An Evaluation of U.S. Navy Dental Corps Classification Guidelines

Transcription

1 MILITARY MEDICINE, 175, 11:895, 2010 An Evaluation of U.S. Navy Dental Corps Classification Guidelines LCDR John W. Simecek, DC USN (Ret.) * ; CAPT Kim E. Diefenderfer, DC USN ABSTRACT Objectives: The aims of this research were to evaluate the effectiveness of two different sets of dental classification guidelines to differentiate dental emergency (DE) rates between deployable and nondeployable personnel. Methods: A retrospective study of the dental records of two cohorts of Marine Corps recruits examined and treated using different classification guidelines was completed. Results: Both classification systems showed significant differences between DE rates of nondeployable and deployable personnel. No statistical difference was observed when comparing the adjusted HRs of the two cohorts. Conclusions: Results of this study suggest that both guidelines are able to distinguish between deployable and nondeployable personnel and give reasonable assurance that class 1 and 2 patients will not experience a DE for a 6-month period. Incorporating factors such as caries risk, number of missing and filled teeth, and number of third molars may improve the ability of the dental classification systems in predicting DE. INTRODUCTION Dental emergencies (DEs) rarely cause mortality, but the morbidity experienced by military personnel can jeopardize mission success and may require medical evacuation. Military dental services utilize classification guidelines to categorize the severity of oral disease in military personnel. Severity of disease and probability of DEs determine the readiness of personnel for deployment (deployable, class 1 or class 2; not deployable, class 3 or class 4). 1 A number of studies have examined the effectiveness of the dental classification guidelines by calculating and comparing the risks of DE of deployable and nondeployable personnel. A review of the literature yielded seven studies of military personnel that reported the DE rates of 11 different military populations or included sufficient data from which the relative risk of DE could be calculated.2 8 In every study, nondeployable patients exhibited a significantly greater risk of DE compared to deployable patients (relative risk range ), even though the U.S. Army, Navy, and Air Force and U.K. armed forces differ on dental conditions for classes 1, 2, and 3 9 and authors often used different definitions for DE. 10 Military readiness relies on diagnosis and treatment to ensure low probability of DE within the 12-month periodic examination cycle. Although DE rates and relative risks were calculated in previous studies, these statistics do not include the impact that time to DE may have on the estimates. Alexander 11 studied this topic by calculating the mean time to DE among fit/fit-ready vs. treatment-required personnel. A significant difference was found, with time to DE equaling 154 days in the fit/fit-ready group and 95 days in the treatment-required * Naval Medical Research Unit San Antonio, 8315 Navy Road, Brooks City Base, TX Restorative Dentistry, Fisher Healthcare Clinic, Naval Health Clinic, 2401 Sampson Street, Great Lakes, IL The opinions expressed in this article are the private views of the authors and should not be construed as reflecting official policies of the U.S. Navy, Department of Defense, or the U.S. Government. The authors are military service members or employees of the U.S. government. This work was prepared as part of our official duties. group. In other words, patients with existing treatment needs experienced DE sooner (following examination) than those without treatment needs. McClave and Brokaw 2 reported that patients with identified treatment needs reported for sick call an average of 238 days (7.92 months) from being classified. Another study 7 reported a mean time to DE in class 3 personnel who experienced a DE of 92 (±119) days. The mean time to DE was significantly less than in class 1 or 2 personnel who experienced DE (418 ± 361 days). Similarly, the median time to DE in class 3 personnel (59 days) was significantly less than in class 1 or 2 personnel (295 days). This study also calculated adjusted hazard ratios (HRs), which included time to DE in their computations. A significantly elevated HR was observed (1.52), which is in agreement with other published reports. The U.S. Navy Dental Corps issued specific guidance to standardize the classification of Navy and Marine Corps personnel in and The 2002 revision resulted in more stringent criteria for the assignment of dental classification status. Two examples of the changes put forth in 2002 are described here. Under the 1996 guidelines, dental caries had to extend at least one-third the distance from the dentinoenamel junction (DEJ) to the pulp (radiographically) for the patient to be nondeployable. The 2002 guidelines gave nondeployable status to all caries lesions extending more than 0.5 mm beyond the DEJ (radiographically), as well as any caries lesions