January – March 2006 

Perspective 1

MG George W. Weightman 

Chief, US Army Dental Corps 3

MG Joseph G. Webb, Jr 

Army Dental Service Support in a Theater of Operations 5

COL Timothy K. Jones, DC, USA

Patient Satisfaction in US Army Dental Treatment Facilities 10

LTC Jeffrey G. Chaffin, DC, USA, et al 

The Expanded Function Dental Assistant Training Program 16

COL W. John Luciano, DC, USA, et al 

US Army Dental Command “Puts More ‘Bite’ Into Health Promotion” 21

Pamila Richter, RDH, et al 

Army Reserve Components Dental Readiness — A Historical Review2 7

Since the First Gulf War 

COL Mark B. Bodenheim, DC, USAR 

Evolving Education Trends in Graduate Dental Education 31

COL Ann Sue von Gonten, DC, USA, COL Kay H. Malone, DC, USA 

Investigation Into Use of Digital Imaging Fiber-Optic Trans-Illumination3 5

(DIFOTI®) in Caries Detection 

MAJ Jerry Carbone, DC, USA, et al 

Prosthodontic Rehabilitation of a Patient with Amelogenesis Imperfecta:4 1

A Clinical Report

LTC Minaxi I. Patel, DC, USA, et al 

Provisional Restorations: An Overview of Techniques and Materials 45

CPT Matthew S. Thunberg, DC, USA, COL James K. Schmitt, DC, USA 

Implant Site Preparation With Distraction Osteogenesis 51

LTC (Ret) Philip J. Pandolfi, DC, USA, LTC G. Morris Gibson, DC, USA 

Xylitol Chewing Gum: A Recommended Addition to the MRE Package 56

LTC Albert E. Scott Jr, DC, USA 

A Policy Perspective for Army Dentists Performing Posterior Restorations 59

LTC M. Nicholas Coppola, MS, USA, et al 

UNITED STATES 

ARMY 

DENTAL CORPS 
LTG Kevin C. Kiley

The Army Surgeon General

Commander, US Army Medical Command

MG George W. Weightman

Commanding General

US Army Medical Department Center and School

January – March 2006 The Army Medical Department Center & School PB 8-06-1/2/3

0601004

PETER J. SCHOOMAKER

General, United States Army

Chief of Staff

DISTRIBUTION: Special

Administrative Assistant to the

Secretary of the Army

By Order of the Secretary of the Army:

Official:

JOYCE E. MORROW

Online issues of the AMEDD Journal are available at https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

A Professional Publication

of the AMEDD Community

The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for

The Surgeon General by the US Army Medical Department Center & School, ATTN:

MCCS-DT, 2423 FSH-Hood ST, Fort Sam Houston, TX 78234-5078.

CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive

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PB 8-06-1/2/3 Jan/Feb/Mar 1

Welcome to the latest edition of our AMEDD Journal. 

I’m convinced that you will find this issue to be 

unique, interesting, and professionally stimulating. 

This quarter’s issue is devoted to the Army Dental 

Corps and we have selected a broad spectrum of 

articles to demonstrate the breadth and depth of this 

great Corps. MG Joseph Webb, the Dental Corps Chief 

and Deputy Surgeon General, starts us off with a 

history of the Dental Corps. You may be surprised to 

learn that it was formally established (by law) in 1911. 

He gives us a very interesting overview of the Corps 

with a description of its many areas of therapeutics, 

research, and graduate dental education programs. He 

also provides insightful comments on three new 

initiatives: the Oral Health Initiative, Digital 

Radiography, and the Expanded Function Dental 

Assistant programs. 

COL Tim Jones follows with a great overview of 

Operational Dentistry in his article titled “Army 

Dental Service Support in a Theatre of Operations.” 

Many of you will be surprised to realize that 

historically 20% to 25% of all Soldiers experience 

dental emergencies within a year while deployed. COL 

Jones concludes that military dentistry clearly must 

accompany the Warfighter and is an integral part in 

maintaining Soldier readiness. 

LTC Chaffin reassures us of the top notch quality of 

dental care in the Army with his “Patient Satisfaction 

in US Army Dental Treatment Facilities.” He provides 

documentation of excellent care that is being provided 

from a patient’s perspective and also identifies future 

areas of study. COL John Luciano, tells us of the 

history and status of “The Expanded Function Dental 

Assistant Training Program” and stresses the great 

return on investment and increased access to care that 

this program has delivered to the AMEDD. 

“US Army Dental Command ‘Puts More “Bite” Into 

Health Promotion’” provides us the why and how of 

putting Health Promotion Programs into dental 

practice. Pamila Richter explains the partnership 

between the Dental Command and the Army Center 

for Health Promotion and Preventive Medicine that 

has been very proactive in delivering state of the art 

health education to our beneficiaries. COL Mark 

Bodenheim in “Army Reserve Components Dental 

Readiness — A Historical Review Since the First Gulf 

War” gives us the unvarnished truth about the poor 

state of reserve dental readiness prior to the Global 

War on Terror and documents the recent 

improvements. He outlines some of the remaining 

challenges to getting dental readiness parity between 

the Active and Reserve Components. 

In “Evolving Education Trends in Graduate Dental 

Education” COL Ann von Gonten describes GDE 

from entry programs all the way through the many 

dental fellowships. She gives great advice on the 

service obligations incurred for training and details the 

selection process. MAJ Jerry Carbone describes a new 

and potentially better method for detecting caries 

compared to the traditional bitewings in his article 

entitled “Investigation Into Use of Digital Fiberoptic 

Trans-Illumination (DIFOTI) in Caries Detection.” 

Perspective 

Major General George W. Weightman 
2 Army Medical Department Journal 

If you’re looking for pictures as proof of the miracles 

our dentists are doing in reconstruction you’ll enjoy 

LTC Minaxi Patel’s “Prosthodontic Rehabilitation of a 

Patient with Amelogenesis Impecta: A Clinical 

Report.” This is an easy read about a rare dental 

condition and the spectacular results achieved through 

aggressive reconstruction. CPT Matthew Thunberg 

gives us some good insights into Dentistry 101 with his 

“Provisional Restorations: An Overview of Techniques 

and Materials,” describing three of the most common 

types of materials used and the techniques for using 

them. 

If you’re not familiar with the term ”Distraction 

Osteogenesis” then you need to read “Implant Site 

Preparation with Distraction Osteogenesis” by LTC 

(Ret) Philip Pandolfi in which he describes a new 

technique to manage reconstruction of defects of the 

alveolar ridge. For those of you with (or contemplating 

having) posterior restorations you’ll enjoy LTC 

Nicholas Coppola’s “A Policy Perspective for Army 

Dentists Performing Posterior Restorations.” Dr. 

Coppola gives us the pros and cons of different 

restoration material and notes the differences between 

civilian and military dental practice. A great read. 

This is a fantastic edition and I want to take the 

opportunity to thank all of our great Army Dentists for 

what they do every day to help maintain the readiness 

of the fighting force. They are pillars of our AMEDD 

team and clearly set a high standard for the rest of the 

Corps to emulate. 

WARRIOR MEDICS! 
PB 8-06-1/2/3 Jan/Feb/Mar 3

Major General Joseph G. Webb, Jr

MG Webb is Chief, US Army Dental Corps 

and Deputy Surgeon General 

As the Chief, Dental Corps (DC), I am truly excited to 

have this special opportunity to contribute a series of 

articles which showcase our great Soldiers, civilians, 

leaders, and clinicians, all of whom represent the 

Army Dental Care System (ADCS). I believe the 

common thread throughout the Army Medical 

Department (AMEDD) is the integration of all the 

Corps (to include the support services) and their 

synergistic relationships. These relationships produce a 

synchronized system of effective and efficient health 

care delivered in support of Soldiers and their 

commanders. The AMEDD Journal is one of many 

superb partners within the AMEDD and we are 

appreciative of this opportunity. 

From 1775–1901, dental service to Soldiers was 

provided by hospital stewards (enlisted medics) who 

by special interest or special training, limited their 

activities to providing dental care in conjunction with 

medical officers. In 1901, the Army authorized 30 

contract dentists for an Army-wide program of dental 

care. Ten years later, the contract positions were 

converted to commissioned officer positions. The 

Army Dental Corps was officially established on 

3 March 1911. 

During the past 36 months, the Army’s operational 

tempo has been tremendous and demanded a renewed 

focus for our personnel and the dental service we 

provide to Soldiers at home station and deployed in 

support of the Global War on Terrorism. The ADCS 

treats over 7,200 patients each day in 173 dental 

clinics, and is represented by 29 Dental Activities 

(DENTACs) and 6 Regional Dental Commands, all of 

which are supported by a single Army Dental 

Laboratory. 

The ADCS professional staff, including our dentists 

assigned to combat units, consists of 933 dentists, 24 

Medical Service Corps officers, 1,115 

noncommissioned officers and enlisted Soldiers, 1,788 

civilians, and 708 contracted employees. Dental 

Officers serve in the following Areas of 

Concentration: General Dentist (63A), Comprehensive 

Dentist (63B), Periodontist (63D), Endodontist (63E), 

Prosthodontist (63F), Public Health Dentist (63H), 

Pediatric Dentist (63K), Orthodontist (63M), Oral and 

Maxillofacial Surgeon (63N), Oral and Maxillofacial 

Pathologist (63P), and Executive Dentist (63R). 

The ADCS is not limited to clinical care; it is a multifaceted organization supporting the Army, training 

dentists, and advancing the science of dentistry. We 

train combat-ready dental technicians from the Dental 

Science Division. Through Graduate Dental Education 

and residency training programs, we provide clinicians 

ready to treat patients in any environment. Our Dental 

and Trauma Research Detachment and Combat 

Development Directorate ensure that our materiel and 

force structure are ready to support the Soldier 

wherever the requirement exists. 

The Dental Command (DENCOM) is the operational 

element responsible for providing dental care and is 

currently implementing the following initiatives to 

increase readiness, improve access to care, and, 

ultimately, support Soldiers and their commanders: 
4 Army Medical Department Journal 

 First Term Dental Readiness (FTDR). FTDR 

ensures that newly assessed Soldiers receive dental 

care to ensure their deployability upon graduation 

from Advanced Individual Training, One Site Unit 

Training, or the Basic Officer Leader Course. 

 Oral Health Initiative (OHI). The OHI is a TriService effort designed to provide routine dental 

care with the express goal of completing all dental 

treatment for Soldiers. The OHI uses allocated 

funds to refer service members to the private 

sector for some routine dental care, thereby 

increasing the dental wellness of the served 

population. All three services are in the first year 

of this initiative. Twelve selected Army 

DENTACs have established private sector care 

networks to reduce the backlog of dental needs. 

 Digital Radiography. The Digital Enterprise 

Viewing and Acquisition Application (DEVAA) 

software was developed by DENCOM. DEVAA 

supplements existing hardware for image 

acquisition, manipulation and diagnostic viewing. 

The image management enhancement allows all 

Army dental digital radiographs acquired in Army 

dental clinics to be transported and stored in a 

central image archive. DEVAA software has been 

deployed to over 80 of the Army’s 173 dental 

clinics worldwide. Army dental clinics will be 

100% digitized within the next 12 months. 

 Expanded Function Dental Assistant (EFDA). The 

EFDA program is based on labor-substitution 

principles using highly trained dental assistants to 

increase the output of general dentistry teams. 

Personnel from the EFDA program are completely 

embedded in both FTDR and Dental Care 

Optimization (DCO). DCO is a key initiative 

aimed at increasing access to care by using the 

best clinical practices. EFDAs are also used 

extensively to expedite the surge requirements for 

dental care generated by mobilizations. 

The Department of Defense and Army environment 

we now face includes challenges of Base Realignment 

and Closure, Army Modular Force, Quadrennial 

Defense Review, Integrated Global Presence and 

Basing Strategy, and the military-to-civilian 

conversion. Internal to Army Medicine, volatility is 

increased by constrained resourcing, increased use of 

private sector dental care, recruitment and retention 

challenges, and a possible transition to the 

development of a Joint Medical Command. From my 

recent conversations with our retired Dental Corps 

General Officers, I am amazed at the similarity of the 

challenges and issues they faced. 

The history of US Army Dentistry provides a constant 

reminder that the personnel of the ADCS are our most 

valuable asset. I am very proud to be a part of a great 

team, doing tremendous work each day. I am confident 

we will respond with a renewed vigor to work through 

the challenges. Together we will reshape the future 

and remain an integral partner within the AMEDD. 
PB 8-06-1/2/3 Jan/Feb/Mar 5

Army Dental Service Support in a 

Theater of Operations 

COL Timothy K. Jones, DC, USA

Warfighters are the centerpiece of the US Army and 

are the ultimate weapons system. Their health and 

fitness, including dental health, is the basic guarantor 

of military success. The further into a deployment, the 

greater the decrease in opportunities and resources to 

enhance and maintain Soldier health and effectiveness. 

This makes the emphasis upon preventive medical 

steps employed both before departure and during a 

contingency deployment even more important. Dental 

care is an integral part of overall Force Health 

Protection and shares in the Army Medical Department 

mission to conserve the fighting strength. 

IMPORTANCE OF FIELD DENTISTRY

Historically, 20% to 25% of all Soldiers will 

experience a dental emergency during a 1-year 

deployment. The largest number of Soldier complaints 

in 1943 involved lack of adequate dental support.1

 In 

the Korean War there were 133,720 dental visits that 

resulted in 493,441 dental procedures.2

 The average 

time a unit loses a Soldier with a dental emergency 

which requires evacuation to the rear is 5 days.3

Liewehr4

 calculates that this fact leads to a potential 

loss to a division of 18,000 man-days during a 1-year 

deployment. Payne and Posey5

 found a peacetime field 

dental emergency rate at Fort Irwin and Fort Drum to 

be 21% of the total medical sick call in field exercises 

involving 24,500 Soldiers. They further determined 

that the dental emergency rate was 167 per one 

thousand troops in one year. The result was an annual 

lost duty time of 121.5 days per thousand Soldiers. 

Ludwick et al6

 found a dental emergency rate of 200 

dental emergencies per 1,000 deployed personnel per 

year in Navy and Marine personnel in Vietnam. Nasser 

and Storz7

 found that 14% of medical sick call 

reporting to the 12th Evacuation Hospital during 

Operation Desert Storm were dental emergencies. The 

actual percentage of dental emergencies was higher 

because many Soldiers experiencing dental 

emergencies reported directly to field dental clinics 

and bypassed the hospital. Grover et al8

 found an even 

higher dental emergency rate among Army recruits — 

260 per 1,000 Soldiers every 6 months which extends 

to a rate of 520 dental emergencies per 1,000 Soldiers 

per year. Swan and Karpetz9

 found a dental emergency 

rate of Canadian military personnel in Somalia in 1993 

to be 232 dental emergencies per 1,000 troops per 

year. Lost time due to dental emergencies can have a 

tremendous impact on unit readiness. These historical 

cases illustrate the necessity that military dentistry 

must accompany warfighters whenever and wherever 

they deploy. 

DENTAL CARE IN THEATER* 

The type of dental care provided to deployed Soldiers 

is called operational care, which is composed of 

“essential” dental care (to prevent a Soldier from 

becoming a casualty) and “emergency” dental care. 

Relief of oral pain, elimination of acute infection, 

control of life-threatening oral conditions (hemorrhage, 

cellulitis, or respiratory difficulty) and treatment of 

trauma to teeth, jaws, and associated facial structures 

are considered emergency care. It is the most austere 

type of care and is available to Soldiers engaged in 

tactical operations. Common examples of emergency 

treatments are simple extractions, antibiotics, pain 

medication, and temporary fillings. Essential care

includes dental treatment necessary to intercept 

potential emergencies. This type of operational care is 

necessary for prevention of lost duty time and 

preservation of fighting strength. 

TYPES OF DENTAL SUPPORT

There are three levels of dental support in a Theater of 

Operations; unit, hospital, and area. These levels are 

defined primarily by the relationship of the dental 

assets attached to the Combat Health Support 

supporting the patient population within each level: 

*Note: The doctrine of dental operations discussed in this paper is based upon Department of the Army FM 4-02.19, 

Dental Service Support in a Theater of Operations.
6 Army Medical Department Journal 

Unit — Support provided by a dental team organic to 

divisional and brigade medical companies and all 

Special Forces Groups. The dental team provides 

operational dental treatment to Soldiers during tactical 

operations. The dental team is composed of one 

general dentist (comprehensive dentist and dental 

assistant in the division main medical company) and 

dental assistant and their field equipment. 

Hospital — Support provided by the hospital dental 

staff to minimize loss of life and disability resulting 

from oral and maxillofacial injuries and wounds. The 

hospital dental staff provides dental support to all 

injured or wounded Soldiers as well as the hospital 

staff. Each Combat Support Hospital has one oral and 

maxillofacial surgeon, one comprehensive dentist, one 

expanded function dental assistant, and one dental 

assistant. The oral and maxillofacial surgeon uses 

other hospital support personnel (such as operating 

room assistants) when required. 

Area Dental Support — Support provided on an area 

support basis by dental companies and dental 

personnel in area support medical companies. These 

dental companies also provide operational care. The 

dental companies are comprised of modular dental 

teams that are capable of operating separate dental 

treatment facilities, or by consolidating units and 

operating one or more large facility, depending upon 

the particular operation. Other teams may be employed 

to provide far forward operational dental care. Older 

type dental companies (medical company, dental 

support) have one prosthodontist in addition to 14 

general dentists. Newer type dental companies (dental 

company, area support) have one prosthodontist, one 

periodontist, and one endodontist in addition to the 24 

general dentists. Both the old and new type dental 

companies have far forward teams (one dentist and one 

dental assistant with their dental equipment) that can 

deploy wherever needed. The older type dental 

companies are being phased out as the newer type 

dental companies are activated. Area dental support 

may also be provided by the one general dentist and 

one dental assistant assigned to each area support 

medical company. 

DENTAL STAFF OFFICER POSITIONS

The senior dental officer position in a specific regional 

combatant command is known as Army Dental 

Surgeon and Chief, Dental Services in the Army 

Surgeon Cell (known as the UEy Dental Surgeon until 

the recent decision on naming conventions of Army 

Transformation units). This new dental staff position is 

a wartime Professional Filler System requirement in a 

dedicated, regionally focused Army. Among other 

duties, the Army Dental Surgeon is charged with the 

establishment of an effective and consistent program 

for dental services and dental operations on a theaterwide basis. 

Medical Deployment Support Command

(MDSC) (formerly known as the Theater Medical 

Command (MEDCOM)). There are two dental staff 

officers in the headquarters company: 

1. The MDSC Dental Surgeon establishes and 

disseminates Army theater policy on dental 

matters. The Surgeon exercises technical 

control over all dental units in the theater 

through the medical brigade Dental Surgeons, 

directs the dental service element of the 

headquarters, and provides dental staff support 

to the MEDCOM commander. 

2. The MDSC preventive dentistry officer 

supports the MDSC Dental Surgeon in all staff 

actions. Specific duties include: 

 Providing oral health surveillance 

information in support of policy and 

procedure development. 

 Developing plans and orders concerning oral 

fitness and preventive dentistry programs. 

 Recommending treatment policies. 

 Developing programs for dental support of 

humanitarian and civic action operations. 

Medical Support Command (formerly known as 

Medical Brigade). In the past, the senior dental 

company commander had the additional designation as 

brigade Dental Surgeon and was located in the 

brigade’s command section. In Army Transformation, 

a formal position exists for the Dental Surgeon in the 

Medical Support Command. He exercises technical 

control over dental assets in hospitals and dental units 

subordinate to the Medical Support Command. The 

Medical Support Command Dental Surgeon also 

provides technical supervision for unit-level dental 

support (in Brigade Combat Teams, Armored Cavalry 

Regiments, and Special Forces Groups) as well as for 
PB 8-06-1/2/3 Jan/Feb/Mar 7

dental assets assigned within the Medical Support 

Command. A senior dental NCO assigned to the 

security, plans, and operations section assists the 

Medical Brigade Dental Surgeon. 

Division. The senior dental officer in a division is 

assigned to the division main medical company in the 

main support battalion. In addition to his patient care 

responsibilities, he acts as the Division Dental Surgeon 

and exercises technical supervision over the dental 

assets in the division forward support battalions. 

Dental officers in the forward support medical 

companies of the forward support battalions serve as 

Dental Surgeons to the supported maneuver brigades. 

The division main medical company is deleted as part 

of Army Transformation. As more brigades are 

activated, the division main medical companies 

provide the resources for the new brigade medical 

companies. Therefore, the positions for division dental 

staff officer and dental officers in division main 

medical companies will be deleted. 

Brigade Combat Teams, Armored Cavalry 

Regiments, and Special Forces Groups. The dental 

officer in the medical element of these units also 

serves as Dental Surgeon for the parent brigade-sized 

unit. 

GENERAL FIELD DENTAL SETS

Dental Instrument and Supply Sets, Emergency 

Care (DISS) — Assigned to every dental officer in a 

field clinical position. This small dental emergency kit 

is contained in a hand-carried medical aid bag. It 

contains the bare minimum of instruments and 

materials for simple extractions and expedient 

temporary restorations. Essential to this kit is the 

battery-operated handpiece which allows the dental 

officer to open an infected tooth, prepare a cavity for 

temporary restoration, or section a tooth for extraction. 

The DISS is intended for use when the situation does 

not permit the setup of the dental officer’s standard 

equipment. 

Dental Equipment Set, Comprehensive Dentistry 

(DES) — The backbone for providing operational 

care. The field dental equipment associated with the 

DES is compact, rugged, and has a limited power 

demand. Every dental officer in a field clinical 

position is issued the DES. This set provides the dental 

armamentarium used in the diagnosis and treatment of 

caries, defective restorations, occlusal trauma, tooth 

luxation/evulsion, gingivitis, early/moderate 

periodontitis, periodontal absess, traumatic or 

inflammatory oral lesions, routine endodontics, and 

postmortem examination. Major items of equipment 

include one portable field-type dental chair and stool 

unit, one dental operating and treatment unit, one 

dental light set, and a compressor. 

Dental Equipment Set, Dental Support — Found in 

both the area support treatment platoon and the 

medical company (dental services). It contains items 

which can be shared in a clinical environment (area 

support treatment platoon), and is issued to each 

forward treatment team. It provides necessary support 

items including a curing light, composite resin, an 

electric pulp tester, a sterilizer, a sink, and a laboratory 

table. 

Dental Equipment Set, Emergency Denture Repair

A small set which provides basic materials for 

expedient denture repairs. 

Dental Equipment Set, Dental X-ray, Field — In 

addition to the standard dental x-ray capability for the 

dental team, this set includes an associated hand-held x

-ray apparatus and new digital radiology capability. 

SPECIALIST FIELD DENTAL SETS

Dental Equipment Set, Prosthodontic — Provides 

clinical and laboratory items necessary to support 

fixed and removable prosthodontic procedures. The 

prosthodontic set must be used in conjunction with the 

general dentistry DES. 

Dental Equipment Sets, Endodontic and 

Periodontic — Recently added to support the new 

endodontist and periodontist positions in the new 

dental companies which are replacing the current, 

smaller dental companies. The sets are also used in 

conjunction with the general dentistry DES. 

Oral and Maxillofacial Surgery Set — Another new 

addition intended to support the oral and maxillofacial 

surgeon in the Combat Support Hospital. The set 

contains modern bone drill and plating systems. 

Dental Hygiene, Field, Dental Equipment Set — 

Includes those instruments and materials necessary for 

preventive dentistry services provided by preventive 

dental specialists. 
8 Army Medical Department Journal 

NEW FIELD DENTAL EQUIPMENT

Dental Field Treatment Operating System 

(DEFTOS) — An innovative new dental system that 

has the potential to reduce the weight of current dental 

systems by 50%, volume by 67%, and power 

requirements by 67%. 

The decreases are primarily the result of the 

development of a miniaturized system which uses 

electric instead of air turbine dental handpieces. The 

change eliminates the requirement for a large air 

compressor. An important second order effect of the 

system is that it has the potential, if fielded, to increase 

the mobility of dental teams by the reduction of 

weight, volume, and power requirements. The 

reduction of size and increase in deployability and 

mobility of dental teams are mainly accomplished 

through the elimination of the requirement for a five 

kw generator and associated trailer. 

The system enables the dental team to operate with a 

two kw generator, rechargeable batteries, solar energy, 

or 24–28 volt DC military vehicle system. The 

DEFTOS is currently under long-term testing by the 

Army Medical Department Board. It was pronounced 

clinically acceptable by the DEFTOS Clinical InProcess Review Team in September 2003. It has been 

approved by the FDA for clinical use and has passed 

Military Standard 810E environmental tests, which 

include shock to 40 g, vibration at transportation 

levels, a drop from four feet, and settling dust. 

Electric Motor Handpiece — A slow speed system in 

the Dental Emergency Aid Bag designed for bone 

removal, tooth sectioning, and caries removal. It is 

intended to be used when the standard dental operating 

unit can not be set up such 

as during unit movement 

operations. It adds the 

ability to provide dental 

c a r e i n a u s t e r e 

environments and in highly 

mobile operations. Two 4-

hour batteries are included 

with the handpiece. Recently a solar panel battery 

charger was added to the Dental Emergency Aid Bag. 

This eliminates the need for AC power to recharge the 

batteries. Full recharge of the batteries is achieved in 3 

to 8 hours. 

Digital Radiography — Currently being introduced 

into the field dental environment and will eventually 

be assigned to all dental teams. Headquarters, 

Department of the Army, has 

r e c e n t l y a p p r o v e d a n 

Operational Requirements 

D o c u me n t f o r d i g i t a l 

radiography. It will replace 

current dental x-ray chemical 

processing systems. A laptop 

computer is fielded with each 

digital radiography system as 

part of the set. The system has 

been issued to many units deploying to Operation Iraqi 

Freedom and other operations. Funding has been 

identified for procurement of more than one hundred 

digital radiography systems. Feedback from deployed 

dentists has been positive. 

