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Army Reserve Components dental readiness--a historical review since the First Gulf War.

Introduction

As distinguished from Component 1, which is the Army Active Component (AC), the Army Reserve Components (RC) consist of Component 2, the Army National Guard (ARNG), and Component 3, the US Army Reserve (USAR). During the First Gulf War, over 150,000 Army RC Soldiers were mobilized for active duty. In the largest call up since the Korean War, over 350,000 Army RC Soldiers have been mobilized since 9/11 for the Global War on Terrorism (GWOT). In March 2001, the American Forces Information Services News Articles quoted an Army Reserve source stating "roughly 35 to 45 percent of Army Reservists activated during the Gulf War needed dental work before they could deploy." (1) In February 2004, The Military Coalition, a consortium of nationally prominent uniformed services and veterans' organizations, presented testimony to the Total Force Subcommittee of the House Armed Services Committee stating "the number one deployment problem in the First Gulf War was dental 'unreadiness,' and the same is true today." (2) This article provides a brief review of improvements in the dental readiness and dental mobilization processing of the Army RC between the first Gulf War and present GWOT operations.

Historical Perspective

In 1968, the Army implemented the Oral Health Maintenance Program which targeted younger Army Active Component Soldiers by requiring an annual dental exam and appointments to eliminate adverse dental conditions. This was in response to dental nonbattle injury emergency rates that averaged 16% during Vietnam. (3,4) The Army identified dental readiness as a deployment priority for commanders during the 1980s and initiated the Oral Health Fitness Program. The program identified Army AC Soldiers at the highest risk of being a dental casualty through the use of a Dental Fitness Classification (DFC) numbering system of DFC 1 thru DFC 4. This system, which is in use today, labels a DFC 1 Soldier as needing no examination or treatment procedures within the next 12 months. Soldiers in DFC 2 do require routine treatment but the conditions present are not expected to cause a dental emergency within the next 12 months. Soldiers classified as DFC 3 have dental disease conditions that will likely cause a dental emergency within the next 12 months. Classification DFC 4 indicates that an annual exam is required to determine a DFC. (5) Commanders began receiving monthly reports on the dental readiness of their troops and only Soldiers in a DFC 1 or DFC 2 status were recommended for deployment into theatre. Soldiers in DFC 4 cannot be deployed until a DFC is determined. Soldiers in DFC 3 are not considered deployable because studies have identified that deployed DFC 3 Soldiers experience significantly higher dental emergency rates than Soldiers in DFC 1 or DFC 2. (6,7) During this period, the US Army Dental Command (DENCOM) set goals to maintain 95% of the Army AC in DFC 1 or DFC 2, contributing to the rapid deployability of these forces.

In contrast, the Army RC, which now consists of over 550,000 Soldiers, did not have a command directed or funded dental readiness program during this same period. This contributed to the previously noted poor states of dental readiness during the First Gulf War. US Army Reserve Dental Service Detachments were activated in August 1990 to augment the Army AC dental corps in preparing Army RC Soldiers for deployment. During the 1990s, the poor state of Army RC dental readiness identified during the Gulf War mobilizations did not bring substantial changes in addressing the issues. In 1998, the Department of Defense (DoD) issued HA policy 98-021 which directed that Active Duty (i.e., Active Component) and Selected Reserve personnel (excluding members of the Individual Ready Reserve or IRR) undergo a periodic dental examination on an annual basis. (8) Although this policy created an examination requirement for all DoD RC personnel, it did not fund a contracted method to meet that requirement. By the close of the 20th century, the introduction of the Army RC Tricare Dental Program provided the first funded program for Army RC dental readiness. However, it was an optional program requiring monthly premiums and treatment copayments from the Soldier, thereby resulting in a poor participation rate. Small Army RC units mobilized between 1997 and 2001 continued to present to deployment stations with DFC 3 rates ranging from 14% to 36%. (9-11)

