Level Two dentists move around the combat area of operations (AOR), carrying with them a full set of field dental equipment. They provide basic preventative care, but also manage most dental emergencies they encounter, from a lacerated lip to a broken tooth, depending on the extent of the injury and whether dental repair or restoration can be done in the field. If not, the soldier would be referred to the next level and the closest dental company for treatment by an oral surgeon.

“Level Three is a combat support hospital, where dental officers and specialists are found. Level Four is Landstuhl [Regional Medical Center, Germany], then Walter Reed [National Military Medical Center-Bethesda] would be the fifth level, where you have comprehensive reconstruction and the technologies we [DTRD] are researching would be applied,” Hale added.

“In addition, all dental officers, before going overseas, learn advanced techniques in caring for maxillofacial injuries. But our main contribution is how to help stabilize the wound to protect against infection at the point of injury.”

Maxillofacial dentistry focuses on problems around the mouth, jaw, and neck, including reconstructive surgery to rebuild areas of the face.

“According to the Joint Theater Trauma Registry, more than 26 percent of [combat] injuries involve the face,” Williams added. “The format [for combat dentistry] that will change for the battlefield will be stabilization. We’re not trying to do long-term or final care or therapy at the theater level, we’re just trying to stabilize the patients and keep them alive.”

Modern combat dentistry actually begins with each new soldier’s initial exam during basic training. At that point – or any subsequent exam – they are placed into one of four categories, with only the first two eligible for deployment.

“Dental Fitness Class 1 is soldiers with no dental problems or disease, while those defined as Class 2 have some disease, but nothing that would cause a dental emergency within 12 months; for example, gingivitis,” Colthirst explained.

“Class 3 exhibit great concerns and [are] not deployable because those probably would cause an emergency within 12 months. For example, a large cavity close to the pulp that would cause pulpitis – a swelling – and the soldier would experience pain. Class 4 is where we don’t yet know the status, so the soldier needs to come in for oral exams.”

The same classification decisions are made after deployment, whether the result of a toothache or a facial injury.

“Once a soldier presents with a dental emergency in theater, he is classified as Class 3. If there is severe pain or loss of function, a soldier in Class 3 could be withdrawn from combat duty. But each case is evaluated individually,” he said.

“We don’t have a pain scale to say this anomaly is more severe than another, so we have to go by what the patient says. By gathering all the information, both objectively and subjectively, we make a determination and classification. And if we can restore the tooth or treat the problem, the soldier would move back to Class 2.”

To no small degree, soldier dental care is directly related to each individual’s pre-military habits, going all the way back to childhood.

“In the 1970s, there were a lot of soldiers with bad teeth, because fluoride did not become a big thing until the 1960s. Many thought they were fine, but in your 20s, you are at the highest level of danger for dental disease,” Hale said. “So in Vietnam, Army dentists played an important role in preparing soldiers to go into an austere combat environment, getting them at least to Class 2. So recruits got trained, a haircut, and their teeth fixed. The dentists also went to theater, to maintain care.

“The big difference today is we have moved beyond controlling disease – such as with fluoride. We are now looking at a chewing gum with peptide to potentially lessen the extent and impact of bacteria. Even better, this technology will go to the general population, from which we draw our soldiers. Because in the 21st century, we would like to see a better, healthier general population, where kids coming into the military have better teeth. We’re also shouldering that responsibility as Army dentists.”