Dental Morbidity in United Kingdom Armed Forces, Iraq 2003

Military Medicine, Jun 2005 by Richardson, Peter S

The aim of this article was to review the dental morbidity experienced by U.K. armed forces serving in Iraq from deployment on Operation Telic in January 2003 until the end of phase 1 on May 1, 2003. U.K. Armed Forces dental teams treated 1800 emergency patients, including 135 prisoners of war. A total of 1523 of these were regular troops and 101 were reservists or Royal Fleet Auxiliary troops. This gave morbidity rates of 148 cases per 1,000 personnel per year for the Royal Navy/Royal Marines and 160 cases per 1,000 per year for the Army. Lost restorations and fractured teeth were by far the most common problems experienced, followed by pericoronitis, pulpitis, and periapical pathological conditions. Both the rates of morbidity and the types of problems experienced were very similar to those reported by other nations in previous conflicts.

Introduction

Dental emergencies have always been a major source of morbidity during military conflict. During the Boer War (1899-1902), so many British soldiers had trouble with their teeth that 1 in 30 were admitted to the hospital for this reason and, despite the Ministry of Defence shipping out a consignment of mincing machines to make the rations easier to chew, 1% of soldiers were returned to the United Kingdom as permanently unfit for duty for dental reasons.

Many dental problems that cause servicemen to request treatment in the field are relatively minor and not all are strictly pathological in nature; nevertheless, all conditions that lead to personnel seeking professional help are traditionally included in reports on dental morbidity. Mahoney and Combs1 reviewed the dental morbidity rates reported by military personnel in more recent conflicts and found them to vary between 150 and 200 cases per 1,000 personnel per year in well-prepared forces. In modern times, lost fillings and fractured teeth have been the most common problems reported during deployments, and this continued to be the case in Operation Desert Storm; Deutsch and Simecek2 found that morbidity rates for U.S. Marines were very similar to those found for Marines serving in Vietnam,3 despite the improvements in dental health that have been reported in the intervening 20 years. The same morbidity rates continued in 2001, when Chafin et al.4 reported 156 emergencies per 1,000 personnel per year among U.S. Army personnel deployed to Bosnia.

The Danes reported that they found it possible to make troops fit for deployment at short notice and that they would expect little need for treatment in the field.5 However, Chaffin et al.4 found that U.S. Army personnel still had a morbidity rate of 156 cases per 1,000 personnel per year, despite all class 3 personnel having been treated before deployment, and Alien and Smith6 reported that, even when there were essentially no class 3 personnel deployed, morbidity rates were still 160 cases per 1,000 personnel per year during a U.S. deployment to Sinai. Immediately before deployment, it is usually very difficult to gain access to soldiers to provide treatment, because they tend to have urgent training requirements. Moreover, observations for the Royal Navy (RN) and for U.K. troops during the first Gulf conflict indicate that last minute attempts to provide treatment usually result in more iatrogenic pathological conditions on short deployments than if no treatment had been undertaken.

Monitoring operational morbidity rates is fundamental to the planning of dental provision in the military because the data provide evidence on where resources are required and whether policy and/or establishment changes have had any effect. Benchmarking performance against other nations is valuable but must be treated with caution because of possible differences in the underlying dental health of the troops and variations in the reporting or interpretation of data.

Dentistry within U.K. Armed Forces is organized as a Tri-Service Defence Dental Agency (DDA), but treatment is generally provided by uniformed or civilian dental staff of the respective single Service. Until 2002, the DDA assessed the suitability of personnel for deployment based on the four NATO Dental Fitness Categories detailed in NATO Standardization Agreement 2466.7 This agreement defines the categories as follows: category 1, fully dentally fit; category 2, dental treatment is required but the condition is not expected to cause a problem within the next year; category 3, treatment is required and the condition is expected to cause a problem within the next year; category 4, dental examination is overdue.

In the United Kingdom, however, category 2 was usually not used for anyone with pathological conditions but was used only for those requiring elective treatment. Category 3 was used for all those requiring treatment for pathological conditions, regardless of the risk of them experiencing problems within the next year. In 2002, the United Kingdom moved to an assessment of the likelihood of experiencing morbidity while deployed but did this not by fully implementing NATO Standardization Agreement 2466 but by categorizing personnel into three dental risk categories, as follows: high risk, the examining dental officer considers it likely that the patient will experience symptoms related to dental pathological conditions within the next year; medium risk, the examining dental officer considers there is a moderate risk that the patient will experience symptoms related to dental pathological conditions within the next year; and low risk, the examining dental officer considers it unlikely that the patient will experience symptoms related to dental pathological conditions within the next year. This system was untested at the beginning of 2003 but formed a useful basis to prioritize the treatment of personnel when, as was usually the case, time and resources were inadequate to ensure that all troops scheduled for deployment were 100% dentally fit.