Dental Fitness Classification in the Canadian Forces

Transcription

1 MILITARY MEDICINE, 7, :8, 8 Dental Fitness Classification in the Canadian Forces Major Richard R. Groves, CFDS ABSTRACT The Canadian Forces Dental Services utilizes a dental classification system to identify those military members dentally fit for an overseas deployment where dental resources may be limited. Although the Canadian Forces Dental Services dental classification system is based on NATO standards, it differs slightly from the dental classification systems of other NATO country dental services. Data collected by dental teams on overseas deployments indicate a low rate of emergency dental visits by Canadian Forces members who were screened as dentally fit to deploy. INTRODUCTION To put the dental classification of the Canadian Forces (CF) in perspective, a short introduction of the CF and CF Dental Services (CFDS) is required. Canada has a single military force, the CF, with air, land, and sea capabilities. The CFDS provides comprehensive dental treatment to 65, members (all Regular Force members and those Reserve Force members on extended full-time duty or overseas deployments) and restricted (emergency) dental treatment to another 5, Reserve Force members. The mission of the CFDS is to provide effective operational dental support and the highest quality in-garrison dental care, appropriate to the needs of the patient, and to establish and maintain a high level of oral health for all CF members. The two dimensions of the CFDS mission, operational dental support and in-garrison dental care, are closely linked. The most effective and efficient way to reduce the need and scope of dental support in operations is to ensure that personnel are at a level of dental fitness in-garrison that will allow for quick deployment. Dental Unit delivers in-garrison dental care through dental detachments located across Canada and two more in Europe. Six of these detachments have one or more satellite clinics to better serve patients geographically separated from the parent base. CFDS also delivers operational dental care, with dental platoons embedded in the three-brigade group field ambulance units and dental sections with Canadian Field Hospital and aboard the two replenishment ships. All military personnel wear a land force (army) uniform whether they serve at air, sea, or land establishments. Military dentists and dental technicians (dental hygienists and assistants) are augmented by public service employees and third-party contractors. There are a total of dental teams and 6 dental hygienists to look after the CF population. Director Dental Services, Dental Policy and Programs, Canadian Forces Dental Services, Ottawa, Ontario, Canada. The opinions expressed in this article are the private views of the author and should not be construed as reflecting official policies of the Canadian Forces Dental Services, the Department of National Defence, or the Canadian government. This manuscript was received for review in October 6 and accepted for publication in October 7. DEFINITIONS The following CF definitions are used in this article: phase examination is the periodic dental examination to determine dental fitness and produce a treatment plan colloquially referred to as a phase ; CF member denotes any military member of the CF, including all officers and noncommissioned members of the Regular Force and Reserve Force components; and CF Dental Care Program (CFDCP) refers to A-MD-7-89/JD-, the CF Dental Care Program document. It is the principal reference for this article. CANADIAN FORCES DENTAL CARE PROGRAM The CFDCP is published by the Director Dental Services and includes dental fitness goals, the CF dental classification definitions, and the preventive dentistry program followed by CFDS clinicians. It requires that all entitled CF personnel be examined periodically and be provided appropriate care to achieve and maintain individual and collective dental readiness for operations. It establishes priorities for care, selection criteria for rehabilitative care, and evidenced-based guidelines. The original CFDCP was developed in 98, after a CFDS Dental Condition Study revealed a high prevalence (8%) of gingivitis and/or periodontal disease in the CF. Further analysis of treatment returns indicated that the amount of periodontal treatment performed was less than that required to control these diseases. It was therefore considered essential that a new dental care program be developed and implemented which would ensure that CF members with periodontal disease receive appropriate treatment and preventive care. A 5-year review of the CFDCP ending in 99 brought about a number of modifications to the original program. The 99 edition of the CFDCP aimed to match disease prevention to an individual s risk of future disease and directed preventive services to those at high risk of future disease. In 999, the program was updated based on recommendations from the 997 Dental Care Workshop. The most significant recommendation called for the adoption of the NATO Dental Fitness Classification System (STANAG 66, edition ). The classes of dental fitness for members of the CF were modified to comply with the NATO Dental Classification System and a new color code system was Downloaded from by guest on October 8 8 MILITARY MEDICINE, Vol. 7, January Supplement 8

