Army Dental Service support in a theater of operations.
Importance Of Field Dentistry
Historically, 20% to 25% of all Soldiers will experience a dental emergency during a 1-year deployment. The largest number of Soldier complaints in 1943 involved lack of adequate dental support. (1) In the Korean War there were 133,720 dental visits that resulted in 493,441 dental procedures. (2) The average time a unit loses a Soldier with a dental emergency which requires evacuation to the rear is 5 days. (3) Liewehr (4) calculates that this fact leads to a potential loss to a division of 18,000 man-days during a 1-year deployment. Payne and Posey (5) found a peacetime field dental emergency rate at Fort Irwin and Fort Drum to be 21% of the total medical sick call in field exercises involving 24,500 Soldiers. They further determined that the dental emergency rate was 167 per one thousand troops in one year. The result was an annual lost duty time of 121.5 days per thousand Soldiers. Ludwick et al (6) found a dental emergency rate of 200 dental emergencies per 1,000 deployed personnel per year in Navy and Marine personnel in Vietnam. Nasser and Storz (7) found that 14% of medical sick call reporting to the 12th Evacuation Hospital during Operation Desert Storm were dental emergencies. The actual percentage of dental emergencies was higher because many Soldiers experiencing dental emergencies reported directly to field dental clinics and bypassed the hospital. Grover et al (8) found an even higher dental emergency rate among Army recruits--260 per 1,000 Soldiers every 6 months which extends to a rate of 520 dental emergencies per 1,000 Soldiers per year. Swan and Karpetz (9) found a dental emergency rate of Canadian military personnel in Somalia in 1993 to be 232 dental emergencies per 1,000 troops per year. Lost time due to dental emergencies can have a tremendous impact on unit readiness. These historical cases illustrate the necessity that military dentistry must accompany warfighters whenever and wherever they deploy.
Dental Care In Theater (*)
The type of dental care provided to deployed Soldiers is called operational care, which is composed of "essential" dental care (to prevent a Soldier from becoming a casualty) and "emergency" dental care. Relief of oral pain, elimination of acute infection, control of life-threatening oral conditions (hemorrhage, cellulitis, or respiratory difficulty) and treatment of trauma to teeth, jaws, and associated facial structures are considered emergency care. It is the most austere type of care and is available to Soldiers engaged in tactical operations. Common examples of emergency treatments are simple extractions, antibiotics, pain medication, and temporary fillings. Essential care includes dental treatment necessary to intercept potential emergencies. This type of operational care is necessary for prevention of lost duty time and preservation of fighting strength.
Types Of Dental Support
There are three levels of dental support in a Theater of Operations; unit, hospital, and area. These levels are defined primarily by the relationship of the dental assets attached to the Combat Health Support supporting the patient population within each level:
Unit--Support provided by a dental team organic to divisional and brigade medical companies and all Special Forces Groups. The dental team provides operational dental treatment to Soldiers during tactical operations. The dental team is composed of one general dentist (comprehensive dentist and dental assistant in the division main medical company) and dental assistant and their field equipment.
Hospital--Support provided by the hospital dental staff to minimize loss of life and disability resulting from oral and maxillofacial injuries and wounds. The hospital dental staff provides dental support to all injured or wounded Soldiers as well as the hospital staff. Each Combat Support Hospital has one oral and maxillofacial surgeon, one comprehensive dentist, one expanded function dental assistant, and one dental assistant. The oral and maxillofacial surgeon uses other hospital support personnel (such as operating room assistants) when required.
Area Dental Support--Support provided on an area support basis by dental companies and dental personnel in area support medical companies. These dental companies also provide operational care. The dental companies are comprised of modular dental teams that are capable of operating separate dental treatment facilities, or by consolidating units and operating one or more large facility, depending upon the particular operation. Other teams may be employed to provide far forward operational dental care. Older type dental companies (medical company, dental support) have one prosthodontist in addition to 14 general dentists. Newer type dental companies (dental company, area support) have one prosthodontist, one periodontist, and one endodontist in addition to the 24 general dentists. Both the old and new type dental companies have far forward teams (one dentist and one dental assistant with their dental equipment) that can deploy wherever needed. The older type dental companies are being phased out as the newer type dental companies are activated. Area dental support may also be provided by the one general dentist and one dental assistant assigned to each area support medical company.
Dental Staff Officer Positions
The senior dental officer position in a specific regional combatant command is known as Army Dental Surgeon and Chief, Dental Services in the Army Surgeon Cell (known as the UEy Dental Surgeon until the recent decision on naming conventions of Army Transformation units). This new dental staff position is a wartime Professional Filler System requirement in a dedicated, regionally focused Army. Among other duties, the Army Dental Surgeon is charged with the establishment of an effective and consistent program for dental services and dental operations on a theater-wide basis.