Initial GWOT Mobilizations

The terrorist attacks of September 11, 2001 once again brought the spotlight on the state of Army RC dental readiness. The beginning of a command directed and funded dental readiness program with no cost to the Army RC Soldier began to take shape in 2002 when premobilization annual dental "screenings" to remove Soldiers from DFC 4 status were provided by Army RC military and contracted dental personnel. The key word here is "screening." Army RC dental exam regulations only required a tongue blade dental screening without radiographs--regulation relics of World War II. On the other hand, Army AC Soldiers treated within DENCOM facilities received an annual dental examination to include radiographs, which meet existing standards of care. (12) The large scale Army RC mobilizations that began in January 2003 for Operation Iraqi Freedom revealed the folly of this double standard when DENCOM facilities had to repeat examinations of nearly all Army RC Soldiers to the AC standard of care. In addition, DFC 3 rates showed little improvement from the First Gulf War operations. From January through August of 2002, Army RC Soldiers mobilized for Operation Noble Eagle and Operation Enduring Freedom presented to mobilization platforms with DFC 3 rates of 25%. (13) In January 2003, over 20 Medical Support Units, the Army's new processing support unit consisting of USAR medical and dental personnel used to augment MEDCOM AC personnel, were mobilized. Even with this augmented support, internal DENCOM statistics indicated that 65% of the workload needed to deploy the Army RC was performed by AC Dental Corps personnel. Once again, precious manpower was diverted from maintenance of the Army's AC dental readiness goals for Component One Soldiers.

Changes In Policy

In June 2003, the DENCOM commander, COL Sidney Brooks, directed his mobilization staff to begin exploring Army RC dental readiness deficiencies and ways to improve the dental readiness processing of Army RC Soldiers arriving at mobilization platforms. This included creating a "One Army" dental readiness examination and documentation standard that would be applied to all three Army components. Working through policy changes implemented by the dental surgeons of the ARNG and USAR, use of the "One Army" dental exam standard by the Army RC began in April 2004. By February 2005, the revised Army RC dental examination standards were published in Army Regulation 40-501. (14) According to internal DENCOM statistics, increased funding appropriated to the Army RC to improve dental readiness combined with command emphasis and published Army RC examination standards significantly reduced the Army RC examination rate at mobilization platforms from 87% in December 2003 to 48% by December 2005.

The next directive focused on reduction of the Army RC DFC 3 rate presenting to Army dental stations at the mobilization platforms. DFC 3 dental treatments performed at mobilization platforms consume time that could be spent on predeployment training. Studies have indicated that DFC 3 treatment time ranges from 2 to 2.75 hours. (15,16) This lost time factor does not include the loss of training time due to transportation for appointments or Soldiers assigned to quarters or light duty in order to recuperate from some dental treatment procedures. Beginning in November 2002, Army RC Soldiers receiving mobilization orders were permitted to receive DFC 3 treatment at no cost in order to improve premobilization access to DFC 3 dental treatment. Due to the short time between receipt of the mobilization order and the report date at the mobilization platform, DFC 3 rates did not improve. This situation precipitated a change in law authorizing treatment upon receipt of an alert order. The change permitted more time for completion of treatment prior to arrival at mobilization platforms. However, in the arena of DFC 3 rates, less dramatic improvements occurred during GWOT operations. According to internal DENCOM statistics, Army RC Soldiers presenting to mobilization platforms in a DFC 3 status improved from 22% in December 2003 to 16% in December 2005.

DENCOM Mobilization Operations

In comparison to the First Gulf War, the numbers and duration of Army RC Soldiers mobilized through the Army Dental Care System (ADCS) during the present GWOT operations are significantly greater. The increased workload and its duration identified issues within the Soldier Readiness Processing (SRP) dental station operations located at each mobilization platform. During the First Gulf War, mobilization operations affected the ADCS for less than a year and standardization of processing procedures was not a priority. With the present duration of GWOT mobilization operations, it was necessary to implement long-term standardized processing protocols at SRP dental stations. This action was necessary to improve processing efficiency, create accurate data measuring tools, and reduce duplication of Army RC premobilization dental readiness services. Using lessons learned and input from SRP dental station personnel, DENCOM issued initial operational standards for all SRP dental stations in July 2005.