Portable Handheld X-ray System — Currently being 

issued, the system will be used by all dentists assigned 

to brigades, divisions, field dental units, and field 

hospitals. It greatly reduces the weight and volume 

requirements associated with other x-ray equipment. 

The system has received very positive clinical 

feedback from dentists in the field. 
PB 8-06-1/2/3 Jan/Feb/Mar 9

Oral and Maxillofacial Equipment Set (M477) — 

Currently being fielded to oral and maxillofacial 

surgeons assigned to Army field hospitals, the set 

contains modern drill sets and titanium bone plating 

systems. Headquarters, Department of the Army, has 

approved the Operational Requirements Document for 

the M477. 

Shelter System — Intended for brigade and division 

dental teams of the near future, the ChemicallyBiologically Protection Shelter System (CBPSS) is a 

lightweight, multipurpose shelter that provides full 

chemical and biological protection and creates a 

contamination-free, environmentally controlled area 

for level 1 and 2 medical treatment units. The CBPSS 

is mounted to the back of a dedicated heavy 

HMMWV, has its own auxiliary power and ambient 

environmental control, is easily employed, has air lock 

entrances, and is 100% mobile. 

The new dental equipment sets and fielding initiatives 

will increase the capabilities of deployed dental assets 

in theater while reducing weight and cube. The result 

is increased deployability of field dentistry. 

ACKNOWLEDGEMENT

This article also appears in Military Dentistry: Terrain, 

Trends and Training (New Delhi: 2005) by MG 

Paramjit Singh and BG Vimal Arora. Reprinted with 

permission of the author. 

REFERENCES

1. Jeffcott GF. A History of the US Army Dental Services in 

World War II. Washington, DC: US Government 

Printing Office; 1955. 

2. Field Manual 8-55: Army Medical Services Planning 

Guide (U). Washington, DC: US Dept of the Army; 

1960. 

3. Allen FW, Smith BE. Impact of dental sick call on 

combat effectiveness: the dental fitness class 3 soldier. 

Mi Med. 1992;157:200-233. 

4. Liewehr F. US Army Dental Corps, endodontics and 

dental readiness. Mil Med. 2000;165(2):127. 

5. Payne TF, Posey WR. Analysis of dental casualties in 

prolonged field training exercises. Mil Med. 

1981;146:265-271. 

6. Ludwick WE, Pogas JA, Gendron EG, Weldon AL. 

Dental emergencies occurring among Navy-Marine 

personnel serving in Vietnam. Mil Med. 1974;139: 

121-123. 

7. Nasser FE, Storz JP. Report on dental casualty 

treatment at 12th Evac. Army Med Dept J. 1994;10: 

38-42. 

8. Grover PS, Carpenter WM, Allen GW. Predictability of 

dental emergencies by panography. Mil Med. 

1983;148:148-149. 

9. Swan ES, Karpetz E: Dental casualties during Canadian 

UN operations in Somalia. J Can Dent Assoc. 

1995;61:991-997. 

AUTHOR

COL Jones is Chief, Concepts & Requirements Division and 

Dental Consultant at the Directorate of Combat and 

Doctrine Development, US Army Medical Department 

Center & School, Fort Sam Houston, TX. 
10 Army Medical Department Journal 

ABSTRACT

Background. Dental health is an integral part of 

overall military readiness and patient satisfaction 

serves as an important motivator for compliance in the 

provision of dental care to a community.

Methods. Secondary analyses of 17 fiscal quarters of 

surveys from fourth quarter, FY 2000 through fourth 

quarter, FY 2004 were conducted for this project. In 

total, 69,059 surveys with no missing data from Army 

respondents were analyzed. The report focuses on a 

descriptive analysis of the results with mean scores of 

overall patient satisfaction with the clinical experience 

and their satisfaction with the individual dentist 

contact. 

Results. Overall satisfaction was rated high as the 

mean score for overall satisfaction with today’s visit 

was 6.49 (SD .91) and overall satisfaction with the 

clinic’s ability to take care of the Soldiers needs was 

rated 6.38 (SD .91) on a seven point bipolar rating 

scale. The mean response to rating the number of days 

waited for an appointment was 3.98 (SD 1.03). The 

mean satisfaction scores with the dentists were 

extremely high with the means ranging from 4.48 to 

4.64 on a 5-point scale, with five equaling excellent 

satisfaction. 

Conclusions. The results of this study clearly indicate 

that patients are satisfied with the dental care they 

receive at military dental clinics. This finding is 

consistent with previous literature on military dental 

satisfaction. A training vehicle could be developed to 

ensure that military dental providers and 

administrators understand the importance of patientprovider interactions and waiting times to overall 

satisfaction. 

INTRODUCTION

The dental health of a Soldier directly affects the risk 

of a dental emergency while deployed. Maintaining a 

high level of good dental health throughout the force is 

an integral part of overall military readiness as clinical 

dental resources are not always readily available in the 

deployed environment. Soldiers must be encouraged to 

be as proactive in their personal dental health care as 

they are in other medical areas. Patient satisfaction is a 

very important element in that effort Satisfaction is 

widely recognized as a principal outcome measure of 

quality throughout the healthcare arena. The Assistant 

Secretary of Defense for Health Affairs has mandated 

that military dentistry assess the level of patient 

satisfaction. Since active duty Army Soldiers receive 

the bulk of their dental care from the 172 US Army 

dental treatment facilities around the world, 

monitoring customer satisfaction in those facilities is 

an important component of maintaining the highest 

standards of dental health throughout the force. This 

study assesses levels of satisfaction in military dental 

treatment facilities. 

LITERATURE REVIEW

Traditionally, dental satisfaction has been assessed by 

the dentist’s technical competence and mechanical 

precision.1

 Patient opinions played no role in this 

method of measuring quality. However, eventually 

consumerism became an integral part of the dental 

patient mindset, and dentists were forced to “compete” 

for patients. Consequently, consideration of patient 

satisfaction became an important part of providing 

dental services.2

A large body of work in the field of patient satisfaction 

exists in the dental literature. Ross and Duff found that 

patients return to the dentist for subsequent care due to 

Patient Satisfaction in US Army Dental 

Treatment Facilities 

LTC Jeffrey G. Chaffin, DC, USA 

COL David Moss, DC, USA 

LTC Bruce Brehm, DC, USA 
PB 8-06-1/2/3 Jan/Feb/Mar 11

satisfaction with the interpersonal component of the 

dental relationship rather than the technical quality of 

the care received.3 Evidence for both medical and 

dental patient satisfaction studies show that desirable 

interactions lead to more satisfied patients who better 

understand and more accurately follow prescribed 

regimens.4,5 A satisfied patient may have a different set 

of behaviors that ultimately evolve into not only 

increased satisfaction, but also a healthier individual. 

McKeithen6

 found that personality was the most 

frequently mentioned feature of an ideal dentist. 

Collet7

 discovered that the dentist’s personality was 

the major reason that patients became dissatisfied and 

changed their dentist. In 1974 Koslowsky et al8

 also 

ascertained that patient concerns focused on the 

dentist’s personality and technical competence, and 

that fees ranked lowest in importance of those factors 

studied. These pioneering studies all seemed to 

directly link satisfaction with the interpersonal 

relations between the dentist and the patient. Whereas 

dentists often assume that quality equates to technical 

expertise, Crall and Morris9

 and Abrams et al10 found 

that patient satisfaction did not correlate well to 

dentists’ perception of quality treatment. 

In 1999 Newsome and Wright reviewed 46 studies of 

patient satisfaction and found the factors most 

commonly identified with dental patient satisfaction 

were technical competence, interpersonal factors, 

convenience, costs, and facilities.11 Davies and Ware 

developed the Dental Satisfaction Questionnaire and 

found that access, availability/convenience, cost, pain, 

and quality were all independent elements of patient 

satisfaction.12

Dental patient satisfaction among active duty service 

members has not been widely studied. Chisick 

conducted two studies of dental satisfaction among 

active duty military members.13,14 Similar to the 

civilian studies, Chisick focused on access issues 

(availability/convenience), provider interpersonal 

skills, and pain control to determine possible 

predictors of satisfaction. Costs were not included 

because active duty military members are not required 

to pay for dental care. Chisick concluded that active 

duty personnel were generally very satisfied with 

military dental care and satisfaction did not vary 

significantly across demographics. Access was a 

consistent predictor of decreased satisfaction levels. 

METHODS

Survey Instrument 

The Department of Defense (DoD) Dental Satisfaction 

Survey (DSS) used in this project monitors the 

satisfaction of military beneficiaries who receive 

treatment in military dental clinics throughout the 

world. The DSS was developed by a Tri-Service 

working group in 1998, approved by the DoD 

Institutional Review Board and implemented in 1999 

by the Tri-Service Center for Oral Health Studies 

(TSCOHS). There is no central dental appointment 

system, therefore the DSS can not be managed 

centrally with a traditional mailing of survey 

instruments to a randomly selected number of patients 

who have received care in the system. The DSS survey 

is administered in the individual dental clinics with the 

use of the Random Appointment Time Slot Generator 

system which designates the day on which the clinics 

administer the DSS. On the selected day, front desk 

personnel administer the survey at the conclusion of 

the appointment. The surveys are sent to TSCOHS 

monthly. The surveys are anonymous and do not 

contain patient identifiers. The survey is composed of 

27 questions focusing on access, quality, interpersonal 

relationships, overall satisfaction with dental care, 

overall satisfaction with the dental clinic, and 

demographic data. 

This project is a secondary analysis of dental patient 

satisfaction data. The surveys analyzed for this project 

were administered between the fourth quarter of 

FY 2000 and the fourth quarter of FY 2004. A copy of 

the survey instrument and 17 digitized text files (one 

per quarter) of data were received directly from 

TSCOHS. 

Variables/Statistics 

The 17 text files were imported into Statistical 

Packages for Social Science, version 12. One master 

file was created with 658,443 surveys. Those who 

responded affirmatively about seeing a dentist during 

the visit and selecting Army affiliation were kept in 

the study. Those who only saw the hygienist and had a 

prophylaxis were not included in the study. Questions 

pertaining to satisfaction with hygienist were deleted. 

Three questions rating the time patients waited past 

their appointment were also deleted as there were very 

few responses to those questions. The result was a data 

set of 69,059 with no missing data. 
12 Army Medical Department Journal 

This project presents descriptive analyses only. 

Satisfaction with the individual dentist was rated on a 

5-point scale as follows: Poor (1), Fair (2), Good (3), 

Very Good (4), Excellent (5). Overall satisfaction 

measures were based on the patient responses to 

questions concerning their satisfaction with the dental 

care for “today’s” visit and their level of satisfaction 

with the clinic’s ability to take care of their dental 

needs. These overall satisfaction measures utilized a 7-

point bipolar rating scale as follows: Completely 

dissatisfied (1), Very dissatisfied (2), Somewhat 

dissatisfied (3), Neither satisfied nor dissatisfied (4), 

Somewhat satisfied (5), Very satisfied (6), Completely 

satisfied (7). 

RESULTS

A total of 69,059 surveys with no missing data from 

the fourth quarter of FY 2000 through the fourth 

quarter of FY 2004 were analyzed for this project. The 

majority of subjects were male (76.5%) and reported 

being on active duty (97%). The bulk of active duty 

respondents were enlisted personnel (83.2%) with the 

remaining subjects being officers. All demographic 

information is presented in Table 1. 

Overall satisfaction was rated high as the mean score 

for overall satisfaction with today’s visit was 6.49 

(SD .908) on a 7-point scale. This indicates a high 

level of satisfaction classified as between very 

satisfied and completely satisfied. Overall satisfaction 

with the clinic’s ability to take care of the Soldiers’ 

needs was rated 6.38 (SD .905). This rating is also 

indicative of a high level of satisfaction. The 

distribution of responses to these overarching 

satisfaction questions are shown in Table 2. Another 

important attribute to assess satisfaction is the patient’s 

predilection to return to the clinic for future needs. 

Over 97% of respondents cited that, if given a choice, 

they would return to the Army dental clinic for future 

care. 

Access to care has been shown to be a consistent 

predictor of satisfaction. This survey contained some 

surrogate access measures such as waiting times. The 

mean response to rating the “number of days waited 

for an appointment” was 3.98 (SD 1.03). Almost 9% 

of respondents rated the waiting time to be either poor 

or fair as noted in Table 3. This is a small percentage, 

but this finding is important as it demonstrates some 

dissatisfaction with waiting times to make 

appointments. The survey also revealed that 5.8% 

(n=4025) were not seen for their appointment on time. 

The civilian literature has shown that extended waiting 

times are consistent with lower satisfaction scores. 

The mean satisfaction scores with the dentist were 

extremely high with means ranging from 4.48 to 4.64 

on a 5-point scale, with five equaling excellent 

satisfaction. Table 3 presents all mean scores and 

frequency distributions for satisfaction with providers 

and waiting times. Very few respondents had negative 

ratings for their provider interactions. 

DISCUSSION

This is the first time that satisfaction in Army dental 

clinics has been assessed over an extended period of 

time. The results of this study clearly indicate that 

patients are satisfied with the dental care they receive 

at military dental clinics. The finding is consistent with 

the literature on military dental satisfaction. The 

results are positive and the majority of beneficiaries 

are very satisfied with the care they receive. This is 

evidenced by the finding that 93.1% of respondents 

were either very or completely satisfied with the 

n n% 

Gender 

Male 52,862 76.5 

Female 16,197 23.5 

Beneficiary 

Active duty 66,948 97.0 

Active duty dependent 1,814 2.6 

Retiree 297 0.4 

Rank 

E1 – E4 28,204 40.8 

E5 – E9 29,218 42.4 

Warrant Officer 2,283 3.3 

Officer 9,354 13.5 

Age Group 

Up to 17 years 610 0.9 

18-19 years 5,300 7.7 

20-29 years 34,047 49.3 

30-39 years 20,079 29.1 

40-49 years 7,491 10.8 

50 years and above 1,532 2.2 

Table 1. Demographics of Survey Respondents 
PB 8-06-1/2/3 Jan/Feb/Mar 13

Table 3. Frequency Distribution and Mean of Responses to Questions Concerning Satisfaction With the 

Dentist and Access to Dental Services 

Survey Responses 

Interaction with Dentist (1) Poor (2) Fair (3) Good (4) Very Good (5) Excellent Mean (SD) 

Friendliness and courtesy 0.1% 0.7% 6.1% 20.7% 72.4% 4.64 (0.641) 

Attention given to what you 

had to say 

0.2% 0.8% 7.2% 22.6% 69.3% 4.60 (0.672) 

Thoroughness of treatment 0.1% 0.7% 7.0% 21.9% 70.3% 4.61 (0.658) 

Explanation of dental 

procedures 

0.4% 1.8% 9.4% 23.5% 64.9% 4.51 (0.770) 

Amount of time with dentist 0.3% 1.5% 10.2% 25.8% 62.2% 4.48 (0.760) 

How much you were helped 

by dentist 

0.2% 1.0% 8.9% 24.5% 65.4% 4.54 (0.713) 

Overall quality of care from 

the dentist 

0.2% 0.7% 6.5% 20.6% 72.0% 4.64 (0.650) 

Access to Care 

Rating of number of days 

waited for appointment 1.8% 7.1% 21.9% 29.2% 39.9% 3.98 (1.03) 

Note: n(total) = 69,059 

Table 2. Frequency Distribution and Mean of Responses to Questions Concerning Overall 

Satisfaction With “Today’s” Visit and the Clinic in General 

 Response 

All things considered, 

how satisfied are you 

with the dental care from 

today’s visit? 

All things considered, 

how satisfied are you with 

the clinic’s ability to take 

care your dental needs? 

(1) Completely Dissatisfied 0.9% (n=690) 0.6% (n=426) 

(2) Very Dissatisfied 0.6% (n=435) 0.7% (n=496) 

(3) Somewhat Dissatisfied 0.3% (n=236) 0.6% (n=365) 

(4) Neutral 1.1% (n=756) 1.3% (n=897) 

(5) Somewhat Satisfied 3.9% (n=2 699) 5.7% (n=3 933) 

(6) Very Satisfied 29.9% (n=20 681) 37.4% (n=25 848) 

(7) Completely Satisfied 63.2% (n=43 643) 53.7% (n=37 094) 

 Mean (SD) 6.49 (0.908) 6.38 (0.905) 

Note: n(total) = 69,059 
14 Army Medical Department Journal 

received care during that day’s visit. Similarly, 93.1% 

were either very or completely satisfied with the 

ability of the clinic to take care of their dental needs. 

The scores for access rate satisfaction as good, but the 

number of negative responses indicate this to be a 

source of dissatisfaction for military members. 

Dentists working in military dental treatment facilities 

should be aware of the importance of their interaction 

with the patient in the determination of overall 

satisfaction. That interaction is the primary driver of 

satisfaction. Dentists should be aware of this finding to 

improve the patient-dentist interaction. This project 

could not assess whether the severity of the dental 

needs of the military member affected their level of 

satisfaction. If patients with more severe and/or urgent 

needs were found to be less satisfied with dental care, 

they may not be as likely to return for their needed 

care and thus would have an increased probability of 

being a dental casualty. Unfortunately, while all 

military dental clinics use a common dental 

classification system to identify the patient’s levels of 

urgency for care, the information was not collected in 

this survey. A study design that incorporates the 

military’s dental classification system ratings for a 

patient with their level of satisfaction would allow 

exploration of the correlation of a patient’s current 

dental needs severity with their level of satisfaction. 

The results of this study may be generalized to military 

beneficiaries seeking care in Army dental treatment 

facilities. There are a few limitations for the results. 

One limitation is that this survey evaluated satisfaction 

of those who actually accessed the dental clinics, as 

opposed to all eligible beneficiaries. The second 

limitation revolves around the 5-point scale that 

assessed satisfaction with providers and waiting times. 

This 5-point scale had no true neutral and thus skewed 

the responses toward satisfaction. A new survey 

format has corrected this so a true neutral will be 

available in the future. Future studies should attempt to 

focus on all eligible beneficiaries and not only users of 

military dental facilities. 

CONCLUSIONS

Satisfaction with the level and the perceived quality of 

care provided by dentists in military treatment 

facilities are high. Access to care measures receive 

good ratings, but there is some discontent with the 

ability to make appointments. The authors suggest that 

a simple training vehicle be developed so that military 

dental providers and administrators understand the 

importance of patient interactions and waiting time as 

factors in overall patient satisfaction. 

REFERENCES

1. Kress GC, Shulman JD. Consumer satisfaction with 

dental care: where have we been, where are we going?. 

J Am College of Dent. 1997;64(1):9-15.

2. Kress GC. Patient satisfaction with dental care. Dent 

Clin North Am. 1988;32(4):791-802. 

3. Ross CE, Duff RS. Returning to the doctor: the effect of 

client characteristics, type of practice and experiences 

with care. J Health Soc Behav. 1982;23:119-131. 

4. Francis V, et al. Gaps in doctor-patient communication: 

patient’s response to medical advice. N Engl J Med. 

1969;280:259. 

5. Korsch B, et al. Gaps in doctor-patient 

communications. I. Doctor-patient interaction and 

patient satisfaction. Pediatrics. 1969;42:855. 

6. McKeithen EJ. The patient’s image of the dentist. J Am 

College Dent. 1966;33:87-107. 

7. Collett HA. Influence of dentist-patient relationship on 

attitudes and adjustment to dental treatment. J Am Dent 

Assoc. 1969;79:879-884. 

8. Kolslowsky M, Bailit H, Valluzzo P. Satisfaction of the 

patient and provider: evaluation by questionnaire. J 

Public Health Dent. 1974;34:188-194. 

9. Crall JJ, Morris AL. Relationships among structure, 

process, and outcome scores derived from evaluations 

of 300 general dental practices. J Dent Ed. 1988;52

(11):643-646. 

10. Abrams RA, Ayers CS, Vogt-Petterson M. Quality 

assessment of dental restorations: a comparison by 

dentists and patients. Community Dent Oral Epidemiol. 

1986;14:317-319. 

11. Newsome P, Wright G. Dental patient satisfaction: an 

appraisal of recent literature. Br Dent J. 1999;186

(4):166-170. 

12. Davies AR, Ware JE. Development of a dental 

satisfaction questionnaire for the health insurance 

experiment. Santa Monica, CA: The Rand Corporation; 

1982. 

13. Chisick MC. Satisfaction with military dental care by 

active duty Soldiers. Mil Med. 1994;159(7):501-504. 

14. Chisick MC, Poindexter F. Satisfaction of active duty 

US service members with military dental care. Mil Med. 

1998;163(12):813-816. 
PB 8-06-1/2/3 Jan/Feb/Mar 15

AUTHORS

LTC Chaffin is a resident in the US Army-Baylor Graduate 

Program in Health Care Administration, Fort Sam Houston, 

TX. 

COL Moss is assigned to the Office of The Surgeon General 

in Falls Church, VA. 

LTC Brehm is the Public Health Dental Officer at the US 

Army Dental Command, Fort Sam Houston, TX. 
16 Army Medical Department Journal 

INTRODUCTION

The purpose of this article is to provide a brief genesis 

and current status of one of the US Army Dental 

Command’s (DENCOM) most cost-effective strategic 

initiatives, the Expanded Function Dental Assistant 

(EFDA) training program. This article provides a 

historical perspective, describes the needs that drove 

the program’s establishment, and presents a limited 

background on how the program was organized and 

funded. This article also addresses the return on 

investment of the initiative and discusses a number of 

lessons learned. 

HISTORICAL PERSPECTIVE

The EFDA program is a labor-substitution initiative 

aimed at increasing the output of general dentistry 

teams. The practice of using specially trained dental 

assistants to perform reversible dental restorative 

procedures (placing fillings) and limited oral hygiene 

procedures came into vogue in the late 1970s1-3 and 

early 1980s. At that time the United States faced a 

national shortage of dentists. 

The Army trained a number of these civilian, 

expanded-duty dental assistants, referred to as Dental 

Therapy Assistants (DTAs), in a formal 1-year 

program. These individuals, trained in the mid to late 

1970s, proved highly effective and tended to stay in 

government service. Due in large part to the high 

retention rate of these individuals and the relatively 

high cost of the formal 1-year training program, DTA 

training met a relatively quick demise. By the mid 

1980s the national shortage of dentists reversed into a 

glut of dentists as the effects of government-sponsored 

increases in dental school enrollment began to impact 

the workforce. This glut of dentists dampened the 

national enthusiasm for training ancillaries in 

expanded functions. 

Training of enlisted Soldiers in expanded functions, 

except hygiene procedures, was also terminated, 

although not until the 1990s. The cost and training 

time required to bring these Soldiers to a level of 

clinical competency was not in line with the relatively 

short utilization period experienced in the field. A 

common perception among Soldiers was the belief that 

they would not remain competitive for promotion if 

their primary duty consisted of direct patient care. This 

factor may have contributed to their short clinical life 

as practicing expanded-function dental assistants. 

By the late 1990s the majority of DTAs remaining in 

the system was engaged in providing oral hygiene 

services in response to the national shortage of dental 

hygienists. The enlisted expanded-function dental 

assistants, referred to as X2s, were also providing 

hygiene services. Using these individuals to provide 

hygiene support to those patients requiring less 

extensive hygiene care allowed the number of 

available registered dental hygienists to focus on 

patients with more advanced needs. 

NEED FOR INCREASED ACCESS TO CARE

Unmet patient needs for access to timely, costeffective routine care drove the Dental Corps to put in 

place the Dental Care Reengineering Initiative4

(DCRI), in 1997. DCRI was designed by a team of 

dentists at the direction of MG James J. Cuddy, then 

the Deputy Surgeon General and Chief of the Dental 

Corps. The DCRI team conferred with a number of 

civilian consulting groups as well as the Indian Health 

Service (IHS). The resulting dental care delivery 

model incorporated a number of best practices from 

the private sector and lessons learned from the IHS. 

One of the more salient features of the DCRI delivery 

model was the use of multichair, multiancillary 

primary care teams led by general and/or 

comprehensive dentists. Even using conventional 

The Expanded Function Dental 

Assistant Training Program 

COL W. John Luciano, DC, USA 

COL Larry G. Rothfuss, DC, USA 

COL Ann S. von Gonten, DC, USA 
PB 8-06-1/2/3 Jan/Feb/Mar 17

dental assistants, the literature documents significantly 

higher production for providers using multiple dental 

care delivery units (dental chairs) and multiple 

ancillaries.5,6

As DCRI matured and incorporated lessons learned, 

enhanced optimization opportunities emerged. In 

2001, a site visit to the US Navy dental facilities at 

Pearl Harbor served to greatly refine the optimization 

concept. The Navy dental commander, CAPT Robert 

Hutto, was experimenting in training Navy enlisted 

dental technicians in expanded duties. These assistants 

were then placed in multiancillary teams consisting of 

two EFDAs and one conventional dental assistant. 

When compared to conventional treatment teams of 

one provider and one dental assistant, the EFDA teams 

showed productivity increases of between 92% and 

155% over baseline.7

 The increased productivity 

translated to faster access to care for beneficiaries at 

Pearl Harbor. The information gleaned from the 

observations and briefings allowed DCRI to evolve 

into a new program named Dental Care Optimization 

(DCO). 

THE NEW ARMY EFDA PROGRAM

The Navy experience re-energized the DENCOM into 

pursuing the reintroduction of expanded duty dental 

assistants into primary care teams. Unlike the Navy, 

the Army decided to focus on training civilians. As 

past experience with the DTAs trained in the 1970s 

indicated, Army trained civilian ancillaries tend to 

remain in government service, fully engaged in patient 

care for their entire career. The Army experience with 

enlisted ancillaries had proven to be just the opposite. 

To ensure the maximum return on training dollars, the 

Army decided to train civilian ancillaries in advanced 

functions. 

