Embed Size (px)
Citation preview
Oral Health Status and Treatment Needs of Navy and Marine Corps
Reserve Components
Andrew K. York, CAPT, DC, USNDavid L. Moss, LTC, USA, DC
Susan W. Mongeau, Lt Col, USAF, DC
Tri-Service Center for Oral Health StudiesUniformed Services University of the Health Sciences
Bethesda, MDFebruary 2003
Table of Contents
Background 2
Methods 2-3
Study Sample 3
Oral Health Status (DoD Dental Classification) 4
Operative Treatment Needs 5-7
Oral Surgery (extraction) Treatment Needs 8-9
Endodontic Treatment Needs 10-11
Prosthodontic Treatment Needs 12-13
Periodontic Treatment Needs 14-15
Treatment Needs Expressed as Dental Weighted Values 16-20
Department of Defense Oral Health and Readiness Standards 21-22 (Appendix A)
1
Background
Prior to this study, the dental treatment need among Navy and Marine Corps Reserve Components was largely unknown. Anecdotal accounts from Operation Desert Storm (1991) reported poor dental health and large amounts of dental treatment need.
In October 2001, the largest reserve component mobilization in a decade began with the onset of Operation Noble Eagle/Enduring Freedom. This presented a unique opportunity to assess the dental condition of this group. The Tri-Service Center for Oral Health Studies (TSCOHS) was tasked and funded by the DoD Health Affairs, TRICARE Management Activity (TMA) to develop and implement a scientific protocol to assess and document the oral health status and treatment needs of these mobilized reservists.
In October 2001, the Navy Bureau of Medicine and Surgery Dental Division tasked all Navy Dental Commands to collect and submit data, according to the protocol provided by TSCOHS, for all reservists mobilizing through their command.
Methods
1. Data Collection Reservist dental records are reviewed by Navy dental personnel as part of the mobilization process. This review determines whether or not a dental examination is required, based upon the individual’s DoD Dental Classification, Appendix A. Navy Dentistry captures the results of patient dental examinations and tracks their individual treatment needs using form EZ603. All dental facilities were tasked to send TSCOHS a copy of the most recent EZ603 from the dental record of each reservist mobilizing through their facility. If a new dental examination was performed, a copy of that new EZ603 was collected. If a new dental examination was not required, a copy of the most recent EZ603 in the patient’s record was collected. All data was received by TSCOHS via US mail in postage paid, pre-addressed envelopes.
2. Computer Data Entry / AnalysisTSCOHS dental personnel manually transferred the treatment needs for 7,008 Navy and Marine Corps reservists into a customized computer data entry screen designed using Microsoft Access® 2000. This data was then converted into a SPSS ® 11.0 database for statistical analysis.
2
3. Study Sample
The six month data collection period ran from October 2001 through March 2002. TSCOHS received data from 19 Navy dental treatment facilities (DTF) representing 12 Naval Dental Centers (NDC) world-wide, Table 1. Table 2 shows the total number of records analyzed for Navy and Marine Corps reservists. We collected 55.3% of Navy reservists and 35.3% of Marine Corps reservists, mobilized during the study period. The sample is approximately 10% of all Navy and Marine Corps reservists and representative of the entire group. The representative strength of this large sample is bolstered by the natural randomization resulting from data collection at many geographically disbursed data collection sites. No indications of systematic bias were found.
NDC # SUBMITED
Camp Lejeune 948
Camp Pendleton 288
Europe 9
Gulf Coast 1,215
Great Lakes 762
Mid-Atlantic 685
Northeast 126
National Naval Dental Ctr.
