Background The goal of the Defence Health Services (DHS) is to make and maintain ADF members ‘fit to fight’. Health strategies based on this goal have to be focused not only on the notion of ‘fit to fight’ but ‘fit for living and life’. Strategies which ignore the latter would be short-sighted. In dentistry, there is a need to have a suitable risk management strategy to initially screen ADF members in order to identify at-risk patients and plan intervention strategies so as to achieve these goals. This risk assessment must be sensitive enough to accurately estimate the likelihood that a dental problem will occur. Focused treatment planning at this stage will give better long-term dental outcomes in the ADF with fitter members and more stable dentitions1. The (American) National Institute of Health suggests that all patients should not be treated in the same fashion, but rather prevention programs should be matched to the disease risk of the individual patient2. Additionally, a suitable pre-deployment risk management assessment is essential so that dental casualties are better managed, either by preventing most casualties or better management of casualties in the field3.
In determining a suitable risk management assessment of deployed personnel, it is necessary to define what outcome(s) needs to be measured so as to capture dental casualty numbers accurately. In the past researchers have focused on the concept of the dental emergency, but what is meant by dental emergency has been somewhat vague. In July 2006, an international workshop at the Great Lakes Naval Base, Illinois was held to standardize military dental research definitions, in order to achieve agreement on what should be measured. The consensus from the workshop was that dental emergencies are presentations at the dental surgery where the patient is in pain or sufficient discomfort that they are unable to discharge their duties to the standard required. While unscheduled dental visits (UDVs) are defined as any visit to the dentist which is not part of their dental treatment plan following their Annual Dental Examination but doesn’t include matters of a trivial nature such as orthodontic consultations and impressions for mouthguards4. It is this outcome that researchers need to capture because UDVs reflect the range and frequency of visits to the dental units both while on deployment and in garrison.
Methods A cross sectional study was conducted amongst 878 deployable personnel in the Australian Defence Force (ADF) stationed at seven ADF bases. The bases were selected because they had the largest numbers and highest proportion of deployable personnel from among the 79 bases that house Australia’s deployable personnel. They were located in four Australian jurisdictions: New South Wales, Victoria, Queensland and the Northern Territory. Study subjects were selected at the time of their mandatory annual dental examination (ADE), with the intention to enroll approximately 10% of personnel at each base. This was to be achieved by selecting all subjects who completed their ADE within a period of five consecutive weeks during 2006. Where enrolment was slower than expected, the period was extended in an attempt to enroll the target of 10% of the base’s population. Ultimately, enrolment occurred over periods of up to three months. For the purpose of the study, unscheduled dental visits were defined as any visit to the dentist in the previous twelve months which was not part of their dental treatment plan following their ADE, but excluding matters of a trivial nature such as orthodontic consultations and impressions for mouthguards4. In light of this the calculation of the prevalence of total UDVs was determined as:
1. The number of UDVs as reported in a dental records audit, 2. The number of self-reported visits to non ADF employed dentists, and 3. The number of self-reported visits to other health professionals for problems relating to the mouth or jaw.
Excluded from this count were: 1. Visits for trivial or non-dental reasons such as: a. Impressions for mouthguards, b. Orthodontic consultations, and c. Tonsillitis.
2. Participants who self-reported UDVs but responded negatively to the questions, Did you have a problem? or Was the visit necessary for the relief of pain?, and whose explanations for their visits were inadequate, and
3. Double and Triple positive responses to having a UDV.
All three Services were included, as there may have been differences in presentations for UDVs between the services. The study had an unequal number of males (779) to females (99), reflecting the gender balance in the ADF. The age range was between 17-56, with the majority of participants falling within the 17-35 year range, again reflecting the range in the ADF5.
A comparative Australian population was identified using the data from the National Survey of Adult Oral Health (NSAOH) 2004 -20066. In using the NSAOH, a positive UDV was assessed as a person: 1. Between the ages of 17-55, 2. Having private health insurance, 3. Usually visit the dentist for an annual checkup, and 4. Who had visited the dentist for a problem within the last 12 months.
As data on participants’ presentation to other health professionals for oral problems was not available in the NSAOH data, comparisons with the ADF data was limited to the documented UDVs and those visits to non-ADF dental facilities.
Results
Target Population Table 1 shows the distribution and returns from each of the 7 selected sites with 69.9% of respondents coming from the Army, 25.5% from the Air Force and 4.6% from the Navy.