The DENCOM looked at various options for training a 

Beta test cohort of students. After investigating a 

number of civilian training options, the DENCOM 

partnered with the IHS, who had trained EFDAs since 

the 1970s. The IHS training model calls for a basic 

skills, 1-week didactic course followed by a year of on

-the-job training and utilization. Following mastery of 

the basic skills and one year of experience, the student 

was eligible to attend another week-long course 

focused on placing more advanced dental restorations.8 

This was a major change from the year-long training 

model used by the Army to train the earlier generation 

of EFDAs/DTAs. The fact that the IHS had been using 

this model successfully for so long did not lessen the 

anxiety of the staff in the Department of Dental 

Sciences at the Army Medical Department Center and 

School (AMEDDC&S). 

Dr. Terry Haney of the IHS taught the Beta test course 

in August 2001. The Department of Dental Sciences 

staff observed the training and was pleasantly 

surprised at the initial skills developed by students. 

The students returned home to a locally designated 

training mentor. The mentor, a practicing dentist, was 

charged with evaluating all the restorations placed by 

the student and ensuring safe, quality care for the 

patient. Students performed only those procedures that 

were clinically reversible. 

In partnership with the MEDCOM Civilian Personnel 

Office and the Department of Dental Sciences, the 

DENCOM developed its own EFDA training program 

with the IHS program as the model. The training flow 

is depicted in Figures 1 and 2. 

A business case analysis seeking funding from the 

MEDCOM Venture Capital Program (VCP) was 

compiled and submitted almost simultaneously with 

the DENCOM-funded Beta test. The rules of 

engagement for VCP provided 3 years of funding for 

initiatives that would prove self-sufficiency at the end 

of the 3-year period, or for initiatives that did not 

necessarily move to self-sufficiency but that did 

correct a clinical deficiency. 

The DENCOM’s VCP submission targeted the 

production of a pilot program cohort of 60 EFDAs. 

The program also sought to build multiancillary 

primary treatment teams by funding a replacement 

dental assistant once the student selected for training 

successfully reached the first EFDA promotion point. 

The Navy’s experience and previously cited references 

stressed the importance of having multiple ancillaries 

on the team. A team with an EFDA and a dentist and 

no other ancillaries proved to be ineffective. 

RETURN ON INVESTMENT

The success of the EFDA program is demonstrable 

through the program’s return on investment (ROI). 

During FY 2005, the DENCOM’s centrally-managed 

EFDA program produced 235,719 Dental Weighted 

Values (DWVs) of treatment. This is equivalent to 

$23.5 million of dental treatment. DENCOM spent 

$3.84 million to support the program. The DENCOM 
18 Army Medical Department Journal 

acquired approximately $6 of dental care for every 

dollar funding the program. The ROI was even larger 

during FY 2004. DENCOM received about $10 in 

productivity for every dollar funding the program. 

The Dental Corps’ EFDA program has proven itself to 

be so extremely cost-effective that it was fully funded 

via the Program Objective Memorandum (POM) for 

FY 2006-2011 which covers training costs for over 

140 EFDAs as well as a number of backfill contract, 

conventional dental assistants. The demonstrated ROI 

provided an undeniable case for POM insertion. The 

summary of consolidated EFDA productivity for 

October 2005 is presented in the Table. 

EFDA-trained personnel are completely embedded in 

several key Army dental initiatives. EFDAs are used 

extensively in Dental Care Optimization (DCO). DCO 

is an initiative aimed at increasing access to care by 

using best clinical practices. The First Term Dental 

Figure 1. Phase 1 of the EFDA training program. Adapted from the Workload and Scheduling Database 

of the US Army Dental Command, Ft Sam Houston, TX 

One week course 

in basic operative 

d e n t i s t r y a t 

AMEDDC&S 

Return to duty station 

Clinical hands-on 

t r a i n i n g a n d 

certification/grading 

of performance 

Center and School 

issues certificate 

of training 

Successful performance at 

GS05 level for 12 months 

Non-competitive 

promotion to GS05 

Figure 2. Phase 2 of the EFDA training program. Adapted from the Workload and Scheduling Database 

of the US Army Dental Command, Ft Sam Houston, TX 

Return to duty station 

Clinical hands-on 

t r a i n i n g a n d 

certification/grading 

of performance 

Attend advanced 

course at AMEDDC&S

Non-competitive 

promotion to GS06

Center and School 

issues certificate 

of training 
PB 8-06-1/2/3 Jan/Feb/Mar 19

Readiness Program ensures that newly accessed 

Soldiers from all three Army components receive 

dental care that will allow them to be deployable upon 

graduation from Advanced Individual Training. 

EFDAs are also used extensively to expedite the surge 

requirements for dental care generated by 

mobilizations. 

The current Army EFDA inventory is 142 employees 

dispersed among various CONUS installations. 

DENCOM plans to train up to 32 new EFDAs in 

FY 2006. The planned future end point for EFDA 

program sustainment is approximately 200 EFDAs 

used throughout DENCOM. 

LESSONS LEARNED

The short length of this article precludes presentation 

of the numerous lessons learned. The following are 

three of the more significant of those insights that 

might be applicable to other clinical strategic 

initiatives: 

1. Fairness of the selection process must be 

ensured for any competitive program that offers 

a limited number of training seats. The 

DENCOM used central selection boards held in 

San Antonio versus a local selection process at 

the operational level. The EFDA selection 

boards have clearly defined procedures designed 

to select those who will both successfully 

complete this challenging training and work well 

in multiancillary treatment teams. The board 

consists of five or six voting board members and 

two nonvoting members. The nonvoting member 

representatives from the MEDCOM Equal 

Employment Opportunity Office and the 

MEDCOM Civilian Personnel Division ensured 

a fair and consistent selection process. 

2. The EFDA program relies heavily on the clinical 

mentor/designated trainer to refine and expand 

the student’s clinical skills. To guarantee the 

success of this critical relationship, the provider 

selected for this important role must believe in 

the value of the program, fully understand the 

training requirements, and be willing to commit 

the time and effort required to train the students. 

The local command must ensure that students 

have educational continuity through an 

individual designated trainer, rather than be 

shifted from clinician to clinician. 

3. Rather than start de novo, DENCOM elected to 

build on an existing, already highly successful 

IHS program. This partnership with another 

federal service allowed for the rapid 

development and fielding of the Army program. 

Other federal services face healthcare issues 

similar to those of the Army. When addressing 

corporate healthcare challenges, it is always 

worthwhile to investigate how other federal 

healthcare organizations are responding to the 

same situations. 

CONCLUSION

All three DoD dental services face the twin challenges 

of preparing large numbers of service members for 

deployment with a shrinking pool of general dentists. 

The DENCOM’s EFDA program has been and 

continues to be a proven, highly successful method for 

leveraging the productivity output of general and 

comprehensive dentists to better meet the needs of our 

service members. 

REFERENCES

Total DWVs† 23,670.68 

Number of EFDAs 142 

DWVs attributed to dental 

prophylactic services 

2,985.91 

DWVs attributed to dental 

restorative services 

20,689.77 

Average workload per EFDA 

per month 

166.69 DWVs 

Average dollar value of 

prophylactic care provided 

per EFDA per month 

$2,103.00 

Average dollar value of 

restorative care provided per 

EFDA per month 

$14,567.00 

Summary of EFDA* Productivity for October 

2005 (Source: DENCOM Workload and 

Scheduling Database) 

*Expanded function dental assistant 

†Dental weighted values of treatment 
20 Army Medical Department Journal 

1. Abramowitz J. The implementation of a program for 

utilizing auxiliaries: the experience of the Indian Health 

Service. J Public Health Dent. 1972;32(3):142-148. 

2. Pelton, et al. Economic implications of adding two 

expanded-duty dental assistants to a practice. JADA. 

1973;87:604-607. 

3. Abramowitz J, et al. Four-year study of the utilization 

of dental assistants with expanded functions. JADA. 

1973;87:623-635. 

4. Fretwell LD, et al. Concept and Feasibility Plan for the 

Implementation of a Team Dental Health Care Delivery 

Model for the Army Dental Care System. Internal 

document, US Army Dental Command (6 February 

1997). 

5. King, Brunner. Use of multiple operatories in dental 

care delivery. Report #82-0021982. US Army Medical 

Department Dental Studies Office; 1982. 

6. Lalumandier, Riddle, Wojcik. Assistant/Dentist: 

Productivity as Determined by Configuration. Internal 

study. Army Medical Department Directorate of Health 

Care Studies and Analyses; 30 March 1994. 

7. Hutto R. Dental Treatment Delivery: Expanded 

Function Methodology. Command briefing; July 2001; 

US Navy Base, Pearl Harbor, HI. 

8. Sundberg M. After Action Report: Interview With the 

Indian Health Service. Claremore, Oklahoma. Internal 

Document, US Army Dental Command; 17 January 

1997. 

AUTHORS

COL Luciano is currently on staff at the Office of the Corps 

Specific Branch Proponent Office, Dental Corps, Academy 

of Health Sciences, US Army Medical Department Center 

and School, Fort Sam Houston, TX. 

COL Rothfuss is currently on staff at the United States 

Army Dental Command, Fort Sam Houston, TX. He is the 

Program Manager for Expanded Function Dental Assistant 

Program and First Term Dental Readiness. 

COL von Gonten is currently on staff at the United States 

Army Dental Command, Fort Sam Houston, TX and serves 

as the Dental Consultant. 
PB 8-06-1/2/3 Jan/Feb/Mar 21

ABSTRACT

In 1998, the Army Dental Care System launched a 

campaign to revitalize health promotion termed “Put 

More ‘Bite’ Into Health Promotion.” This article 

discusses the content, rationale, and evidence base for 

the original health promotion program. The initiatives 

of the introductory program include mouthguard 

fabrication and counseling, sealant placement and 

education, and skin, lip and oral cancer. Considering 

today’s operational tempo and recruit health, 

prevention and promotion are integral components of a 

nation at war. As such, the program has been expanded 

to include caries and tobacco risk assessment, and the 

supporting prevention interventions. 

INTRODUCTION

This article provides program background and updates 

the status of the current US Army Dental Command’s 

(DENCOM) Health Promotion Program. In 1994, The 

Surgeon General of the United States launched a 

campaign to improve the delivery of preventive health 

services in the US. The intent of the initiative was to 

increase preventive screenings and immunizations, 

counseling for health behavior change, the delivery of 

age and sex risk-specific preventive services, and the 

promulgation of health education and promotion 

messages.1

 Prevention messages are typically received 

at Army Troop Medical Clinics (TMC). While 

utilizing the TMC to promote health is the 

conventional method of practice, Army leaders 

recognized a problem — young healthy troops were 

not receiving the important health promotion 

messages. Young, healthy Soldiers typically spend 

limited time in the TMC where health promotion 

messages are available. Although the majority of 

Army Soldiers are young and healthy, inherent risk 

factors are associated with military service. Soldiers 

often face dietary changes which are often high in 

sugar content. This risk factor is compounded by longterm deployments which places them in stressful 

situations. Both diet and stress adversely affect both 

oral and general health. Military routines and 

regulations ensure certain healthy behaviors such as 

vigorous exercise, seat belt use, helmet use for 

motorcyclists, and annual dental examinations. 

However, other behaviors such as tobacco use, binge 

drinking, and high blood pressure control have large 

gaps between Soldiers’ behaviors and the Healthy 

People 2010 goals.2

 For example, about 34% of Army 

Soldiers have smoked cigarettes within the past 30 

days, whereas the Healthy People 2010 goal is 12% or 

less. 

The key to successfully increasing patient awareness 

about health problems and risk factors is the repetitive 

delivery of a simple, well-focused message through 

multiple channels. A major solution set includes 

expansion of the TMC’s health promotion programs to 

Army dental clinics. All Soldiers are required to have 

an annual dental examination, and many Soldiers 

require subsequent appointments. Every patient 

encounter presents an opportunity to advise Soldiers 

about health risks and good health practices in a 

positive, encouraging manner. The value of a dental 

appointment is exponentially enhanced by increasing 

Soldiers’ health awareness and promoting healthy 

lifestyle practices. 

The success of such a program requires commitment 

and behavioral change, not only on the part of patients, 

but also on the part of dental health care providers. 

Studies have shown the difficulty of changing health 

care providers’ delivery of preventive services. 

Targeted group discussion and interactive workshops 

are more effective than simply distributing educational 

material to providers or having large formal lectures.3

With these factors in mind, the DENCOM partnered 

with the US Army Center for Health Promotion and 

Preventive Medicine in 1997 to develop and 

US Army Dental Command “Puts More 

‘Bite’ Into Health Promotion” 

Pamila Richter, RDH 

LTC Georgia de la Cruz, DC, USA 

LTC Jeffrey Chaffin, DC, USA 
22 Army Medical Department Journal 

implement a preventive campaign: “Put More ‘Bite’ 

Into Health Promotion.” The campaign puts more 

dental health into health promotion, and health 

promotion into the Army Dental Care System. The 

ultimate goal of the campaign is to improve the health 

of Soldiers by increasing the delivery of preventive 

health services and screenings, enhancing Soldiers’ 

awareness about disease risk factors, and encouraging 

behavior change through health promotion and 

education. 

INITIAL PROGRAM IMPLEMENTATION

“Successful implementation of any health promotion 

initiative requires behavioral change, not only on the 

part of patients but also on the part of health care 

providers.”4

 The program’s objective was to develop a 

narrow, well-focused, evidence-based set of clinically 

delivered health promotion initiatives that would be 

easy for dental health practitioners to implement and 

ultimately would significantly enhance the oral and 

general health of Soldiers. The initial program 

included four dental-clinic-based, patient-oriented, 

health promotion initiatives: 

1. Sealant education and placement 

2. Mouthguard education and fabrication 

3. Tobacco cessation and interdiction counseling 

4. Skin, lip, and oral cancer screening and 

counseling 

The introductory program was intentionally limited to 

only four initiatives to make the program manageable 

for busy clinicians and ensure their acceptance. Patient 

handouts, fact sheets and posters were designed to 

reinforce each of the initiatives. Training which 

provided an opportunity to introduce both the 

initiatives and supporting materials was conducted at 

each of the 29 Army Dental Activities located 

worldwide. 

RESULTS

A 2004 program evaluation survey of Army dentists 

who provide clinical care shows that the frequency of 

delivery of health promotion and preventive dentistry 

services provided by US Army dentists increased 

significantly since an initial survey in 1997. The 

percentage of providers who performed individual oral 

hygiene instruction on a daily or weekly basis 

increased from 88% to 92%. The percentage of 

providers who counseled Soldiers daily or weekly on 

tobacco use and periodontal health increased from 

75% to 81% and from 69% to 80%, respectively. Over 

half (56%) of all clinical dentists now provide fluoride 

and nutrition counseling. About one third (33%) 

educate Soldiers on the need for mouthguards, up from 

24%.5

CURRENT HEALTH PROMOTION INITIATIVES

The health promotion program has evolved since 

initial implementation. The initial program focus on 

general health promotion has expanded to include 

dental health education and prevention. The expansion 

was needed to address the high levels of dental disease 

among Army recruits and dental degradation during 

frequent deployments. New components to the original 

program include caries risk and tobacco assessments 

and the supporting prevention interventions such as 

fluoride. 

Caries Risk Assessment 

Dentists often use Caries Risk Assessment (CRA) in 

their clinical practices, but usually only on an intuitive 

level. CRA is a simple and quick method of 

determining a Soldier’s risk for future caries and easily 

translates into the development of personalized 

prevention programs. The scientific literature has long 

suggested that a risk-based assessment of an individual 

patient’s dental history and oral health status is an 

important prerequisite for appropriate prevention and 

treatment.6-9 Dental studies of the epidemiology of 

dental disease over the past 20 years consistently show 

that the prevalence of dental disease is not uniform 

within our population but is actually skewed.10,11

These studies demonstrate that 20% to 25% of the 

population harbor the majority of oral disease.12 The 

1994 Tri-Service Center for Oral Health Studies on 

Recruits and Active Duty revealed that the military 

population’s oral disease levels parallel what is seen 

within the US; however, the severity may actually be 

amplified. 

In conventional caries management, the suspicion of 

caries often leads to a restoration without an attempt to 

determine if caries is active, static, or remineralizing. 

The latest information on caries diagnosis and 

treatment suggests the need to review traditional 

strategies used in dental caries management. Caries 

risk assessment and management typically approach 

dental caries as an infectious disease process and 
PB 8-06-1/2/3 Jan/Feb/Mar 23

address the individual patient’s risk of disease. 

Interventions are based on the patient’s risk and known 

disease patterns. A relatively new practice in dentistry 

includes remineralization of incipient or noncavitated 

lesions. Where in the past such lesions would have 

been restored, the use of caries risk assessment can 

help identify those patients who would be best treated 

with traditional restorative dentistry versus those who 

would benefit from a remineralization program. 

The literature espouses many different CRA 

methodologies. DENCOM utilizes the CRA program 

and prevention strategies developed by the American 

Dental Association (ADA).13 This system relies 

heavily on past caries activity. Studies show that the 

best indicator for future caries is past caries 

experience.14,15 At each periodic oral examination, 

Soldiers are classified as being at low, moderate, or 

high risk for dental caries. Dental care providers must 

also take into account modifying factors in conjunction 

with the CRA parameters when placing a Soldier into 

a caries risk category. The guidelines advocated by the 

ADA are designed to assist the practitioner, but the 

practitioner’s professional judgment becomes 

paramount in the ultimate decision to place the Soldier 

into a specific category. Modifying factors for CRA 

classification include, but are not limited to: 

 cariogenic diet, 

 white spot lesions, 

 unusual tooth morphology including the presence 

of deep uncoalesced pits and fissures, 

 fluoride exposure, 

 oral hygiene, 

 frequency of dental visits, 

 medical conditions, especially those physical and 

mental conditions that limit personal oral 

hygiene, 

 medications, particularly those that predispose 

patients to decreased salivary flow, and 

 systemic conditions. 

Once patients are identified as high risk for dental 

disease, practitioners implement prevention activities 

tailored to the facilities and the supported populations. 

Education is a key component to prevention. Without 

proper knowledge, patients remain unable to affect a 

change in their personal activities. Deployed Soldiers 

face increased risk due to changes in diet and personal 

oral hygiene practices. In theater, challenges exist to 

access dental resources. For some patients at high risk 

for caries, dietary analysis and counseling prove very 

beneficial. Each treatment encounter provides the 

opportunity for basic oral hygiene instructions and 

nutrition counseling. These instructions are paramount 

as many incoming Soldiers have never received 

education on oral heath, and others benefit from 

educational reinforcement. 

Fluorides have proven beneficial for all at-risk 

patients, regardless of age. Perhaps the best prevention 

regimens in the dentist’s arsenal are community water 

fluoridation, home-applied fluorides, and 

professionally applied fluorides. Fluoride remains the 

single most important factor responsible for the 

decline of caries prevalence in children and adults.16

The proper frequency of professionally applied 

fluoride is determined through an assessment of 

fluoride exposure and the patient’s caries risk 

category. All moderate and high caries-risk Soldiers 

should receive a 4-minute fluoride treatment or a 

fluoride varnish application. All deploying Soldiers are 

considered high risk due to theater conditions. The 

degree of oral health degradation seen in redeployed 

Soldiers makes it imperative that dental personnel do 

everything possible to reduce the risk of oral health 

issues prior to deployment. 

Other noteworthy caries prevention tools include 

xylitol and chlorhexidine. Xylitol is a natural 

alternative sweetener used to sweeten gums and 

candies. Xylitol possesses antimicrobial actions and 

effectively reduces caries incidence when used 

regularly.17 Chlorhexidine is a topical rinse that kills 

Streptococcus mutans which can be professionally 

prescribed after removing active caries. 

Tobacco Risk Assessment 

Tobacco use is the single leading preventable cause of 

death in the US, accounting for 430,000 deaths each 

year.18 A study prepared by the Centers for Disease 

Control reported that tobacco was responsible for more 

deaths in the United States than AIDS, alcohol-related 

deaths, homicides, and automobile accidents 

combined.19 Tobacco serves as a risk factor for many 

diseases, including oral cancer, periodontal disease, 

heart disease, lung cancer, and other respiratory 

diseases. Tobacco use in any form potentially results 

in serious effects on human health. Tobacco control 
24 Army Medical Department Journal 

and intervention are consistent with the mission of 

military readiness. Smoking has also been shown to 

increase the risk of injury in a number of military 

populations, possibly due to unfavorable effects on the 

immune system.20-22 Healthcare providers have both 

professional and moral obligations to practice 

preventive medicine by encouraging tobacco cessation. 

Dental providers are afforded a unique opportunity to 

educate and influence patients on the hazards of 

tobacco use due to the frequency of Soldiers’ visits to 

the dental clinics, the preventive nature of dentistry, 

and the trust that patients place in dental providers. 

Additionally, the oral cavity is the usual site for the 

inhalation or ingestion of tobacco. Dentists’ unique 

knowledge of the portal of tobacco entry creates a 

prime opportunity for the diagnosis of pathology and 

education of patients. 

The total expense of tobacco use to the military and its 

impact on readiness may be underestimated. A recent 

study of Air Force recruits identified smoking as the 

best predictor for premature discharge from the 

military.23 Smoking was not necessarily the cause of 

the discharges, but was indicative of a general lifestyle 

that was not compatible with military life. The study 

concluded that Air Force recruits who smoke were 

responsible for $18 million of excess training costs per 

year. When this data was extrapolated to the 

Department of Defense (DoD), over $130 million per 

year was spent on excess training costs due to the early 

discharge of smokers from training. Two other Navy 

studies concluded that cigarette smoking was related to 

attrition from Naval basic training in a dose-response 

manner. In one study, smoking 0, 1, 2, and 3 packs per 

day was associated with attrition of 8%, 12%, 23%, 

and 28%, respectively.24 The other study found that 

smoking 0, 1, 2, and 3 packs per day were associated 

with attrition of 18%, 32%, 43%, and 54%, 

respectively.25

Dental providers must appreciate the value of 

counseling patients on tobacco use and the risks 

involved. Tobacco education is not limited to current 

tobacco users. Ensuring that tobacco-free Soldiers 

remain tobacco-free is equally as important as 

cessation education. Since so many Soldiers take up 

the habit once they join the military, every patient, 

whether they are a tobacco user or nonuser, requires 

counseling. Counseling both users and nonusers can be 

as simple as “Not using tobacco products is the single 

most important decision you can make for your 

health.” 

Dental clinics may opt to tailor their own tobacco 

cessation protocol or refer patients to other cessation 

activities on post. Tobacco education comes in 

multiple formats and can be participatory in nature as 

well. Providers need to identify that there are 

“teachable moments” in almost any dental encounter 

and utilize those moments to impart the tobacco 

message. As such, dental providers act as vital 

messengers of the tobacco cessation message. The 

recently released Veterans’ Affairs/DoD Tobacco 

Clinical Practice Guidelines for the Management of 

Tobacco Use suggest that individual tobacco 

interventions may be more successful than the 

traditional tobacco cessation classes for some 

Soldiers.26 At each annual dental examination, dentists 

classify a patient as a smoker, a user of smokeless 

tobacco, a user of multiple forms of tobacco, or not a 

user of tobacco. Time constraints and frustration with 

perceived low success rates often present a deterrent to 

tobacco counseling. Nonetheless, our Army greatly 

benefits from this health promotion program. 

The Agency for Healthcare Research and Quality 

(AHRQ) recommends the use of “The 5As” — ask, 

advise, assess, assist, and arrange — which were 

designed for simple counseling steps. Tobacco 

screening is the most important step to cessation. All 

patients should be asked if they use tobacco products 

and be advised of the hazards of tobacco. It is crucial 

to address tobacco use to all patients, whether they are 

currently using the products or not, because they may 

start. Tobacco users are strongly advised to quit. At 

this point, the Soldier’s willingness to quit is assessed. 

If they have no desire to even address quitting, the 

provider can utilize the AHRQ’s “5Rs” which will be 

discussed later. Once the patient is assessed, the 

provider can assist in setting up a quit date and then 

arrange for either a follow-up appointment or referral 

to a tobacco cessation class. If the patient is not ready 

to consider tobacco cessation, the “5Rs” — relevance, 

risks, rewards, roadblocks and repetition — are used. 

The information given to Soldiers must be relevant and 

motivational. The negative impact both financially and 

health wise are addressed as risks. Rewards are the 

potential benefits, both financial and health related. 
PB 8-06-1/2/3 Jan/Feb/Mar 25

Roadblocks are potential problems that may cause a 

patient to be unsuccessful. Finally, all “Rs” must be 

repeated each time a Soldier visits the clinic. 

Meals Ready to Eat (MRE) 

Other health promotion efforts focus on efforts to 

reduce degradation of dental readiness during 

deployment. MREs contain carbohydrate-rich foods 

essential for energy in a field environment, but which 

also contribute greatly to the potential for tooth decay. 

An oral health survey of a combat arms unit conducted 

in January 2004 confirmed that the amount of oral 

disease in Soldiers in a deployed combat arms unit 

doubled in 6 months.27 In February 2004, the Joint 

Services Operational Rations Forum approved the 

replacement of the sugared chewing gum currently in 

the MREs with a xylitol-containing variety. Defense 

Supply Service Center now uses xylitol gum in the 

current MRE version. Also, powdered drink mixes 

made with alternative sweeteners are replacing the 

sugar-sweetened drink mixes in the MREs. 

CONCLUSION

Health promotion continues to be a vital part of Army 

health care. The dental health promotion program has 

evolved to include significant initiatives to maximize 

Soldier health. The results of the prevention program 

easily translate into the ability to deploy healthier 

Soldiers and directly increase the readiness of the 

force. 

REFERENCES

1. Department of Health and Human Services, Public 

Health Service, Office of Disease Prevention and 

Health Promotion. Put Prevention Into Practice 

Education and Action Kit. Washington, DC; US 

Government Printing Office:1994. 

