michael J. Ryhn; COL Jeffrey S. Almony; COL Albert M. Manganaro 

The United States Army Dental Corps 

A century of commitment, service, and care 
LTG Eric B. Schoomaker 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center and 

School 

January – March 2011 The Army Medical Department Center & School PB 8-11-1/2/3 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1 

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JOYCE E. MORROW 
 January – March 2011 1

EDITORS’ PERSPECTIVE

As mentioned by MG Rubenstein above, this special 

issue of the AMEDD Journal opens with a commentary by MG Ted Wong, the Chief of the Army Dental 

Corps. He proudly introduces us to his Corps with an 

overview of the past and present, and insight to the 

broad range of skills and capabilities of the men and 

women dedicated to the dental health and readiness of 

today’s Soldiers. 

COL Samuel Passo and COL (Ret) John King have 

contributed an abridged, updated version of their 

Dental Corps pamphlet, Highlights in the History of 

Army Dentistry. This is an excellent, chronological 

collection of snapshots of the events and people 

involved in the evolution of dental services for military 

personnel. It is an informative, revealing look at not 

only the advances in technology and education which 

drove the progress of dental science, but also how the 

influences of politics, economy, and social norms 

affected various aspects of the development of the 

dental care structure within the Army. 

COL Jeffrey Hodd’s article quickly brings us to the 

cutting edge of the practice of modern dentistry. He 

describes the adaptation of computer-aided design and 

computer-aided manufacturing technology into the 

process of tooth restoration. He focuses on the 

evolution and application of one of the currently 

available systems in use at some Army dental 

facilities. His clear, technically detailed article clearly 

describes the capabilities of the system and how it is 

used to create a finished restoration component, such 

as a crown, at the dental clinic during a single patient 

visit. This is in contrast to the normal process of the 

Perspectives Perspectives

This special issue of the AMEDD Journal celebrates 

an event that is truly significant, not only for the milestone itself, but also for what it represents for the 

Army Medical Department as an institution. On March 3, 

1911, President Howard Taft signed legislation 

creating the United States Army Dental Corps as a 

permanent corps of the Army Medical Department, 

thus establishing the profession of dentistry as the third 

essential element, along with physicians and nurses, in 

maintaining a healthy, effective fighting force. Now, 

100 years later, the Army Dental Corps has grown 

from a specified, limited niche in Army medicine to a 

corps of medical professionals, not only highly skilled 

in all aspects of oral healthcare, but also contributing 

as full partners in diverse responsibilities throughout 

the entire spectrum of today’s Army Medical Department, including research, training, planning, and 

command. Army dental officers are also serving in a 

variety of assignments and positions across the Department of Defense, representing both their profession 

and Army medicine with pride and distinction. 

I congratulate the Army Dental Corps for 100 years of 

devoted service to our Nation and am proud to have 

the opportunity to present this centennial tribute. This 

issue of the AMEDD Journal was scheduled and created especially for this occasion, and I know you will 

find its contents both informative and truly impressive. 

It recognizes the splendid past of Army dental care, 

and provides examples of the current state of science 

practiced by today’s Army Dental Corps. The breadth 

and scope of the capabilities of Army dental professsionals, both past and present, are shown with clarity 

and detail. The reader will fully understand their indispensable role in accomplishing and maintaining the 

superior level of total healthcare provided to today’s 

American Warrior, wherever he or she may serve. 

I warmly welcome the Chief of the Army Dental 

Corps, MG Ted Wong, to this special publication. His 

opening article conveys the pride and dedication demonstrated daily by not only the men and women of the 

Dental Corps, but the other dental professionals working with them throughout the Army Dental Care System. I join MG Wong in calling for all military medical professionals to celebrate this milestone, not only 

for what it represents today, but also as the starting 

point for another century of continued growth and 

excellence dedicated to the overall health and wellbeing of our gallant Warfighters.

COMMANDER’S INTRODUCTION

MG David A. Rubenstein 
2 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Perspectives 

use of a latex molding material to create an impression 

of the patient’s teeth, from which a ceramic cast is 

created, which is then sent to a laboratory, usually 

geographically distant, where a crown or other 

restoration item is constructed and sent to the dental 

clinic. Of course, this process involves multiple steps, 

several days, and at least 2 patient visits over a period 

of time. The system described in COL Hodd’s article 

eliminates all the interim steps. In the hands of a 

skilled dental staff, it generates a digital map of the 

teeth patient’s, designs the crown for restoration, and 

constructs that crown, which the dentist then puts into 

place. The article contains 2 illustrated case studies 

which clearly demonstrate this advanced capability. 

Another approach to the use of digital dental 

impressions is described by COL Michael Craddock 

and COL Richard Windhorn. In their article, they 

discuss another system which creates the digital map 

of the patient’s teeth, which is then transmitted 

electronically to the Army Dental Laboratory at Fort 

Gordon, Georgia. Using that digital map, the 

Laboratory creates the cast model of the patient’s 

teeth, and from that creates the restoration crown, 

which is sent to the dental clinic. As is the case 

described in the earlier article, this process eliminates 

all laboratory preparation work by the treating dentist, 

and markedly expedites the process of creating the 

restoration item, but a return visit by the patient is 

required for completion of the restoration. However, 

the tradeoff is a smaller, less expensive suite of equipment at the dental facility, which is an important factor 

for facilities in remote, undeveloped locations, or for 

units which may be called to deploy at any time. 

One of the most critical considerations of the process 

of endodontic, or root canal, treatment is achieving a 

complete seal of the root canal space to prevent later 

bacterial contamination, and resulting infection. LTC 

John McKissock and his team conducted an extended 

(10-month) laboratory study of 2 common products 

used by endodontists to seal the canals to determine if 

either was superior in preventing leakage over time. 

This is an excellent example of a carefully designed 

and documented scientific study which established 

identical procedures and environment for each 

individual sample, included a representative control 

group, and followed precise, controlled evaluation 

methodology for the results. The article by LTC 

McKissock et al is yet another illustration of the extent 

of the knowledge, technical expertise, and initiative 

that is characteristic of today’s military dental 

professionals. 

The benefits and uses of digital technology in 

healthcare seem to be limitless, not only in research 

and direct patient care, but also in areas of support, 

resulting in markedly enhanced productivity. LTC 

Jeffrey Marks and MAJ Thomas Strohmeyer describe 

the evolution of one the most significant of such tools 

in military dental care, the Army Dental Command’s 

Corporate Dental Application (CDA). Originally 

conceived and developed as a standard solution to 

replace an array of locally implemented scheduling 

and workload applications, the flexible, modular 

design of the CDA has allowed adaptation and growth 

into a tool that supports numerous functions at many 

levels of Army dental care. Their article is an excellent 

overview of a true success story—a “home grown” 

enterprise application developed, implemented, and 

maintained by the Dental Command’s own 

Information Management and Technology Division. 

The CDA has been successfully extended far beyond 

its original concept, and continues to be adapted by 

innovative units to assist them in providing the best 

possible dental care, wherever they may be. One such 

significant initiative is the subject of the next article. 

Accurate, current examination and treatment records 

are a necessity for all medical practitioners. The 

Department of Defense has pursued development of a 

standard electronic military medical record for a 

number of years, and a dental record module has been 

a part of that effort. However, to date no satisfactory, 

military-wide application has been fielded. 

Consequently, over time the Dental Command has 

increasingly turned to the existing CDA which, 

although not originally designed to capture treatment 

data, has been modified several times to accommodate 

such use. As described by COL Steven Eikenberg et al 

in their article, during 2 deployments to Iraq, the 

502nd Dental Company Area Support developed 

methodologies and practical protocols to use the CDA 

as their electronic dental record in-theater, with 

excellent results. Their work led to further 

modification of the CDA to improve its utility, as well 

as the development of Army policies and guidelines to 

establish uniformity of the recorded data. This 

excellent article contains the impressive treatment 

encounter and diagnosis data collected by the 502nd 

during their latest deployment. The data clearly 

demonstrates the significant utility and value that this 
 January – March 2011 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

adaptation represents, not only to healthcare in a 

deployed environment, but in potential garrison 

applications as well. 

The extended combat operations since 2001 have 

involved extensive mobilization of Army Reserve and 

Army National Guard units. Similarly to previous 

major activations of Reserve Components, during the 

early years of these mobilizations, a large percentage 

of activated Soldiers were deemed not dentally ready 

for duty. COL Mark Bodenheim addressed this 

situation in the January-March 2006 AMEDD Journal, 

where he described the aggressive actions taken by the 

US government to mitigate the problem. In this issue, 

he provides an update on the implementation of 

programs and electronic records and reporting systems 

which have dramatically improved the readiness of 

reporting Reserve Component Soldiers. His article is 

an eye-opening look at the extensive efforts that were 

involved in coordinating, synchronizing, and 

standardizing the dental reporting systems that existed 

across the 3 Army components. Also, he discusses 

steps taken to support dental care to Reserve 

Component Soldiers outside of alert and activation 

status, a critical element in reducing the extent of 

dental readiness problems upon mobilization. COL 

Bodenheim’s article provides valuable insight into the 

complexities and extent of coordinated work involved 

in contending with this serious aspect of national 

military readiness. 

All military services face a situation similar to that 

described above with regard to their recruit training 

centers. Since new recruits are from the general 

population, their oral health conditions vary 

significantly, reflecting their pre-entry dental health 

care history which is dependent on financial factors, 

availability of care providers, and simple personal 

attention to oral hygiene. As with activated Reserve 

Soldiers, most new recruits require dental work to 

achieve operationally ready condition, and that work 

must be completed before the recruit reaches 

deployable status. Therefore, dental resources must be 

allocated to ensure those in the recruit pipeline receive 

the necessary care as they move through training. As 

part of the planning process, the Department of 

Defense periodically conducts a detailed survey of the 

oral health condition of arriving recruits. COL David 

Moss has provided the portion of that report presenting 

data on the Army’s recruits in 2008. That data is 

compared to data from surveys in 1994 and 2000 to 

illustrate trends (or the lack thereof) and spotlight the 

areas of dental care that commonly require the most 

attention. This article is informative and interesting, 

not only for its application to support of operational 

readiness, but also for its insight into oral health 

conditions among the demographic of the civilian 

population from which the military draws recruits. 

For years the Army Dental and Trauma Research 

Detachment was located at Great Lakes, IL, where it 

performed its mission with great dedication and 

effectiveness, in spite of the seemingly relative 

isolation from other Army medical and dental 

resources. However, in the past year that situation has 

improved dramatically. In their informative article, 

MAJ Davin Mellus and Ms Jacqueline Amaya 

describe the recent relocation of the Detachment to the 

new Battlefield Health and Trauma (BHT) Research 

Institute on the grounds of the Brooke Army Medical 

Center in San Antonio. In conjunction with the 

relocation, the Detachment has also been aligned under 

the Army’s Institute of Surgical Research (ISR), which 

is one of the keystones of the BHT Research Institute, 

along with Navy and Air Force research units. MAJ 

Mellus and Ms Amaya detail how the relocation and 

realignment represent a major milestone in both the 

mission and capabilities of the Detachment. The 

relocation into state-of-the-art facilities provides 

significant opportunities for extensive onsite 

collaboration among top notch researchers in related 

fields. The markedly improved availability of 

resources and the alignment with ISR has allowed the 

Detachment to redefine its mission into areas that until 

now were impractical, or in some cases impossible, for 

them to pursue. For many readers, this article may be 

an introduction to a vitally important component of 

Army healthcare. For others, it presents valuable 

information about the evolution of an invaluable 

resource for information and assistance in the areas of 

craniofacial trauma and infectious dental diseases. 

In discussions of the practice of medicine, one often 

hears the question “who heals the healers?” In Army 

medicine, the answer is simple: we do! In this special 

issue of the AMEDD Journal, we are pleased to 

include an article detailing a research project directed 

specifically at the health and well-being of those in the 

oral health profession who provide patient care. Dr 

David Greathouse and his research team have 

contributed a report on their study evaluating upper-
4 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

extremity musculoskeletal disorders, including carpal 

tunnel syndrome, among experienced Army dental 

assistants as they underwent training to become 

preventive dental specialists. Their research sought to 

determine whether the 12 week intensive training 

course would instigate any physical problems, or 

exacerbate any such problems individuals may have 

had prior to entering the course. This study is one of 

several focused on dental caregivers which has been 

conducted within the Army-Baylor University 

Doctoral Program in Physical Therapy. The report is a 

very thorough, extensively researched and referenced, 

comprehensive presentation of the research team’s 

study project, including detailed data of their results. 

Publication of this excellent report serves 2 important 

purposes; it highlights a potential area of concern for 

dental caregivers as they practice their specialties, and 

it demonstrates the level of professional expertise and 

capability within military medicine which is available 

to our personnel, including the best care for caregivers 

that can be provided. 

This special tribute to the US Army Dental Corps 

closes with 5 clinical reports illustrating the broad 

range of skills and capabilities that is characteristic of 

Army dental professionals. Each of these articles 

presents a different facet of oral care, including fracture repair, total dental rehabilitation, and various 

types of tumor removals, all of which required significant reconstruction of bone structure and tooth replacement. These articles are but a few examples of the excellent work done every day by the dedicated members 

of the US Army Dental Corps and their associated 

dental support personnel in locations worldwide. 

COL Karen Keith and CPT Tyler Clark present a 

somewhat unique case involving a penetrating wound 

to the roof a child’s mouth which included a palatal 

fracture and displacement of the bone up into the nasal 

vestibule. Their article carefully describes the unusual 

circumstances surrounding the injury and the method 

used to repair the damage. They also use the unique 

situation and characteristics of this injury to discuss 

the broader considerations that clinicians should 

understand when presented with an injury of this 

nature. Their detailed literature search produced a 

wealth of information about undiagnosed associated 

injuries, neurologic concerns, and the efficacy of 

various diagnostic techniques. All dental professionals 

should be familiar with the information presented in 

this article because this type of injury is usually one of 

children, and therefore may not be seen by military 

clinicians very often. 

MAJ Thomas Johnson and his coauthors describe a 

case that was diagnosed as a not uncommon benign 

tumor on the gingival tissue, but, on further 

examination, led to a more involved treatment 

protocol. In this interesting case, the tumor was 

associated with a dental implant which itself had been 

positioned incorrectly when inserted. Further, the 

tumor normally develops in women during puberty 

and pregnancy, but this female patient was 

postmenopausal and undergoing hormone replacement 

therapy. The treatment involved removal of the tumor, 

but also removal of the implant, and placement of a 

new implant requiring some restoration of bone tissue. 

The authors performed a literature search to 

investigate the possible relationship of the tumor to the 

hormone replacement therapy. Their findings indicate 

that no locatable research has been conducted on that 

relationship. This is a clearly presented, wellillustrated article that completely documents all 

aspects and considerations of this diagnosis and 

treatment. It should be of interest to all dental 

practitioners who encounter similar tumors among 

women in similar age and therapy circumstances. 

The military healthcare professional rarely ceases to 

apply his or her skill, talents, and knowledge to 

contribute to the health and wellbeing of society after 

leaving active duty for the last time. Such is the case 

with retired COL Richard Collins, who teamed with 

Dr Rafael Flores Asturias to present a case they 

encountered at a volunteer dental clinic in Guatemala. 

They discovered and treated a rare tumor, called 

benign cememtoblastoma. Their literature search 

revealed less than 100 reported cases of this particular 

type of tumor. Complicating the condition was a 

secondary, unusually rapid growing lesion. That rapid 

growth had been stimulated by a previous, fairly 

primitive treatment procedure. Correct treatment of 

this tumor ultimately involved significant surgical 

procedures, and resulted in removal of teeth, a nerve 

bundle, and portions of the jaw bone which required 

reconstruction. This article contributes a superbly 

presented, clearly documented and illustrated case 

study to the body of literature concerning this fairly 

rare condition. The careful diagnosis and extensive 

treatment performed under less than ideal clinical 

Perspectives 
 January – March 2011 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

circumstances is yet another testament to the skill, 

knowledge, and, above all, dedication of the dental and 

medical professionals that wear the uniforms of the US 

military. 

Almost everyone knows someone who, for whatever 

reason, has lost all of their teeth as they aged, usually 

from a lifetime of neglect of their oral hygiene and 

dental care. However, we would consider it to be unusual (outside of trauma) for a young person, especially a teenager, to have an advanced dental condition 

that endangered virtually all of their teeth. COL David 

Mott, LTC(P) Minaxi Patel, and LTC Dong Soo Park 

have contributed a clinical report documenting such a 

situation. They describe a 19-year-old Soldier’s 

presentation with a condition known as dentinogenesis 

imperfecta, a genetic disorder that affects the majority 

of the teeth, which, without treatment, ultimately 

results in serious deterioration and tooth loss. In the 

case of advanced deterioration such as they 

encountered here, the only effective treatment is total 

rehabilitation, which is a multidiscipline endeavor 

involving prosthodontics, periodontics, and dental 

implant surgeries. The article is an excellent case study 

of careful research, thorough planning, close 

coordination, and a complex course of treatment over a 

period of time, during which 8 teeth were extracted, 7 

implants were placed, and 16 teeth received crowns. 

The treatment not only resolved the complaints of oral 

pain and sensitivity, but also tenderness in the muscles 

of the jaw and the aesthetics of the appearance of the 

teeth. As depicted in the article’s imagery, the process 

and results were indeed impressive, yet another 

example of the exceptional level of oral healthcare our 

Army Dental Corps professionals provide to Soldiers 

every day, wherever they may be. 

This special issue of the AMEDD Journal closes with 

an excellent, clearly presented clinical report 

describing treatment of another type of oral tumor, an 

ameloblastoma. In their article, MAJ Michael Ryhn, 

COL Jeffrey Almony, and COL Albert Manganaro 

detail the potentially serious nature of this aggressive 

form of tumor, and present the concerns and 

complications of the corrective surgical procedures. As 

with some of the other procedures described in this 

issue, portions of the patient’s jaw bone were removed, 

bone grafts inserted, and reconstruction with dental 

implants was performed to replace the lost teeth. This 

article portrays another team of skilled, dedicated 

military dental professionals who collaborate to create 

a total treatment plan, and then work over an extended 

period of time to restore the patient to full function and 

health. This informative article is well researched and 

illustrated, and provides further insight to the extent of 

the talents, skill, knowledge, and capabilities that are 

hallmarks of the members of the United States Army 

Dental Corps. 

The United States Army 

Medical Department 

The United States Army 

Medical Department 

Center and School 
6 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

As the 26th Chief, US Army Dental Corps, I am 

excited to be a part of this Dental Corps Centennial 

issue of the Army Medical Department Journal. On 

March 3, 2011, the US Army Dental Corps will 

celebrate its 100th anniversary. This historic event 

marks a 100-year milestone for the Army Dental Care 

System (ADCS), and for all of Army medicine. I invite 

you to enjoy this special issue of the AMEDD Journal, 

dedicated as a centennial tribute to the Dental Corps 

and the men and women of the ADCS. In these pages 

you will learn more of the history of our proud Corps 

and become familiar with its founders and many of the 

key individuals and events from the past. Today, the 

ADCS enjoys the fruits of remarkable efforts and 

perseverance by the Corps’ founders, members of 

American dental professional associations, and all our 

past Corps’ leaders and members, whose collective 

accomplishments leave an outstanding legacy of 

selfless service, gallant leadership, and an unflagging 

organizational esprit de corps. The leaders and 

members of the ADCS of today are poised to leverage 

this winning legacy into our next 100 years of service. 

In addition to the historical perspectives, you will 

discover among the articles in this issue the high levels 

of diverse skills and professional competencies that are 

involved in providing the superb dental healthcare that 

is the norm for modern Army dentistry. The subjects 

range from interesting case studies of procedures 

addressing some relatively uncommon conditions, to 

the application of the most current technologies in 

support of our delivery of dental care. There is also an 

article examining disorders of the muscles, tendons, 

and nerves in wrists and hands of Army dental 

assistants and specialists, another example of Army 

medicine’s dedication to “heal the healers.” 

First, however, this issue is a celebration of our 

history. We note that from 1775 to 1901, at the 

beginning of efforts to provide service to Soldiers, 

such care was provided by hospital stewards (enlisted 

medics), who, by their own special interest or training, 

chose to limit their medical activities to providing 

dental care with medical officers. In 1901, the Army 

authorized 30 contract dentists for an Army-wide 

program of dental care. Ten years later, these contract 

positions were converted to commissioned officer 

positions. Through the vision of, and persistent 

attempts by, civilian and Army dentists at the turn of 

the 20th century, Congress officially established the 

Army Dental Corps on March 3, 1911. Our 100 years 

of official existence is replete with inspiring examples 

and stories of men and women of the Army Dental 

Corps demonstrating dedicated service, valor, and 

commitment to taking care of Soldiers in all sorts of 

environments and all types of operations, across all 

theaters of operation. 

We are currently in our 10th year of continuous 

support for overseas contingency operations, and the 

Army’s operational tempo has been tremendous and 

unrelenting, demanding our unwavering attention to 

the dental healthcare services we provide to our 

Warriors. Our focus remains supporting a Nation and 

Army at war, ensuring the dental readiness of our 

deploying forces by providing high quality dental care 

that is a hallmark of the ADCS. Through the actions 

and accomplishments of Army dental personnel 

everywhere, we continue to demonstrate that dental 

healthcare is a vital component of overall Soldier 

health and Army readiness, and the ADCS is a key 

member of the Army Medical Department healthcare 

team. 

The ADCS is an amalgamation of Active Component, 

Army National Guard, and Army Reserve personnel—

officers and enlisted Soldiers, Department of the Army 

civilians, and contract service providers. Today, our 

The US Army Dental Corps: 

100 Years Old and Better Than Ever 

MG M. Ted Wong, DC, USA 

MG Wong is Commanding General, William Beaumont Army Medical Center, Fort Bliss, Texas, and Deputy 

Commanding General for Readiness, Western Regional Medical Command, Fort Sam Houston, Texas. He is also the 

Chief of the US Army Dental Corps. 
 January – March 2011 7

workforce consists of over 1,350 dentists (Active 

Duty, Reserve, Army National Guard, civilian 

government employees, and contractors), over 3,350 

noncommissioned officers and enlisted Soldiers from 

all components, and over 3,000 civilian and contract 

service providers. We are a diverse organization of 

highly skilled professionals, all of whom serve 

America’s Warriors in dental treatment facilities, in 

command and staff positions, and in deployed operations. The majority of our personnel assets are in the 

generating force organization, the Army Dental Command. In a typical day, the Dental Command sees 

about 9,000 patients, taking almost 5,000 radiographs, 

and producing nearly 27,000 dental procedures valued 

at close to $3,000,000. 

Army Dental Corps members are not limited to 

providing clinical care. They are a group of multitalented, well trained, and highly skilled leaders and 

healthcare professionals who function in a variety of 

positions and assignments across the Army and the 

Department of Defense. Dental officers of all 

specialties serve as mentors in our postgraduate dental 

education residency programs, which produce a wide 

variety of proficient specialists. Dental officers in the 

Army Medical Department Personnel (AMEDD) 

Proponent Directorate ensure the Army maintains the 

correct dental force structure. The staff in the AMEDD 

Center and School, Department of Dental Science 

provides professional leadership training for officers 

and noncommissioned officers, basic and advanced 

dental training for enlisted Soldiers, and business 

management training. The US Army Dental and 

Trauma Research Detachment, newly relocated to Fort 

Sam Houston and aligned with the Army Institute of 

Surgical Research, enhances the recovery from 

wounds through cutting-edge, bioengineering research. 

New combat equipment emanates from the AMEDD 

Directorate of Combat and Doctrine Development to 

ensure that our materials and equipment provide only 

optimum support to Soldiers, whenever and wherever 

they are called to deploy. The staff at the Army 

Human Resources Command manages the worldwide 

distribution and assignment of dental personnel. 

It is a distinct honor and privilege to be a member of 

and represent the premier dental healthcare 

organization in the world, where I serve with the finest 

healthcare professionals imaginable. Throughout my 

visits and interagency contacts, I hear from our 

patients and other Army leaders about the outstanding 

healthcare and readiness support we provide to 

Soldiers. It is a tribute to the committed dedication and 

selfless service to patients, and the continual personal 

commitment to the mission by the men and women of 

the Army Dental Corps and the ADCS. I am 

completely confident that the Army Dental Corps is 

fully prepared to provide another century of exemplary 

and compassionate dental healthcare services to our 

Warriors, in garrison or deployed anywhere in the 

world. Wherever you may be on March 3, 2011, please 

join me and all Army dental healthcare professionals 

in our celebration of the Army Dental Corps’ 100th 

Anniversary! 

The United States Army 

Dental Corps 
8 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

Experience is valuable to improving performance in every 

field. Many personal experiences do not offer themselves at 

a time or place which is safe, convenient, or accessible. 

History serves as the community record of experience, and 

within the military community it is valued as one of the 

instruments of situational analysis. A problem exists for the 

unique profession of military dentistry in that published 

records of military dental history are very few, and dentists 

frequently focus on dentistry’s vast and growing scientific 

information pool, often to the neglect of military history. As 

this is written in 2011, there are only 3 books presenting 

aspects of the history of Army dentistry. One is limited to 

the period of World War II.1

 Another concerns dental care at 

the US Military Academy at West Point.2 The most 

comprehensive and detailed history was only recently 

published and covered the period from the Revolutionary 

War until 1941.3

 Realizing the need and importance to 

capture more of the Army dental care experience, starting in 

1974 staff members in the Office of the Chief of the US 

Army Dental Corps produced a pamphlet which chronicles 

major and significant events in the oral health care of Army 

beneficiaries. The name of this useful pamphlet is 

Highlights in the History of Army Dentistry.

4

 Technology 

has presented the option to make it available on the internet 

rather than published in hard copy, a convenient and 

practical medium for an historical publication which is 

constantly evolving. 

On the auspicious occasion of celebrating 100 years since 

the establishment of the US Army Dental Corps in 1911, 

MG Ted Wong, current Chief of the US Army Dental 

Corps, has requested a historical update of Highlights. 

Another part of the celebration is a special Dental Corps 

centennial edition of the AMEDD Journal, and it was 

proposed that the 2011 update of Highlights be included in 

this issue of the AMEDD Journal. However, since the 

Highlights has, over the last 37 years, increased in content 

and length, inclusion of it in toto is not possible. Consequently, the following highlights were extracted and abridged to 

reduce the length. However, a complete, unabridged version 

of the updated Highlights in the History of Army Dentistry

will be available (and maintained) on the internet.4

Highlights is best described as a chronology written to give 

succinct information about significant events that have 

changed Army dentistry. Highlights is absolutely not a 

definitive history. Highlights in the History of Army 

Dentistry is organized chronologically which provides 

valuable perspective as to how some events lead to others, 

how events and people are related in time. There are more 

lessons to learn if the reader discovers a topic of interest and 

looks for entries related to it. For example, a theme of developing the education and training schools unique to Army 

dentistry can be traced by linking entries for the dates March 

1916, September 1916, November 15, 1917, March 15 

1918, May 1921, January 6, 1922, and July 1, 1939, among 

others. By becoming familiar with Highlights, the user can 

find many such themes such as changes in administrative 

organization, dental lab support, research units, dental 

support to the major wars and conflicts, etc. Help with 

Highlights and other dental history issues is available from 

the Dental Corps Consultant for Dental History. 

Highlights in the History of Army Dentistry 

COL Samuel A. Passo, DC, USA 

COL (Ret) John E. King, DC, USA 

HIGHLIGHTS

REVOLUTIONARY WAR (1776 – 1781) 

The Continental Army was established on 14 June 1775 without any idea of providing dental support to troops. The practice 

and later policy that soldiers were responsible for their own dental care continued until 1901, although there were several 

notable exceptions. 

1776 – Paul Revere performed the first recorded case of military forensic identification on the remains of MG Joseph 

Warren at Bunker Hill about 10 months after Warren’s death in that famous battle. 

THE EARLY REPUBLIC

During the War of 1812 with England, the Mexican War (1846 - 1848) and the westward settlement of America, Soldiers 

sought needed care from civilian dentists or itinerant tooth drawers. In remote locations where no civilian dental source was 

available Army physicians and hospital stewards (some with preceptor-type training in dentistry) were the only sources of 

emergency dental care. Accounts of the time indicate most physicians and stewards were ill-prepared to provide this 

service. 
 January – March 2011 9

6 March 1840 – The Baltimore College of Dental Surgery was established as the first dental school. Although this was 

primarily a civilian event, it signaled the advancement that dentistry had achieved in technology, science, education, and 

professional organization. These advances legitimized the argument by many civilian dentists of the early 1800s that the US 

military should recognize dentistry as a specialized medical requirement. As dentistry began to promote itself as a 

profession many dentists also brought attention to government leaders that Soldiers and sailors suffered from lack of access 

to qualified dental care. 

31 July 1860 – The American Dental Association (ADA) held its first convention in Washington DC. It adopted a 

resolution to support the appointment of dental officers for the Army and Navy. Organized dentistry continued to press the 

Army and Congress for military dentistry throughout the American Civil War. Note: The Southern Dental Association 

separated from the ADA with the division of the nation into the northern Union and southern Confederacy. Dental 

organization separation continued until 1897 when the 2 associations reunited under the name of the National Dental 

Association (NDA). In 1922 the NDA once again assumed the name American Dental Association. 

CIVIL WAR (1861 – 1865) 

During the American Civil War, Union Soldiers continued to get dental care wherever they could, even though large 

numbers of potential recruits were turned away because they did not have 6 opposing upper and lower front teeth to bite off 

the end of the tough, paper powder cartridges used with muzzle-loaded weapons. Answering civilian criticism of poor 

access to dental care, a succession of Army leaders, resisting the idea of providing dentists to the Army, repeated the 

spurious argument that existing surgeons had the skill and knowledge to manage dental emergencies. 

13 May 1861 – Confederate leadership was apparently more sympathetic to dental needs of Soldiers because as early as 13 

May 1861 Dr J. B. Deadman, a North Carolina dentist who enlisted as a private in the Confederate Army, was appointed to 

be a post dentist. Throughout the war, dentists were being either detailed from their units or contracted as civilians to serve

the Confederate military. 

17 February 1864 – The Army of the Confederacy finally acknowledged that its Soldiers could not afford dental care when 

the Congress of the Confederate States of America (CSA) passed a law to conscript dentists. It became policy that all 

Soldiers with dental training who were already on duty were to be assigned to provide dental services, and they were to 

have “rank, pay and perquisites [privileges] which their position in the army entitles them; and in addition, such extra duty 

pay for extraordinary skill and industry, as the Surgeon General will allow.” Most CSA dentists were hospital stewards. 

September 1864 – Dental Cosmos (a dental journal) reported many actions that had been taken by the ADA and its 

members to secure dental care for Union Soldiers, including a visit on behalf of the association by Dr S. S. White to 

President Abraham Lincoln. All efforts to secure such care failed during the Civil War. 

4 April 1872 – William Saunders, a hospital steward at West Point became the first Soldier to be recognized as a US 

military dentist. He was directed by Special Orders to provide dental service for cadets and staff of the US Military 

Academy at West Point. Saunders had provided dental care as part of his duties since 1858. 

Late 1800s – In the late l800s the American Dental Association and individual dentists continued to lobby Congress for a 

military dental corps, but legislation introduced on this matter failed to pass. 

SPANISH-AMERICAN WAR (APRIL 1898 – DECEMBER 1898) 

PHILIPPINE INSURRECTION (FEBRUARY 1899 – JULY 1902) 

For the first time US forces were deployed to foreign soil in Cuba, Puerto Rico, and the Philippines, far from any acceptable 

source of civilian dental care. Army physicians were forced to confront the reality that their medical training was deficient 

in care of oral conditions. A significant number of trained dentists served in the capacities of hospital stewards and some 

were appointed by local command authorities to focus their service on dentistry. Dr W. H. Ware was appointed to practice 

dentistry and upon deployment in August 1898 established the first Army field dental clinic in Manila, Philippines; and on 

30 September 1898, Dr J. W. Horner was designated “Corps Dentist for the Seventh Army Corps” and provided a dental 

clinic in Jacksonville, Florida. Both were enlisted dentists whose assignments had been as hospital stewards. This 

recognition of need and demonstration of value of dentists contributed significantly to justifying Army wide use of contract 

dentists and eventually commissioned status for dental surgeons. 

February 1899 – Seven black (African American) regiments were deployed to Cuba during the Spanish-American War. 

Although it is unclear exactly when CPT William Thomas Jefferson, a dentist in civilian life, deployed it was recorded that 
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he served with his regiment in Cuba and was stationed at San Luis De Cuba in February 1899. In addition to his command 

responsibilities as a line officer, he also found time to provide dental care for his regiment. Possibly, Dr Jefferson was the 

first African American dentist to perform dentistry in the US military. He was likely the first African American 

commissioned officer to provide dental care in the Army although it was as a line officer, not a dental officer. 

2 February 1901 – Still dealing with support of deployed troops at war against the Philippines, Congress passed legislation 

directing the Army Surgeon General to employ 30 civilian contract dentists to provide dental care for officers and enlisted 

men of the Regular and Volunteer Army. They would be attached to the Medical Department, not assigned to it. Candidates 

for the positions had to be graduates of a medical or dental school and to pass a qualifying dental examination. Dental 

school graduates who were already in the Army Hospital Corps were excused from the exam. These dental surgeons held no 

rank but wore the same uniform as medical officers, except for silver “DS” insignia on the shoulder boards. Initially they 

were assigned to posts in continental United States (CONUS), Cuba, Puerto Rico, and the Philippines.

11 February 1901 – Dr John Sayre Marshall, MD, father of the Army Dental Corps, was appointed to be the first contract 

dentist, senior supervising contract dental surgeon, and president of the first Army Board of Dental Examiners. Appointed at 

age 55, his career had already included private practice (1876 – 1901), book publications, specializing and lecturing in oral 

surgery at several universities, and establishing the Dental Department at Northwestern University (1886). He lobbied for an 

Army dental service, and for 10 years following his appointment as a contract dental surgeon he provided masterful 

leadership toward establishing a commissioned Dental Corps. On 13 April 1911, he became the Army’s first commissioned 

dental officer. He retired on 17 June 1911 as Captain, US Army Dental Corps, at age 65. 

25 February 1901 – The first Army Board of Dental Examiners met in Washington, DC, to begin examinations of 8 

candidates. Dr Robert T. Oliver, DDS, of Indiana and Dr Robert W. Morgan, DDS, of Virginia were the second and third 

contract dentists appointed and joined Board President Marshall to complete the 3-member board. By 21 December 1901, 

seventy-one dentists had been examined and 28 of the 30 positions had been filled. 

11 November 1901 – African American hospital steward William A. Birch sent an application for appointment to an Army 

contract dental surgeon position. Documentation showed that he was a 1900 graduate of Indiana Dental College and had 

been providing dental services to US Soldiers in the Philippines. Dr Birch is probably the first African American to serve as 

an Army dentist (although officially as an enlisted corpsman). To date, historians have been unable to determine who was 

the first African American dentist to be commissioned in the US Army Dental Corps. 

20 April 1906 – Dr Leonie von Meusebach-Zasch became the first woman dentist to work for the Army (probably the first 

woman dentist employed by the US government) when she was hired to support Army emergency relief for victims of the 

San Francisco earthquake. 

3 March 1911 – The US Army Dental Corps (DC) of commissioned officers was established with the passing of H R 

31237, Amendment 49 and President Taft’s signing it into Public Law No. 453, 36 Stat. 1054. This event followed many 

years of National Dental Association discourse, congressional hearings, and the failure of previous bills. The law provided 

that dental officers could be of no higher rank than first lieutenant. Contract officers with 3 years’ experience were 

commissioned first lieutenant. New candidates who were board examined and accepted were appointed Acting Dental 

Surgeons for a period of 3 years before commissioning. Acting dental surgeons had the same status as contract dentists, 

received less pay than lieutenants, and could not be ordered to war. Civilian dentists immediately started lobby efforts to 

upgrade the rank and pay to be more comparable with military physicians. The Act of 3 March 1911 had a major impact on 

the civilian status of dentistry as a profession. Before the enactment of the military dental corps authorization, the words 

“dentistry,” “dental profession,” and “dental surgeon” had no significance or recognition under the law. The United States 

government set precedent for the “official recognition” of dentistry as a profession. 

WORLD WAR I (6 APRIL 1917 – 11 NOVEMBER 1918) 

Summer 1914 – The World War began in Europe. Although the US would not declare war until April 1917, concern for 

readiness to enter the war had a significant affect on changes in US Army and US Army dentistry. 

March 1916 – The Preparedness League of American Dentists, 1,700 civilian dentists, organized to provide free dental 

service for men wishing to enlist. The League also established a standard course for military training of dentists and 

provided study clubs for dentists who expected to enter the reserves. Dental schools cooperated by using the League course 

standards and by making League courses available. Between 4,000 and 5,000 dentists were estimated to have completed the 

training. By 1918 Preparedness League dentists had provided approximately a million pro bono dental procedures to men 

selected for military service. 

Highlights in the History of Army Dentistry 
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THE ARMY MEDICAL DEPARTMENT JOURNAL

3 June 1916 – Congress passed the National Defense Act of 1916 that included reorganization of the Army Dental Corps. 

Under this act, the probationary contract system was abolished, permitting immediate commissioning of dental officers as 

first lieutenants with advancement to captain after 8 years and to major after 24 years of active service. The act also 

authorized the Army Dental Reserve Corps. 

September 1916 – The first Army dental training school was established at Fort Bliss, El Paso District, Texas, by CPT 

Robert T. Oliver. Tensions along the US/Mexican border in 1916, including raids by Pancho Villa, resulted in a dramatic 

deployment along the border and significant influx of both active and National Guard dental officers. This created 

awareness that dentists with good civilian education and experience still lacked operational field skills, military 

administrative knowledge, and trauma related training that are unique to military service. The Fort Bliss dental school 

served as a model for similar schools needed soon in World War I. (See a more complete description of Army dental 

education and training in May 1921 entry.) 

6 April 1917 – The United States declared war on Germany and entered World War I with a Dental Corps of 86 Regular 

officers. By 30 November 1918, the number of active duty dental officers peaked at 4,620 from the Regular Army, Army 

Reserve, and National Guard, with 1,864 stationed in Europe. Note: In September 1917, 891 dentists who were in the 

Medical Enlisted Reserve Corps were called to active duty as privates, although 1,079 other reservists were allowed to wait 

commissioning as Dental Corps officers. 

9 August 1917 – MAJ William H. G. Logan, MD, DDS, a Medical Corps Reserve officer, was appointed to be the chief of 

the newly established Dental Section, Personnel Division, of the Office of the Surgeon General, and first Chief, Army 

Dental Corps. As a civilian Dr Logan had been a leader in establishing the Dental Reserve Corps in 1916. As DC Chief he 

significantly increased the number of Dental Reserve officers, organized maxillofacial surgical teams, and initiated dental 

officer basic training and an enlisted dental assistant training program at Fort Oglethorpe, Georgia. He was the president of 

the National Dental Association (1917-1918) and after his discharge on 12 February 1919 became dean of Chicago College 

of Dental Surgery (1920-1923) and then of Loyola University College of Dentistry (1923-1943). 

20 August 1917 – The first dental unit of the American Expeditionary Forces (AEF) landed in France with CPT Robert T. 

Oliver in charge. Oliver had been designated on 25 June 1917 to be Chief Dental Surgeon, AEF, by General John J. 

Pershing. Oliver had developed a good working relationship with Pershing in the Philippines that continued when 

supporting him in the Mexican border operation. CPT Oliver assumed the dental surgeon duties on 1 September 1917. 

6 October 1917 – A law was passed authorizing Army Dental Corps officers the same rank, pay, promotion, and retirement 

rights as officers of the Medical Corps. This law also directed that all dental and medical students be permitted to complete 

their dental or medical education before being called to active duty. 

15 November 1917 – Basic training and combat casualty care courses were established for dental officers at the new Dental 

Section, Sanitary School, Langres, France. (See a more complete description of Army dental education and training in May 

1921 entry.) 

15 March 1918 – Basic and technical training for dental officers and enlisted dental assistants was initiated at Camp Greenleaf, Fort Oglethorpe, Georgia. (See a more complete description of Army dental education and training in May 1921 entry.) 

World War I Statistics – From July 1917 to May 1919, 1,396,957 Soldiers of the American Expeditionary Forces were 

treated for many different dental conditions. Dental officers provided 1,505,424 restorations, 384,427 extractions, 60,387 

crowns, and 13,140 dentures. Seven dental officers and 7 enlisted dental assistants were killed in action. Eight dental 

officers died of disease, and 36 dental officers and enlisted dental assistants were wounded in combat. 

By 1920 Dental Corps officers were located in England, France, Belgium, Germany, Russia, and Poland. 

12 February 1919 – At COL Logan’s discharge, LTC Frank Laflamme was named Chief, Dental Section, Personnel 

Division, Office of the Surgeon General (OTSG), and became the second Chief, Army Dental Corps. He served as interim 

chief until August 1919. 

21 August 1919 – COL Robert T. Oliver, now the Dental Corps’ ranking officer, returned from his AEF position and was 

named Chief, Dental Section, Personnel Division, OTSG. He became the third Chief, Army Dental Corps. Before his entry 

into Army service, Oliver had a successful civilian career that was interrupted by his voluntary enlisted time during the 

Spanish-American War. His wartime experience influenced him to become an activist in organized dentistry for an Army 

dental corps. Oliver was one of the original 3 members of the Army Dental Examining Board. COL Oliver was later elected 
12 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

president of the American Dental Association (1930-1931) and while on active duty served as professor for the dental 

Reserve Officers’ Training Corps (ROTC) at the University of Pennsylvania. 

May 1921 – The Medical Field Services School (MFSS) was established at Carlisle Barracks, Pennsylvania. The training in 

military medical support for dental officers and enlisted dental personnel that had been conducted at the Fort Bliss dental 

school before the World War, the Sanitary School in Langres, France, and Fort Oglethorpe, Georgia during the War, was 

centralized at the new MFSS. In January 1922 dentistry specific subjects that had been taught at these schools were 

transferred to the Army Dental School at the Army Medical Center in Washington, DC. The MFSS continued to teach the 

medical support and military subjects to dental personnel and remained at Carlisle Barracks until it moved to Fort Sam 

Houston, San Antonio, Texas, in 1946. In December 1972, as it was occupying new facilities at Fort Sam Houston, the 

MFSS was redesignated the US Army Academy of Health Sciences (AHS), and in July 1994 the AHS became an element 

of the Army Medical Department (AMEDD) Center and School instead of a separate command. Enlisted dental training, 

dental NCO and dental officer military training continued to be conducted by the AHS Dental Science Division. Graduate 

Dental Education for officers has been delivered under other programs. 

6 January 1922 – The War Department established an Army Dental School at the Army Medical Center in Washington, 

DC The faculty included 11 Dental Corps and 18 Medical Corps officers. The school was opened to give postgraduate 

courses in advanced military dental surgery, provide an organization for research of dental problems, and train enlisted 

personnel to meet the requirements of dental service. COL Siebert D. Boak was the first commandant. This school was the 

predecessor of the US Army Institute of Dental Research. 

POST WORLD WAR I DEMOBILIZATION 

30 June 1922 – Congress passed the National Defense Act of 1922, reducing the size of the Army from 300,000 to 150,000 

Soldiers and the size of the Regular Army Dental Corps from 298 to 158 officers. DC downsizing was accomplished by 

retirement, resignation, and the involuntary separation of 77 dental officers. 

1924 – The Army adopted the practice of “expedient dentistry” consisting primarily of emergency care, extractions, and 

dentures. 

July 1924 – COL Rex H. Rhoades was named Director, Dental Division, OTSG, and the fourth Chief, Army Dental Corps. 

1927 – Three Central Dental Laboratories were established to produce dental appliances and prosthesis. Each laboratory 

served one or more corps areas. They were established at the Army Medical Center, Washington, DC (later named Walter 

Reed Army Medical Center); Fort Sam Houston, Texas; and Letterman General Hospital, San Francisco, California. The 

name was changed to the Regional Dental Activity in 1962 and to Area Dental Laboratory in 1981. 

