The advanced body armor, improved helmets, heavily armored vehicles, and better, faster, closer medical care provided in the past decade of combat in Southwest Asia have made this war unique – the most striking result being the lowest killed-in-action rate of any war due to greatly reduced mortal head and torso wounds.

The enemy countered by turning almost exclusively to improvised explosive devices (IEDs) – from small booby traps aimed at foot soldiers to bombs up to 500 pounds, designed to at least overturn even the most heavily armored vehicle. The resulting blasts, combining fast-moving hot shrapnel with fire and concussion, also increased wounds to the still-exposed faces and limbs of warfighters who would not have survived such attacks in any previous conflict.

Some of the severe damage done is well known: a record number of amputations – but an equally high rate of limbs saved; traumatic brain injury (TBI), considered the “signature” injury of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom-Afghanistan (OEF); post-traumatic stress disorder (PTSD), in reality just the latest termfor what in previous conflicts was called “battle fatigue” or “shell shock”; and severe burns, especially to the face and hands.

But one area often overlooked in reports of combat injuries is a direct result of more than 5,000 warfighters with severe facial injuries – wounds requiring both the immediate battle theater treatment and follow-up/long-term care of combat dentists, periodontists, and oral and maxillofacial surgeons in the Army Dental Command (DENCOM) and the advances developed by the Army Dental and Trauma Research Detachment (DTRD).

“There is a definite correlation between the increased survival rate and the rate of head and dental injuries, especially from a macrofacial standpoint – fractured bones, jaw, burns,” noted Lt. Col. Richard L. Williams, DTRD’s deputy commander. “They are surviving and become clinical cases.”

That, in turn, has changed combat dentistry forever – to a point far beyond what most people, even in the military, might define as “dentistry.” The teeth, mouth, jaw, and related muscles, nerves, and skeletal structures are intricately related to all parts of the face – and to the brain. As a result, DENCOM and DTRD have expanded their work to incorporate or align with other specialists in everything from vision and hearing to brain damage and face transplants.

“There are ongoing studies to determine the real connection and function of the oral nerve system to other parts of the body,” noted Maj. Paul M. Colthirst, a dental epidemiologist who served as a dental surgeon with a Stryker Brigade in Iraq.

Overall, the Army has advanced traditional dentistry far beyond “brush and floss,” “drill and fill,” and dentures.

“When an IED goes off within 50 meters, the shrapnel comes at you at 5,000 feet per second, which can penetrate an MRAP [mine-resistant ambush-protected vehicle]. And the enemy is now wrapping those with copper, which becomes plasma that melts through metal,” DTRD Commander Col. Robert G. Hale said.

“More than 90 percent of battle injuries are penetrating, while civilian injuries are mostly blunt trauma. So the manifestation of the injuries is entirely different from what most doctors deal with and where [Army] research has focused.”

There are five levels of military medical staging of equipment and personnel. The first are combat medics, today trained to the level of a civilian paramedic – or beyond – who are in the field with soldiers at risk. But with the higher point-of-injury survival rate in Iraq and Afghanistan, loss of blood (hemorrhage) became the most immediate priority, leading to regular warfighters receiving medical training equal to a World War II or Korean medic. In addition, every Army combatant carries an improved Individual First Aid Kit (IFAK) that includes a one-handed tourniquet that can be self-applied and a nasopharyngeal airway to help a fellow soldier breathe after a facial injury has blocked his or her airway.

“The second level, at the battalion level, is where you see the first dentists in a war zone, who are still at risk from combat beyond the Green Zone,” Hale said. “A couple of dentists working for me also assisted medics [in treating] war injuries, not just to the face, but anywhere. They earned Bronze Stars for their actions in Ramadi [a central Iraqi provincial capital, at one point during OIF described as the ‘deadliest city in the world’].”