Improving the Dental Fitness of the British Army by Changing the Strategy for Dental Care Provision for Recruits from a Vertically Equitable Model to a Horizontally Equitable Model

Military Medicine, Nov 2007 by Hurley, Sara Jane, Tuck, Jeremy

Background: The dental health of the British Army has been reported as being in decline for the past 10 years, and this is having a significant impact on operations. One of the major factors in the decline is the increasing number of recruits who enlist with outstanding dental treatment needs. The current policy for provision of routine dental care to recruits targets resources toward those with the worst dental health and provides only emergency dental care for the remainder. Aims: The goal was to review recruit dental care provision, to determine whether improvements in the overall dental health of the trained Army could be made during recruit training. Results: It was found that >85% of recruit dental treatment need could be met with the routine provision of 2 hours of dental treatment during training. Conclusion: A horizontally equitable model of recruit dental care, whereby all recruits access routine dental care during training, has been recommended to and accepted by the chain of command.

Introduction

Although dental morbidity is seldom fatal, it can affect the ability to eat and to speak and can affect general well-being.1 Despite the perception of soldiers as more stoic individuals, the military is not immune to the impact of poor oral health.2 The U.K. Adult Dental Health survey of 1998 reported that 45% of men and 41% of women in full-time employment had taken time off work for dental treatment,3 with 25% of a sample workforce having taken time off work within the previous year4 and 8% of sufferers reporting dental pain sufficient to alter their quality of life.5 The most common presenting feature of dental disease is pain; studies described the pain as having the severity of either chest or back pain6 and causing sleep loss, lapses in concentration, and changes in mood and temperament.7

Dental morbidity continues to be described by dental professionals of armed forces around the world, and several articles have attempted to quantify the burden of dental morbidity in trained service personnel in barracks,8"11 on exercises,12"14 and on operations.15-21 However, the published data have not allowed detailed comparisons to be made, because of problems of case definition and inclusion criteria. In studies that examined the oral health of recruits, it was regularly reported that recruits around the world exited basic fraining with a substantial backlog of unmet dental care needs.22"26 It is acknowledged that trainees have large demands for dental care with minimal time to seek treatment during initial entry fraining.27 The U.S. policy for management of oral morbidity in recruits gives the highest priority to recruits who have the greatest risk of experiencing a dental emergency within 12 months.28 Although this policy has been considered to be very effective, 38.8% of recruits never achieved complete oral health (class l).29 As recently reported, a modification of the policy has been introduced that targets more dental care to those with the greatest need earlier in their careers, to preserve the combat effectiveness and availability of personnel in the trained Army strength.30

The British Army has reported the burden of dental morbidity on the fighting force since medical and dental support for the military became more professionalized and systematized in the middle of the 19th century. During the Crimean War, 150 years ago, poor oral health resulted in soldiers being unable to bite through cartridge paper to load their weapons or to chew the hard biscuits and salted meat that were their daily rations.31 Similarly, during the Boer War at the turn of the 20th century, >5,000 soldiers needed to be returned to the United Kingdom because they were unable to eat their "iron rations."32 Current U.K policy is to assess each servlceperson's dental operational risk in terms of being at high, medium, or low risk of experiencing dental morbidity during the next year.

Dental fitness in the British Army is the lowest recorded since tri-service record-keeping began in 1997.33 The increasingly high levels of dental disease that persist within the trained Army have resulted from the escalating number of operational deployments, increased turnover of personnel, and the demands of framing, which limit access of trained personnel to routine dental care. The high levels of oral dis ease in the Army are exacerbated by the enlistment of recruits with a high prevalence of untreated carious lesions.34 British Army units have deployed into operational theaters with substantial levels of untreated dental needs and have experienced higher rates of operational dental emergencies.35 Operational dental data indicated that 50% of all U.K. troops who experienced serious dental morbidity on operations were categorized as high risk before deployment,36 with similar observations being made by other authors.37 It was thought, in the United Kingdom, that the current use of dental resources was failing to meet the dental needs and that a review of dental care provision should be conducted, to investigate whether there was an alternative care model that might reverse the current adverse trend. One element of this review was to examine the dental care provided to U.K. recruits. Current policy, like that of the United States, targets resources to those with the worst oral health, providing only emergency care to the remainder. Although this policy is vertically equitable and provides care to those who need it most, it has meant that those with lower levels of oral morbidity have not received advice and treatment that might have arrested or reversed preexisting oral disease. In fact, this lost cohort might have been in danger of seeing their oral health worsen, leading them to need more complex restorations that might be expected to fail early as a result of being further down the tooth "death spiral"38 and might be a major cause of failure on operations.18'3940

Furthermore, the training schedule for U.K. recruits is very taut and leaves little time for personnel to be absent from class without running the risk of being put back in their training. An additional complication is that, as has been reported, those with the poorest health may well be educationally disadvantaged41 and, in a military training environment, are the ones who can least afford to be away from training. This means that recruits often fail to appear for treatment, and their immediate superiors, although not actually being complicit in the failure to attend an appointment, do not pursue this disciplinary issue with sufficient vigor, thus tacitly condoning the behavior. Such failure to engage by the chain of command has been noted to have a deleterious effect on the health of the military population in other health areas.42 The aims of this article are to describe the review undertaken regarding dental support for U.K. Army recruits and to discuss the policy recommendations made as a result of the review.