15 June 1928 – COL Julien R. Bernheim was named Director, Dental Division, OTSG, and fifth Chief, Army Dental 

Corps. 

1931 – The first dental officer was sent for specialty training in oral surgery. 

15 June 1932 – COL Rex H. Rhoades repeated as Director of Dental Division (now part of Professional Division), OTSG, 

and became the sixth Chief, Army Dental Corps. The size of the active Dental Corps remained at 158 officers. 

20 September 1934 – COL Frank P. Stone was named Chief, Dental Division, Professional Service, OTSG, and seventh 

Chief, Army Dental Corps. 

RAMPING UP – ANTICIPATING A NEW WAR

30 June 1937 – The first increase in the size of the Dental Corps since 1922 occurred. The number of Regular Army dental 

officers increased by 25 to 183 Dental Corps officers. This began a series of increases leading up to the massive 

mobilization of World War II. 

29 January 1938 – The rank of brigadier general was authorized by the 75th Congress (Public Law 423) for the director of 

the Dental Division, OTSG. This law also directed an increase in the Regular Army Dental Corps to 258 officers. In April 

1938 the authorized DC strength was again increased to 316 officers. In this time frame the Dental Reserve Corps reached 

5,199 officers, exceeding the projected wartime requirement of 5,000 officers. All reserve Dental Corps recruitment was 

directed to cease, and the size of the Dental Reserve Corps rapidly dropped below 5,000. 

Highlights in the History of Army Dentistry 
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THE ARMY MEDICAL DEPARTMENT JOURNAL

14 March 1938 – Leigh C. Fairbank was promoted to Brigadier General becoming the first Dental Corps officer to achieve 

general officer rank. He was named Chief of the Dental Division, OTSG, and eighth Chief, Army Dental Corps. General 

Fairbank served until 16 March 1942. (See also 18 December 1959 entry.) 

1 July 1939 – The Army Dental Internship Program (one year) opened with 8 civilian dentists. Upon successful completion 

of the program, the dentists would be eligible for commissioning as first lieutenants. 

WORLD WAR II (8 DECEMBER 1941 – 2 SEPTEMBER 1945) 

Aggressive acts by Germany in Europe and by Japan against China in 1937 and 1938 resulted in American apprehension 

about the potential for involvement in hostilities. The 1 September 1939 German invasion of Poland precipitated the 

declaration of war on Germany by France and Great Britain. Again military expansion in preparation for war became a 

factor molding the Army dental service. 

October 1941 – The War Manpower Commission established the Procurement and Assignment Service that selected, 

inducted, and assigned dentists into the military services. As a result of the 1938 suspension of recruitment, the Dental 

Reserve Corps had dropped to 4,428 by June 1941. Meanwhile the active force was rapidly expanding, activating over 

2,000 reserve dental officers during 1941. 

8 December 1941 – The day following the bombing of Pearl Harbor by the Japanese, the United States entered World War 

II with an active duty Dental Corps of 316 Regular Army and 2,589 reserve Dental Corps officers (2,905 total). 

28 January 1942 – An Army dental officer, LTC George R. Kennebeck, was named the first chief of the new Dental 

Section, Office of the Army Air Forces Surgeon General. (See also 12 May 1949 entry concerning establishing USAF.) 

17 March 1942 – BG Robert H. Mills was appointed Director, Dental Division, OTSG, Assistant Surgeon General, and 

ninth Chief, Army Dental Corps (now numbering 3,446 officers). Mills was promoted 7 October 1943 to the temporary rank 

of major general, becoming the first dental officer to hold this rank. He retired on 17 March 1946. 

9 April 1942 – MAJ Roy L. Bodine, Jr became a prisoner of war of the Japanese when Bataan in the Philippines fell. He 

spent 3 and a half years as a POW in the Philippines, Japan and Korea before being liberated on 7 September 1945. His acts 

of caring for and leadership of fellow POWs were inspiring and representative of other US Army dental POWs. His 

leadership to the Dental Corps continued until his retirement at the rank of Colonel in 1961. 

1943 – The Army was faced with a shortage of glass artificial eyes. Research-minded Army dental officers in 3 widely 

separated locations experimented with clear synthetic resin and fashioned a plastic eye which was adopted for routine use 

by the Army. Army dental personnel were also important in the development of improved custom hearing-aid adapters and 

fabrication techniques of tantalum plates for repair of skull defects. 

Dental services in Replacement Centers operated on 8-hour shifts around the clock because of a shortage of dental 

equipment and facilities. Later this would be cut to two 8-hour shifts as newly constructed dental clinics were completed to 

provide dental care for the Soldiers during their 15-day stay at the centers. 

7 July 1944 – Ben Louis Salomon, Captain, US Army Dental Corps (later to posthumously be awarded the Medal of 

Honor) was killed in action on the Pacific island of Saipan while valiantly defending severely wounded Soldiers and 

covering the evacuation of ambulatory wounded. CPT Salomon, a graduate of the Dental College of the University of 

Southern California in 1937, was acting battalion surgeon for the 2d Battalion, 105th Infantry Regiment, 27th Infantry 

Division, when a massive banzai suicide attack of 3,000-5,000 Japanese Soldiers struck the 1st and 2d Battalions outside of 

Tanapag village early on the morning of 7 July 1944. Japanese Soldiers quickly penetrated the American lines and advanced 

into the battalion’s rear areas where they began attacking the patients at Salomon’s battalion aid station. In hand-to-hand 

combat, Salomon fought off the attackers and then took over a machine gun whose crew had been killed so that his medics 

and the walking wounded would have time to get back to the regimental aid station. When US forces reoccupied the area on 

8 July, CPT Salomon was found dead at the machine gun with 98 Japanese Soldiers piled in front of his position. Although 

recommended for the Medal of Honor in July 1945, the recommendation was not sent forward for approval because of a 

misinterpretation at Division level of the Geneva Convention concerning medics’ use of weapons. The Army Dental Corps 

honored CPT Salomon by memorialization of a Dental Clinic at Fort Benning, GA in his name. It would be over 56 years 

before Salomon’s heroism was finally recognized with presentation of the Medal of Honor. (See entry for 1 May 2002) CPT 

Salomon is the only Army Dental Corps officer to receive a Medal of Honor. 

For a more detailed account of CPT Ben L. Salomon and the long quest to obtain a Medal of Honor in recognition of his 

selfless actions, go to: http://history.amedd.army.mil/moh/Salomon.html 
14 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

1 November 1944 – The Dental Corps active duty strength reached its highest level with 15,292 officers. By 31 May, 1945, 

7,103 of these officers would be overseas. The concept of operations throughout this war was unit dental support, as 

opposed to area support, with each Army division typically having more than 30 dental officers. 

World War II Statistics – During the period 1 January 1942, – 31 August 1945, the Army Dental Corps completed the 

following procedures: 16,231,264 extractions, 69,546,560 restorations, 579,473 full dentures, and 2,032,684 partial 

dentures. Twenty dental officers were killed by enemy action. In addition to these 20, 5 later succumbed to their wounds, 10 

died in captivity, and 81 lost their lives to disease and nonbattle injury. Over 18,000 dentists served during World War II. 

1946 – The Medical Field Service School (MFSS), including the Dental Section, moved to Fort Sam Houston, Texas, after 

26 years at Carlisle Barracks, Pennsylvania. In December 1972, as it was occupying new facilities at Fort Sam Houston, the 

MFSS was redesignated the US Army Academy of Health Sciences (AHS), and in July 1994 the AHS became a subordinate 

element of the Army Medical Department Center and School instead of a separate command. (See also May 1921 entry for 

more on organizational lineage.) 

17 March 1946 – BG Thomas L. Smith was named Director, Dental Division, OTSG, Assistant Surgeon General, and tenth 

Chief, Army Dental Corps (now reduced to 5,011 officers). As a result of a law passed 7 August 1947 to grant the 

permanent rank of major general to the chief of the Army Dental Corps, General Smith was promoted to major general on 

24 January 1948. General Smith served as chief until 20 April 1950. 

12 May 1949 – The US Air Force Dental Service was established. MG George R. Kennebeck moved from Chief of the 

Army Air Corps Dental Service to be Chief of the US Air Force Dental Corps. 

20 June 1950 – MG Walter D. Love was sworn in as Chief, Dental Division, OTSG, and eleventh Chief, Army Dental 

Corps. He retired on 30 April 1954. 

KOREAN WAR (25 JUNE 1950 – 27 JULY 1953) 

25 June 1950 – North Korea invaded South Korea. By the next day, President Harry S. Truman had authorized use of US 

forces in the conflict. 

21 March 1951 – Dr Helen E. Myers was commissioned into the Army Dental Corps, becoming the first woman to serve as 

an Army dental officer. Entering with the rank of captain, she reported for duty at Fort Lee, Virginia. 

1952 – The concept of area dental support, as opposed to unit dental support, was introduced during the Korean War. This 

would evolve into the KJ Detachment of the Vietnam War era, redesignated the HA Detachment in the early 1970s, and 

subsequently the Dental Company of the post-1991 Gulf War era. The idea of a dental command and control unit (AI 

Detachment) was also conceived for the Korean operation but not implemented until Vietnam. Note: Units were given 

random letter designations unrelated to titles or functions. The AI Detachment evolved into the Dental Battalion after the 

1991 Persian Gulf War. (See entries 23 December 1965, 6 April 1992, 30 June 1993, and 30 March 2003 for later evolution 

of dental command and control.) 

27 June 1952 – COL (later brigadier general) Pearson W. Brown was the first dental officer to graduate from the resident 

course, US Army Command and General Staff College, Fort Leavenworth, Kansas. On 20 June 1957, COL Brown also 

became the first dental officer to graduate from the resident course, US Army War College, Carlisle Barracks. BG Brown 

had been one of the original 8 Army dental interns in 1939. 

Korean War Statistics – Peak strength of the Dental Corps during this conflict was 2,641 officers with 370 serving in 

Korea. Two Army dental officers were killed and one declared dead while missing in action. 

12 April 1954 – BG Oscar P. Snyder was promoted to major general and sworn in as Chief, Dental Division, OTSG, and 

twelfth Chief, Army Dental Corps. General Snyder retired in November 1956. 

1956 – Army dentistry’s first involvement in the Vietnam War was by LTC (later BG) Jack P. Pollock, during a 120-day 

temporary duty assignment to the US Military Assistance Advisory Group, Vietnam. He served as the Medical Advisory 

Team chief and the dental adviser for the team. Later (1967-1968) COL Pollock served as commander of the 932d Medical 

Detachment (AI) in Vietnam, and in 1970 he was the first armed forces dental officer to be appointed as the Special 

Assistant for Dental Affairs, Office of the Assistant Secretary of Defense for Health Affairs. He was promoted to brigadier 

general in April 1972 and was the first Deputy Commander, Health Services Command (1973-1977). 

1 December 1956 – BG James M. Epperly was promoted to major general, and sworn in as Chief, Dental Division, OTSG, 

and 13th Chief, Army Dental Corps. He retired in September 1960. 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

1957 – A course of instruction was established at the Medical Field Service School, Fort Sam Houston, to train enlisted 

military dental hygienists. 

10 August 1957 – The first modern, air-conditioned dental clinic built exclusively for dentistry to replace the World War II 

“temporary” structures was opened and memorialized in the name of CPT John S. Marshall at Fort Dix, New Jersey. That 

clinic was closed in the early 1990s. On March 31, 2009, the CPT John Sayre Marshall Dental Clinic was dedicated in 

memory of CPT Marshall at Fort Drum, New York.

18 December 1959 – BG (Ret) Leigh C. Fairbank personally presented the first award of the Fairbank Medal to MAJ 

Kenneth W. Thomasson. The award, endowed by General Fairbank, honors the dental officer with the highest scholastic 

standing in the AMEDD Officer’s Advanced Course of the Medical Field Service School. 

1 August 1960 – COL Joseph L. Bernier was promoted to major general and sworn in as Chief, Dental Division, OTSG, 

Assistant Surgeon General for Dental Services, and fourteenth Chief, Army Dental Corps (now numbering 1,747 officers). 

General Bernier is well known for initiating an aggressive Army-wide preventive dentistry program in November 1960. He 

used the Army preventive program as a model for promoting the prevention movement in civilian practice. Among 

specialists in oral pathology, Dr Bernier is given credit for leadership in organizing oral pathology as a specialty and 

specifically for establishing the American Academy of Oral Pathology. 

1 July 1961 – The first 2-year Army General Dentistry Residency Program was established at Fort Hood, Texas. 

1 January 1962 – The US Army Institute of Dental Research was activated at Walter Reed Army Medical Center, replacing 

the Army Dental School and the Dental Division, Walter Reed Army Institute of Research. Its mission continued to include 

both research and postgraduate dental training. 

1 March 1962 – Central Dental Laboratories in CONUS were redesignated US Army Regional Dental Activities. The name 

was changed again in 1981 to the US Army Area Dental Laboratory; then in 1998, laboratory consolidation resulted in only 

one remaining laboratory at Fort Gordon, being redesignated The Army Dental Laboratory. 

VIETNAM WAR (1950 – 1973) 

Although establishing dates for the beginning and ending of US Army involvement in the Vietnam War is debatable, the US 

established a US Military Assistance Advisory Group (MAAG) as early as 3 August 1950 and the last US combat troops 

left Vietnam 29 March 1973. There was relatively continuous involvement of US forces between those dates. As for US 

Army Dental Corps participation, it began in 1956 with LTC (later brigadier general) Jack P. Pollock’s MAAG assignment 

(see 1956 entry) and ended 1 April 1973 with the departure of the single remaining Dental Corps officer, MAJ Alfred F. 

Tortorelli. (see 1 April 1973 entry). 

18 April 1962 – The 36th Medical Detachment (Dental Service) under the command of LTC John W. Rudisill arrived at 

Nha Trang, Vietnam. This was the first dental unit to deploy and was of the KJ Detachment type (area support) originally 

fielded at the end of the Korean War. Initially dental units deployed with equipment sets that resembled those used during 

World War II and Korea. The electric motor, belt-driven handpieces and old fixed-position tubular canvas chairs were relics 

of previous wars. After the first few years of supplementing the outdated equipment with stateside-type fixed equipment, a 

compressed-air, rotor handpiece system (the Encore unit), developed specifically for field military use, was delivered, 

giving a modern, mobile capability required for operational support. 

23 December 1965 – Operational dental command and control was realized for the first time with the deployment to 

Vietnam of the 932d Medical Detachment. This AI Detachment (command and control) was assigned to the 44th Medical 

Brigade, and by August 1968 controlled 13 subordinate KJ Detachments (area support). Dramatic improvement in dental 

operation proved the value of dental command over dental assets. 

14 July 1967 – Army Regulation (AR) 40-4, Army Medical Service Facilities, organized installation dental service in 

CONUS to be within the Medical Support Activity (MEDSAC) for administrative purposes. About a year later the 

MEDSAC was converted to an Army Medical Department Activity (MEDDAC) with the post hospital commander having 

command authority over dental services. In Vietnam the value of dental command and control was being proven while 

conversely, under this CONUS organization, making dentistry subordinate to hospital command was shown to be 

inefficient. In addition to problems with securing appropriate resources and low morale of dental personnel, large numbers 

of Soldiers were being deployed without meeting the dental fitness standards enforced in previous wars. 

15 November 1967 – BG Robert B. Shira was promoted to major general and sworn in as Assistant Surgeon General for 

Dental Services, OTSG, and 15th Chief, Army Dental Corps (then 2,656 officers strong). After General Shira’s retirement 

in 1971 he became dean of Tufts University School of Dental Medicine and was elected president of the ADA (1975-1976).
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1968 – Major improvements in Vietnam mission support occurred after General Shira visited Vietnam in the spring of 

1968. Tactical commanders in the field complained bitterly to him about Soldiers lost from their duties because of dental 

emergencies. Improvement measures included: a 20% increase in dental officer strength in Vietnam by June, increased 

availability of field dental equipment, implementation of the Dental Combat Effectiveness Program (DCEP) to eliminate 

potential dental emergency conditions in Soldiers with combat military occupation specialties, use of an improved 

intermediate restorative material (IRM) to avoid unnecessary extractions, field screening and sustaining care at theater inprocessing and at forward troop sites in Vietnam, and mass application of self-applied 9% fluoride paste. 

6 December 1968 – The Army Oral Health Maintenance Program (AOHMP) was implemented targeting active duty 

Soldiers age 25 years and younger. Caries control was the clinical goal. The program required Soldiers in this target group 

to have an annual dental exam during their month of birth and offered appointments to eliminate adverse dental conditions. 

Oral hygiene instruction and professionally applied topical fluorides were emphasized. 

January 1970 – The Army General Dentistry Board provided to Army graduates of the 2-year in General Dentistry 

Residency the first professional certification examination for a “specialty” of General Dentistry. On 15 May 1978, the board 

offered the certification examination to qualified candidates from the Navy and Air Force. On 29 July 1980, the name was 

changed to the Federal Services Board of General Dentistry and offered the certifying exam to all of the US federal 

services. In August 2003 the Dental Corps Chiefs of the Army, Air Force, Navy, Public Health Service and Veterans 

Administration gave final approval for the merger with the civilian American Board of General Dentistry, with the ABGD 

taking over completely over a period extending to 2008. 

September 1970 – Mutual support programs between reserve component dental units and active dental services began 

during weekend training at Fort Devens, Massachusetts. These units treated family members and retired Soldiers who 

otherwise would not have received dental care. The Mutual Support Program, expanded on 16 May 1974, assigned dental 

reserve personnel from 9 readiness regions to installation dental activities. 

11 January 1971 – Phase II of the Army Oral Health Maintenance Program (AOHMP) was implemented, calling for the 

birth-month dental examination and preventively oriented care for Soldiers over 25. The emphasis in this age group was 

prevention of periodontal disease. In October 1974 the 2 phases of the AOHMP were combined into a single program with 

no age-specific distinction in treatment goals. 

1 December 1971 – COL Edwin H. Smith, Jr., was promoted to major general and sworn in as Assistant Surgeon General 

for Dental Services, OTSG. He was the 16th Chief, Army Dental Corps. 

27 March 1972 – The Dental Therapy Assistant (DTA) concept was approved by Department of the Army for immediate 

implementation. DTAs were expanded duty auxiliaries who could work under the supervision of dental officers to provide 

certain reversible dental procedures such as placing rubber dam and placing and carving amalgam. Under this concept 

dental officers increased their productivity by working with a team of regular assistants and one or 2 DTAs. Training of 

civilian assistants to be DTAs began in the fall of 1972 at 22 CONUS installations, with a curriculum designed and 

supported by the Dental Science Division at the Medical Field Service School (later called the Academy of Health 

Sciences). Also in the fall of 1972 a new dental clinic design was approved that better supported the team concept and made 

more efficient use of multiple operatories. Due in large part to perceptions in the civilian sector that substituting dental 

auxiliary labor for dentist labor was not necessary to meet public demand for dental services, the Army’s DTA training was 

discontinued. The existing DTAs continued to function until normal attrition of promotion and leaving Army employment 

eliminated them. (See also the March 2002 entry concerning EFDA, a later program to establish a dental personnel type 

with expanded function.) 

1 April 1973 – The end of Army dental service in Vietnam was marked by the departure of the single remaining Dental 

Corps officer, MAJ Alfred F. Tortorelli. Withdrawal of dental units had begun in July 1969; by 30 April 1972, the 

command and control unit (932d Medical Detachment) had been inactivated; and on 12 February 1973, the last dental unit 

(38th Medical Detachment (HA)) was inactivated. 

Vietnam War Statistics – The greatest number of dental officers on active duty during the conflict was 2,817 with a 

maximum of 290 being stationed in Vietnam at any one time. The concept of support was a combination of unit support 

(approximately one dentist per brigade), hospital support (usually an oral surgeon per hospital), and area support (14 dental 

service units and one dental command and control unit). Four Army dental officers and 4 dental enlisted Soldiers were 

killed in Vietnam. 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

1 April 1973 – The US Army Health Services Command (HSC) was activated at Fort Sam Houston, Texas, to provide 

command and control over all active duty medical assets in CONUS except field units (TOE). Previously, many technical 

functions had been controlled by the Office of the Surgeon General, and command was provided by commanders at local 

installations. Dental staff guidance for HSC was provided by the Director of Dental Services, initially COL Richard 

Howard. BG Jack Pollock, DC, was assigned as the first Deputy Commander, HSC. 

1974 – The Department of Defense (DoD) directed all 3 services to adopt a standard productivity reporting method. The 

Army had previously used a similar Army wide dental reporting system until 1967. This allowed the Army Dental Corps to 

compare current productivity with that achieved before MEDDAC assumed command over dental services. The analysis 

showed productivity had fallen 17%. Other statistics showed the Dental Corps to have the lowest retention rate of all Army 

officer corps. As a result, The Surgeon General appointed ad hoc committee of general officers to review dental services. 

The committee verified many inefficiencies of the MEDDAC organization as it related to dental services. 

1 July 1974 – The one-year General Practice Residency Program replaced the one-year Dental Intern Program. This 

residency was an effective recruiting tool and provided a reservoir of better trained young officers for many remote 

assignments. 

2 May 1975 – A job description for civilian Community Health Dental Hygienists (CHDH) was approved by Headquarters, 

Department of the Army. This action acknowledged that in addition to clinical preventive dentistry there are many 

community based measures that contribute significantly to Soldier and family member oral health. However over the next 

decade, the need to use hygienists in their clinical rolls diverted their concentration on community efforts and the use of 

CHDH and these positions vanished from the Army. 

29 August 1975 – COL George Kuttas was promoted to brigadier general and assumed the position of Deputy Commander, 

7th Medical Command, Europe. He was the first Dental Corps general officer to serve in this position. 

1 September 1975 – BG Surindar N. Bhaskar was promoted to major general and sworn in as Assistant Surgeon General 

for Dental Services, OTSG, and as 17th Chief, Army Dental Corps, with 1,856 officers. Armed with the recommendations 

of the Army Surgeon General’s ad hoc committee on dental services, General Bhaskar set about planning and implementing 

the Installation Dental Service Management Program. 

18 February 1976 – The Installation Dental Service Management Program was initiated by the Surgeon General as a trial. 

The program consisted of organizational changes to give to Dental Corps officers authority over, and accountability for, 

dental functions. Also, a large number of measures were directed at increasing dental officer time for patient care, reducing 

administrative overhead, and basing dental leadership appointments on merit. The trial was successful. See entries about 

regulatory changes in December 1977 and legislative changes in October 1978. 

27 May 1976 – The Mobilization Designee (MOBDES) Program for reserve Dental Corps officers was implemented. 

Reserve dental officers assigned to the MOBDES Program trained to play a specific wartime role in the event of a reserve 

mobilization and to serve as the adviser for all reserve activities related to their unit. 

29 November 1976 – The Dental Corps was the first AMEDD corps to hold a command selection board and develop a 

command selection list from which dental commanders and other key dental staff positions would be filled. The philosophy 

was that selection of commanders should be based on merit rather than on date of rank. 

16 May 1977 – Staffing of dental commands was revised to make the executive officer a Medical Service Corps (MSC) 

position. With this change, trained health care administrators relieved dental officers of administrative tasks so they could 

spend more time on activities for which their dental training was required. 

7 December 1977 – Changes to AR 40-1, Composition, Mission, and Functions of the Army Medical Department, and AR 

40-4, Army Medical Department Facilities/Activities, directed worldwide adoption of the major elements of the Installation 

Dental Service Management Program initiated in February 1976. This followed health care studies that indicated a more 

than 65% increase in productivity and dramatic improvements in dental officer retention rates under the program. The 

regulation established the Dental Activity (DENTAC) concept: all dental units were to be commanded by a dental officer, 

funds for dental operations would be “fenced,” and enlisted personnel in these units would be under the control of dental 

officers. The installation dental commander would be responsible directly to the post commander rather than through the 

post medical commander. 

21 September 1978 – The Dental Specialist (Military Occupational Specialty [MOS] 91E) course structure was revised to 

create a 44-week Dental Hygienist training course. The course would be accredited by the ADA and produce graduates who 

were eligible for state dental hygiene board examinations. 
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20 October 1978 – US Public Law 95-485, 10 USC 3081, was passed by Congress, enacting the principles of the 

Installation Dental Service Management Program. The law specified that the Assistant Surgeon General/Chief of the Dental 

Corps was responsible to the Surgeon General and through the Surgeon General to the Chief of Staff of the Army, for all 

matters concerning dentistry and dental health of the Army. It also stipulated that dental personnel would be organized into 

dental units commanded by a Dental Corps officer and that the dental commander was directly responsible to the 

commander of the installation served. Under this DENTAC concept, management indicators continued to demonstrate the 

value of dental command and control. 

17 February 1979 – BG George Kuttas was promoted to major general and sworn in as Assistant Surgeon General for 

Dental Services and 18th Chief, Army Dental Corps, with 1,764 officers. 

26 October 1981 – The 4 Regional Dental Activities that provided dental laboratory support to the Army were redesignated 

US Army Area Dental Laboratories (ADL). They were located at Alameda, California; Fort Gordon, Georgia; Fort Sam 

Houston, Texas; and Walter Reed Army Medical Center, Washington, DC 

8 July 1982 – The DoD Dental Chiefs Council was officially established as a subordinate element of the DoD Health 

Council by DoD Directive 5136.8. The primary members of this Council were the Chiefs of the Dental Corps for the Army, 

Navy and Air Force. The Chief Dental Officer of the Public Health Insurance was also invited to participate. 

1 December 1982 – BG H. Thomas Chandler was promoted to major general and sworn in as Assistant Surgeon General 

for Dental Services and 19th Chief, Army Dental Corps (1,810 officers). 

25 October 1983 – Operation Urgent Fury. In the wake of a violent overthrow of the Caribbean island government of 

Grenada, the United States combined with 6 Caribbean states in a joint operation to restore peace and public order. Dental 

personnel were organic to the deploying units. After-action reports indicated that dental officers were heavily involved in 

alternate wartime roles (eg, combat casualty care) during the combat phase of the operation; provided sustaining dental care 

to Soldiers during the occupation phase; and delivered humanitarian support at the request of Grenadian civilian authorities 

since the operation severely disrupted the civilian dental infrastructure. 

8 November 1983 – The Surgeon General directed that combat casualty and surgical training be provided to dental officers 

to prepare them for alternate medical roles during wartime. Since dental officers are used to augment AMEDD casualty care 

capability, during periods of overwhelming casualties, they should receive appropriate training. 

12 December 1985 – An airplane carrying 248 Soldiers of the 101st Airborne Division crashed in Gander, Newfoundland, 

killing all aboard. Contrary to administrative policy of that time, their dental records were on board and lost in the resulting 

fire. This created difficulties in identifying remains. In order to avoid future mass casualty identification problems, 

personnel regulations were modified to make adequate dental identification records a requirement for operational troop 

movement. By January 1986 a program was established to store backup (duplicate) panographic radiographs at the Central 

Panograph Storage Facility (CPSF) in Monterey, California. During the early 1990s the use of antemortem/postmortem 

DNA sample comparison, and the capability to take, store and retrieve digital panographic images negated the need for 

physical, central storage and the CPSF was closed. 

1 December 1986 – BG Bill B. Lefler was promoted to major general and sworn in as Assistant Surgeon General for 

Dental Services and 20th Chief, Army Dental Corps, with 1,715 officers. 

1 March 1987 – In an update of AR 40-35, Preventive Dentistry, the Oral Health Fitness Program replaced the Army Oral 

Health Maintenance Program as the method for improving Soldier readiness. The principal feature of the program was the 

Dental Fitness Classification System to identify and target Soldiers at highest risk of being casualties from preventable 

dental conditions. 

1 August 1987 – The Dependents Dental Plan (DDP) was first implemented (authorized on 8 November 1985 by PL 99-

145 and funded in December 1986 by PL 99-500, the FY 1987 Defense Appropriations Bill). This was voluntary dental 

insurance for family members of active duty military personnel. The cost of the premium was shared by the government and 

the Soldier. The plan paid 100% of diagnosis and preventive services and 80% of most restorative procedures. 

1 October 1987 – Eighty-one contract civilian dentists were hired for CONUS dental clinics. This action was required due 

to a loss of military Dental Corps positions, reducing the authorized strength to 1,679. (Actual assigned strength at that time

was 1,648 officers.) 

1 June 1989 – Fixed prosthodontics (Area of Concentration [AOC] 63F) and removable prosthodontics (AOC 63G) 

specialties were combined into the personnel management code for prosthodontics (AOC 63F); training was combined into 

a single residency training program of prosthodontics. 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

20 December 1989 – Operation Just Cause. US troops forcefully took control of Panama, partly because of physical 

harassment by Panamanian Defense Forces of US personnel stationed in that country, and largely to remove dictator 

Manuel Noriega because of his corrupt military oppression and his support of illegal drug trafficking. The dental support for 

maneuvering troops came predominately from the Panama DENTAC, with the addition of unit dental support that deployed 

with CONUS-based units. The operation was completed by January 1990. 

12 January 1990 – AR 600-8-101, Personnel Processing (In-and-Out and Mobilization Processing), implemented dental 

readiness standards for all military personnel movement as a means of enforcing the Oral Health Fitness Program described 

in AR 40-35, Preventive Dentistry. Both regulations require as a condition for deployment, that Soldiers attain oral health 

level (as indexed by the dental fitness class) that lowers the risk of dental emergency for at least a year. 

PERSIAN GULF WAR (1990 – 1991) 

2 August 1990 – Iraq invaded Kuwait threatening the stability of the region. A coalition force of approximately 20 nations 

lead by the US was immediately organized to liberate Kuwait. 

8 August 1990 – The first US troop units arrived in Saudi Arabia along with their organic unit dental support. (Army dental 

support continued for a year past the end of the conflict, until February 1992.) 

13 August 1990 – The advance party of the 257th Medical Detachment (Dental Service) arrived in the Kuwait Theater of 

Operations (KTO). The main body followed within the next few weeks. 

23 August 1990 – The activation for the impending operation of reserve component units began. Dental Activities 

expanded for dental processing during mobilization and deployment. Reserve and National Guard personnel were found to 

have a much greater requirement for dental readiness procedures than active duty Soldiers. 

18 September 1990 – The Dental Consultant, US Army Central Command, arrived in Riyadh, Saudi Arabia, to provide 

dental staff support to this major Army command headquarters. 

1 December 1990 – BG Thomas R. Tempel was promoted to major general, and on 3 December became the Assistant 

Surgeon General for Dental Services and the 21st Chief, Army Dental Corps. The active duty Dental Corps numbered 1,619 

officers. 

8 December 1990 – Dental units from Europe began to arrive in the KTO. They included the 2d Medical Detachment (AI) 

for command and control and the 87th, l22d, and 123d Medical Detachments (HA) for area support dental services. Before 

the combat phase started the units were task organized so that the 2d Med Det, 122d Med Det, and 123d Med Det supported 

echelons above corps; the 87th Med Det supported the VII Corps; and the 257th Med Det supported the XVIII Airborne 

Corps. Oral and maxillofacial surgeons accompanied Army hospitals, and maneuver units had their organic unit dental 

support. Until actual combat started, the massive military buildup was intended to deter Iraq from further aggression and 

was called Operation DESERT SHIELD. During this phase, dental support provided care to sustain the oral health of the 

force. 

17 January 1991 – The air war started. The combat phase of the war was called Operation DESERT STORM. Army dental 

elements moved with troops to treat dental emergencies and provide dental sustaining care to Soldiers while waiting for the 

ground war to start. 

24 February 1991 – The ground war began. Dental care was provided to treat dental emergencies, treat oral and 

maxillofacial combat casualties, and perform alternate wartime roles. Emergency dental care was also provided to civilian 

refugees and enemy prisoners of war. 

27 February 1991 – The combat ended and dental units resumed sustaining dental care for the US military force. During 

the phased withdrawal of supported units dental units were also redeployed. The last dental unit to withdraw was the 122d 

Med Det, remaining until February 1992 to support residual security and redeployment personnel. 

Persian Gulf War Statistics – Mobilization and deployment dental processing was provided to 243,829 DoD personnel 

between 2 August 1990 and the end of the war. Five reserve dental units and a number of Individual Mobilization 

Augmentees (IMA) were activated to help with the massive dental workload brought on by reserve force mobilization. This 

period also saw the stateside dental capability depleted by deployment of active duty dental personnel. There were 550 

dental reservists activated: 223 DC officers, 5 MSC officers, and 322 enlisted. In the KTO, by the time of peak US Army 

activity in February 1991, 300,000 Soldiers were being supported by 25 oral and maxillofacial surgeons, 96 other dental 

officers, and dental enlisted personnel. 
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END OF COLD WAR

Events in 1989 and 1990 in Eastern Europe led to the dissolution of the Soviet Union and dramatic movement toward 

democracy of former Communist-bloc countries. US military planners quickly began actions to draw down the size of the 

force in Europe, as well as to downsize the US military forces worldwide. Downsizing and restructuring the dental 

organization became the main trends of the early 1990s. Downsizing required that some dental officers who were eligible 

for retirement be mandated to do so by Selective Early Retirement Boards (SERBs). Other officers were offered severance 

bonuses and partial retirement benefits for early separation or retirement. Fortunately, involuntary reduction in force (RIF) 

measures were not needed. 

1991 – The Area Dental Laboratories (ADL) at Alameda, CA and at Walter Reed were closed, leaving ADL at Fort Gordon 

and Fort Sam Houston to provide dental laboratory services to Army dental activities. 

16 October 1991 – Strategic plan “Medical Force 2000” began its restructuring of dental units in Europe by reflagging the 

87th and 561st Medical Detachments (HA) to be Medical Companies (Dental Service). Other HA detachments converted to 

the new force structure over the next several years. 

6 April 1992 – The 163rd Medical Battalion (Dental Service) was activated in Korea, becoming the first dental TOE 

command and control unit (formerly a Medical Detachment, AI) to function under the Medical Force 2000 structure. 

Subordinate units included the newly reflagged 655th and 618th Medical Companies (DS) and the 56th Medical 

Detachment (DS). 

27 August 1992 – Operation Andrew. Immediately following the devastating impact of Hurricane Andrew on 24-26 

August, the 257th Medical Detachment (DS), and dental elements of the 82d Airborne and 10th Mountain Divisions carried 

out a textbook example of effective domestic support activities to help the civilian dental community reestablish dental 

services to the affected area. 

9 December 1992 – Operation Restore Hope (December 1992-March 1994). US troops were deployed to the east African 

country of Somalia to provide security for international humanitarian famine relief organizations against conditions of 

anarchy and armed gangs. Marines and 10th Mountain Division members made up a force of about 21,000. Army dental 

support was provided by 11 dental officers and the supporting dental assistants. These personnel were split between 2 

periods of rotation. 

31 December 1992 – Mandatory reductions under the Conventional Forces Europe (CFE) Treaty included reduced dental 

assets. Prior to CFE there were 11 Dental Activities (DENTAC) in Europe with 62 Dental Treatment Facilities (DTF). By 

1995 there were 3 remaining DENTAC at Landstuhl, Heidelberg, and Wuerzburg, Germany, with 7 Dental Clinic 

Commands subordinate to them. Collocated with the TDA dental units in 1995 were also 6 TOE dental units under the 93d 

Medical Battalion (dental command and control unit). ( See also 30 June 1993 entry.) Most of the positions in the TOE were 

filled by personnel from the TDA units through the Professional Filler System (PROFIS) and memorandums of agreement. 

January 1993 – AMEDD reorganization included assigning MG Thomas R. Tempel to the position of Deputy Surgeon 

General. The reorganization also established the US Army Medical Command (MEDCOM), with worldwide command and 

control over all Army TDA medical assets. The headquarters was established in San Antonio, Texas, replacing the 

Headquarters, Health Services Command. The Surgeon General then assumed 2 “hats”: as Surgeon General he continued as 

the senior medical staff officer to the Army Chief of Staff, and he also became the commander of the MEDCOM. After MG 

Tempel left the position of Assistant Surgeon General and Chief, Army Dental Corps, in December 1994 he continued in 

the position of Deputy Surgeon General. 

30 June 1993 – Headquarters, 93d Medical Battalion (Dental Service), was activated. Through the Medical Force 2000 

restructuring initiative, the 93d replaced the 2d Medical Detachment (AI) as the dental command and control headquarters 

for designated dental companies in Europe. 

1 October 1993 – The US Army Institute of Dental Research was reorganized as the US Army Dental Research Detachment, subordinate to the Walter Reed Army Institute of Research, Walter Reed Army Medical Center, Washington, DC. 

1 November 1993 – The US Army Dental Command (DENCOM) was provisionally activated in San Antonio, Texas, as a 

major subordinate element of the US Army Medical Command. COL (later major general) Patrick D. Sculley, previously 

the Director of Dental Service, HSC, became the DENCOM’s first commander. (On 2 October 1994, provisional status was 

removed.) This action established Army dental service delivery under a dental command with worldwide authority over all 

TDA dental units. Subordinate to the DENCOM were 8 Dental Service Support Areas (DSSA). Subordinate to the DSSA 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

were a total of 31 DENTAC and 20 Dental Clinic Commands and the Area Dental Laboratories. This organization was 

transitional to one officially adopted on 1 June 1998. (See entry for 1 June 1998.) 

13 July 1994 – BG(P) John J. Cuddy, a Dental Corps officer, assumed command of the US Army Medical Department 

Center and School at Fort Sam Houston, Texas. On 18 July BG Cuddy was frocked with rank of major general. 

14 July 1994 – BG Robert E. Brady assumed command of the 30th Medical Brigade, US Army, Europe. The 30th Medical 

Brigade replaced the 7th Medical Command for medical command and control of all field medical units (TOE) in Europe. 

Having a dental officer command a major medical TOE unit was part of the Surgeon General’s (LTG Alcide M. LaNoue’s) 

policy to make assignment of general officer positions in the AMEDD without regard to Corps. Appointment of MG 

Tempel as Deputy Surgeon General and MG Cuddy as commander of the AMEDD Center and School were also seen as a 

result of this policy. 

1 October 1994 – The senior dental NCO position at the Medical Battalion (Dental Service) was converted from staff 

sergeant major, who was specified to be an MOS 91E, to command sergeant major, MOS immaterial from within the Career 

Management Field (CMF) 91. Soldiers who had been assigned the Military Occupational Specialty (MOS) of 42D, Dental 

Laboratory Specialist, were reclassified to be a subspecialty of Dental Specialist (MOS 91E) and identified with an 

Additional Skill Identifier (ASI) of “N5,” ie, MOS 9lEN5. 

1 December 1994 – MG John J. Cuddy officially became the 22nd Chief, US Army Dental Corps. Actual DC strength was 

1,244 officers. For the first time in Dental Corps history the Office of the Chief was not physically in the Washington, DC, 

area, but moved to San Antonio, where MG Cuddy also commanded the AMEDD Center and School. The Senior Dental 

Corps Staff Officer, however, remained at the Falls Church, Virginia, office to coordinate operations in the Washington 

area. From October 1995 to 25 February 1996 MG Cuddy was also Installation Commander for Fort Sam Houston, TX. 

16 January 1995 – BG Patrick D. Sculley assumed command of the US Army Center for Health Promotion and Preventive 

Medicine, the first time that this major AMEDD TDA subordinate command of the Medical Command was commanded by 

a Dental Corps Officer. 

January 1996 – December 2005 Balkan operations – SFOR. The demise of the Soviet Union in 1991 had reawakened 

centuries old ethnic feuds between myriad Balkan factions of Eastern Europe. In early 1998, war broke out between Serbs 

and ethnic Albanians living in the Serbian province of Kosovo. The US provided troops to NATO peacekeeping forces for a 

series of 6 month rotations of a Stabilization Force (SFOR) in Bosnia and Herzegovina. Dental support for US Forces was 

provided by a combination of dental personnel organic to deploying units and personnel requested by FORSCOM, and 

tasked from DENCOM to support during these rotations. 

13 March 1996 – Upon the retirement of MG Tempel, MG Cuddy relocated to Falls Church and assumed the 

responsibilities of Army Deputy Surgeon General while retaining his position as Chief of the Dental Corps. 

1 October 1997 – The Area Dental Laboratory at Fort Sam Houston was closed leaving the Fort Gordon ADL as the only 

remaining laboratory for dental support. The creation of one Center of Excellence for dental laboratory services allowed consolidation of the dental laboratory mission at Fort Gordon. This business decision was driven by post-cold war downsizing, 

better capability to manage case transportation and communications, and improved efficiency through technology at Fort 

Gordon. On 1 July 1998 the name was changed from Area Dental Laboratory to The Army Dental Laboratory. 

1 October 1997 – As a result of Interservice Training Review Organization (ITRO) recommendations the Army’s Dental 

Assistant and Dental Laboratory Technician training program was consolidated with that of the Air Force and Navy at 

Sheppard Air Force Base, Texas. The Department of Dental Science, Fort Sam Houston graduated the last Dental 

Laboratory Specialist Course (91EN5) on 17 October 1997 and the last Dental Specialist Course (91E) on 31 October 1997. 

After trial period, the Army felt the consolidated program at Sheppard AFB was not meeting the Army’s needs for dental 

assistants and in October 1999 Army enlisted Dental Specialist (91E) training was returned to the Academy of Health 

Sciences, Department of Dental Science. Training for 91EN5 remained at Sheppard AFB. 

1 June 1998 – The DENCOM’s subordinate Dental Service Support Areas (DSSA) were renamed Regional Dental 

Commands (RDC) and the number of RDC reduced to 6: Great Plains, North Atlantic, Southeast, Western, Pacific, and 

European Regional Dental Commands. Subordinate to RDA were 28 Dental Activities (DENTAC) and 24 Dental Clinic 

Commands (DCC). 

2 December 1998 – Upon the retirement of MG Cuddy, BG Patrick D. Sculley moved to Falls Church to serve as the 

Special Assistant to the Surgeon General. 
22 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Highlights in the History of Army Dentistry 

1 June 1999 – Upon promotion to major general, Patrick D. Sculley officially became the 23rd Chief, US Army Dental 

Corps, the Army Deputy Surgeon General, and the Chief of Staff, US Army Medical Command. Actual DC strength was 

984. MG Patrick D. Sculley retired 31 May 2002 

1 June 1999 – Joseph G. Webb, Jr., then DENCOM Commander, was promoted to Brigadier General, and assumed duties 

as the Assistant Surgeon General and Deputy Chief of Staff for Force Sustainment, US Army Medical Command, with his 

office remaining in San Antonio. BG Webb was the first dental officer selected by “corps immaterial” general officer 

AMEDD board selection. Prior to this Dental Corps officers only competed with other dental officers for star positions. 

1 October 1999 – Medical Force 2000 (MF2K), the TOE force structuring concept from 1993, was replaced in 1999 with 

AMEDD’s Medical Reengineering Initiative (MRI). The first operational organization of the MRI force came on line as the 

618th Medical Company (Dental Service) converted to the 618thDental Company Area Support (MRI) in Seoul, Korea. 

The MRI Dental Company replaced a MF2K dental structure that had included a Dental Battalion and 2 Dental Companies, 

each roughly half the size of the MRI Company. The MF2K Dental Company that was deactivated in this conversion, the 

665th Med Co (DS), was the last continuously operating dental unit remaining in the Republic of Korea since the Korean 

War. 

1 October 1999 – As part of a DA pilot program of multicomponent units (MCU) the 673rd Medical Company (DS) at Fort 

Lewis included 6 reserve dental officers and 8 reserve enlisted Soldiers on the TOE of 59 personnel. (See entry for 20 

March 2004 concerning deployment to OIF.) 

1 July 2001 – DENCOM underwent reorganization so that under 6 Regional Dental Commands there was 29 Dental 

Activities and 16 Dental Clinic Commands. The changes included: Ft. Meade Dental Clinic Command was redesignated as 

a Dental Activity (DENTAC) under the North Atlantic Regional Dental Command; 5 Dental Clinic Commands were 

redesignated to be Clinics under DENTACs (White Sands, Ft. Monmouth, Redstone Arsenal, Hunter Army Airfield, and 

Baumholder). 

HOMELAND SECURITY AND WAR IN AFGHANISTAN(2001 – PRESENT) 

OPERATION NOBLE EAGLE AND OPERATION ENDURING FREEDOM. 