2 introduced. The 99 CFDCP document, the CFDCP 999 Policy Changes document, and an Oral Disease Risk Management Program form the basis of this new CFDCP document. DENTAL CLASSIFICATION The dental fitness classification system used by the CFDS is based on the NATO system in STANAG 66 and is published in the CFDCP document (see Annex). There are four levels of dental fitness: Class : Optimal Oral Health These individuals are dentally healthy and satisfied with their state of oral health. They are deployable and coded green. A recall period of, 8, or months may be assigned to these patients. Class : Operational Dental Fitness These patients have a stable dental condition which is unlikely to result in a dental emergency within months. They are deployable and are coded green. A recall period of months is assigned to these patients. Class : Potential Dental Casualty These individuals have an unstable dental condition that is likely to result in a dental emergency within months. They are in a potential dental casualty state. They are nondeployable and coded yellow. Once assigned as fitness class, patients remain class until the required treatment is completed, then are assigned to class. Class : Undetermined These individuals have either not been examined within the prescribed periodic examination interval, have no dental record, or have an incomplete record. They are nondeployable and are coded yellow. The Defence Planning Guide set a goal of 9% dental fitness (class and class combined) for Regular Force members, which is reflected in the CFDCP. For the past decade, CFDS has struggled with this goal due to resource issues. In particular, it is the number of Class : Undetermined patients that is too high. However, since all class patients were dentally fit at their last visit, the expectation is that a large proportion of them will still be dentally fit when they do present for an examination. Some aspects of the CFDCP were designed to reduce the number of phase examinations required each year, freeing resources to carry out higher priority treatment. Instead of seeing every patient on a strict -month recall, those patients that require treatment to become dentally fit are not assigned a recall date until the necessary work is completed, effectively delaying their recall examination. Also, fitness Class : Optimal Oral Health was defined to identify those patients for whom it may be appropriate to extend the recall period to 8 or months. The usefulness of fitness class has been reduced for several reasons. Anecdotally, many of the patients with this level of oral health insist on an annual examination and cleaning and are upset if an extended recall period is recommended. Some dentists were reluctant to allow any patient to have a recall period greater than months, especially for oral cancer screenings. Finally, the conditions required to assign fitness class are so stringent that only 5% of the CF population can achieve this fitness level. This has resulted in very few patients being coded class and only.% of the CF population was assigned a recall period greater than months. CFDS may get better functionality from the classification system if the class and fitness levels are redefined based on a requirement other than attempting to reduce the number of recall examinations. Although CF dental fitness class is described with language very similar to the STANAG 6 description of class, in practice the required fitness level to be classified class is higher. The CFDCP annex contains 6 pages of detailed criteria that must be met before a patient is assigned class or class dental fitness. These criteria are sorted by both dental discipline and dental disease/condition. All nonelective dental treatment must be completed before a CF member is assigned to an operational or optimal dental fitness classification. Specifically, criteria are detailed for the following clinical disciplines and disease, condition, and function headings: oral diagnosis/radiology/oral medicine; operative dentistry; endodontics; oral surgery; periodontics, prosthodontics; orthodontics; patient management; health and risk; dental caries, pulp, and periapical tissue; periodontal diseases, occlusion, temporomandibular joint dysfunction (TMD); tooth crown, restorations, and prostheses; esthetics, implants, and orthodontic appliances; third molars, teeth, and roots; pain, infection, and problems of probable dental origin; and soft tissues and radiographic anomalies. During the phase recall examinations, a Periodontal Screening and Recording (PSR) score