With the recent announcement of the Department of Defense (DOD) policy emphasizing reducing the number of non-deployable service members and improving personnel readiness across the force, readiness is an increasingly significant topic.

Dental health is a key aspect of personnel readiness, and the U.S. Army provides a representative example of military branches’ efforts to maintain oral health- and dental-readiness levels among its service members, important not only to their general health status, but also to minimize soldiers’ risk of dental emergencies in theater and to reduce the need for medical evacuation.

In order to determine soldiers’ dental readiness and minimize their risk of dental emergencies while deployed, the Army utilizes the Department of Defense Oral Health and Readiness Classification System, assigning their status to one of four classes.

In describing the terms “oral health” and “dental readiness,” Col. Georgia Rogers, DMD, MPH, consultant to the surgeon general for dental public health, explained how they differ. “When you say someone’s in a state of oral health, it means that they don’t have any diseases or problems in the mouth that are going to affect their ability to function or speak,” she said. “For the Army, dental readiness means that the soldier is either in a state of oral health, or they have minor levels of oral diseases or conditions that are not expected to become a dental emergency within the next year. They’re low risk. It doesn’t mean they’re disease free; it just means that we don’t think their problems are going to become serious.”

However, despite best efforts to screen and treat dental conditions as efficiently as possible, sometimes dental emergencies during deployment do occur due to pre-existing disease, postoperative complications arising from last-minute dental treatment at mobilization platforms, new disease, or orofacial injuries, Rogers explained. Lifestyle differences in deployed environments, including poor oral hygiene, unhealthy diet, or tobacco use, can exacerbate dental problems such as pain or infection caused by cavities, infected wisdom teeth, or acute gingivitis.

“The reason these dental emergencies are important is because when a soldier has to be transported by their unit for dental care in theater, it’s not just that soldier. You usually lose several people because you have to transport the soldier in a vehicle, sometimes with a convoy,” said Rogers. “So, unless you’re stationed on a forward base that has a dentist, it can be very difficult for the unit. And sometimes the infections and problems are severe enough that the soldier has to be medically evacuated.”

Rogers noted, “Dental disease and non-battle injury data from July 2009 to June 2011 for Operation Iraqi Freedom shows that on average, a soldier is lost for three days each time they seek dental care. This does not include the soldiers that are lost to the unit to transport the soldier who needs dental treatment.”

In order to determine soldiers’ dental readiness and minimize their risk of dental emergencies while deployed, the Army utilizes the Department of Defense Oral Health and Readiness Classification System, assigning their status to one of four classes.

Dental Class 1 indicates the soldier has had a complete dental checkup and cleaning within the past year and requires no dental treatment (dental wellness); Class 2 assignment means the soldier requires some type of dental care, such as a simple filling or dental cleaning, but the treatment needs are unlikely to cause a dental emergency in the next 12 months; Class 3 designation specifies the soldier requires dental care as soon as possible for urgent dental treatment needs that are likely to cause a dental emergency in the next 12 months; and Class 4 means the soldier is in need of an annual dental exam to determine oral and dental health.

Classes 1 and 2 are dentally ready for deployment, while Classes 3 and 4 are considered not dentally ready and non-deployable.

“One of the big highlights in Army dentistry since 2013 has been improvements not only in dental readiness, but dental wellness,” said Maj. Peter Drouillard, DDS, deputy chief, Dental Programs, U.S. Army Medical Command. He cited current numbers for active-duty soldiers showing that 63.3 percent are Class 1, 34 percent are Class 2, 0.8 percent are Class 3 with urgent dental treatment needs, and 1.8 percent are Class 4, in need of an exam. That translates to dental readiness levels at 97.3 percent.

For unit commanders, a color-coded monitoring and reporting system for readiness clearly shows which of their soldiers need dental exams or treatment, said Rogers, so they can ensure those soldiers complete their treatment. “One of the most important things is that the command team stays on top of the issue, and encourages those soldiers to come in for care,” she said.

“Even though a Dental Class 2 soldier is deployable, they still require some type of treatment for an oral disease or condition, so they are at a slightly increased risk for dental emergencies during deployment,” Rogers said. “Studies have shown that a Class 2 soldier is about twice as likely to have a dental emergency as a Dental Class 1 soldier. A Dental Class 3 soldier is about seven or eight times more likely to have a dental emergency than a Dental Class 1 soldier, so I think the classification system works fairly well at predicting emergencies. Ensuring that soldiers do their best to not just attain, but maintain Dental Class 1 status reduces their risk of being taken out of the fight by a dental emergency.”

Regarding the recent DOD policy changes concerning military retention for non-deployable service members, Rogers said, “The new policy is looking at soldiers who are non-deployable for 12 months or more, and fortunately for the soldiers, there are very few dental conditions that fall into that category. Most Dental Class 3 problems can be treated within 30 to 90 days. A small percent takes longer, but very few last for more than a year.”

Oral health is important for many reasons whether deployed or not, and can have an effect on general health. “People use their mouth all day long, to communicate and interact socially,” said Rogers, “and yet they don’t really think about how important their mouth is until they lose that function.”

Rogers indicated studies have linked dental problems with cardiovascular disease, diabetes, dementia, and stroke. She added, “Other studies have shown that people in poor dental health are usually less likely to be willing to eat a healthy, high fiber, whole grain diet with fresh fruits and vegetables, tending to prefer processed foods because they require very little or no chewing, so it can affect your nutrition intake.”