364
Northwest 629
Pearl Harbor 138
Southeast 566
Southwest 1,278
TOTAL 7,008
Navy Marine Corps
Total Reservists Mobilized (Oct 01- Mar 02)
9,827 4,467
Total Records Analyzed 5,432 1,576
Percent of Reservists Captured
55.3 35.3 Table 1
Table 2
3
Methods
Figure 1. Dental Class Distribution After Inprocessing Exam
19.9[1.1]
8.4[0.7]
71.7[1.2]
17.9[1.9]
76.1[2.1]
6.0[1.2]
0
20
40
60
80
100
Class 1 Class 2 Class 3
Pe
rce
nt
Navy Marine Corps
[ ] Margin of Error = 1.96*SE
Oral Health Status (DoD Dental Classification)
Figure 1 shows the DoD dental classification distribution among Navy and Marine Corps reservists. There are no Class 4 reservists since those who had not received a dental examination within 12 months were reexamined at inprocessing. Based on dental classification, Navy reservists enjoyed significantly better oral health compared to Marine Corps reservists.
4
Figure 3. Number of Tooth Surfaces Requiring Restoration(Per 1000 Reservists)
923[865-981]
1199[1121-1277]
276[236-316]
1828[1664-1992]
2392[2178-2606]
564[465-663]
0
500
1000
1500
2000
2500
Class 2 Class 3 Total
Navy Reserve Marine Reserve
Operative Treatment Needs
Marine Corps reservists require statistically significantly more operative treatment (1467 restorations per 1000 reservists) compared to Navy (684 restorations per 1000 reservists), Figure 2. Figure 3 shows that Marine Corps reservists need twice as many tooth surfaces restored.
Figure 2. Number of Teeth Requiring Restoration (Per 1000 Reservists)
564[532-596]
120[103-137]
684[644-724]
266[220-312]
1201[1104-1298]
1467[1349-1585]
0
500
1000
1500
Class 2 Class 3 Total[ ] 95% CI
[ ] 95% CI
5
Figure 5. Distribution of Class 3 Operative Treatment Needs
0.2[0.1]
0.4[0.2]
5.7[0.6]
93.7[0.7]
0.4[0.3]
1.2[0.5]
12.4[1.6]
86[1.7]
0
20
40
60
80
100
None 1 to 3 4 to 6 7 or more
Pe
rce
nt
Navy Reserve Marine Reserve
Figure 4. Distribution of Operative Treatment Needs
1[0.3]
3.6[0.5]
25.8[1.2]
69.6[1.2]
34.7[2.4]
4.4[1.0]
9.9[1.5]
51[2.5]
0
20
40
60
80
100
None 1 to 3 4 to 6 7 or more
Pe
rce
nt
Operative Treatment Needs
Less than one-third of Navy reservists require operative treatment, while approximately half of Marine Corps reservists require operative treatment. Figures 4 and 5 provide the distribution of all operative treatment needs and Class 3 operative treatment needs, respectively.
[ ] Margin of Error = 1.96*SE
[ ] Margin of Error = 1.96*SE
6
Number of Teeth
Number of Teeth
Figure 6. Restorations Required by Number of Surfaces(Among NAVY Reservists Requiring Restorations)
1 Surface48%
2 Surface35%
3 Surface11%
4 or More Surfaces6% Figure 7. Restorations Required by Number of Surfaces
(Among MARINE CORPS Reservists Requiring Restorations)
1 Surface52%
2 Surface37%
3 Surface7%
4 or More Surfaces4%
Operative Treatment Needs
Approximately half of all restorations required are one surface, and more than one-third are two surface restorations, Figures 6 and 7. There are no clinically significant differences in the surface distribution of restorations required by Navy and Marine Corps reservists.
7
Figure 8. Number of Required Tooth Extractions by Dental Class and Extraction Complexity (Per 1000 Reservists)
27[18-36]
14[9-19]
107[93-121]
148[130-166]
41[31-51]
45[36-54]
62[52-72]
292[250-334]
116[87-145]
763[693-833]
647[583-711]
54[36-72]
355[308-402]
62[41-83]
0
100
200
300
400
500
600
700
800
Simple CL2 Complex CL2 Simple CL3 Complex CL3 Total CL2 Total CL3 Total
Navy Reserve Marine Reserve
Oral Surgery (Extraction) Treatment Needs
Marine Corps reservists require approximately 5 times the number of extractions per 1000 reservists compared to Navy reservists. This difference is both statistically and clinically significant. Figure 8 shows extraction needs by dental classification and extraction complexity. A complex extraction is defined as requiring surgical removal and/or tooth sectioning. All impaction removals are considered complex.