exhibiting enamel surface cavitation (regardless of depth); this change substantially increased the number of caries lesions classified as dental class 3, rendering the patient nondeployable until restoration is complete. Criteria for a nondeployable classification of third molars in 1996 required past or present pain or pathosis as determined by clinical and radiographic examination. The 2002 guidelines maintained past or present pain or pathosis as reasons for nondeployability, but added oral communication and malposition that would not allow normal eruption. The latter guideline, which does not require previous or present symptoms, increases the number of conditions that impose nondeployable status to the sailor or marine. MILITARY MEDICINE, Vol. 175, November

2 Previous studies have reported selected statistics to describe rates of DE within dental classifications. Military services often define dental classification categories differently, but no comparison of classification guidelines has been reported. The aims of this study were to compare the effectiveness of each classification guideline to predict DE among patients within each dental classification category, as well as to compare the effectiveness of U.S. Navy Dental Corps classification guidelines in effect from 1996 to October 2002 with the guidelines in effect after October METHODS Sample Description Cluster samples of dental records of 1,077 Marines stationed at six dental treatment facilities (DTFs) at Camp Lejeune, North Carolina and Camp Pendleton, California who received their initial dental examinations between January 1, 1999 and December 31, 2000 (cohort 99), and 921 Marines stationed at four DTFs at Camp Lejeune and Camp Pendleton, who received their initial dental examinations between October 1, 2002 and July 31, 2005 (cohort 03) were analyzed. Data collection was completed during for cohort 99 and for cohort 03. Definition of Dental Classifications DoD guidelines describe four dental classification categories: Class 1, patients with a current dental examination, who do not require dental treatment or re-evaluation until the next annual examination; class 2, patients with a current dental examination, who require nonurgent dental treatment or dental reevaluation for oral conditions that are judged unlikely to result in DE within 12 months; class 3, patients who require urgent or emergent dental treatment for conditions that are likely to result in DE within 12 months; class 4, patients who have not received a dental examination within the past 12 months, or patients with unknown dental classifications. 1 The patient s dental classification often changes as required treatment is completed and as new treatment needs are identified after each annual examination. Therefore, dental records of cohorts were reviewed and each treatment was coded to identify the reason for the visit. The date of each dental attendance was recorded along with the dental classification assigned the patient at the conclusion of each dental visit. Variable Types The variable class was defined as the dental classification at the conclusion of each dental attendance and was reduced to a binary variable (deployable or nondeployable) by including class 1 and 2 patients in one category and class 3 and 4 in the other. The classification of the patient for each DE was the dental classification documented in the dental record at the conclusion of the previous dental attendance. Attendances at which the dental classification was not documented were classified with the most recently recorded classification. A DE was defined as any unscheduled dental attendance for which a chief complaint was documented in the dental record or any appointment at which pain or other chief complaint was documented. Each DE was coded to indicate the specialty required to treat the oral condition ( Table I ). DE were also coded as an initial attendance for an oral condition or attendance to render postoperative care. DE due to postoperative problems were not included in the analysis, since patients with conditions for which postoperative appointments are expected would not ordinarily be considered deployable until the condition is resolved. Covariates utilized in this study included: 1 age; 2 gender; 3 missing or filled teeth (MFT) as documented in the initial forensic examination (any tooth that was noted as restored in the forensic examination was counted as filled); 4 caries teeth requiring treatment at the initial dental examination (any tooth requiring treatment, including those for which sealants are recommended, was counted as caries); 5 third molars number of third molars documented at the initial dental examination, erupted, and unerupted. Statistical Analysis Within-class time at risk was defined as the total time that patients were in each of the dental classifications. Evaluating within-class time at risk was problematic due to classification changes occurring in patients after examinations and treatment. Calculation of the time at risk was accomplished by