is recorded for each patient. Further periodontal examination and treatment are triggered by PSR scores of or. The PSR system, including patient management, is shown in Table I. Dental fitness classification data, including the PSR score, is stored in an electronic database called DentIS, along with Canadian Dental Association treatment codes for all dental treatment provided. DentIS data are stored on a secure central server accessible by all CFDS clinics over the Defence Wide Area Network. Fitness reports can be generated by individual, by subunit, by unit, by formation, by base, by element (land, air, sea), by component (Regular Force or Reserve Force), or for the entire CF. DentIS will soon be augmented by an electronic health record, the CF Health Information System (CFHIS), which includes electronic scheduling, medical and dental charting, and digital imaging components. Currently, no diagnosis codes are used by CFDS, and the treatment codes do not list tooth number or surfaces. CFHIS will link tooth number and surfaces with the appropriate Downloaded from by guest on October 8 MILITARY MEDICINE, Vol. 7, January Supplement 8 9

3 TABLE I. Periodontal Screening Record Code Descriptive Label Clinical Findings Health Colored area of the probe remains visible in the deepest probing depth in the sextant, indicating a probing depth of.5 mm. No calculus or defective margins are detected. Gingival tissues are healthy with no bleeding after gentle probing. Bleeding on probing Colored area of the probe remains visible in the deepest probing depth in the sextant, indicating a probing depth of.5 mm. No calculus or defective margins are detected. There is bleeding after gentle probing. Calculus and/or defective margins Colored area of the probe remains completely visible in the deepest probing depth in the sextant, indicating a probing depth of.5 mm. Supra- or subgingival calculus and/or defective margins are detected. Probing depth mm Colored area of the probe remains partly visible in the deepest probing depth in the sextant, indicating a probing depth of mm. Probing depth 5.5 mm Colored area of the probe completely disappears, indicating a probing depth of 5.5 mm. treatment codes. The dental treatment planning module of CHFIS has a drop-down list of diagnoses that can be selected by users and also allows free text entries. It will eventually be possible to search dental records using these diagnoses. DEPLOYED OPERATIONS CFDS does not systematically collect data with respect to dental emergencies and the dental classification system, but since the mid-99s dental teams on deployed operations have submitted ad hoc reports. Historically, CF members have been dentally fit to a high standard before deployment on operations, and one dental team has been able to look after the emergency dental needs of a large deployed population. The data that are currently available have either been collected by individual dental officers to support specific observations and recommendations, or has been asked for by local headquarters for medical situation reports. The first set of data (Fig. ) presented in this article was collected in Afghanistan by Major Robert Hart from August to December and was presented to the World Dental Federation Section Defence Forces Dental Services Annual Congress in Montreal in 5. A single CFDS dental team was responsible for providing dental services for coalition forces from Canada, Belgium, the United States, Hungary, Norway, and other countries. He collected the data to support his observation that deployed Canadian troops were more dentally fit than those of the other nations and that this was reflected in the amount of treatment required. Since the Canadian troops had easy access to the dental facility, they accounted for most of the dental visits. However, many of these visits were for dental cleanings or other nonurgent, nonresource-intensive procedures. By categorizing the visits by procedure type, he was able to show that soldiers from the other countries represented required a higher proportion of lengthy procedures, such as endodontic or surgical procedures. The same data can be used to estimate the number of unscheduled dental visits by CF troops. Over the 7-week period, Major Hart saw an average of CF patients ( procedures) per week and an average of patients from other contingents ( procedures) per week. The total number of CF personnel in theater averaged 78. There was obviously enough demand for treatment to justify a dental team in theater, but the team had the capacity to look after an even larger population. The CF dental visits were at the rate of 77 visits per, personnel/year. Since of the 7 procedures for CF members were preventive in nature (possibly dental cleanings) and scheduled visits were also included in these totals, the number of emergency visits was much lower but cannot be identified with any certainty. From August 5 until the present, CFDS dental teams in Afghanistan are embedded in a multinational medical unit, which collects patient data from all sections. The current Procedure Diagnostic Preventive X-ray Fixed Prostho Removable Prostho Ortho Endo Restorative Other Surgical Total Visits Total Procedures FIGURE. Canada Belgium Procedural results. USA Hungary Norway 8 5 Downloaded from by guest on October 8 MILITARY MEDICINE, Vol. 7, January Supplement 8