11 September 2001 – Four commercial jetliners, hijacked by terrorists, crashed into the west side of the Pentagon, 2 of the 

World Trade Center towers in New York City, and into a nonpopulated area of Pennsylvania. Army dental personnel from 

the Pentagon dental clinic assisted in evacuation, triage and emergency care of over 90 Pentagon wounded. Dental 

personnel from the Walter Reed dental clinic were also involved in the triage and treatment of wounded evacuated to Walter 

Reed Army Medical Center. 

25 September 2001 – Secretary of Defense Donald H. Rumsfeld announced that the war against terrorism outside the 

United States would be known as Operation Enduring Freedom, and Operation Noble Eagle would designate US military 

operations in homeland defense and civil support to US federal, state and local agencies. 

September 2001 – Dental forensic operations. As part of the immediate military response for homeland security, 

designated as Operation Noble Eagle, Army Dental Corps Oral Pathologists and support personnel from the Armed Forces 

Institute of Pathology (AFIP) were sent to Dover Air Force Base to participate in the identification of remains. 

Identification was accomplished through various means including matching antemortem dental records, fingerprints, bone 

analysis and DNA comparisons. Despite the closure of the Central Panograph Storage Facility in Monterey, California, 

panographs of many military victims were still on file at the facility. With commercial planes grounded, the Department of 

Defense dispatched these dental records cross-country by military aircraft. Panographs again proved to be a valuable 

comparison tool for making positive victim identification. Three weeks into the mission, dental identifications were 

performed in over 63% of the cases, and in 30% of the cases dental evidence served as the sole method of identification. 

7 October 2001 – Operation Enduring Freedom, Afghanistan. The initial US military response to the 11 September 2001 

terrorist attacks on the United States was assigned the name Operation Enduring Freedom (OEF). Having identified the Al 

Qaida terrorist organization as responsible for the September11 attack, the US launched an offensive against this group and 

the extremist Taliban government of Afghanistan that harbored them. Dental support to OEF further taxed Army dental 

resources already spread thin by other worldwide requirements. 

March 2002 – DENCOM began training of Expanded Function Dental Assistants (EFDA). In the post Sept 11, 2001 

terrorist attack milieu of ramping up for increased military conflict while at the same time guided by Secretary of Defense 

Donald Rumsfeld’s DoD reorganization initiatives the Army Dental Care System (ADCS) was faced with the difficulty of 

preparing larger numbers of Soldiers for deployment with a shrinking pool of general dentists. Building on its previous 
 January – March 2011 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

reengineering experience (the Dental Care Reengineering Initiative (DCRI)) the ADCS pursued a program to optimize 

dental care delivery and improve clinical efficiencies. Dental Care Optimization (DCO) is the name used for the updated 

reengineering efforts. After careful study of efficient delivery systems, DCO adopted, along with other best clinical 

practices, the use of multichair, multiancillary primary care teams led by general (AOC 63A) and/or comprehensive dentists 

(AOC 63B) and enhanced with dental assistants with advanced training. These Expanded Function Dental Assistants 

(EFDA) were selected from currently employed civilian dental assistants and provided advanced training, allowing them to 

perform reversible dental restorative and dental hygiene procedures. (See also 27 March 1972 entry concerning DTA, an 

earlier program to establish a dental personnel type with expanded function.) 

1 May 2002 – President George W. Bush presented the Medal of Honor posthumously to CPT Ben L. Salomon, Dental 

Corps, for his “extraordinary heroism and devotion to duty” on 7 July 1944 during the campaign to capture the island of 

Saipan in the Mariana Islands. In the absence of living family members President Bush presented the award to 

representatives of the Army Dental Corps and the University of Southern California, Salomon’s dental school. Salomon is 

the only US Army Dental Corps Officer to be award the Medal of Honor. (See entry for 7 July 1944 and OTSG website 

http://history.amedd.army.mil/moh/Salomon.html for more details.) 

1 August 2002 – Upon promotion to major general, Joseph G. Webb, Jr. officially became the 24th Chief, US Army Dental 

Corps. He also assumed the duties of Commanding General, Pacific Regional Medical Command, and Tripler Army 

Medical Center, TRICARE Pacific Lead Agent, and Commander (PROFIS) of the 18th MEDCOM. This marked the first 

time a dental officer was placed in command of an Army Medical Center (MEDCEN). Actual DC strength was 1001, with 

budgeted end strength of 1138. In June 2004 MG Webb became the US Army Deputy Surgeon General and was reassigned 

to the Surgeon General’s Office in Falls Church, VA. 

OPERATION IRAQI FREEDOM (2003 – 2010) 

Threatened by indications that Iraq had supported terrorism against the US and that Iraqi President Saddam Hussein 

possessed weapons of mass destruction which he would use against US interests, President George W. Bush first supported 

diplomacy through the United Nations, and also prepared for military operations in Iraq. The operations were referred to As 

Operation Iraqi Freedom (OIF), See 31 August 2010 for President Barack Obama’s declaration of the end of OIF. 

RAMPING UP TO WAR

January 2003 – OIF dental support was initiated by processing (classification and treatment) of troops at 16 different active 

duty installations. In all, over 120,000 active and reserve Army forces were screened and treated for duty in Iraq and 

Kuwait. 

17 January 2003 – The first Reserve Component, Installation Medical Support Units (IMSU) that provided dental support 

arrived at 15 different power projection platforms (PPPs) across the US IMSU dentists augmented the capabilities 

DENTAC responsible for mobilizing US Army Reserve (USAR) and Army National Guard (ARNG) Soldiers for active 

service. In all, 75 dentists and 179 dental assistants from 21 IMSUs and one US Army Hospital (USAH) were activated. 

Dental officers were activated for 90-day rotations, with 30 eventually extending beyond their initial 90-day call-up. 

February 2003 – The Reserve Component (RC), Individual Mobilization Augmentee (IMA) for the DENCOM Commander 

was placed on active duty to direct the use of RC dental assets within Continental US (CONUS). 

March 2003 – Reserve Component (RC), Individual Mobilization Augmentee (IMA) dentists arrived at various Active Duty 

units to backfill for 55 deploying active duty DENCOM dentists. The active duty dentists were reassigned from their normal 

duty location by the Professional Filler System (PROFIS) Program to fill deploying units. In all, 17 IMAs activated for 90-

day rotations, with 2 extending voluntarily beyond the initial 90 days. In mid-March an additional Six RC dentists activated 

from Installation Medical Support Units (IMSU). 

20 March 2003, Invasion of Iraq – President George W. Bush gave the order to liberate Iraq from its corrupt dictator, 

Saddam Hussein, and his oppressive regime. Over 233,000 US Army Soldiers were deployed in support of Operation Iraqi 

Freedom (OIF). 

In addition to dental support from dental personnel organic to deployed tactical units, Medical Companies (area support 

dental services) were also deployed. The 93rd Medical Battalion (Dental Service) from Heidelberg, Germany, commanded 

by COL (later major general) Russell J. Czerw, provided dental command and control to most of the dental companies in 

theater. In the early stages of OIF, elements of the 93rd supported V Corps and theater missions in Kuwait and Iraq. 
24 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

It is interesting to observe that the 93rd Med Bn served as a transition between earlier Medical Detachment AI dental 

command and control units (that existed from Vietnam War until the end of the Gulf War) to the multifunctional medical 

battalion concept implemented in 2007 as part of the Secretary of Defense's Transformation Planning Guidance. Although it 

was designated as a medical battalion (dental service), like the AI detachment was in earlier operations, the 93rd was task 

organized to also provide command and control to subordinate units with functions other than dental. 

1 May 2003 – “Major military operations” of OIF ended, but operations to stabilize Iraq continued. Two AC units, 502nd 

and the 561st Medical Companies (Dental Service) remained in theater to provide area dental support after the 

redeployment of the 2 units with RC personnel, the 673rd and the 965th. Later other Med Co (DS) rotated into and out of 

Iraq to provide dental support to the stabilization phase of the Iraq war. One example is the 380th Med Co (DS) a Reserve 

Component unit from Millington, TN. 

June – July 2003 – A second rotation of RC dentists were activated: 27 IMSU dentists to support mobilization platforms, 2 

IMSU dentists and 2 US Army hospital dentists to support CONUS Replacement Center (CRC) missions, and 5 IMA 

dentists were activated to support continuing OIF mobilizations and demobilizations 

July 2003 – First Term Dental Readiness (FTDR). Because of high operational tempo, first term Soldiers frequently 

deployed to areas of military operations soon after arrival at their first permanent duty station, leaving very little time for

predeployment medical/dental processing. The US Army Medical Command and the US Army Training and Doctrine 

Command signed a memorandum of understanding in July 2003 to implement a First Term Dental Readiness pilot program 

at Army Advanced Individual Training (AIT) and one-station unit training (OSUT) sites. The pilot program began 1 

October 2003 at Fort Sill, Oklahoma, and 1 November 2003 at Fort Knox, Kentucky. The goal of FTDR program is to have 

95% of AIT graduates dentally ready to deploy when they arrive at their first permanent duty station. 

October 2003 – Health Professions Loan Repayment Program (HPLRP). Dental officer recruitment and retention rates 

were severely and negatively affected by the overwhelming burden of dental school educational debt. With the intent to 

relieve this situation, the DENCOM initiated the Active Duty Health Professions Loan Repayment Program (HPLRP). The 

program provided payment of educational loans tied to securing a dental degree. Officers eligible for participation in this 

program must have between 18 months and 14 years of service as of 31 January 2004. Direct accessions and those with less 

than a 4-year Health Professions Scholarship Program (HPSP) scholarship were eligible for the HPLRP. There were no new 

starts in the HPLRP program in 2007, but the Dental Corps was included in the AMEDD Corporate HPLRP program, with 

emphasis on recruitment. Effective 1 April 2007, uncommitted HPLRP recruitment funds were reallocated as a retention 

tool. 

10 July 2006 – COL Russell J. Czerw was promoted to major general and became the 25th Chief of the US Army Dental 

Corps. On 11 July he assumed the position of Commander, US Army Medical Department Center and School and Post 

Commander of Fort Sam Houston, Texas. When MG Czerw assumed the duties as Dental Corps Chief, budgeted Corps 

strength was 1,104, but the actual strength had declined into the lower 900s throughout FY06. As Corps Chief, MG Czerw 

made officer recruitment and retention his number one priority. He assigned a Dental Corps junior officer to the US Army 

Recruiting Command (USAREC) as assistant to the USAREC Dental Corps Program Manager, and to act as the command's 

personal subject matter expert regarding potential DC Corps accessions, and serve as liaison to dental schools and national/

state/local dental entities. By FY10, Dental Corps recruiting missions were met and/or exceeded for Health Professions 

Scholarship students and Active Duty and Reserve Component Direct Accessions. In his role as Commander of Ft Sam 

Houston and the AMEDDC&S, MG Czerw was instrumental in coordinating actions dictated by the Base Closure and 

Realignment Committee. The major tasks in that responsibility were the creation of the Joint Medical Training Campus for 

all US military services' enlisted medical training, establishment of Joint Base San Antonio, and oversight of Ft Sam 

Houston installation infrastructure enhancements totaling more than $2 billion. 

26 August 2006 – 15 August 2007 US Army Reserve MG Ronald D. Silverman became the first dentist to command 

medical operations in a theater of combat operations. MG Silverman commanded 3rd Medical Command and Task Force 3 

in Operation Iraqi Freedom. Task Force 3 was a multiservice medical force of more than 3,000 Soldiers assigned to 30+ 

medical units. 

1 October 2006 – the Military Occupation Specialty (MOS) field 91E was recoded to be MOS 68E for all Dental 

Specialists. This new code includes 68E for Dental Specialist, 68EN5 for Dental Laboratory Specialist and 68EX2 for 

Preventive Dentistry Specialist. 

15 March 2007 – The Chief, US Army Dental Corps approved the appointment of COL Priscilla Hamilton as the Deputy 

Chief of the US Army Dental Corps. COL Hamilton, who had been serving in the Corps Chief’s office as the senior DC 

Highlights in the History of Army Dentistry 
 January – March 2011 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

Staff Officer, was the first person to occupy this new position. She later became the first woman to command the US Army 

Dental Command in August, 2010. 

24 March 2010 – The US Army Dental and Trauma Research Detachment, US Navy Institute of Dental and Biomedical 

Research ,and the US Air Force, Dental Evaluation and Consultation Service Detachment relocated from Great Lakes Naval 

Center near Chicago, IL to Fort Sam Houston, TX. The 3 military dental research units are collocated in a new 25,000 

square foot facility, the Battlefield Health and Trauma Research Institute.

7 May 2010 – COL M. Ted Wong became the 26th Chief of the US Army Dental Corps. Promoted directly to major 

general, he was selected to serve as the Deputy Commanding General for Readiness, Western Regional Medical Command 

and the Commanding General for William Beaumont Army Medical Center at FT. Bliss, Texas. The actual Dental Corps 

strength when MG Wong became Chief of the Corps was 975 dental officers. 

31 August 2010 – President Barack Obama announced the end of America’s “combat role” in the 71⁄2 year war in Iraq by 

withdrawing 90,000 troops. A transitional force of 50,000 troops remained, down from the peak of 170,000 in 2007. This 

new military phase in the Iraqi conflict is called “Operation New Dawn.” Dental operations in Iraq were reduced 

proportionately to the reduction of force. 

REFERENCES

1. Jeffcott GF. United States Army Dental Service in World War II. Washington, DC: Office of The Surgeon General, 

US Dept of the Army; 1955. 

2. Hyson JM. The United States Military Academy Dental Service: A History 1825 – 1920. West Point, New York: 

United States Military Academy; 1989. 

3. Hyson JM Jr, Whitehorne J, Greenwood JT. A History of Dentistry in the United States Army to World War II. 

Washington, DC: Borden Institute, Office of the Surgeon General, US Dept of the Army; 2008. 

4. King JE, Hynson RG. Highlights in the History of US Army Dentistry, Year 2007. Fort Sam Houston, TX: Office of 

Medical History, US Army Medical Dept; 2007. Available at: http://history.amedd.army.mil/corps/dental/general/

highlights/highlights.html. Accessed October 15, 2010. 

AUTHORS

COL Passo is currently assigned to the Fort Knox Dental Activity as a Periodontist. He is also Consultant for Dental 

History to the Chief of the Army Dental Corps. 

Before his retirement, COL (Ret) King was the Consultant for Dental History to the Chief of the Army Dental Corps. 

He continues active interest in promoting the use of history as an aid to management. 

Unique requirements of military dental care 

include, but are not limited to, a high degree of 

mobility and ability to set-up quickly. This photo 

from World War I shows one of many ways Army 

dental officers adapted civilian dental equipment, 

Army-designed field dental equipment, and 

standard military vehicles for these capabilities. 
26 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

Computerized dentistry was introduced in 1980 when 

Dr Werner Mörmann of the University of Zurich, 

anticipating the attraction of restoring posterior teeth 

with tooth-colored materials, developed the bonded 

ceramic inlay technique while at the same time 

addressing the issue of fabricating the restorations 

using computer-aided design/computer-aided 

manufacturing (CAD/CAM). This technology would 

enable a dentist to complete one or multiple ceramic 

restorations (inlays, onlays, veneers, and full crowns) 

chairside in a single appointment. Currently, there are 

4 CAD/CAM systems on the market designed for the 

ceramic restorative dental application: CEREC Acquisition Center (Sirona, Bensheim, Germany), E4D 

(D4D Technologies, Richardson, TX), Lava C.O.S. 

(3M ESPE, St. Paul, MN), and iTero (Cadent, Carlstadt, NJ). The CEREC system is 

the original and most-researched 

system on the market and has been 

used in the US Army Dental Command since 2003, and will 

therefore be the focus of this 

article. Following is a brief 

discussion of the evolution of 

CEREC and CAD/CAM, a review 

of the literature, a detailed 

explanation on the use of the 

current state of the art CEREC AC, 

and an examination of the benefits 

of CAD/CAM to the US Army 

dental mission. 

On September 19, 1985, the first 

chairside ceramic inlay restoration was placed at the 

University of Zurich Dental School with the CEREC 1 

CAD/CAM system (Sirona Dental Systems, Charlotte, 

NC). The concept that a machine-milled ceramic 

restoration could be fabricated chairside with the 

benefit of only one dental visit was revolutionary for 

restorative dentistry. Even so, the idea was initially 

met with skepticism among practicing dentists, raising 

questions on the viability of its future acceptance.1

The CEREC (ceramic reconstruction) system has 

evolved dramatically over the past 25 years, 

encompassing 3 generations of equipment and 

software since the introduction of CEREC 1, which 

offered only ceramic inlays and veneers, through 

CEREC 2 which included onlays and full crowns, up 

to the present-day CEREC 3 which offers enhanced 

capabilities designed to improve overall speed and 

accuracy. Through continuous research and 

development, there have been significant hardware and 

software changes to the original CEREC system 

(Figure 1). The separation of the milling chamber from 

the image capture and design hardware led to a 

significant improvement in clinical efficiency by 

allowing simultaneous design of one restoration while 

milling a second one. Form grinding of dental 

ceramics (milling units) changed from a less precise 

diamond grinding wheel, which required more clinical 

adjustment, to a more precise 2-bur 

system in 2006 with a reduced 

diameter at the tips allowing for a 

more optimal internal and external 

detail of the ceramic restoration. 

Later improvements to the 

computer’s speed, size, and 

memory, along with the change 

from a 2-dimensional design 

program (CEREC 2 in 1994), to a 3-

dimensional (3D) one (CEREC 3 in 

2003), resulted in a more realistic 

virtual display for dentists to design 

restorations in a way that they were 

used to seeing with stone casts. The 

3D design also allowed better work 

flow, and software tools enabled 

manipulation of the digital partial or full crown 

anatomy to the preparation, adjustment of the proximal 

contacts, and the ability to adjust the occlusion with 

the introduction of the antagonist tool to the opposing 

tooth contacts. In 2006, Mehl and Blanz2

 introduced a 

biogeneric model software database for inlays, onlays, 

and partial crowns. In 2010, the latest CEREC 

software (version 3.8) includes full crowns, 

eliminating the biomimetic crown database for full 

CAD/CAM Dentistry for Today’s 

 On-The-Go Military 

COL Jeffrey A. Hodd, DC, USA 

Figure 1. CEREC history: 

1. Prototype 

2. CEREC 1, 1987 (inlays, veneers) 

3. CEREC 2, 1994 (onlays, crowns) 

4. CEREC 3, 2000 (2003 3D) 

5. CEREC AC, 2009 
 January – March 2011 27

crowns. The biogeneric dynamic database, according 

to their research, looked at hundreds of caries-free and 

wear-free teeth as they scanned each individual tooth. 

The scans were completed at 100,000-point resolution 

per occlusal surface, capturing detailed anatomy. 

Using this database, average tooth characteristics were 

determined that encompass the statistical median of 

the population. During the biogeneric mathematical 

calculation, the average tooth shape is compared with 

the residual points on the surface of the tooth. 

Depending on the variance from the residual tooth 

structure to the average-shaped tooth, a final specific 

anatomy is proposed by the program. With full 

crowns, the software scans its neighboring teeth or an 

unrestored tooth in either dental arch to naturally 

reconstruct the occlusal surface while taking into 

consideration the antagonist (opposing) tooth. The end 

result is a more precise restoration with minimal to no 

adjustments intraorally.3

 In the 

most recent evolution, the CEREC 

Acquisition Center (AC) unit 

(Figure 2), has introduced a newly 

developed light-emitting diode 

camera (the Bluecam) that replaces 

the infrared-emitting camera from 

the CEREC Acquisition Unit 

system. The Bluecam features 

greater depth of field, higher 

precision, shorter acquisition times, 

an antishake feature, and automatic 

image capture. 

As the CEREC hardware and 

software continued to improve, 

developments in ceramic materials 

ran in concert. The first ceramic material used for the 

CEREC 1 was the Mark I Vitablocs (Vident 

Zahnfabrik, Bad Säckingen, Germany) and has the 

longest clinical track record in the dental literature.4

 It 

was a fine-particle, feldspar-based ceramic that could 

be pressed into a block and then machined into a 

dental restoration. From 1987-1997, the Mark I was 

predominately replaced with the Mark II (Vident 

Zahnfabrik), a fine-grained, high-glass content, 

feldspar-based ceramic. Through continual 

development, and in order to keep pace with changes 

in the equipment, the materials became even stronger, 

and other companies joined the ranks, such as Ivoclar 

Vivadent, which developed the ProCAD block (Ivoclar 

Vivadent Inc, Amherst, NY) that was composed of 

40% infiltrated leucite glass. Later, after several 

modifications, ProCAD became Empress CAD. The 

use of ProCAD is also well documented in the dental 

literature.5

 Most recent developments include the 

lithium disilicate ceramic called IPS e-max CAD, that 

has a high flexural strength while maintaining its 

esthetics. In 2007, Sirona Dental Systems introduced 

their CEREC block which has properties similar to the 

Mark II block, but with its own shading nomenclature. 

All of the available blocks are offered in 

monochromatic or polychromatic form and can be 

stained and glazed to accommodate the desired 

esthetic effect. 

PROVEN TRACK RECORD OF CAD/CAM TECHNOLOGY

Regardless of the 25-year history of CAD/CAM in the 

dental office, it differs from traditional treatment and 

manufacturing methods and has been one of the most 

critically examined restorative 

dental technologies, despite its 

exceptional clinical performance. 

While there are 4 restorative dental 

CAD/CAM systems on the market 

today, all of the global clinical 

evidence-based literature regarding 

this technology pertains to CEREC. 

According to a recent PubMed* 

search, there are 427 referenced 

articles for CEREC. The 5 most 

common areas discussed in the 

literature and among fellow dentists 

can be attributed to fit, longevity, 

strength, wear characteristics, and 

postoperative sensitivity. 

Marginal adaptation or fit varied through the 3 major 

generations of CEREC. Several authors have 

compared the marginal adaptation of the ceramic 

restoration to the prepared tooth by following 

thousands of patients and Mark I and II Vitablocs 

(Vident Zahnfabrik) restorations over the course of the 

CEREC evolution6-15 The CEREC 1 and CEREC 2 

technology on marginal gaps appeared to be 

significant with an approximate range between 200 

and 300 μm. With this increased gap, the resin-based 

composite cement would wear at the margin, leading 

to ditching along the tooth-restoration occlusal 

Figure 2. Chairside CEREC AC, CEREC 3 

Compact, and MCXL milling unit. 

*PubMed, a service of the US National Library of Medicine, 

provides search access to the MEDLINE database of citations, 

abstracts, and some full text articles on life sciences and 

biomedical topics (http://www.ncbi.nlm.nih.gov/pubmed). 
28 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

interface and minimal change at the interproximal 

tooth surfaces. Despite this clinically detectable 

discrepancy of the restoration, there was no evidence 

of secondary caries or microleakage, and, therefore, no 

clinical failure due to the margin wear. With the 

CEREC 3, marginal gaps significantly decreased; 

Nakamura and colleagues16 reported a margin gap of 

53 to 67 μm for CEREC 3 crowns. The marginal gap 

with the CEREC 3 AC system continues to be 

consistent with these latter values. 

Many advances in dental technology have taken place 

since the introduction of CEREC, and as CEREC has 

evolved, so have adhesive bonding techniques and 

methods. Several authors have validated the longevity 

of CEREC restorations. The Kaplan-Meier method 

survival probability was consistently 90% or greater at 

10 years for many studies.6,12,17-24 Ceramic fracture 

was the overwhelming primary reason for failure, 

followed by supporting tooth fracture. Ceramic 

fracture was thought to be a result of occlusal stress or 

insufficient ceramic thickness. Hickel and Manhart25

reviewed clinical studies in the dental literature during 

the 1990s to determine annual failure rates of posterior 

restorations in stress-bearing areas. They found annual 

failure rates of cast gold inlays from 0% to 5.9%. For 

CAD/CAM, they found the annual failure rate to be 

0% to 4.4%. CAD/CAM was slightly better than gold, 

which is often considered to be the gold standard. It is 

important to note that improvements in both CEREC 

technology and bonding techniques promise to 

produce even better results for restorations being 

placed today and in the future. 

The fabrication of indirect all-ceramic restorations has 

proven to be a strong and reliable technique, and it is 

difficult to reproduce the exceptional strength and 

material composition through traditional fabrication 

means. CEREC materials are different in that they are 

industrially manufactured under controlled conditions 

and are presintered. This stringent guideline ensures 

that the ceramic blocks have consistent particle size, 

no porosity, and strength throughout the material. 

Combining the ability of adhesive technology and 

structurally reliable, industrially prepared ceramics, 

many authors6,8,9,11,12,25-30 have reported a low level of 

restoration failure and low restoration fracture rates, 

making CEREC-generated restorations clinically 

durable and successful. The 2 major mechanisms for 

clinical failure for all other similar ceramic 

restorations are ceramic fracture due to inadequate 

thickness of the ceramic material (<1.5 mm) and tooth 

fracture due to the thin remaining walls of tooth 

structure (≤1 mm). Bremer and Geurtsen31 specifically 

looked at the fracture resistance of teeth following 

treatment with various types of adhesive restorations, 

and found there was no significant difference between 

the mean values of sound intact teeth (2,102 N) and 

the teeth with the CEREC ceramic inlay restorations 

(2,139 N). 

Wear characteristics are always a concern for dentists 

when restoring teeth with various restoration types, 

since enamel is subject to different wear rates against 

different restorative materials. Therefore, the surface 

finish and microstructure of materials greatly influence 

enamel wear. CEREC ceramic restorations have 

among their qualities enamel-like wear characteristics 

due to the fine-grained particle size, absence of 

porosity, consistent manufacturer conditions, and 

uniform strength throughout the ceramic block. A 

number of studies show that CEREC materials level of 

tooth enamel wear essentially is equivalent to that of 

tooth enamel against tooth enamel if the surface is 

polished or glazed.32-35 It is true that a machine-milled 

restoration alone decreases the strength of the 

ceramics. However, ceramics can be polished using 

rubber wheels of different coarseness and diamond 

paste to produce a surface that is superior to glazing, 

which brings the strength back to at least that of the 

premilled material. Furthermore, improvements in 

strength of about 160 MPa can be achieved by 

combining polishing and overglazing procedures with 

surface materials designed for these blocks. Al-Hiyasat 

and colleagues36 investigated human enamel wear 

against 4 dental ceramics and gold and found that gold 

was the least abrasive material and most resistant to 

wear, although the difference in wear between the 

machinable ceramic and gold was not statistically 

significant. CEREC restorations are less abrasive to 

the opposing dentition than other restorative options. 

The final attribute of CEREC restorations that is 

documented in the literature is postoperative 

sensitivity. Early clinical studies on CEREC-generated 

restorations reported significant levels of postoperative 

sensitivity. Several of these authors conveyed that 

most of the cases that involved sensitivity usually 

resolved within one month or less with no return in 

sensitivity. Some sensitivity issues were attributed to 

CAD/CAM Dentistry for Today’s On-The-Go Military 
 January – March 2011 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

the single appointment which resulted in occlusal 

interferences due to the technology at that time.6,17,37-39

More recent studies have reported less postoperative 

sensitivity due to the advancement in adhesive 

materials, luting technique, and the addition of 

occlusion-adjustment capability in the software . These 

authors found that there were no sensitivity issues at 

the standard recall appointments of the patients during 

the 3 to 5 years studied. This lack of postoperative 

sensitivity in chairside CAD/CAM restorations can be 

attributed to careful isolation techniques such as the 

Isolite system (Isolite Systems, Santa Barbara, CA) 

which provides upper and lower suction, tongue and 

cheek retraction, light illumination, and mouth prop 

stabilization support. When acquiring an optical image 

of the preparation, good isolation techniques ensures 

the preparation, powdering, and the picture are all in 

concert with one another, which ultimately allows for 

a more predictable outcome with the luting process. 

The ability to deliver the restoration in a single 

appointment also prevents the potential for tooth 

contamination due to a possible poor fitting, leaking, 

or loss of the provisional restoration as seen in 

conventional crown fabrication techniques.7,40 In 

summary, the evidence-based literature showed 

support for using the CEREC system in all of the 

primary areas of consideration when evaluating the 

efficacy of a restorative dental technology. 

CEREC ACQUISITION CENTER: STATE OF THE ART

DENTAL INTERFACE

Today, the state of the art CAD/CAM chairside 

equipment is the CEREC AC. The CEREC AC is 

designed to interface optimally with dental practice 

workflow while providing the most comprehensive 

array of CAD/CAM solutions, high level of digital 

impression precision and efficiency. The CEREC AC 

is easy to use and is powered by the short wavelength, 

lightweight Bluecam camera which offers an extensive 

depth of field, access to difficult areas intraorally, and 

the ability to acquire razor-sharp, 3-dimensional 

optical impression images of the prepared tooth and 

the antagonist (opposing tooth surface). A half-arch 

digital impression can be captured in 40 seconds, and a 

full-arch digital impression can be captured in 2 

minutes. The high resolution of the produced virtual 

model has benchmarks that are approaching those 

established with laboratory scanners.41 The CEREC 

AC also provides a convenient reserve battery pack, 

enabling the machine to move from operatory to 

operatory without powering down. This is especially 

beneficial when there are multiple dentists in the clinic 

using the machine in the same day. The CEREC AC 

occupies minimal floor space, has a large 19-inch 

monitor, and a refined keyboard for optimal 

ergonomics and efficiency. The newest software for 

the CEREC AC is version 3.8. The patented 

Biogeneric software technology offers sophisticated 

restoration design and superb functionality. Using the 

patient’s natural tooth structure as a basis, the software 

automatically creates perfect anatomical form for any 

single partial-coverage or full coverage tooth 

restoration. In the case of inlay and onlay restorations, 

the biogeneric software uses the residual occlusal 

structure surrounding the cavity of the prepared tooth. 

In the case of crowns, the user creates digital 

impressions of the preparation and a further intact 

tooth, preferably the antagonist, adjacent tooth, or the 

contralateral tooth to generate a matching restoration 

proposal. Scientific analysis demonstrates that the 

restoration proposal closely reproduces the original 

occlusal surface that is unique to that specific patient. 

The clinical applications of the CEREC AC allows the 

dentist to create esthetic, efficiently produced, allceramic inlays, onlays, veneers, and crowns with 

several ceramic block options available on the market 

today. Now with in-office fabrication of these 

restorations, there is little need to use an outside 

laboratory unless the dentist wants to send a digital 

impression via CEREC Connect, and have a 

stereolithography 3-dimensional model fabricated 

from Sirona and the final restoration fabricated from a 

CEREC dental laboratory. 

PREPARATION, POWDER, PICTURE AND WORKFLOW

In order for the CEREC AC process to be successful, 

the dentist needs to acquire the proper training and 

practice in order to get past the learning curve that is to 

be expected with any new technology. Additionally, 

the dentist must incorporate sound clinical dentistry 

principles regarding case selection, preparation 

guidelines, intraoral isolation techniques, and an 

understanding of adhesive dentistry parameters. The 

fundamentals of CEREC dentistry can be summed up 

with the “3 Ps”: preparation, powder, and picture for 

optimal clinical success. The preparation geometries 

and reduction parameters are specific for each type of 

restoration. The proper tooth reduction of all-ceramic 

restorations allows for adequate thickness of the 

ceramic material in order to prevent a potential 
30 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

fracture of the restoration, but the overall reduction of 

the tooth is equivalent to a metal-ceramic restoration. 

The all-ceramic preparation must have the appropriate 

wall taper, as well as smooth and rounded surfaces to 

reduce any internal stress or microfractures of the 

ceramic material. As compared to traditional crown 

preparation guidelines of sharp, retentive, and resistive 

tooth form features, the all-ceramic crown preparation 

is usually devoid of these sharp angles, grooves, and 

boxes, and solely relies on adhesion to the enamel and 

dentin.42 This is not to say, however, that the dentist 

should ignore the importance of having an appropriate 

amount of surface area to gain an achievable bond to 

the remaining tooth surfaces. Bindl and colleagues43

studied classic, reduced, and endodontic crown 

preparations for premolars and crowns. They found 

that classic and reduced crowns had similar survival 

rates, but the endodontic crowns were acceptable only 

for molars. They attributed the success of the reduced 

crown preparations compared to the classic crown 

preparations to the adhesive luting technique used with 

the ceramic block material. 

The workflow for acquiring and designing a full crown 

restoration on the CEREC AC is effortless with onscreen instructions that guide the dentist through each 

phase of the CEREC process. Once the preparation is 

complete, the dentist can further evaluate it by taking 

an optical digital image to evaluate the preparation 

criteria, adjacent proximal contacts, and marginal 

assessment on the large monitor, and then refine the 

tooth as necessary. Again, the accuracy of the software 

design is limited to the accuracy of the data imported 

into it, and it all starts with good tooth preparation. 

Occasionally, preparation margins are subgingival and 

are difficult to image. A diode laser or electrosurgery 

instrumentation can assist in the retraction of the 

gingival tissues to reveal all tooth margins to the 

camera clearly. Once the preparation is satisfactory, 

the dentist will take additional digital images of the 

preparation to form a working model, but first a light 

blue film of reflective powder (Optispray, Sirona 

Dental Systems) is applied to the surfaces of the 

preparation and the surrounding teeth to be recorded. 

The Optispray is quick, effective, and hygienic. The 

homogenous coating enhances the imaging capabilities 

of the CEREC Bluecam, especially with regard to the 

preparation margins. The CEREC Optispray is water 

soluble and easy to irrigate off the tooth and soft tissue 

surfaces once the virtual model is rendered. 

The CEREC AC Bluecam camera has the capability to 

take pictures automatically within the specified 14 mm 

focal range. When holding the camera over the tooth 

surface, the camera automatically detects the right 

moment to trigger the exposure, whether it is directly 

on the tooth surface or slightly above the tooth surface. 

In both cases, the parallel light beam ensures an 

optimum depth of field as well as a high level of 

handling flexibility. The camera’s blue light 

illuminates the treatment site and offers a built-in, 

antishake system, combined with a short capture time, 

to ensure that images are acquired only when the 

camera is absolutely still. The CEREC software 

automatically eliminates any substandard images.44 To 

further capture additional images, all the dentist must 

do is move the camera in a mesial or distal direction 

over the relevant areas to capture the digital images 

required (usually 5 or less) for the working virtual 

model. It takes less than a minute to make optical 

impressions for the preparation and antagonist, 

provided you have a proper application of reflective 

blue spray and excellent isolation technique. 

The virtual model is usually constructed in 60 to 90 

seconds due to the improved software algorithms. The 

CEREC AC articulates the opposing arches in 2 ways. 

The first involves the use of a negative image of a bite 

registration material such as Virtual CADbite 

registration (Ivoclar Vivadent Inc, Amherst, NY) to 

produce a virtual working opposing model, thereby 

eliminating the need to scan the opposite arch 

separately. The second is by scanning both arches 

separately and then acquiring a third (Buccal) scan 

with both arches together in maximum intercuspation. 

The camera is positioned parallel to the buccal 

surfaces of the teeth and at least one or 2 images are 

sufficient to correctly articulate the maxillary and 

mandibular arches to a virtual articulated model. An 

advantage to this second method is that the model can 

be virtually opened to confirm the virtual occlusal 

contacts and the preoperative clinical patient occlusal 

contacts prior to the delivery of anesthetic. The next 

step in the workflow process is to virtually trim the 

model in order to view the proximal tooth surfaces 

during the design process. Next, the preparation 

margin is marked using the automatic margin finder. 

For those difficult regions, the manual mode option is 

available to highlight the difficult area in a grayscale 

view. This mode is less precise and should only be 

used in limited circumstances. The next step is to 

CAD/CAM Dentistry for Today’s On-The-Go Military 
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THE ARMY MEDICAL DEPARTMENT JOURNAL

establish the insertion axis for the proposed 

restoration. Any visible yellow color along the 

preparation indicates an undercut or undesirable 

insertion axis and should be reorientated as necessary 

by eliminating all the visible yellow color. A 

biogeneric restoration will be proposed according to 

the patient’s own signature morphology. Restoration 

proposals generally require minimal editing by using 

the position, rotate, edit, scale, shape, form, and drop 

tools provided by the software. The dentist can often 

design the entire restoration within 5 to 7 minutes due 

to the proprietary biogeneric technology.3

The CEREC AC software has additional design 

features to give the dentist more design options in 

simple and in more complex treatment cases. The 

“correlation” option allows the dentist to copy 

information from a diagnostic wax-up for a more 

desirable occlusal relationship or from parts of the 

patient’s natural remaining tooth structure. Examples 

of these two options include cases involving multiple 

restorations either in the anterior or posterior regions 

to include full-mouth rehabilitation or if a patient 

should fracture a cusp and there is sound intact tooth 

structure remaining to copy. The software simply takes 

the digital impression of the copied information and 

constructs an exact copied proposal which can then be 

superimposed and altered as necessary using the 

editing tools. The “Biogeneric Reference” option 

allows the dentist to either mirror the adjacent tooth, 

such as restoring an anterior tooth #8 and taking the 

mirror image of #9, or select an intact contralateral 

tooth, such as restoring #3 and copying reference data 

from tooth #14, or use some other intact tooth in the 

arch to aid in the proper biogeneric design. The 

“Articulation” option allows the dentist to consider 

information from a dynamic bite registration if the 

patient’s occlusal scheme was in unilateral balanced 

articulation. The proposed restoration can now be 

adjusted with the editing tools through the virtual bite 

registration in order to eliminate any unwanted 

occlusal interferences. 

Once the restoration design is physically completed, 

the dentist chooses a restorative material that best 

accommodates the patient’s treatment situation. The 

advantage of the CEREC AC is that it is the only 

system capable of making use of all of the available 

materials on the market. The dentist can satisfy most 

esthetic situations by choosing either monochromatic 

or polychromatic blocks that are available through 

Sirona, Vita, and Ivoclar Vivadent dental companies. 

The polychromatic or multiblocks have a built-in 

gradient effect with different levels of translucency to 

mimic most teeth provided that there is no underlying 

condition such as metal post and cores that would 

influence the value of the restoration. All of these 

materials can be stained and glazed to best meet the 

patient’s esthetic needs. Once the appropriate block is 

chosen to match the patient’s dentition, the dentist can 

begin milling the restoration by using the CEREC MC 

XL or CEREC 3 compact units. Simply place the 

block in the chuck, tighten in place, and press the start 

button. The milling unit has 2 diamonds, one flat 

ended and one tapered at the end to shape the final 

restoration with minimal damage to the ceramic block. 

The burs are cooled constantly with ports of a sprayed 

water and oil mixture. The MC XL is extremely quiet, 

has colored illumination in the milling chamber to 

indicate the milling status, and has a precision milling 

range of ±25 μm. 

After only a few minutes, the final restoration is 

completely milled to the designed specifications. The 

dentist can now retrieve it from the milling chamber 

and perform a trial fit by applying a luting try-in gel 

cement color for verification on the restoration. Next, 

the dentist will use surface finishing techniques to 

refine the milled restoration by using impregnated 

polishing points, disc, and polishing paste with a stiff 

bristle brush to bring the restoration to a smooth finish. 

Alternately, in less than 20 minutes, the dentist can 

characterize the restoration even further by using a 

staining and glazing process in the dental laboratory or 

office to accommodate demanding esthetic situations. 

Lastly, the dentist will prepare the porcelain surface 

with a hydrofluoric acid gel solution, rinse, dry, and 

apply a silane coupling agent for the adhesive resin 

cement. The tooth is etched, primed, bonded, and the 

restoration is cemented with an acceptable ceramic 

resin luting medium, the excess cement is removed 

with fine-course diamonds, and the restoration 

receives a final polish intraorally. The end result is a 

reliable, predictable esthetic restoration, and, most of 

all, a happy patient. 

BENEFITS TO THE MILITARY DENTAL PRACTICE

It is safe to say that CAD/CAM dentistry is here to 

stay. With its improved ease of use, it is becoming 

increasingly popular in practice, with a corresponding 

influx of additional systems entering the market 
32 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

including E4D, Lava C.O.S., and iTero. The CEREC 

AC and the E4D are the only 2 systems with chairside 

milling capability. The Lava and iTero systems require 

the digital impression to be sent to an outside source. 

The overall approach to CAD/CAM technology and 

the decisions that surround each restoration option 

have become easier and more predictable through 

improvements in milling software, innovative 

restoration design options, and the array of ceramic 

material selection. 

As with most technology, the patient plays a major 

role in how the dentist chooses to practice dentistry. 

Most patients today live a busy lifestyle with competing demands for their time. This also holds true for 

our active duty military population; additional time 

spent in the dental chair is not typically a priority or 

always possible. The main advantage of using CAD/

CAM technology is the concept of having the patient 

come in for only a “single appointment” to prepare the 

tooth, make an optical impression, design, mill, and 

customize the final restoration, a process that would 

normally require multiple visits. This concept is very 

appealing to most dentists and patients, and has 

numerous time-saving benefits for the military dental 

practice, including a single administration of anesthetic, no retraction cord packing, no final impression 

material, no provisional restoration, and, depending on 

the system in use, no outside laboratory costs or 

turnaround time. The initial startup cost of the equipment is significant; however, the return on investment 

is realized by the savings from lower CAD/CAM 

operating material costs over time. The dentist must 

fabricate a minimum of 20 restorations per month to 

be cost effective. The average CEREC crown fabrication cost is approximately $30, compared to a traditional metal-ceramic crown at $200. Most single-unit 

restorations can be completed in 60 to 90 minutes. As 

the dentist’s confidence increases, the treatment of 

quadrants and complete dental arches can be completed either at the dental chair or in the dental 

laboratory on traditional casts. In the laboratory, the 

technician can apply the same concepts from the dentist working intraorally and now indirectly fabricate 

the restorations on the mounted articulated dental casts. 

A primary mission for the Army Dental Corps is First 

Term Dental Readiness. Why? Getting our Soldiers 

“war ready” is the primary objective of all dental team 

members in order to reduce avoidable dental 

emergencies for Soldiers who are deployed in a war 

zone. CAD/CAM is an extremely useful tool for 

accomplishing dental readiness in an efficient manner 

with high quality results. Following are two cases that 

highlight this treatment efficiency where traditional 

methods would have failed to deliver a completed 

treatment plan, given the time constraints involved. 

Case 1 is a more traditional application of the CAD/

CAM technology. Case 2 is an example of the 

technology used for full-mouth reconstruction. Both 

cases were completed by prosthodontic residents and 

the author at Fort Gordon, Georgia, using the CEREC 

AC and MC XL milling CAD/CAM equipment. 

Case 1 

An Active Duty 19-year-old Soldier was referred to 

the Tingay Dental Clinic Endodontic Department for a 

symptomatic tooth #30 (Figures 3 and 4). Clinically, 

tooth #30 had a large coronal amalgam restoration. 

The patient’s occlusion was in cross-articulation (crossbite) and the oral hygiene was fair. The patient was 

due to deploy in 2 days. The traditional treatment plan 

would be to do a cuspal coverage amalgam after the 

root canal was completed, however, the patient’s 

occlusal scheme presented something of a dilemma. If 

a cuspal amalgam was to be placed, most dentists 

would struggle to maintain the patient’s current 

occlusion and probably place the restoration out of 

occlusion and below the occlusal plane to prevent 

fracture of the freshly placed amalgam. However, with 

CEREC the dentist can now reconstruct the patient’s 

current tooth morphology and maintain a harmonious 

situation that accommodates that particular patient’s 

needs. In this case, the dentist prepared the tooth and 

the pulp chamber to accommodate a combined core 

and crown restoration, often referred to as an endo 

crown43 (Figure 5). The dentist chose to design the 

restoration in correlation mode, thereby copying the 

tooth from a diagnostic wax-up of tooth #30 to mimic 

what was present prior to treatment (Figure 6). Once 

the design was completed, the restoration was milled, 

fitted, finished, polished, and cemented (Figure 7). The 

preoperative and postoperative photos, Figures 8 and 9 

respectively, confirm an exact replica of the tooth 

morphology and occlusion of tooth #30. The patient 

was now in a stable, deployable status after a single 

visit (Figure 10). 