2. Bray RM, et al. 2002 Department of Defense Survey of 

Health Related Behaviors Among Military Personnel. 

RTI International; RTI/7841/006-FR; October 2003. 

3. Sohn W, Ismail AI, Tellez M. Efficacy of educational 

interventions targeting primary care providers' practice 

behaviors: an overview of published systematic 

reviews. J Public Health Dent. 2004;64(3):164-172. 

4. Chisick M. Put more bite into health promotion: a 

campaign to revitalize health promotion in the Army 

dental care system. Mil Med. 2001;166:1079-1086. 

5. Unpublished program evaluation data collected in 2004 

by Ms. Carlla Jones, Program Coordinator, Health 

Promotion and Prevention Initiatives Program, US 

Army Center for Health Promotion and Preventive 

Medicine. 

6. Newbrun E, Leverett D. Risk assessment dental caries 

working group summary statement. In Bader JD, ed. 

Risk Assessment in Dentistry. Chapel Hill: University of 

North Carolina Dental Ecology; 1990. 

7. Leverett DH, Featherstone JD, Proskin HM, Adair SM, 

Eisenberg AD, Mundorff-Shrestha SA, Shields CP, 

Shaffer CL, Billings RJ. Caries risk assessment by a 

cross-sectional discrimination model. J Dent Res. 

1993;72(2):529-537. 

8. Beck JD, Weintraub JA, Disney JA, Graves RC, Stamm 

JW, Kaste LM, Bohannan HM. The University of North 

Carolina caries risk assessment study: comparisons of 

high risk prediction, any risk prediction, and any risk 

etiologic models. Community Dent Oral Epidemiol. 

1992;20(6):313-321. 

9. Disney JA, Graves RC, Stamm JW, Bohannan HM, 

Abernathy JR, Zack DD. The University of North 

Carolina caries risk assessment study: further 

developments in caries risk prediction. Community Dent 

Oral Epidemiol. 1992;20(2):64-75. 

10. Caplan DJ, Weintraub JA. The oral health burden in the 

United States: a summary of recent epidemiological 

studies. J Dent Educ. 1993;57(12):853-862. 

11. Burt BA. Trends in caries prevalence in North 

American children. Int Dent J. 1994;44:403-413. 

12. Kaste LM, Selwitz RH, Aldakowski RJ, Brunelle JA, 

Winn DM, Brown LJ. Coronal caries in the primary and 

permanent dentition of children and adolescents 1–17 

years of age: United States, 1988–1991. J Dent Res. 

1996;75(spec issue):631-641. 

13. Caries diagnosis and risk assessment: a review of 

preventive strategies and management. J Am Dent 

Assoc. 1995;126(spec suppl):S2-S3. 

14. Seppa L, Hausen H, Pollanen L, Helasharju K, 

Karkkainen S. Past caries recordings made in public 

dental clinics as predictors of caries experience in early 

adolescence. Community Dent Oral Epidemiol. 

1989;17:277-281. 

15. Hill IN, Blayney JR, Zimmerman SO. Deciduous teeth 

and future caries experience. J Am Dent Assoc. 

1967;74:430-434. 

16. Scheinin A, Banoczy J, Szoke J, et al. Collaborative 

WHO xylitol field studies in Hungary: three-year caries 

activity in institutionalized children. Acta Odonto 

Scand. 1985;43:327-347. 
26 Army Medical Department Journal 

17. Trahan L. Xylitol: a review of its action on mutans 

streptococci and dental plaque – its clinical 

significance. Int Dent J. 1995;45:77-92. 

18. McGinnis JM, Foege WH. Actual cases of death in the 

United States. JAMA. 1993;270:2207-2212. 

19. CDC. Projected smoking-related deaths among youth – 

United States. MMWR CDC Morbid Surveill Sum. 

1996;45:971-974. 

20. Knapik JJ, Sharp MA, Canham-Chervak ML, Hauret K, 

Patton JF, Jones BH. Risk factors for training-related 

injuries among men and women in basic combat 

training. Med Sci Sports Exerc. 2001;33:946-954. 

21. Jones B, Knapik JJ. Physical training and exerciserelated injuries: surveillance, research, and injury 

prevention in military populations. Sports Med. 

1999;27:111-125. 

22. Altarac M, Gardner JW, Popovich RM, Potter R, 

Knapik JJ, Jones BH. Cigarette smoking and exerciserelated injuries among young men and women. Am J 

Prev Med. 2000;18(S3):96-102. 

23. Klesges RC, Haddock CK, Change CW, et al. The 

association of smoking and the cost of military training. 

Tob Control. 2001;10(1):43-47. 

24. Quester AO. Boot camp attrition rates: predictions for 

FY 1999. Alexandria, VA: Center for Naval Analysis; 

1999. Report No. CAB 99-57. 

25. Larson GE, Booth-Kewley S, Ryan AK. Predictors of 

Naval attrition, II: a demonstration of potential 

usefulness for screening. Mil Med. 2002;167:770-776. 

26. Veterans Administration, DoD Clinical Practice 

Guidelines for the Management of Tobacco Use. 

Washington, DC: Department of Veteran Affairs; 2004. 

27. Unpublished data collected in 2004 by LTC de la Cruz 

and COL Inouye, Directorate of Health Promotion and 

Wellness, US Army Center for Health Promotion and 

Preventive Medicine. 

AUTHORS

Pamila Richter is the Health Promotion Director at the US 

Army Dental Command, Fort Sam Houston, TX. 

LTC de la Cruz is the Dental Public Health Staff Officer at 

the Directorate of Health Promotion and Wellness US Army 

Center for Health Promotion and Preventive Medicine, 

Aberdeen Proving Ground, MD. 

LTC Chaffin is a resident in the US Army-Baylor Graduate 

Program in Health Care Administration, Fort Sam Houston, 

TX. 
PB 8-06-1/2/3 Jan/Feb/Mar 27

INTRODUCTION

As distinguished from Component 1, which is the 

Army Active Component (AC), the Army Reserve 

Components (RC) consist of Component 2, the Army 

National Guard (ARNG), and Component 3, the US 

Army Reserve (USAR). During the First Gulf War, 

over 150,000 Army RC Soldiers were mobilized for 

active duty. In the largest call up since the Korean 

War, over 350,000 Army RC Soldiers have been 

mobilized since 9/11 for the Global War on Terrorism 

(GWOT). In March 2001, the American Forces 

Information Services News Articles quoted an Army 

Reserve source stating “roughly 35 to 45 percent of 

Army Reservists activated during the Gulf War needed 

dental work before they could deploy.”1

 In February 

2004, The Military Coalition, a consortium of 

nationally prominent uniformed services and veterans’ 

organizations, presented testimony to the Total Force 

Subcommittee of the House Armed Services 

Committee stating “the number one deployment 

problem in the First Gulf War was dental ‘unreadiness,’ and the same is true today.”2

 This article 

provides a brief review of improvements in the dental 

readiness and dental mobilization processing of the 

Army RC between the first Gulf War and present 

GWOT operations. 

HISTORICAL PERSPECTIVE

In 1968, the Army implemented the Oral Health 

Maintenance Program which targeted younger Army 

Active Component Soldiers by requiring an annual 

dental exam and appointments to eliminate adverse 

dental conditions. This was in response to dental 

nonbattle injury emergency rates that averaged 16% 

during Vietnam.3,4

 The Army identified dental 

readiness as a deployment priority for commanders 

during the 1980s and initiated the Oral Health Fitness 

Program. The program identified Army AC Soldiers at 

the highest risk of being a dental casualty through the 

use of a Dental Fitness Classification (DFC) 

numbering system of DFC 1 thru DFC 4. This system, 

which is in use today, labels a DFC 1 Soldier as 

needing no examination or treatment procedures 

within the next 12 months. Soldiers in DFC 2 do 

require routine treatment but the conditions present are 

not expected to cause a dental emergency within the 

next 12 months. Soldiers classified as DFC 3 have 

dental disease conditions that will likely cause a dental 

emergency within the next 12 months. Classification 

DFC 4 indicates that an annual exam is required to 

determine a DFC.

5 Commanders began receiving 

monthly reports on the dental readiness of their troops 

and only Soldiers in a DFC 1 or DFC 2 status were 

recommended for deployment into theatre. Soldiers in 

DFC 4 cannot be deployed until a DFC is determined. 

Soldiers in DFC 3 are not considered deployable 

because studies have identified that deployed DFC 3 

Soldiers experience significantly higher dental 

emergency rates than Soldiers in DFC 1 or DFC 2.6,7

During this period, the US Army Dental Command 

(DENCOM) set goals to maintain 95% of the Army 

AC in DFC 1 or DFC 2, contributing to the rapid 

deployability of these forces. 

In contrast, the Army RC, which now consists of over 

550,000 Soldiers, did not have a command directed or 

funded dental readiness program during this same 

period. This contributed to the previously noted poor 

states of dental readiness during the First Gulf War.

US Army Reserve Dental Service Detachments were 

activated in August 1990 to augment the Army AC 

dental corps in preparing Army RC Soldiers for 

deployment. During the 1990s, the poor state of Army 

RC dental readiness identified during the Gulf War 

mobilizations did not bring substantial changes in 

addressing the issues. In 1998, the Department of 

Defense (DoD) issued HA policy 98-021 which 

directed that Active Duty (i.e., Active Component) and 

Army Reserve Components Dental 

Readiness — A Historical Review Since 

the First Gulf War 

COL Mark B. Bodenheim, DC, USAR 
28 Army Medical Department Journal 

Selected Reserve personnel (excluding members of the 

Individual Ready Reserve or IRR) undergo a periodic 

dental examination on an annual basis.8

 Although this 

policy created an examination requirement for all DoD 

RC personnel, it did not fund a contracted method to 

meet that requirement. By the close of the 20th 

century, the introduction of the Army RC Tricare 

Dental Program provided the first funded program for 

Army RC dental readiness. However, it was an 

optional program requiring monthly premiums and 

treatment copayments from the Soldier, thereby 

resulting in a poor participation rate. Small Army RC 

units mobilized between 1997 and 2001 continued to 

present to deployment stations with DFC 3 rates 

ranging from 14% to 36%.9-11

INITIAL GWOT MOBILIZATIONS

The terrorist attacks of September 11, 2001 once again 

brought the spotlight on the state of Army RC dental 

readiness. The beginning of a command directed and 

funded dental readiness program with no cost to the 

Army RC Soldier began to take shape in 2002 when 

premobilization annual dental “screenings” to remove 

Soldiers from DFC 4 status were provided by Army 

RC military and contracted dental personnel. The key 

word here is “screening.” Army RC dental exam 

regulations only required a tongue blade dental 

screening without radiographs — regulation relics of 

World War II. On the other hand, Army AC Soldiers 

treated within DENCOM facilities received an annual 

dental examination to include radiographs, which meet 

existing standards of care.12 The large scale Army RC 

mobilizations that began in January 2003 for 

Operation Iraqi Freedom revealed the folly of this 

double standard when DENCOM facilities had to 

repeat examinations of nearly all Army RC Soldiers to 

the AC standard of care. In addition, DFC 3 rates 

showed little improvement from the First Gulf War 

operations. From January through August of 2002, 

Army RC Soldiers mobilized for Operation Noble 

Eagle and Operation Enduring Freedom presented to 

mobilization platforms with DFC 3 rates of 25%.13 In 

January 2003, over 20 Medical Support Units, the 

Army’s new processing support unit consisting of 

USAR medical and dental personnel used to augment 

MEDCOM AC personnel, were mobilized. Even with 

this augmented support, internal DENCOM statistics 

indicated that 65% of the workload needed to deploy 

the Army RC was performed by AC Dental Corps 

personnel. Once again, precious manpower was 

diverted from maintenance of the Army’s AC dental 

readiness goals for Component One Soldiers. 

CHANGES IN POLICY

In June 2003, the DENCOM commander, COL Sidney 

Brooks, directed his mobilization staff to begin 

exploring Army RC dental readiness deficiencies and 

ways to improve the dental readiness processing of 

Army RC Soldiers arriving at mobilization platforms. 

This included creating a “One Army” dental readiness 

examination and documentation standard that would 

be applied to all three Army components. Working 

through policy changes implemented by the dental 

surgeons of the ARNG and USAR, use of the “One 

Army” dental exam standard by the Army RC began 

in April 2004. By February 2005, the revised Army 

RC dental examination standards were published in 

Army Regulation 40-501.

14 According to internal 

DENCOM statistics, increased funding appropriated to 

the Army RC to improve dental readiness combined 

with command emphasis and published Army RC 

examination standards significantly reduced the Army 

RC examination rate at mobilization platforms from 

87% in December 2003 to 48% by December 2005. 

The next directive focused on reduction of the Army 

RC DFC 3 rate presenting to Army dental stations at 

the mobilization platforms. DFC 3 dental treatments 

performed at mobilization platforms consume time that 

could be spent on predeployment training. Studies 

have indicated that DFC 3 treatment time ranges from 

2 to 2.75 hours.15,16 This lost time factor does not 

include the loss of training time due to transportation 

for appointments or Soldiers assigned to quarters or 

light duty in order to recuperate from some dental 

treatment procedures. Beginning in November 2002, 

Army RC Soldiers receiving mobilization orders were 

permitted to receive DFC 3 treatment at no cost in 

order to improve premobilization access to DFC 3 

dental treatment. Due to the short time between receipt 

of the mobilization order and the report date at the 

mobilization platform, DFC 3 rates did not improve. 

This situation precipitated a change in law authorizing 

treatment upon receipt of an alert order. The change 

permitted more time for completion of treatment prior 

to arrival at mobilization platforms. However, in the 

arena of DFC 3 rates, less dramatic improvements 

occurred during GWOT operations. According to 

internal DENCOM statistics, Army RC Soldiers 

presenting to mobilization platforms in a DFC 3 status 
PB 8-06-1/2/3 Jan/Feb/Mar 29

improved from 22% in December 2003 to 16% in 

December 2005. 

DENCOM MOBILIZATION OPERATIONS

In comparison to the First Gulf War, the numbers and 

duration of Army RC Soldiers mobilized through the 

Army Dental Care System (ADCS) during the present 

GWOT operations are significantly greater. The 

increased workload and its duration identified issues 

within the Soldier Readiness Processing (SRP) dental 

station operations located at each mobilization 

platform. During the First Gulf War, mobilization 

operations affected the ADCS for less than a year and 

standardization of processing procedures was not a 

priority. With the present duration of GWOT 

mobilization operations, it was necessary to implement 

long-term standardized processing protocols at SRP 

dental stations. This action was necessary to improve 

processing efficiency, create accurate data measuring 

tools, and reduce duplication of Army RC 

premobilization dental readiness services. Using 

lessons learned and input from SRP dental station 

personnel, DENCOM issued initial operational 

standards for all SRP dental stations in July 2005. 

CONCLUSION

Although significant progress in Army RC dental 

readiness has been accomplished between the First 

Gulf War and present GWOT operations, a 

continuation of improvements must occur in order to 

reach the DoD goal of 95% dental readiness (Dental 

Class 1 or 2) for the RC as reaffirmed in DoD HA 

policy 06-001.17 The Army RC is no longer the second 

or third line of the deploying force. The RC now 

deploys with the first line operational force alongside 

their AC counterparts. The DENCOM has initiated the 

First Term Dental Readiness program which ensures 

that DFC 3 AC and RC Soldiers are treated before 

graduation from AIT training. The future conversion to 

electronic dental records will greatly reduce the 

incidents of missing examination and treatment 

documentation which currently cause re-examination 

of Soldiers at the SRP dental stations. Reducing DFC 3 

rates after the Soldier has graduated from AIT is a 

more complicated subject. Since treatment is 

authorized only during the time between the alert of 

the unit and its arrival at the mobilization platform, a 

unit commander and staff may find it difficult to 

coordinate multiple dental appointments for significant 

percentages of the unit’s Soldiers who are DFC 3 

while attending to those numerous other 

premobilization requirements. As one of the possible 

solutions to this problem, the Army should explore a 

dental plan to provide Soldiers with no cost DFC 3 

treatment throughout the year rather than only upon a 

mobilization alert. A major paradigm shift concerning 

the dental readiness of its Reserve Components has 

occurred within the Army. Stakeholders should be 

pleased and understand the importance of continuing 

this improvement into the future. 

REFERENCES

1. Rhem KT. New TRICARE Program to Boost Dental 

Readiness of Reserves. American Forces Information 

Service News Articles, March 21, 2001. 

2. Washington R, Schwartz S. Statement of the Military 

Coalition. Total Force Subcommittee, House Armed 

Services Committee, February 25, 2004. 

3. Hutchins DW, Barton RF. Epidemiology of Oral 

Emergencies in Combat. Washington, DC: US Army 

Institute of Dental Research; Report #CSCRD1031967. 

4. Ludwick WE, Gendron EG, Pogas JA, et al. Dental 

emergencies occurring among Navy-Marine personnel 

serving in Vietnam. Mil Med. 1974:139;121-123. 

5. Policy on Standardization of Oral Health and 

Readiness Classifications. Health Affairs Policy 02-

011. Washington, DC, Assistant Secretary of Defense, 

June 2002. 

6. Teweles RB, King JE. Impact of troop dental health on 

combat readiness. Mil Med. 1987;152:233-235. 

7. Chaffin JG, King JE, Fretwell LD. US Army dental 

emergency rates. Mil Med. 2001;166:1074-1078. 

8. Policies on Uniformity of Dental Classification System, 

Frequency of Periodic Dental Examinations, Active 

Duty Overseas Screening, and Dental Deployment 

Standards. Health Affairs Policy 98-021. Washington, 

DC, Assistant Secretary of Defense, February 1998. 

9. Chaffin JG and Horning T. RC dental readiness in 

‘Call Forward 97.’ Army Med Dept J. 1998:29-33. 

10. Chaffin JG, King JE, Fretwell LD. US Army dental 

emergency rates. Mil Med. 2001;166:1074-1078. 

11. Chaffin JG, Brooks S, Kahue P. Dental cost of 

deploying a National Guard unit to Bosnia. Mil Med. 

2002;167:474-477. 

12. Periodic Oral Evaluations. US Army Dental Command 

Policy Letter 05-25; DENCOM Commander, Fort Sam 

Houston, TX, January 2006. 
30 Army Medical Department Journal 

13. Moss DL, York AK, Mongeau SW. Oral Health Status 

and Treatment Needs of Army Reserve Component 

Soldiers. Tri-Service Center for Oral Health Studies 

(TSCOHS), Uniformed Services University of the 

Health Sciences, Bethesda, MD, February 2003. 

14. Standards of Medical Fitness. Army Regulation AR 40-

501, Page 102, 10-27, Washington, DC, Headquarters, 

Department of the Army, February 2005. 

15. Amstutz RD, Shulman JD, Williams TR. Dental Fitness 

Class 3 Treatment Needs; A Report of Consultation. 

Defense Technical Information Center; Report CR 92-

066. US Army Medical Center and School, 1992. 

16. Chaffin JG, Mazuji N. Class 3 Treatment Time. Mil 

Med. 2004;169:696-698. 

17. Policies on Oral Health and Readiness. Health Affairs 

Policy 06-001. Washington, DC, Assistant Secretary of 

Defense, January 2006. 

AUTHOR

COL Bodenheim is the Individual Mobilization 

Augmentation Commander, Reserve Affairs. He is currently 

on staff at the US Army Dental Command, Fort Sam 

Houston, TX. 
PB 8-06-1/2/3 Jan/Feb/Mar 31

The Army Dental Corps is recognized for its 

outstanding dental graduate training opportunities. The 

availability of appealing Graduate Dental Education 

(GDE) programs serves as a powerful recruiting and 

retention tool and enhances the quality of our team and 

the dental care we provide to maintain the force. 

Congress established the F. Edward Hébert Armed 

Forces Health Professions Scholarship Program 

(AFHPSP) for Dentistry which significantly increased 

the number of obligated new accessions and created 

tremendous new opportunities for recent dental school 

graduates eligible for postgraduate dental education. 

The residency and fellowship programs vary from year 

to year and are designed to both optimize Dental Corps 

force management and offer its officers educational 

and financial incentives. This article describes these 

recent changes in the GDE application and selection 

process. 

PROGRAM PARAMETERS

The selection of specialty programs and number of 

residents trained are validated annually by the Dental 

Corps representative of the Army Medical Department 

(AMEDD) Personnel Proponent Directorate (APPD). 

In this role, APPD is responsible for building the 

AMEDD of tomorrow by designing officer career 

fields that support the Army’s mission. Modifications 

in the selection process for GDE opportunities 

significantly affect life cycle management and assist 

the Corps in its recruiting and retention initiatives. A 

climate of opportunity has been created which matches 

the individual officer’s expectations with the needs of 

the Army Dental Corps. 

Educational standards for dental professionals in the 

US are maintained by periodic postgraduate program 

accreditation by the Commission of Dental 

Accreditation (CODA) in association with the 

American Dental Association (ADA). Advanced 

training in general dentistry is available through 1-

Year Advanced Education in General Dentistry 

(AGD-1) Programs at the following sites: Fort 

Benning, GA; Fort Campbell, KY; Fort Carson, CO; 

Fort Lewis, WA; Fort Jackson, SC; and Fort Sill, OK. 

AGD-1 programs provide additional clinical training 

for dentists in the performance of increasingly 

complicated clinical procedures. Students are accepted 

on the basis of their grades in dental schools, class 

rank, their scores in the National Dental Board 

Examination Parts I and II, and letters of 

recommendation. 

Postgraduate dental education programs include 

residency programs in the ADA-recognized specialties 

of dental public health, endodontics, oral and 

maxillofacial pathology, oral and maxillofacial 

surgery, orthodontics, pediatric dentistry, periodontics, 

and prosthodontics. 

FELLOWSHIP AND PHD TRAINING

Fellowship and PhD training in the Army Dental 

Corps produces highly qualified dental officers for 

utilization in specific specialized areas of dentistry. 

For example, an Oral and Maxillofacial Surgery 

Fellowship is offered which allows oral and 

maxillofacial surgeons an opportunity to attend a 1-

year course of instruction for the purpose of obtaining 

advanced clinical skills. In the past 5 years, these 

fellowships have included advanced training primarily 

in the fields of trauma and cosmetic surgery. 

Following training, graduates typically are assigned as 

Program Directors, Assistant Program Directors, or 

mentors in one of the Army’s six Oral and 

Maxillofacial Surgery residency programs, thus further 

propagating their newly acquired special skills. 

Fellowships with sister federal services are also 

available. In 2004, the first Army resident went to the 

Orofacial Pain Fellowship at the Orofacial Pain 

Center, Naval Postgraduate Dental School, National 

Naval Medical Center, Bethesda, MD. This specific 

area of dentistry is concerned with the diagnosis and 

Evolving Education Trends in Graduate 

Dental Education 

COL Ann Sue von Gonten, DC, USA 

COL Kay H. Malone, DC, USA 
32 Army Medical Department Journal 

management of pain and dysfunction of the motor and 

sensory components of the trigeminal nerve system. In 

the past, these types of disorders were referred to as 

“temporomandibular disorders.” However, growing 

evidence in the field indicates that patients may have 

signs and symptoms external to the masticatory system 

that refer pain to the head and neck area. The 

fellowship affords Army dentists a unique opportunity 

to obtain the merged set of skills required to manage a 

patient population that formerly fell outside the realm 

of traditional medicine and dentistry. Graduates of this 

program are typically assigned to an Oral and 

Maxillofacial Surgery Residency Program to better 

facilitate a team approach for the management of 

complex issues presented by orofacial pain patients. 

Another fellowship program offered through sister 

federal services is the 1-year Maxillofacial Prosthetics 

Fellowship. A maxillofacial prosthodontist (AOC 63F) 

has completed a 1-year fellowship in the field of 

maxillofacial prosthetics. Maxillofacial prosthetics 

encompasses the rehabilitation of patients presenting 

with congenital or acquired head and neck defects. 

Acquired defects include those defects resulting from 

surgical treatment, trauma, or pathology. Nonliving 

tissue substitutes in the form of prostheses may be 

used in extraoral prostheses involving the ear, nose, 

eye, or other head and neck structures. Intraoral 

prostheses are used to reconstruct oral cavity defects of 

the maxilla and mandible as well as associated 

structures. The maxillofacial prosthodontic training 

emphasizes a team approach to rehabilitative services 

with other medical specialties. Areas of concentration 

include palatopharyngeal function, radiation therapy, 

chemotherapy, and oculofacial defects. The Army 

Dental Corps has approximately five utilization tours 

for maxillofacial prosthodontists. These assignments 

are typically located at the Army’s major medical 

centers. 

Specialists are also offered PhD and fellowship 

training opportunities in dental materials. Program 

graduates participate in a utilization tour at the US 

Army Dental and Trauma Research Detachment which 

conducts research and development in military 

dentistry and the treatment of combat maxillofacial 

injuries. This includes research to devise new and 

improved methods of emergency surgical management 

of maxillofacial wounds on the battlefield and to 

develop improved methods of treating oral and 

maxillofacial wound infections. Graduates will also be 

involved in epidemiological investigations of field 

dental needs and in the development of dental 

materials, equipment, devices, methodologies, and 

materials that enhance combat dental services. 

Especially significant work is being done to lower the 

14% to 19% deployment dental emergency rate. 

NEUTRAL YEAR

DoD Instruction (DODI) 6000.131 specifies key active 

duty service obligation (ADO) information for Health 

Professions Scholarship Program (HPSP) recipients. 

Section E2.1.15 addresses Graduate Professional 

Education (GPE), of which GDE is a subset, and 

defines ADOs for internships such as the Army’s 1-

Year Advanced Education in General Dentistry 

Program. DODI 6000.13 notes that “while internship 

(GPE-1) is included in the definition of GPE, it is 

obligation neutral; i.e., an ADO is neither incurred nor 

discharged during internship.” 