[ ] 95% CI
8
Figure 10. Distribution of Class 3 Tooth Extraction Needs
00.4[0.2]
1.7[0.4]
97.9[0.4]
0.2[0.2]
1.7[0.6]
3.4[0.9]
94.7[1.1]
0
20
40
60
80
100
None 1 to 2 3 to 4 5 or more
Perc
en
t
Navy Reserve Marine Reserve
Figure 9. Distribution of Tooth Extraction Needs93.4[0.7]
4.6[0.6]
1.9[0.4]
0.1[0.1]
72.8[2.2]
12.8[1.7]
14[1.7]
0.4[0.3]
0
20
40
60
80
100
None 1 to 2 3 to 4 5 or more
Perc
en
t
Oral Surgery (Extraction) Treatment Needs
Only 6.6% of Navy reservists require a tooth extraction, compared to 27.2% of Marine Corps reservists, Figure 9. Class 3 extraction needs are limited to 2.1% of Navy and 5.3% of Marine Corps reservists, Figure 10.
[ ] Margin of Error = 1.96*SE
[ ] Margin of Error = 1.96*SE
9
Figure 11. Number of Required Endodontic Procedures (Per 1000 Reservists)
4[2-6]
5[3-7]
17[13-21]
26[21-31]
6[2-10]
7[3-11]
23[14-32]
36[24-48]
0
5
10
15
20
25
30
35
40
Anterior Premolar Molar Total
Navy Reserve Marine Reserve
Endodontic Treatment Needs
Approximately two-thirds of endodontic treatment required is on molar teeth, Figure 11. There is no statistically significant difference in endodontic treatment need between Navy and Marine Corps reservists.
[ ] 95% CI
10
Figure 12. Distribution of Endodontic Treatment Needs
0 0 0
0.3[0.1]
1.8[0.4]
97.9[0.4]
0.1[0.2]
0.3[0.3]
2.5[0.8]
97.1[0.8]
0
20
40
60
80
100
None 1 2 3 >3
Perc
en
tEndodontic Treatment Needs
There is no significant difference between the percentage of Navy (2.1%) and Marine Corps (2.9%) reservists requiring endodontic treatment, Figure 12. Only 0.4% of reservists require more than one endodontic treatment.
[ ] Margin of Error = 1.96*SE
11
Figure 13. Number of Required Prosthodontic Procedures (Per 1000 Reservists)
15[11-19]
135[118-152]
10[4-16]
104[77-131]
0
50
100
150
Fixed Units RPDs
Navy Reserve Marine Reserve
Prosthodontic Treatment Needs
There is no statistically significant difference between the prosthodontic treatment need of Navy and Marine Corps reservists, when expressed as units per hundred reservists.
[ ] 95% CI
12
Figure 14. Distribution of Fixed Prosthetic Units Required
0.4[0.2]
1.3[0.3]
5.3[0.8]
93[0.7]
0.4[0.3]
1.1[0.5]
3.8[0.9]
94.7[1.1]
0
20
40
60
80
100
None 1 to 2 3 to 4 5 or more
Perc
en
t
Navy Reserve Marine Reserve
Prosthodontic Treatment Needs
The requirement for fixed prosthodontic care is confined to less than 7% of Navy and Marine Corps reservists, Figure 14. There is no statistically significant difference between services in the distribution of number of fixed prosthodontic units required.
