“The drawback is it requires immunosuppression, so transplanting a hand becomes a lifestyle issue as opposed to transplanting a kidney, lung, etc., which are life-saving. When there is a life-threatening liver or heart problem, it is a simple decision to put them on potentially life-changing immunosuppression. Hand transplants are not life-saving decisions and putting patients on immunosuppression makes the patient more susceptible to infection, cancers – which may even, at some point, take the limb anyway.”

The solution being pursued by military researchers involves manipulating the immune system to accept the transplant through immunal modulation and immunal tolerance. The result would be the recipient’s immune system accepting the transplant without the risks that come with drugs used to suppress the immune system.

“This is a very large focus in the composite tissue transplant community,” he added. “If we can unlock immunal tolerance, you can imagine the applicability of composite tissue transplantation for reconstruction.”

Such techniques apply to facial reconstruction – especially burn treatment – and a host of other injuries that are far more common in this conflict than previous wars. At the same time, great strides already have been made in many related areas, such as repairing dental injuries – which also has led to discoveries of how various parts of the body interact, sometimes resulting in problems previously considered unrelated to the primary injury.

Col. Robert G. Hale, a member of the Army Dental Corps, recently took command of DTRD, which has developed major advances in dental care, replacement, and reconstruction. The standard assumption is warfighters in austere locations, especially in combat, are unable to care for their dental health as they would at home, leading to an increase in toothaches, cavities, and other dental emergencies. While a toothache might seem the least of a combat warrior’s problems, it actually has the same benefit to the enemy as a wound from a gunshot or explosive – at least two other soldiers are needed to transport the ill or injured to receive medical care, thus removing three warriors from the fight.

While improved helmets have reduced puncture wounds to the skull, the face remains exposed to blast burns and other damage from exploding IEDs.

“An explosion always results in some insult to the brain – and those shockwaves are cumulative. We have nerve tissue within teeth, as well, and as yet we have not determined if there is a risk of a sub-lethal blast to the dental region,” Hale said. “There have been a lot of advancements in dental care, not always in response to the war but technologies developed over the interwar years. For example, we now have bone regeneration technology, which is basically bone in a bottle – bone proteins we can mix up, apply to a sponge, put in a bottle and bone will grow.

“Titanium technology in recent years has revised tooth replacement. Now we no longer have to save a damaged tooth, but remove it, repair the socket and make a titanium implant that won’t rust, decay, or fall out, with a porcelain crown interface with the bone screw. We also don’t wire teeth anymore; we use titanium bone plates. If you have a fractured jaw, we will take a titanium bone plate, which looks like a small track with holes, bend it to the perfect shape, then rebuild the jaw using plates and screws.”

Another mouth-related discovery Hale wants to see DoD and the VA put into clinical trials involves PTSD and TBI patients with headaches that do not respond to or require undesirable levels of drugs. The question is whether dental mouth guards can reduce those headaches, perhaps ending the need for pain medications.

Although he is a dentist by trade, Hale said issues involving teeth only occupy about 20 to 25 percent of his time. The rest is devoted to research and treatment on facial injuries and reconstruction. Even so, some important efforts there stem from ongoing advances in dentistry, especially in the immediate treatment of blast wounds to reduce infection and scarring by killing bacteria and sealing the wound/burn in transit.

“There’s an area I call biofilm-impaired wound healing. Biofilm is a bacterial slime that occurs in all wounds open for more than a few hours, impairing the body’s ability to heal,” he said. “The last thing you want in a battlefield injury is for it to become infected and not heal. When that happens in the extremities, the worst effect is loss of a limb. When the face doesn’t heal, it causes scarring, which can be intense.

“If we could help at the very start to reduce biofilm formation and seal open wounds, that would be a great improvement. Dentistry has very advanced biofilm researchers because dental plaque is a biofilm that destroys tooth enamel and causes gum diseases. That same type of biology happens on open wounds. So dentistry has some of the government’s premier scientists working on biofilms.”

Another major area of concern is eye injuries, ranked as the second most common military injury and having the worst return-to-duty rate among warfighters – 20 percent compared to 80 percent for other battle trauma.

TATRC and MRMC have joined forces with a multi-disciplinary group comprising military, academic, and civilian medical researchers looking to improve protection, treatment, and recovery. Bolstered by an additional $7 million in DoD funding, they have stepped up research into eye injuries from burns and penetrating wounds, lasers, chemical, biohazard, and environmental exposure, and vision problems associated with TBI.