In 2001, the Dental Corps issued the following policy 

in compliance with DODI 6000.13: 

“All personnel who entered the HPSP on or after 

1 Oct 2002 will not discharge nor incur any 

obligation while participating in AGD-1. 

Personnel who entered the HPSP or have military 

service obligations incurred through subsidized or 

pre-professional education or training (i.e., HPSP, 

ROTC) prior to 1 Oct 2002, will discharge 

obligation while participating in AGD-1. ROTC 

obligors who enter the AGD-1 prior to 1 Oct 

2006 will also discharge obligation while 

participating in AGD-1.”2 

EXPANDED DENTAL GRADUATE TRAINING

OPPORTUNITIES

Traditionally, senior dental students and newly 

accessed officers could apply only for the AGD-1 

program. Selection to attend an Army dental specialty 

training program was limited to dentists who were 

currently serving on active duty with the Army. 

However, dental accessions entering the Army Dental 

Corps in FY 2002 with an active duty service 

obligation were allowed to apply for specialty training 

as well as the AGD-1 program. Thus, FY 2002 

accessions competed for training slots with current 

active duty dental officers. Accelerated opportunities 

for earlier board certification increases availability of 

incentive pays to a larger number of officers early in 

their careers — a critical retention tool. Residents 
PB 8-06-1/2/3 Jan/Feb/Mar 33

enrolled in 2-year or greater specialty training 

programs are not eligible to receive Dental Additional 

Specialty Pay (DASP). However, these officers have 

the opportunity to become board certified following 

successful completion of the program and thereby will 

be eligible for Board Certified Specialty Pay (BCP) 

very early in their careers. Officers selected for 

training will also have an accelerated opportunity to 

execute Dental Multiyear Retention Bonus incentive 

contracts. The personal financial implications of loss 

of DASP during the initial entry years, when payment 

schedules are at a minimum, can quickly be offset by 

early qualification for BCP. The Dental Corps benefits 

from early training opportunities by producing an 

increased number of highly trained dentists providing 

quality dental care for eligible beneficiaries. 

The HPSP and otherwise obligated accessions are 

eligible to apply for dental specialty training programs 

in the following specialties: 2-Year Advanced 

Education in General Dentistry Program (AGD-2), 

periodontics, endodontics, prosthodontics, pediatric 

dentistry, orthodontics, oral, and maxillofacial surgery, 

and oral and maxillofacial pathology. FY 2002 

accessions selected for the AGD-2 residency training 

by the December 2001 board were scheduled to begin 

training as early as July 2002 in lieu of attending an 

AGD-1 program. New accessions for all other 

specialty training were selected 18 months in advance 

of the residency start dates to enter the July 2003 

training programs. These officers were either prepositioned for duty at the installation where they 

would train, or they may have attended a planned 

AGD-1 program in the US and were then reassigned 

for residency training. 

Two annual selection boards are held: (1) The 

December dental specialty board administered by the 

GDE administrators and the Army Human Resources 

Command, and (2) the February AGD-1 board 

administered by the US Army Recruiting Command 

(USAREC). The AGD-1 board also accepts 

applications for any available unfilled FY specialty 

training positions. Officers not selected for residency 

training in an ADA-approved dental specialty are not 

precluded from applying to the February AGD-1 

board. Students not selected or who do not desire to 

compete for 2-year (or greater) GDE programs are still 

eligible to apply for the traditional AGD-1 training 

programs. 

DUAL TRAINING

In 2001, a policy was implemented which provides 

general dentistry officers (AOC 63B) the opportunity 

to apply for a second graduate dental specialty training 

program. Officers must meet the following criteria: (1) 

successful completion of a primary residency in a 

dental specialty recognized as such by ADA and/or 

federal services, (2) achievement of certification by the 

recognized specialty board in the officer's primary 

specialty, and (3) service for a period of 5 years in the 

active component US Army Dental Corps in their 

primary specialty. While the policy in no way 

guarantees selection for a second residency, 

opportunities to compete for secondary training in 

another specialty will exist as long as the policy is in 

effect. 

DIRECT ACCESSION TRAINING OPPORTUNITIES

Despite many requests, prior to 2002 GDE policy 

prohibited direct accession application to advanced 

education training opportunities. In FY2002, USAREC 

allowed direct accessions to apply for both the AGD-1 

and AGD-2 programs. The policy does not extend to 

those under current obligation to another branch of 

federal service. A direct accession officer incurs a 3-

year initial ADO which is not concurrent with 

residency training. If the officer attends a civilian 

training program, the remainder of the initial 3-year 

ADO and the newly incurred training ADO will be 

consecutive (additive). 

CHANGE IN PREREQUISITES REQUIREMENTS

FOR RESIDENCY PROGRAMS

Other changes in prerequisite requirements for 

residency programs have occurred in certain dental 

specialties. In April 2001, the ADOs for orthodontics 

and endodontics increased from 2 years to 3 years. 

Effective May 2004, Dental Corps policy was 

amended to recognize those qualified applicants with 

significant active duty service experience. The current 

criteria for residency selection states that “When 

sufficient numbers of active duty applicants exist, 

applicants to endodontics, orthodontics, and pediatric 

dentistry must have a minimum of 2 years active duty 

service prior to the first day the residency selection 

board convenes.”2 
34 Army Medical Department Journal 

REFERENCES

1. Department of Defense Instruction 6000.13. Medical 

Manpower and Personnel. 30 June 1997. 

2. Policy Revision of Obligation – Advanced General 

Dentistry Program (AGDP-1). US Army Medical 

Command. 1 October 2002. 

AUTHORS

COL von Gonten is currently on staff at the United States 

Army Dental Command, Fort Sam Houston, TX and serves 

as the Dental Consultant. 

COL Malone is the Chief, Graduate Dental Education, 

Academy of Health Sciences, US Army Medical 

Department Center and School, Fort Sam Houston, TX. 
PB 8-06-1/2/3 Jan/Feb/Mar 35

Caries is an infectious disease process caused by 

bacteria. The bacteria involved are primarily 

Streptococcus mutans and Lactobacillus.

1,2 The 

process is dynamic, characterized by periods of 

demineralization and remineralization.1,3 If 

demineralization is allowed to continue, the enamel 

surface will eventually lose its integrity, resulting in a 

hole formation (cavitation). As Steinberg4

 points out, 

“Prior to cavitation, the caries process is considered to 

be reversible.”

Caries diagnosis remains a difficult task. In North 

America, caries is often diagnosed using tactile (often 

with use of a dental explorer), visual (light and 

magnification), and radiographic means. The use of an 

explorer to diagnose caries is not considered to be 

consistently accurate and may lead to a false positive 

diagnosis or to the unnecessary destruction of tooth 

structure.5

 Technological advances such as the 

DIAGNOdent Caries Detector (KaVo America Corp., 

Lake Zurich, IL 800/323-8029) have shown promise in 

the diagnosis of occlusal caries.1,6 Compared to 

traditional examination methods for the detection of 

occlusal caries (use of mirror, explorer, and 

magnification loupes), DIAGNOdent has been shown 

to have a higher sensitivity (0.92) than traditional 

methods (0.82).6

Use of the electronic caries monitor (ECM) has also 

shown some promise for the detection of enamel and 

dentin caries in occlusal surfaces of posterior teeth. 

Sensitivity values for ECM regarding the detection of 

noncavitated occlusal caries have been shown to range 

from 0.65–0.78.7

 Visual inspection methods for the 

detection of occlusal enamel caries resulted in a 

sensitivity of 0.60. Use of bitewing radiographs or 

fiber-optic trans-illumination have been shown to be 

inefficient for the diagnosis of occlusal caries.7

Dentists routinely rely on bitewing radiographs to help 

diagnose interproximal caries. Unfortunately, while 

radiographs do provide information about variations in 

mineral density, they provide no clue as to whether or 

not a lesion is cavitated.8

 Also, radiograph imaging 

exposes patients to ionizing radiation.9

Recently, use of Digital Imaging Fiber-Optic Transillumination, (DIFOTI®, registered trademark of 

Electro-Optical Sciences, Inc., Irvington, NY 800/729-

8849) for the diagnosis of interproximal caries has 

been evaluated and has shown promise in the detection 

of interproximal, occlusal, and smooth surface carious 

lesions. DIFOTI has been shown to have a sensitivity 

value of 0.56 compared to 0.21 for bitewing 

radiographs when used for the detection of 

interproximal caries. DIFOTI has also been shown to 

be three times more sensitive than radiographs for the 

detection of occlusal caries.10

DIFOTI uses a fiber-optic illuminator in a disposable 

mouthpiece to deliver light to a tooth surface. The light 

travels through tooth structure and is captured by an 

electronic charged coupling device (CCD) camera. 

The camera digitally images the light and projects the 

image on a computer monitor in real time (Figure 1). 

Carious tooth structure scatters and absorbs more light 

than the surrounding healthy tooth structure. 

Demineralized areas will appear darker compared to 

the more translucent brighter background of 

surrounding caries-free tooth structure. 

DIFOTI received FDA approval in 1999. This 

promising technology has potential to allow a dentist 

to evaluate demineralization on all tooth surfaces as 

well as inspect for tooth fractures and defective 

restorations.1

Investigation Into Use of Digital Imaging 

Fiber-Optic Trans-Illumination (DIFOTI®) 

in Caries Detection 

MAJ Jerry Carbone, DC, USA 

COL Bernard Hennessy, DC, USA 

COL (Ret) Steven Hondrum, DC, USA 
36 Army Medical Department Journal 

This study was conducted to determine sensitivity and 

specificity of detecting the presence and extent of 

interproximal carious lesions using both traditional 

examination techniques (bitewing radiographs) and 

DIFOTI on 32 extracted maxillary and mandibular 

teeth. 

MATERIALS AND METHODS

Extracted human adult teeth were collected from three 

US Army dental clinics. Teeth were examined for 

inclusion in the study; any teeth exhibiting gross 

decay, missing tooth anatomy or large restorations 

were excluded. Eventually, 32 teeth which showed 

possible signs of the presence of caries based on visual 

inspection were selected. Teeth were stored in 5% 

neutral buffered formalin. The selected teeth were 

mounted in pairs with interproximal surfaces in 

contact to simulate the relationship found in the dental 

arch. Teeth were mounted in medium pink baseplate 

wax for support and numbered. 

The wax was melted into a 1-

inch cube formed around the 

paired teeth with only the 

clinical coronal portion of the 

teeth visible above the wax. 

The blocks of teeth were 

photographed from the buccal 

side (Figure 2). 

The project consisted of four 

phases. During Phase 1, the 

visible surfaces of each tooth 

were cleaned with prophy 

paste and a rubber cup as 

recommended prior to use of 

the DIFOTI system. The DIFOTI system was used to 

image each set of mounted teeth showing both buccal 

and lingual views (Figure 3). Each image was 

Figure 2. Teeth mounted in wax photographed 

from the buccal side. 

Figure 1. Differences in imagery obtained using trans-illumination and radiography (Reprinted 

with permission from Electro-Optical Sciences).

Figure 3. Buccal and lingual DIFOTI images of specimen 24. 
PB 8-06-1/2/3 Jan/Feb/Mar 37

identified with appropriate tooth numbers. All DIFOTI 

images were made by the primary author (Carbone). 

Images were saved on CD-ROM for future viewing. 

After completion of DIFOTI imaging, each block of 

teeth was radiographed. Exposures were made at 70 

kVp (kilovoltage peak) and 7 mA (milliamperage) on 

Kodak DF58 Ultraspeed periapical film using the 

Gendex GX 770 Intraoral X-ray System. The source-to

-film distance for each radiograph was 21 centimeters. 

Each pair of specimens was exposed. Films were 

developed at the same time using the A/T 2000® XR 

film processor (Air Techniques, Inc., Hicksville, NY, 

800-247-8324). Each pair of specimen numbers was 

exposed on film for use later in the assessment phase 

(Figure 4). 

Phase 2 involved five dentists, each of whom was 

participating in a 1-year Advanced Education in 

General Dentistry Program and had less than 9 months 

experience as a practicing dentist. None of the dentists 

participated in Phase 1 of the study. Prior to 

participating in Phase 2, each dentist received 

approximately 2 hours of hands-on familiarization 

with the DIFOTI equipment. This training was 

conducted by a sales management consultant who was 

not a dentist or a trained technical consultant. During 

Phase 2, each of the five dentists independently 

assessed the presence, location, and extent of 

interproximal lesions in the experimental teeth 

mounted in wax cubes as described previously. The 

examinations were all performed under identical 

conditions. The examining dentists evaluated both the 

mounted teeth and corresponding radiographic and 

DIFOTI images using the same ambient lighting and 

light box. Initially they examined mounted tooth 

blocks and corresponding DIFOTI images. Each tooth 

block and the corresponding radiographic image were 

assessed 3 days later. On both occasions, the 

examiners were asked to record suspected lesions on 

standardized diagrams in ink, noting the exact location 

and size using the following arbitrary categories: 

1. No caries 

2. Caries in enamel only 

3. Caries extending to dentino-enamel junction 

4. Caries extending just past the dentino-enamel 

junction 

5. Caries well into the dentin (encroaching pulp) 

For purposes of determining sensitivity and specificity, 

categories 1 and 2 were defined as “no caries” and 

categories 3, 4, and 5 were defined as “yes caries”. 

During Phase 3 of the study, all experimental teeth 

were removed from the wax mountings and sent to the 

US Army Dental Materials Laboratory at Fort Gordon, 

GA for sectioning. The teeth were sectioned 

mesiodistally through the suspected carious sites using 

a Isomet low speed saw (Buehler Ltd., Lake Bluff, IL; 

800-283-4537) with a 0.30 mm thick diamond 

wafering blade (no. 11-4244, Buehler Ltd.). 

During Phase 4, each of the 64 sections was viewed 

using a surgical microscope at 15x power (model 

M705-115, Global Surgical Corporation, St. Louis, 

MO; 800/861-3585). Each buccal and lingual section 

was evaluated for caries depth and assigned to one of 

the same five arbitrary categories as used in Phase 2. 

The sectioned teeth were photographed using a 

Minolta DiMAGE 5 digital camera (Konica Minolta 

Photo Imaging, Mahwah, NJ 201/574-4000) mounted 

on a tripod with a source distance of 25 mm (Figure 5). 

Figure 4. Radiographic imagery of mounted 

specimens 24 and 25. 

Figure 5. Photograph of specimen 24. 
38 Army Medical Department Journal 

RESULTS

As illustrated in the Table, sensitivity ranged from 

0.09–0.55 for radiographs and from 0–0.45 for 

DIFOTI for all examiners. Specificity ranged from 

0.86–1.0 for radiographs and from 0.90–1.0 for 

DIFOTI. Consensus sensitivity and specificity values 

were determined by three or more examiners agreeing 

on a caries category. 

A comparison of the consensus results for all 

examiners determined that the sensitivity for DIFOTI 

was 0.18. Consensus sensitivity for radiographs was 

determined to be 0.45. 

Specificity values were also determined. Experimental 

results for use of radiographs showed a specificity of 

1.0. Experimental use of DIFOTI as a diagnostic tool 

also resulted in a specificity value of 1.0. The KruskalWallis test was calculated to determine a statistical 

difference in caries diagnosis between radiographs and 

DIFOTI. The test showed a significant difference in 

the diagnosis of caries using radiographs vs. DIFOTI 

(ρ = 0.003). The χ

2

 test was used to show statistical 

differences between sensitivity (as represented by 

categories 1 and 2 [no caries]) and specificity 

(categories 3, 4, and 5 [yes caries]) data for 

radiographs and DIFOTI (ρ = 0.017). 

Correlation and regression analysis revealed that the 

diagnosis of positive caries increased as the depth of 

the caries increased for both consensus X 

(radiographs) and consensus D (DIFOTI). The 

correlation was positive but not strong: consensus X 

(radiograph) r = 0.62 (ρ = 0.0002); consensus D 

(DIFOTI) r = 0.63 (ρ = 0.0001). 

DISCUSSION

Digital Imaging Fiber-Optic Trans-illumination has 

been introduced as a diagnostic system for the early 

detection of caries. The technology allows image 

formation without the use of ionizing radiation; images 

can be immediately viewed by both dentist and patient. 

DIFOTI has shown promise in the detection of 

interproximal, occlusal, and smooth surface carious 

lesions. In 1997, Schneiderman et al10 assessed the use 

of DIFOTI to diagnose caries on 50 extracted human 

teeth. In their study, 5 clinicians “experienced in oral 

diagnosis” were asked to assess radiological images of 

extracted teeth. Four of the clinicians received 2 hours 

training in DIFOTI, after which their performance 

using both technologies (radiographic evaluation and 

DIFOTI) was scored to determine sensitivity and 

specificity values. Sensitivity for interproximal 

surfaces was determined to be 0.56 for DIFOTI and 

0.21 for radiographs. Specificity for DIFOTI was 0.76 

compared to 0.91 for radiographs. 

In 2002, Young1

 reviewed the literature to evaluate 

caries detection technologies and modern caries 

treatment methods. In this review DIFOTI was 

referred to as a “diagnostic instrument for early and 

reliable detection of caries without the need for 

ionizing radiation.” Young cautioned that clinicians 

who use DIFOTI (and compare results from 

radiographic analysis) must understand differences 

between interpreting radiographs and DIFOTI images. 

Unlike radiographs in which the “incident beam is 

transmitted through the entire tooth” resulting in an 

image which can show the extent of carious lesion 

penetration into a tooth, DIFOTI images only the light 

emerging from the surface of the tooth closest to the 

CCD camera. DIFOTI images surface changes and not 

necessarily the depth of lesion penetration. It is 

important to note that the manufacturer of DIFOTI 

does not claim the device measures the extent of caries 

penetration. 

In this study, 5 relatively inexperienced general 

dentists (each with less than 9 months of clinical 

Sensitivity and Specificity Values from Experimental Examiners 

Examiner 1 Examiner 2 Examiner 3 Examiner 4 Examiner 5 

Method X D X D X D X D X D 

Sensitivity 0.36 0.27 0.09 0 0.55 0.45 0.09 0.18 0.36 0.27 

Specificity 0.86 1.0 1.0 1.0 0.95 0.90 1.0 1.0 1.0 1.0 

* X – Radiograph; D – DIFOTI 
PB 8-06-1/2/3 Jan/Feb/Mar 39

practice experience at the time of the study) received 

minimal instruction in the use of DIFOTI. Specifically, 

each dentist was given hands-on familiarization as 

previously described and then afforded the opportunity 

to use the equipment in a full mouth survey on one or 

two subjects. No attempt was made to measure any of 

the dentist’s proficiency with the equipment. 

Approximately 2 weeks later each of the dentists 

served as examiners in this study and attempted to 

diagnose caries in both conventional radiographic 

images and DIFOTI images. As shown in the Table, 

one of the examiners, Examiner 3, performed 

considerably better in diagnosing caries from 

radiographic images and DIFOTI compared to the 

other examiners. Experimental sensitivity values for 

Examiner 3 were 0.55 for radiographs and 0.45 for 

DIFOTI in comparison to the consensus experimental 

sensitivity of 0.18 for DIFOTI and 0.45 for 

radiographs. Our experimental results do not compare 

well with previously documented experimental results. 

In a study using five clinicians “experienced in oral 

diagnosis,” Schneiderman et al10 found DIFOTI to 

have sensitivity more than twice that of radiography 

for the diagnosis of interproximal caries. Prior to 

participating in the study the “experienced” clinicians 

calibrated their performance against a known standard. 

The manufacturer of DIFOTI claims a sensitivity value 

of 0.69 for the diagnosis of interproximal caries. 

Clearly the results of the current study may reflect 

errors due to both the inexperience of the examiners in 

caries diagnosis and possible inexperience in 

interpreting DIFOTI images. Both Cortes et al11 and 

Lavonius et al12 report that extensive training with 

fiber-optic trans-illumination equipment is required to 

use the method successfully. Young1

 points out that 

“interproximal lesions can be picked up using DIFOTI 

only by careful angulation.” This suggests that the 

DIFOTI system may have been more effective in 

detecting caries if the experiment examiners had been 

more proficient in manipulating the fiber-optic 

handpiece to effectively view interproximal tooth 

structure. 

Although the results of this study suggest that our 

examiners needed more instruction in the efficient use 

of DIFOTI, the technology has great potential as a 

powerful patient education tool. The DIFOTI

technology can show subtle surface changes associated 

with potentially demineralized tooth surfaces. 

Demineralized tooth structure can be documented. 

Then, after successful treatment designed to 

remineralize the tooth, the areas can be reviewed again 

by both the dentist and the patient. The technology 

also shows promise in evaluating anterior teeth for 

potentially defective interproximal restorations or 

early interproximal demineralization, all without the 

need to expose a patient to ionizing radiation. 

CONCLUSIONS

1. DIFOTI can be a useful diagnostic adjunct, 

particularly when used to confirm the absence of 

disease (specificity). 

2. A significant training period is necessary to ensure 

effective use of this technology. Such training will 

allow the dentist to properly handle the DIFOTI 

handpiece to expose all potential carious surfaces 

and to properly interpret DIFOTIimages. 

3. The DIFOTI technology may be most useful in 

identifying demineralized areas of tooth structure 

and monitoring the results of remineralization 

therapy. 

ACKNOWLEDGEMENT

The authors gratefully acknowledge the rental of a 

DIFOTI system and the technical support provided by 

Electro-Optical-Sciences, Inc. 

REFERENCES

1. Young D. New caries detection technologies and 

modern caries management: merging the strategies. Gen 

Dent. 2002;50:320-331. 

2. Anderson MH, Bales DJ, Omnell KA. Modern 

management of dental caries: the cutting edge is not the 

dental burr. JADA. 1995;126:727-743. 

3. Hume W. Need for change in standards of caries 

diagnosis—perspective based on structure and behavior 

of the caries lesion. J Dent Educ. 1993;57:439-443. 

4. Steinberg S. A paradigm shift in the treatment of caries. 

Gen Dent. 2002;50:333-338. 

5. Bader JD, Brown JP. Dilemmas in caries diagnosis. 

JADA. 1993;124:48-50. 

6. Ouellet A, Hondrum S, Pietz D. Detection of occlusal 

carious lesions. Gen Dent. 2002;50:346-350. 

7. Ashley PF, Blinkhorn AS, Davies RM. Occlusal 

caries diagnosis: an in vitro histological validation of 

the Electronic Caries Monitor (ECM) and other 

methods. J Dent. 1998;26:83-88. 
40 Army Medical Department Journal 

8. Tan P, Evans R, Morgan M. Caries, bitewings, and 

treatment decisions. Aust Dent. J 2002;47:138-141. 

9. Langland OE, Langlais RP. Principles of Dental 

Imaging. Baltimore: Williams and Wilkins 

Publishing Co; 1997. 

10. Schniederman A, Elbaum M, Shultz T, Keem S, 

Greenebaum M, Driller J. Assessment of dental caries 

with digital imaging fiber optic transillumination 

(DIFOTI®): in vitro study. Caries Res. 1997;31:103-

110. 

11. Cortes DF, Ellwood RP, Ekstrand KR. An in vitro 

comparison of a combined foti/visual examination of 

occlusal caries with other diagnostic methods and the 

effect of stain on their diagnostic performance. 

Caries Res. 2003;37:8-16. 

12. Lavonius E, Kerosuo E, Kallio P, Pietila I, Mjor IA. 

Occlusal restorative decisions based on visual 

inspection-calibration and comparison of different 

methods. Commun Dent Oral Epidemiol.

1997;25:156-159. 

AUTHORS

MAJ Carbone is a graduate of the Fort Sill Comanche 

Advanced Education in General Dentistry 12-Month 

Program (AGD-1) and is currently serving as a dental 

officer for the 464 Med Co (Dental). 

COL Hennessy is the former Assistant Director of the 

Comanche AGD-1 program and is currently serving as 

Assistant Director of the Fort Hood Advanced Education in 

General Dentistry Two Year Program (AGD-2). 

COL (Ret) Hondrum is Chief, Dental Materials Laboratory, 

Fort Gordon, GA. 
PB 8-06-1/2/3 Jan/Feb/Mar 41

ABSTRACT

This clinical report describes the prosthodontic 

treatment for a 28-year-old male diagnosed with 

Type 1 hypoplastic amelogenesis imperfecta. The 

patient presented with considerable sensitivity and 

attrition of the teeth. The goal of the treatment was to 

restore masticatory function and aesthetics. A 

combined dental therapy approach was used, and 

canine protected occlusion was developed in the final 

restorations to decrease lateral forces on the posterior 

dentition. Functional and aesthetic results were 

achieved. 

OVERVIEW: AMELOGENESIS IMPERFECTA

Amelogenesis imperfecta (AI) is defined as a rare 

developmental hereditary abnormality caused by 

autosomal or X-linked dominant or recessive genes. 

Witkop and Backman reported that the occurrence of 

AI in the western population is between 1:4,000 and 

1:14,000.1

 AI appears to affect primary and permanent 

dentition in both the maxillary and mandibular arches 

with no racial or gender predilection.1,2 Lench and 

Crawford3

 reported a structural abnormal gene mapped 

to the loci on the short and long arms of the X 

chromosome which causes X-linked AI while Forman4

reported autosomal dominant AI located to 

chromosome 4q. 

The normal process of amelogenesis in tooth 

development involves the formation of normal enamel 

and occurs in three stages: the formative, calcification, 

and maturation stages. During the formation stage, the 

organic enamel matrix is synthesized. During the 

calcification and maturation stages, the organic enamel 

matrix begins mineralization while the enamel crystal 

matures. Clinically, AI appears as an alteration of 

enamel formation resulting in hypoplasia, 

hypocalcification, and hypomaturation. Enamel 

hypoplasia results in a decreased quantitative enamel 

formation. The enamel in hypocalcification appears 

normal but poorly mineralized while hypomaturation 

results in an abnormal mineralization in the final 

stages of tooth formation.5

 The most common form, 

the hypoplastic type, is deficient in normal enamel. 