[ ] Margin of Error = 1.96*SE
13
Figure 15. Distribution of Periodontal Screening and Recording (PSR) Score
5.3[0.6]
20.7[1.1]
39.9[1.3]
22.9[1.1]
11.2[0.9]
6.5[1.2]
33[2.3]
42.4[2.4]
15.4[1.8]2.7
[0.8]
0
20
40
60
80
100
PSR 0 PSR 1 PSR 2 PSR 3 PSR 4
Pe
rce
nt
Navy Reserve Marine Reserve
Periodontic Treatment Needs
The periodontal condition of each reservist is indicated by the Periodontal Screening and Recording (PSR) score. PSR scores are defined as PSR 0 (maximum probing depth less than 3.5mm, no calculus or defective margins, gingival tissues are healthy with no bleeding on probing); PSR 1 (maximum probing depth less than 3.5mm, no calculus or defective margins, bleeding on probing); PSR 2 (maximum probing depth less than 3.5mm, calculus or defective margins present); PSR 3 (probing depth 3.5mm to 5.5mm); PSR 4 (probing depth greater than 5.5mm). Figure 15 shows significantly less PSR 0 and PSR 1, and significantly more PSR 3 Marine Corps reservists compared to Navy. This indicates higher levels of periodontal disease among Marine Corps reservists.
Significantly more Marine Corps reservists require dental prophylaxis compared to Navy reservists, Figure 16. Among Class 2 reservists nearly half require a dental prophylaxis as their only dental treatment need, Figure 17.
[ ] Margin of Error = 1.96*SE
14
Figure 16. Percent of Navy and Marine Corps Reservists Requiring a Dental Cleaning
81.3[1.1]
55.9[1.3]
25.4[1.2]
93.3[1.2]
55.3[2.5]
38[2.4]
0
20
40
60
80
100
Dental Tech RDH Total
Per
cen
tPeriodontic Treatment Needs
Figure 17. Percent of Navy and Marine Corps Class 2 Reservists Requiring ONLY Dental Cleaning
50.4[1.6] 38.4
[2.8]
47.6[1.4]
0
20
40
60
80
100
Perc
en
t
Navy Reserve Marine Reserve Total
[ ] Margin of Error = 1.96*SE
[ ] Margin of Error = 1.96*SE
15
Dental Treatment Needs Expressed As Dental Weighted Values (DWV)
American Dental Association Current Dental Terminology (CDT3) is a list of dental procedures and nomenclature used by civilian and military dentistry to record dental treatment provided. Dental Weighted Values (DWV) are weights assigned by military dentistry to each CDT3 dental procedure. These weights (DWV) are based on the fee charged by civilian dentists for each procedure (DWV = Civilian Fee /100). The use of dental weighted values allowed us to convert the treatment needs of Navy and Marine Corps reservists into the dollar cost to provide the required dental care.
Table 3 provides the DWV, by treatment type, and the overall civilian cost estimate for the Navy reserve component. Information is provided for treatment necessary to achieve military operational readiness (DoD Class 1 or 2), and treatment necessary to achieve full dental health (DoD Class 1), Appendix A. Table 4 provides similar information for the Marine Corps reserve component. Dental examination and bitewing radiographs for those who have not been examined for more than 12 months are included in the Class 3 cost, since this is required treatment.
In a simultaneous sub-study of 300 reservists mobilized at NDC Great Lakes, 75% needed a new panoramic radiograph to be in compliance with dental and forensic requirements. Therefore, for every 1000 reservists mobilized an estimated 750 would require a panoramic radiograph (0.70 DWV). This would add 750 * 0.70 * $100 = $52,500 to the cost estimates provided in Tables 3 and 4.
Based on the mean number of DWV needed, the average civilian cost to move a Class 3 reservist to Class 2 is $448 (Navy) and $436 (Marine Corps). Another $957 (Navy) and $878 (Marine Corps) worth of care would be required to move this reservist to Class 1(oral health). For the average Class 2 reservist, a mean of $466 (Navy) and $614 (Marine Corps) worth of care would be needed to reach Class 1. Eleven percent of Navy reservists and only 1% of Marine Corps reservists require no dental treatment.