Case 2 

An Active Duty 23-year-old Soldier was referred to 

the Tingay Dental Clinic Endodontic and 

CAD/CAM Dentistry for Today’s On-The-Go Military 
 January – March 2011 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

Prosthodontic departments for a 

comprehensive evaluation. The 

patient presented with a suspected 

generalized enamel defect and a 

past history of drug abuse prior to 

entering active duty. Due to the 

weak enamel surfaces, multiple 

carious, and defective restorations 

were present along with a 

debilitated occlusion. Several teeth 

were symptomatic and the hygiene 

was poor (Figure 11). The patient 

was due to deploy in 7 months. 

The patient was assigned to a firstyear prosthodontic resident for a 

complete examination and a 

definitive treatment plan. After 

gathering all the baseline data, fullmouth radiographs, and diagnostic 

casts, a diagnostic wax-up was 

Figure 3. Tooth #30 preoperative 

periapical radiograph, post endodontic 

treatment. 

Figure 6. Tooth #30 diagnostic wax-up 

for the correlation mode design. 

Figure 9. Tooth #30 postoperative buccal view.

Figure 4. Tooth #30 clinical occlusal 

view, post endodontic treatment. 

Figure 7. Tooth #30 final milled and 

polished ceramic endo crown prior to 

cementation (Sirona’s multicolor 

ceramic block).

Figure 10. Tooth #30 postoperative 

periapical radiograph, final ceramic restoration. 

Figure 5. Tooth #30 endo crown preparation. 

Figure 8. Tooth #30 preoperative buccal view.
34 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

CAD/CAM Dentistry for Today’s On-The-Go Military 

prepared to determine a viable treatment plan. Despite 

the generalized breakdown of the dentition, the patient 

advocated that he was interested in keeping all of his 

remaining teeth if possible. It was determined that the 

patient needed some immediate endodontic therapy for 

several teeth, oral hygiene instructions, diet 

counseling, soft tissue debridement, 4 posterior 

quadrants of crown lengthening procedures to gain an 

acceptable clinical crown height due to the level of 

prior tooth destruction, multiple prefabricated dowel 

and cores, and 28 CEREC all-ceramic restorations 

using the IPS e-max (Ivoclar Vivadent, Amherst, NY) 

CAD (lithium disilicate) material (Figure 12). 

The milled lithium disilicate block must undergo a 2-

stage crystallization process before cementation. The 

first stage is the “blue-violet block” precrystallized 

state. At this stage the glass ceramic has a crystal size 

range of 0.2 to 1.0 μm, with approximately 40% lithium metasilicate crystals by volume. This precrystallized state allows the block to be milled easily without 

excessive diamond bur wear and damage to the material. The final crystallization occurs after the crown 

has been milled to the desired form and then crystallized in a porcelain oven at 850°C in a vacuum. The 

metasilicate crystal phase is dissolved completely and 

the lithium disilicate crystallizes. During this process, 

the blue color gets converted to the selected tooth shade 

and results in a glass ceramic with a fine-grained size 

of approximately 1.5 μm and a 70% crystal volume in 

a glass matrix. The end result is an enhanced strength 

monolithic restoration that has a flexural strength of 

360 MPa, which is approximately 21⁄2 times greater than 

the other feldspathic monolithic block materials available. An advantage in using a monolithic (one-piece) 

material is that it helps prevent possible chipping, 

fracture, or delamination of the veneering porcelain as 

seen occasionally in a bilayered ceramic crown.45-48

Many dentists may consider this case to be impossible 

even with CEREC, but I decided that my extensive 

experience with both prosthodontics and CAD/CAM 

systems was up to the challenge. The prosthodontic 

resident and I developed a timeline for all required 

treatment to be accomplished in the short period of 

time available. The CEREC AC system was used to 

fabricate 22 full-contour lithium disilicate ceramic 

crowns and 6 ceramic veneers in the laboratory on 

articulated master casts. The diagnostic wax-up was 

systematically constructed to a more harmonious, 

functional situation, and the correlation mode of design was the optimal choice to copy the diagnostic waxup “blueprint” information (Figure 13). With the new 

CEREC Bluecam camera and the more sophisticated 

software, detailed digital impressions were made from 

both the tooth preparation master casts and the 

duplicated diagnostic wax-up stone cast (Figure 14). 

They were then superimposed in the design process 

and minor adjustments were made using the software 

editing tools. After the milling process was completed 

for each of the ceramic restorations, they were fitted to 

the master cast to verify contours, interproximal, and 

occlusal contacts. All restorations were custom stained 

and glazed in the precrystallized state and then fully 

crystallized in the porcelain oven at 850°C in a 

vacuum (Figure 15). The full-mouth rehabilitation case 

was completed in a segmental fashion, and all ceramic 

restorations were cemented and followed normal 

bonded-ceramic protocol (Figure 16). The patient was 

followed for 2 weeks before his deployment and he 

was asymptomatic. The patient is scheduled to return 

after his one-year deployment to assess and evaluate 

the possibility of replacing the mandibular anterior 

veneers to full-coverage restorations. Ultimately, the 

patient endured a lot of treatment in a short window of 

available time, but the end result proved to be worth 

the effort (Figures 17 and 18). 

Figure 11. Case 2 preoperative frontal view. 

Figure 12. IPS e-max CAD (lithium disilicate) block and precrystallized (bluestate) milled crown restorations.
 January – March 2011 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

CONCLUSION

CAD/CAM systems like the CEREC AC have given 

Army Dental Corps professionals almost unlimited 

potential to reliably and efficiently fabricate chairside 

ceramic restorations in the military dental 

environment. Currently, there are approximately 30 

chairside CEREC and other systems distributed 

throughout the Army Dental Command Regions. This 

technology is a viable tool because over the past 25 

years CAD/CAM dentistry has proven to be an 

esthetically pleasing, effective, time saving, and cost 

effective approach to everyday dentistry restorative 

options. As we have seen through the progression of 

dentistry over the years, several dental techniques of 

the past, such as gold foil restorations, have become a 

lost art. As technology continues to progress, traditional 

impression techniques may become the new lost art as 

digital capabilities become the norm. Time will tell. 

Further, the Army Dental Corps can only benefit from 

the introduction of new companies and systems into 

the mix, providing a choice for the system that best 

serves the military dental practice. The next 5 years in 

CAD/CAM dentistry will surely be a roller coaster on 

which you will want to be riding. Now is an incredible 

time to be practicing dentistry! 

Figure 13. CEREC AC software correlation mode of the 

proposed restoration from the diagnostic wax-up. 

Figure 15. Maxillary master cast with final crystallization, staining, and glazing of the restorations. 

Figure 14. Diagnostic wax-up duplicated in dental 

stone. The blueprint for the final restorations. 

Figure 17. Preoperative smile. 

Figure 16. Postoperative frontal view. 

Figure 18. Postoperative smile. 
36 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

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CAD/CAM Dentistry for Today’s On-The-Go Military 
 January – March 2011 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

29. Mörmann WH, Gotsch T, Krejci I, Lutz F, Barbakow 

F. Clinical status of 94 CEREC ceramic inlays after 3 

years in situ. In: Mörmann WH, ed. International 

Symposium on Computer Restorations: State of the 

art of the CEREC method. Chicago, Illinois: 

Quintessence Publishing; 1991:355. 

30. Palleson U, van Dijken JW. An 8-year evaluation of 

sintered ceramic and glass ceramic inlays processed 

by the CERECCAD/CAM system. Eur J Oral Sci. 

2000;108:239-246. 

31. Bremer BD, Geurtsen W. Molar fracture resistance 

after adhesive restoration with ceramic inlays or resin

-based composites. Am J Dent. 2001;14(4):216-220. 

32. Krejci I, Lutz F, Reimer M. Wear of CAD/CAM 

ceramic inlays: restorations, opposing cusps, and luting 

cements. Quintessence Int. 1994;25(3):199-207. 

33. Abozenada B, Pober R, Giordano R. In-vitro wear of 

restorative dental materials. Paper presented at: The 

IADR/AADR/CADR 80th General Session; March 8, 

2002; San Diego, CA. Available at: http://

iadr.confex.com/iadr/2002SanDiego/techprogram/

abstract_13523.htm. Accessed May 24, 2006. 

34. McLaren E, Abuzenada B, Pober R, Giordano R. 

Material testing and layering techniques of a new two

-phase all-ceramic glass veneering porcelain for 

bonded porcelain and high-alumina frameworks. 

Quintessence Dent Technol. 2003;26:1-13. 

35. McLaren E, Giordano R. Zirconia-based ceramics: 

material properties, esthetics, and layering techniques 

of new veneering porcelain, VM9, high-alumina frameworks. Quintessence Dent Technol. 2005;28:1-12. 

36. Al-Hiyasat AS, Saunders WP, Sharkey SW, Smith 

GM, Gilmour WH. Investigation of human enamel 

wear against four dental ceramics and gold. J Dent. 

1998;26(5-6):487-495. 

37. Magnuson D, Oden A, Krystek I. Clinical evaluation 

of CEREC restorations. In: Mörmann WH, ed. 

International Symposium on Computer Restorations: 

State of the art of the CEREC method. Chicago, 

Illinois: Quintessence Publishing; 1991:339. 

38. Fasbinder DJ, Lampe K, Dennison JB, Peters MC, 

Nematollahi K. Clinical performance of CAD/CIM 

generated ceramic onlays (abstract 2711). J Dent Res. 

1999;78(special issue):444. 

39. Otto T. Experience with CEREC in a Swiss practice. 

In: Mörmann WH, ed. CAD/CIM in Aesthetic 

Dentistry: CEREC 10 Year Anniversary Symposium. 

Chicago, Illinois: Quintessence Publishing; 1996:601. 

40. Molin MK, Karisson SL. A randomized 5-year 

clinical evaluation of 3 ceramic inlay systems. Int J 

Prothodont. 2000;13(3):194-200. 

41. Mehl A, Ender A, Mörmann W, Attin T. Accuracy 

testing of a new intraoral 3D camera. Int J Comput 

Dent. 2009;12(1):11-28. 

42. IPS Empress CAD Instructions for Use Chairside. 

Amherst, NY: Ivoclar Vivadent; 2006. 

43. Bindl A, Richter B, Mörmann WH. Survival of 

ceramic computer-aided design/manufacturing 

crowns bonded to preparations with reduced 

macroretention geometry. Int J Prosthodont. 2005;18

(3):219-224. 

44. Gedosev M. The perfect companion: CEREC 3D 

software upgrade V3.40. Int J Comput Dent. 2009;12

(1):59-70. 

45. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic 

materials and systems with clinical recommendations: 

a systematic review. J Prosthet Dent. 2007;98(5):389-

404. 

46. Della Bona A, Kelly JR. The clinical success of allceramic restorations. JADA. 2008;139(9 suppl):8S-13S. 

47. Pjetursson B, Sailer I, Zwahlen M, Hämmerle C. A 

systematic review of the survival and complication 

rates of all-ceramic and metal ceramic 

reconstructions after an observation period of at least 

three years, part I: single crowns [published 

correction appears in Clin Oral Implants Res. 

2008;19(3):326-328]. Clin Oral Implants Res. 

2007;18(suppl 3):73-85. 

48. Fasbinder DJ, Dennison JB, Heys D, Neiva G. A 

clinical evaluation of chairside lithium disilicate 

CAD/CAM crowns: A two-year report. JADA. 

2010;141(suppl):10S-14S. 

AUTHOR

COL Hodd is Assistant Director, Prosthodontics, US 

Army Dental Activity, Fort Gordon, Georgia. 
38 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

One of the first known dental impressions that resulted 

in dental casts was made by the German Philip Pfaff in 

1756.1

 Since then, dental impression materials have 

progressed to a point of very high accuracy. Recently, 

the “digital” impression has emerged where the 

impression material is replaced by a digital camera. 

Presently, there are 4 chairside digital impression 

systems on the US market: iTero (Cadent Inc, 

Carlstadt, NJ); E4D Dentist (D4D Technologies, 

Richardson, TX); CEREC Connect (Sirona, Bensheim, 

Germany), and Lava Chairside Oral Scanner (C.O.S.) 

(3M ESPE, St Paul, MN). While the iTero, E4D, and 

CEREC Connect use cameras that take individual 

snapshots of the teeth, the Lava C.O.S. camera takes a 

continuous video. This article will discuss the use of 

the Lava C.O.S. digital impression 

and the dental laboratory Lava CAD/

CAM (3M ESPE, St Paul, MN) 

system by the US Army Dental 

Command. 

THE ARMY DENTAL LABORATORY

In the Army Dental Care System, 

dental impressions and casts have to 

be shipped to the only centralized 

dental laboratory for the US Army, 

the Army Dental Laboratory (ADL), 

located on Fort Gordon, near Augusta, 

Georgia. It is a unique command, 

reporting directly to the US Army 

Dental Command, and supports 147 

dental clinics worldwide. The unique 

mission of the 95 (49 military, 38 

government civilian, 8 contract) 

employees who work there is to 

produce fixed crowns, bridgework, 

removable dentures, and orthodontic 

appliances for the dental beneficiaries 

receiving care in the Army Dental 

Care System. During its 31-year history at this 

location, the ADL has adapted to changes in the way 

the dental profession is practiced. Because 80% to 

85% of their work involves fixed dental prostheses, the 

lab has adapted to new impression materials and 

techniques. One of the most recent changes has been 

the use of CAD/CAM to fabricate zirconia-based 

crowns and bridges. This technique can also be used to 

fabricate crowns using more traditional materials, and 

allows for more rapid and more accurate production. 

The new technology of a digital impression in the 

dental workflow of a restoration combines the dental 

office with the CAD/CAM dental laboratory in the 

electronic world. 

In the Army Dental Care System, casts are shipped via 

commercial shipping from all over the world. The use 

of the new digital impression by the 

C.O.S will eliminate the initial 

physical shipment to the ADL. The 

ADL will use the digital impression to 

have a specialized civilian facility 

fabricate physical dental casts. These 

casts are computer-generated using 

new technology called stereolithography (SLA), a rapid prototyping 

technology. The SLA machine generates the casts by curing layer upon 

layer of light-sensitive polymer resin 

material.2

 The SLA casts are then 

mounted (Figure 1)and the dental dies 

are cut-out and margins trimmed 

(Figure 2). The completed, articulated 

SLA casts are then shipped to the 

ADL for a nominal fee. 

The ADL can use the articulated SLA 

casts to fabricate a variety of 

restorations from many materials; 

gold, metal ceramic, or all-ceramic. 

For example, the ADL can use the 

Is the US Army Dental Corps Ready for the 

 Digital Impression? 

COL Michael R. Craddock, DC, USA 

COL Richard J. Windhorn, DC, USA 

Figure 1. Articulated stereolithography 

cast. 

Figure 2. Cut-out dental die with 

margins trimmed. 
 January – March 2011 39

laboratory 3M ESPE Lava CAD/

CAM system (Figure 3) to fabricate 

wax patterns from the digital 

impression, cast the gold crown, and 

perform final seating / occlusion 

adjustments on the articulated SLA 

casts. The same could be said for the 

all-ceramic crown or fixed dental 

prosthesis; the laboratory Lava 

system fabricates the very strong, allceramic zirconia framework (Figure 

4) from the digital impression and the 

lab technician then stacks the 

porcelain onto the zirconia framework. Final adjustments are on the 

articulated SLA casts. The turnaround time for submitted cases can 

be substantially reduced with the 

digital impression. More importantly, the dental lab 

work for the submitting dentist is virtually eliminated 

with the use of the digital impression. The digital 

impression is “dropped” into a virtual case-pan at the 

ADL computer, very similar to a civilian dentist 

dropping their material impression into a case-pan of a 

local dental laboratory. This newest method eliminates 

the need to pour stone dies and ship them to the 

laboratory; which saves time, materials, and shipping 

costs. In addition, studies3,4 have shown that crowns 

fabricated using CAD/CAM technology exhibit better 

marginal integrity and fit. 

LAVA CHAIRSIDE ORAL SCANNER

System Description 

The 3M ESPE Chairside Oral Scanner (C.O.S.) is a 

standalone mobile unit (Figure 5). Basically, it is a 

computer with a touch screen monitor and a video 

camera (called the Wand by 3M ESPE). The computer 

runs on the LINUX operating system and connects by 

encryption through a wireless connection to a router in 

the clinic. The Wand scanning camera is comprised of 

192 LEDs and 22 lenses, has a 13.2 mm wide tip, and 

weighs 14 ounces (Figure 6). This is one of the 

smallest end of scanners on the market. It is placed in 

the patient’s mouth (Figure 7) and the 3D-in-motion 

technology enables the user to capture approximately 

20 3D data sets per second (close to 2400 data sets per 

arch) with patented wavefront sampling technology.5

There is no keyboard, but a virtual keyboard can be 

displayed on the monitor. The wand has protective 

plastic infection barrier sleeves. 

Disinfection of the monitor involves 

using a typical dental surface 

disinfectant. A list of recommended 

disinfectants is provided by 3M ESPE. 

Workflow Procedures 

Preparation of selected tooth/teeth is/

are performed. The same principles 

for a preparation design are followed 

for gold, metal ceramic, or allceramic. Conventional tissue 

retraction and saliva control 

procedures are still needed. Many aids 

are on the market that can assist the 

dental team in isolating and assisting 

in obtaining a digital impression (eg, 

the OptraGate lip and cheek retractor 

(Ivoclar-Vivadent, Amherst, NY) as seen in Figure 7). 

Next, a titanium dioxide based spray is used to coat all 

surfaces. As compared to the CEREC, only a light 

spraying is needed because the C.O.S. only needs 

reference points to form a virtual picture of the 

preparation(s). A unique battery-powered titanium 

dioxide sprayer is provided with the C.O.S. system 

(Figure 8). 

The dentist begins the scan by pressing the button on 

the wand or by pressing the start key on the touchscreen monitor. A pulsating blue light is emitted by the 

wand. The dentist then slowly moves the camera over 

the occlusal surfaces, then buccal, then lingual, and 

Figure 3. Lava Mill CNC 500 at the 

Army Dental Laboratory. 

Figure 4. Lava CNC 500 milling zirconia block at the Army 

Dental Laboratory. 
40 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

ending where the scan began. This 

completes the “scanning loop.” If 

there is a sudden movement, the 

software will pause allowing the 

dentist to reorient the camera. As the 

teeth are scanned, the captured areas 

will turn light yellow, leaving red 

areas that need further scanning. The 

image is then evaluated on the 

monitor by rotating the image with 

simple finger movements on the touch 

screen (Figure 9). The dentist then 

scans the opposing arch and then the 

buccal occlusal surfaces with the patient in maximal 

intercuspation (Figure 10). Respraying of the surfaces 

may be needed due to loss of titanium dioxide on 

surfaces from movement, saliva, etc. Total time for the 

three scan phases is typically less than ten minutes, 

depending on experience of operator and complexity 

of case. 

After review of the completed scans (Figure 11), the 

dentist fills in an on-screen electronic prescription and 

sends the encrypted case through the wireless network 

(Figure 12) to 3M ESPE servers. If multiple patients 

are being scanned during a day and to reduce chairside 

time, all cases can be uploaded at once during the 

night. The case(s) are transferred to registered 3M 

ESPE laboratories, in this case the Army Dental 

Laboratory. The ADL uses software to mark the 

preparation margins. If the Laboratory has problems 

with a margin location, they can send the capture areas 

of the margins in question to the dentist by email. The 

dentist then can mark the margins in question and 

return the information to the ADL. The digital case is 

then sent to a third-party facility that generates the 

SLA casts. The articulated SLA casts with cut-out 

preparation dies is returned to the ADL. This process 

usually requires no more than 3 days from the time the 

dentist sends the electronic impression/prescription. If 

a dentist wants to mark his or her own 

preparation margins, the marginmarking computer and software can 

be purchased from 3M ESPE. 

While waiting for the articulated SLA 

casts, the ADL can start milling wax 

patterns for metal ceramics/gold 

crowns, or all-ceramic frameworks/

crowns (Figure 13). Final porcelain 

addition and fit / adjustment are 

completed upon arrival of the 

articulated SLA casts. Typically, total 

in-house time for a simple digital impression 

restoration is planned to be less than 10 calendar days. 

This period rivals any similar restoration time from a 

civilian dental laboratory for a digital impression or a 

conventional material impression. 

The digital impression is a major new paradigm shift 

for the fabrication of a dental fixed restoration in the 

Army Dental Care System. Due to the widespread 

global locations of Army dental clinics, the use of new 

dental technologies like the digital impression in 

conjunction with new CAD/CAM technologies at the 

ADL has the potential to greatly reduce time and costs. 

This can be of great benefit to the Army Dental Corps, 

the Army and other US military services, and, most 

importantly, the military dental care patient. 

ACKNOWLEDGEMENT

The photos in Figures 1 through 5, Figures 7 through 

11, and Figure 13 were provided by the author. The 

images in Figures 6 and 12 are courtesy of 3M ESPE. 

REFERENCES

1. Craig RG, Hanks CT, eds. Restorative Dental 

Materials. 9th ed. St Louis, Missouri: C.V. Mosby; 

1993:8. 

2. Pilsner D. Implementing digital impression. J Dent 

Technol. November/December 2010:28. 

3. Christensen GF. Clinicians Report [serial online]. 

April 2010:3-4. Available at: http://www.clinicians 

report.org/. Accessed November 29, 2010. 

4. Farah JW, Powers JM, eds. CAD/CAM update. The 

Dental Advisor [serial online]. 2009;26(7). Available 

at: http://www.dentaladvisor.com/publications/thedental-advisor/26-07.shtml. Accessed November 29, 

2010. 

Is the US Army Dental Corps Ready for the Digital Impression? 

Figure 5. The 3M ESPE Lava Chairside Oral Scanner unit. 

Figure 6. The wand used with the LAVA C.O.S. digital scanner. 

(Image reproduced from the 3m ESPE Lava C.O.S. user manual 

with permission.) 
 January – March 2011 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

5. Rohaly J, Hart DP, Brukilacchio TJ, inventors. 3M Innovative Properties Co, assignee. Three-channel camera 

systems with non-collinear apertures, US Patent 7,372,642. May 13, 2008. 

AUTHORS

COL Craddock is Chief of Prosthodontics, US Army Dental Activity, Fort Carson, Colorado. 

COL Windhorn is Commander, US Army Dental Laboratory, Fort Gordon, Georgia. 

Figure 7. LAVA C.O.S. wand in use. Figure 8. 3M ESPE battery-powered titanium 

dioxide sprayer. Figure 9. Typical scan of preparation. 

Figure 10. Scan of maximal intercuspation. Figure 11. Completed up-close scan of 

preparation margins. 

Figure 13. Example of a LAVA scan and design at the 

Army Dental Laboratory Figure 12. Example of 3M ESPE LAVA C.O.S. lab 

prescription. (Image reproduced from the 3m ESPE Lava 

C.O.S. user manual with permission.) 
42 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND AND LITERATURE REVIEW

Even before Kakehashi et al proved in their landmark 

1965 germ-free rat study that bacterial contamination 

of the root canal system is the cause of apical periodontitis,1

 endodontists have sought the most effective 

means to seal the root canal space. Although successful endodontic therapy is a multifactorial process of 

bacterial elimination, the apical to coronal seal is well 

accepted as a key element of preventing reinfection 

and refractory disease.2

 Once pathogenic microorganisms have been reduced below a patient’s 

threshold to cause disease, the goal is to 3-dimensionally fill and seal the complex root canal system.3-5

However, the manner in which this goal is achieved 

has fueled a great deal of research and innovation. 

Currently, there are many obturation systems 

available. For the purposes of this study, 3 obturation 

techniques are described: lateral compaction, 

continuous wave of condensation, and a less common 

single-cone technique. The first, lateral compaction, 

uses a master cone of gutta-percha supplemented by 

accessory cones. To this day, it is likely to be the first 

technique taught in dental school.6

 In 1967, Schilder 

described a warm vertical compaction technique that 

hydraulically pushes thermoplasticized gutta-percha 

into the most apical parts of the canal system with a 

series of custom fitted pluggers.5

 Another warm vertical compaction technique incorporates thermoplasticized gutta-percha dispensers and standardized master 

cones that precisely match the taper of nickel titanium 

rotary files and is known as the continuous wave of 

condensation technique.7

 Once mastered, this technique can reduce the time required to complete obturation and is the technique of choice of many practitioners today.6

 The third technique, the single-cone 

technique, has been used for years in various forms. In 

1984, Cohen and Burns described a technique using a 

single, uncondensed but fitted gutta-percha master 

cone for obturation.8

 The appeal of the single-cone 

technique is simplicity and speed of obturation.9

Regardless of the technique implemented, the type and 

composition of sealer is a key component in achieving 

the goal of a sealed root canal system. Today, a 

popular epoxy resin based sealer, AH Plus (E/T 

Endodontic Technologies Ltd, Halifax, Nova Scotia, 

Canada), has performed well in in vitro leakage 

studies.10-12 Recently, glass-ionomer-based sealers 

have been reintroduced because of their chemical bond 

to dental hard tissues,13,14 fluoride release, 

Ten-Month In Vitro Leakage Study of a 

 Single-Cone Obturation System 

LTC A. John McKissock, DC, USA 

COL Pete Mines, DC, USA 

COL Mark B. Sweet, DC, USA 

Col Steven L. Klyn, DC, USAF 

ABSTRACT

The purpose of this study was to compare the in vitro sealing ability of the continuous wave of condensation technique 

using gutta-percha and an epoxy resin based sealer, AH Plus to the sealing ability of the single-cone, glass-ionomerbased Activ GP Precision Obturation System over 10 months. Fifty maxillary anterior teeth were randomly divided into 

2 test groups (20 canals each) and 2 control groups (5 positive and 5 negative). All teeth were stored in 0.9% saline. 

Group 1 (GP) was prepared with rotary instruments and obturated with the continuous wave of condensation technique 

using gutta-percha and AH Plus sealer. Group 2 (Activ GP) was prepared with rotary instruments and obturated using 

the heatless, single-cone, glass-ionomer-based Activ GP Precision Obturation System. Each canal orifice was sealed 

with amalgam and stored for 10 months in 100% humidity at 37°C. Amalgam was removed and leakage was evaluated 

by fluid transport at 10 psi. The median leakage for Group 1 (GP) was 0.500 mm and Group 2 (Activ GP) was 18.865 mm. 

A Mann-Whitney Rank Sum test was used to evaluate the data and determine if a difference existed between the 2 

groups. Under the conditions of this study, the Activ GP glass-ionomer-based single-cone obturation technique 

demonstrated statistically significant higher leakage rates than a continuous wave of condensation technique. 
 January – March 2011 43

antimicrobial activity and biocompatibility.15 One such 

recently introduced glass-ionomer sealer is the Activ 

GP Precision Obturation System (Brasseler USA, 

Savannah, GA). 

The Activ GP System combines a single-cone 

technique with a glass-ionomer-based sealer that the 

manufacturer claims will create a “monoblock” 

between the tooth, sealer, and core material. The term 

“monoblock” has been used in many of the 

methacrylate based obturation systems not examined 

here. Monoblock generally refers to a gap-free, solid 

mass of different materials that simultaneously 

improves the seal and fracture resistance of the filled 

canals.16 The Activ GP System uses a gutta-percha 

master cone that has been coated and impregnated with 

glass ionomer particles. The rationale is the glassionomer-based sealer will bond to the dentinal walls of 

the canal as well as the glass ionomer particles in and 

on the master cone. The manufacturer recommends a 

heatless single-cone technique that relies on tapered 

cones that match prepared canals, as well as a glassionomer-based sealer to fill canal irregularities and 

seal the apical canal space. Unfortunately, single-cone 

techniques have not historically met the challenges of 

providing a 3-dimensionally filled and sealed root 

canal system.17 The unfavorable geometry of the canal 

space18 and a preponderance of sclerotic radicular 

dentin in the canal’s apical third19 prevents a true, gapfree seal as suggested by the monoblock moniker used 

in many advertisements. 

The purpose of this study is to compare the newly 

introduced Activ GP obturation system to the 

continuous wave of condensation technique with a 

resin based sealer over a 10-month period. 

MATERIALS AND METHODS

All procedures were completed by one investigator. 

Fifty extracted, single-canal, human anterior teeth with 

at least 15 mm of root length were collected and stored 

in 0.9% saline. Calculus and soft tissue remnants were 

removed by mechanical means. All teeth were 

examined for cracks or fractures, as well as to confirm 

a single apical foramen using transillumination 

(Microlux Transilluminator, Adent Inc, Danbury, CT) 

and a dental operating microscope (Global Surgical 

Corporation, St Louis, MO). Teeth with canal 

curvatures greater than 10o or canal patency greater 

than an International Standards Organization (ISO) 

size 15 K-type file (Henry Schein Inc, Melville, NY) 

were discarded. 

The crowns were removed with a #557 carbide bur 

(Henry Schein, Melville, NY), leaving no less than 15 

mm root sections. Working length was determined by 

subtracting 1.0 mm from the length that a 10 K type 

file was first visible at the apical foramen. All canals 

were hand filed to a 20 K type file using full-strength 

sodium hypochlorite (Clorox, Oakland, CA) as a 

lubricant. The 50 root canals were randomly divided 

into 2 experimental groups (n=20) and 2 control 

groups (n=5). 

EXPERIMENTAL GROUP 1: CONTINUOUS WAVE OF

CONDENSATION

Canal preparation was completed using a crown down 

technique with 0.04 tapered nickel-titanium rotary 

instruments to a size 40 rotary file. The root canals 

were irrigated with sodium hypochlorite using a 28-

gauge side port syringe (Max-i-Probe, Dentsply Rinn, 

Elgin, IL). Patency and apical stops were confirmed 

with a 10 K type file and a 40 K type file respectively. 

A final rinse of 5 ml of 17% ethylenediamine 

tetraacetic acid (Pulpdent Corp., Watertown, MA) was 

followed by 5 ml of sodium hypochlorite rinse. All 

canals were then dried using paper points (Henry 

Schein, Melville, NY). 

An epoxy resin-based sealer, AH Plus, was mixed 

according to the manufacturer’s instructions and 

applied to the root canal walls while placing a size 

40/0.04 taper master gutta-percha cone (Dia-ISO 

GT .04; DiaDent, Burnaby, BC, Canada) to working 

length. Once seated, a 0.08 tapered System B heat 

source plugger (SybronEndo, Orange, CA) set at 200°

C was introduced into the canal. The System B was 

activated and slowly pushed into the canal within 4 

mm of working length. The plugger was then held in 

position for 10 seconds, reactivated for 1 second, and 

withdrawn. A 5/7 plugger (Hu-Friedy Mfg Inc, 

Chicago, IL) was immediately introduced into the 

canal to assure seating of the apical plug. The coronal 

canal walls were coated with the epoxy resin-based 

sealer and backfilled with warm gutta-percha from an 

Obtura II (Spartan, Fenton, MO) set at 185°C. The 

warm gutta-percha was immediately down-packed 

with a 5/7 plugger. 
44 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Since the obturated canals were to be stored for 10 

months, the coronal 2 to 3 mm of gutta-percha was 

removed with the System B, sealed with a 2 to 3 mm 

amalgam restoration (Tytin amalgam, Kerr 

Corporation, Orange, CA), and stored in 100% relative 

humidity at 37oC for 10 months. 

EXPERIMENTAL GROUP 2: SINGLE-CONE TECHNIQUE

(ACTIV GP) 

Experimental Group 2 was prepared the same as 

Group 1 in regards to working length, hand filing, and 

smear layer removal. The final canal preparation was 

completed using a crown down technique with 0.04 

tapered nickel-titanium rotary instruments to a size 40 

rotary file. 

Per the manufacturer’s recommendations, the Activ 

GP glass-ionomer sealer was mixed and placed in the 

canal with a clean 40 K type file using a circular 

motion to the working length. An Activ GP 0.04 taper 

gutta-percha master cone was coated with sealer and 

slowly inserted to working length, allowing the sealer 

to escape coronally. The coronal 2 to 3 mm of guttapercha was removed with the System B, and the canal 

orifice was sealed with an amalgam and stored in 

100% relative humidity at 37oC for 10 months. 

EXPERIMENTAL GROUPS 3 AND 4: POSITIVE AND

NEGATIVE CONTROLS

Five roots were treated the same as Group 1 with the 

exception that no sealer was used. These 5 roots served 

as the positive controls to test the maximum fluid flow 

through the fluid transport device. The last 5 roots 

were treated the same as Group 1 with the exception 

that the root surfaces were sealed with cyanoacrylate 

to act as the negative controls. All roots were sealed 

with amalgam and stored in 100% relative humidity at 

37oC for 10 months. 

LEAKAGE TESTS

Using a fluid transport model (Figure 1) as described 

by Maloney et al,20 Koagel et al,21 and Stratton et al,22

Plexiglass blocks were penetrated by an 18-gauge 

stainless steel tube (SafetyGlide Needle, Franklin 

Lakes, NJ) so that 1.0 mm of tubing protruded from 

the root side of the Plexiglass. The 2.0 to 3.0 mm deep 

amalgam restorations were removed from each root 

with a 330 carbide bur. The roots were mounted with 

viscous cyanoacrylate cement to the Plexiglass blocks 

with the orifices located over the steel tubing. The 

negative controls were re-treated with cyanoacrylate 

prior to testing. 

Each Plexiglass-root assembly (Figure 2) was attached 

to the fluid transport-measuring device. The fluid 

transport device used compressed nitrogen gas and a 

pressure pot to push a solution of 0.02% sodium azide 

at 10 psi through the stainless steel tube of the 

Plexiglass-root assembly and ultimately the root being 

tested. The fluid rates through the tested specimens 

were quantified by measuring the progress of a tiny air 

bubble as it traveled within the polyethylene tubing 

along a 150 mm Fisher Scientific ruler. Each specimen 

was tested 3 times for 3 minutes and the bubble’s 

movement was recorded to the tenth of a millimeter. A 

Mann-Whitney Rank Sum test (SigmaStat 3.5, Point 

Richmond, CA) was 

calculated to determine the 

existence of a statistically 

significant difference 

between the two groups. 

Values of P<.05 were 

considered significant. 

RESULTS

The leakage of the negative 

controls was uniformly 

zero and the leakage of the 

positive controls was 

immeasurably high. The 

leakage results of 14 of the 

20 teeth (70%) in Group 2 

Ten-Month In Vitro Leakage Study of a Single-Cone Obturation System 

See Figure 2 

Figure 1. General schematic of the fluid transport model used to 

conduct the leakage tests on study objects. 

Figure 2. Photo of typical 

Plexiglass-root assembly test 

object. 
 January – March 2011 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

(Activ GP) were immeasurably high using a fluid 

transport system with a 150 mm ruler. The 6 teeth that 

registered measurable levels in Group 2 (Activ GP) 

had a median leakage of 18.865 mm, and the median 

leakage for Group 1 (GP) was 0.500 mm. 

A Mann-Whitney Rank Sum test indicated the 

differences in the median values is greater than would 

be expected by chance. The results showed a 

statistically significant difference between the test 

groups (P=<.001). 

COMMENT

Although obturation techniques and materials continue 

to improve, the results of this study remind one that no 

current obturation technique or material can 

completely seal a complex root canal space.23-25 The 

advantage of testing leakage with a fluid transport 

model is its unique ability to quantify leakage. Under 

the conditions of this study, the magnitude of 

difference between the two test groups is statistically 

significant. 

The high leakage rates of the Activ GP obturation 

system may be due to the potential for gapping along 

the sealer/dentin interface.26 Additionally, the 

contribution of glass ionomer’s adhesive properties in 

the apical third of a canal has been theorized but not 

demonstrated in the literature.21-30 Also, some 

researchers have expressed concern over glassionomer cement/sealer’s propensity for disintegration 

and leakage.31,32

In vitro studies of another glass-ionomer sealer, KetacEndo (3M/ESPE, Minneapolis, MN), found lower 

leakage rates than traditional zinc oxide-eugenol 

sealers.25,33,34 However, this is not conclusive and 

some studies have found more leakage with glassionomer-based sealers.10,35 An English-language 

literature search for glass-ionomer sealer studies failed 

to reveal any studies for a period greater than 90 days. 

It appears that time may be correlated to the Activ GP 

obturation system’s high leakage rates and the concern 

for disintegration of glass-ionomer-based sealers 

merits further research. 

One consistent finding of fluid transport model studies 

is that sealers have lower leakage rates when the sealer 

is the thinnest.36 A single-cone technique is often 

considered inferior to continuous wave of 

condensation because the volume of sealer is high 

relative to the volume of the cone.37 The Activ GP 

obturation system is no exception, especially when 

ovoid shaped canals are obturated. The imbalance in 

sealer-to-cone ratio promotes void formation and 

likely reduces the quality of the seal.38 Currently, the 

goal is to maximize the amount of solid core material 

and minimize the amount of sealer39 to best seal the 

root canal system, entomb remaining bacteria and fill 

irregularities of the prepared canal.40

Under the conditions of this study, the incorporation of 

glass ionomer in the sealer and master cone of the 

Activ GP obturation system does not appear to solve 

the historically poor in vitro leakage rates often 

associated with single-cone techniques. However, any 

correlation between fluid transport leakage rates and 

bacterial leakage is currently unknown.33

CONCLUSION

Within the parameters of this study, a complete seal 

did not occur for any test group. Using a fluid 

transport system, the Activ GP glass-ionomer-based 

single-cone obturation technique demonstrated 

significantly higher leakage rates than a continuous 

wave of condensation and gutta-percha technique 

(P=<.001). 

REFERENCES

1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects 

of surgical exposures of dental pulps in germ-free and 

conventional laboratory rats. Oral Surg Oral Med 

Oral Pathol Oral Radiol Endod. 1965;20:505-516. 

2. Paque F, Sirtes G. Apical sealing ability of Resilon/

Epiphany versus gutta-percha/AH Plus: immediate and 

16-month leakage. Int Endod J. 2007;40:722-729. 

3. Michaud R, Burgess J, Barfield R, Cakir D, McNeal 

S, Eleazer P. Volumetric expansion of gutta-percha in 

contact with eugenol. J Endod. 2008;34:1528-1532. 

4. Ozok AR, van der Sluis LW, Wu MK, Wesselink PR. 

Sealing ability of a new polydimethylsiloxane-based 

root canal filling material. J Endod. 2008;34:204-227. 

5. Schilder H. Filling root canals in three dimensions. 

Dent Clin North Am. 1967;11:723-744. 

6. Cailleteau JG, Mullaney TP. Prevalence of teaching 

apical patency and various instrumentation and 

obturation techniques in United States dental schools. 

J Endod. 1997;23:394. 
46 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

7. Buchanan L. Continuous wave of condensation 

technique. Endod Prac. December 1998;115-125. 

8. Cohen S, Burns RC, eds. Pathways of the Pulp. 3rd 

ed. St Louis, MO: C.V. Mosby; 1984:XX-XX. Cited 

by: Beatty RG, Vertucci FJ, Zakariasen KL. Apical 

sealing efficacy of endodontic obturation techniques. 

Int Endod J. 1986;19(5):237-241. 

9. Horsted-Bindslev P, Andersen MA, Jensen MF, 

Nilsson JH, Wenzel A. Quality of molar root canal 

fillings performed with the lateral compaction and the 

single-cone technique. J Endod. 2007;33:468-471. 

10. Monticelli F, Sword J, Martin RL, Schuster GS, 

Weller RN, Ferrari M, Pashley DH, Tay FR. Sealing 

properties of two contemporary single-cone 

obturation systems. Int Endod J. 2007;40:374-385. 

11. Ozok AR, van der Sluis LW, Wu MK, Wesselink PR. 

Sealing ability of a new polydimethylsiloxane-based 

root canal filling material. J Endod. 2008;34:204-207. 

12. Brackett MG, Martin R, Sword J, Oxford C, 

Rueggeberg RA, Tay FR, Pashley DH. Comparison 

of seal after obturation techniques using a 

polydimethylsiloxane-based root canal sealer. J 

Endod. 2006;32:1188-1190. 

13. Aboush YE, Jenkins CB. An evaluation of the 

bonding of glass-ionomer restoratives to dentine and 

enamel. Br Dent J. 1986;161:179-184. 

14. Powis DR, Folleras T, Merson SA, Wilson AD. 

Improved adhesion of glass ionomer cement to dentin 

and enamel. J Dent Res. 1982;6:1416-1422. 

15. De Bruyne MA, De Moor RJ. The use of glass 

ionomer cements in both conventional and surgical 

endodontics. Int Endod J. 2004;37:91-104. 

16. Teixeira FB, Teixeira EC, Thompson J, Leinfelder 

KF, Trope M. Dentinal bonding reaches the root 

canal system. J Esthet Restor Dent. 2004;16:348-354. 

17. Whitworth J. Methods of filling root canals: 

principles and practices. Endod Top. 2005;12:2-24. 

18. Schwartz RS. Adhesive dentistry and endodontics: 

part 2-bonding in the root canal system: the promise 

and the problems-a review. J Endod. 2006;32:1125-

1134. 

19. Kim YK, Grandini S, Ames JM, Gu L, Kim SK, 

Pashley DH, Gutmann JL, Tay FR. Critical review on 

methacrylate resin-based root canal sealers. J Endod. 

2010;36:383-399. 

20. Maloney SM, McClanahan SB, Goodell GG. The 

effect of thermocycling on a colored glass ionomer 

intracoronal barrier. J Endod. 2005;31:526-528. 

21. Koagel SO, Mines P, Apicella M, et al. In vitro study 

to compare the coronal microleakage of Tempit 

UltraF, Tempit, IRM, and Cavit by using the fluid 

transport model. J Endod. 2008;34:442-444. 

22. Stratton RK, Apicella MJ, Mines P. A fluid filtration 

comparison of gutta-percha versus Resilon: a new 

soft resin endodontic obturation system. J Endod. 

2006;32:642-645. 

23. Wu MK, Wesselink PR. Endodontic leakage studies 

reconsidered. part 1. methodology, application and 

relevance. Int Endod J. 1993;26:37-43. 

24. Camps J and Pashley D. Reliability of the dye 

penetration studies. J Endod. 2003;29:592-594. 

25. Bal AS, Hicks ML, Barnett F. Comparison of 

laterally condensed .06 and .02 tapered gutta-percha 

and sealer in vitro. J Endod. 2001;27:786-788. 

26. Tay FR, Loushine RH, Lambrecechts P, Weller RN, 

Pashley DH. Geometric factors affecting dentin 

bonding in root canals: a theoretical modeling 

approach. J Endod. 2005;31:584-589. 

27. Miletic I, Anic I, Pezelj-Ribaric S, Jukic S. Leakage of 

five root canal sealers. Int Endod J. 1999;32:415-418. 

28. Oliver CM, Abbott PV. An in vitro study of apical 

and coronal microleakage of laterally condensed 

gutta percha with Ketac-Endo and AH-26. Aust Dent 

J. 1998;43:262-268. 

29. Koch K, Min PS, Stewart GG. Comparison of apical 

leakage between Ketac-Endo sealer and Grossman 

sealer. Oral Surg Oral Med Oral Pathol. 

1994;78:784-787. 

30. de Gee AJ, Wu MK, Wesselink PR. Sealing 

properties of Ketac-Endo glass ionomer cement and 

AH26 root canal sealers. Int Endod J. 1994;27:239-

244. 

31. Friedman S, Lost C, Zarrabian M, Trope M. 

Evaluation of success and failures after endodontic 

therapy using glass ionomer cement sealer. J Endod. 

1995;21:384-390. 

32. Schäfer E, Zandbiglari T. Solubility of root canal 

sealers in water and artificial saliva, Int Endod J. 

2003;36:660. 

33. Dalat DM and Önal B. Apical leakage of a new glass 

ionomer root canal sealer. J Endod. 1998;24:161-163. 

34. Wu MK, De Gee AJ, Wesselink PR . Leakage of four 

root canal sealers at different thickness. Int Endod J. 

1994b;27:304-308. 

35. Smith MA, Steiman HR. An in vitro evaluation of 

micro-leakage of two new and two old root-canal 

sealers. J Endod. 1994;20:18-21. 