4 reporting from the CF dental team includes numbers of patient visits, categories of patient visits, and patient disposition. Patient data are kept separately for CF members, Canadian civilians (contractors, etc.), and members of other military contingents. Patient visits are categorized as urgent sick parade, nonurgent sick parade, or scheduled. Although these terms are not defined, and hence it is up to the judgement of the dental officer which category to use for each visit, separating urgent from nonurgent visits is a useful exercise. During the predeployment phase, it is a burden on the unit s preparing for deployment to have members absent due to dental screenings and dental treatment. The justification for this burden is that it is an investment dentally fit troops should experience fewer dental emergencies during the deployment, potentially reducing MEDEVACS and time away from duty for dental visits. Therefore, it is in the dental service s advantage to report a low number of urgent dental visits in theater. Conversely, if the dental team in theater is not productive, it is difficult to justify its presence the number of military personnel in theater is closely controlled, and there seems to always be a need for more front-line troops. Thus, reporting a high total number of dental visits becomes advantageous. If the dental emergencies that occur are not related to dental fitness, but are due to external factors such as trauma, that helps support both the need for predeployment dental fitness and the inclusion of dental personnel in the deployed force. The raw data for the -month period from August 5 until November 5 are presented: patients seen (CF per total); urgent sick parade (9 of ); nonurgent sick parade ( of 79); scheduled (9 of ); and total visits (58 of 6). There were,8 CF troops in theater. The rate of sick parade visits (unscheduled dental visits) was visits per, patients/year, while urgent sick parade visits were at the rate of visits per, patients/ year. These numbers compare very favorably with the few rates of unscheduled dental visits that have previously been reported by other military dental services. For the same -month period and patient visits, there were a total of 9 dental procedures performed on CF personnel and,8 total procedures performed. The procedures are categorized using the Canadian Dental Association dental treatment code groupings and do not represent the etiology of the dental complaint that prompted the visit. The procedures for CF per total were: diagnostic ( of 8), preventive services ( of 9), restorative (9 of ), prosthetic removable ( of 8), prosthetic fixed ( of 6), orthodontics ( of ), periodontics ( of 8), surgical ( of 98), X-ray ( of 78), endodontics ( of ), other (e.g., phase ; of 9), and total (9 of,8). CONCLUSIONS The CFDS has very detailed guidelines to assist dentists in the assignment of dental classification. With an aggressive recall system aimed to achieve a rate of 9% dentally fit, extremely few CF members are deployed as potential dental casualties. It may be prudent to reexamine the definitions of the two classes of dental fitness that represent dental health. The rationale for optimal dental fitness was to reduce the number of recall dental examinations, but it has not had the desired effect. The CFDS Dental class fitness level is higher than that detailed in STANAG 6. This may be why there is a low number of unscheduled dental visits among deployed CF members. There is little perceived benefit for the CFDS to acquire more detailed data. The current classification system and high rate of dental fitness of deployed CF members places very little strain on deployed dental teams. Therefore, CF dental team deployment is based more on geographical concerns than on troop numbers. Without more detailed data, it is not possible to validate CFDS guidelines for dental classification. The data that are collected, both informally at the initiative of the dental officer and those reports required by non-cfds headquarters, support the need for deployed dental teams in theater based on the number of procedures performed. It would be advantageous for CFDS to be able to demonstrate that dentally fit deployed personnel experience a lower rate of emergency dental needs than those that are dentally unfit or unclassified, particularly if the dental visits that did result were not due to underlying dental conditions or disease but were the result of accidents or other trauma. Improved data collection would allow the separation of emergency dental visits from