Medical Deployment Support Command (MDSC) (formerly known as the Theater Medical Command (MEDCOM)). There are two dental staff officers in the headquarters company:
1. The MDSC Dental Surgeon establishes and disseminates Army theater policy on dental matters. The Surgeon exercises technical control over all dental units in the theater through the medical brigade Dental Surgeons, directs the dental service element of the headquarters, and provides dental staff support to the MEDCOM commander.
2. The MDSC preventive dentistry officer supports the MDSC Dental Surgeon in all staff actions. Specific duties include:
* Providing oral health surveillance information in support of policy and procedure development.
* Developing plans and orders concerning oral fitness and preventive dentistry programs.
* Recommending treatment policies.
* Developing programs for dental support of humanitarian and civic action operations.
Medical Support Command (formerly known as Medical Brigade). In the past, the senior dental company commander had the additional designation as brigade Dental Surgeon and was located in the brigade's command section. In Army Transformation, a formal position exists for the Dental Surgeon in the Medical Support Command. He exercises technical control over dental assets in hospitals and dental units subordinate to the Medical Support Command. The Medical Support Command Dental Surgeon also provides technical supervision for unit-level dental support (in Brigade Combat Teams, Armored Cavalry Regiments, and Special Forces Groups) as well as for dental assets assigned within the Medical Support Command. A senior dental NCO assigned to the security, plans, and operations section assists the Medical Brigade Dental Surgeon.
Division. The senior dental officer in a division is assigned to the division main medical company in the main support battalion. In addition to his patient care responsibilities, he acts as the Division Dental Surgeon and exercises technical supervision over the dental assets in the division forward support battalions. Dental officers in the forward support medical companies of the forward support battalions serve as Dental Surgeons to the supported maneuver brigades. The division main medical company is deleted as part of Army Transformation. As more brigades are activated, the division main medical companies provide the resources for the new brigade medical companies. Therefore, the positions for division dental staff officer and dental officers in division main medical companies will be deleted.
Brigade Combat Teams, Armored Cavalry Regiments, and Special Forces Groups. The dental officer in the medical element of these units also serves as Dental Surgeon for the parent brigade-sized unit.
General Field Dental Sets
Dental Instrument and Supply Sets, Emergency Care (DISS)--Assigned to every dental officer in a field clinical position. This small dental emergency kit is contained in a hand-carried medical aid bag. It contains the bare minimum of instruments and materials for simple extractions and expedient temporary restorations. Essential to this kit is the battery-operated handpiece which allows the dental officer to open an infected tooth, prepare a cavity for temporary restoration, or section a tooth for extraction. The DISS is intended for use when the situation does not permit the setup of the dental officer's standard equipment.
Dental Equipment Set, Comprehensive Dentistry (DES)--The backbone for providing operational care. The field dental equipment associated with the DES is compact, rugged, and has a limited power demand. Every dental officer in a field clinical position is issued the DES. This set provides the dental armamentarium used in the diagnosis and treatment of caries, defective restorations, occlusal trauma, tooth luxation/evulsion, gingivitis, early/moderate periodontitis, periodontal absess, traumatic or inflammatory oral lesions, routine endodontics, and postmortem examination. Major items of equipment include one portable field-type dental chair and stool unit, one dental operating and treatment unit, one dental light set, and a compressor.
Dental Equipment Set, Dental Support--Found in both the area support treatment platoon and the medical company (dental services). It contains items which can be shared in a clinical environment (area support treatment platoon), and is issued to each forward treatment team. It provides necessary support items including a curing light, composite resin, an electric pulp tester, a sterilizer, a sink, and a laboratory table.
Dental Equipment Set, Emergency Denture Repair A small set which provides basic materials for expedient denture repairs.
Dental Equipment Set, Dental X-ray, Field--In addition to the standard dental x-ray capability for the dental team, this set includes an associated hand-held x-ray apparatus and new digital radiology capability.
Specialist Field Dental Sets
Dental Equipment Set, Prosthodontic--Provides clinical and laboratory items necessary to support fixed and removable prosthodontic procedures. The prosthodontic set must be used in conjunction with the general dentistry DES.
Dental Equipment Sets, Endodontic and Periodontic--Recently added to support the new endodontist and periodontist positions in the new dental companies which are replacing the current, smaller dental companies. The sets are also used in conjunction with the general dentistry DES.
Oral and Maxillofacial Surgery Set--Another new addition intended to support the oral and maxillofacial surgeon in the Combat Support Hospital. The set contains modern bone drill and plating systems.
Dental Hygiene, Field, Dental Equipment Set--Includes those instruments and materials necessary for preventive dentistry services provided by preventive dental specialists.