Drouillard pointed to another connection between oral and general health. “The mouth can also be used as a diagnostic tool to reflect systemic conditions that are occurring in the body,” he said. “Sometimes findings in the mouth can alert an astute dentist to consult with other medical providers to determine whether the patient’s at increased risk for [other diseases]. So the mouth can also be a window into systemic health.”

Poor oral health can also cause difficulty sleeping and inability to concentrate. “Sometimes people say, ‘I can put up with a little bit of a toothache,’” Rogers said. “But the infections and the pain are usually very distracting, so when you’re out on a mission when you’re deployed, if you’re having a problem concentrating on what’s around you, having difficulty focusing on what people are telling you, you have pain when you try to sleep, you can’t sleep, it runs people down quickly. So that’s usually why they have to end up being medically evacuated even if they try to tough it out.”

To advance oral health and readiness, the U.S. Army Dental Command initiated several programs in a multi-faceted effort to improve soldiers’ dental treatment and increase efficiency. Implemented in 2004, the First-term Dental Readiness program provides a dental exam and treatment to recruits, and those with Class 3 problems are identified. “The goal is to complete the dental care that they need so that at least 95 percent of soldiers who graduate from Advanced Individual Training, or AIT, having completed both the initial entry training portion of basic and career training for their specialty, are dentally ready,” Rogers said. “The goal is to get them to their first permanent duty station ready and deployable.”

Another program, Go First Class, “was a major change in the way that we operate our clinical operations as far as scheduling,” Drouillard explained. “It was implemented across the Army Dental Care System in 2013, and the big change is that it combined a required annual dental exam with a dental cleaning and, if possible, minor restorative care, into one single patient encounter or appointment.” Previously accomplished at separate times, the new program provided more efficient and cost-effective care, and, he added, “We’ve seen dramatic improvements particularly in dental wellness rates because several of our soldiers only needed a cleaning to be converted from a Class 2 state to a Class 1 state. By addressing that treatment need and/or one or two fillings, we were able to move them to a better classification of dental readiness.”

… it’s also crucial to keep Army dentistry readiness programs fresh and to educate new dentists coming into the fold about those programs as personnel changes occur.

A third readiness initiative, implemented in 2010, then revised and fully fielded in 2015, is the High Caries Risk Program. “It’s an Army-wide initiative to help soldiers break the cycle of decay-repair-decay,” Drouillard said. “So there’s disease, then you fill it, and then you get disease around that filling, and the cycle perpetuates when dental treatment is performed but the soldier’s individual risk factors are not addressed. You didn’t address the cause of the disease, you just addressed the sequelae. The High Caries Risk Program was developed to provide education and intervention through several factors – nutritional assessment, application of fluoride varnishes to increase that beneficial effect of fluoride in the mouth, tobacco cessation counseling, and practical oral hygiene reminders.”

The Army Dental Care System is supporting other endeavors to improve readiness, including research on the treatment of sleep apnea, a sleep disorder in which breathing stops and starts. “We are using oral appliances for mild and moderate sleep apnea treatment in place of CPAP [continuous positive airway pressure] machines and other devices,” said Drouillard. “For a deploying soldier carrying around [an oral appliance] versus having to both transport and maintain a CPAP machine, it makes a big difference. There’s been a large push to involve Army dentistry in that aspect of care, and of course, that has a readiness aspect to it as well; if you can improve a soldier’s care for sleep apnea, then potentially they could be more fit to fight.”

Another ongoing effort involves increasing use of CAD/CAM (computer-aided design/computer-aided manufacturing) technology. Rogers explained that if a soldier in a stateside setting needs a crown, for example, they could transmit a digital image of the prepared tooth from a handheld scanner to a dental facility with CAD/CAM capability where a crown could be milled and shipped. “Theoretically if you have that on site, the patient goes home with the crown the same day. And if you’re nearby, you could have their crown back in 24 to 48 hours,” she said. Without this technology, it can take weeks for the same process, so this improves readiness because when a patient is waiting for a crown, they’re usually considered Dental Class 3, and non-deployable for that time.

Drouillard added, “In theater care, you would reduce how far the soldier would have to be evacuated back if there were something that happened that required a dental prosthesis if you could mill that at a combat support hospital, for example, instead of evacuating them all the way back to a higher level of care in the United States or somewhere in Europe. It gives us a little bit more versatility to address dental treatment needs at a lower level. We’re not quite there yet, but it’s certainly something that’s been discussed.”

Regarding hurdles encountered in dental health and readiness efforts, Rogers said, “I always say that the big challenge we have in the Army isn’t attaining dental readiness; it’s maintaining it. We can treat soldiers into Dental Class 1 and treat their disease, for the most part. But the challenge is keeping them there.”

With soldiers having access to dental care, but only about 63 percent currently dentally healthy, or Class 1, Rogers said, “It reinforces the fact that dental treatment is not the biggest determinant of oral health. Personal habits are.”

Drouillard noted that it’s also crucial to keep Army dentistry readiness programs fresh and to educate new dentists coming into the fold about those programs as personnel changes occur. “The military is renowned for moving the pieces around; soldiers move around the country and the world, so as you transition, it’s important to sustain the gains that you’ve accomplished through successful dental programs,” he said.

“Our job as dental leaders is to educate line commanders on not only the benefits of oral health, but the potential risks that they’re susceptible to if they find themselves in an austere environment and the soldier develops a toothache,” Drouillard concluded. “That is a challenge and something that we deal with, both as dental providers and military officers – educating our leaders working as a team, the same way our medical colleagues do, to get information to the fighting force.”

This article was first published in the Veterans Affairs & Military Medicine 2018 Spring edition publication.