considering the time period within each dental class documented in the patient s dental record. Hazard ratios (HRs) were calculated using Cox proportional hazards model. The Cox modeling yields statistical evidence of the relative risk using time of occurrence of DE within the two dental classifications (deployable = class 1 or 2; nondeployable = class 3 or 4). The HR with robust sandwich variance estimators was employed to control for multiple events within patients. This statistical test controls for potential confounders and clustering of multiple DEs within Type Operative Endodontic Oral Surgery Oral Medicine Prosthodontic Periodontic Trauma TABLE I. Types of Dental Emergencies Description Caries, fractured restorations, fractured teeth, reversible pulpitis requiring restorative treatment. Caries or fractured restoration that requires root canal therapy (RCT), irreversible pulpitis, apical periodontitis, periapical abscess, retreatment of RCT. Pericoronitis, eruption pain. Aphthous ulcers, herpetic lesions, TMJ dysfunction, erosion sensitivity (requiring only palliative treatment). Loose, fractured or lost crowns, broken removable dentures. Gingival pain, periodontal infections. Trauma from external objects. 896 MILITARY MEDICINE, Vol. 175, November 2010

3 patients and allows for determination of independent covariates. The models were adjusted for (i) caries (continuous) at initial examination; (ii) MFT at initial examination (continuous); (iii) third molars present at initial examination (continuous); (iv) age (continuous); and (v) gender (male, female). The means (±SD) were calculated for times to DE and other continuous variables and t -tests were performed to determine statistical significance. Median times to DE were also calculated with the Kruskall-Wallis test used to test significance. c 2 tests were used to determine statistical differences of DE among the classifications. To control for the difference in follow-up between cohort 03 and cohort 99, the calculations of mean and median times to DE were limited to 2 years. All α levels were set at Statistical intervals are set at 95% confidence (CI). Data manipulations and analyses were conducted with SAS (version 9.1) statistical software, EpiInfo (version 3.2.2) statistical software, Microsoft Excel, and an online statistical calculator. This research protocol was evaluated by the Institutional Review Board of the Naval Institute for Dental and Biomedical Research, Great Lakes, Illinois and approved by the appropriate authority. RESULTS The dental records of 1,077 U.S. Marines whose initial examinations were performed between January 1999 and December 2000 (cohort 99) and 921 U.S. Marines whose initial examinations were performed between October 2002 and July 2005 TABLE II. Distribution of Dental Emergencies (DEs) by Type and Deployability Status for Cohort 99 and Cohort 03 Cohort 99 Cohort 03 Number of DEs (%) Number of DEs (%) Type of DE Nondeployable Deployable Nondeployable Deployable Operative 65 (20) 267 (80) 41 (24) 128 (76) Endodontic 66 (59) 46 (41) 39 (60) 26 (40) Oral Surgery 53 (21) 205 (79) 39 (39) 60 (61) Oral Medicine 19 (14) 119 (86) 19 (22) 68 (78) Prosthodontic 8 (17) 40 (83) 6 (43) 8 (57) Periodontic 9 (15) 51 (85) 7 (21) 26 (79) Trauma 6 (20) 24 (80) 7 (27) 19 (73) Total 226 (23) 752 (77) 158 (32) 335 (68) TABLE III. (cohort 03) were reviewed. The average age was slightly higher in cohort 03 compared to cohort 99 (19.9 vs. 19.6; p < 0.01), and cohort 03 included more males than cohort 99 (>99% vs. 94%; p < 0.01). On average, patients in cohort 03 had more teeth requiring treatment due to caries (4.3 vs. 3.0; p < 0.01) and fewer third molars (2.9 vs. 3.1; p < 0.05). Both cohorts had an average of 3.8 MFT at initial examination. The mean follow-up was 3.2 years for cohort 99 and 2.2 years for cohort 03. There were 1,471 DEs during the follow-up (493 in cohort 03; 978 in cohort 99). The distribution of DEs by type of treatment and deployability status is described in Table II. One half of all subjects did not experience a DE during follow-up (cohort 03 = 53%; cohort 99 = 47%). There was a significant difference in the distribution of DE among the DoD classifications ( p < 0.01). For cohort 03, 158 of the 493 DEs (32%) occurred in class 3 patients, 271 DEs (55%) were in class 2 patients, and 64 DEs (13%) were in class 1 patients. For cohort 99, 225 of the 978 DEs (23%) occurred in class 3 patients, 1 DE (0.1%) occurred in a class 4 patient; 623 DEs (64%) were in class 2 patients, and 129 DEs (13%) were in class 1 patients. The Cox proportional hazards model was used to determine whether class 3 or 4 patients were at greater risk of having DEs than class 1 or 2 patients. When all variables (age, gender, caries, MFT, and third molars) were introduced into the model for all DEs, neither age nor gender was significantly associated with DEs. Therefore, only caries, MFT, and third molars were introduced in the final hazard models. Table III describes the HRs by DE, class, MFT, caries, and third molars. When dental