other unscheduled and scheduled dental visits and would indicate the etiology of the dental condition that prompted emergency dental visits. ANNEX B TO CFDCP Service members are considered dentally fit (classes and ) when the following conditions are satisfied: dental caries there is no evidence of active (progressing) caries extending into the dentine and active (progressing) caries are limited to the enamel and preventive care is indicated (Note: The determination of whether interproximal caries are active (progressing) is made by radiographic monitoring of the lesion. At least two radiographic images are necessary to make this determination.); pulp and periapical tissue there are no teeth with symptoms and signs of irreversible pulpal damage or necrotic pulps, no teeth with incomplete endodontic treatment, and no endodontically treated teeth with symptoms or with a periradicular radiolucency that has increased in size 6 months after treatment (Note: Pulp capping or inadequate treatment should not necessarily negate dental fitness provided there is good evidence of clinical and radiographic stability. Direct pulp capping is usually unacceptable for personnel subject to barometric pressure changes (e.g., aircrew, divers.); periodontal diseases there is no evidence of active periodontal diseases that are beyond control by primarily self-care. Professional care in the form of mainte- Downloaded from by guest on October 8 MILITARY MEDICINE, Vol. 7, January Supplement 8

5 nance therapy may be required as a secondary measure to control the patient s condition and no periodontally involved teeth with associated apical involvement, which are untreated, and when treated do not show both clinical and radiographic signs of resolution; tooth mobility there is no significant tooth mobility, which interferes with speech, oral function, or occupational function, such as the wearing of oxygen masks or diving mouthpieces; occlusion and TMD occlusion is stable with speech and function uncompromised, parafunctional activity is not excessive and the potential for long-term damage is considered to be minimal, TMD or occlusal dysfunction is being managed and the patient is asymptomatic, and orthodontic condition is stable (Note: personnel on deployment must be in a stable orthodontic condition.). These conditions are also a part of the dentally fit criteria: restorations there are no defective permanent restorations (cracked, loose, or leaking) that are causing symptoms or tissue damage or cannot be maintained by the patient, no temporary restorations with interim material present, and no posterior teeth requiring immediate protective cuspal coverage to maintain the structural integrity of the tooth; dental prostheses dental prostheses are retentive and stable in function commensurate with the occupational commitment of the individual, dental prostheses permit adequate mastication and communication and are esthetically acceptable, and no temporary fixed prostheses are present (Note: in this policy document, restorations and prostheses are classified as either permanent or temporary in nature. A permanent restoration or prostheses is considered a definitive treatment, whereas a temporary restoration or prostheses is intended for short-term use and may be fabricated from interim restorative materials or materials of a more permanent nature.); esthetics natural or prosthetic teeth are present in sufficient numbers to provide a degree of orofacial esthetics sufficient for normal life in society; third molars there are no unerupted, partially erupted, or malposed third molars with historical, clinical, or radiographic signs or symptoms of pathosis that require extraction (Note: the presence of third molars, in communication with the oral cavity, which are unlikely to erupt into functional occlusion and have a history of repeated pericoronal infection, may preclude the dentally fit classification. Where the prognosis is unclear, individual occupational and operational commitments must be taken into consideration.); teeth and roots (nonrestorable, unerupted, partially erupted, malposed) there are no unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that require extraction, no nonrestorable teeth; and no functionless roots in communication with the oral cavity (Note: buried roots with no associated pathology may be left in situ and monitored.); pain, infection, and problems of probable dental origin the individual is free of pain, there are no chronic oral infections or pathological lesions, including pulp or periapical pathology, and there is no history of recent unresolved problems diagnosed as of probable dental origin; and soft tissues and radiographic anomalies tissues are free from abnormality and there are no suspicious lesions that require evaluation or biopsy. (Note: benign oral lesions may be present and require monitoring.) Downloaded from by guest on October 8 MILITARY MEDICINE, Vol. 7, January Supplement 8