The crown of the teeth appear blanched, “snowcapped,” yellow-brown, pitted, or grooved. 

Radiographic examination usually shows a full 

complement of teeth, but the crowns of the teeth either 

have very thin enamel or lack enamel completely. The 

teeth actually resemble crown preparations with 

characteristic excessive interdental spacing.6

Cosmetic rehabilitation of patients with AI has been 

open to a variety of treatment options. Complete 

coverage restorations are often recommended. The 

complications presented by teeth with short clinical 

crowns demand a comprehensive treatment plan and 

proper sequencing of therapy to achieve function and 

aesthetics without compromising the periodontium.7

Early intervention can prevent later restorative 

problems. However, some patients may not seek 

treatment until young adulthood, leading to the need 

for complex restorative treatment.8 

CLINICAL REPORT

A 28-year-old male presented with the chief 

complaints of considerable sensitivity of his teeth, 

difficulty chewing, and displeasure with his present 

dental appearance. Oral examination revealed smooth 

enamel hypoplasia, a skeletal open occlusal 

relationship, a dental midline discrepancy, short 

clinical crowns, occlusal wear, and aesthetic 

disharmonies (Figure 1). 

Prosthodontic Rehabilitation of a 

Patient with Amelogenesis Imperfecta: 

A Clinical Report

LTC Minaxi I. Patel, DC, USA 

LTC David A. Mott, DC, USA 

COL Michael F. Cuenin, DC, USA 
42 Army Medical Department Journal 

The patient’s medical history was unremarkable and 

he reported that his sister had similar clinical findings. 

A diagnosis of AI was made from the clinical and 

radiographic features. Although dental treatment had 

been previously provided, the composite resin 

restorations were inadequate to maintain the dentition 

in stable occlusion (Figure 2). 

Photographs, radiographs, and dental casts were made. 

Diagnostic casts were duplicated and mounted in a 

semiadjustable articulator (model 2240; Whip Mix 

Corp, Louisville, KY) at the vertical dimension of 

occlusion (VDO). The interocclusal distance was 

evaluated phonetically to be about 3 to 4 mm, 

therefore, the patient’s vertical dimension was not 

altered. A Broadrick occlusal plane analyzer was used 

as a guide for determining an acceptable plane of 

occlusion. Diagnostic preparations were made on the 

stone casts and a diagnostic waxing was completed 

with a mutually protected concept of occlusion. 

From the diagnostic waxing procedure, it was 

determined that the mandibular right and left first and 

second molars would need crown lengthening, and the 

occlusion distal to the mandibular right canine would 

have to be restored with reverse articulation (Figure 3). 

The patient exhibited mild localized gingivitis and was 

referred for a comprehensive periodontal evaluation. 

Initial treatment involved scaling and root planning to 

include oral hygiene instructions. A 0.2% 

chlorohexidine mouth rinse was also prescribed. 

Complete rehabilitation of the dentition was based on 

patient desires, clinical findings, radiographic 

evaluation, periodontal consultation, and evaluation of 

diagnostic casts. Fabrication of gold restorations for 

maxillary and mandibular posterior teeth and metal 

ceramic crowns for maxillary and mandibular 

premolars and anterior teeth was planned. The 

treatment plan was presented and discussed with the 

patient, who accepted it. 

Surgical periodontal therapy consisted of clinical 

crown lengthening procedures for mandibular right 

and first and second molars. All other teeth had the 

necessary minimum 5 mm of clinical crown length. 

Good initial healing was noted at 2 weeks and the 

Figure 3. Preop mandibular occlusal view showing 

the mandibular right and left first and second 

molars which need crown lengthening. Also, the 

occlusion distal to the mandibular right canine will 

need restoration with reverse articulation. 

Figure 2. Preop maxillary occlusial view of resin 

composite restorations which were inadequate at 

maintaining the dentition in stable occlusion. 

Figure 1. Preop anterior occluded view of 28 yearold-male with smooth enamel hypoplasia, skeletal 

open occlusal relationship, dental midline 

discrepancy, short clinical crowns, occlusal wear, 

and aesthetic disharmonies. 
PB 8-06-1/2/3 Jan/Feb/Mar 43

prosthodontic phase of the treatment was begun after 

at least 6 weeks. All the teeth were prepared and 

provisionalized at the determined VDO. The planned 

occlusion was evaluated clinically and final 

impressions for maxillary right and left second molars 

and mandibular right and left first and second molars 

were made with vinyl polysiloxane material in stock 

trays. Impressions were also made of provisional 

restorations for fabrication of a new custom incisal 

guide table. Gold crowns were fabricated and 

evaluated for fit on the teeth and then luted with resinmodified glass ionomer cement (Vitremer; 3M Dental 

Products, St. Paul, MN). Impressions for all other 

prepared teeth were made, and a definitive maxillary 

and mandibular cast was formed and mounted in an 

articulator with trimmed dies of prepared teeth at the 

VDO. The maxillary and mandibular completed 

restorations were evaluated in bisque bake (Figures 4, 

5). All restorations were characterized, glazed, 

polished, and then luted with Vitremer cement. Home 

care instructions were given, and the patient was 

scheduled for periodic maintenance care. 

SUMMARY

The treatment of patients with AI presents an 

interesting challenge to the restorative dental team. 

The main clinical characteristics are extensive loss of 

tooth tissue, poor aesthetics, and tooth sensitivity.9 The 

complexity of the management of patients with AI 

should start with early diagnosis to prevent later 

restorative problems and the key participation of the 

prosthodontist in overall treatment planning. This 

clinical report describes a treatment sequence based on 

a multidisciplinary approach.10 Treatment is usually 

combined to meet biologic, restorative, and aesthetic 

requirements imposed by short clinical crowns. 

Preoperative treatment planning included an accurate 

diagnostic wax-up, evaluation of clinical crown 

lengths, and a visualization of the desired result. For 

the patient described above, enhanced aesthetics was 

possible because the clinical crown and root form were 

favorable for complete-coverage restorations 

(Figure 6). Canine-protected occlusion was developed 

in the final restorations to decrease lateral forces on 

the posterior dentition. 

Figure 6. Enhanced aesthetics was possible 

because the clinical crown and root form were 

favorable for complete coverage restorations. 

Figure 5. Completed mandibular restoration. 

Figure 4. Completed maxillary restoration. 
44 Army Medical Department Journal 

REFERENCES

1. Witkop CJ. Amelogenesis imperfecta, dentinogenesis 

imperfecta and dentin dysplasia revisited: problems in 

classification. J Oral Pathol. 1988;17:547-553. 

2. Backman B, Holm AK. Amelogenesis imperfecta: 

prevalence and incidence in a northern Swedish county. 

Community Dent Oral Epidemiol. 1986;14:43-47. 

3. Lench NJ, Winter GB. Characterization of molecular 

defects in X-linked amelogenesis imperfecta (AIH1). 

Hum Mutat. 1995;5:251-259. 

4. Crawford PJ, Aldred MJ. Clinical features of a family 

with X-linked amelogenesis imperfecta mapping to a 

new locus (AIH3) on the long arm of the x 

chromosome. Oral Surg Oral Med Oral Pathol. 

1993;76:187-191. 

5. Tuğrul S, Aslihan U. Restoring function and aesthetics 

in a patient with amelogenesis imperfecta: a clinical 

report. J Prosthet Dent. 2003;90:522-525. 

6. Langlais RP, Miller SC. Colas Atlas of Common Oral 

Disease, ed.2. Baltimore: Williams & Wilkins; 

1998:32. 

7. Sengun A, Ozer F. Restoring function and aesthetics in 

a patient with amelogenesis imperfecta: a case report. 

Quintessence international. 2002;33:413-421. 

8. Bergendal B. The role of prosthodontist in habilitation 

and rehabilitation in rare disorders. Int J Prosthodont. 

2001;14:466-470. 

9. Davarpanah M, Jansen CE, Vidjak FM, et al. Int J 

Periodontics Restorative Dent. October 1998;18(5):424

-33. 

10. Suna T, Mubin U, et al. Amelogenesis imperfecta: the 

multidisciplinary approach: a case report. Quintessence 

international. 2004;35:11-14. 

AUTHORS

LTC Patel is Chief of Prosthodontics at the US Army 

Leighton Dental Clinic, Wuerzburg, Germany. 

LTC Mott is Chief of Periodontics at the US Army Leighton 

Dental Clinic, Wuerzburg, Germany. 

COL Cuenin is Commander, European Regional Dental 

Command. 
PB 8-06-1/2/3 Jan/Feb/Mar 45

Provisional restorations play a critical role in the 

successful treatment of the prosthodontic patient. An 

interim restoration that meets the functional and 

aesthetic requirements of the patient can mean the 

difference between success and failure of a treatment 

plan. Clinicians have often made the mistake of 

regarding the provisional as being merely “temporary” 

and thus do not devote adequate time and effort to this 

phase of treatment. This may result in the fabrication 

and cementation of an interim restoration, which is 

inadequate functionally and/or morphologically. 

According to Shillingburg,1

 aside from meeting the 

individual patient’s aesthetic desires, the restorations 

should also meet the following requirements: 

1. Provide pulpal protection. 

2. Provide positional stability. 

3. Provide the patient with the proper occlusal 

function. 

4. Be easily cleanable. 

5. Be strong and retentive. 

6. Be aesthetically pleasing. 

7. Margins should not impinge upon the gingival 

tissues. 

Campagni and Caponigro2

 accurately describe the 

requirements of a successful provisional as one that 

mimics the planned restoration(s) in occlusal and axial 

morphology as well as aesthetics, while fulfilling its 

requirements for maintaining tooth position and 

protecting the tooth structure during function. 

Numerous techniques and materials for fabrication of 

single-unit or multiple-unit provisional restorations 

have been described in the literature to meet these 

requirements. This article seeks to provide the 

clinician with an overview of various techniques and 

materials which have proven to be useful and thus 

have endured over the years. 

THE DIRECT TECHNIQUE

This technique utilizes a prefabricated stent or matrix 

filled with the practitioner’s choice of provisional 

material, which is placed directly onto the patient’s 

prepared teeth. After initial polymerization, the 

material/matrix assembly is removed from the mouth, 

trimmed, and polished. 

Kaiser and Cavazos3

 describe the following technique: 

1. On the patient’s diagnostic cast, wax in any 

missing teeth. 

2. Duplicate the cast and fabricate a matrix from a 

material of the clinician’s choosing. 

3. Prepare the teeth. 

4. Lubricate the teeth. 

5. Place autopolymerizing resin into the matrix and 

seat onto the prepared teeth. Use a pumping 

motion to ensure that the provisional restoration 

will not get locked into any undercuts. 

6. After initial set, remove the matrix from the 

mouth and allow the provisional restoration to 

completely polymerize. 

7. Trim, contour, and polish. 

Nayyar and Edwards4

 also describe a direct technique 

for use with a single unit using a commercially 

available metal crown in which the crown is relined 

directly on the tooth with autopolymerizing resin : 

1. Measure the mesial/distal width of the tooth to 

be prepared. 

2. Pick out a corresponding commercially available 

metal provisional crown. 

3. Seat the crown, trim any excess material below 

the margin to the proposed finish line. 

4. After preparation, lubricate the prepared tooth 

and coat with cavity varnish. 

Provisional Restorations: An Overview 

of Techniques and Materials 

CPT Matthew S. Thunberg, DC, USA 

COL James K. Schmitt, DC, USA 
46 Army Medical Department Journal 

5. Pour acrylic resin into the crown, seat it and 

have the patient bite into the centric occlusion. 

6. After initial set, lift the crown 3 mm and reseat. 

Repeat this action three or four times. 

7. Remove, trim, and contour after the acrylic resin 

reaches final set. 

One of the disadvantages of using a commercially 

available metal provisional crown is that the patient 

may complain about metallic taste when chewing food. 

Polycarbonate crowns may also be used in the 

preparation of an anterior tooth for a single-unit 

restoration. However, the aesthetic demands of 

patients often prevent their use in this region of the 

mouth. 

Christensen5

 describes another method for direct 

fabrication of a single-unit using wax as a stent: 

1. Fabricate a baseplate wax impression of the 

tooth to be prepared plus one to two teeth mesial 

and distal. 

2. Prepare the tooth. 

3. Place acrylic resin in the wax impression and 

seat it onto the lubricated prepared tooth. 

4. As polymerization occurs, pump the wax matrix 

up and down a few times. 

5. After initial polymerization, remove the wax 

matrix from the mouth and allow it to 

completely polymerize extraorally. 

6. Trim and polish. 

Psichogios et al6

 describe a direct technique for 

provisionalizing multiple single-units and three- or 

four-unit fixed partial dentures: 

1. Fabricate a diagnostic waxing. 

2. Construct a dual arch custom impression tray. 

3. Take an impression using an addition silicone. 

4. Trim the impression material 3 – 4 mm apical to 

the gingival margins of the diagnostic waxing 

and only include cusp tips or incisal edges of the 

opposing arch. 

5. Prepare the teeth and coat with a lubricant. 

6. Use a BisGMA restorative material to fill the 

impression. 

7. Have the patient close into the custom tray. 

8. Remove the tray after two minutes. 

9. Bench polymerize for another two minutes. 

10. Trim and polish. 

Many clinicians are familiar with and readily employ 

these direct techniques. The matrix material used may 

differ from clinician to clinician, but the general 

techniques are similar. While the direct technique 

reduces chair time, it has two major disadvantages: 

 Evidence exists indicating that an adverse 

pulpal reaction occurs caused by the free 

monomer and heat generated by the 

polymerization reaction. 

 Distortion can occur due to the “pumping” of 

the matrix on and off during polymerization of 

the resin.7

Despite these disadvantages, the direct technique 

continues to be a very popular and highly utilized 

method for provisional fabrication. When performed 

properly, this method can produce very aesthetic and 

functional provisional restorations. 

INDIRECT METHOD

This method of provisional restoration fabrication, 

which is taught in most dental schools, has several 

advantages: 

 The pulp is protected due to polymerization 

occurring on a stone cast. Shillingburg1

 states 

that any vital tooth that is being relined should 

be done so via the indirect method because of 

this exothermic heat increase. 

 Moulding8 found that the indirect method had 

significantly less marginal discrepancy than the 

direct technique that utilizes a pumping motion. 

Crispin et al9

 found that marginal fit could be 

improved by 70% using the indirect method to 

fabricate provisional restorations. 

 Auxiliaries are able to fabricate the majority of 

the provisional restorations in the lab, leaving 

the practitioner free to treat other patients. 

The techniques described by various authors for 

fabricating provisional restorations via the indirect 

method are very similar. Differences occur in the 
PB 8-06-1/2/3 Jan/Feb/Mar 47

acrylic resin used and whether pressure pots are 

utilized. Chee et al10 found that pressure curing 

polymethyl methacrylates reduced porosity and 

increased transverse strength when compared with the 

technique of bench curing. The indirect technique is 

described as follows: 

1. Prior to preparing teeth, form a matrix on 

diagnostic casts. 

2. Prepare the teeth. 

3. Take an irreversible hydrocolloid impression of 

prepared teeth. If two retraction cords are used, 

make the alginate impression after placement of 

the first cord. 

4. Pour impression up with quick-set plaster. 

5. Place the matrix onto the stone cast to ensure 

proper fit. Lubricate the stone model with a tin 

foil substitute and then add acrylic resin. For 

optimal aesthetics, place an incisal shade of resin 

into the matrix and feather the resin up the facial 

side of the teeth. Then add the body shade of 

resin. 

6. Rubber band the matrix to the stone cast to 

ensure complete seating and place in a pressure 

pot with hot water at 20 psi for five minutes. 

7. Remove and mark the gingival margin on the 

provisional restoration with a sharp lead pencil. 

8. Trim and contour. 

9. Polish the restoration with pumice on a rag 

wheel, followed by a diamond stone on a rag 

wheel. 

For provisional restoration of a fixed partial denture, it 

is recommended that the practitioner place a ball of 

completely polymerized acrylic resin into the pontic 

space. (The ball should fill at least 50% of the pontic 

space). This will help offset the significant amount of 

shrinkage that frequently occurs in the pontic area to 

due to excessive bulk of material. 

Davidoff11 describes an indirect method that uses heatpolymerizing acrylic resin. In this method, all steps are 

similar to those described above, except that a heatpolymerizing acrylic resin is used. The filled matrix is 

placed on the cast and placed in a pressure pot at 250 

degrees Celsius at 30 psi for 30 minutes. If required, a 

chairside reline with autopolymerizing acrylic resin 

can be performed. Although the indirect method has 

been shown to produce provisional restorations of 

superior strength and marginal integrity, few clinicians 

use the strictly indirect method. 

INDIRECT/DIRECT METHOD

This is probably the most popular method used for the 

provisionalization of fixed partial dentures. It 

combines the advantages of both the direct and indirect 

methods thus capturing the best of both techniques. 

One of the main benefits of this technique is that the 

clinician must reline the prefabricated shell. Barghi 

and Simmons12 showed that relining of provisional 

restorations fabricated via the direct method 

substantially improved marginal adaptation. Campagni 

and Caponigro2

 also list the following advantages for 

the indirect/direct method: 

 Decreased chair time. 

 Auxiliaries can fabricate the shell. 

 The provisional restoration can be relined 

intraorally with the patient in centric occlusion, 

thereby minimizing the amount of occlusal 

adjustment necessary 

Several techniques for this method of provisional 

fabrication are presented below. 

Campagni and Caponigro2

 describe the following 

method: 

1. Add a bulk of wax to the gingival area of the 

teeth to be prepped on casts. This ensures an 

adequate amount of provisional material in the 

marginal area. 

2. Duplicate the cast. 

3. Make a clear matrix. 

4. Minimally prepare the teeth included in the 

provisional restorations. Reductions should be 

half that of actual preparations. 

5. Gingival extensions should be 2 mm apical to 

the expected gingival finish line. This results in 

a 2 mm gingivectomy. 

6. Place a tin foil substitute on the cast. 

7. Methyl methacrylate is placed in the matrix. The 

matrix is then seated on the cast and the whole 

apparatus is placed into a pressure pot at 20 psi 

for five minutes. 
48 Army Medical Department Journal 

8. The shell is trimmed slightly then tried in the 

patient’s mouth after preparations have been 

completed. 

9. Reline is accomplished using polyethyl 

methacrylate and a pumping motion. 

10. Trim, contour, and cement the provisional 

restoration. 

Christensen5

 also advocates using the above method 

with one slight variation. He suggests removing the 

shell at the first detection of exothermia and cooling it 

under running water. The shell is then replaced and a 

pumping motion is used until complete polymerization 

has taken place. 

Chiche13 describes the following technique: 

1. A preformed shell is made in the lab and tried on 

the patient after preparations of the abutment 

teeth are completed. 

2. Acrylic resin is added to the shell and then 

seated onto the preparations under occlusal 

pressure at the patient’s vertical dimension of 

occlusion. 

3. The shell is lifted 1–2 mm to prevent it from 

being locked into any undercuts below the 

margins. 

4. Spray the abutment teeth with water to retard the 

heat generated during polymerization. 

5. Reseat the shell. 

6. When the bulk of material is at the doughy stage, 

remove the shell and lightly adapt a fresh mix of 

acrylic resin over the margins. 

7. Quickly reseat the shell and have the patient 

gently close into centric occlusion. 

8. Again lift the shell 1–2 mm so water can be 

sprayed onto the abutment teeth. 

9. Reseat the shell. 

10. Repeat this procedure three times until the 

acrylic resin is set. 

11. Mark outer edge of margins with a pencil. 

12. Trim, contour, and polish the provisional 

restoration. 

Vahidi14 advocates an indirect/direct method utilizing 

light cured composite resins for the shell and then 

relining on the tooth preparation with 

autopolymerizing acrylic resin: 

1. Prepare the teeth on the cast. 

2. Apply a thin coat of die isolation material to the 

cast (Visio-Gem die isolation material, ESPE 

Premier Dental Products, Norristown, PA). 

3. Build up a core of body shade resin and then 

follow with a layer of incisal shade resin. 

4. Light cure for 90 seconds. 

5. Remove cured restoration, trim excess, and add 

to deficient areas. 

6. Polish using pumice and composite polishing 

paste. 

7. Complete intraoral tooth preparation and reline 

the provisional shell with autopolymerizing 

resin. 

It is the clinician’s responsibility to determine which 

of the three described techniques works best in his/her 

hands. Success by the standards established by 

Shillingburg1

 can be achieved by using any of the 

above techniques with proper training and adequate 

practice. If this high standard is met, the final 

prosthesis will have a greater chance of success. The 

dentist will know better how the patient will tolerate 

the final prosthesis. The provisional restoration is also 

used as an important diagnostic tool to determine the 

patient’s aesthetic expectations. 

PROVISIONAL MATERIALS

Equally important as technique in provisional 

fabrication is the material the clinician employs in the 

technique. A clinician may choose from numerous 

materials. Oftentimes the choice depends on what 

works best in the clinician’s hands. This is perhaps the 

most important characteristic when deciding upon the 

material to use, however, research has shown some 

materials to be superior to others. The remainder of 

this article focuses on a simple overview of some of 

today’s most popular materials in use for provisional 

restoration fabrication. It should be noted that any 

brand names of material are listed for example 

purposes only. 
PB 8-06-1/2/3 Jan/Feb/Mar 49

Jet polymer comes in many different shades, which 

allows the clinician to obtain excellent aesthetic 

results. Wang et al15 conducted a study that measured 

certain characteristics of the following provisional 

materials: PEMA, PMMA, Bis-GMA, light-cured 

composites, and polyvinyl methyl methacrylate. The 

authors found that Jet (PMMA) had the worst wear 

resistance of the materials, but had one of the highest 

transverse strength values. Due to its high exothermic 

heat, the authors of this article agree with others that 

PMMA should be used only in the indirect method, or 

in the fabrication of the shell for the indirect/direct 

method. 

In their study, Wang et al15 found that Snap was 

significantly less hard at one week than the PMMAs, 

but marginal fit was similar to Jet. The authors also 

found that Snap was not as color stable as the 

composite resins, but significantly more color stable 

than the PMMAs. Krug16 stated that the PEMAs 

provided the clinician with more working time and 

induced less chemical and exothermic irritation to the 

pulp. He also stated that the PEMAs were less color 

stable than the PMMAs, but heat processing the resin 

at 135 degrees Fahrenheit for five minutes at 20–25 

psi will alleviate the problem of hardness and color 

stability. Christensen5

 states that PEMA has a low cost 

and relatively good fit, however, the material should 

not be used for long span provisional restorations 

(insufficient strength) or left in the mouth for over 2 

weeks (color instability). Tjan et al17 found that 

SplintlineTM (Lang Dental Mfg. Co. Inc, Wheeling IL.) 

had better marginal adaptation than that of PEMA. 

Christensen5

 also lists cost as a disadvantage of the 

bisacryl composites. Wang et al15 found in their study 

of six different materials that Protemp exhibited the 

least amount of temperature increase upon curing and, 

along with AlikeTM (Coe Laboratories, Inc., Chicago) 

had the best marginal adaptation. Another advantage 

of this material is that light-cured composite can be 

added to correct any deficiencies and this can reduce 

Polymethyl Methacrylate (PMMA) – Jet® (Lang 

Dental Mfg. Co. Inc.) 

Advantages 

 Good marginal fit, especially if the indirect 

technique is used. 

 Polishes to a high shine. 

 Very durable. 

 Can achieve a high transverse strength, 

especially with use of a pressure pot during 

polymerization. 

Disadvantages: 

 High exothermic heat that can stress the 

pulp. 

 PMMA exhibits low abrasion resistance. 

 Acrylic resin monomer is toxic to the pulp. 

 PMMA experiences a high volume of 

shrinkage (about 8%). 

(Source: Shillingburg1

) 

Polyethylmethacrylate – SnapTM (Parkell, 

Farmingdale, NY), Trim® II (Harry J. Bosworth 

Co., Skokie, IL)

Advantages 

 Polishes to a good shine. 

 Minimal exothermic heat increase. 

 Good stain resistance. 

 Low percentage shrinkage compared with 

PMMAs. 

Disadvantages: 

 PEMA exhibits low transverse strength 

compared to the PMMAs. 

 Poor fracture toughness. 

 Durability is less than that of the PMMAs. 

(Source: Shillingburg1

) 

Microfill Resin – Durafill VSTM (Heraeus Kulzer, 

Armonk, NY) 

Advantages 

 Light cured. 

 Excellent polish results. 

 Putty-like consistency makes them user 

friendly. 

 Only a slight exothermic reaction. 

Disadvantages: 

 High cost. 

 Brittleness limits use to single tooth 

restorations or to veneers. 

(Source: Christensen5,19) 
50 Army Medical Department Journal 

potentially marginal porosity that is sometimes found 

with the use of autopolymerizing resins.18 

The microfill resins are highly useful for inlays and 

onlays. Christensen19 also promotes their use for 

certain veneer cases, but did not specify which cases 

are better suited for the microfill resins. 

SUMMARY

Three types of provisional restoration materials and 

techniques were described in this article. Many other 

methods and materials are available to the clinician. 

The material and technique of choice should be based 

not only on scientific evidence, but also by what works 

best in the hands of the individual clinician. The 

ultimate goal is to fabricate a provisional restoration 

that is aesthetic, functional, and similar in contour to 

what is desired in the final prosthesis. If the clinician is 

able to achieve this in the provisional stage, achieving 

success in the final prosthesis will be that much easier. 

REFERENCES

1. Shillingburg H Jr. Fundamentals of Fixed 

Prosthodontics Third Edition. Berlin, Germany: 

Quintessence Publishing Co. Inc.; 1997. 

2. Campagni W, Caponigro C. Provisional restorations. 

CDA J. April 1988. 