caries, MFT, and number of third molars were introduced into the model, the adjusted HRs for DEs equaled 2.02 (CI ) for cohort 03 and 2.34 (CI ) for cohort 99. Patients in cohort 03 with higher MFT and caries scores at the initial examination were more likely to experience DE. However, the number of third molars at initial examination was not independently associated with DE. For cohort 99, caries and the number of third molars at initial examination were independently associated with increased DEs. The number of MFT at initial examination, however, was not associated with DE. The guidelines used for each cohort were able to differentiate between deployable and nondeployable personnel. The rate of DE occurring in class 3 or 4 patients was Cox Proportional Hazards Model Comparing Patients With and Without Dental Emergencies and 95% Confidence Limits for Cohort 99 and Cohort 03 All Dental Emergencies Operative and Endodontic Dental Emergencies Third Molar Dental Emergencies Variable Cohort 99 Cohort 03 Cohort 99 Cohort 03 Cohort 99 Cohort 03 Classa 2.34 ( ) 2.02 ( ) 3.09 ( ) 2.23 ( ) 2.02 ( ) 2.75 ( ) Missing, Filled Teeth b 1.02 ( ) 1.04 ( ) 1.05 ( ) 1.06 ( ) 1.00 ( ) 0.98 ( ) Cariesc 1.04 ( ) 1.03 ( ) 1.08 ( ) 1.04 ( ) 0.98 ( ) 1.02 ( ) Third Molars d 1.07 ( ) 0.98 ( ) 0.97 ( ) 0.93 ( ) 1.64 ( ) 1.47 ( ) a Class 3 or 4 versus class 1 or 2. b Increase in risk per missing or filled tooth at initial examination. c Increase in risk per carious tooth at initial examination. d Increase in risk per third molar present at initial examination. MILITARY MEDICINE, Vol. 175, November

4 statistically greater than the rate of DE in class 1 or 2 patients in both cohorts. However, the overlap of CI indicates no statistical difference between classification guidelines in the ability of class to predict DE among deployable vs. nondeployable personnel. Cox proportional hazard models were also constructed for data that included only operative and endodontic DEs and third molar DEs (see Table III ). When dental caries, MFT, and number of third molars were introduced into the model, the adjusted HR for operative and endodontic DEs equaled 2.23 (CI ) for cohort 03 and 3.09 (CI ) for cohort 99. Patients with a greater number of MFT and caries at the initial examination were more likely to experience operative and endodontic DEs, while the number of third molars at initial examination was not associated with operative and endodontic DE. For third molar DEs, when dental caries, MFT, and number of third molars were introduced into the model, the adjusted HR equaled 2.75 (CI ) in cohort 03 and 2.02 (CI ) for cohort 99. Patients with a greater number of third molars at the initial examination were more likely to experience third molar DE, while neither the number of MFT or dental caries at initial examination was associated with third molar DE. Both guidelines were able to differentiate between deployable and nondeployable personnel. However, the overlap of confidence intervals indicates no statistical difference between the guidelines for either operative and endodontic or third molar DE. Due to the difference in follow-up between cohorts, only DEs that occurred within the first 24 months of service were included for the analysis of times to DE. There were 386 (78% of 493) DEs in cohort 03 and 537 (55% of 978) DEs in cohort 99 that occurred within the first 24 months. In cohort 03 and cohort 99, respectively, among those patients who experienced a DE, class 3 or 4 patients experienced DEs in an average of 108 (±138) and 86 (±115) days, while class 1 or 2 patients experienced DEs in 244 (±176) and 280 (±191) days. Median time to DE was 58 days (cohort 03) and 35 days (cohort 99) for class 3 or 4 patients and 236 days (cohort 03) and 277 days (cohort 99) for class 1 or 2 patients. Both the mean and median time to DE were significantly less for class 3 or 4 than class 1 or 2 patients in each cohort (both p < 0.01). When comparing the guidelines, cohort 03 had a significantly greater median time to class 3 or 4 DEs ( p < 0.01) and significantly lower mean and median times to class 1 or class 2 DEs, than cohort 99 (both p < 0.05). There was no statistical difference noted in the mean time to class 3 or 4 DE between the cohorts. DISCUSSION Dental classification systems used by defense forces of many countries are intended to identify those military personnel whose dental conditions increase the probability of DE within 12 months, and, thus, serve as a rationale for determining deployability. This article compares U.S. Navy guidelines that were in effect after October 2002 (cohort 03) with the guidelines in effect during (cohort 99). Statistical analyses of the relative risks of DE reveal that class 3 or 4 patients are more likely to experience DE than class 1 or 2 patients for both cohort 03 and cohort 99. The adjusted HRs indicate that both classification systems show a significant difference between DE rates of class 3 or 4 and class 1 or 2 personnel. These findings support the results of other studies in which the