Conclusion

Although significant progress in Army RC dental readiness has been accomplished between the First Gulf War and present GWOT operations, a continuation of improvements must occur in order to reach the DoD goal of 95% dental readiness (Dental Class 1 or 2) for the RC as reaffirmed in DoD HA policy 06-001. (17) The Army RC is no longer the second or third line of the deploying force. The RC now deploys with the first line operational force alongside their AC counterparts. The DENCOM has initiated the First Term Dental Readiness program which ensures that DFC 3 AC and RC Soldiers are treated before graduation from AIT training. The future conversion to electronic dental records will greatly reduce the incidents of missing examination and treatment documentation which currently cause re-examination of Soldiers at the SRP dental stations. Reducing DFC 3 rates after the Soldier has graduated from AIT is a more complicated subject. Since treatment is authorized only during the time between the alert of the unit and its arrival at the mobilization platform, a unit commander and staff may find it difficult to coordinate multiple dental appointments for significant percentages of the unit's Soldiers who are DFC 3 while attending to those numerous other premobilization requirements. As one of the possible solutions to this problem, the Army should explore a dental plan to provide Soldiers with no cost DFC 3 treatment throughout the year rather than only upon a mobilization alert. A major paradigm shift concerning the dental readiness of its Reserve Components has occurred within the Army. Stakeholders should be pleased and understand the importance of continuing this improvement into the future.

References

(1.) Rhem KT. New TRICARE Program to Boost Dental Readiness of Reserves. American Forces Information Service News Articles, March 21, 2001.

(2.) Washington R, Schwartz S. Statement of the Military Coalition. Total Force Subcommittee, House Armed Services Committee, February 25, 2004.

(3.) Hutchins DW, Barton RF. Epidemiology of Oral Emergencies in Combat. Washington, DC: US Army Institute of Dental Research; Report #CSCRD-1031967.

(4.) Ludwick WE, Gendron EG, Pogas JA, et al. Dental emergencies occurring among Navy-Marine personnel serving in Vietnam. Mil Med. 1974:139;121-123.

(5.) Policy on Standardization of Oral Health and Readiness Classifications. Health Affairs Policy 02-011. Washington, DC, Assistant Secretary of Defense, June 2002.

(6.) Teweles RB, King JE. Impact of troop dental health on combat readiness. Mil Med. 1987;152:233-235.

(7.) Chaffin JG, King JE, Fretwell LD. US Army dental emergency rates. Mil Med. 2001;166:1074-1078.

(8.) Policies on Uniformity of Dental Classification System, Frequency of Periodic Dental Examinations, Active Duty Overseas Screening, and Dental Deployment Standards. Health Affairs Policy 98-021. Washington, DC, Assistant Secretary of Defense, February 1998.

(9.) Chaffin JG and Horning T. RC dental readiness in 'Call Forward 97.' Army Med Dept J. 1998:29-33.

(10.) Chaffin JG, King JE, Fretwell LD. US Army dental emergency rates. Mil Med. 2001;166:1074-1078.

(11.) Chaffin JG, Brooks S, Kahue P. Dental cost of deploying a National Guard unit to Bosnia. Mil Med. 2002;167:474-477.

(12.) Periodic Oral Evaluations. US Army Dental Command Policy Letter 05-25; DENCOM Commander, Fort Sam Houston, TX, January 2006.

(13.) Moss DL, York AK, Mongeau SW. Oral Health Status and Treatment Needs of Army Reserve Component Soldiers. Tri-Service Center for Oral Health Studies (TSCOHS), Uniformed Services University of the Health Sciences, Bethesda, MD, February 2003.

(14.) Standards of Medical Fitness. Army Regulation AR 40-501, Page 102, 10-27, Washington, DC, Headquarters, Department of the Army, February 2005.

(15.) Amstutz RD, Shulman JD, Williams TR. Dental Fitness Class 3 Treatment Needs; A Report of Consultation. Defense Technical Information Center; Report CR 92-066. US Army Medical Center and School, 1992.

(16.) Chaffin JG, Mazuji N. Class 3 Treatment Time. Mil Med. 2004;169:696-698.

(17.) Policies on Oral Health and Readiness. Health Affairs Policy 06-001. Washington, DC, Assistant Secretary of Defense, January 2006.

COL Bodenheim is the Individual Mobilization Augmentation Commander, Reserve Affairs. He is currently on staff at the US Army Dental Command, Fort Sam Houston, TX.

COL Mark B. Bodenheim, DC, USAR
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Author:Bodenheim, Mark B.
Publication:U.S. Army Medical Department Journal
Date:Jan 1, 2006
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