3. Kaiser D, Cavazos E. Temporization techniques in 

fixed prosthodontics. Dent Clin North Am. 1985;29

(2):403-412. 

4. Nayyar A, Edwards W. Fabrication of a single 

posterior intermediate restoration. Dent Tech. 

1978;39(6):688-691. 

5. Christensen G. Provisional restorations for fixed 

prosthodontics. J Am Dent. 1996;127:249-252. 

6. Psichogios P, Monaco E. Expedient direct approach 

for esthetic and functional provisional restorations. J 

Prosthet Dent. 2003;89:319-322. 

7. Fisher D, Shillingburg H Jr, Dewhirst R. Indirect 

temporary restorations. J Am Dent. 1971;82:160-163. 

8. Moulding M, Loney R. Marginal accuracy of 

provisional restorations fabricated by different 

techniques. Int J Prosthodon. 1994;7(5):468-472. 

9. Crispin BS, Watson JF, Caputo AA. The marginal 

accuracy of treatment restorations: a comparative 

analysis. J Prosthet Dent. 1980;44:283-290. 

10. Chee W, Donovan TE, Daftary F, Siu TM. The effect 

of vacuum-mixed autopolymerizing acrylic resins on 

porosity and transverse strength. J Prosthet Dent. 

1988;60(4):517-519. 

11. Davidoff R. Heat-processed acrylic resin provisional 

restorations: an in-office procedure. J Prosthet Dent. 

1982;48(6):673-675. 

12. Barghi N, Simmons EW. The marginal integrity of 

temporary resin crowns. J Prosthet Dent. 

1976;36:274-277. 

13. Chiche G. Improving marginal adaptation of 

provisional restorations. Quintessence Int. 1990;21

(4):325-329. 

14. Vahidi F. The provisional restoration. Dent Clin 

North Am. 1987;31(3):363-381. 

15. Wang R, Moore K, Goodacre C, Swartz M, Andres 

C. A comparison of resins for fabricating provisional 

fixed restorations. Int J Prosthodont. 1989;2(2):173-

184. 

16. Krug R. Temporary resin crowns and bridges. Dent 

Clin North Am. 1975;19(2):313-320. 

17. Tjan A, Castelnuovo J, Shiotsu G. Marginal fidelity 

of crowns fabricated from six proprietary provisional 

materials. J Prosthet Dent. 1997;77(5):482-485. 

18. Wood M, Halpern B, Lamb M. Visible light-cured 

composite resins: an alternative for anterior 

provisional restorations. J Prosthet Dent. 1984;51

(2):192-194. 

19. Christensen G. The fastest and best provisional 

restorations. JADA 2003;134:637-639. 

AUTHORS

CPT Thunberg graduated from the 1-Year Advanced 

Education in General Dentistry Program at Fort Carson, CO 

in 2003. He is presently serving his second tour in Iraq, 

assigned as the Regimental Dental Surgeon for the 3rd 

Armored Cavalry Regiment. 

COL Schmitt is the prosthodontic mentor of the 1-Year 

Advanced Education in General Dentistry Program, Fort 

Carson, CO. 
PB 8-06-1/2/3 Jan/Feb/Mar 51

INTRODUCTION

Management of the deficient alveolar ridge has always 

presented an aesthetic as well as a functional problem 

for the restorative dentist. Various nonsurgical 

treatment options have been attempted to manage this 

problem. Removable partial dentures have traditionally 

been used to mask the problem by extending the 

denture base to cover the defect. Tissue-colored 

porcelain on a fixed partial denture or acrylic resin 

augmentation on a removable partial denture may be 

used if the deficiency is minimal. The end result is 

usually restoration of function for the patient with 

some improvement in aesthetics. Surgical options have 

varied from ridge augmentation with alloplasts to 

reconstruction with autologenous bone. Although both 

options have been widely used with success, there are 

some disadvantages. Alloplasts are not absorbed and 

sometimes tend to migrate from their original position. 

Autologenous bone continues to be the gold standard 

in reconstruction but does have unpredictable 

resorption patterns along with possible donor site 

morbidity. A fairly new technique called distraction 

osteogenesis has been developed to help manage this 

problem. 

REVIEW OF THE LITERATURE

In 1902, Alessandro Codivilla used a method of 

external fixation to lengthen a femur.1

 Throughout the 

century, the works of Putti2

 in 1921, Haboush and 

Finkelstein3

 in 1932, and Ilizarov4-7 in 1951 have lead 

to development of distraction osteogenesis in the 

craniofacial skeleton. McCarthy8

 applied the technique 

developed by Ilizarov to the mandible in patients 

diagnosed with craniofacial microsomia, Nager 

syndrome, and developmental micrognathia. Building 

on the success of distraction osteogenesis in the 

mandible along with the advances in science and 

technology, the technique was applied to the midface. 

Molina and Ortiz-Monisterio9

 along with Polley and 

Figueroa10 successfully distracted the maxilla. Hidding 

and Zoller11 from the University of Cologne, Germany, 

developed a device and method for distraction of the 

deficient alveolar ridge. This technique is described in 

this article. 

CASE # 1 — ANTERIOR MANDIBLE

A 22-year-old male presented to the dental clinic with 

complaint of missing teeth. He had sustained a 

mandibular fracture at age 6 which resulted in the loss 

of his maxillary central incisors, 3 mandibular incisors, 

and delayed eruption of the mandibular left canine 

(Figure 1). The patient was evaluated by the 

prosthodontic, orthodontic, and oral and maxillofacial 

surgery departments. The orthodontist suggested that 

an attempt be made to orthodontically move the 

mandibular canine into occlusion if the tooth was not 

ankylosed. The patient did not want to commit to 

orthodontic treatment. The prosthodontic treatment 

plan was to extract the lower left canine and remaining 

incisor and restore the maxilla and mandible with 

implants. Following extractions, a vertical 

defect was present which could be corrected with 

alveolar distraction osteogenesis. 

Implant Site Preparation With 

Distraction Osteogenesis 

LTC (Ret) Philip J. Pandolfi, DC, USA 

LTC G. Morris Gibson, DC, USA 

Figure 1. View of 22-year-old male — mandibular 

fracture at age 6; missing maxillary central incisors 

and three mandibular incisors; delayed eruption of 

the mandibular left canine. 
52 Army Medical Department Journal 

The patient was taken to the operating room and 

administered a general anesthetic. A vestibular 

incision was made and both mental foramen and 

nerves were identified. Minimal soft tissue dissection 

was completed to ensure maximal blood supply to the 

transport segment. The distractor was adapted to the 

mandible and the vector was established. The 

distractor was secured with four screws and then 

removed to ensure that the original position of the 

distractor was maintained (Figure 2). 

An anterior osteotomy was made with a 701 fissure 

bur and completed with fine osteotomes to avoid 

disruption of the lingual mucosa (Figure 3). 

Once the distractor was repositioned and fixed with 

screws, it was activated to ensure there were no 

interferences, then returned to the original position. A 

postoperative panoramic radiograph was made (Figure 

4). The distractor was then passively left in place for 1 

week to enable a stable clot to form in the osteotomy 

site and the mucosal incision to heal. 

After 1 week the distractor was activated at a rate of 1 

mm per day until the established height was obtained 

(Figures 5 and 6). When the final vertical height was 

reached, the distraction process was terminated and 

left in place for 3 months to enable bone healing. The 

distractor was removed and implants were placed 

(Figure 7). 

Figure 3. An anterior osteotomy was made with a 

701 fissure bur and completed with fine osteotomes 

to avoid disruption of the lingual mucosa. 

Figure 5. Frontal view – distractor activated at a 

rate of 1 mm per day until established height 

obtained. 

Figure 2. The distractor was secured with 4 screws, 

then removed to ensure that the original position of 

the distractor was maintained. 

Figure 4. The distractor was repositioned and fixed 

with screws, activated to ensure there were no 

interferences, then returned to the original position. 
PB 8-06-1/2/3 Jan/Feb/Mar 53

CASE # 2 — POSTERIOR MAXILLA

A 50-year-old male presented seeking implant 

replacement of a missing a maxillary first molar. The 

radiograph (Figure 8) showed deficiency of vertical 

bone height. In this situation an increase of vertical 

bone height was necessary prior to implant placement. 

Alveolar distraction was completed in this area and the 

implant was placed (Figures 9, 10). 

Figure 6. Profile view – distractor 

activated at a rate of 1 mm per day 

until established height obtained. 

Figure 7. The distractor was removed and implants 

were placed after 3 months to enable bone healing. 

Figure 8. Deficiency of vertical bone height in 50 

year-old male with missing maxillary first molar. 

Figure 9. Completed alveolar distraction. 

Figure 10. Implant in place. 

CASE # 3 — ANTERIOR MAXILLA

A 24-year-old male presented with a history of anterior 

maxillary trauma. Teeth 9 and 10 had been avulsed, 

reimplanted, and stabilized with a nonrigid splint. The 
54 Army Medical Department Journal 

The interdental bone subsequently became exposed 

and was removed as a 3 mm by 6 mm sequestrum 

leaving a bony and soft tissue defect. Further 

evaluation revealed that teeth 9 and 10 had become 

ankylosed. The decision was made to remove the teeth 

and restore with implants after site preparation. 

Distraction osteogenesis was completed in the anterior 

maxilla (Figure 12). 

A passive orthodontic appliance with two acrylic resin 

denture teeth was used to allow the patient to have 

replacement teeth during the distraction and implant 

process (Figure 13). 

DISCUSSION

Distraction osteogenesis has undoubtedly enhanced the 

treatment of oral and maxillofacial deficiencies. 

However, as with any other procedure, patient 

selection and education is of paramount importance. 

Distraction osteogenisis is another treatment option in 

reconstruction of deficient bony areas. There are, 

however, limitations to this procedure. Large defects 

may still be more effectively treated with autologenous 

bone grafting. Anatomic structures such as the 

maxillary sinus, nasal floor, and inferior alveolar nerve 

may limit the technique. 

Although distraction osteogenesis has been used 

successfully in many areas, the basic principles 

developed by Ilizarov4-7 must be followed. Ilzarov 

identified certain factors such as rigidity of the bone 

fragment, preservation of soft tissue, rate, and rhythm 

as important in the success of distraction. Based on the 

findings of Hidding and Zoller,11 a 7-day latency 

period is observed after the osteotomy is completed 

and the distractor is placed. This latency period allows 

soft tissue wound healing along with clot formation in 

the surgical site. After 1 week the distraction process is 

started at a rate of 1 mm per day until the desired 

height is reached, followed by a 3-month stabilization 

period.5

 After the stabilization period, the distractor is 

removed and the implants are placed. We have found 

that distraction can be started in younger patients after 

5 days with a stabilization period of 2 months. In 

contrast, some older patients may require an extended 

time frame. 

Figure 11. A 24-year-old male. Teeth 9 and 10 had 

been avulsed, reimplanted, and stabilized with a 

nonrigid splint. The teeth received endodontic 

treatment and the area was observed over several 

months. 

Figure 12. Distraction osteogenesis completed in 

the anterior maxilla. 

Figure 13. A passive orthodontic appliance with 

2 acrylic resin denture teeth was used to provide 

replacement teeth during the distraction and 

implant process. 

teeth received endodontic treatment and the area was 

observed over several months (Figure 11). 
PB 8-06-1/2/3 Jan/Feb/Mar 55

CONCLUSION

Horizontal and vertical defects of the alveolar ridge 

present an aesthetic challenge to the restorative dentist. 

With the introduction of alveolar distraction 

osteogenesis the problem of vertical bone height can 

be controlled. Although the vertical defect can now be 

corrected, the horizontal deficiency may remain. A 

solution to this problem is to overdistract the ridge, 

then reduce it to the desired height at the time of 

implant placement. In most cases this technique has 

produced sufficient results. In those situations where 

horizontal deficiency persists, autogenous bone from 

the chin or ramus may be adequate. Most procedures 

can be safely performed as an outpatient procedure 

with intravenous sedation. Postoperative patients are 

managed similarly to third molar surgery patients, but 

with less discomfort. 

REFERENCES

1. Peltier L. On the means of lengthening, in the lower 

limbs, the muscles and tissues which are shortened 

through deformity, a. codivilla. Clin Orthop. 

1994;301:4-9. 

2. Putti V. The operative lengthening of the femur. JAMA. 

1921;77:934. 

3. Haboush EJ, Finkelstein H. Leg lengthening of the tibia 

and fibula. J Bone Joint Surg. 1927;9(A):128. 

4. Ilizarov GA. The tension-stress effect on the genesis 

and growth of tissues: part I. the influence of stability of 

fixation and soft tissue preservation. Clin Orthop. 

1989;238:249-281. 

5. Ilizarov GA. The tension-stress effect on the genesis 

and growth of tissues: part. II. the influence of the rate 

and frequency of distraction. Clin Orthop. 

1989;239:263-285. 

6. Ilizarov GA. Clinical application of the tension-stress 

effect for limb lengthening. Clin Orthop. 1990;250:8-

26. 

7. Ilizarov GA. The principle of the Ilizarov Method. Bull 

Hosp Jt Di. 1997;56(1). 

8. McCarthy JG. Mandibular bone lengthening. Oper 

Techn Plast Recon Surg. 1994;1(2):99-104. 

9. Molina F, Ortiz-Monisterio F. Maxillary Distraction: 

Three Years of Clinical Experience. Proceedings of the 

65th Annual Scientific Meeting of the American Society 

of Plastic and Reconstructive Surgeons, Dallas, Texas. 

Plast Surg Forum. November 1998:19-54. 

10. Polley JW, Figueroa A. Management of severe 

maxillary deficiency in childhood and adolesence 

through distraction osteogenesis with an external, 

adjustable, rigid distraction device. J Craniofac Surg. 

1997;8:181-188. 

11. Hidding J, Zoller J. Alveolar bone distraction. Atlas of 

Craniomaxillofacial Osteosynthesis. Stuttgart, GE: 

Thieme Medical Publishers; 1999:139-140. 

AUTHORS

When this article was written, LTC (Ret) Pandolfi was 

Chief, Oral and Maxillofacial Surgery Department of the US 

Army Dental Activity, US Army Hospital, Heidelberg, GE. 

LTC Gibson is Chief, General Dentistry Department, US 

Army Hospital, Heidelberg, GE. 
56 Army Medical Department Journal 

INTRODUCTION

MREs (Meals, Ready-to-Eat) are packaged meals that 

are provided to US military personnel in a field 

environment or whenever hot cooked meals are 

unavailable. The contents of one MRE meal bag 

provides an average of 1250 kilocalories, 13% protein, 

36% fat and 51% carbohydrate. It includes a main 

entrée, a side dish, dessert, a bakery item, crackers, 

candy, spread, coffee, beverage mix, snacks, chewing 

gum pellets and an accessory pack. It provides onethird of the military recommended daily allowance of 

vitamins and minerals determined essential by The 

Surgeon General of the United States. MREs are high 

in fermentable carbohydrates. The daily consumption 

of 3 MREs, along with snacks and sweetened drinks, 

creates an ideal environment for caries causing 

bacteria to thrive. The increased use of smokeless 

tobacco also adds additional sucrose to be consumed 

and fermented. 

There is great emphasis placed on dental readiness in 

today’s military. The importance of annual dental 

examinations and prompt treatment of potentially 

serious dental conditions cannot be overstated. 

Deployment can occur in a matter of weeks and the 

Soldier must be dentally fit to deploy with the unit. 

Once arriving at their destination, Soldiers should be 

given every opportunity to maintain their dental health 

in a field/combat environment, which includes 

providing them with oral supplements to provide 

dental benefits. 

CARIES FORMATION

In general, the oral hygiene practices of military 

personnel decline in a field/combat environment for a 

number of reasons. Some of the reasons offered are no 

running water, too busy, long duty hours, no floss, no 

toothpaste, no toothbrush, and on and on. Couple those 

reasons with high carbohydrate meals and these 

personnel become a high risk for developing new 

dental caries. 

Dental caries is a dietary carbohydrate-modified, 

bacterial infectious disease. Caries result from the 

demineralization of tooth structure due to the acid 

produced by bacteria metabolizing fermentable 

carbohydrates. High sugar/carbohydrate intake and 

low levels of fluoride exposure, will lead to higher 

levels of caries causing bacteria, i.e., Streptococcus

mutans. As a result, enamel becomes demineralized 

and caries develop. The longer a fermentable 

carbohydrate stays around teeth, the greater the acid 

formation and caries activity. The critical pH of plaque 

is 5.5. Below this level, hydroxyapatite begins to 

dissociate, leading to mineral loss and caries 

formation. The drop in pH itself will not produce 

caries unless it is coupled with other parameters, such 

as bacteria, susceptible tooth, time, and a food source. 

All carbohydrates, starches, maltose, glucose, lactose, 

fructose and sucrose are used by S mutans and other 

plaque bacteria to produce organic acids as metabolic 

by-products that result in a drop in pH. It is important 

that this high risk population be provided with a daily 

oral supplement with an effective and proven record in 

lowering the incidence of dental caries by decreasing 

levels of S mutans, increasing plaque pH, as well as 

other anticariogenic effects. The data proves that 

xylitol chewing gum provides a superior efficacy in 

reducing caries rates in high-risk populations.1

XYLITOL GUM

Xylitol is found in nature in a variety of fruits, berries, 

and vegetables. It is a 5 carbon-sugar molecule that 

cannot be utilized by S mutans and has been 

documented to reduce levels of this bacteria if used 

long enough. It is not fermented by bacteria and is 

considered to be non-cariogenic.2

 It is extracted from 

the bark of birch trees for commercial use. The dental 

benefits of xylitol was discovered in Finland in 1970. 

The preventive and partly remineralizing effect of 

xylitol was shown in the Turku Sugar Studies in 

Finland in 1971-1973.3

 Numerous studies over the past 

25 years have suggested that a 5-10 gram daily 

consumption of xylitol in the form of gum can result in 

Xylitol Chewing Gum: A Recommended 

Addition to the MRE Package 

LTC Albert E. Scott Jr, DC, USA 
PB 8-06-1/2/3 Jan/Feb/Mar 57

a 30% to 85% reduction in caries. The specific effects 

of xylitol are: 

1. Enhances remineralization 

2. Decreases plaque formation 

3. Decreases oral levels of S mutans

4. Anticariogenic properties 

5. Increases plaque pH 

Xylitol gum showed a superior effect with respect to 

remineralization and plaque reduction.4

 An increased 

concentration of xylitol in the gum resulted in a lower 

number of S mutans in both saliva and plaque.5

It is documented that chewing gum increases salivary 

flow, which increases the buffering capacity of saliva. 

Even the use of sucrose chewing gum after meals and 

snacks (in the presence of fluoride from toothpaste) 

can enhance the remineralizing potential of the mouth, 

probably as a result of salivary stimulation.6

 The act of 

chewing causes the saliva to flow into the 

interproximal spaces. Salivary flow increases 2.7 times 

with chewing gum.7

 There is a rapid rise in plaque pH 

to safe levels above 5.5, after chewing gum, when 

plaque has been exposed to fermentable carbohydate. 

The xylitol chewing gum regimen resulted in 

significantly higher plaque pH than no gum, sucrose 

gum, or sorbitol gum.8

 The use of sucrose substitutes 

that provide the hedonistic appeal of sucrose, yet are 

not fermented by the plaque flora to the low pHs that 

are associated with caries, is a reasonable approach to 

caries control.9

 Chewing xylitol gum would have a 

much greater effect than the sucrose-laden chewing 

gum pellets currently present in MRE packages. Longterm habitual xylitol consumption decreased the 

prevalence of S mutans in the interproximal areas of 

the subjects and subsequently decreased the proximal 

and overall caries indices.10 Two pellets of xylitol 

chewing gum should be included in each MRE 

package with the instructions to chew both pieces for 

at least 5 minutes after each meal. Chewing for 5 

minutes is recommended, because that is when the 

concentration of xylitol in the saliva is greatest. If the 

service member is in a field environment where only 

MREs are served, then 3 MREs daily with 2 xylitol 

chewing gum pellets per MRE would represent the 

minimum recommended 3 times a day. This amount is 

equivalent to the recommended dosage of 5-10 grams 

of xylitol per day. (The maximum is 2 pieces 5 times a 

day.) Gastrointestinal intolerance at doses higher than 

those needed to achieve dental benefits is the only 

known side effect. 

CONCLUSION

Military personnel in a field environment, where high 

carbohydrate foods are consumed and little or no 

regular oral hygiene is performed, would benefit 

greatly from chewing xylitol chewing gum, if it was 

included in the place of the current sucrose chewing 

gum in MRE packages. Chewing xylitol gum should 

be a supplement and not a substitute for good oral 

hygiene, which should include brushing and flossing at 

least twice daily. The Michigan Xylitol Programme 

(1986-95) results suggest that the use of xylitol 

chewing gum can be considered a valuable additional 

tool in caries prevention and stabilization of caries in 

all age groups.11 

EDITOR’S NOTE: The 2004 Joint Services Operational 

Ration Forum approved the replacement of sugar gum 

in the MRE package with xylitol gum. The xylitol 

replacement gum went into production in 2005 and is 

currently being incorporated in MREs. 

REFERENCES

1. Gales MA, Nguyen TM. Sorbitol compared with 

Xylitol in prevention of dental caries. Ann 

Pharmacother. January 2000;34(1):98-100. 

2. Edgar WM. Sugar substitutes, chewing gum and 

dental caries – a review. Br Dent J. January 10, 

1998;184(1):29-32. 

3. Honkala S, Honkala E, Tynjala J, Kannas L. Use 

of Xylitol chewing gum among Finnish School 

Children. Acta Odontol Scand. December 1999;57

(6):306-309. 

4. Steinberg LM, Odulsala F, Mandel ID. 

Remineralizing potential, antiplaque and 

antigingivitis effects of xylitol and sorbitol 

sweetened chewing gum. Clin Prev Dent. Sep-Oct 

1992;14(5):31-34. 

5. Wennerholm K, Arends J, Birkhed D, Ruben J, 

Emilson CG, Dijkman AG. Effects of xylitol and 

sorbitol in chewing gums on mutans streptococci, 

plaque pH and mineral loss of enamel. Caries Res. 

1994;28(1):48-54. 
58 Army Medical Department Journal 

6. Manning RH, Edgar WM. Salivary stimulation by 

chewing gum and it’s role in the re-mineralization 

of caries-like lesions in human enamel in situ. J 

Clin Dent. 1992;3(3):71-74. 

7. Dawes C, Macpherson LM. Effects of nine 

different chewing gums and lozenges on salivary 

flow rate and pH. Caries Res. 1992;26(3):176-182. 

8. Aquirre-Zero O, Zero DT, Proskin HM. Effects of 

chewing gum on salivary flow rate and acidogenic 

potential of dental plaque. Caries Res. 1993;27

(1):55-59. 

9. Loesche WJ, Grossman DS, Earnest R, Corpron R. 

The effect of chewing xylitol gum on the plaque 

and saliva levels of Streptococcus mutans. J Am 

Dent Assoc. April 1984;108(4):587-592. 

10. Isokangas P, Tenovuo J, Soderling E, Mannisto H, 

Makinen KK. Dental caries and mutans 

streptococci in the proximal areas of molars 

affected by the habitual use of xylitol chewing 

gum. Caries Res. 1991;25(6):444-448. 

11. Makinen KK, Makinen PL, Pape HR Jr, Peldyak J, 

Hujoel P, Isotupa K, Soderling E, Isokangas PJ, Allen 

P, Bennett C. Conclusion and review of the Michigan 

Xylitol Programme (1986-1995) for the prevention 

of dental caries. Int Dent J. February 1996;46

(1):22-34. 

AUTHOR

LTC Scott is currently the Officer-In-Charge of the 

Bull Dental Clinic, Fort Lee, VA. 
PB 8-06-1/2/3 Jan/Feb/Mar 59

ABSTRACT

This study reviews trends and behaviors in both the 

civilian and Army dental communities with regard to 

posterior restorations and choices of material for the 

restoration, and suggests policy perspectives for Army 

dentists based on this behavior. Items of research 

interest include provider experience, type of 

restorative material used, and the survival time of a 

posterior restoration. Data are obtained from the 

Washington Dental Service and the Army Dental Care 

System. The methodology used to review performance 

is Data Envelopment Analysis. The study shows that 

efficient dental providers produce longer lasting 

restorations regardless of material, and there is no 

difference in survival rate between amalgam and 

composite restorations when the restoration is 

performed by an efficient provider. The study has 

managerial implications for the improvement of 

military dental services through increased operational 

efficiency. The study has policy implications for better 

allocation of Army health resources and improved 

dental readiness within the military force structure. 

INTRODUCTION

The longevity of dental restorations depends on many 

factors including dental materials, the dentist, and 

patient hygiene habits. Dentistry is often referred to as 

a cottage industry, yet the cost of dental services are 

substantial. In 2001, US national dental expenditures 

were $65.6 billion, an 8% increase from 2000.1

 Since 

dental restorations do not last forever, a cycle of 

restoration replacement is critical within DoD because 

dental readiness is a requirement for US military force 

deployment. A systematic review on the literature of 

the longevity of dental restorations concluded that 

50% of all restorations will last 10 to 20 years, 

although significantly higher and lower survival times 

have been reported.2

Several types of commonly used restorative materials 

are used for posterior teeth. These include amalgam, 

composite resin, glass ionomers, gold, and porcelain. 

Dental amalgam is an alloy of mercury that 

incorporates silver, tin, copper, and zinc. Amalgam 

remains a popular dental restorative material because it 

is versatile, adapts well to use in the wet oral 

environment, and is relatively inexpensive. Previous 

studies have found amalgam to be the most cost 

effective and durable restorative material available.3-8

Composite material is a quartz and resin base material 

that can be matched to the patient’s natural tooth color 

and is seen as more cosmetically pleasing to patients. 

However, it has been viewed as less reliable for 

posterior restorations because of increased mastication 

forces and the potential marginal leakage due to 

insufficient bonds on large sub-gingival restorations. 

Less common restorative materials for posterior teeth 

include glass ionomers, gold, and porcelain. Glass 

ionomers are also used in a limited fashion, primarily 

serving as an interim or temporary restoration. Gold 

and porcelain based restorations are also options for 

restoring posterior teeth, but are significantly more 

expensive.3-4 Cast gold restorations function well due 

to similar wear properties to enamel, but laboratory 

fees significantly increase costs and the restorations 

generally do not meet the aesthetic concerns of the 

21st century. Porcelain restorations meet aesthetic 

concerns but are expensive and can wear opposing 

enamel surfaces. The cost of porcelain and gold 

restorations make them impractical for use within the 

Army and DoD. 

With respect to the two common restorative materials, 

amalgam has historically been considered the 

restorative material of choice for most dental providers 

due to the perception of superior performance and 

lower cost. However, due to increasing aesthetic 

concerns of the military population and public 

A Policy Perspective for Army Dentists 

Performing Posterior Restorations 

LTC M. Nicholas Coppola, MS, USA 

Jeffrey P. Harrison, PhD 

LTC Jeffrey G. Chaffin, DC, USA 

Darrell E. Burke, PhD 
60 Army Medical Department Journal 

concerns over the safety of amalgam restorations due 

to the perceived effects of mercury, amalgam 

restorations may no longer be the consumer or 

provider restorative material of choice. 

Supporting these public concerns, the 1999 American 

Dental Association (ADA) Services Rendered Survey 

reported that 54.1% of all restorations placed in the US 

in 1999 were composite resin based.5

 This significant 

shift toward composite use has not taken place in the 

military, where more effective and less expensive 

amalgam is still popular. This investigation evaluates 

the longevity of amalgam and composite posterior 

restorations, including the impact of efficiency with 

respect to Army dental providers. 

BACKGROUND

In the civilian community, amalgams are more 

frequently placed on posterior teeth. This is because 

dental insurance companies are more likely to 

reimburse a patient for an amalgam restoration on a 

molar, but decline to reimburse for composite 

restorations because the amalgam restoration is 

cheaper and fits the standard of care.6,7 The ADA 

conducted a nationwide survey of dental fees in 1999 

which found that the average cost (based on the 75th 

percentile) of an amalgam posterior two-surface 

restoration is approximately $93, while a similar 

composite restoration costs approximately $139.8

Amalgam restorations in permanent teeth have been 

the most common operative dentistry procedure in the 

United States.9-14 Dentists have avoided placing more 

aesthetic posterior composite restorations because of 

their perceived inferiority and higher costs to patients, 

as well as the likelihood of their being refused 

reimbursement by the dental insurance companies.11,15-

17 Some researchers suggest that amalgam’s acceptable 

record of accomplishment has established a practice 

guideline that establishes it as the posterior material of 

choice in restorative dental practice.18 Recent research 

suggests that, in fact, improved materials and 

techniques are resulting in superior composite 

restorations, with failure rates virtually 

indistinguishable from those of amalgam.19 The results 

of this study are significant as DoD strives to increase 

the dental readiness of the force structure while 

minimizing dental costs. 

Though composite restorations are gaining popularity 

in private practice settings, public settings such as the 

military and public health clinics may be slower to 

adopt these practices. The perceived durability 

combined with being less expensive and technique 

sensitive makes amalgam the chosen restoration 

material. The Army Dental Care System (ADCS) 

provides dental services for the 485,000 active duty 

Soldiers worldwide and their family members 

overseas. The system can be viewed as providing 

dental care in a public health arena. The 1999 ADA 

data on restorative material use is a reflection of 

private practitioner trends as the data comes from 

insurance claims. In that study, 54% of all restorations 

were composite restorations, while only 46% were 

amalgam. The figure compares composite and 

amalgam restorations placed by the ADCS versus the 

US national average. 

The trend shown by private practitioners is not 

consistent with restorations by Army dental providers. 

In fiscal year 2002, 60.7% of all restorations placed in 

the ADCS were amalgam, and 38.1% of posterior 

restorations were composite. The data clearly 

documents a practical variance between increased use 

of posterior composite restorations by private dentists 

versus the amount used by Army dental providers. 

Why has the shift to composite resin experienced in 

the US civilian sector not been mirrored by military 

providers? One reason may be that military dental 

providers still view amalgam as the material of choice. 

Another reason may be lack of training of providers in 

posterior composite restorations, a situation which 

could be addressed in continuing education and 

residency training. 

Comparison of amalgam and composite 

restorations placed by the Army Dental Care 

System from FY 2000 through FY 2002 with 

the US average. 

0

10

20

30

40

50

60

70

FY '00 FY '01 FY '02 US Avg

Amalgam Composite 
PB 8-06-1/2/3 Jan/Feb/Mar 61

The results of this study have managerial implications 

at the clinic level and policy implications at the Army 

level. Currently, Army practitioners make their own 

decisions of which material to use based on training 

and their judgment as to the best material for the 

particular patient. If composite restoration longevity 

were to surpass amalgams in repeated studies, the 

Army may want to review existing policies and initiate 

a continuing education program on the use of posterior 

resin restorations. 

DATA AND STATISTICAL INSTRUMENT

For the statistical part of the study, data were obtained 

from the Washington Dental Service, Seattle, WA. 

This dental insurance claims database contains over 

1.5 million patient encounters and over 23,000 

contributing dentists. Providers and patients are 

followed from January 1993 through December 1999. 

A total of 1,240 dentists in the database met researcher 

selected screening criteria of performing at least onehundred posterior restorations over 7 years. The final 

patient sample size included 279,999 restorations, of 

which 194,484 were amalgams and 85,515 were 

composites. DEA-Solver Professional Version 2.0 

(SAITECH Decision Support Systems, May 2001) was 

used as the statistical measuring instrument in the 

analysis. Data were obtained from the ACDS for the 

policy part of the study. 

METHODS

In order to analyze the differing effectiveness of 

amalgam and composite survival times, this study 

employs a relatively new technique, data envelopment 

analysis (DEA). In the DEA methodology, efficiency 

is defined as a Pareto-optimal allocation of resources. 

An allocation is Pareto-optimal or Pareto-efficient if 

production and distribution cannot be reorganized to 

increase the utility of one or more units without 

decreasing the utility of other units. Stated another 

way, efficiency is a simple ratio whose quotient is 

derived as a function of outputs over inputs where 

E = fx (O/I). DEA has been successfully applied in 

numerous examples from many industries, and 

specifically to the study of health care organizations 

and professionals.20-27

DEA introduces the concept of decision-making units 

(DMU), in this case the individual dentist, by 

considering multiple inputs and outputs while 

identifying the most efficient providers. A DMU is 

regarded as the entity responsible for converting inputs 

into outputs and whose performance is to be evaluated. 

In DEA, Inputs are defined as any factor used as a 

resource by the DMU for producing something of 

value. It may also be any environmental factor that 

bears a strong effect on how the resources are 

consumed. Outputs are the amount of goods, services, 

or other outcomes obtained as a result of the 

processing of resources or any factor that describes the 

qualitative nature of the resulting outcome.26-30 The 

DEA program algorithm is briefly presented by the 

following equation28-30: 

Where 

E denotes the efficiency score for each dentist in the 

set of o = 1...n dentists 

yro is the selected output "r" produced by each dentist 

in the set "o" 

xio is the selected input “I” used by each dentist in 

the set "o" 

yrj is the selected output "r" produced by dentist "j" 

xij is the selected input "I" used by dentist "j" 

In this formulation, ur and vi are the weights assigned 

respectively to output "r" (survival time) and input "i", 

both obtained from DEA. The constant is represented 

by co. 

 s 

 ∑ ur yro + co

 r = 1 

 Minimize E =

 s 

 ∑ vi xio

 i = 1 

 Subject to: 

 s 

 ∑ ur yro + co

 r = 1 

  1 

 s 

 ∑ vi xio

 i = 1 

 ur 0; vi  0
62 Army Medical Department Journal 

The output variable includes the survival time of the 

restoration, while inputs represent provider experience, 

amalgam, and composite materials. When the 

aforementioned equation is linearized for conceptual 

purposes, the efficiency formulation of a dentist can be 

expressed as: 

Efficiency = f [(survival time)/(amalgam + composite + 

 provider experience)] 

Efficient dental providers receive an efficiency score 

of 1.0. 

RESULTS

Table 1 displays frequencies for efficient and 

inefficient providers. Table 2 shows that 122 

providers, which constituted approximately 10% of the 

study population, were found to be efficient. Table 2 

suggests a disparity between efficient and inefficient 

providers. The average material survival time for 

efficient dentists is 46.47 months, for inefficient 

dentists it is 41.79 months. Efficient dentists have an 

average restoration longevity of 4.7 months longer 

than that of the inefficient providers. An interesting 

finding is that the average experience for efficient 

dental providers is approximately 25 years, whereas 

inefficient providers have approximately 5 years less 

experience. The difference is significant (ρ <.001, χ

2 

= 

18.98). The results suggest that efficient providers are, 

on average, 17% more experienced than inefficient 

providers. Efficient providers also performed 44% of 

their total replacements with composite material, while 

inefficient providers used composite material only 

29% of the time. This suggested that in order to 

become efficient, inefficient providers should perform 

more composite restorations. 

Table 2. Comparison of age, experience, and survival times of restorations between efficient 

and inefficient dentists. 

Inefficient Providers Efficient Providers 

Total Number 1,118 122 

*Provider years of experience 20.25 24.5 

Average survival time of restoration (months) 41.79 46.47 

Mean age of dental provider 46.7 50.9 

*Chi-square (χ

2

) = 18.98 ρ < 0.0001 

Table 1. Frequencies of provider services for amalgam and composite restorations between inefficient 

and efficient providers.

Inefficient Providers Efficient Providers 

Encounters Percentage Encounters Percentage 

Total 216,376 15,607 

Amalgam 152,693 71% 8,695 56% 

Composite 63,683 29% 6,912 44% 

Amalgam Severity 2 Surface 61,891 40.59% 3,787 43.55% 

Amalgam Severity 3 Surface 61,237 40.10% 3,096 35.61% 

Amalgam Severity 4 Surface 29,475 19.30% 1,812 20.84% 

Composite Severity 2 Surface 35,639 55.96% 3,814 55.18% 

Composite Severity 3+ Surface 28,044 44.03% 3,098 44.82% 
PB 8-06-1/2/3 Jan/Feb/Mar 63

Post hoc analysis was performed, and iDEAs-W was 

used to identify theoretical possibilities for 

improvement of the inefficient population of dental 

providers. A virtual output/virtual input quotient was 

calculated to achieve an Iota (ι) value by balancing 

projections of inefficient provider properties along the 

efficiency frontier. Projections provide information on 

the relative changes required by each dentist that must 

be made in order to reach the efficiency frontier. 

Iota is obtained by standardizing the total weighted 

distance by the virtual input. Iota values are a measure 

of total inefficiency in terms of proportional input 

reduction. An Iota value less than one (ι < 1), indicates 

inefficiency. A ι =.5 indicates that the DMU should be 

able to decrease input by 50% to be efficient. The 

theoretical model in this case returned an ι = .807, 

suggesting that only 20% of dentists in this population 

are capable of achieving efficiency with 5 years 

additional experience without changing their amalgam 

based practice pattern. 

DISCUSSION

This study suggests that the longevity rate of a 

restoration is related to the experience of the provider. 

This is particularly important within the Army because 

dental health status is critical for individual and unit 

deployment. The results also suggest that providers 

who work with amalgam, regardless of severity, are 

less likely to be efficient than are providers who work 

with composite restorations. This is significant 

because amalgam is the compound of choice within 

the Army. The finding may suggest that less 

experienced providers may need additional continuing 

education focused on the placement of posterior resin 

restorations, since 71% did not use composite material. 

This is an appropriate area for further study within the 

Army. 

The research suggests a positive correlation between 

experience and success for procedures. The growing 

options for dental restoration within private industry 

will also become a growing trend for Army consumers 

in the years to come. From a managerial perspective, 

military dental clinics have not traditionally given 

patients options. As a result, managers in military 

dental clinics may encourage dental providers to 

practice both amalgam and composite material 

restorations in order to increase efficiency and quality. 

Military dentists who wish to improve efficiency are 

challenged to implement meaningful programs and 

services that can positively affect military readiness. 

This study clearly demonstrates that Army dental 

clinics may be missing an opportunity to improve 

efficiency by expanding the use of composite 

restorations. Additionally, it is clear that as the level of 

efficiency of dental providers increases, the quality 

and longevity of the dental restoration also increases. 

Improvements in the training of Army dental providers 

will provide better patient care and ultimately increase 

the life of a posterior restoration. This will result in 

increased military readiness. Therefore, Army dental 

clinic managers are encouraged to integrate the use of 

composite restorations and improved provider training 

in their strategic planning process to ensure 

operational efficiency and improve military readiness. 

POLICY IMPLICATIONS

This study suggests that provider experience and 

practice patterns are key indicators for the success of a 

posterior restoration. This finding is particularly 

important within the Army where recent dental 

graduates compose a large percentage of the general 

dentistry provider force. These results would suggest 

the Army should invest additional training funds early 

in a dentist’s career to improve their practice 

efficiency. Also, it may be appropriate to consider the 

range of clinical practice, quality of practice, and 

efficiency of practice. The results also support the use 

of retention bonuses later in a dentist’s career to retain 

efficient providers. 

Military dentistry continues to seek best practices as a 

method to improve quality and reduce costs. If 

posterior composite restorations were found to last 

longer than amalgam, long-term cost savings could be 

realized by extending the replacement cycle of 

restorations. Future research in restoration compounds 

that address the replacement cycle could reduce costs 

and enhance the deployability of individuals in 

military units. Since this study shows employment of 

experienced providers results in 4.7 months of 

longevity in the restoration and improved dental 

fitness of the population, the findings stress the 

importance to the military of hiring experienced 

dentists. This can be achieved by selective hiring from 

dental schools or the use of hiring bonuses for dentists 

in private practice. Additionally, a retention bonus 
64 Army Medical Department Journal 

may be a sound economic investment to encourage 

experienced dentists to remain on active duty. 

The data also suggest that dental providers with a more 

restricted scope of practice (i.e., higher percentage of 

amalgams regardless of severity) are less likely to be 

efficient than those dental providers with a broader 

scope of practice (i.e., higher percentage of composite 

restorations). While this finding may have different 

implications within the Army due to unique practice 

settings, it does suggest that inefficient dental 

providers should broaden their scope of clinical 

practice to include both amalgam and composite 

restorations to become efficient. By providing 

additional training to dental providers, it is possible to 

improve the overall rate of efficiency leading to an 

improved state of dental readiness and lower overall 

costs. 

This study has implications within the Army because 

military readiness is affected by the choice of dental 

materials. During the recent mobilization of forces for 

Operation Iraqi Freedom, approximately 25% of the 

reserve component Soldiers had emergent dental 

conditions effecting their deployment. Over half of 

those emergent conditions were corrected with dental 

restorations. The prevailing thought is that posterior 

amalgam restorations should be utilized on this highrisk group. However, the research suggests that 

composite restorations can last as long or longer than 

amalgams when performed by an experienced 

provider. 

The results of this study suggest that dental experience 

is key to restoration survivability. However other 

factors bear mentioning. The first factor addresses 

patient preference and the policy implications of 

preference. As already mentioned, the use of 

composites has recently exceeded amalgam for the 

first time in the civilian practice setting. Clearly, 

patients are interested in composite restorations. 

Reasoning behind this trend may be explained through 

Rogers’ diffusion of innovation theory.31 In brief, 

tenets of the theory suggest that the relative advantage, 

compatibility, and observability of an innovation 

(composite resin) will positively increase its adoption 

by (in this context) dental patients. Many patients and 

some dental professionals remain concerned about the 

effects of mercury in amalgam, despite clinical studies 

dismissing the risk. Thus composite has a perceived 

advantage of being a safer alternative to amalgam. In 

addition, the aesthetics, or cosmetic value, of 

composites versus amalgam is immediately observable 

to patients and quite compatible with the current 

societal pressure to maximize one’s appearance. In 

summary, the perceived advantage and concerns over 

one’s appearance have served to create a strong public 

demand for the use of composite resin and have given 

patients a viable choice. By offering composite 

restorations to military beneficiaries, the Army may 

gain a strategic advantage in recruitment and retention 

leading to a significant increase in patient satisfaction. 

Surprisingly, only 70% of all North American dental 

schools teach their students how to repair a resin-based 

composite dental filling.32 The gaining popularity of 

this material combined with the similar longevity 

identified from this study necessitates composite repair 

practices at all schools. From a policy perspective, the 

Army may want to ensure similar coverage is offered 

to all military beneficiaries. 

SUMMARY

There have been few long-term studies of the 

longevity rate of amalgam or composite material and 

none that have considered the experience of the 

provider in the longevity rate.33,34 This study has 

important implications for the Army because it 

suggests that experience is a key factor in the 

longevity rates of composite restorations. 

Since experience is such a significant factor in 

restoration longevity rates, this study has implications 

for provider selection, training, retention, and specialty 

pay. Additionally, the study may improve the level of 

efficiency of practice within military dental clinics as 

well as improve the deployability of active duty and 

reserve military members. A 10% increase in 

efficiency would result in significant cost savings and 

an improved readiness posture for the military. The 

impact of a 10% increase in efficiency created by the 4

-month increased longevity of restoration is even more 

important because it represents a long-term systemwide saving that is compounded as newer materials 

and procedures are used throughout military dental 

care. More importantly, the financial savings are 

enhanced by the improved deployability of the active 

duty and reserve forces. 

Portions of this article were included in the 

presentation “Performance of Dental Providers on 

Restorations — A DEA Evaluation” at The 16th 

Triennial Conference of the International Federation of 

Operational Research Societies, 8 – 12 July, 2002, 

hosted by the UK Operational Research Society, 

University of Edinburgh, Scotland.
PB 8-06-1/2/3 Jan/Feb/Mar 65

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66 Army Medical Department Journal 

31. Rogers E. Diffusion of Innovations. 4th ed. New York, 

NY: The Free Press; 1995. 

32. Gordan VV, Mjor IA, Blum IR, Wilson N. Teaching 

students the repair of resin-based composite 

restorations: a survey of North American dental 

schools. J Am Dent Assoc. 2003;134:317-323. 

33. Osborne JW, Norman RD, Gale EN. A 14-year clinical 

assessment of 12 amalgam alloys. Quintessence Int. 

1991;22:857-864. 

34. Coppola MN, Ozcan YA, Bogacki R. Evaluation of 

performance of dental providers on posterior 

restorations using amalgam or composite material: does 

experience matter? a data envelopment analysis (DEA) 

approach. J Med Syst. 2003;27:447-458. 

AUTHORS

LTC Coppola is an Assistant Professor in the US ArmyBaylor University Graduate Program in Health Care 

Administration, US Army Medical Department Center & 

School, Fort Sam Houston, TX. 

Dr. Harrison is Assistant Professor of Health Administration 

at the University of North Florida, Jacksonville, FL. 

LTC Chaffin is a resident in the US Army-Baylor Graduate 

Program in Health Care Administration, Fort Sam Houston, 

TX. 

Dr. Burke is Assistant Professor in the School of 

Information Studies, Florida State University, Tallahassee, 

FL. 
PB 8-06-1/2/3 Jan/Feb/Mar 67

CORRECTION

In the October – December 2005 issue of the AMEDD Journal, the table “Brooke Army Hospital 

Residents 1947 – 1962” in the article “Development of Army Residency Programs: Pathology at Fort 

Sam Houston” contained incomplete information for several entries. Correct information for those 

entries is provided herein. The Journal regrets the error. 

NAME BIRTH SCHOOL RESIDENT DEATH LOCATION

Grahm, Harvey P. 1917 Duke ‘52 57-61 12/17/99 Suwanee, GA 

Keller, Edward S. 1924 McGill ‘55 57-58 11/26/90 Everett, WA 

Lardinois, Clifford C. 1919 Wisconsin ‘51 52-55 10/13/94 Huron, SD 

Snyder, Dale R. 1927 Pennsylvania ‘54 56-59 10/27/02 McLean, VA 

Van Auken, Howard A. 1904 Michigan ‘31 48-51 10/18/83 San Antonio, TX 

2005 Spurgeon Neel Writing Competition Winners 

COL Thomas Munley, Executive Vice-President of the Army Medical Department Foundation, has announced 

that CPT Kevin Goke, William Beaumont Army Medical Center, Fort Bliss, TX, and 1LT Rene De La Rosa, 

Brooke Army Medical Center, Fort Sam Houston, TX, has been selected as winners of the 2005 Spurgeon Neel 

Writing Competition. CPT Goke is a psychiatric nurse and 1LT De La Rosa is a medical-surgical nurse. 

The article by CPT Goke and 1LT De La Rosa, titled “Mental Health Services at FOB Abu Ghraib: Nafsea 

(Psychology) Through the Wire” appeared in the July-September 2005 issue of the AMEDD Journal. The article 

provides a look at the history and current medical and mental health care provided to both US troops and Iraqi 

detainees. The judges determined that this article best exemplified the history, legacy, and traditions of the Army 

Medical Department. 

As Neel Writing Award winners, CPT Goke and 1LT De La Rosa will divide a $500 monetary prize and receive 

specially-designed medallions that will be presented at an AMEDD Museum Foundation special event in March. 
68 Army Medical Department Journal

The US Army Medical Department was formed on 27 July, 1775, when the Continental Congress authorized a 

Medical Service for an army of 20,000 men. It created the Hospital Department and named Dr. Benjamin 

Church of Boston as Director General and Chief Physician. On 14 April, 1818 the Congress passed an Act which 

reorganized the staff departments of the Army. The Act provided for a Medical Department to be headed by a 

Surgeon General. Dr. Joseph Lovell, appointed Surgeon General of the United States Army in April 1818, was 

the first to hold this position in the new organization. The passage of this law marks the beginning of the modern 

Medical Department of the United States Army. 

Throughout its early history, the size and mission of the US Army Medical Department would wax and wane in 

response to military events around the world. There was, however, no formal regimental organization until 

World War I. Then, in the late 1950s, the brigade replaced the regiment as a tactical unit. In the reorganization 

that followed, some Army units lost their identity--their lineage--their history. This loss did not go unnoticed and 

the US Army Regimental System was created in 1981 to provide soldiers with continuous identification with a 

single regiment. Department of the Army Regulation 600-82, The US Army Regimental System, states the 

mission of the regiment is to enhance combat effectiveness through a framework that provides the opportunity 

for affiliation, develops loyalty and commitment, fosters a sense of belonging, improves unit esprit, and 

institutionalizes the war-fighting ethos. 

The US Army Medical Department Regiment was activated on 28 July, 1986, during ceremonies at Fort Sam 

Houston, in San Antonio, Texas, the "Home of Army Medicine." Lieutenant General Quinn H. Becker, the US 

Army Surgeon General and AMEDD Regimental Commander, was the reviewing officer. He was joined by 

general officers of the US Army Reserves and the Army National Guard, representing the significant 

contributions and manpower of the reserve forces in the Total Army concept. 

This Regimental web site (http://ameddregiment.amedd.army.mil/default.asp) is designed to provide you with 

useful information about the US Army Medical Department (AMEDD) Regiment. Through the web site, you 

can learn the history of the AMEDD Regiment, the symbolism behind our heraldic items, how to wear the 

Regimental Distinctive insignia, and various programs available to you and your unit. 

The Office of the AMEDD Regiment is located in Aabel Hall, Building 2840, on Fort Sam Houston, Texas. The 

Regimental staff can provide further information pertaining to the history of the Army Medical Department, the 

AMEDD Regiment and assist with any of the services described in this web page. 

For additional information please contact the Army Medical Department Regimental Office at the following 

address: 

Commander 

US Army Medical Department Regiment 

ATTN: MCCS-GAR 

2250 Stanley Road 

Fort Sam Houston, Texas 78234-6100 

The telephone number is Commercial (210) 221-8455 or DSN 471-8455. The fax number is 8697. 

The email address is amedd.regiment@amedd.army.mil 

THE US ARMY MEDICAL DEPARTMENT 

REGIMENT 
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, 

and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed 

print medium to encourage dialogue concerning health care issues and initiatives. 

REVIEW POLICY

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriate 

subject matter expert for further review and assessment. 

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personal 

relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state 

explicitly whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interest 

notification section on the title page, providing additional detail, if necessary, in a cover letter that accompanies the 

manuscript. 

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this 

assistance, if any. 

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done 

so in the manuscript. 

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis, 

and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source

had no such involvement, the authors should so state. 

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with 

the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki 

Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki 

Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body 

explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the 

institutional and national guide for the care and use of laboratory animals was followed. 

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Articles should be submitted in digital format, preferably an MS Word document, either as an email attachment (with 

illustrations, etc), or by mail on CD or floppy disk accompanied by one printed copy of the manuscript. Ideally, a manuscript 

should be no longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. In 

general, 4 double-spaced MS Word pages produce a single page of 2 column text in the AMEDD Journal production format. 

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles 

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. 

Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript. The following is a synopsis of the 

American Medical Association reference format: 

 Reference citations of published articles must include the authors’ surnames and initials, article title, publication title, 

year of publication, volume, and page numbers. 

 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if 

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited. 

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying 

information as possible (location, dates, presenters, sponsors, titles). 

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Word 

photo files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images 

submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each 

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and 

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

information must be included on the title page of the manuscript. 

6. Submit manuscripts to: 

EDITOR, AMEDD JOURNAL 

ATTN MCCS DT 

2419 HOOD ST STE C 

FORT SAM HOUSTON, TX 78234-7584 

DSN 471-6301 

Comm 210-221-6301 

Email: amedd.journal@amedd.army.mil