point estimates of risk of DE in class 3 or 4 personnel were greater than that of class 1 or 2 personnel. Although each classification system demonstrates differences in risk ratios between deployable and nondeployable personnel, there appears to be no difference between the two classification systems, as observed in the cohorts studied, in their overall abilities to predict DE. The dental conditions prescribed for classification 2 are not expected to result in a DE within a 12-month period. Although approximately one-half of all subjects did not experience a DE in this study, if a Marine did experience a DE, there was a significant difference in the time to DE between class 3 or 4 and class 1 or 2 patients. In both cohorts, DE in class 3 or 4 patients occurred within 4 months, while it took approximately 8 months for DE to occur in class 1 or 2 patients. Although the classification system utilized for cohort 03 was unable to significantly improve the time to DE in class 1 or 2 DEs compared to cohort 99, both cohorts did show that DEs in deployable subjects did not occur for over 6 months. The guidelines in effect for cohort 99 required caries to be at least one-third the distance from the DEJ to the pulp for class 3 status, while the guidelines for cohort 03 required caries to be only 0.5 mm into dentin. The priority of class 3 treatment needs may have caused many moderately large caries lesions in class 2 (cohort 99) patients to be untreated for up to 1 year while the patient awaits the next annual examination. In contrast, moderate-sized caries lesions would have been designated class 3 and thus required restoration before deployment, for cohort 03. As a result, the remaining unrestored (i.e., class 2) caries lesions may have been smaller in size, and thus, less likely to provoke a DE visit in cohort 03 than in cohort 99. Furthermore, more third molars would be class 3 and require extraction in cohort 03. These differences in the guidelines suggest that more treatment would be required for cohort 03 to achieve deployability, and that remaining (i.e., class 2) unmet treatment need would be less, and of less severity, for patients in cohort 03 than in cohort 99. The differences in guidelines for restorative care are observed in the increased adjusted HR for operative and endodontic DE for cohort 99 (cohort 99 HR = 3.09; cohort 03 HR = 2.23), while an elevated HR for third molar DE for cohort 03 (cohort 03 HR = 2.75; cohort 99 = 2.02) may have been the result of a large increase in class 3 third molars. Although not statistically significant, the clinical relevance of such differences must not be overlooked. Classification guidelines that encourage appropriate proactive treatment, while maintaining a preventive approach to patient management, should be expected to reduce the risk of DE at both the individual and population levels. 898 MILITARY MEDICINE, Vol. 175, November 2010

5 Approximately 20% of DEs in cohort 03 were due to oral medicine problems and trauma. DE due to trauma, as well as oral medicine problems such as ulcerations or referred pain due to maxillary sinusitis, cannot be predicted with diagnostic procedures now utilized during periodic oral examinations. Even though clinicians may note that a patient has a history of trauma, aphthous ulcers, or sinusitis, the timing of these events is unpredictable. This relatively large number of unpredictable DE decreases the ability of the guidelines to anticipate the majority of DEs. The only type of DE that was predicted more than 50% of the time was endodontic (see Table II ). Even when DEs were restricted to operative, endodontic, and third molar conditions, which should be more predictable, all comparisons of HRs, which utilize time to DE and allow for control of covariates, reveal overlap of confidence intervals, suggesting no statistical differences in the relative risk of DE for class 3 or 4 compared to class 1 or 2 patients between the two cohorts. Furthermore, the more rigorous deployability criteria set forth by the U.S. Navy Dental Corps 2002 revision to dental classification (guidelines for cohort 03) did not increase the time to DE in those personnel who experienced a DE to or beyond the 12-month requirement. A comparison of the effectiveness of the two guidelines by analyzing data from the two cohorts is problematic. Both guidelines showed significantly greater rates of DE for class 3 or 4 patients than for class 1 or class 2 patients, demonstrating that each was capable of differentiating between class 3 or 4 and class 1 or 2 patients. However, superiority was not observed in the results of the adjusted HRs, which utilize time to DE and control of covariates in the statistical manipulation or by time to DE in subjects who experienced a DE. Each set of guidelines had desirable effects: cohort 03 showed an increase (not significant) in the ability to differentiate third molar DE between the classifications (adjusted HR = 2.75 vs. 2.02) and cohort 99 showed an increase (not significant) in the ability to differentiate