UDVs
Whether the participant had a UDV in the past 12 months is illustrated in Table 2. 16.2% of the participants had a documented UDV in the preceding 12 months, while 6.6% presented as UDVs to non-ADF dental centres and other health professional.
The combined total of all UDVs within the last twelve months, after eliminating double and triple counts, was 20.3% (178 of 876) of the participants.
UDVs by Age, Rank
It is known that age and military rank are significant confounders for lifetime caries experience in the ADF population7. Table 3 illustrates the variations in UDVs and these potential confounders and UDVs. The results indicate that the variables of age and rank are significant and that while change in age is not monotonic there is a trend of increasing UDV prevalence with age, whereas rank shows a lower prevalence for officers.
Comparison with the Australian Population
Data on the Australian population was drawn from the National Survey of Adult Oral Health6 where a UDV was defined as visiting the dentist within the last twelve months for a problem. A comparative population was gained by adjusting for age, for annual visits for a checkup, and whether the person had private health insurance. The comparison with the Australian population (Table 4) shows a significant difference between the ADF population and the general public (32.8% to 20.0%). However, after adjusting for visiting patterns and health insurance coverage, the ADF’s UDV prevalence is comparable to the 19.9% found after these adjustments. Table 4 also shows the effects on the UDV prevalence when a population does not have access to ADEs and/or Health Insurance, with an increase of UDV prevalence to 42.4% and 49.4% respectively.
Table 5 is a comparison of the UDV prevalence across the different age categories. This shows that there is an increase in the UDV prevalence with increasing age, although the ADF population is significantly over-represented in the 17-24 year old category because this age group represents the majority of the ADF.
Reasons for Unscheduled Dental Visits
Breaking down the causes of UDVs is essential to an understanding of how UDVs may be prevented. Accordingly, causes were allocated to one of 8 categories to reflect the range of responses, while avoiding categories which had too few or too many responses to be meaningful. In Table 6, it can be seen that there is little change in the breakdown of the reasons for UDVs between the ADF and the general Australian population.
DISCUSSION Target Population and Response Rate
In the initial protocols, it was intended that the questionnaires would be distributed among the three Services in the ADF in proportions that reflected each Service’s operational personnel contribution. Attempts were made to elicit increased responses from the Navy; however, due to the operational requirements of both fleet bases and the shortage of suitable personnel to oversee the conduct of the study at these sites, these important subpopulations could not be included in the study. It was believed that the Navy might have had issues with access to dental care during maritime operations, where dental access might be assumed to be limited. As can be seen by the breakdown of this distribution in Table 1, the Navy responses were entirely from one source – HMAS MANOORA during Exercise RIMPAC over a small period of time. The dental officer in MANOORA reported that the response rate was less than he had hoped for. The high workload before and during the Exercise meant that many on board declined to participate. This was certainly not the experience with the Army and Air Force, with very few declining to participate. In general, the returns from the questionnaires were excellent, with 85.6% distributed questionnaires returned. A few of these returns 2 were discarded due to their incompleteness. It is believed that the generally high participation rate was due in part to the presence of dental officers at the bases to oversee the conduct of the study.
UDV Prevalence
As described in the results Table 2, the true prevalence of UDVs was 20.3%. The difference in the prevalence of 4.1% between recorded UDVs and the real rate of UDVs means that 20.2% of UDVs are not reflected in the dental documentation.
A comparison of the study’s findings with other studies is shown in Table 7. Whilst other studies measure an incident rate3 of dental emergencies, as opposed to the prevalence of UDVs, some comparisons can still be made.
From Table 7 it can be seen that the recorded prevalence (in the dental documents) is within the range of expectations. It should also be remembered that many of the above studies were recording dental emergencies (often this was ill-defined) and therefore were unlikely to record mild cases of Temporo Mandibular Joint Dysfunction (TMJD) or sensitivity.
Age and Rank
The increase in UDV prevalence across the age categories was not monotonic in the ADF population, and the prevalence in the 17-24 year old age group was significantly higher than for the adjusted population at 23.5% to 12.3%. It is hypothesized that this may be due to a number of factors: the young ADF population may have poorer oral health than a comparable Australian population, as evidenced by their higher Decayed Missing and Filled Teeth score (4.0 cf 3.2) and the young ADF population may have risk behaviours for UDVs that are higher than the general Australian population. The differences between ranks is also interesting, with officers having a markedly lower UDV prevalence of 11.3%. While it is expected that Senior Non-Commissioned Officers (SNCO) would have a higher prevalence given that this represents an older age group, officers still have a lower UDV prevalence after adjusting for age against all ranks.