Ten-Month In Vitro Leakage Study of a Single-Cone Obturation System 
 January – March 2011 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

36. Wu MK, Wesselink PR, Boersma J. A 1-year followup study on leakage of four root canal sealers at 

different thicknesses. Int Endod J. 1995;28:185-189. 

37. Kontakiotis EG, Tzanetakis GN, Loizides AL. A l2-

month longitudinal in vitro leakage study on a new 

silicon-based root canal filling material (Gutta-Flow). 

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 

2007;103:854-859. 

38. Bouillaguet S, Shaw L, Barthelemy J, Krejci I, 

Wataha JC. Long-term sealing ability of pulp canal 

sealer, AH-Plus, GuttaFlow and Epiphany. Int Endod 

J. 2008;41:219-226. 

39. Wu MK, Kašťáková A, Wesselink PR. Quality of 

cold and warm gutta-percha fillings in oval canals in 

mandibular premolars. Int Endod J. 2001;34:485-491. 

40. Ørstavik D. Materials used for root canal obturation: 

technical, biological and clinical testing. Endod Top. 

2005;12:25-38. 

AUTHORS

LTC McKissock is Chief, Endodontic Services, US 

Army Dental Activity, and Officer in Charge, Smith 

Dental Clinic, Fort Carson, Colorado. 

COL Mines is Chief, Endodontic Services, US Army 

Dental Activity, and Officer in Charge, Rohde Dental 

Clinic, Fort Bragg, North Carolina. 

COL Sweet is Commander, Vicenza Dental Clinic 

Command, US Army Garrison, Vicenza, Italy. 

Col Klyn is Chief of Endodontics, 10th Dental 

Squadron, United States Air Force Academy, Colorado. 

Humanitarian relief and assistance missions, such as this one in Haiti in 2009, are 

a regular part of the practice of dentisty by members of the US Army Dental Corps. 

Photo courtesy of the US Army. 
48 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

In 1998, the US Army Dental Command (DENCOM) 

Information Management and Technology Division 

(IM&TD) was tasked with replacing the existing 

scheduling and workload entry applications with a 

single enterprise solution. DENCOM leadership mandated that this single solution must be able to collect, 

process, present, and archive dental workload, readiness, and patient scheduling data. The end result of their 

efforts is the Corporate Dental Application (CDA). 

EVOLUTION OF AN ENTERPRISE SOLUTION

From its initial deployment, CDA has continued to 

evolve as new mission demands have driven the 

addition of new capabilities. These new capabilities 

have not only allowed Army dental providers to 

improve the efficiency of care, but have also resulted 

in significant improvements in the quality of care. 

Originally intended to serve only as a portal for 

entering workload data and updating dental readiness 

classification information, CDA has grown into a 

robust enterprise dental solution comprised of modules 

for scheduling, data entry, reporting, digital image 

acquisition and viewing, and even a dental lab 

management tool. All of these modules are integrated 

into a single data repository that contains one of the 

largest collections of dental data ever accumulated. 

Some examples of the types and volume of data 

processed by CDA include: 

 12,000 appointments scheduled daily 

 1,300 dental lab cases processed monthly 

 Approximately 2 million workload entries per year 

 Approximately 5,000 digital images processed 

daily 

 Over 19 million archived digital images 

SEAMLESS INTEGRATION OF SCHEDULING, WORKLOAD, 

AND READINESS

The core of CDA functions are presented within an 

internet interface that permits providers to collect, 

process, present, and archive dental workload, 

readiness, and patient scheduling data from a single 

portal. Commanders, staff, and functional managers 

throughout the Army can access this information 

online in real-time from a single point of access. 

The primary component within CDA is the Web 

Scheduler. As an appointment is scheduled, the Web 

Scheduler adds the appointment data to a single data 

repository. As changes are made to the appointment, 

these changes can be viewed throughout the dental 

enterprise. These changes are also reflected in realtime within the clinic so that providers can view the 

activities within the entire clinic without leaving their 

treatment area. 

After an appointment is completed, providers must 

complete the treatment needs and workload 

information for that patient encounter within CDA. 

Providers are supplied with visual reminders if these 

details are not completed, and additional reporting 

capabilities allow clinic managers and leadership to 

track such information gaps. As part of the data entry 

process, the provider must also identify a Soldier’s 

dental readiness classification (DRC). 

Providers and unit commanders can also leverage the 

DRC information processed by CDA to improve the 

deployability of Soldiers. Each treatment encounter 

includes a dental readiness component. As a provider 

completes each appointment, they must determine the 

DRC of the Soldier being treated. If a Soldier has 

treatment needs that preclude him or her from deployment, they must account for these needs within the 

US Army Dental Command Information 

 Management: Poised to Provide Quality 

 Support for the Next 100 Years 

LTC Jeffrey S. Marks, MS, USA 

MAJ Thomas E. Strohmeyer, MS, USA 
 January – March 2011 49

system. Other providers can then access the 

information as the Soldier returns for treatment and 

carry out the required procedures. Unit commanders 

are permitted to view the DRC information for 

Soldiers assigned to their units so that they can ensure 

their personnel meet the deployment requirements. 

INTEGRATING DIGITAL IMAGING

In recent years, CDA has added digital radiographic 

images to the data that is collected within the 

enterprise through its integration with the Army Dental 

Digital Repository (ADDR). The ADDR is the central 

image archive that hosts all digital images acquired 

throughout the Army dental enterprise. As of the end 

of fiscal year 2009, the ADDR hosted over 14 million 

digital images. 

One of the primary concerns in the adoption of a 

digital radiography solution for the CDA dental 

enterprise was how to deal with the many sites to 

which digital x-ray equipment had been deployed. To 

completely replace existing systems would quickly 

exhaust the DENCOM’s budget. A system was needed 

that could use existing hardware, but still allow other 

sites to be “digitized” without waiting for all Army 

dental treatment facilities to have the same set of 

equipment across the enterprise. Hardware replacement was not an option, so DENCOM IM&TD turned 

to a software solution to the problem. After examining 

all commercial products available the time, it became 

clear that if a software solution was required, it would 

be necessary for DENCOM IM&TD to develop it. The 

resulting software solution is the Dental Enterprise 

Viewing and Acquisition Application (DEVAA). 

DEVAA creates an industry standard Digital Imaging 

and Communications in Medicine (DICOM) object. 

The use of DICOM ensures interoperability with 

current and future imaging systems and ensures that 

any provider at any location can view the images, 

without requiring proprietary software to take those 

images. DEVAA uses a vendor’s own device drivers 

to initialize the sensors and take the images from 

within the application interface. 

After an image is acquired using DEVAA at the local 

clinic, it is transmitted to the ADDR via the 

Department of Defense Nonclassified Internet Protocol 

Router Network. Digital images are available 24 hours 

a day, 365 days a year from the internet. Images can be 

searched based on the Soldier’s social security number 

and the type of image that the provider wants to view. 

Images can be enhanced by the providers using various 

image tools that are built into the interface. These tools 

allow a user to adjust magnification, contrast, brightness, and even image mirroring. 

DELIVERING A HIGHER STANDARD OF CARE

CDA has provided a significant number of benefits in 

the quality and efficient delivery of care. Key among 

these benefits realized by dental providers is the ability 

to create a real-time view of patient status. To see the 

current status of patients in the clinic, a user only 

needs to view the appointments displayed in the 

scheduler grid. As the status of each patient changes, 

the appointment information is updated in the 

database. CDA depicts the status change using 

predefined color codes. 

Patient care has also been directly enhanced by the 

development of CDA and its associated modules. The 

Web Scheduler incorporates scheduling, workload, 

and readiness into a seamless data process that reduces 

the time requirements for administrative tasks. This 

time-savings results in a corresponding increase in 

time available for providers to perform patient 

treatment tasks. 

CDA used in conjunction with the Interactive Patient 

Check-In application allows patients to check in for 

appointments using standalone machines that update 

the clinic’s overall appointment schedule. This gives 

front desk personnel more time to assist in patient care 

activities. 

Another benefit provided by CDA is the ability to 

better allocate provider resources. Recent history has 

proven that dental readiness can directly impact 

operational capabilities. Before CDA was introduced, 

it was difficult to determine which facilities may be 

experiencing a shortage of specific skills that directly 

impact dental readiness. By using CDA, supervisors 

can generate reports that detail the readiness status at 

the regional dental command, base, and dental treatment facility levels, and assign resources accordingly. 

The integration of digital imaging into the CDA data 

store has greatly increased a provider’s ability to 

identify patient care issues. Digital images allow for 

true “portability” of image records. This portability 
50 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

allows providers to consult other dentists to allow for 

improved teleradiology efforts at any location. In 

addition, the ability to access records taken at another 

site greatly reduces the need to retake images. This 

reduces the cost and risk to the patient from exposure 

to ionizing radiation. 

DEVAA has also allowed for dramatic improvements 

in the workflow process at many clinics. For example, 

workers normally tasked with developing x-ray images 

are now able to assist in other aspects of patient care. 

At basic training bases, new recruits are required to 

have one panographic scan and 4 bitewings taken 

when they are processed upon arrival. Before the 

deployment of DEVAA, it could take an entire day to 

process just the panographic images. After DEVAA 

was deployed, clinic personnel were able to take 5 

digital images in the same amount of time required to 

take traditional film x-rays. 

COORDINATION WITH OTHER AGENCIES

Since 2003, the US Air Force has partnered with the 

DENCOM to use the scheduling features of CDA. 

Relevant data is separated by service, but all data is 

contained in a single data repository. While the Air 

Force does not yet fully utilize all of the capabilities 

provided by CDA, each service has been provided 

with a “total” integrated view of their patient population which directs their efforts to maximize both 

access to care and quality of care accordingly. 

DENCOM IM&TD is also working with the US Navy 

Medical Information Management Center to establish 

a digital image sharing agreement between the 

services. The agreement establishes an image backup 

at the National Naval Medical Center (Bethesda) for 

the Army, and at Fort Sam Houston for the Navy, 

while allowing each service access to the other 

services’ images as necessary. 

The future of technology and its use in healthcare is 

exciting and unlimited, and the DENCOM Information 

Management and Technology Division stands ready to 

support its evolution throughout the next 100 years. 

AUTHORS

LTC Marks is the Chief Information Officer, US Army 

Dental Command, Fort Sam Houston, Texas. 

MAJ Strohmeyer was formerly the Chief Information 

Officer, US Army Dental Command, Fort Sam 

Houston, Texas. 

US Army Dental Command Information Management: 

Poised to Provide Quality Support for the Next 100 Years 

Articles  published  in  the  Army Medical Department Journal  are  indexed  in 

MEDLINE,  the  National  Library  of  Medicine’s  bibliographic  database  of  life 

sciences and biomedical information. Inclusion in the MEDLINE database ensures 

that  citations  to AMEDD Journal  content will  be identified  to  researchers  during 

searches for relevant information using any of several bibliographic search tools, 

including PubMed. 
 January – March 2011 51

The US Army Dental Command (DENCOM) first 

fielded the Corporate Dental Application (CDA) in 

1999 and completed full implementation throughout 

all DENCOM dental treatment facilities in 2000. 

Initially, the CDA focused on the collection of dental 

workload information or dental weighted values which 

were based on the Department of Defense (DoD) 

dental procedure codes. Dental providers entered treatment workload into the CDA and recorded treatment 

notes, treatment plans, and other information on paper 

dental records. In subsequent years, the CDA was enhanced to captured data on patient treatment needs, 

caries risk, and tobacco use. In 2006, a narrative capability was added to the CDA which enables providers 

to type treatment notes into the CDA. Further development of the CDA was halted as resources were focused 

on AHLTA*-dental as an electronic dental record 

(EDR). The Army Medical Command stopped the 

fielding of AHLTA-dental on November 1, 2009.1

Following the cancellation, the Military Health System 

(MHS) planned to evaluate both AHLTA-dental and 

CDA for the comprehensive military EDR.2

 CDA is 

included in the evaluation process because a version of 

CDA is currently deployed in Army and Air Force dental clinics, CDA is in alignment with future EDR requirements and strategies, and CDA has some capabilities that are not supported by AHLTA. Until a final 

agreement is made by all 3 services, paper records will 

continue to be the standard of care in fixed facilities. 

Historically, theater-wide dental emergency and dental 

treatment data had not been collected from a deployed 

environment. Previous deployed dental treatment and 

dental needs studies were based on small sample sizes 

that may not have been representative of the entire 

patient population.3

 Multiple articles were published 

based on dental records maintained by a single dentist 

or small group of dentists.4-6 In 1997, the Naval Dental 

Research Institute gathered data on dental treatment 

provided to US Marines in Desert Storm via a 

retrospective study of available temporary dental 

records.7

There are various legitimate reasons for the failure to 

collect auditable dental data on a sizeable sample 

population in a deployed environment. The technology 

to electronically capture such data was not available 

until the advent of the CDA. In 2003, the 502nd 

Medical Company (Dental Services) deployed to Iraq. 

At that time, Iraq was an immature theater of 

operations. The focus of the 502nd and other deployed 

dental providers was to provide emergency dental care 

in an austere environment using field portable dental 

equipment. Dental officers did not have the technology 

or internet capability to electronically record and 

capture dental workload or treatment needs data. 

In 2005, the 502nd Medical Company (Dental 

Services) was redesignated as the 502nd Dental 

Company Area Support (DCAS) and became a direct 

Use of the Army Dental Command Corporate 

 Dental Application as an Electronic Dental 

 Record in the Iraq Theater of Operations 

COL Steven Eikenberg, DC, USA 

MAJ Robert Keeler, DC, USA 

SFC Thomas Green, USA 

ABSTRACT

More than 97% of the dental encounters in Iraq between June 2009 and July 2010 were captured on an electronic dental 

record. Data from more than 56,000 patient encounters, with detailed treatment notes, and 19,000 DNBI surveys 

indicates that caries accounted for 22.5% of the dental emergency visits, pulpal disease requiring endodontic (root 

canal) therapy accounted for 20%, and visits associated with wisdom teeth (third molars) accounted for 4.2%. This 

data, in combination with the large numbers of one dental officer clinics, indicates that every dental officer must be 

proficient in endodontic and exodontia diagnosis and treatment. There is evidence that Dental Fitness Category 3 

definitions should be revised. 

*AHLTA is the current US military electronic medical record. 
52 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

reporting unit (DRU) to the 1st Medical Brigade. In 

October of 2005 the 502nd deployed to Iraq as a DRU 

to the Medical Task Force (TF MED) under the 

command and control of the 30th MED BDE. The 

502nd occupied fixed dental clinics with established 

internet capability. The 502nd DCAS dutifully 

recorded dental workload in the CDA and maintained 

paper dental records in accordance with established 

policy. The dental records were offered to the unit or 

to the individual Soldier. It was not practical for the 

502nd to maintain copies of the records for 

epidemiologic reasons, therefore, the 2006-2007 dental 

records cannot be retrieved for a retrospective study. 

Record audits were not performed. It is probable that 

not all of the in-theater dental workload was annotated 

in the CDA. 

The 502nd deployed to Iraq as a direct reporting unit 

to the TF MED from June 25, 2009, to June 4, 2010. 

The mission of the 502nd was to “Envision, design, 

and maintain the highest quality patient care system 

for eligible beneficiaries while planning and executing 

the orderly transition of dental resources to an expeditionary HSS [Health Support System]. Support 1st 

Medical Brigade efforts to facilitate long-term, sustainable Iraqi health care delivery.” One of the 5-unit 

Mission Essential Task List items was “Electronically 

collect patient treatment and treatment needs data.” 

Coincidentally, DENCOM added an electronic disease 

and nonbattle injury (DNBI) survey form to the CDA 

in April 2009 as part of an effort to obtain detailed 

information on DNBI in a deployed environment. 

In order to achieve an Army Dental Care System unity 

of effort for data collection, DENCOM incorporated 

several minor changes in the CDA which were 

designed to support the collection and analysis of 

dental data from a deployed environment. Prior to June 

2009, CDA data for deployed providers was collected 

and “sorted” according to the parent unit of the 

clinician; not geographic location of the dental clinic. 

The various organizations from multiple theaters were 

listed in the DEPRDC (deployed; non-DENCOM 

clinics) section of the CDA data. Listed units included 

those currently deployed and units which had 

redeployed. Those units included multiple medical 

companies (dental services), combat support hospitals, 

area support medical companies, and brigade combat 

teams. 

Dental data collected “by unit” could not be easily 

assigned to an area or geographic location, such as a 

forward operating base (FOB). In addition, it was not 

uncommon for more than one dental organization to 

have treatment teams at a single FOB. The inability to 

quickly and accurately assign dental workload to a 

particular location made it difficult for medical 

planners at the theater or task force level to objectively 

and equitably distribute dental assets in-theater. The 

CDA became a valuable tool for medical planners as 

data for deployed providers became retrievable in the 

same fashion as data from DENCOM dental treatment 

facilities (DTFs), individual providers, the DTF 

(geographic location), and region (theater of 

operations). Brigade combat teams and medical units 

with dental providers continued to have the ability to 

collect data for their respective providers. 

The lack of a uniform theater policy for using the CDA 

to collect dental data meant that objective data was not 

available for use to request and justify dental resources 

for the theater based on patient demand. The 502nd 

sought to establish a policy to mandate the use of the 

CDA as an electronic dental record. The commander 

of the 1st Medical Brigade supported the concept. 

Prior to deployment, it became policy for all TF MED 

dental providers to use the CDA as an electronic dental 

record in lieu of paper dental records. This policy also 

mandated the use of the electronic DNBI survey for all 

military dental emergencies. 

In cooperation with DENCOM, the 502nd developed 

written guidelines based on Army Regulation 40-66 8

and Technical Bulletin MED 250 9 for the utilization of 

the CDA as an electronic record. The process and 

standards were established to ensure that all providers 

would know the process to use the CDA as an 

electronic dental record. The first group (26 PROFIS* 

dental officers from the 502nd DCAS) was trained to 

the new standard prior to deployment. The TF 1st 

Use of the Army Dental Command Corporate Dental Application 

as an Electronic Dental Record in the Iraq Theater of Operations 

*PROFIS predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance† units to fill Active 

Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands 

outside of the continental United States upon mobilization or upon the execution of a contingency operation.10

†Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform a 

specific mission for which there is no appropriate table of organization and equipment (the document which defines the structure 

and equipment for a military organization or unit).
 January – March 2011 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

MED, with the 502nd, had command and control of 

85% of the dental assets in the Iraq theater. Clinician 

education in the CDA and electronic record process 

refinement were immediate priorities. To ensure 

compliance with this policy and to maximize the 

reliability of collected dental data, it was decided to 

audit 100% of the CDA electronic patient encounters 

submitted. Clinician compliance with the electronic 

dental record policy, the quality of the data, and 

practical application of the data were readily apparent 

after the first month. 

On September 1, 2009, the Multi-National Corps-Iraq 

(MNC-I) adopted the TF 1st MED policy. The Dental 

Services appendix to the Medical Services Annex of 

MNC-I Operations Order 09-09* stated that “Dental 

treatment documentation and accountability of all 

dental procedures provided for active duty service 

members and other beneficiaries will be recorded on 

the CDA...website.” This policy applied to all dental 

providers in theater. Army dental officers assigned to 

brigade combat teams, and USN and USAF dental 

officers working in Army facilities quickly complied 

with this new policy. To ensure compliance and 

maximize the reliability of collected dental data, it was 

decided to audit 100% of the CDA electronic patient 

encounters submitted in the Iraq theater of operations. 

These “audits” were conducted by the 502nd DCAS 

Commander, who also served as the Theater Dental 

Consultant (TDC). 

An audit process was designed using the concepts 

taught by the US Army Medical Command Lean Six 

Sigma program.†

 A senior dental noncommissioned 

officer (NCO) first reviewed each CDA encounter 

within 48 hours of the treatment submission. There 

were several areas of interest: 

Did the annotated DoD procedure codes, which 

captured the dental workload value, match the 

treatment narrative? 

Were all A0199 coded emergency visits 

accompanied by an electronic DNBI survey form? 

Were emergency dental exams, DoD procedure 

code D0140, written in SOAP format (symptoms, 

observations, assessment, prognosis)? 

Was there a treatment plan recorded for each nonemergency dental exam (DoD procedure code 

D0120)? 

Was the appropriate biographical data entered for 

each patient? 

The number of daily patient encounters entered into 

the CDA ranged from 21 to 405, with a mean of 257 

per day. The dental NCO required approximately 5 

hours to review the daily encounters and record 

apparent discrepancies. The results of the preliminary 

audits were forward to the TDC. The TDC reviewed 

the audit results for each dental officer and then 

personally emailed each dental provider the results of 

the daily record audit. The number of patients treated 

and the value of the dental workload were also listed in 

the email. A member of the dental officer’s chain of 

command was provided a copy of the email 

correspondence between the TDC and individual 

dental officer. The overwhelming majority of the 

audits, more than 91%, stated “zero negative findings.” 

When discrepancies were noted, the dental provider 

was asked to make the appropriate correction. As part 

of the audit process, the dental record audit NCO 

would recheck the patient encounter to ensure the 

corrections were made. On the rare occasion when a 

correction was not submitted, the TDC would again 

email the provider. The TDC spent approximately 75 

minutes supporting the dental audit process. 

The daily record audit has several advantages: 

 Maximizes the probability of uniformity in dental 

workload reporting. 

 Maximizes the probability that all dental workload 

is captured by providers. 

 Provides an opportunity to contact all theater 

dental providers daily and provide positive 

feedback. 

 Enhances the reliability of collected data. 

Over an 11-month period (July 1, 2009 to May 31, 

2010), dental officers in Iraq recorded in the CDA 

more than 56,000 patient encounters (visits) and 

190,000 procedure codes, with a value of $17.7 

million. More than 19,000 of these encounters were 

defined as emergency visits and were accompanied by 

DNBI surveys. It is estimated that the CDA and DNBI 

data captured more than 97% of the dental patient 

*Internal military document not generally accessible by the 

general public. 

†Information available at: http://www.armyobt.army.mil/cpi-kctools-lss.html. 
54 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

encounters in Iraq during this period. The 97% 

calculation is based on patient encounters and 

workload recorded by 2 USAF dental clinics using the 

USAF version of the CDA. The USAF data did not 

include treatment notes or DNBI data. The USAF 

dental production data was incorporated into the 

monthly dental reports to the MNC-I Surgeon. 

The validated dental data was used during the 

deployment by the TDC and TF MED 502nd to 

equitably distribute dental resources during the 

deployment. There were several reasons that a 

redistribution of dental assets was necessary. Military 

and other dental beneficiary populations on the various 

installations continually fluctuated due to troop 

restationing plans, as well as retrograde operations in 

support of the responsible drawdown of forces in Iraq. 

It was often necessary to backfill dental personnel. 

Dental personnel were redeployed early from theater 

for a variety of reasons and personnel replacement 

times ranged from one to 3 months. Dental personnel 

who used the rest and recuperation leave program were 

absent from their clinic for approximately 3 weeks. As 

the troop levels decreased, accompanying productivity 

and patient needs data justified eliminating several 

dental officer PROFIS requests generated by nonDCAS units. 

For the first time, reliable and auditable dental data on 

a valid, representative sample of the entire population 

is available to medical manpower analysts. The Army 

Medical Department (AMEDD) Strategic Studies 

Branch stated that the “dataset provided for the dental 

health project (through the use of electronic dental 

records and electronic DNBI surveys) is by far one of 

the cleanest, most complete datasets encountered in 

years.” It is anticipated that medical planners at the 

AMEDD and Army Command levels can use this data 

to objectively establish dentist, dental ancillary, and 

dental equipment requirements for a deployed patient 

population based on patient needs and potential risk. 

The data clearly indicates that the dental treatment of 

nonmilitary beneficiaries must be considered by 

medical planners. The data reveals that deployed 

dental treatment facilities are significantly more 

efficient when the assistant to dental officer ration is 

greater than 1:1. Many 502nd DCAS and TF 1st MED 

DTFs had a 1:1 plus one staffing ratio. The “plus one” 

is an additional assistant available to perform 

reception, administrative, and instrument sterilization 

duties, as well as chairside assistance. These 1:1+1 

clinics produced 38% more procedures per dentist than 

DTFs with a 1:1 ratio. 

Dental data from any theater and time period should be 

normalized to account for difference in the assigned 

mission, theater policies, staffing ratios for dentists 

and their ancillaries, and theater infrastructure. Data 

collected by the TF MED providers during this period 

includes prophies (dental cleanings) comprising 14% 

of the nonexamination dental procedures. TF MED 

policy was that all dental providers spend 40 to 44 

hours a week providing hands-on patient care. This 

policy increased the amount of routine dental care 

provided to Soldiers on a space available basis. This 

policy contributed to increased levels of Soldier dental 

wellness, enhanced patient morale, and enhanced unit 

morale as TF MED Soldiers stayed busy and 

productive in-theater. 

In 32 various after-action reports, deployed dental 

officers made recommendations for changes to the 

current DoD definitions of Dental Fitness Category 

(DFC) 3. DFC3 is defined as a high risk for a dental 

emergency within 12 months. An examination of 

19,000 DNBI surveys and 56,000 electronic dental 

records may provide the scientific justification for the 

proposed additions to DFC3 definitions: 

1. Endodontically obturated posterior tooth without 

cuspal coverage. Currently, DoD Health Affairs 

(HA) Policy 02-01111 lists DFC2 for “teeth 

restored but for which protective cuspal coverage is indicated.” 

2. Partially erupted wisdom teeth which will not 

erupt into occlusion. Currently HA Policy 02-

011, lists DFC3 only if “historical, clinical, or 

radiographic signs of pathosis.” 

3. All interim restorations or prosthesis. Current 

DFC3 definition is “interim restorations or 

prosthesis that cannot be maintained for a twelve 

month period.” 

4. A Soldier with more than 6 DFC2 lesions. 

5. A Soldier with orthodontic brackets and wire. 

6. A high-caries-risk Soldier with interproximal 

posterior composite restorations. 

The data from the DNBI surveys completed between 

July 1, 2009, and 30 June 30, 2010, are listed in Tables 

1 through 8 and presented in the Figure (page 53). 

Use of the Army Dental Command Corporate Dental Application 

as an Electronic Dental Record in the Iraq Theater of Operations 
 January – March 2011 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

There were 16,084 military personnel DNBI encounters 

recorded, with a total of 19,084 recorded DNBI 

encounters in this period. Unfortunately, the MNC-I 

policy to collect dental emergency data and DNBI 

surveys applied only to military personnel. Some dental 

providers took it upon themselves to record nonmilitary 

DNBI data. 

The gender and component of the military personnel 

who sought emergency dental treatment are shown in 

Tables 1 and 2 respectively. Emergency encounters 

were collected under the code “A0199 emergency visitproblem focused” found in the DoD Guidelines for 

Dental Procedure Codes and Dental Weighted Values.12

According to this code, providers are to take credit only 

once per each unscheduled visit to a dental facility, 

regardless of the reason for which the patient sought 

expedited care. It is obvious that males were the 

predominate group that sought treatment of dental 

emergencies. However, without theater-wide personnel 

data on the component and gender composition of US 

forces in Iraq during this period, which component and 

gender was statistically more prone to seek treatment 

for a dental emergency cannot be determined. Gender, 

component, and age data should indicate which group 

of Soldiers should be the main target audience for 

preventive dental messages. 

The DNBI survey also tracked the number of months 

that the Soldier had been deployed when the Soldier 

sought emergency dental care. Conventional wisdom is 

that dental emergency rates increased as the 

deployment dwell time increased. The data collected 

during this period does not support this conventional 

hypothesis. The number of months a patient had been 

deployed when he or she sought emergency dental 

treatment are shown in Table 3, and percentages for the 

deployment period are shown the Figure. There appears 

to be an initially high dental sick call rate in the first 

month of deployment and another peak at the 7-month 

mark. There are several potential explanations for the 

findings. One potential explanation is that Soldiers 

arrive with untreated dental emergencies. Another 

explanation is sequela from dental treatment just prior 

to deployment. Using CDA data, further investigation 

is warranted. Data on the average dwell time for these 

patients is needed. It is possible that in-theater dental 

sick-call rates are directly related to the amount of time 

since the Soldier’s last dental exam. Soldiers who 

deployed in December 2008 may have had their last 

dental exams anytime between December 2007 and 

Gender Encounters Percentage 

Male 13,572 84.38 

Female 2,512 15.62 

Table 1. Dental emergency encounters 

by gender.

Component Encounters Percentage 

Army Active Duty 9,036 56.18 

Army National Guard 3,977 24.73 

Army Reserve 1,912 11.89 

Air Force 720 4.48 

Navy 289 1.80 

Marine Corps 150 0.93 

Table 2. Dental emergency encounters by 

military service. 

No. of Months 

in Theater 

Emergency 

Visits 

Percentage of 

Emergency Visits 

per Deployed Month 

Cumulative 

Percentage of 

Emergency Visits 

1 2,377 14.8 14.8 

2 949 5.9 20.7 

3 1,090 6.8 27.5 

4 1,152 7.2 34.6 

5 1,322 8.2 42.8 

6 1,229 7.6 50.5 

7 1,627 10.1 60.6 

8 1,508 9.4 70.0 

9 1,265 7.9 77.8 

10 1,047 6.5 84.3 

11 1,070 6.7 91.0 

12 903 5.6 96.6 

13 299 1.9 98.5 

> 13 246 1.5 100.0 

Table 3. Dental emergency encounters by number of months 

deployed. 

Etiology of Chief Complaint 

(Primary Classifications) 

Frequency 

of Diagnosis 

Percentage 

Enamel, dentin, 

or restoration 11,947 48 

Pulpal disease 4,860 20 

Dentoalveolar surgery 

or 3rd molar 3,249 13 

Periodontal disease 2,169 9 

Other dental 

conditions 1,008 4 

Temporomandibular 

disorder 805 3 

External trauma 603 2 

Totals 24,641 100 

Table 4. Etiology of dental chief complaint. 
56 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

December 2008. Other potential factors influencing 

dental sick-call include, but are not limited to, the 

patient’s, caries risk, oral hygiene, and the number of 

untreated DFC2 dental lesions. 

Tables 4 through 8 reveal the etiology of the patient’s 

chief complaint and the multiple etiology subsets. As 

part of the DNBI survey, more than one etiology could 

be applied to a visit. The most notable findings were 

that caries accounted for 22.5% of the dental 

emergency visits, pulpal disease requiring endodontic 

(root canal) therapy accounted for 20%, and visits 

associated with wisdom teeth (third molars) accounted 

for 4.2%. The data, in combination with the large 

numbers of single dental officer clinics, indicates that 

every dental officer must be proficient in endodontic 

and exodontia diagnosis and treatment. The complexity 

of many third molar extractions combined with the 

standard of care to provide sedation therapy for many 

of these patients confirms the theater need for a oral 

and maxillofacial surgeon to support third molar 

exodontias requirements. The alternative is the 

evacuation of military personnel from theater for 

complications from erupting third molars. 

In a deployed environment, the CDA as an electronic 

dental record and electronic DNBI surveys proved a 

significant improvement over paper records and 

surveys. The low record audit error rate indicates that 

dental officers will use a clinician friendly electronic 

record, and that dental officers are aware of the Army 

Dental Care System requirement to collect accurate 

dental data. There is room for improvement. Dental 

record audits could be conducted from a location in the 

United States. A triservice electronic dental record 

should be adopted to ensure all dental data is collected 

and treatment notes are accessible to home duty station 

military DTFs and postdemobilization nonmilitary 

dental providers. Until a triservice solution is adopted, 

CDA as an electronic dental record should be the 

standard of care for deployed providers. DENCOM is 

studying potential modifications and improvements to 

the CDA. In October 2010, an electronic exam form or 

mass event module was added for use at first term 

dental readiness and Soldier readiness processing sites. 

The potential baseline data from an electronic dental 

exam for dental treatment needs could further refine 

dental manpower and equipment requirement 

justifications in both the deployed and fixed facility 

environments. 

Use of the Army Dental Command Corporate Dental Application 

as an Electronic Dental Record in the Iraq Theater of Operations 

Etiology Subset 1 of 7 

Enamel Dentin 

Restoration Diagnosis 

Frequency Percentage 

Fractured with caries 2,319 19.41 

Hypersensitivity 2,262 18.93 

Defective with caries 1,944 16.27 

Caries 1,475 12.35 

Defective without caries 1,349 11.29 

Other 1,262 10.56 

Hyperocclusion 988 8.27 

Fractured without caries 348 2.91 

Totals 11,947 100.00 

Table 5. Subset of enamel dentin restoration 

diagnosis. 

Table 6. Subset of pulpal diagnosis. 

Etiology Subset 2 of 7 

Pulpal Diagnosis 

Frequency Percentage 

Pulpitis 1,629 33.52 

Pulpless /previously treated 888 18.27 

Necrotic pulp 618 12.72 

Periaradicular abscess 578 11.89 

Anatomic space infection 558 11.48 

Other 505 10.39 

Periaradicular periodontitis 84 1.73 

Totals 4,860 100.00 

Etiology Subset 3 of 7 

Dental Alveolar Diagnosis 

Frequency Percentage 

Alveolar osteitis (3-5 day 

postoperation) 1,104 33.98 

Pericoronitis 1,003 30.87 

Other 599 18.44 

Sequestrum from previous extraction 190 5.85 

Normal postoperation 

pain or swelling 184 5.66 

Hemorrhage 109 3.35 

Eruption pain 52 1.60 

Anatomic space infection 8 0.25 

Totals 3,249 100.00 

Table 7. Subset of dental alveolar diagnosis. 

Table 8. Subset of periodontal diagnosis. 

Etiology Subset 4 of 7 

Periodontal Diagnosis 

Frequency Percentage 

Gingivitis/Gingival Bleeding 931 42.92 

Other 747 34.44 

Necrotizing Ulcerative Gingivitis 420 19.36 

Ailing/Failing Implant 36 1.66 

Periodontal Abscess 25 1.15 

Anatomic Space Infection 10 0.46 

Totals 2,169 100.00 
 January – March 2011 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

ACKNOWLEDGEMENT

The authors thank the US Army Dental Command and 

the Dental Staff at the Office of The Surgeon General 

for their superb level of support to the Soldiers of the 

502nd DCAS during the deployment. 

REFERENCES

1. Brewin, Bob. Army abruptly stops rollout of 

electronic dental record application. Government 

Executive.com [serial online]. November 3, 2009. 

Available at: http://www.govexec.com/dailyfed 

/1109/110309bb1.htm. Accessed November 15, 2010. 

2. Brewin, Bob. Military Health to evaluate two 

electronic dental record systems. Government Executive.com [serial online]. November 25, 2009. Available at: http://www.nextgov.com/nextgov/ng_2009 

1125_6460.php. Accessed November 15, 2010. 

3. Eikenberg S, White K. Report of dental emergencies 

treated by the 257th Medical Company (Dental Service) in Haiti during Operation Uphold Democracy. 

Army Med Dept J. September-October 1995:17-21. 

4. Tewles RB, King JE. Impact of troop dental health on 

combat readiness. Mil Med. 1987;152(5):233-235. 

5. Chaffin J, King JE, Fretwell LD. U.S. Army dental 

emergency rates in Bosnia. Mil Med. 2001

(12);166:1074-1078. 

6. Moss DL. Dental emergencies during SFOR 8 in 

Bosnia. Mil Med. 2002;167(11):904-906. 

7. Deutsch WM, Simecek JW. Dental emergencies 

among Marines ashore in Operations Desert Shield/

Storm. Mil Med. 1996:161(10):620-623. 

8. Army Regulation 40-66, Medical Record 

Administration and Health Care Documentation. 

Washington, DC: US Dept of the Army; June 17, 

2008. 

9. Technical Bulletin MED 250: Dental Record 

Administration, Recording, and Appointment 

Control. Washington DC: US Dept of the Army; 

April 28, 2006. 

10. Medical Corps Professional Development Guide. 

Fort Sam Houston, TX: US Army Medical Department Center and School; March 2002:27. 

11. Assistant Secretary of the Army for Health Affairs. 

Memorandum: Policy on Standardization of Oral 

Health and Readiness Classifications. Washington, 

DC: US Dept of the Army; June 4, 2002. Available 

at: http://www.ha.osd.mil/policies/2002/02-011.pdf. 

Accessed October 28, 2010. 

12. Guidelines for Dental Procedure Codes and Dental 

Weighted Values. Falls Church, VA: Tricare 

Management Activity, US Dept of Defense; October 

1, 2009. 

AUTHORS

COL Eikenberg is Commander, 502nd Dental Company 

(Area Support), Fort Hood, Texas. 

MAJ Keeler is Deputy Commander for Clinical 

Services, 502nd Dental Company (Area Support), Fort 

Hood, Texas. 

SFC Green is the Treatment Platoon Leader, 502nd 

Dental Company (Area Support), Fort Hood, Texas. 

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 >13

% Emergency Visits

Cumulative % Dental Emergencies

Months Deployed

Percentage of total emergency visits for dental care throughout the deployment to Iraq (06/09 through 07/10) per deployment month, and the 

cumulative percentage through that month (Table 3, columns 3 and 4). 
58 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

In a previous article in the AMEDD Journal,

1

 I presented a historical review of dental readiness of the 

Army Reserve components from 1968 to the end of 

September 2005. This article focuses on the progress 

of dental readiness for the Army Reserve components 

(RC), which consist of the Army National Guard 

(ARNG) (component 2) and the US Army Reserve 

(USAR) (component 3), for the period October 2005 

through September 2010. During this period, the US 

Army Dental Command (DENCOM) processed over 

192,000 ARNG and 88,000 USAR Soldiers through 

mobilization stations. The dental-ready report rate to 

the mobilization station for ARNG Soldiers improved 

from 56% to 86%, and that for USAR Soldiers 

improved from 36% to 64%. These improvements 

reduced dramatically the “just in time” dental exams 

and treatment that had historically been performed at 

mobilization stations in order to deploy dentally fit 

Soldiers. In August 2008, DENCOM initiated the RC 

Demobilization Dental Reset which, through the end 

of Fiscal Year (FY) 2010, had examined and treated 

over 141,000 RC Soldiers and reset 92% of them to 

the dental deployment standard before their release 

from active duty status. Through the implementation 

of programs and electronic processes described in this 

article, the RC baseline dental readiness as identified 

by the Army Medical Protection System improved 

from approximately 42% dental-ready in FY 2006 to 

approximately 71% dental-ready by the end of FY 

2010. 

HISTORICAL PERSPECTIVE

By the end of FY 2005, RC dental-ready report rates to 

mobilization platforms had improved to 56% for the 

ARNG and 36% for the USAR, from 13% dentalready at the beginning of FY 2004. In November 2005, 

MG Joseph G. Webb, Chief of the Dental Corps and 

Deputy Surgeon General, directed the creation of the 

Dental All Army Working Group (DAAWG) to 

continue the improvement in dental-ready report rates 

and foster cooperation among the dental stakeholders 

of the three Army components. This group consisted 

of dental surgeons from the Army National Guard 

Bureau (NGB), the Army Reserve Command, the 

Office of The Army Surgeon General (OTSG), and the 

DENCOM. This core group of stakeholders would be 

instrumental in directing the future paradigm shifts in 

RC dental readiness. Two issues had to be addressed: 

(a) the development of an all Army synchronized 

electronic dental database which would improve dental 

readiness validation processes at mobilization stations; 

and (b) an Army directed and funded RC dental 

readiness program that operates outside of alert status 

which would improve baseline RC dental readiness, 

leading to dental-ready RC Soldiers presenting to 

mobilization installations. 

SYNCHRONIZED ELECTRONIC DATABASES

In the absence of an Active Component (AC) 

electronic dental record, by 2006 the NGB dental 

surgeon’s office had developed DENCLASS, an 

electronic dental record and dental readiness tracking 

system. At the same time, the DENCOM Information 

Management and Technology Division (IM&TD) had 

developed and implemented the Digital Enterprise 

Viewing and Acquisition Application (DEVAA) for 

use within the Active Army Dental Care System 

(AADCS). DEVAA permitted the standardized storage 

of digital radiographs, regardless of sensor type used 

by any dental treatment facility within the AADCS. By 

June 2007, IM&TD began development of the Army 

Dental Digital Repository (ADDR) to which DEVAA 

images taken at local dental treatment facilities could 

be uploaded, permitting viewing of dental digital 

radiographs worldwide. At the same time, images 

taken by the Federal Strategic Health Alliance 

(FEDS_HEAL), a primary provider network performing premobilization RC dental readiness exams, 

radiographs, and treatment, started transmitting digital 

radiographs to the ADDR. By early 2008, the USAR 

started using DENCLASS for their electronic dental 

Dental Readiness of Army Reserve 

 Components: A Historical Review, Part Two 

COL Mark B. Bodenheim, DC, USAR 
 January – March 2011 59

record. This initiated a series of DENCLASS 

improvements which permitted radiographs and 

electronic examination records produced by the 

Reserve Health Readiness Program (which replaced 

FEDS_HEAL) or direct contracted networks to be 

placed into the ADDR using DENCLASS as the entry 

portal. This improved Soldier Readiness Processing 

(SRP) validation at mobilization stations when paper 

records were lost or incomplete. In early 2009, the 

DAAWG directed that all RC dental readiness data 

must be placed into the ADDR through the 

DENCLASS portal starting October 1, 2009. In early 

2010, the DAAWG directed that a digital panograph 

would be on file in the ADDR for all Army Soldiers 

starting October 1, 2010. DENCLASS also had portal 

links to the DENCOM Corporate Dental Application 

(CDA) database, allowing RC contracted entities to 

see radiographs and dental record documentation, 

regardless of whether that data was produced by the 

RC dental readiness system and recorded in 

DENCLASS or was produced within the AADCS and 

recorded in CDA. These improvements gave new tools 

to all three components to reduce duplication of 

examination and radiographic processes. 

The foundation had been laid for the three Army 

components to synchronize their electronic dental 

databases. The fact that the AC and RC databases were 

not synchronized by a common electronic dental 

record posed a significant challenge. All 

databases were awaiting full development of 

an AHLTA* electronic dental record. In late 

2009, a strategic pause was ordered for the 

AHLTA electronic dental record throughout 

Department of Defense (DoD) dental 

treatment facilities. However, the AADCS 

required an electronic examination document 

that was simple to use for mass events, such 

as the RC demobilization dental reset. In 

early 2010, the DAAWG agreed to an 

aggressive October 1, 2010 deadline to 

produce an AADCS electronic examination 

document for mass events, and to 

synchronize all databases in order to produce 

an RC electronic dental SRP validation 

system. A CDA program team developed the 

Mass Event Module (MEM), creating an 

electronic dental examination record which 

recorded charting of disease, diagnosis, 

treatment procedures required, and the Dental 

Readiness Class (DRC) of a Soldier. By August 2010, 

the MEM was tested and released for system-wide 

implementation for RC mobilizations and 

demobilizations. The use of the MEM eliminated 

multiple paper record processing steps required to 

place data into the ADDR, and provided more 

accurate, standardized examination documentation for 

the RC. 

Another CDA program team tackled synchronizing the 

databases to produce an electronic dental SRP 

validation process. By 2009, the DAAWG realized 

that the way dental data was fed to the Army’s 

Medical Protection System (MEDPROS), which 

reports the medical and dental readiness of AC and RC 

individuals or units, lacked data integrity. Nondental 

unit personnel with MEDPROS write-access could 

change dental readiness data without any electronic 

dental data input or paper proof of dental readiness. In 

addition, CDA and DENCLASS were sending dental 

data to MEDPROS independent of each other, which 

led to system overwrites of DRC status and exam 

dates. Thus, paper records were required at the 

mobilization station in order to verify one source of 

information. By late 2009, the DAAWG agreed to a 

circular system of data flow, illustrated in Figure 1, 

which could only be accessed and changed by 

authorized AC or RC dental personnel using either 

Figure 1. Clinical dental readiness data synchronization. 

Glossary 

MEDPROS - Army Medical Protection System 

CDA - Army Dental Command Corporate Dental Application 

ADDR - Army Dental Digital Repository 

DENCLASS - Army National Guard electronic dental record and dental readiness 

tracking system 

ASDRS - Army Selected Reserve Dental Readines System 

AADCS - Active Army Dental Care System *AHLTA is the current US military electronic medical 

record. 
60 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

CDA or DENCLASS. In December 2009, MEDPROS 

access was limited to dental personnel with writeaccess in DENCLASS or CDA, which led to an 

immediate improvement in dental readiness data 

quality. Then, by August 2010, the single pathway 

flow of dental readiness data was developed whereby 

CDA became the entry point for all dental data to 

MEDPROS. Data produced by DENCLASS would 

update CDA, which in turn would update MEDPROS. 

Data first entered into CDA would then update 

MEDPROS and then update DENCLASS. With a 

single pathway flow of real-time dental readiness data, 

6 common data elements could be used to 

electronically determine if a RC Soldier could be 

validated as dental-ready without the use of paper 

dental records. The RC electronic dental SRP 

validation process was tested in September 2010 and 

fully implemented throughout DENCOM operated 

mobilization and demobilization stations on October 1, 

2010. The RC Soldier’s dental readiness status could 

now be validated electronically using trusted electronic 

dental data. 

PROGRAMMATIC RC DENTAL READINESS SYSTEM

By 2005, dental examinations and DRC 3 treatment at 

no charge to the RC Soldier were based on the RC 

Soldier’s alert for mobilization. Outside of this alert 

status, no dental readiness program was available for 

RC Soldiers. Dental readiness care was being 

delivered by FEDS_HEAL for the USAR and by 

FEDS_HEAL and direct contractors for the ARNG. 

By 2007, DoD directed the creation of a contracted 

medical and dental readiness provider network for the 

RC, the Reserve Health Readiness Program (RHRP), 

to replace FEDS_HEAL. After the RHRP contract was 

approved in September 2007, the RHRP DoD 

representative became a sitting member of the 

DAAWG. In the meantime, the Army leadership was 

developing the Armed Forces Generation cycle 

(ARFORGEN), a rotational plan involving pools 

(reset/train; ready and available) of Army AC and RC 

units. However, except for Soldiers in the alert status 

of the AFORGEN available pool, there was no Army 

directed RC dental readiness program. In December 

2006, the OTSG Dental Staff Officer (action officer), 

COL James Honey, focused the DAAWG to work 

toward an Army directed dental readiness system 

which would provide annual exams and DRC 3 

treatment throughout the ARFORGEN cycle. This 

system would require an electronic database for dental 

readiness tracking and authorization to use RC 

Operation and Maintenance funding to purchase 

contract dental readiness care at home station. The 

necessary authorization for funding was made possible 

in January 2007 when the Secretary of Defense 

directed that RC mobilizations would be limited to one 

year. This meant that RC units did not have the luxury 

of staying at the mobilization platform for 60 to 120 

days prior to deployment but would now be deployed 

within 30 to 60 days of arriving at the mobilization 

station. Consequently, in February 2008, the Assistant 

Secretary of the Army, Manpower & Reserve Affairs 

(ASA-M&RA) issued a policy stating that all Selected 

Reserve Soldiers would deploy within 75 days of 

mobilization. All Selected Reserve Soldiers would 

now qualify as “early deployers” and therefore be 

entitled to dental readiness care in accordance with 

existing Federal law, 10 USC, §1074a (d)(1). This 

policy provided key support for the ongoing staffing 

process to create the Army Selected Reserve Dental 

Readiness System (ASDRS). In April 2008, the 

ASDRS was staffed through Headquarters, Department of the Army in preparation for final approval 

through ASA-M&RA. At the same time, the Army’s 

Chief of Staff also focused on Army Initiative Four to 

“operationalize” the Reserve component forces. Within his first 100 days as Army Surgeon General, LTG 

Eric Schoomaker directed a complete review of RC 

dental readiness. The Assistant Surgeon General for 

Force Projection assembled a multicomponent work 

group in March 2008 to conduct a capabilities-based 

assessment and develop a prioritized list of courses of 

action. In April 2008, I testified before the 

Subcommittee on Oversight and Investigations of the 

House Armed Services Committee,2

 outlining the 

history of RC dental readiness and initiatives that were 

being reviewed by the Army leadership. Proposed 

initiatives included the expansion of the existing First 

Term Dental Readiness program, establishment of paid 

dental readiness days for the RC, creation of an Army 

Selected Reserve Dental Readiness System (ASDRS), 

development of an enhanced TRICARE* dental 

program, and introduction of a demobilization reset. 

By May 2008, the Army’s Vice Chief of Staff directed 

the dental reset of the RC forces upon demobilization, 

and by August 2008, DENCOM implemented the 

Dental Readiness of Army Reserve Components: A Historical Review, Part Two 

*TRICARE is DoD’s health care program for members of the uniformed 

services, their families, and their survivors. Information available at 

http://www.tricare.mil.
 January – March 2011 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

Reserve Components Demobilization Dental 

Reset. By September 2008, the ASA-M&RA 

approved ASDRS and issued a policy 

guidance memorandum which directed the 

Chief, Army Reserve and Director, Army 

National Guard to implement the ASDRS 

using base program readiness (operation and 

maintenance) funding. The memorandum 

included the requirement to achieve the DoD 

Health Affairs dental readiness policy 

standard3

 of 95% DRC 1 or 2 in support of all 

Selected Reserve Soldiers outside of alert for 

mobilization. ASDRS could use contingency 

funds for Ready Reserve Soldiers (Selected 

Reserve, Individual Ready Reserve, and 

Inactive National Guard) once they are alerted 

(and called or ordered to active duty for a 

period of more than 30 days), in accordance 

with 10 USC, §1074a (f)(1). By FY 2010, RC Soldiers 

were being provided paid medical/dental readiness 

days which compensated Soldiers’ time off from their 

civilian jobs to achieve medical and dental readiness 

standards. 

SUMMARY

The multiyear RC dental readiness improvement 

initiative outlined in this article met the original 2 

requirements of the DAAWG: 

 A seamless system of RC dental readiness access 

(Figure 2) throughout the ARFORGEN cycle at no 

cost to the RC Soldier. The DENCOM-commanded AADCS has operational responsibility for 

the First Term Dental Readiness program when the 

RC Soldier is in initial entry training; mobilization/demobilization station dental readiness 

deployment care; and the RC Demobilization 

Dental Reset. The ASDRS, as directed through the 

Chief, Army Reserve and Director, Army National 

Guard, has operational responsibility for RC dental 

readiness throughout the ARFORGEN reset/train, 

ready, and available pools. 

 A trusted, synchronized, electronic dental readiness validation and record system which reduces 

duplication of processes and improves mobilization station efficiencies. Future improvements in 

RC dental readiness will require continued improvements in electronic data system synchronization and RC command-directed implementation 

of the ASDRS. 

REFERENCES

1. Bodenheim MB. Army Reserve components dental 

readiness: a historical review since the first gulf war. 

Army Med Dept J. January-March 2006:27-30. 

2. Challenges Associated with Achieving Full Dental 

Readiness in the Reserve Component: Hearings 

Before the Subcommittee on Oversight and 

Investigations of the House Armed Services 

Committee, 110th Cong, 2nd Sess (April 23, 2008). 

3. Assistant Secretary of Defense for Health Affairs. 

Memorandum: Policy on Oral Health and Readiness 

[HA Policy 06-001]. Washington, DC: US Dept of 

Defense; January 9, 2006. Available at: http://

www.health.mil/libraries/HA_Policies_and_Guide 

lines/06-001.pdf. Accessed November 23, 2010. 

AUTHOR

COL Bodenheim is Chief of Reserve Components 

Operations, US Army Dental Command, and the 

Drilling Individual Mobilization Augmentee to the 

Dental Corps Chief, Fort Sam Houston, Texas. 

Active Army Dental Care System 

RC Selected Reserve Dental Readiness System (ASDRS) 

Veterans Administration Dental Care System 

Figure 2. Army Reserve component Armed Forces Generation cycle dental 

readiness model. RHRP indicates Reserve Health Readiness Program. 
62 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

EXECUTIVE SUMMARY

This report presents the findings from an oral health 

survey of US Army recruits at time of entry into the 

armed services. The survey was conducted from 

December 2007 to November 2008. Prior to analysis, 

the sample of 1,928 Army recruits was weighted to 

represent the estimated total number of Army recruits 

attending basic training (171,348) during this period. 

Weighting factors included military service, gender, 

and military service status or component, thus 

allowing comparisons among Regular (Active Duty), 

Reserves, and National Guard recruits of each service. 

The distribution of the recruits by service: 

 Army 57.1% 

 Marines 15.2% 

 Navy 15.1% 

 Air Force 12.6% 

The distribution of Army recruits by component: 

 Regular 50.3% 

 Reserve 16.8% 

 National Guard 32.9% 

The oral health findings were compared to results from 

the 1994 and 2000 Tri-Service Oral Health Recruit 

Studies where data were available. 

DoD Dental Fitness Classification 

The percentage of recruits in Department of Defense 

(DoD) Dental Fitness Class (DFC) 3 was 52.5% 

compared to 42% in 2000 and 33.3% in 1994. 

Only 4.3% of 2008 Army recruits did not require any 

treatment at the time of examination (DFC 1). 

There was no statistical difference in the distribution 

of DFC among the 3 Army components. 

Treatment Needs 

Almost all (84.3%) 2008 Army recruits needed an oral 

prophylaxis. While only 4.3% of Army recruits were 

DFC 1 at initial exam, an additional 6.7% would be 

DFC 1 after prophylaxis. 

Operative needs were the most common area of dental 

treatment required for recruits. One quarter of recruits 

did not require any restorations and 21% required 7 or 

more restorations. The operative need of recruits was 

similar for all components. Mean number of 

restorations needed for each recruit was 3.7. 

Seventeen percent of recruits required some fixed pros 

care, none were completely edentulous, and no 

removable partial dentures were indicated. 

There was a significant improvement in the percentage 

of Army recruits who required no extractions (39.6%) 

in 2008 compared to 27.1% in 2000. 

The status of 2008 recruits did not significantly change 

when compared to 2000 Army recruits. The percentage 

of 2008 recruits who had a worst periodontal screening 

and recording (PSR) score of 1 was 24.8% compared 

to 28% for year 2000 Army recruits. 

Only 7.7% of 2008 recruits required any endodontic 

treatment, compared to 10.9% in 2000 and 18.1% in 

1994. 

Dental Utilization 

The percentage of 2008 Army recruits who had seen a 

dentist within the 12 months prior to reporting for 

training was 38.3% and increased to 66.5% within the 

previous 2 years. 

The percentage of recruits who had some type of 

dental insurance before reporting to the recruit center 

was 44.3%. 

The 2008 Army Recruit Oral Health 

 Survey Results 

COL David L. Moss, DC, USA 

This article is a reprint of the report, 2008 Army Recruit Oral Health Survey Results, which is the US Army data from the 2008 DoD 

Recruit Oral Health Survey. The Army results and DoD report may be obtained through the Uniformed Services University of the 

Health Services, http://www.usuhs.mil/tscohs/. 
 January – March 2011 63

Perceived Need for Dental Care 

The percentage of 2008 Army recruits who felt they 

needed dental care was 60.4%. 

Among those who felt they needed dental care, 27.1% 

responded that they needed dental care “right away”, 

41.5% “within 6 months.” 

The most common reason for not seeking care prior to 

training was that it was too expensive. 

BACKGROUND

The TRICARE Management Activity directed the TriService Center for Oral Health Studies with 

concurrence by the Services' Deputy Dental Corps 

Chiefs, to conduct the 2008 DoD Recruit Oral Health 

Survey. The primary goal of the survey was to 

estimate the level of dental readiness, oral health, and 

dental treatment needs of recruits entering military 

service. The results provide essential information for 

determining dental manpower requirements and other 

areas of readiness planning that are especially vital 

during wartime. Key objectives of 

the survey were to identify initial 

dental classification and specific 

dental treatment needs for recruits, 

determine dental caries prevalence, 

periodontal status and other oral 

conditions, evaluate levels of risk 

for dental caries, oral cancer, and 

periodontal disease, and describe 

results of the DoD Recruit Oral 

Health Survey Questionnaire. 

When possible, findings from this survey were 

compared to the 1994 and 2000 Tri-Service 

Comprehensive Oral Health Surveys. 

METHODS

For a detailed discussion on the methods used for 

the 2008 DoD Recruit Oral Health Survey, refer 

to the Methods section of the DoD report of the 

2008 DoD Recruit Oral Health Survey (available 

at: http://www.usuhs.mil/tscohs/). 

SAMPLE DEMOGRAPHICS

A total of 1,928 Army recruits were examined at the 

five Army Basic Combat Training (BCT) sites from 

December 2007 thru November 2008 (Table 1). 

The component distribution of the sample is presented 

in Table 2. The numbers were weighted in order to 

adjust the sample to the actual population distribution 

of the 2008 recruit total. 

Tables 3 and 4 present the sample population distribution by pre-enlistment education levels and age. The 

Basic Combat 

Training Location 

Unweighted 

Sample 

Estimated 

Population 

Fort Benning 403 39,041 

Fort Jackson 586 61,613 

Fort Knox 202 19,246 

Fort Leonard Wood 462 33,375 

Fort Sill 275 18,073 

Total 1,928 171,348 

Table 1. Distribution of study sample population across Army Basic Combat Training 

Locations 

Component Male Female Overall 

Active Army 42.4% 7.9% 50.3% 

Army National 

Guard 26.2% 6.6% 32.9% 

Army Reserve 12.0% 4.8% 16.8% 

Total 80.6% 19.3% 100.0% 

Table 2. Distribution of study sample population by component and gender. 

Component Non-high school 

graduate 

High school 

graduate 

Post high 

school studies 

2 year 

degree 

4 year degree 

and beyond 

Active Army 0.8% 33.8% 11.5% 2.2% 2.0% 

Army National 

Guard 1.4% 21.7% 7.9% 1.0% 0.9%

Army Reserve 0.6% 9.6% 4.9% 0.7% 1.1% 

Total 2.8% 65.1% 24.2% 4.0% 4.0% 

Table 3. Distribution of study sample population by pre-enlistment education. 

Table 4. Distribution of study sample population by age. 

Component 

17 18 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 & up 

Active Army 3.2% 20.8% 18.8% 5.0% 1.4% 0.8% 0.2%

Army National 

Guard 3.1% 13.5% 10.9% 3.1% 1.2% 0.9% 0.2%

Army Reserve 1.1% 6.3% 6.2% 1.5% 0.9% 0.6% 0.2%

Total 7.4% 40.4% 36.0% 9.6% 3.6% 2.2% 0.6% 

Age 
64 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

overall percentage of recruits without 

a high school education is 2.8% is 

likely an exaggeration due to National Guard recruits on a split entry option reporting for BCT prior to high 

school graduation. 

FINDINGS

During the dental examination, each 

recruit's DoD Dental Classification was 

calculated based upon the worst dental 

class assigned to each tooth, each PSR 

sextant, soft tissue finding, and 

temporomandibular disorder/orthodontic 

referral as noted by the study examiners. 

Figure 1 shows the trend in DFC 

distribution over the 3 study years. The 

distribution of DFC did not differ 

significantly among the 3 Army 

components for the 2008 data. 

Operative Need

Survey examiners assessed the health status and 

treatment needs of each tooth using standardized 

mirrors and explorers and current radiographs. 

Examiners were instructed to use a very light touch 

when using the dental explorer to avoid causing 

cavitation with aggressive probing. 

The mean number of restorations needed for 2008 

recruits was 3.7. The distribution of required restorations is shown in Table 5. 

This distribution among those that 

required at least one restoration was 

not statistically different across the 3 

study years. The mean number of 

restorations by type for 2008 recruits 

is shown in Table 6. 

This distribution also did not vary 

significantly across the 3 study years. 

The distribution of dental fitness 

class based solely on operative need 

for 2008 recruits is presented in 

Table 7. 

Oral Surgery Requirements 

Among 2008 recruits, there was a 

significant decrease in the number of 

recruits who needed oral surgery treatment. In the 2000 study, 26.6% had no 

need. In the current study, this increased to 39.6%, as shown in Figure 2. 

The average number of extractions 

among all 2008 recruits was 2.1. 

Based only on oral surgery conditions, 

39.6% of 2008 recruits were DFC 1, 35.1% 

DFC 2, and 25.4% were in DFC 3. 

Among 2008 recruits that required at least 

one extraction, the majority required 3 to 4 

teeth removed indicative of a treatment 

plan for the removal of all third molars. 

The mean number of extractions among 

this group by type was 0.9, 0.25, and 2.3 

for simple, complex, and impacted, 

respectively. 

There was no statistical difference for oral 

surgical need across the 3 components. 

Peridontal Health Status and Treatment Needs 

Periodontal status and treatment needs were assessed 

using the Periodontal Screening and Recording (PSR) 

index. Survey examiners recorded the PSR score for 

each sextant of the dentition using the #23/Hu-Friedy 

WHO Style Expro (XP23/11.5B) explorer/periodontal 

probe. 

Figure 3 shows the distribution of recruits by worst 

PSR score in each study year. The percentage of 2008 

The 2008 Army Recruit Oral Health Survey Results 

Figure 1. The DFC classification of Army recruits in each of the 3 Tri-Service 

Oral Health Recruit Studies. 

4.3

43.2

52.5

1.3

56.7

42.1

1.1

65.6

33.3

0%

10%

20%

30%

40%

50%

60%

70%

DFC 1 DFC 2 DFC 3

2008 Recruits

2000 Recruits

1994 Recruits

None 1-3 4-6 7+ 

25.4% 34.0% 19.8% 20.9% 

Table 5. Number of restorations 

required for the 2008 recruit sample 

population. 

1 Sur 2 Sur 3 Sur 4 Sur 

1.53 1.40 0.57 0.17 

Table 6. Mean number of restorations 

by type for the 2008 recruit sample 

population. 

5 Sur 

0.05 

Study Year DFC 1 DFC 2 DFC 3

2008 25% 33% 42%

2000 23% 51% 26%

1994 20% 50% 30%

Table 7. Distribution of DFC 

based only on operative needs 

of the sample population. 
 January – March 2011 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

recruits whose worst PSR score is 3 or 4 

(indicating periodontal disease) has 

decreased significantly from 55% in 1994 

and 18% in 2000 to only 10% in 2008. 

Nearly 90% of 2008 recruits had a worst 

PSR score of 2 or lower. 

The distribution of PSR scores was similar 

among the 3 components as shown in 

Figure 4. 

Prosthodontic Treatment 

Survey examiners assessed the number of 

missing teeth and/or teeth requiring 

removal for each patient and made the 

determination whether to replace missing 

teeth using fixed or removable prostheses. 

Current use of partial or complete removable 

prostheses was assessed along with need for 

their replacement or repair. 

Among 2008 recruits, only 17% required 

any fixed pros care, none were completely 

edentulous, and no removable partial 

dentures were indicated (Table 8). This 

compares to 24% and 34% requiring care in 

2000 and 1994, respectively. The mean 

number of fixed pros units among those that 

required pros care was 2 units. 

ENDODONTIC TREATMENT REQUIREMENT

The majority of endodontic need will be 

diagnosed acutely and not at routine 

examination. Survey examiners assessed 

the potential need for endodontic therapy 

using radiographs and visual inspection. 

Definitive vitality testing for suspect teeth 

was beyond the scope of this survey. If the 

examiner believed a tooth would require 

endodontic care following extensive 

restorative procedures, it was indicated in 

the record as needing endodontic care . 

39.6

17.0

38.6

4.6

26.6

15.5

52.6

5.3

27.1

16.0

54.0

2.9

0%

10%

20%

30%

40%

50%

60%

0 1 -2 3 - 4 5+

2008 Recruits

2000 Recruits

1994 Recruits

Figure 2. Distribution of Army recruits requiring oral surgery in each of the 3 

Tri-Service Oral Health Recruit Studies. 

1.0

24.8

64.0

9.7

0.4

5.0

28.0

49.0

15.0

3.0

5.0

19.0 21.0

50.0

5.0

0%

10%

20%

30%

40%

50%

60%

70%

PSR 0 PSR 1 PSR 2 PSR 3 PSR 4

2008 Recruits

2000 Recruits

1994 Recruits

Figure 3. Distribution by Tri-Service Oral Health Recruit Study year of 

sample population periodontal screening and recording score (based on 

patient’s worst sextant PSR score). 

Figure 4. Distribution by component of 2008 recruit periodontal screening 

and recording score (based on patient’s worst sextant PSR score). 

0.7

23.3

64.5

11.1

0.4 1.3

27.6

63.8

6.9

1.6 0.5

23.9

62.4

11.2

0.7

0%

10%

20%

30%

40%

50%

60%

70%

PSR 0 PSR 1 PSR 2 PSR 3 PSR 4

Active Army

Army National Guard

Army Reserve

Table 8. Distribution of the number of fixed 

prosthodontic units needed by 2008 recruits. 

Fixed Prosthodontic Units 

Needed Mean Fixed Units 

(Per 1,000 Recruits)

None 1 - 2 3-6 7+ 

82.8% 12.8% 3.8% 0.7% 366 
66 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

As shown in Figure 5, only 7.7% of 2008 recruits 

required endodontic treatment at the time of initial 

examination. 

Among those Army recruits who required endodontic 

care, the mean number of teeth is one. 

The distribution of the type of teeth that required 

endodontic care (Figure 6) shows that the majority are 

molars. The 2008 recruit components were not 

statistically different in distribution of endodontic 

treatment need. 

Other Clinical Findings 

Overall, 3.4% of 2008 recruits exhibited a soft tissue 

lesion. The distribution of the types of lesions is very 

similar with the most common being 

pericoronitis, orthodontic issues, and 

aphthous ulcers, 1.2%, 0.6%, and 0.5%, 

respectively. The prevalence of temporomandibular dysfunction was less than 

0.2%. The mean number of dental sealants 

treatment planned was 0.4 per recruit and 

the mean number of teeth treatment 

planned for remineralization was 1.2 

(Table 9). 

Dental Care Prior to Entry 

Dental utilization prior to entering military 

service was assessed for all recruits using a 

self-administered questionnaire. 

The distribution of responses for 2008 

recruits concerning the time since last 

dental visit prior to reporting for training is 

shown in Figure 7. 

The percentage of 2008 recruits who had 

seen a dentist within the last 12 months 

prior to reporting for training was 38.3%, 

increasing to 66.9% within the last 24 months. There 

was no statistical difference among the 3 components 

for time since last visit. 

The 2008 Army Recruit Oral Health Survey Results 

92.3

6.0

1.5 0.2

89.1

8.2

2.5 0.1

81.9

12.3

4.9

0.9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 12 - 3 4 or More

2008 Recruits

2000 Recruits

1994 Recruits

Figure 5. Distribution by Tri-Service Oral Health Recruit Study year of sample 

population recruits who required endodontic treatment. 

Figure 6. Distribution by Tri-Service Oral Health Recruit Study year of the 

types of endodontic treatment required by the sample population. 

14.6

20.3

69.4

19.0

15.0

66.0

10.0

19.0

66.0

0%

10%

20%

30%

40%

50%

60%

70%

80%

Anterior Premolar Molar

2008 Recruits

2000 Recruits

1994 Recruits

Sealants Required 

Mean 

None 1 – 2 3 – 4 5 + 

82% 11.9% 4.2% 1.8% 0.4 

Remineralizations Required 

70.3% 14.9% 4.9% 10% 1.2 

Table 9. Remineralization and 

sealant requirements among 2008 

recruits. 

Figure 7. Time since last dental visit prior to reporting 

for training for 2008 recruits. 

38%

29%

18%

13%

2%

12 months

1 to 2 years

3 to 5 years

More than 5 years

Never
 January – March 2011 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

Among those recruits who received dental care within 

the last 12 months, the percentage that had their teeth 

cleaned prior to reporting for training was 80.6%, 

30.4% had operative care, and 17.2% had teeth 

removed. 

The percentage of 2008 recruits who had some type of 

dental insurance was 44.3% (Figure 8). 

Perceived Need 

Perceived need for dental care was also assessed for all 

recruits using the same self-administered questionnaire. The percentage of 2008 Army recruits who 

felt that they needed dental care was 60.5%. Among 

those that perceived a need for dental care, 27.1% 

responded that they needed dental care right away and 

41.5% responded that they needed dental care within 6 

months. The most common reason for recruits who felt 

they needed care, but had not received it, was the 

anticipated expense. 

AUTHOR

COL Moss is Director, Tri-Service Center for Oral 

Health Studies, Department of Preventive Medicine and 

Biometrics, and Assistant Professor of Preventive 

Medicine and Biometrics at the Uniformed Services 

University of the Health Sciences, Bethesda, Maryland.

Figure 8. Distribution of dental insurance coverage 

among 2008 recruits. 

3.6%

32.8%

7.9%

33.6%

21.6% TRICARE

Private

Subsidized

No insurance

Unknown
68 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The US Army Dental and Trauma Research Detachment 

(DTRD) has relocated from the Naval Training Center, 

Great Lakes, Illinois, to Fort Sam Houston, Texas. This 

move, completed in August 2010, marks a new era in 

military dental research. Not only are the location and 

research buildings new, but the entire DTRD research 

program is new and redefined to reflect new 

opportunities to collaborate with scientists and clinicians 

collocated at the Department of Defense’s largest 

medical research campus. 

In accordance with 2005 Base Closure and Realignment 

Committee action, all combat casualty care military 

research units, less neuroprotection, are now collocated 

on the Battlefield Health and Trauma Research Institute 

(BHT) on the campus of Brooke Army Medical Center in 

San Antonio. The BHT includes the Army Institute of 

Surgical Research (ISR), the Naval Medical Research 

Unit, San Antonio, and the US Air Force Dental Evaluation and Consultation Service. The DTRD, once a detachment of Walter Reid Army Institute of Research, is now 

aligned under the ISR, the surgical research unit of Army 

Medical Research and Material Command (MRMC). 

The DTRD, a detachment of Dental Corps officers 

assigned to MRMC, provides militarily-relevant research 

and solutions to diseases and injuries to the teeth and 

craniomaxillofacial region. It is comprised of 

approximately 40 personnel, including officers, enlisted 

specialists, and civilians. Professional specialties include 

oral and maxillofacial surgeons, periodontists, dental 

public health, comprehensive dentists, prosthodontists, 

microbiologists, physiologists, cell biologists, chemists, 

and microscopists. Assigned enlisted personnel reflect 

diverse military occupational skills, including dental, 

operating room, animal care, and laboratory technicians. 

The collocation of combat casualty care research units at 

the Battlefield Health and Trauma Research Institute 

creates a robust environment for researchers and 

clinicians to collaborate, developing better ways to treat 

battle injuries and diseases of service members. 

MISSION AND VISION

In addition to a renewed research program, DTRD 

redefined its mission to provide militarily-relevant 

research and solutions for the prevention, treatment, and 

rehabilitation of craniofacial trauma and infectious dental 

diseases. DTRD’s mission is the provision of world-class 

solutions in prevention, treatment, and rehabilitation of 

Warfighters with craniofacial trauma and infectious 

dental disease, and contributing expertise across the 

spectrum of combat casualty care. To meet those goals, 

DTRD research focuses on 3 areas: biofilm-induced 

dental disease (and wound impairment), craniomaxillofacial regenerative medicine, and mitigation of facial 

burns and scars. 

DTRD’s research mission receives strong support and 

collaboration from the ISR Extremity/Regenerative 

Medicine and Burn researchers, as well as newly 

collocated combat casualty care research units of the 

Navy and Air Force. To forge strong research 

relationships, DTRD’s Research Steering Committee 

includes DTRD leadership, members of the ISR’s 

extremity research team, and members of both Navy and 

Air Force dental research teams. Leaders from academia 

and the biomedical research industry also hold positions 

on the committee. 

The BHT consists of 2 state-of-the-science research 

buildings, including a newly completed 150,000 sq ft 

building. DTRD, along with the dental research elements 

of the Navy and Air Force, occupies the first floor of this 

new building, designated BHT-2. The BHT also houses a 

50,000 sq ft vivarium allowing scientists to perform 

critical experiments in order to translate research into 

improvements in combat casualty care. 

BIOFILM RESEARCH

No scientific advancements in work by DTRD at the 

Great Lakes location were lost in the transition to San 

Antonio. For example, following relocation, the research 

in the treatment and prevention of biofilm dental disease, 

The US Army Dental and Trauma Research 

 Detachment: Now Part of the Army 

 Institute of Surgical Research 

MAJ Davin E. Mellus, DC, USA 

Jacqueline Amaya 
 January – March 2011 69

a disease which accounts for 20% of sick call cases in the 

combat zone, achieved approval by MRMC’s Decision 

Gate Board to receive $3.8 million for the manufacture of 

antiplaque chewing gum, a drug delivery device, in preparation for Food and Drug Administration clinical trials. 

BONE REGENERATION

According to the Joint Theater Trauma Registry (JTTR) 

data, 26% of battle injuries are to the maxillofacial 

region, which often includes jaw fractures.1

 Resultant 

bone and dentoalveolar defects common after severe and 

comminuted fractures are difficult to reconstruct without 

lengthy, invasive multi-staged procedures involving bone 

graft harvests. Before dental implants can return the jaws 

to full function, reconstruction must precisely position 

the implant supporting bone to the opposing dental arch, 

a requirement seldom achieved without surgical 

revisions. Aggravating reconstruction of major defects is 

a frequent complication and wound healing problems are 

accepted as unavoidable consequences of jaw 

reconstruction using conventional techniques and 

biomaterials. The DTRD, in collaboration with ISR’s 

extremity research group, directly addresses the shortfalls 

of conventional techniques and biomaterials in 

reconstructing bone defects. 

Using a novel flowable biomaterial, DTRD now performs 

research on critical size defects in animals to tune the 

biomaterial’s characteristics for optimal bone regeneration. The flowable nature of the biomaterial promises to 

allow the surgeon to reconstruct bone defects through 

minimally invasive surgical procedures, manipulating the 

biomaterial as it sets into the proper shape and orientation 

to the opposing dental arch. Continued success of this 

bone regeneration research elevates the standard of care 

in jaw reconstruction by achieving better clinical results 

through fewer and less invasive surgeries. 

FACIAL BURNS AND SCARS

Another major thrust of DTRD research is to mitigate the 

consequences of severe facial burns and scars. According 

to JTTR data, facial burns occur in 77% of all burned 

service members who are evacuated from the combat 

theater.2

 Severe facial burns and scars often lead to 

contractures and hypertrophic scars which are especially 

problematic to the eyelids, nostrils, and mouth. The effect 

to the injured service member is lifelong microstomia, lip 

incompetence, ectropion, and facial disfigurement, conditions all important to the dental profession. 

Improvement over conventional care of facial burns and 

scars includes strategies to modulate inflammation and 

comprehensively reconstruct the wound through 

advanced regenerative medicine and tissue engineering 

technologies. To deploy these technologies, DTRD is 

collaborating with bioengineers at University of Texas, 

Arlington, to develop an in situ bioreactor in the form of 

a custom, multifunctional polymer-based mask. The basic 

concept of this “biomask” is to optimize the burn wound 

bed, modulate excessive inflammation, and tissueengineer all layers of the skin sequentially under a 

protective mask that enhances tissue engraftment. 

Development will take many years, but, if successful, the 

biomask will represent a paradigm shift in facial burn 

management. 

Over the short time since DTRD arrived in San Antonio, 

the collocation of combat casualty care research has 

already proved to be a successful strategy. Located on the 

campus of a major medical center, DTRD’s research and 

development of devices, therapeutic agents, and 

techniques to treat and rehabilitate craniomaxillofacial 

trauma and prevent infectious dental disease has been 

given a new focus. DTRD’s new home fosters 

continuous, direct, and personal contacts with BHT 

researchers, enriching the process of exchanging ideas 

and technologies. The net result is acceleration of new 

biomedical technologies to return the Wounded Warrior 

to full function and a normal life. 

REFERENCES

1. Lew TA, Walker JA, Wenke JC, Blackbourne LH, 

Hale RG. Characterization of craniomaxillofacial 

battle injuries sustained by United States service 

members in the current conflicts of Iraq and 

Afghanistan. J Oral Maxillofac Surg. 2010;68(1):3-7. 

2. Kauvar DS, Wolf SE, Wade CE, Cancio LC, Renz 

EM, Holcomb JB. Burns sustained in combat 

explosions in Operations Iraqi and Enduring 

Freedom. Burns. 2006;32(7):853-857. 

AUTHORS

MAJ Mellus is Chief, Oral and Maxillofacial Surgery, 

Cranio-Maxillo-Facial Surgery Section, US Army 

Dental and Trauma Research Detachment, US Army 

Institute of Surgical Research, Fort Sam Houston, Texas. 

Ms Amaya is the Administrative Officer, US Army 

Dental and Trauma Research Detachment, US Army 

Institute of Surgical Research, Fort Sam Houston, Texas. 
70 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

Median mononeuropathy at or distal to the wrist or 

carpal tunnel syndrome is one of a number of muscle-, 

tendon-, and nerve-related disorders that affect people 

performing intensive work with their hands. During 

the past 20 years there has been a tremendous increase 

in the reported cases of CTS,1-3 resulting in an 

increased focus on occupational surveillance and 

screening.2

 Dental hygienists reportedly have a high 

prevalence of upper-extremity musculoskeletal 

disorders, including CTS.4-13 

OVERVIEW

Dental personnel, including dentists, dental hygienists, 

and dental assistants, have been reported as having a 

high prevalence of upper-extremity musculoskeletal 

disorders, including carpal tunnel syndrome (CTS). A 

research study was developed and implemented to 

determine the presence of median and ulnar 

neuropathies in a population of experienced dental 

assistants as they trained to become preventive dental 

specialists. Subjects completed a history form, were 

interviewed, underwent a physical examination, and 

Clinical and Electrodiagnostic Abnormalities 

 of the Median Nerve in Army Dental 

 Assistants Before and After Training as 

 Preventive Dental Specialists 

 David G. Greathouse, PhD, PT 1LT Bryan B. Pickens, SP, USA 

 1LT Tiffany M. Root, SP, USA Thomas G. Sutlive, PhD, PT 

 CPT Carla R. Carrillo, SP, USA LTC Scott W. Shaffer, SP, USA 

 1LT Chelsea L. Jordan, SP, USA COL Josef H. Moore, SP, USA 

ABSTRACT

Purpose: Dentists and dental hygienists have been reported as having a high prevalence of upper-extremity 

musculoskeletal disorders, including carpal tunnel syndrome. Unfortunately, previous research has not involved the 

impact of preventive dental specialist training on dental assistants. Therefore, the purpose of this study was to 

determine the presence of median and ulnar neuropathies in US Army dental assistants before and after training as 

preventive dental specialists. 

Methods: Thirty-five US Army dental assistants (24 female, 11 male; age range 18-41 years) volunteered for the study. 

Twenty-eight preventive dental specialist students completed both the pretraining and posttraining data collections. 

Subjects were evaluated during the first and last weeks of their 12-week course. Subjects completed a history form, 

were interviewed, and underwent a physical examination. Nerve conduction status of the median and ulnar nerves of 

both upper extremities were obtained by performing motor, sensory, comparison (unilateral median to ulnar distal 

motor and sensory latencies), and F-wave nerve conduction studies (NCS). Descriptive statistics for subject demographics and pre to post physical examination and nerve conduction variables were calculated. Chi square (χ

2

) analysis was 

also conducted to determine if a significant shift in the prevalence of neuropathies occurred following dental training. 

Results: With the exception of comparison studies, pre-NCS and post-NCS electrophysiological variables were normal. 

Specifically, 9 subjects (26%) involving 14 hands (20%) were found to have meaningful (>1.0 millisecond) delayed 

median to ulnar distal motor latency comparisons in the pretraining assessment. Additionally, there was no statistically 

significant shift in the prevalence of electrodiagnostic abnormalities of the median nerve following the 12-week training 

program (χ

2

=0.280, P=.60). 

Conclusion: The prevalence of clinical and electrodiagnostic abnormalities of the median nerve in this sample of US 

Army dental assistants closely mirrors the prevalence reported for other dental professionals. This study also 

demonstrates that, for this sample, the 12-week training program did not appear to affect the electrophysiologic status 

of the median or ulnar nerves. 
 January – March 2011 71

had nerve conduction studies performed on both upper 

extremities during the pretraining and posttraining data 

collection sessions. The pretraining data collected on 

experienced dental assistants has been presented14 and 

served as a baseline measure in this study to determine 

the effects of preventive dental specialist’s training. 

Although the prevalence of clinical and 

electrodiagnostic abnormalities of the median nerve in 

this sample closely mirrors the prevalence reported for 

other dental professionals, the 12-week training 

program did not appear to further impact the 

electrophysiologic status of the median or ulnar 

nerves. Further long-term prospective research 

involving the impact of dental practice and techniques 

for reducing upper extremity injuries in dental 

professionals appears to be warranted. 

REVIEW OF THE LITERATURE

Lalumandier and McPhee11 surveyed US Army dental 

personnel and stated that 75% of dental hygienists 

reported having hand problems, and 56% exhibited 

probable or classic symptoms of CTS. In a study 

determining the presence of hand problems in Army 

dental personnel, 45% of the dental personnel 

surveyed indicated hand problems, and 25% were 

determined to indicate a high probability of CTS.12

The authors concluded that Army dental personnel are 

at greater risk of developing CTS than the general 

public.12 In a separate investigation, Rice et al13

reported symptoms associated with CTS were noted by 

75.6% of the dental workers, 11% reported diagnosed 

CTS, and 53% reported back and shoulder pain. 

Individuals in the dental hygienists and dental assistantexpanded function group were found to be at the 

greatest risk for developing upper extremity 

symptoms, CTS, and back pain. Other investigators 

have reported the prevalence of CTS among dental 

hygienists was 3%,9

 6%,15 7%,8 and 8%.4

Several ergonomic risk factors associated with CTS 

include repetitiveness of work, forceful exertions, 

mechanical stress, posture, temperature, and 

vibration.16 These risk factors may be present for 

dentists and dental hygienists as dental instruments 

may cause contact stress over the carpal tunnel, and 

wrists may be held in awkward positions for prolonged 

periods.17 In a study of dental hygienists, Bramson et 

al17 evaluated several risk factors using hand-surface 

goniometry and electromyography, and concluded that 

dental hygienists’ exposure to high-risk postures was 

minimal, and that the force they exerted during work 

was of medium risk. 

Median mononeuropathy at or distal to the wrist and 

other musculoskeletal dysfunction of the upper 

extremities is a well-documented problem among 

dentists and dental hygienists. Unfortunately, there is a 

lack of information in the literature to document the 

presence of CTS or upper extremity musculoskeletal 

dysfunction in Army dental assistants (MOS* 68E) as 

they train to become Army preventive dental 

specialists (MOS 68E-X2). The job description for the 

preventive dental specialist is similar to that of a 

civilian dental hygienist, however, the training and 

educational requirements for the 2 positions are 

different. Therefore, the purpose of this study was to 

determine the presence of clinical and electrodiagnostic abnormalities of the median and ulnar nerves in 

both upper extremities in this sample of Army dental 

assistants during their training to become Army 

preventive dental specialists. 

METHODS AND MATERIALS

All dental assistants (n=47) participating in the 

September 2007 and January 2008 preventive dental 

specialist classes were approached to participate in this 

study. Three potential subjects declined to participate, 

2 volunteered but were dropped from the course prior 

to data collection, and 7 volunteered but were not 

included in the study as they had no prior clinical 

experience as an Army dental assistant. The 7 dental 

assistants without dental assistance experience had 

proceeded directly from completion of the dental 

assistant course and matriculated into the preventive 

dental specialist course. All participated in the study 

during the first and last weeks of their 12-week 

Preventive Dental Specialist Course. A prerequisite for 

admission in the Army Preventive Dental Specialist 

Course is completion of the Army Dental Assistant 

Course. 

Experimental procedures, risks, and subject rights 

were discussed with all subjects before participation in 

the study. All subjects signed an institutionallyapproved, written consent form. Pregnant individuals 

were excluded. The study was approved by the 

Institutional Review Board of the Brooke Army 

Medical Center, Fort Sam Houston, Texas. 

*Military occupational specialty.
72 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

A history, physical examination, and upper quarter 

neuromusculoskeletal screen were performed to determine the status of the neural integrity of the median 

and ulnar nerves. These assessments were performed 

in both the pretraining and posttraining phases of the 

data collection. 

History 

A history was taken from each patient in questionnaire 

format. The history included information pertaining to 

demographics, medical history, military background, 

dental assistant experience, hand dominance, and the 

amount of time using a computer.

Physical Examination 

A physical (screening) examination was part of the 

evaluation process of each subject. The physical 

examination included assessment of active range of 

motion, manual muscle tests, sensory evaluation, 

reflex testing, and select special tests.18,19 Specifically, 

active range of motion was assessed for the cervical 

spine, shoulders, elbows, and wrists and hands. 

Manual muscle testing was performed for all major 

muscle groups in both upper extremities. Sensory 

assessment was determined with both light touch and 

pain/pin prick assessment of both peripheral nerves 

and dermatomes in both upper extremities. Muscle 

stretch reflexes (also known as deep tendon reflexes) 

were obtained from the biceps brachii, brachioradialis, 

and triceps in the upper extremities, and the quadriceps 

(patellar tendon), and triceps surae (Achilles tendon), 

in the lower extremities. Both upper and lower 

extremity pathological reflexes were assessed with the 

Hoffman sign (upper extremity) and Babinski sign 

(lower extremity). Last, the special tests of Tinel’s sign 

of median and ulnar nerves at the wrist, Tinel’s sign of 

the ulnar nerve at the elbow, Phalen’s test, and the 

assessment of the radial pulses during positional 

changes of the upper extremities and neck (Adson’s 

maneuver) were examined.18,19

Nerve Conduction Studies 

At the time of volunteer solicitation, potential subjects 

were instructed to abstain from exercising for one hour 

prior to testing. Skin temperature at the wrist was 

measured using a digital thermometer model TM99A 

(Cooper Instrument Corporation, Middlefield, CT), 

and was maintained at or above 32°C. If skin 

temperature fell below this value, the wrist, hand, and 

forearm were rewarmed with warm towels. 

The Cadwell Sierra LT electromyograph and 

stimulator (Cadwell Laboratories, Inc, Kennewick, 

WA) were used to measure the compound motor 

action potential (CMAP) and sensory nerve action 

potential (SNAP) latencies and amplitudes. The 

stimulating current was a monophasic pulse 0.1 

millisecond long. The oscilloscope was set to a sweep 

duration of 2.0 milliseconds per division and a gain of 

20 μV per division for the SNAPs. For the CMAPs, 

the oscilloscope was set to a sweep duration of 2.0 

milliseconds per division and a gain of 5 mV per 

division. The filter settings were 10 Hz to 10 kHz for 

the motor potentials and 10 Hz to 2 kHz for the 

sensory potentials. The sensory latency was measured 

at the negative peak of the SNAP, and the amplitude 

was measured from negative peak to positive peak. 

The motor latency was measured from the negative 

takeoff of the evoked CMAP, while the amplitude was 

measured from the baseline to the negative peak of the 

evoked response. The obtained results were recorded 

manually and on computer printout.

Specific details for performing the median and ulnar 

nerve conduction studies (NCS) were presented in a 

study by Harkins et al20 and follow procedures previously described.14,21-24 The median and ulnar nerve 

palmar and digital distal sensory latencies (DSLs), 

distal motor latencies (DMLs), F-wave latencies, and 

conduction velocities were obtained from both upper 

extremities. All NCS procedures included 

measurement of the anatomic course of the nerve: 

median and ulnar palmar DSLs (8 cm), median and 

ulnar digital DSLs (14 cm), and median and ulnar 

DMLs (8 cm). In addition to comparing median nerve 

palmar and digital DSLs, DMLs, F-wave latencies, and 

conduction velocities with a chart of normal values, 

comparison studies between median and ulnar palmar 

DSLs, digit DSLs (digit 2 and digit 5, digit 4 median/

ulnar), and DMLs in the same and opposite extremities 

were obtained. Examination of median and ulnar 

latencies in the same extremity and median and ulnar 

latencies in opposite extremities has been shown to 

assist in early electrodiagnosis of CTS.14,21-24 

Data Management and Analysis 

Descriptive statistics for subject demographics and 

nerve conduction study variables and chi square (χ

2

) 

analysis for NCS comparison studies were calculated 

using Statistical Package for Social Sciences software, 

version 12.0 (SPSS Inc, Chicago, IL). 

Clinical and Electrodiagnostic Abnormalities of the Median Nerve in Army Dental Assistants 

Before and After Training as Preventive Dental Specialists 
 January – March 2011 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

RESULTS

Pretraining Assessment 

History

Thirty-five subjects participated in this study (24 

female, 11 male). The age of the subjects ranged from 

18 to 41 years, and the mean ±SD was 23.3±5.6 

years.14 Thirty of the subjects were right-handed. The 

mean number of months the dental assistants had been 

working in a dental clinic prior to preventive dental 

specialist training was 13.9 months, with a range of 2 

to 84 months. All subjects had been in the military for 

at least 4 months, had completed basic combat 

training, and had completed dental assistant training. 

When asked about warm-up exercises prior to 

practicing as a dental assistant, 33 subjects responded 

to performing no warm-up exercises, and 2 subjects 

responded affirmatively. Thirteen of the subjects 

reported that they did not take breaks when working as 

a dental assistant, and 22 subjects did report taking 

breaks from work at 30 minutes (6 subjects), 45 

minutes (2 subjects), 60 minutes (5 subjects), and less 

frequently than every hour (9 subjects).14

In assessing the time the subjects spent working on a 

computer, the mean time was 5.9 hours per week with 

a range of one to 25 hours per week. Six of the 

subjects played video games with a mean of 1.8 hours 

per week. Only five of the subjects reported playing 

musical instruments with a mean of 0.4 hours per week 

(range 1-5 hours/week). 

When asked to describe their general health, thirty of 

the subjects reported being in excellent/good health 

and five of the subjects failed to respond to this 

question. None of the subjects reported having a 

history of neuropathic disease, renal disease, 

peripheral vascular disease, thyroid disease, diabetes, 

or arthritis.14 When asked if they had experienced an 

injury, sixteen of the subjects responded affirmatively. 

Twelve of the subjects responded positively to having 

a problem with their head, neck, or upper extremities 

during the previous 6 months prior to data collection. 

All other subjects denied having any musculoskeletal 

problems in the past 6 months. 

When asked specifically about current pain or 

symptoms in the neck or upper extremity, the 

following information was gathered: neck or scapular 

pain (n=8), left arm/forearm pain (subject 24), right 

wrist/hand pain and/or numbness/tingling (N/T) 

(subjects 5, 8, 12, and 13), and left wrist/hand pain 

and/or N/T (subjects 12 and 14).14

In review of the subjects’ history, the following 

subjects had subjective complaints suggestive of 

median or ulnar dysfunction: subject 5 had right wrist 

pain, subject 12 had N/T and pain in the right digit 3-

4-5 and left digit 4, and subject 14 had N/T in the 

palm of the left hand.14 Otherwise, from the 

information obtained in the history, there were no 

indicators suggesting median or ulnar nerve 

abnormalities in the upper extremities of these dental 

assistants. 

Screening Examination

All subjects had normal active mobility of the cervical 

spine, shoulder, elbow, wrist and hand. Quadrant tests 

were determined to be normal without radicular 

symptoms in either upper extremity. 

Motor Strength – Subject 19 had 4/5 strength right flexor 

pollicis longus and flexor digitorum profundus digit 2 

(anterior interosseous nerve); subject 24 had 4

/5

strength left elbow extensors, left wrist extensors, left 

wrist flexors, and left abductor pollicis brevis; subject 

30 had 4

/5 strength left/right shoulder abduction and 4/5

strength left abductor digiti minimi (ADM); and 

subject 39 had 4

/5 strength left/right ADM.14

Otherwise, all subjects were assessed to have normal 

(

5

/5) muscle strength for the neck flexors, extensors, 

and rotators (C1-5); and both upper extremities to 

include the scapula elevators, depressors, protractors, 

and retractors (C1-5); shoulder flexors, abductors, and 

external/internal rotators (C5-6); elbow flexors and 

extensors (C5-8); wrist flexors and extensors (C6-8); 

finger flexors and extensors (C7-T1); and hand 

intrinsics (C8-T1). All upper extremity peripheral 

nerves (motor components) and myotomes (C4-T1) 

were assessed during motor testing. 

Sensation – Subject 10 had decreased pinprick in the 

palmar surface of left digit 5.14 Otherwise, all subjects 

had normal peripheral nerves (sensory components) 

and C4-T1 dermatome sensory testing results for light 

touch and pain/pin prick in both upper extremities. 

Muscle Stretch Reflexes and Pathological Signs –All subjects displayed present and equal muscle stretch 

reflexes and pathological signs (Hoffman and 
74 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Babinski) were absent in all subjects in both the upper 

and lower extremities. 

Special Tests –Ten subjects had positive findings for 

the special (provocative) tests (Tinel’s or Phalen’s) of 

the median or ulnar nerves (Table 1). All other 

subjects were noted to have negative findings with the 

performance of special tests.

Thoracic Outlet Tests –Subject 9 had decreased radial 

pulses bilaterally in the scalene, costoclavicular, and 

clavipectoral fascia/humeral positions. Otherwise, all 

subjects displayed normal radial pulses when the upper 

extremities were tested in the 3 thoracic outlet 

syndrome testing positions.14,18,19

Other than subjects 24, 30, and 39 (motor strength), 

subject 10 (sensory testing), and the 10 subjects that 

had positive findings on the special tests portion of the 

physical examination, there were no diagnostic 

indicators or evidence of median and ulnar nerve 

abnormalities in either upper extremity of the dental 

assistants tested during the physical examination 

portion of the assessment.14

Nerve Conduction Studies

The results of the nerve conduction studies are 

presented in Table 2. The values for these 

electrophysiological variables for each subject were 

compared to a chart of normal values. This chart of 

normal values was developed in the Clinical 

Electrophysiological Laboratory, Texas Physical 

Therapy Specialists, and revalidated at the 

Electrophysiological Laboratory, US Army-Baylor 

University Doctoral Program in Physical Therapy. The 

chart of normal values depicted in Table 2 is similar to 

other charts of normal values.14,21-24

When comparing the results of the study with the chart 

of normal values, all subjects had normal NCS values 

including conduction latencies, amplitudes, and conduction velocities of the median and ulnar nerves in 

both upper extremities. Interestingly, when comparison studies between the median and ulnar palmar 

DSLs, digital DSLs, and DMLs in the same and 

opposite extremities, and the digit 4 median/ulnar 

comparison study in the same extremity were assessed, 

there were electrodiagnostic abnormalities of the median nerve at or distal to the wrist in 9 subjects (26%) 

involving 14 hands (20%) (Table 3).14 In the present 

study, the normal comparison values for palmar14,21-26

and digital DSLs14,21-28 were a difference of less than 

0.5 millisecond, for DMLs14,21-26 were a difference of 

less than 1.0 millisecond, and for digit 4 median/ulnar 

comparison a difference of less than 0.6 millisecond.14,21-24,29 When using these comparison values, 

prolonged latency differences in the median-ulnar DMLs 

in the same extremity were observed in the right upper 

extremities in 4 subjects (4, 12, 32, and 38). When 

using these comparison values, prolonged latency differences in the median-ulnar DMLs in the same extremity were also observed in both upper extremities of 5 

subjects (7, 9, 11, 25, and 39). In addition, subject 39 

also had a prolonged difference of 0.7 millisecond 

between the digit 4 median and ulnar digital DSLs 

comparison study in the right hand (Table 3).30-32 

Posttraining Assessment 

The preventive dental specialist course is a 12-week 

course that includes both didactic and clinical learning 

experiences. Twenty-eight of the subjects successfully 

completed the training to become preventive dental 

specialists and were tested during their last week of 

training (posttraining assessment). Seven of the 

subjects failed to complete the training due to 

academic or administrative problems and were not 

tested during the second phase (posttraining) of data 

collection. 

Clinical and Electrodiagnostic Abnormalities of the Median Nerve in Army Dental Assistants 

Before and After Training as Preventive Dental Specialists 

Table 1. Subjects with positive findings on special tests of 

the upper extremities (pretraining).*

Subject Hand Tinel’s Sign 

at wrist 

(median) 

Tinel’s Sign 

at wrist 

(ulnar) 

Tinel’s Sign 

at elbow 

(ulnar) 

Phalen’s 

Test 

7 Left X 

7 Right X†

8 Left X X 

10 Right X 

11 Right X† 

14 Left X 

29 Left X 

32 Right X X 

32 Left X 

35 Right X X X 

35 Left X X X 

38 Left X X 

38 Right X X 

41 Right X X 

*Data from Greathouse et al.14 Reproduced with permission. 

†Subjects with electrodiagnostic abnormalities of the median nerve or 

distal to the wrist. 
 January – March 2011 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

History

In review of the subjects’ posttraining history, the 

following subjects had subjective complaints suggestive of median or ulnar dysfunction: subject 5 had right 

wrist pain (median, pretraining complaint); subject 7 

had N/T in the right palm (median, new); subject 8 

had N/T left D5 (ulnar, new); subject 9 had N/T in the 

palm of both hands (median, new); subject 11 had 

right > left hand pain (median, new); subject 12 had N/T 

and pain in the right digit 3-4-5 and left digit 4 (ulnar, 

pretraining complaint); and subject 30 had N/T right 

digit 1 (median, new). Otherwise, from the information 

obtained in the history, there were no indicators suggesting median or ulnar abnormalities in the upper 

extremities of these subjects that had completed the 

preventive dental specialty course. 

Screening Examination

In the posttraining screening examination, the following subjects had findings on the physical examination 

to suggest median or ulnar abnormalities: subject 7 had 

a positive Tinel’s sign over the median nerve at the 

wrist in both hands (median, pretraining finding); subject 8 had a positive Tinel’s sign over the left ulnar 

nerve at the elbow and wrist (ulnar, pretraining finding) and decreased sensation to light touch and pain in 

the palmar surface of left D5 (ulnar, new); subject 11 

had a positive Tinel’s sign over the right median nerve 

at the wrist (median, new); and subject 12 had 

decreased sensation to the palmar aspect of the left D5 

(ulnar, new). Other than the subjects mentioned above, 

there were no diagnostic indicators or evidence of 

median and ulnar nerve abnormalities in either upper 

extremity of the subjects tested during the posttraining 

physical examination portion of the assessment. 

Nerve Conduction Studies

As in the pretraining nerve conduction evaluation, 

when comparing the results of the study with the chart 

of normal values, all subjects had normal NCS values 

Table 2. Mean, standard deviation, and range of values for neural conduction measurements 

(pretraining, n=35).*

 Right upper extremity Left upper extremity Normal 

Values 

Median nerve Mean SD Range Mean SD Range 

Motor 

DML (ms) 3.5 0.4 2.8–4.2 3.4 0.4 2.7–4.1 <4.2 

 Amp CMAP (mV) 9.0 2.7 5.0–14 8.7 2.5 5.0–17 >5.0 

 MNCV BE - W (meters per second) 58.4 3.6 50–68 59.2 4.0 51–68 >50.0 

Sensory 

 Palmar DSL (ms) 1.8 0.2 1.6–2.2 1.8 0.1 1.6–2.1 <2.2 

 Palmar Amp SNAP (μV) 78.5 36.9 24–164 72.9 35.4 15–144 >15.0 

 2 Digit DSL (ms) 2.9 0.2 2.5–3.5 2.8 0.2 2.5–3.3 <3.5 

 2 Digit Amp SNAP (μV) 32.8 19.9 15–110 30.8 12.9 15–83 >15.0 

 F-Wave (ms) 26.2 2.1 21.6–30.3 25.8 2.1 21.5–29.6 <32.0 

Ulnar nerve 

Motor 

 DML (ms) 2.6 0.3 2.2–3.3 2.7 0.3 2.2–3.2 <3.6 

 Amp CMAP (mV) 8.5 2.3 5–14 8.0 1.9 5–12 >5.0 

 MNCV BE - W (meters per second) 60.9 5.9 50–73 60.5 4.1 54–72 >50.0 

 MNCV AE - BE (meters per second) 67.2 8.8 52–96 64.4 8.0 54–92 >50.0 

Sensory 

 Palmar DSL (ms) 1.7 0.1 1.4–2.0 1.7 0.1 1.5–2.1 <2.2 

 Palmar Amp SNAP (μV) 39.0 24.1 15–110 35.0 20.0 15–99 >15.0 

 5 Digit DSL (ms) 2.9 0.2 2.4–3.4 2.9 0.2 2.4–3.3 <3.5 

 5 Digit Amp SNAP (μV) 36.2 34.0 15–164 30.6 20.6 15–101 >15.0 

 F-Wave (ms) 26.2 2.4 20.7–31.2 26.2 2.1 22.5–31.3 <32.0 

*Data from Greathouse et al.14 Reproduced with permission. 

AE indicates above elbow; Amp, amplitude; BE, below elbow; CMAP, compound motor action 

potential; DML, distal motor latency; DSL, di stal sensory latency; MNCV, motor nerve conduction velocity; SNAP, sensor y ner ve action potential; W, wrist. 
76 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

including conduction latencies, amplitudes, and 

conduction velocities of the median and ulnar nerves 

in both upper extremities. Similarly, when comparison 

studies between the median and ulnar palmar DSLs, 

digital DSLs, and DMLs in the same and opposite 

extremities, and the digit 4 median/ulnar comparison 

study in the same extremity were assessed, there were 

electrodiagnostic abnormalities of the median nerve at 

or distal to the wrist in 6 subjects (21%) involving 10 

hands (18%) (Table 4). When using these comparison 

values, prolonged latency differences in the medianulnar DMLs in the same extremity were observed in 

the right upper extremities in 2 subjects (12 and 32). 

When using these comparison values, prolonged latency differences in the median-ulnar DMLs in the same 

extremity were also observed in both upper extremities 

of 4 subjects (7, 9, 11, and 39). In addition, subject 12 

also had a prolonged difference of 0.7 millisecond 

between the digit 4 median and ulnar digital DSLs 

comparison study in their right hand (Table 3).30-32

In comparing the pretraining and posttraining nerve 

conduction data, six of the subjects had electrodiagnostic evidence of median abnormalities at or distal 

to the wrist during both phases of testing. Two of the 

subjects (4 and 25) with electrodiagnostic evidence of 

median abnormalities at or distal to the wrist in the 

pretraining phase of data collection failed to successfully complete the preventive dental specialist course 

and were not tested during the posttraining phase of 

data collection. One subject (38) had electrodiagnostic 

evidence of right median nerve abnormality during the 

pretraining data collection, but on posttraining assessment, results of the NCS comparison studies were 

normal. There was no new electrodiagnostic evidence 

of median nerve abnormalities during the posttraining 

phase of data collection in the other 22 subjects. There 

was no statistically significant shift of the nerve conduction values in the prevalence of median 

neuropathies following the 12-week training program 

(χ

2

=0.280, P=.60). 

COMMENT

To our knowledge, no studies have used histories, 

physical examinations, and NCS to assess the status of 

the median and ulnar nerves in dental assistants 

enrolled in a preventive dental specialist course. A 

thorough history and physical examination are 

considered essential screening tools for detecting signs 

Clinical and Electrodiagnostic Abnormalities of the Median Nerve in Army Dental Assistants 

Before and After Training as Preventive Dental Specialists 

Table 3: Subjects with positive findings on neural conduction comparison studies (pretraining).*

 Palmar DSL (ms) Digital DSL (ms) DML (ms) D4 DSL (ms) 

Subject Hand Median Ulnar Difference Median Ulnar Difference Median Ulnar Difference Median Ulnar Difference 

004 R 1.7 1.8 0.1 2.7 2.8 0.1 3.9 2.6 1.3† 2.8 2.8 0.0 

 L 1.8 1.8 0.0 2.7 2.7 0.0 3.6 2.9 0.7 2.8 2.7 0.1 

007 R 1.8 1.6 0.2 2.8 2.4 0.4 3.9 2.3 1.3† 2.9 2.5 0.4 

 L 2.0 1.5 0.5 2.6 2.4 0.2 3.4 2.3 1.1† 3.1 2.6 0.5 

009 R 1.8 1.5 0.3 2.8 2.6 0.2 3.4 2.3 1.1† 2.8 2.5 0.3 

 L 1.8 1.7 0.1 2.6 2.8 0.2 3.8 2.2 1.6† 2.7 2.7 0.0 

011 R 1.7 1.6 0.1 2.5 2.8 0.3 4.2 2.2 2.0† 2.5 2.4 0.1 

 L 1.7 1.7 0.0 2.5 2.7 0.2 3.8 2.3 1.5† 2.6 2.5 0.1 

012 R 2.0 1.6 0.4 3.1 2.8 0.3 3.7 2.4 1.3† 3.2 2.8 0.4 

 L 1.9 1.6 0.3 2.8 2.7 0.1 3.2 2.3 0.9 2.9 2.6 0.3 

025 R 2.2 1.7 0.5 3.2 3.1 0.1 4.0 2.4 1.6† 3.3 2.8 0.5 

 L 1.9 1.6 0.3 3.0 2.9 0.1 3.7 2.6 1.1† 3.2 3.0 0.2 

032 R 2.1 1.8 0.3 3.1 3.2 0.1 4.1 3.0 1.1† 3.4 3.0 0.4 

 L 1.9 1.8 0.1 2.8 2.9 0.1 3.7 3.1 0.6 3.2 2.8 0.4 

038 R 1.9 1.8 0.1 3.0 2.9 0.1 4.0 2.7 1.3† 3.2 3.1 0.1 

 L 2.0 1.8 0.2 3.3 3.3 0.0 3.6 3.1 0.5 3.6 3.4 0.2 

039 R 2.0 1.6 0.4 3.0 2.7 0.3 3.8 2.4 1.4† 3.1 2.4 0.7†

 L 2.0 1.5 0.5 3.0 2.6 0.4 3.9 2.6 1.3 3.3 2.9 0.4 

*Data from Greathouse et al.14 Reproduced with permission. 

†Indicates electrodiagnostic abnormalities of the median nerve.

DSL indicates distal sensory latency; DML, distal motor latency. 

NOTE: Prolonged DML difference > 1..0 millisecond (normal < 1.0 millisecond). 

Prolonged D4 median/ulnar difference > 0.6 millisecond (normal < 0.6 millisecond). 
 January – March 2011 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

and symptoms of peripheral neuropathy.14,21-24,33 Nerve 

conduction measurement is often performed on the 

median and ulnar nerves to determine whether certain 

entrapment neuropathies are present.14,21-24,33-40 Nerve 

conduction measurement is considered the gold 

standard when assessing the electrophysiologic status 

of the peripheral nerve.14,21-24,33-43

As a result of the 12-week course, 5 subjects had new 

complaints suggestive of median or ulnar nerve 

abnormalities: subject 7 (right median); subject 8 (left 

ulnar); subject 9 (bilateral median), subject 11 

(left > right median), and subject 30 (right median). 

Two subjects had continuing subjective complaints of 

a right median nerve dysfunction (subject 5) and a left 

ulnar and median nerve function (subject 12). 

Subject 7 had N/T in the palm of the right hand on the 

posttraining assessment but had a positive Tinel’s sign 

over both median nerves at the wrist and 

electrodiagnostic findings of bilateral median abnormalities at or distal to the wrist in both the pretraining 

and posttraining assessment. Subject 8 had N/T in the 

left digit 5 on the posttraining physical examination as 

well as decreased sensation in the left digit 5. Subject 

8 continued to have a positive Tinel’s sign at the left 

ulnar nerve at the wrist and elbow suggestive of a left 

ulnar abnormality, however, nerve conduction testing 

of the left ulnar nerve was normal. Subject 9 had N/T 

in the palms of both hands (posttraining) suggestive of 

bilateral median nerve dysfunction; but there were no 

physical examination findings to suggest a bilateral 

median nerve compromise. However, subject 9 had 

pretraining and posttraining electrodiagnostic evidence 

suggestive of a bilateral median nerve abnormality at 

or distal to the wrist. 

Subject 11 had a new finding of bilateral (right > left) 

hand pain and a positive Tinel’s sign over the right 

median nerve at the wrist (pretraining) but a normal 

physical assessment on the posttraining examination. 

Subject 11 also had electrodiagnostic evidence on both 

the pretraining and posttraining NCS testing 

suggestive of bilateral median nerve abnormality. 

Subject 30 had a new finding of N/T of the right digit 

(thumb) suggestive of a right median nerve 

abnormality but a normal physical examination and 

nerve conduction studies. 

Two subjects had consistent complaints during both 

testing sessions. Subject 5 had right wrist pain but 

normal physical examination and nerve conduction 

studies on both pretraining and posttraining 

assessments. Subject 12 had complaints of bilateral 

median and ulnar nerve dysfunction on both exams 

and a new loss of sensation of the left digit 5. The 

nerve conduction studies for subject 12 were 

consistent for electrodiagnostic abnormalities of the 

right median nerve at or distal to the wrist but the 

bilateral ulnar nerve studies were normal. 

Of the 35 dental assistants that participated in the 

pretraining assessment, 14 hands (20%) in 9 subjects 

(26%) had electrodiagnostic abnormalities of the 

Table 4: Subjects with positive findings on neural conduction comparison studies (posttraining). 

 Palmar DSL (ms) Digital DSL (ms) DML (ms) D4 DSL (ms) 

Subject Hand Median Ulnar Difference Median Ulnar Difference Median Ulnar Difference Median Ulnar Difference 

007 R 1.8 1.5 0.3 2.8 2.6 0.2 3.7 2.5 1.2 2.9 2.6 0.3 

 L 1.9 1.7 0.2 2.8 2.7 0.1 3.8 2.7 1.1 3.2 2.6 0.6 

009 R 1.8 1.6 0.2 2.8 2.8 0.0 3.6 2.5 1.1 3.0 2.6 0.4 

 L 1.7 1.7 0.0 2.6 2.8 0.2 3.6 2.1 1.5 2.8 2.7 0.1 

011 R 1.7 1.7 0.0 2.7 3.0 0.3 4.2 2.9 1.3 3.0 2.9 0.1 

 L 1.6 1.8 0.2 2.6 2.8 0.2 4.1 2.7 1.4 2.8 2.7 0.1 

012 R 2.2 1.7 0.5 3.2 2.9 0.3 4.0 2.9 1.1 3.5 2.8 0.7 

 L 2.1 1.8 0.3 3.1 3.1 0.0 3.6 3.1 0.5 3.3 3.0 0.3 

032 R 2.0 1.8 0.2 2.8 2.8 0.0 3.7 2.6 1.4 2.9 2.8 0.1 

 L 1.8 1.7 0.1 2.6 2.6 0.0 3.4 2.7 0.7 2.8 2.8 0.0 

039 R 2.0 1.8 0.2 3.0 2.8 0.2 4.2 2.8 1.4 3.1 2.7 0.4 

 L 2.0 1.7 0.3 3.0 2.7 0.3 3.9 2.5 1.4 3.2 2.6 0.6 

DSL indicates distal sensory latency; DML, distal motor latency. 

Prolonged DML difference > 1..0 millisecond (normal < 1.0 millisecond). 

Prolonged D4 median/ulnar difference > 0.6 millisecond (normal < 0.6 millisecond). 

Subjects 004 and 025 did not complete the preventive dental specialist training, and therefore did not participate in the posttraining assessment. 
78 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

median nerve at or distal to the wrist.14 Six of these 9 

subjects continued with electrodiagnostic 

abnormalities of the median nerve at or distal to the 

wrist (6 subjects (21%), 10 hands (18%)). Two 

subjects (4 and 25) did not complete the course, and 

subject 38 improved his nerve conduction findings 

from the pretraining to posttraining assessments. 

There was no statistically significant shift of the nerve 

conduction values in the prevalence of median 

neuropathies following the 12-week training program 

(χ

2

=0.280, P=.60). It appears that the 12-week 

training program did not affect the median and ulnar 

nerve function as assessed by physical examination 

and nerve conduction testing. There was no 

electrodiagnostic evidence on either the pretraining or 

posttraining nerve conduction studies to suggest ulnar 

nerve abnormalities at or distal to the wrist, in the 

forearm, or at the elbow (cubital tunnel). 

Of the 35 dental assistants that participated in the 

pretraining assessment, 14 hands (20%) in 9 subjects 

(26%) had electrodiagnostic abnormalities of the 

median nerve at or distal to the wrist.14 Review of the 

number of months the 9 dental assistants with 

pretraining electrodiagnostic abnormalities of the 

median nerve at or distal to the wrist had been 

practicing in the dental clinic indicated that 5 subjects 

had been practicing in a dental clinic greater than 12 

months, and 4 subjects reported practicing less than 12 

months. When considering warm-up exercises, breaks 

during clinical practice, and amount of time per week 

on the computer, playing video games, or playing a 

musical instrument, there were no consistent factors 

that separated the 9 dental assistants from the group 

studied. All of the 9 dental assistants that had 

electrodiagnostic abnormalities of the median nerve at 

or distal to the wrist described their general health to 

be good or excellent, and none of these subjects had a 

history of neuropathic disease, renal disease, 

peripheral vascular disease, thyroid disease, diabetes, 

or arthritis. 

Dental hygienists reportedly have a high prevalence of 

upper-extremity musculoskeletal disorders, including 

CTS.4-13 In their survey of Army dental personnel, 

Lalumandier and McPhee11,12 stated that 75% of dental 

hygienists reported having hand problems, and 56% 

exhibited probable or classic symptoms of CTS. Rice 

et al13 reported symptoms associated with CTS were 

noted by 75.6% of the dental workers, 11% reported 

diagnosed CTS, and 53% reported back and shoulder 

pain. With the documented incidence of carpal tunnel 

syndrome in dentists and dental hygenists, there are no 

studies, to our knowledge, that have documented the 

incidence of carpal tunnel syndrome in dental 

assistants enrolled in a preventive dental specialist 

course. The present study demonstrated that 

electrodiagnostic abnormalities of the median nerve at 

or distal to the wrist or carpal tunnel syndrome is 

present in 9 Army subjects (26%) pretraining and 6 

subjects (21%) posttraining. However, only 2 of the 9 

subjects had objective findings on the clinical 

examination suggestive of median nerve dysfunction. 

In a population such as the dental assistants studied 

here, it is reasonable to expect that subclinical upper 

extremity mononeuropathies secondary to repetitive 

overuse may be present. In the early stages of a 

mononeuropathy of this type, many individuals with a 

clinically detectable problem are not aware that their 

neural function has been impaired.44 Atroshi et al44 

examined 125 asymptomatic controls with NCS of the 

median nerves and reported that 18% (n=23) had 

electrophysiological evidence of carpal tunnel 

syndrome. 

Atroshi et al44 have stated that the estimation of the 

prevalence of carpal tunnel syndrome in a general 

population may contribute to the early diagnosis and 

effective treatment of subjects and provide useful data 

for the interpretation of results that estimate the 

prevalence of carpal tunnel syndrome in specific 

occupational groups. Franzblau and Werner45-47 further 

suggest that performing NCS of individuals without 

symptoms of carpal tunnel syndrome is important 

because it permits the assessment of the overall 

relationship between the electrophysiological 

properties of the nerve and other clinical features of 

carpal tunnel syndrome. Although no strong evidence 

exists regarding the prevention or progression of CTS, 

it makes sense, theoretically, to identify a problem 

early, where a minor intervention, such as a resting 

night splint or ergonomic changes in the work 

environment, might rectify the dysfunction.45-47

A valuable extension of this study would be evaluations of these preventive dental specialists as they progress through their dental health careers, and to reevaluate them in 5 to 10 years to determine whether the 

Clinical and Electrodiagnostic Abnormalities of the Median Nerve in Army Dental Assistants 

Before and After Training as Preventive Dental Specialists 
 January – March 2011 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

individuals who presented with early electrodiagnostic 

abnormalities of median nerve at or distal to the wrist 

later develop symptomatic carpal tunnel syndrome. 

CONCLUSION

This study examined a sample of 35 Army dental 

assistants during their training to become preventive 

dental specialists for the presence of clinical and 

electrodiagnostic abnormalities of the median and 

ulnar nerves. All electrophysiological variables were 

normal for motor, sensory, and F-wave (central) values 

when compared to a chart of normal values in both the 

pretraining and posttraining assessments. Based on 

comparison studies of median and ulnar motor 

latencies in the same hand, 14 hands (20%) among 9 

subjects (26%) were found to have electrodiagnostic 

abnormalities of the median nerve at or distal to the 

wrist at the pretraining assessment.14 During posttraining assessment, there were no new cases of 

electrodiagnostic median nerve abnormalities and no 

statistically significant shift of the nerve conduction 

values in the prevalence of median neuropathies 

following the 12-week training program. Ulnar nerve 

electrophysiological function was within normal limits 

for all subjects examined. Nerve conduction comparison studies may provide sensitive measures and 

early indicators for the detection of early median nerve 

compromise at or distal to the wrist. Additional longterm prospective studies examining the prevalence and 

prevention of upper extremity disorders, to include 

carpal tunnel, appear to warrant further investigation.

ACKNOWLEDGEMENT

The authors thank COL Robert Lutka, SFC Charles A. 

Aponte, SFC Heide C. Mayberry, SFC Michael C. 

Mason, and SSG Gerald M. Bradford (AMEDD Center 

and School, Fort Sam Houston, Texas) for their support 

of this study and their assistance in recruiting the dental 

assistants who participated. 

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Clinical and Electrodiagnostic Abnormalities of the Median Nerve in Army Dental Assistants 

Before and After Training as Preventive Dental Specialists 
 January – March 2011 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

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AUTHORS

Dr Greathouse is Director, Clinical Electrophysiology Services, Texas Physical Therapy Specialists, New Braunfels, 

Texas, and Adjunct Professor, US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, 

Texas. 

1LT Root is a staff physical therapist at Ireland Army Community Hospital, Fort Knox, Kentucky. At the time of this 

study, she was a student in the US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, 

Texas. 

CPT Carrillo is a staff physical therapist at Evans Army Community Hospital, Fort Carson, Colorado. At the time of 

this study, she was a student in the US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam 

Houston, Texas. 

1LT Jordan is a staff physical therapist at Madigan Army Medical Center, Fort Lewis, Washington. At the time of this 

study, she was a student in the US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, 

Texas. 

1LT Pickens is a staff physical therapist at Reynolds Army Community Hospital, Fort Sill, Oklahoma. At the time of 

this study, he was a student in the US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam 

Houston, Texas. 

Dr Sutlive is an Associate Professor, US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam 

Houston, Texas. 

LTC Shaffer is an Associate Professor, US Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam 

Houston, Texas. 

COL Moore is Professor and Program Director, US Army-Baylor University Doctoral Program in Physical Therapy, 

Fort Sam Houston, Texas. 
82 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Oral and maxillofacial surgeons are often consulted to 

evaluate intraoral trauma in children. The pediatric 

population is exceptionally susceptible to penetrating 

trauma of the palate due to developing coordination 

issues and the tendency to put objects into mouths.1

While the vast majority of such cases are easily 

managed on an outpatient basis, clinicians should have 

a high index of suspicion for the potential devastating 

effects of these types of injuries. They can appear 

rather innocuous at initial presentation, but can 

actually lead to potentially fatal or highly morbid 

complications. We present a case of penetrating palatal 

trauma with a unique etiology and approach to 

treatment, and discuss some of the consequences that 

have been presented in the literature, with a treatment 

protocol to remind providers of the need for vigilance 

in this trauma scenario. 

CASE REPORT

A 6-year-old female reported to the Emergency 

Department at Madigan Army Medical Center with a 

complaint of pain and bleeding from the roof of her 

mouth. She had been running on the playground at 

school. She tripped and fell toward a friend, who was 

holding a tree branch. One of the smaller branches 

penetrated her palatal mucosa and bone. Upon examination in the Emergency Department, her vitals were 

noted to be within normal limits for her age. Her 

medical history was significant only for a history of 

jaundice as an infant and an allergy to penicillin. 

Immunizations were up-to-date. The patient was hemodynamically and neurologically intact. Examination 

of the oral cavity revealed a hemostatic, stellate 

puncture wound just to the left of the patient’s midline 

at the junction of the hard and soft palate (Figure 1). 

Closer intraoral examination of the wound revealed a 

palatal fracture just lateral to the midline suture, with 

the fractured bone vertically displaced into the nasal 

vestibule toward the caudal septal cartilage. The 

computed tomography scan image (Figure 2) 

demonstrates the degree of displacement of the 

fractured piece. Due to concern for scarring and future 

septal deviation as well as potential infection, the 

patient was taken to the operating room for general 

anesthesia to manually reduce the fractured bone and 

to better explore the wound. Intraoperatively, a 

combination of digital manipulation intraorally and the 

use of a #15 scaler intranasally successfully 

repositioned the maxillary bone (Figure 3). Inspection 

of the septum revealed no deviation, laceration, or 

hematoma. Fast absorbing gut suture was used to close 

the palatal mucosa and the patient was placed on 

postoperative antibiotics for 5 days (Figure 4). A 

palatal stent was fabricated from a preoperative model 

and secured to the dentition with suture for 5 days. 

Instructions were provided to the patient and parents. 

The patient had an uneventful postoperative course 

and healed without incident or sequela (Figure 5). 

DISCUSSION

Penetrating injury to the palate can range from 

relatively innocuous to rather significant and dangerous, depending on the location of the entry wound 

intraorally. Most bleeding is self-limited unless the 

palatine artery is injured. Management of most such 

injuries can be on an outpatient basis, but clinicians 

must remain vigilant should the patient’s status 

deteriorate. Potentially devastating effects of penetrating palatal trauma include overt carotid vessel 

disruption with significant hemorrhage and intimal 

tearing with thrombus formation and propagation that 

can result in ischemic infarcts. Oral bacterial 

contamination can cause severe infections into major 

fascial planes or the mediastinum.2

 If the injury is 

located off the palatal midline, the proximity of the 

carotid vasculature cannot be discounted. Occlusion of 

the middle cerebral artery and ischemic infarctions 

have been reported.3,4 The subsequent neurologic 

deficits can manifest as partial or complete hemiparesis, homonymous hemianopsia, Horner’s syndrome, 

facial nerve paralysis, gait issues, or death.5,6 The 

concern is that initially the patient will have a “lucid 

interval” with neurologic deterioration not evident for 

up to 2 days after the injury when the thrombus has 

had time to form and propagate toward the cerebral 

circulation.7

 Clinicians should watch for development 

of irritability, vomiting, drowsiness, visual changes, 

seizures, and motor deficits. Transtentorial herniation 

Palatal Fracture in a Child 

COL Karen M. Keith, DC, USA 

CPT Tyler L. Clark, DC, USA 
 January – March 2011 83

and death can ensue with progression of a thrombus to 

the anterior and middle cerebral arteries that produces 

infarction, edema and mass effect.8

 While only 32 cases 

of internal carotid artery thrombus have been reported 

in the English literature prior to 2006,9

 clinicians 

should be cognizant of its significance. 

Raska et al5

 did a review of the literature to provide a 

recommended treatment protocol for penetrating trauma in children. Some authors suggest that noninvasive 

angiography studies are as accurate as traditional 

angiography without the potential complications of 

catheterization.10,11 Raska et al recommended angiography to rule out vascular injury once the patient was 

appropriately resuscitated, and also proposed a more 

aggressive protocol than some. They felt that traditional 

angiography remained the gold standard as computed 

tomography angiography and magnetic resonance 

Figure 4. Fast absorbing gut suture was used to close 

the palatal mucosa. 

Figure 2. Computed tomography scan image showing 

displacement of the fractured piece of maxillary bone. 

Figure 5. The healing palatal wound. 

Figure 1. The palatal wound. 

Figure 3. The combination of intraoral digital 

manipulation and the use of a #15 scaler intranasally 

successfully repositioned the maxillary bone. 
84 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

angiography have proved inferior in detecting vascular 

injuries in adults. Studies are not available in children 

because of the infrequency of significant vascular 

pathology in this population. Biffl et al12 and Miller et 

al13 did prospective studies that support Raska’s claim 

that traditional catheter angiography appears more 

sensitive at detecting vascular injuries. Hellman’s 

group,14 however, reviewed 131 cases of impalement 

injuries over a 17-year period where diagnostic 

imaging was not performed until development of 

neurologic deficits and concluded that management 

and outcomes of oral-pharyngeal palate injuries were 

not enhanced by prior diagnostic maneuvers. 

Some providers will recommend hospitalization and 

anticoagulation, but this is not a universal approach. 

Because significant damage to the carotid vasculature 

is very rare and development of symptoms has been 

reported to take 96 hours, routine hospitalization for 

48 to 72 hours is not universally recommended.8

 Routine hospitalization for observation incurs impractical 

costs in the current healthcare environment. Hengerer 

et al7

 reported improvement in neurologic symptoms 

after initiating anticoagulation, but Frantzen et al15 did 

a case series of 8 patients where no difference was 

noted in outcome. Before considering anticoagulation, 

dissection must be ruled out. Cothren et al16 reviewed 

more than 13,000 blunt trauma cases at a level one 

trauma center over a 7-year period. Most patients sustained multiple trauma. One hundred fourteen patients 

had a diagnosed carotid artery injury. Seventy-three 

were anticoagulated and none developed a stroke. 

Forty-six percent of the remaining 41 patients not 

receiving anticoagulation for one reason or another 

sustained cerebral ischemia. Fabian et al17 concluded 

similar benefits of anticoagulation with their 11-year 

study of blunt carotid injuries. Angiography demonstrated dissections, pseudoaneurysms, thromboses and 

carotid-cavernous sinus fistulae. The fistulae were surgically repaired. Anticoagulation with heparin resulted 

in 20% mortality, whereas lack of anticoagulation 

resulted in 100% mortality. Miller et al18 noted a 

stroke reduction from 64% to 6.8% in their study using 

anticoagulation. Raska et al5

 recommend using 

enoxaparin sodium, since antiplatelet therapy can be as 

effective as anticoagulation, while acknowledging that 

randomized studies do not exist to establish a 

definitive regimen in the pediatric population. 

Recent literature remains inconclusive as to the most 

appropriate and beneficial regimen for penetrating 

palatal trauma in children, given the infrequency of 

damage to the internal carotid artery (0.6%) and the 

preferences of various providers, weighing costs and 

risks.19 Conservative management is prudent in the 

majority of cases with judicious use of antibiotics, debridement and repair, and initial consideration of noninvasive imaging. Invasive studies might be indicated if 

the injury location is more lateral and, thus, more 

likely to involve the internal carotid artery. Aggressive 

therapy is warranted in the face of neurologic deficits. 

CONCLUSION

Our case represents an unusual etiology for this type of 

injury, as the child was not holding the source of 

impalement, and enough force was generated to 

actually fracture the bone and not merely rupture the 

soft tissue. This injury was also located more midline 

than the majority of cases reported in the literature. 

She was managed surgically due to the extent of the 

open wound and consideration for infection, as well as 

the degree of displacement of bone. Only mild 

consideration for vascular involvement was entertained. Too often, children are running, playing, or 

even riding in a moving vehicle with lollipops, popsicles, wands, and other similar “stick items” in their 

hands or in their mouths. While most patients will 

never present to medical personnel, impalement injuries should be examined and the possibility of 

serious consequences considered. It is incumbent upon 

parents and caregivers to monitor the actions of 

children. Not all accidents can be prevented, but in 

doing a risk assessment of certain activities, many 

traumatic injuries can be prevented. Should a child 

sustain a penetrating injury to the palate, providers 

must have a high index of suspicion and use 

appropriate monitoring and diagnostic modalities to 

avoid serious morbidity. 

REFERENCES

1. Zeltser R, Kalter A, Casap N, Regev E. Oropharyngeal impalement injuries in children: report of 

2 cases. J Oral Maxillofac Surg. 2003;61(4):510-514. 

2. Wu K, Ahmed A. Penetrating injury to the soft palate 

causing retropharyngeal air collection. Emerg Med J. 

2005;22(2):148-149. 

3. Woodhurst WB, Robertson WD, Thompson GB. 

Carotid Injury due to intraoral trauma: Case report 

and review of the literature. Neurosurgery. 1980;6

(5):559-563. 

Palatal Fracture in a Child 
 January – March 2011 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Mains B, Nagle M. Thrombosis of the internal carotid 

artery due to soft palate injury. J Laryngol Otol. 

1989;103(8):796-797. 

5. Raska GM, Cordova SW, Lema R, Goldwasser MS. 

Management of penetrating trauma to the soft palate: 

a case report. J Oral Maxillofac Surg. 2007;65

(7):1279-1285. 

6. Higgins GL III, Meredith JT. Internal carotid artery 

thrombosis following penetrating trauma of the soft 

palate: an injury of youth. J Fam Pract. 1991;32

(3):316,319-322. 

7. Hengerer AS, DeGroot TR, Rivers RJ, Pettee DS. 

Internal carotid artery thrombosis following soft 

palate injuries: a case report and review of 16 cases. 

Laryngoscope. 1984;94:1571-1575. 

8. Joseph MJ, Lewis S. Stroke after penetrating trauma 

of the oropharynx. Pediatr Emerg Care. 2002;18

(3):179-181. 

9. Randall DA, Kang DR. Current management of 

penetrating injuries of the soft palate. Otolaryngol 

Head Neck Surg. 2006;153(3):356-360. 

10. Brietzke SE, Jones DT. Pediatric oropharyngeal 

trauma: what is the role of CT scan?. Int J Pediatr 

Otorhinolaryngol. 2005:69(5):669-679. 

11. Auerbach EG, Martin ET. Magnetic resonance 

imaging of the peripheral vasculature. Am Heart J. 

2004;148(5):755-763. 

12. Biffl WL, Ray CE Jr, Moore EE, Mestek M, Johnson 

JL, Burch JM. Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma. 

2002;53:850-856. 

13. Miller PR, Fabian TC, Croce MA, Cagiannos C, 

Williams JS, Vang M, et al. Prospective screening for 

blunt cerebrovascular injuries: analysis of diagnostic 

modalities and outcomes. Ann Surg. 2002;236(3):386-

395. 

14. Hellman JR, Schott SR, Gootee MJ. Impalement 

injuries of the palate in children: review of 131 cases. 

Int J Pediatr Otorhinolaryngol. 1993;26:157-163. 

15. Frantzen E, Jacobsen HH, Therkelsen J. Cerebral 

artery occlusion in children due to trauma to the head 

and neck. J Neurol. 1961;11:695-700. 

16. Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray 

CE Jr, Johnson JL, et al. Anticoagulation is the gold 

standard therapy for blunt carotid injuries to reduce 

stroke rate. Arch Surg. 2004;139(5): 540-546. 

17. Fabian TC, Patton JH Jr, Croce MA, Minard G, 

Kudsk KA, Pritchard FE. Blunt carotid injury: 

importance of early diagnosis and anticoagulant 

therapy. Ann Surg. 1996;223(5):513-522. 

18. Miller PR, Fabian TC, Bee TK, Timmons S, 

Chamsuddin A, Fikle R, Croce MA. Blunt 

cerebrovascular injuries: diagnosis and treatment. J 

Trauma. 2001;51(2):279-286. 

19. Pereira KD, Wang BS, Webb BD. Impalement 

injuries of the pediatric craniofacial skeleton with 

retained foreign bodies. Arch Otolaryngol Head Neck 

Surg. 2005;131(2):158-162. 

AUTHORS

COL Keith is Chief and Program Director, Oral and 

Maxillofacial Surgery, Madigan Army Medical Health 

Care System, Joint Base Lewis McChord, Washington. 

CPT Clark is Chief Resident, Oral and Maxillofacial 

Surgery, Madigan Army Medical Health Care System, 

Joint Base Lewis McChord, Washington. 

Insignia of the Madigan Army Medical Center, 

Joint Base Lewis McChord, Washington. 
86 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The pyogenic granuloma is a pedunculated or sessile 

nodular lesion commonly encountered intraorally and in 

extraoral sites. Intraorally, the lesion exhibits a marked 

predilection for the gingiva, where 75% of all oral pyogenic 

granulomas occur.1

 The lesion, which has limited growth 

potential, is considered a reactive process in response to a 

local irritant rather than a neoplasm. The name of this lesion 

has persisted despite recognition that the soft tissue growth 

is unrelated to pyogenic bacterial infection.1

 Furthermore, 

the lesion is unrelated to granulomatous inflammation, 

which is characterized by predominance of activated 

macrophages with epitheliod appearance.2

 The terms 

pregnancy tumor and granuloma gravidarum have been 

used for this lesion due to its association with pregnancy. 

Another term, lobular capillary hemangioma, provides the 

most accurate clinicopathologic description of the lesion and 

is perhaps most useful.1

Clinically, the surface of a pyogenic granuloma may appear 

smooth or lobulated, and a progression in color from pink to 

red to purple occurs over time.1

 The surface of the pyogenic 

granuloma may be ulcerated or fibrous depending upon the 

age of the lesion and the persistence of irritation or trauma. 

Histologic examination reveals highly vascular tissue 

resembling normal granulation tissue, with an inflammatory 

infiltrate consisting of neutrophils, lymphocytes, and plasma 

cells.1

The etiology of pyogenic granuloma is thought to involve an 

imbalance between inhibitors and enhancers of 

angiogenesis. Yuan et al reported increased expression of 

vascular endothelial growth factor (VEGF) and basic 

fibroblast growth factor (bFGF) and decreased expression of 

angiostatin and thrombospondin-1 in pyogenic granuloma 

tissue compared to healthy gingiva and gingiva affected by 

periodontitis.3

 However, there was no significant difference 

among the 3 groups in expression of estrogen receptor.3

Interestingly, VEGF and bFGF expression has been shown 

to be higher in pyogenic granulomas during pregnancy, 

Pyogenic Granuloma Occurring in a 

 Postmenopausal Woman on Hormone 

 Replacement Therapy 

MAJ Thomas M. Johnson, DC, USA 

LTC William J. Demsar, DC, USA 

COL Robert W. Herold, DC, USA 

COL Frederick C. Bisch, DC, USA 

COL Robert C. Gerlach, DC, USA 

COL Gary D. Swiec, DC, USA 

ABSTRACT 

Pyogenic granuloma is a benign nodular lesion occurring most commonly on the gingiva of females during periods of 

elevated sex hormones such as puberty and pregnancy. Possible molecular mechanisms responsible for the appearance 

of pyogenic granuloma in this demographic have been suggested. Increased incidence of pyogenic granuloma in post 

menopausal women on hormone replacement therapy has not been reported. 

A 49-year-old woman with preexisting titanium implant placement in the left posterior mandible presented with 

complaint of food impaction and slight discomfort associated with the implant. Clinical examination revealed slight 

soft tissue erythema and edema, but no foreign body could be identified. Subsequently, a nodular gingival lesion 

associated with the implant developed and was treated by conservative surgical excision. Histologic characteristics of 

the lesion were consistent with pyogenic granuloma. The patient was informed of the diagnosis. No evidence of 

recurrence could be identified after 6 months. 

Like peripubertal and pregnant women, postmenopausal women treated with hormone replacement therapy may be at 

increased risk for pyogenic granuloma. Observational studies designed to establish an association between hormone 

replacement therapy and pyogenic granuloma have not been conducted. Dentists should be aware of putative 

pathophysiologic mechanisms for pyogenic granuloma formation and the possibility that hormone replacement may 

trigger these mechanisms. 
 January – March 2011 87

when steroid hormone levels are high, compared to 

expression in regressing pyogenic granulomas post partum.4

Furthermore, the precipitous drop in VEGF after parturition 

is associated with endothelial apoptosis and regression of 

pyogenic granuloma.5

 Another mechanism of pyogenic 

granuloma regression after pregnancy may involve tumor 

necrosis factor-alpha (TNF-a). This macrophage-derived 

cytokine has been shown to increase upon withdrawal of 

female steroid hormones.4,6,7 Downstream molecules in TNFa signaling have been demonstrated to participate in 

modulation of angiogenesis and endothelial regression, 

however, conflicting reports regarding the role of TNF-a 

signaling in angiogenesis appear in the literature.8-10 In 

addition to enhancing expression of proangiogenesis 

mediators and suppressing expression of angiogenesis 

inhibitors, female sex hormones may directly inhibit 

apoptosis of granuloma cells.4 

CASE REPORT

A 49-year-old African American woman was referred to the 

US Army Advanced Education Program in Periodontics, 

Fort Gordon, Georgia, for crown lengthening of teeth #2-5, 

#8, and #13-15 prior to definitive prosthetic treatment. 

Approximately one year prior to the evaluation for crown 

lengthening, the patient had endosseous implants placed in 

the posterior mandible bilaterally at another facility. She 

was asymptomatic at the time of presentation. The patient’s 

past medical history was significant for hyperlipidemia. Her 

medications included simvastatin, conjugated estrogen, a 

multivitamin, and an herbal supplement (Tunguska Blast). 

The patient had a history of 3 caesarean sections, a 

hysterectomy, and bimaxillary advancement with 

genioplasty with no complications. She had a history of very 

light smoking but had not smoked in over 25 years. She 

reported occasional alcohol use, and her family history was 

noncontributory. 

Five weeks following nonsurgical endodontic therapy of 

tooth #3, the patient presented for crown lengthening of 

teeth #2-5 under moderate sedation. The procedure was 

performed without complication, and the patient exhibited a 

normal postoperative course. The morning of the 

appointment for the same procedure on the contralateral 

side, the patient complained of pain and swelling associated 

with implant #19 area. She reported eating popcorn and felt 

that she had an impacted popcorn fragment between the 

healing abutment and the gingiva. 

Clinical examination revealed slight erythema and edema of 

the keratinized tissue overlying the implant. The healing 

abutment was removed in attempt to identify a foreign body. 

No foreign body was found. The site was irrigated 

thoroughly with chlorhexidine and the healing abutment was 

replaced. At 2 weeks, a firm ovoid nodule measuring 1 cm 

1 cm  0.7 cm was present (Figure 1). The nodule was 

connected to the buccal aspect of the peri-implant tissue by 

a short, narrow stalk. The pedunculated nodule had a lobular 

appearance, generally the same color as surrounding tissue, 

with some areas exhibiting a bluish red hue. The nodule was 

excised and submitted for histologic analysis with the 

differential diagnosis of pyogenic granuloma, peripheral 

ossifying fibroma, peripheral giant cell granuloma, or 

traumatic fibroma. Histologic evaluation revealed a lobular 

mass of acute and chronically inflamed granulation-like 

tissue, with numerous ananstomosing vascular channels 

(Figure 2). A diagnosis of pyogenic granuloma was made. 

The malpositioned implant was removed (Figure 3), and a 

new fixture was placed in the correct position (Figure 4). 

DISCUSSION

Pyogenic granulomas have limited growth potential and 

usually regress after elimination of the precipitating 

stimulus. For lesions that do not regress, adequate treatment 

usually consists of conservative surgical excision. Although 

malignant transformation is not reported, pyogenic 

granulomas can reach considerable size and be distressing to 

the patient. Moreover, appearance of the lesion can delay 

treatment and result in the need for additional procedures. 

The effects on periodontal tissues of elevated endogenous 

steroid hormones during pregnancy and oral contraceptive 

drugs have long been recognized. The present case is an 

example of pyogenic granuloma occurring in a 

postmenopausal woman on hormone replacement therapy 

(HRT). Postmenopausal osteoporosis is a common problem 

that accounts for significant morbidity and diminished 

quality of life among middle-aged women. Patients are 

diagnosed with osteoporosis when a bone scan reveals a T 

score less than -2.5 and osteopenia when the T score falls 

between -1 and -2.5.11 A wide range of antiresorptive and 

anabolic agents are available for treatment and prevention of 

osteoporosis. Estrogens are antiresorptive agents approved 

by the Food and Drug Administration for prevention only.11

Estrogens inhibit bone resorption by binding to receptors on 

osteoblasts, directly increasing production of osteoprotegrin 

and decreasing production of colony stimulating factor-1.12

Additionally, estrogens decrease production of TNF-a and 

interleukin-1 by monocytes within the marrow and may 

exert an anabolic influence on osteoblasts.12 Strong evidence 

suggests that HRT has a large, favorable effect on bone 

mineral density in postmenopausal women.13 Furthermore, 

decreased bone mineral density is associated with increased 

fracture risk.14 Data from the Womens Health Initiative 

suggests a reduction in hip fracture risk of 36% to 39% for 

patients taking HRT.15,16 In addition to slowing the decline 

in bone mineral density after menopause, estrogens may 

have other beneficial effects including possible protection 

against endometrial and colorectal cancer.15 However, risks 

associated with HRT are concerning. Specific risks may be 

dependent upon whether the patient has a history of 
88 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Pyogenic Granuloma Occurring in a Postmenopausal Woman on Hormone Replacement Therapy 

Figure 1. Preoperative clinical appearance (A) and post excision (B). 

A 

B 

A B 

C D 

Figure 2. Histomicrographs of lesion. Frame A: Low power (2x) hematoxylin and eosin staining 

revealed a lobular mass of granulation-like tissue, with numerous ananstomosing vascular channels. 

The ulcerated surface was replaced with a fibrinous exudate. Frame B: 10x view of fibrinous exudate 

of ulcerated surface. Note the chronically inflamed edematous fibrovascular connective tissue. Frame 

C: 20x view demonstrating acute and chronically inflamed fibrous connective tissue with numerous 

thin-walled blood vessels of varying sizes. Frame D: High power 60x view demonstrating vascular 

channels lined by plump endothelial cells within an edematous delicate fibrovascular stroma with 

acute and chronic inflammatory cell infiltrate. 
 January – March 2011 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

hysterectomy and the particular HRT regimen. Healthy 

postmenopausal women with no history of hysterectomy 

taking estrogen plus progestin appear to be at increased risk 

of coronary heart disease, stroke, pulmonary embolism, and 

breast cancer.15 Postmenopausal women with history of 

hysterectomy taking conjugated equine estrogen alone 

appear to be at increase risk of stroke but not coronary heart 

disease, and these patients may have no increase or even a 

reduced risk of breast cancer.16,17

Studies of the relationship between female sex hormones 

and pyogenic granuloma formation suggest that elevated 

steroid hormone levels may create an imbalance between 

angiogenesis enhancers and inhibitors. This mechanism may 

represent the basis for increased incidence of pyogenic 

granuloma in peripubertal and pregnant women. It seems 

biologically plausible that post menopausal women taking 

hormone replacement therapy would experience a similar 

increased incidence of pyogenic granuloma. However, no 

investigations of such a relationship appear in the literature. 

Clinicians should be aware of putative pathophysiologic 

mechanisms for pyogenic granuloma formation and the 

possibility that hormone replacement may trigger these 

mechanisms. 

REFERENCES

1. Neville BW, Damm DD, Allen CM, Bouquot JE. 

Oral and Maxillofacial Pathology. 2nd ed. 

Philadelphia: WB Saunders and Company; 2002:447-

449. 

A B 

Figure 3. The implant present on initial presentation (A) was malpositioned distobuccally and had excessive distal inclination 

relative to the occlusal plane. The implant was removed via conservative osteotomy (B) using a fine-tipped piezoelectric 

instrument. 

Figure 4. A new 4.0 x 10mm titanium implant was placed mesiolingual to the original implant and with a more upright 

inclination. The defect resulting from removal of the malposed fixture was addressed using a mixture of anorganic bovine 

matrix and collagen as well as a resorbable collagen membrane (A). The surgical wound was closed with 5-0 Gortex sutures (B). 

A B 
90 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Pyogenic Granuloma Occurring in a Postmenopausal Woman on Hormone Replacement Therapy 

2. Cotran RS, Kumar V, Collins T. Robbins Pathologic 

Basis of Disease. 6th ed. Philadelphia: WB Saunders 

and Company; 1999:532-533. 

3. Yuan K, Jin YT, Lin MT. The detection and 

comparison of angiogenesis-associated factors in 

pyogenic granuloma by immunohistochemistry. J 

Periodontol. 2000;71(5):701-709. 

4. Yuan K, Wing LYC, Lin MT. Pathogenic roles of 

angiogenic factors in pyogenic granulomas in 

pregnancy are modulated by female sex hormones. J 

Periodontol. 2002;73(7):701-708. 

5. Yuan K, Lin MT. The roles of vascular endothelial 

growth factor and angiopoietin-2 in the regression of 

pyogenic granuloma. Oral Dis. 2004;10(3):179-185. 

6. Tabibzadeh S, Sataswaroop PG, von Wolff M, 

Strowitzki T. Regulation of TNF-alpha mRNA 

expression in endometrial cells by TNF-alpha and by 

estrogen withdrawal. Mol Hum Reprod. 1999;5

(12):1141-1149. 

7. Pacifici R, Brown C, Puschech E, Friedrich E, 

Slatopolsky E, Maggio D, et al. Effect of surgical 

menopause and estrogen replacement on cytokine 

release from human blood mononuclear cells. Proc 

Natl Acad Sci U S A. 1991;88(12):5134-5138. 

8. Asahara T, Chen D, Takahashi T, Fujikawa K, 

Kearney M, Manger M, et al. Tie2 receptor ligands, 

angiopoietin-1 and angiopoietin-2, modulate VEGFinduced postnatal neovascularization. Circ Res. 

1998;83(3):233-240. 

9. Hanahan D. Signaling vascular morphogenesis and 

maintenance. Science. 1997;277(5322):48-50. 

10. Kim I, Kim JH, Ryu YS, Liu M, Koh GY. Tumor 

necrosis factor-alpha upregulates angiopoietin-2 in 

human umbilical vein endothelial cells. Biochem 

Biophys Res Commun. 2000;269(2):361-365. 

11. Rosen CJ. Clinical practice. Postmenopausal 

Osteoporosis. N Engl J Med. 2005;353(6):595-603. 

12. Eastell R. Role of oestrogen in the regulation of bone 

turnover at the menarche. J Endocrinol. 2005;185

(2):223-234. 

13. Wells G, Tugwell P, Shea B, Guyatt G, Peterson J, 

Zytaruk N, et al. Meta-analyses of therapies for 

postmenopausal osteoporosis. V. Meta-analysis of the 

efficacy of hormone replacement therapy in treating 

and preventing osteoporosis in postmenopausal 

women. Endocr Rev. 2002;23(4):529-539. 

14. Marshall D, Johnell O, Wedel H. Meta-analysis of 

how well measures of bone mineral dentistry predict 

occurrence of osteoporotic fractures. Br Med J. 

1996;312(7041):1254-1259. 

15. Rossouw JE, Anderson GL, Prentice RL, LaCroix 

AZ, Kooperberg C, Stefanick ML, et al. Risks and 

benefits of estrogen plus progestin in healthy 

postmenopausal women: principal results from the 

Women’s Health Initiative randomized controlled 

trial. JAMA. 2002;288(3):321-333. 

16. Anderson GL, Limacher M, Assaf AR, Bassford T, 

Beresford SA, Black H, et al. Effects of conjugated 

equine estrogen in postmenopausal women with 

hysterectomy: the Women’s Health Initiative 

randomized controlled trial. JAMA. 2004;291

(14):1701-1712. 

17. Stefanick ML, Anderson GL, Margolis KL, Hendrix 

SL, Rodabough RJ, Paskett ED, et al. Effects of 

conjugated equine estrogens on breast cancer and 

mammography screening in postmenopausal women 

with hysterectomy. JAMA. 2006;295(14):1647-1657. 

AUTHORS

MAJ Johnson is Chief of Periodontics, US Army Dental 

Activity, US Military Academy, West Point, New York. 

LTC Demsar is Chief, Oral and Maxillofacial 

Pathology, William Beaumont Army Medical Center, 

Fort Bliss, Texas. 

COL Herold is an Assistant Director of the US Army 

Advanced Education Program in Periodontics, Tingay 

Army Dental Clinic, Fort Gordon, Georgia. 

COL Bisch is Director, US Army Advanced Education 

Program in Periodontics, Tingay Army Dental Clinic, 

Fort Gordon, Georgia. 

COL Gerlach is an Assistant Director of the US Army 

Advanced Education Program in Periodontics, Tingay 

Army Dental Clinic, Fort Gordon, Georgia. 

COL Swiec is Chief of Periodontics, Fort Meade Dental 

Activity and is the Consultant to The Army Surgeon 

General for Periodontics. 
 January – March 2011 91

ABSTRACT

The case of a 19-year-old woman with benign 

cementoblastoma is described along with a brief 

review of the literature and clinopathology of the 

lesion. This lesion developed a more aggressive 

nature. A discussion of treatment and rationale is 

included. 

INTRODUCTION

Benign cementoblastoma is one of 4 World Health 

Organization recognized cemental neoplasms. The 

others include periapical cementosseous dysplasis, cementifying fibroma and gigantiform familial cementoma. Benign cementoblastoma is a slow-growing 

benign tumor arising from cementoblasts. The tumor is 

fused to the partly resorbed root(s) of the associated 

tooth. Radiographically, it appears as a dense 

radiopacity with a peripheral radiolucent border. The 

benign cementoblastoma is associated with mild pain 

and can produce jaw expansion as the tumor enlarges. 

Pynn describes the tumor histologically in his case 

report, “the lesion consists of broad trabeculae and 

sparsely cellular cementum. These merge with areas of 

cemental islands in a vascular stroma with prominent 

characteristic radiating columns of cementum running 

perpendicular to the surface of the lesion.”1

REVIEW OF THE LITERATURE

Although Norgberg states that this lesion was first 

recognized in 1930,2

 Bouquot reports that the lesion 

was described in 1839.3

 This tumor is unusual, with 

fewer than 100 cases reported and represents less than 

1% of odontogenic tumors. Ulmansky et al cite pain, 

expansion, and a radiopaque lesion with a radiopaque 

“halo” as the most characteristic features of the lesion.4

Eversole proposed that this tumor may reach 

maximum proportions before mineralization, and the 

classical radiographic appearance is secondary.5

 There 

is a predilection for females under the age of 25, with 

the mandible being by far the most common location. 

The tumor has been associated with multiple teeth, 

impacted molars, and deciduous teeth. Noteworthy is 

the observation that 90% of the cases involve the first 

molar/premolar area.1

 There have been reports of 

aggressive behavior,6,7 however, this is considered a 

benign lesion and does not require radical surgical 

treatment. The treatment of choice is complete 

removal by enucleation with extraction of the 

associated teeth.1

 Biggs and Benenati describe a more 

conservative approach performing an endodontic 

procedure on the involved tooth and surgically 

removing the tumor.8

CASE REPORT

A 19-year-old Guatemalan woman presented at a 

Chimaltenango volunteer dental clinic on February 1, 

2006, with a chief complaint of moderate pain in her 

left mandible of approximately 20 months duration. 

There had been no history of previous infection 

associated with the lesion. The patient stated that she 

had some type of growth in her left mandible and had 

undergone a “scraping” procedure in Guatemala City 

in 2005. Clinical examination revealed no facial 

swelling, and all vital signs within normal limits. 

Intraorally there was buccal and lingual expansion of 

the area of the left first mandibular molar and the left 

second mandibular bicuspid (Figure 1). The gingivae 

An Aggressive Benign Cementoblastoma 

COL (Ret) Richard E. Collins, DC, USAR 

Rafael Flores Asturias, DDS 

Figure 1. Buccal and lingual expansion of the area of the left 

first mandibular molar and second mandibular bicuspid. 
 January – March 2011 92

An Aggressive Benign Cementoblastoma 

had a red velvety appearance. There was no cellulitis 

or suppuration. There was no mandibular nerve 

dysthesia, and all teeth in the quadrant tested vital. 

Pain was noted when biting on teeth numbers 19 and 

20 or by applying moderate finger pressure to the 

expanded areas. The patient also stated that the 

discomfort had almost disappeared after the initial 

procedure, but that it was now returning and increasing 

in intensity at a noticeable pace. A panorex radiograph 

dated May 18, 2004, demonstrated a well-demarcated 

lesion, surrounded by a radiolucent halo at the apices 

of teeth numbers 19 and 20 (Figure 2). A panorex 

taken on February 1, 2006 (Figure 3), revealed a much 

larger and irregular radiopaque lesion with a more 

disorganized center and displacement of the inferior 

alveolar canal inferiorly, as well as bowing of the 

inferior border of the mandibular left side. Given the 

relatively rapid increase in size of the lesion in 18 

months, the patient was referred to an oral and 

maxillofacial surgeon in Guatemala City for evaluation 

and treatment. 

After evaluation by this specialist, a differential 

diagnosis was developed: 

Benign cementoblastoma 

Focal cementossseous dysplasia 

Cementofying fibroma 

The surgical plan was to remove teeth numbers 1, 16, 

17, 19, 20, and 32, and to enucleate the lesion transorally. The procedure was performed on September 

20, 2006, at an outpatient oral surgery center in 

Guatemala City under general anaesthesia. A 

crevicular incision from the midline with a buccal 

release was extended to the left proximally to No. 17 

area (Figure 4). As the mucoperiosteal flap was 

elevated, the mental nerve was noted, as well as buccal 

expansion of the cortical plate adjacent to teeth 

numbers 19 and 20 (Figures 5, 6). Teeth numbers 17, 

19, and 20 were then removed. The buccal plate 

adjacent to the lesion was removed. At this point, 

because of concern for possible fracture of the inferior 

border of the mandible below #19 when the tumor was 

removed, a 2.4 titanium reconstruction plate was 

placed at the inferior border transorally with 4 screws 

(Figure 7). The tumor was then enucleated. The lingual 

plate was noted to be partially absorbed. A 2.0 

titanium tension band plate was then placed with 7 

screws (Figure 8). 

The mandibular neurovascular bundle was within the 

lesion and was removed along with the tumor in the 

area of numbers 19 and 20. After removal of teeth 

numbers 1, 16, and 32, the defect was irrigated with 

saline and closed with 3-0 polyglactic suture. The 

patient tolerated the procedure well, and the specimens 

were submitted to pathology, which returned a report 

with a final diagnosis as benign cementoblastoma. 

After 3 weeks, she returned for a follow-up 

examination and panorex (Figure 9) without pain or 

swelling. She did, however, have anaesthesia in the 

distribution of the left mental nerve. On her follow-up 

exam on May 9, 2007, there was bony regeneration of 

the surgical defect and the oral tissues were within 

normal limits; paresthesia remained, but had 

diminished slightly over the intervening months. 

Figure 2. The panorex radiograph image of the lesion (note 

surrounding halo, lower right side) dated May 18, 2004. 

Figure 3. Panorex radiograph image dated February 1, 2006. 

Note the increased size of the lesion (image lower right side) 

in comparison with that shown in Figure 2. 
 January – March 2011 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

DISCUSSION

A case of benign cementoblastoma is presented. This 

lesion had a number of characteristics seen in this 

group of tumors. The patient’s age, sex, location, and 

initial radiographic presentation all were consistent 

with benign cementoblastoma. However, the behavior 

of the lesion, with rapid growth over 18 months after 

the “scraping” procedure, was a concern. Langdon7

reported a similar case and made the following 

observations: 

The lesion secondarily did not present with a 

classical radiographic appearance and did not 

grow slowly. 

Stimulus of the lesion produced rapid growth. 

His pathology report stated that the lesion “was 

not an inflammatory process”. ( No such wording 

was found in the pathology of this case). Given the 

facts that the patient was otherwise healthy and 

had never been pregnant, the question arises; what 

accounted for the rapid extension of the tumor? It 

is significant that she had some type of incomplete 

surgical “scraping” procedure the previous year. 

One can only speculate that it stimulated an 

acceleration of tumor growth. This activity would 

parallel tumor overgrowth in children with 

cherubism who are injudiciously subjected to 

premature reshaping procedures in the mandible. 

Figure 4. The crevicular incision to the left proximal to the area 

of tooth #17. 

Figure 5. The elevated mucoperiosteal flap reveals the mental 

nerve and the buccal expansion of the cortical plate next to 

teeth numbers 19 and 20. 

Figure 6. A closer view of the exposed mental nerve and 

buccal expansion of the cortical plate next to teeth numbers 

19 and 20. 

Figure 7. A 2.4 titanium reconstruction plate was placed 

transorally with 4 screws to protect the inferior border of the 

mandible before the tumor was removed. 
94 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

An Aggressive Benign Cementoblastoma 

In planning this case, the problem list included: 

 Postoperative morbidity to the mandibular 

neurovascular bundle due to the proximity of the 

tumor and/or plating screws. 

 Intra or postoperative mandible fracture from the 

tumor removal. 

 Necessity for autogenous bone graft reconstruction 

intra or postoperatively. 

 Transoral vs. percutaneous surgical approach. 

 Loss of vitality to the teeth adjacent to the lesion 

(numbers 18 and 21). 

 Reoccurrence of the lesion. 

Judicious presurgical planning paid dividends in the 

outcome of this case. 

 The procedure was performed transorally. 

 The involved teeth as well as 4 impacted third 

molars were removed. 

 A reconstruction plate was placed at the inferior 

border transorally to obviate an intraoperative 

fracture. 

 The mandibular neurovascular bundle was removed 

along with the tumor. 

 Due to the patient’s age and mandibular 

vascularity, no reconstruction was necessary as the 

defect filled by osteoneogensis. 

The patient will be followed at yearly intervals. Teeth 

numbers 19 and 20 will be replaced with a prosthesis. 

ACKNOWLEDGEMENT

The authors thank COL (Ret) James V. Johnson (DC, 

USAR), who was instrumental in helping to raise funds 

and obtain oral surgery hardware, and for his review of 

this manuscript. We also thank MAJ Chris Collins, MC, 

USA, for his assistance in assembly, organization, and 

review of the pictures, slides, pathology reports, etc.

REFERENCES

1. Pynn BR, Sands TD, Bradley G. Benign 

cementoblastoma: a case report. J Can Dent Assoc. 

2001;67(5):260-262. 

2. Norberg O. Zur Kenntnis der dysontogenetischen 

Geschwultste der Kieferknochen. Wschr Zahnheilkd. 

1930;46:321-355. 

3. Bouquot JE, Lense EC. The beginning of oral 

pathology: part 1: first dental journal reports of 

odontogenic tumors and cysts, 1839-1860. Oral Surg

Oral Med Oral Pathol. 1994;78:343-350. 

4. Umansky M, Hjorting-Hansen E, Praetorius F, 

Hacque MF. Benign cementoma: a review and five 

new cases. Oral Surg Oral Med Oral Pathol. 

1994;77:48-55. 

5. Eversole LR, Sabes WR, Dauchess VG. Benign 

cementoblastoma. Oral Surg Oral Med Oral Pathol. 

1973;36:824-829. 

AUTHORS

COL (Ret) Collins is the former (retired) Endodontic 

Coordinator in the Managed Health Care Division of the 

University of Texas Medical Branch at Galveston. 

Dr Flores is an oral and maxillofacial surgeon practicing 

in Guatemala City, Guatemala. 

Figure 8. A 2.0 titanium tension band plate was placed with 7 

screws after the tumor was enucleated. 

Figure 9. The panorex radiograph image 3 weeks postsurgery. 
 January – March 2011 95

ABSTRACT

This clinical report describes the multidiscipline 

treatment for a 19-year-old service member who entered 

the military diagnosed with dentinogenesis imperfecta. 

The patient presented with multiple teeth with extensive 

dental caries, considerable sensitivity, and an inability to 

function due to the extent of the dental disease. The goal 

of the treatment was to restore function and aesthetics. A 

combined treatment approach was initiated which 

involved prosthodontics, periodontics, and dental implant 

therapies. Functional and aesthetic results were achieved. 

OVERVIEW: DENTINOGENESIS IMPERFECTA

Dentinogenesis imperfecta (DGI) is defined as an 

autosomal dominant disorder in dentin mineralization in 

both the primary and permanent dentitions.1 DGI is the 

most common of all dental genetic diseases affecting 

some 1:8000 births.2

 Dentinogenesis Imperfecta can be 

grouped into 3 clinical entities, Shields Type I, II, and III. 

There are several known subtypes and all share a 

common clinical appearance.3

Common characteristics include uniform yellow to blue 

crowns with enamel that easily fractures due to the poor 

dentin support. The crowns are usually bulbous or bell 

shaped with short roots and pulp chambers, which 

presents narrowed by an excessive production of the 

defective mineralized dentin matrix.4

 The defective 

dentin, shown in Figure 1, has a yellow translucent hue 

and takes on a characteristic gray to brownish-blue 

discoloration that has prompted the term hereditary 

opalescent dentin.5

In Dentinogenesis Imperfecta Type I, the dentin 

mineralization defects are coupled with Osteogenic 

Imperfecta related bone diseases characterized by a 

systemic condition involving bone fragility, blue sclera of 

the eyes, joint laxity, and hearing impairment. It is cause 

by a defect in collage formation. DGI-II (hereditary 

opalescent dentin) has the same dentin defects as DGI-I 

but has not been found to be related to any collagen 

defect and has no osteogenic component. DGI-III, also 

known as Brandywine type, is a complex heterogeneous 

disorder, which occurs in an isolated racial group. Both 

collagen and mineralization are affected and the teeth 

appear opalescent as in DGI types I and II but have a 

shell-like appearance. It was initially described in a 

triracial, isolated population in Brandywine, Maryland.6,7

Diagnosis is based on a thorough family history, pedigree 

construction, and detailed clinical examination. 

Differential diagnosis may include hypocalcified form of 

amelogenesis imperfecta, congenital erythropoietic 

porphyria, Kostmann’s condition (conditions leading to 

early tooth loss), cyclic neutropenia, Chediak-Hegashi 

syndrome, histiocytosis X, Papillon–Lefevre syndrome, 

tetracycline discoloration and staining of the teeth, 

vitamin D-dependent and vitamin D-rickets.8 

CLINICAL REPORT

A 19-year-old service member presented for routine 

dental treatment with a chief complaint/concern of pain, 

sensitivity, difficulty chewing, and overall displeasure 

with the appearance of her teeth. A review of the 

patient’s health questionnaire revealed a medical history 

that was significant for a smoking habit and multiple 

family members with the same dental presentation. 

Extraoral examination revealed slight tenderness when 

palpating the masseter and temporalis muscles. 

Tenderness was thought to be related to poor occlusion. 

Intraoral examination revealed yellowish to blue-gray 

appearance of the anterior dentition and extensive dental 

caries associated with most maxillary and mandibular 

Dental Rehabilitation of a Patient with 

 Dentinogensis Imperfecta: A Clinical Report 

COL David A. Mott, DC, USA 

LTC (P) Minaxi I. Patel, DC, USA 

LTC Dong Soo Park, DC, USA 

Figure 1. Pretreatment anterior view of 19 year-old service 

member with yellowish gray crowns, defective enamel and 

dentin, midline discrepancy and aesthetic disharmonies. 
96 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

posterior teeth. The patient stated that many teeth would break 

easily with normal function (Figure 2). The prosthodontic 

evaluation revealed a dental midline discrepancy, short clinical 

crowns complicated with extensive dental caries, malalignment 

of the anterior teeth, and occlusal and aesthetic disharmonies. 

Photographs, radiographs, and dental casts were completed. A 

comprehensive periodontal review confirmed gingival tissues 

as firm and fibrotic, generalized 2 mm to 3 mm periodontal 

probe depths, moderate to heavy plaque with slight calculus 

accumulation, extensive caries, and bilateral mandibular 

lingual tori (Figure 3). The patient was referred to the oral 

pathologist and the diagnosis of dentinogenesis imperfecta was 

confirmed. 

Complete rehabilitation of the dentition was based on the 

patient’s desires, clinical findings, radiographic evaluation, and 

periodontal health. The treatment plan involved extraction of 

all hopeless teeth with extensive dental caries (numbers 3, 4, 5, 

12, 13, 14, 18, and 19) and fabricating an interim removable 

partial denture. The fabrication and placement of the interim 

removable partial denture and provisional crowns appeared to 

resolve the facial muscle tenderness and reestablished occlusal 

support. Following the healing process and the reevaluation 

phase, the patient was treatment planned to have dental 

implants placed for teeth numbers 3, 4, 5, 12, 13, 14, and 19 

(4.011.5 and 5.011.5; 3i-Implant Innovations Inc, Palm 

Beach Garden, FL). After adequate healing and implant 

integration, implants supported metal ceramic crowns were 

fabricated. Metal ceramic crowns were also fabricated for the 

remaining maxillary and mandibular teeth (numbers 6, 7, 8, 9, 

10, 11, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29) (Figures 4 and 5). 

The combined treatment plan with the prosthodontist and 

periodontist provided for the complete rehabilitation with full 

function and aesthetics. All aspects of the patient’s concerns 

Dental Rehabilitation of a Patient with Dentinogensis Imperfecta: A Clinical Report 

Figure 2. Pretreatment maxillary occlusal view revealing extensive dental caries and destruction of enamel and dentin. 

Figure 3. Pretreatment mandibular occlusal view revealing 

extensive dental caries. 

Figure 4. Maxillary occlusal view showing full coverage with 

porcelain fused to metal crowns on remaining maxillary teeth 

and implant abutments to replace premolars and molars. 

Figure 5. Mandibular oclusal view showing full coverage 

crowns on anterior teeth and implant abutments to replace 

molar. 
 January – March 2011 97

THE ARMY MEDICAL DEPARTMENT JOURNAL

were addressed with complete resolution of the patient’s 

chief concern. The prosthodontic phases of treatment included preparation and provisionalization of all remaining teeth. All restorations were characterized, glazed, 

polished, and then luted with permanent cement (Figures 

6, 7, 8). Home care instructions were provided and the 

patient was scheduled for periodic maintenance care. 

REFERENCES

1. Witkop C. Hereditary defects of dentin. Dent Clin 

North Am. 1975;19:25-45. 

2. Neville BW, Damm DD, Allen CM, Bouquot JE. 

Oral and Maxillofacial Pathology. Philadelphia, 

Pennsylvania: W.B. Saunders Company; 1995:84-87. 

3. Shields ED, Bixler D, El-Kafrawy AM. A proposed 

classification for heritable human dentine defects 

with a description of a new entity. Arch Oral Biol. 

1973;18:543-553. 

4. Regezi JA, Sciubba J. Oral Pathology, Clinical 

Pathologic Correlations. 2nd ed. Philadelphia, Pennsylvania: W.B. Saunders Company; 1993:509-510. 

5. Regezi JA, Sciubba JJ. Pogrel MA. Atlas of Oral and 

Maxillofacial Pathology. Philadelphia, Pennsylvania: 

W.B. Saunders Company; 2000:152. 

6. Langlais, RP, Miller CS. Color Atlas of Common 

Oral Diseases. 2nd ed. Baltimore, Maryland: 

Williams & Wilkins; 1998:32. 

7. Hursey RJ Jr, Witkop CJ, Miklashek D, Sackett LM. 

Dentinogenesis imperfecta in a racial isolate with 

multiple hereditary defects. Oral Surg Oral Med Oral 

Pathol. 1956;9:641-658. 

9. Barron MJ, McDonnell ST, Mackie I, Dixon MJ. 

Hereditary dentine disorders: dentinogenesis 

imperfect and dentine dysplasia. Orphanet Journal of 

Rare Diseases [serial online]. November 20, 

2008;doc 3:31. 

AUTHORS

COL Mott is Commander, US Army Dental Activity –

Japan, Camp Zama. 

LTC (P) Patel is Chief, Prosthodontics Services, US 

Army Dental Activity, Fort Stewart, Georgia. 

LTC Park is Officer-in-Charge and Chief, Periodontics 

Services, US Army Carius Dental Clinic, Seoul, South 

Korea. 

Figure 6. Post treatment maxillary occlusal view showing 

porcelain fused to metal completed restorations of the dental 

implants, teeth numbers 3, 4, 5, 12, 13, 14. 

Figure 7. Post treatment mandibular occlusal view 

showing porcelain fused to metal completed restoration 

of the tooth #19 dental implant. 

Figure 8. Post treatment anterior occluded view. 
98 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

The ameloblastoma is the most commonly found 

odontogenic neoplasm.1-3 It is considered a benign 

neoplasm with aggressive tendencies. While it rarely 

metastasizes, it can recur with treatment other than 

resection and sometimes even with resection.3,4

Presented is a case of a US Soldier from initial diagnosis, to resection, bone grafting, and reconstruction 

with dental implants and a fixed dental prosthesis. 

REPORT OF THE CASE

A 28-year-old female Soldier presented to the 

Landstuhl Oral and Maxillofacial clinic after 

redeployment from Iraq for left mandibular swelling in 

July 2005. The patient presented with a chief 

complaint of “pressure when biting.” Physical exam 

was significant for slight mobility of the left second 

premolar and buccal expansion of the mandible in the 

same region. A panoramic radiograph showed a well 

defined, corticated, multilocular radiolucent lesion in 

the region of the left premolar-molar region. The 

patient’s medical history was significant for exercise 

induced asthma and a penicillin allergy. Under local 

anesthesia, a biopsy of the cortical bone and soft tissue 

was taken and submitted to the oral pathologist. 

Microscopically, the specimen consisted of variably 

dense fibrocollagenous tissue with numerous islands of 

odontogenic epithelium that exhibited central cystic 

changes. The basal epithelium was composed of columnar cells with hyperchromatic nuclei. The nuclei of 

the columnar cells were polarized away from the surrounding connective tissue. The lesion was diagnosed 

as a solid ameloblastoma, follicular variant (Figure 1). 

The patient was redeployed from Iraq to her home 

station of Fort Bragg, North Carolina. The patient was 

then treatment-planned for en bloc resection. On August 30, 2005, she underwent a 5 cm left mandibular 

resection as well as removal of the left lateral incisor, 

canine, premolars and molars (Figure 2). A WalterLorenz 2.4 mm reconstruction plate, which was prebent using a stereolithic model, was placed to prevent 

a continuity defect (Figure 3). 

In January 2006, the patient returned to the operating 

room for a left anterior superior iliac crest graft to the 

left mandible as well as placement of a cadavaric 

mandibular crib. 

Postoperative healing was unremarkable until March 

2006 when the patient noted increased pain and 

drainage in the left submandibular region. A 2 mm 

fistula was noted in that area. An incision and drainage 

was completed with some improvement of patient’s 

symptoms per the patient. Due to continuation of 

symptoms postoperatively, the patient was taken back 

to the main operating room where the cadavaric crib 

was removed. The patient’s symptoms again 

improved. The patient returned to the operating room 

in October 2006 for implant placement. She was 

treatment planned for placement of 4 implants (3i Full 

Osseotite Certain, Biomet Inc, Warsaw, IN) in the 

Solid Ameloblastoma, Resection to 

 Reconstruction: A Case Report 

MAJ Michael J. Ryhn, DC, USA 

COL Jeffrey S. Almony, DC, USA 

COL Albert M. Manganaro, DC, USA 

Figure 1 Photomicrograph of the tumor showing islands of 

odontogenic epithelium (Hemotoxylin and Eosin staining, 

original magnification ×100). 
 January – March 2011 99

reconstructed mandible. A surgical guide was 

fabricated with the prosthodontist and used to ensure 

proper implant placement and angulation. Intraoperatively, the implant planned for the left first premolar 

engaged the reconstruction plate and was not placed. 

The other implants were placed without incident in the 

molar, premolar, and canine positions. The implant 

sites were augmented with a cadavaric bone graft 

(Puros, Zimmer Dental Inc, Carlsbad, CA). The implants osseo-integrated for 5 months and were 

uncovered in June 2007. In July 2007, the prosthodontist restored the patient’s dentition with a 5 unit fixed 

dental prosthesis. In October 2007, the patient returned 

to the oral and maxillofacial clinic for follow-up and 

was found to have a draining fistula in the left submandibular region. Under intravenous sedation, a fistulectomy was performed. The patient noted tremendous 

relief from the previous symptoms. Follow-up in 

January 2008 showed the patient with no complaints, 

functioning well with the dental prosthesis and 

radiographs showed no recurrence of tumor (Figure 4). 

The patient was counseled on the need for annual 

radiographs to ensure no recurrence of the tumor. 

DISCUSSION

The ameloblastoma is an epithelial odontogenic tumor 

that has an unknown origin.1-4 It may possibly arise 

from the enamel organ, the lining of an odontogenic 

cyst or possibly from the oral mucosal basal cells. The 

3 broad subtypes of ameloblastoma are the solid or 

multicystic, unicystic, and the peripheral. The 

multicystic or solid group is the most commonly 

encountered ameloblastoma and is subdivided into 6 

histological subtypes: follicular, plexiform, acanthomatous, granular cell, desmoplastic and basal cell 

types.1,2 The histopathologic subclassification does not affect treatment. The 

less common unicystic group is subdivided into the luminal, intraluminal, 

and mural ameloblastoma.1

 In the mural 

unicystic ameloblastoma there is 

microinvasion of the underlying 

connective tissue with the majority of the 

lesion being confined to the cystic 

lumen. The peripheral ameloblastoma is 

also encountered less frequently then the 

multicystic or solid variant.2,5 The 

peripheral ameloblastoma is typically 

found in the posterior gingival or the 

Figure 2 Radiograph of resected mandible – 5 cm showing 

lesion between premolar and molar. 

Figure 3. Stereolithic model of patient’s mandible (left) which 

was used to custom-fit the Walter-Lorenz 2.4 mm reconstruction plate (right). 

Figure 4. Panoramic radiograph of restored mandible. 
100 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

alveolar mucosa. The peripheral ameloblastoma is 

confined to the soft tissue and is the easiest to manage 

surgically. 

The current recommendation for the treatment of the 

multicystic or solid variant is resection with 1 to 1.5 

cm boney margins, and one anatomical boundary.1

Frozen section are indicated when cortical perforation 

is present. Research has shown that recurrence is 

possible, either by incomplete removal of tumor cells, 

seeding of the cells by rotary instrumentation, or poor 

treatment planning. One complicating factor with recurrence is it has been found to occur between one and 

23 years after surgery.3,6 Bearing this in mind, longterm, close follow-up is critical for patients that have 

been treated for ameloblastoma, owing to its slow 

growth and aggressive nature. The differential diagnosis for a multilocular, radiolucent lesion in the body of 

the mandible is ameloblastoma, keratocystic odontogenic tumor (parakeratinizing odontogenic keratocyst), 

odontogenic myxoma or central giant cell lesion.1,2,7 

REFERENCES

1. Marx RE, Stern D, eds. Oral and Maxillofacial 

Pathology: A Rationale for Diagnosis and Treatment. 

Carol Stream, IL: Quintessence Publishing; 2003. 

2. Neville BW, Damm DD, Allen CM, Bouqout J. Oral 

and Maxillofacial Pathology. 3rd ed. St Louis, MO: 

Saunders Elsevier; 2009. 

3. Carlson ER, Marx RE. The ameloblastoma: Primary, 

curative surgical management. J Oral Maxillofac 

Surg. 2006;64:484-494. 

4. Ferretti C, Polakow R, Coleman H. Recurrent 

ameloblastoma: report of 2 cases. J Oral Maxillofac 

Surg. 2000;58:800-804. 

5. El-Hakim IE, El-Khashab MM. Peripheral and mural 

ameloblastoma in the mandibular canine region of a 

13-year-old boy. J Oral Maxillofac Surg. 

2000;58:1150-1154. 

6. Arotiba GT, Ladeinde AL, Arotiba JT, Ajike SO, 

Ugboko VI, Ajayi OF.Ameloblastoma in Nigerian 

children and adolescents: a review of 79 cases. J Oral 

Maxillofac Surg. 2005;63:747-751. 

7. Lilly GE. Differential diagnosis of lesions of the 

jawbones. J Oral Sur. 1970;28:65-69. 

AUTHORS

MAJ Ryhn is the Assistant Program Director, Oral and 

Maxillofacial Surgery Residency, Womack Army 

Medical Center, Fort Bragg, North Carolina. 

COL Almony is the Program Director and Chairman, 

Oral and Maxillofacial Surgery Residency, Womack 

Army Medical Center, Fort Bragg, North Carolina. 

COL Manganaro is the Chief Oral Pathologist, 

Womack Army Medical Center, Fort Bragg, North 

Carolina. 

Solid Ameloblastoma, Resection to Reconstruction: A Case Report 

Insignia of the Womack Army Medical 

Center, Fort Bragg, North Carolina. 
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