operative and endodontic DE (adjusted HR = 3.09 vs. 2.23). Although the statistical analyses utilizing HR and time to DE cannot bestow superiority to either set of guidelines, the guidelines set forth in 2002 prescribe treatment that may increase the sensitivity of the classification system to predict DE. The percentage of class 1 patients who experienced a DE was the same for both cohorts (13%). However, the percentage of class 2 patients who experienced DE was 9% greater (cohort 03 = 55%; cohort 99 = 64% p < 0.01) in cohort 99 than in cohort 03 with an equal increase in DE in class 3 for cohort 03 (cohort 03 = 32%; cohort 99 = 23% ( p < 0.01). However, the sample differences observed in this study require that further study be undertaken to determine the validity of this finding. Our findings suggest that the dental classification system, as currently utilized, might be refined by incorporating both past and recent disease activity. Results from this study indicate that both the number of caries lesions and MFT at initial examination are independent predictors of DE. To improve the predictive ability of the classification system, a more in-depth approach, incorporating diseased, missing, or filled teeth (DMFT), recent disease activity, and other risk factors, may be indicated. Our previous studies of U.S. Navy personnel have revealed that those who enter the U.S. Navy with greater treatment needs continue to require more dental care throughout their enlistments, in spite of intensive treatment to achieve and maintain deployable status. Compared to patients who were caries-free at entry into the U.S. Navy, those who were caries-active at accession, even after receiving complete restorative treatment, required more restorations (1.9 vs. 1.2) 14 and were twice as likely to experience a restorative or endodontically related dental emergency 15 during their first 4 years of military service. The American Dental Association recommends that a recent history of dental caries (one or more lesions within the past 3 years) and/or the presence of one or more specific risk factors should lead to an assessment of moderate or high caries risk. 16,17 Although the U.S. Navy has employed formal caries risk management guidelines, which mirror those of the American Dental Association, since 1999, 18,19 current Navy and DoD dental classification guidelines do not include caries risk status in determining deployability. Incorporation of caries risk status into the dental classification guidelines would mandate a more aggressive preventive approach and active surveillance of those patients who may be predisposed to DE. While it may be impractical to restrict deployability indefinitely solely on the basis of caries risk, a nondeployable period of 6 to 12 months following moderate or extensive restorative treatment may be both reasonable and effective in limiting the incidence of DE. Further study is needed to determine whether such changes would improve the oral health and decrease the risk of DE in deployed personnel. ACKNOWLEDGMENTS Funding was provided by the Bureau of Medicine and Surgery award no. N RCG4001. REFERENCES 1. Department of Defense : Individual Medical Readiness. Washington, DC, DoD, January 3, McClave RJ, Brokaw WC : A study of United States Army dental fitness class 3 patients. Mil Med 1988 ; 153: Teweles R, King J : Impact of troop dental health on combat readiness. Mil Med 1987 ; 152: Richardson P : Dental risk assessment for military personnel. Mil Med 2005 ; 170: Simecek J, Patterson C : Dental emergencies in U.S. Navy personnel during a deployment at sea. J Dent Res 1997 ; 76: 209 (abstract1561). 6. Halverson B, Simecek J : Emergent dental conditions occurring in Navy personnel. J Public Health Dent 1997 ; 57: Simecek JW, McGinley JL, Levine ME, Diefenderfer KE, Ahlf RL : A statistical method to evaluate dental classification systems used by military dental services. Mil Med 2008 ; 173 (1, Suppl) : York AK, Martin G, Moss DL : A longitudinal study of dental experience during the first four years of military experience. Mil Med 2008 ; 173 (1, Suppl) : Proceedings of the International Workshop : Dental classfication and risk assessment: prevention of dental morbidity in deployed military MILITARY MEDICINE, Vol. 175, November

6 personnel. An international workshop July 11 13, Mil Med 2008 ; 173 (1, Suppl) : xi. 10. Proceedings of the International Workshop : Dental classfication and risk assessment: prevention of dental morbidity in deployed military personnel. An international workshop July 11 13, Mil Med 2008 ; 173 (1, Suppl) : xii. 11. Alexander DCC : Dental recall status and unscheduled dental attendances in British warships. Mil Med 1996 ; 161: Department of the Navy : Bureau of Medicine and Surgery. Managed Dental Health Care Program. Washington, DC, Department of the Navy, June Department of the Navy : Bureau of Medicine and Surgery. Changes to the Dental Classification System. Washington, DC, Department of the Navy, October 2, Simecek JW, Diefenderfer KE, Ahlf RL, Ragain JC, Jr : