Dental utilization of active duty/previous active duty US military: a cross-sectional analysis of the 2010 Behavior and Risk Surveillance Survey

Irregular dental visits affect quality of life and aspects of overall health. For example, 47.2% of Americans (64.7 million) have mild, moderate, or severe periodontal disease [1]. And periodontal disease has been associated with poorer diabetes control, cardiovascular disease, and a variety of other chronic inflammatory diseases. Regular dental visits have been recognized as an important component of individual medical readiness by the Department of Defense. In 2010, the United States had 1,431,000 military personnel on active duty [2]. Non-combat dental emergencies have a negative impact on military operations. A retrospective study of the dental emergency rates for Army personnel in Bosnia in 2000 indicated 156 dental emergencies per 1000 soldiers per year [3]. A study of all reported U. S. Army dental emergencies from 2009-2010 indicated 11,642 soldiers had dental emergencies, resulting in an average time loss of 24 hours per unit per week and an estimated financial cost in time of $14.7 million and an estimated cost in treatment of $13.9 million [4]. Additionally, there is a negative impact on combat effectiveness.4 The officials at the Department of Defense, being aware of the impact of non-combat dental emergencies in deployment, have Dental Readiness instructions within the instructions for Individual Medical Readiness. The instructions apply to the Army, Navy, Air Force, Marines, and Coast Guard (when the Coast Guard is not operating as a service within the Navy) [5] [6]. The minimum goal for the overall Individual Medical Readiness program is more than 75% of service members being fully medically ready [5]. The stated goal for dental readiness is 95% [6]. A Dental Fitness Class 1 or Class 2 rating (DFC) status is required for personnel to qualify for mobilization. There are 4 DFC ratings ranging from Class 1 in which an individual has a current examination (an examination within the previous 12 months) and no dental needs to Class 4 (DFC4) in which the person is not considered deployable [5] [6]. In Class 1 (DFC1), an individual has a current examination (an examination within the previous 12 months) and no dental needs. An individual with Class 1 designation are worldwide deployable [5] [6]. In Class 2, an individual has a current dental exam, and does require non-urgent care, but his or her dentist reports that the condition will remain stable and not become an urgent dental need during the next 12 months [5] [6]. An urgent dental need/emergency need is a condition of oral disease, trauma, loss of function, or other concern that causes a patient to seek immediate dental treatment.6 The non-urgent needs could include caries which are likely to remain stable for the next 12 months, repair of minor defective restorations, or a dental prophylaxis [5] [6]. This classification also includes treatment that can be deferred for 12 months for stable, advanced periodontal disease; temporomandibular disorder in remission; or symptomless unerupted/partially erupted/malposed teeth which are not pathological but are recommended for prophylactic removal, etc. [5] [6]. The instructions in this classification are that if a service man or woman has active orthodontic treatment, the treatment should be made passive if the deployment is less than 6 months; and if the deployment is greater than 6 months, there should be consideration of removal of active appliances and placing the dentition into passive retention [5] [6]. The Class 2 determination requires the examining dentist to predict if an urgent dental issue or a dental emergency situation is likely to occur. Civilian examining dentists from across the country are not calibrated in making such determinations; therefore, the reliability of the classification is questionable. Also, dental emergencies resulting from ulcerations, trauma, or referred pain of maxillary sinusitis are not predictable [7]. Another criticism of attempting to make a Class 2 determination is the lack of an analysis component for future risk [8]. Military personnel may not have an immediate acute need, but there may be a documented need for care at the Class 2 level which becomes emergent; or a person about to deploy may undergo extensive treatment before being deployed and he or she may develop emergent post-treatment problems [8]. Prediction of future dental need is difficult and an acceptable level of prediction has not been determined. In 1983, a study of deployment to the Sinai indicated a dental emergency rate of 160 dental emergencies/1000 soldiers/year [8]. In 2000, soldiers deployed to Bosnia had a dental emergency rate of 156/1000 soldiers/year (121 dental emergencies/1000 Dental Fitness Class 1 soldiers/year and 185 dental emergencies/1000 Dental Fitness Class 2 soldiers/year) [3]. Researchers in 2011, using a time frame of 3 ½ months and a sample of 3940 soldiers classified as deployable (Classes 1 and 2 combined, N=3806) and nondeployable (N=134) indicated that there were 39 dental emergencies in the nondeployable group (29.1%) and 216 in the deployable group (5.7%) [10]. The risk ratio was 5.13; 95%; Confidence interval: 3.82,6.88 [10]. These and similar studies indicate that although there may be a need for improvement in prediction, the dental emergencies for the military personnel being deployed have been similar across many years. There is a need to develop a valid and reliable model for predicting dental emergencies which includes caries risk, periodontal health and tobacco use.8,11 There is also a need for standardization of the classifications to limit confusion and improve prediction [11]. In Class 3 (DFC3), an individual requires urgent or emergent dental care.5,6 He or she is not normally considered worldwide deployable [5] [6]. This classification includes needed follow-up treatment, treatment that cannot be maintained for 12 months, acute periodontal needs, radiographic pathosis that requires treatment, chronic infections, acute temporomandibular disorders, or edentulous areas requiring immediate treatment for communication, or mastication, or acceptable esthetics [5] [6]. In Class 4 (DFC4), an individual needs a periodic dental evaluation (the last dental visit was greater than the previous 12 months), or the individual has an unknown classification [5] [6]. He or she is not considered worldwide deployable [5] [6]. In the general population overall dental care, as measured by dental utilization, has been reported to be decreasing for adults since the mid-2000s [12]. In 2003, 42% of U.S. adults visited the dentist within the previous year, whereas in 2010, 37% of U.S. adults were reported to have visited the dentist [12]. A variety of reasons, such as dental anxiety [13] [14] [15] [16] [17] [18] [19], need for care [20], and financial barriers [21] [22] [23] [12] may explain infrequent dental visits or dental avoidance. However, among individuals serving in the military or who have served in the military, there is a potential for a carry-over effect to have internalized the importance of the Dental Readiness instructions, to take charge of their oral situation, to plan, to use critical thinking, and to be less likely to leave things to chance. Therefore, it is highly plausible that dental utilization of individuals who are serving or who have served in active duty in the U.S. military may be substantially higher than individuals who have not served in the U.S. military. While there have been studies of dental utilization among the active military personnel, these studies have been specific to specific branches and have not examined carry-over effects. Therefore, the objectives of this study are to better understand 1) dental utilization of individuals who are serving or who have served in active duty in the U.S. military as compared to the general public which had not served in the U.S. military and 2) dental utilization of individuals who are currently serving as compared with individuals who are no longer active duty, but have been in active duty within the previous year. The rationale for the study is that there is a need to know if returning personnel are more or less likely to utilize dental care and to inform policies to encourage dental utilization if needed. The research hypotheses are: 1) there will be a statistically significant difference between the dental utilization and utilization of preventive services among individuals who have been active duty or who are currently active duty in the U.S. military vs. the general U.S. public which had never served in the U.S. military; and 2) dental utilization and utilization of preventive services among participants who are currently active duty will be equivalent to those who are not active duty but were active within the previous 12 months.