16
Table 3. DWV Associated With Providing Required Treatment by Procedure Type
(Per 1000 Mobilized Navy Reservists) Procedure Type Class 2 DWVs Class 3 DWVs Total DWVs
Exam/Bitewings
(Class 4s only)
n/a 253.1 253.1
Operative 498.6 123.1 621.7
Oral Surgery
(Extractions)
150.0 52.8 202.8
Endodontics n/a 140.5 140.5
Prosthodontics 1105.4 40.0 1145.4
Periodontics 2245.8 249.5 2495.3
TOTAL DWVs
(Civilian Cost)
3999.80
($399,980)
859.0
($85,900)
4858.8
($485,880)
17
Table 4. DWVs Associated With Providing Required Treatment by Procedure Type
(Per 1000 Mobilized Marine Reservists) Procedure Type Class 2 DWVs Class 3 DWVs Total DWVs
Exam/Bitewings
(Class 4s only)
n/a 297.4 297.4
Operative 1073.9 271.20 1345.1
Oral Surgery
(Extractions)
1014.4 174.6 1189.0
Endodontics n/a 199.9 199.9
Prosthodontics 807.4 72.5 879.9
Periodontics 2889.7 321.1 3210.8
TOTAL DWVs
(Civilian Cost)
5785.4
($578,540)
1336.7
($133,670)
7122.1
($712,210)
18
Figure 18. Distribution of Cost* of Treatment Needed Among Class 2 Reservists
9.3
3.1 1.7 1.3 1.4 0.7 1.13.2
18.5
9.9
2.9 2.1 1.7 1.2 2.6
6.6
15.5
56.1
6.26.6
15.2
33.1
0
10
20
30
40
50
60
<200 200-399 400-599 600-799 800-999 1000-1199 1200-1399 1400-1599 1600-1799 1800-1999 >2000
Dollars
Per
cen
t
Navy Reservists Marine Corps Reservists
Dental Treatment Needs Expressed As Dental Weighted Values (DWV)
Over half of Navy Class 2 reservists and one third of Marine Corps Class 2 reservists require less than $200 of dental treatment, while approximately three percent of Class 2 reservists require more than $2,000 of dental care.
* Based on Dental Weighted Values
19
Figure 19. Distribution of Cost* of Treatment Needed Among Class 3 Reservists
17.6
7.84.43.14.24.65.3
9.912.1
13.215.110.5
14.6
3.955.7
11.711.3 8.913.813.8
3.5
0
10
20
30
40
50
60
<200 200-399 400-599 600-799 800-999 1000-1199 1200-1399 1400-1599 1600-1799 1800-1999 >2000
Dollars
Per
cen
t
Navy Reservists Marine Corps Reservists
Dental Treatment Needs Expressed As Dental Weighted Values (DWV)
Class 3 patients by definition require more urgent dental treatment than Class 2 patients. On the average, they also require a larger quantity of dental care as reflected in the cost of treatment distribution, Figure 19. Approximately, one sixth of Class 3 reservists require more than $2,000 of dental care.
* Based on Dental Weighted Values
20
21
Department of DefenseOral Health and Readiness Standards
The oral health status of uniformed personnel shall be classified as follows:
a. Class 1. (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.
b. Class 2. Patients with a current dental examination, who require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:
1. Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.
2. Interim restorations or prostheses that can be maintained for a 12‑month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated.
c. Class 3. Patients who require urgent or emergent dental treatment. Class 3 patients are not normally considered to be worldwide deployable.
1. Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.
2. Interim restorations or prostheses that cannot be maintained for a 12‑month period.
Appendix A
3. Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.
a) Acute gingivitis or pericornitis.b) Active progressive moderate or advanced periodontitis.c) Periodontal abscess. d) Progressive mucogingival condition.e) Periodontal manifestations of systemic disease or hormonal disturbances.f) Heavy subgingival calculus.
4. Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication, or acceptable esthetics.
5. Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.
6. Chronic oral infections or other pathologic lesions including:a) Pulpal, periapical, or resorptive pathology requiring treatment.b) Lesions requiring biopsy or awaiting biopsy report.
7. Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections, or provide timely follow-up care (e.g., drain or suture removal) until resolved.
8. Acute temporomandibular disorders requiring active treatment that may interfere with duties.
d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients are normally not considered to be worldwide deployable. 22