Comparison with the Australian Population
The comparative analysis of the UDV prevalence and the adjusted Australian population (as seen in Table 5) indicates that the prevalence in the ADF population is remarkably similar to the Australian population of the same age range and dental visiting habits (19.9% to 20.0%). Table 5 also shows that, for the same age range, if ADEs are not performed, even though they have private health insurance, the UDV rate increases significantly to 42.4%. Further to this, a lack of private health insurance increases the prevalence to 49.4%
The results strongly suggest that the critical factor in reducing the prevalence of UDVs is the ADE and that a lack of affordable access to dental care further exacerbates the problem. This is in line with expectations, given that ADEs should identify potential problems before the patient becomes aware of them, but once an individual realizes they have a dental problem, then the issue of affordability would be of lesser concern. Additionally, if the ADF were to remove the universal requirement for an ADE then the UDV prevalence would increase significantly. That is not to say that some individuals could not safely afford to have a dental examination less frequently, given their individual low risk for becoming a UDV.
Reason for UDVs
Essential to an understanding of how UDVs may be prevented is breakdown of the causes of these UDVs. Table 7 compares these findings with previous studies of Australian, US, and British Defence personnel8-10.
The breakdown consistently indicates that fractured / broken fillings and caries are the most frequent reasons for UDVs. On this basis, treatment and prevention strategies should be implemented to reduce the occurrence of these dental events. Interestingly, though this was first reported 37 years ago, it remains the major reason for UDVs today, and furthermore, the prevalence of UDVs remains the same as it was 37 years ago.
Clearly, from the study, there appears to be an under-reporting of unscheduled dental visits in the ADF. The implications of this under-reporting are:
- An incomplete individual dental record for forensic and treatment history purposes. The wide range of reasons and the significant number of these presentations means that there may be substantial discrepancies in an individual’s dental records. Examining dentists would have difficulty in assessing an individual’s treatment history to assist in their treatment planning if the records were incomplete. There would be problems, too, in victim identification as often Defence personnel deaths are the result of some catastrophic event and identification may be obliged to rely on incomplete records of an individual’s oral health status.
- ADF members visiting non-ADF dental centres are receiving treatment which may or may not be desirable from the ADF’s point of view. For example, members seeking treatment for fractured and broken fillings and teeth will often receive posterior composite resin fillings, which may be more susceptible to further fracture. This leads to the dilemma on return to the ADF dental centre of whether to accept the inferior filling or replace it. This situation will lead to a lack of quality control and consistency in terms of the standard of treatment provided to ADF members.
- An underestimation of what would be required to deal with these UDVs for military health planning purposes. Personnel and material for health deployments are based on known casualty rates. If the reported rates are too low, then this may lead to a reduced dental fitness of the deployed force and hence a reduced number of fit personnel for the mission.
Furthermore, the prevalence of UDVs has operational significance as 16-20% of deployable personnel, who are deemed dentally fit, are likely to experience a dental problem within the following 12 months, which clearly cannot be predicted under the present dental classification system. This prevalence suggests that there is a continuing need to maintain the capability to deploy dental teams in the field, based on the numbers of personnel deployed and the prevalence of UDVs.
Conclusion
This study indicates that there is a significant under-reporting of UDVs in the ADF. Over 4% of ADF personnel visit non-ADF dental centres and other health professionals on occasion for problems associated with their oral health. This represents 20% of all UDVs. The implications of this under-reporting and external treatment are:
- Incomplete individual dental records for forensic and treatment history purposes,
- Loss of quality control over dental treatment, and
- Underestimation of what would be required to deal with these UDVs for military health planning purposes.
The overall high prevalence of UDVs within the deployable ADF population also indicates that there is a continuing need for the operationally deployable dental officer.
The comparison of UDV prevalence in the ADF and the Australian population indicates that the rate is equal to a similar age group who has annual dental examinations and has health insurance. Furthermore, the removal of the requirement for ADEs and the provision of dental treatment without a validated predictive evaluation of a member’s risk of UDV would be expected to significantly increase the UDV prevalence.