New Field Dental Equipment
Dental Field Treatment Operating System (DEFTOS)--An innovative new dental system that has the potential to reduce the weight of current dental systems by 50%, volume by 67%, and power requirements by 67%.
The decreases are primarily the result of the development of a miniaturized system which uses electric instead of air turbine dental handpieces. The change eliminates the requirement for a large air compressor. An important second order effect of the system is that it has the potential, if fielded, to increase the mobility of dental teams by the reduction of weight, volume, and power requirements. The reduction of size and increase in deployability and mobility of dental teams are mainly accomplished through the elimination of the requirement for a five kw generator and associated trailer.
The system enables the dental team to operate with a two kw generator, rechargeable batteries, solar energy, or 24-28 volt DC military vehicle system. The DEFTOS is currently under long-term testing by the Army Medical Department Board. It was pronounced clinically acceptable by the DEFTOS Clinical In-Process Review Team in September 2003. It has been approved by the FDA for clinical use and has passed Military Standard 810E environmental tests, which include shock to 40 g, vibration at transportation levels, a drop from four feet, and settling dust.
Electric Motor Handpiece--A slow speed system in the Dental Emergency Aid Bag designed for bone removal, tooth sectioning, and caries removal. It is intended to be used when the standard dental operating unit can not be set up such as during unit movement operations. It adds the ability to provide dental care in austere environments and in highly mobile operations. Two 4-hour batteries are included with the handpiece. Recently a solar panel battery charger was added to the Dental Emergency Aid Bag. This eliminates the need for AC power to recharge the batteries. Full recharge of the batteries is achieved in 3 to 8 hours.
Digital Radiography--Currently being introduced into the field dental environment and will eventually be assigned to all dental teams. Headquarters, Department of the Army, has recently approved an Operational Requirements Document for digital radiography. It will replace current dental x-ray chemical processing systems. A laptop computer is fielded with each digital radiography system as part of the set. The system has been issued to many units deploying to Operation Iraqi Freedom and other operations. Funding has been identified for procurement of more than one hundred digital radiography systems. Feedback from deployed dentists has been positive.
Portable Handheld X-ray System--Currently being issued, the system will be used by all dentists assigned to brigades, divisions, field dental units, and field hospitals. It greatly reduces the weight and volume requirements associated with other x-ray equipment. The system has received very positive clinical feedback from dentists in the field.
Oral and Maxillofacial Equipment Set (M477)--Currently being fielded to oral and maxillofacial surgeons assigned to Army field hospitals, the set contains modern drill sets and titanium bone plating systems. Headquarters, Department of the Army, has approved the Operational Requirements Document for the M477.
Shelter System--Intended for brigade and division dental teams of the near future, the Chemically-Biologically Protection Shelter System (CBPSS) is lightweight, multipurpose shelter that provides full chemical and biological protection and creates contamination-free, environmentally controlled area for level 1 and 2 medical treatment units. The CBPSS is mounted to the back of a dedicated heavy HMMWV, has its own auxiliary power and ambient environmental control, is easily employed, has air lock entrances, and is 100% mobile.
The new dental equipment sets and fielding initiatives will increase the capabilities of deployed dental assets in theater while reducing weight and cube. The result is increased deployability of field dentistry.
This article also appears in Military Dentistry: Terrain, Trends and Training (New Delhi: 2005) by MG Paramjit Singh and BG Vimal Arora. Reprinted with permission of the author.
(*) Note: The doctrine of dental operations discussed in this paper is based upon Department of the Army FM 4-02.19, Dental Service Support in a Theater of Operations.
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(3.) Allen FW, Smith BE. Impact of dental sick call on combat effectiveness: the dental fitness class 3 soldier. Mi Med. 1992;157:200-233.
(4.) Liewehr F. US Army Dental Corps, endodontics and dental readiness. Mil Med. 2000;165(2):127.
(5.) Payne TF, Posey WR. Analysis of dental casualties in prolonged field training exercises. Mil Med. 1981;146:265-271.
(6.) Ludwick WE, Pogas JA, Gendron EG, Weldon AL. Dental emergencies occurring among Navy-Marine personnel serving in Vietnam. Mil Med. 1974;139: 121-123.
(7.) Nasser FE, Storz JP. Report on dental casualty treatment at 12th Evac. Army Med Dept J. 1994;10: 38-42.
(8.) Grover PS, Carpenter WM, Allen GW. Predictability of dental emergencies by panography. Mil Med. 1983;148:148-149.
(9.) Swan ES, Karpetz E: Dental casualties during Canadian UN operations in Somalia. J Can Dent Assoc. 1995;61:991-997.
COL Jones is Chief, Concepts & Requirements Division and Dental Consultant at the Directorate of Combat and Doctrine Development, US Army Medical Department Center & School, Fort Sam Houston, TX.
COL Timothy K. Jones, DC, USA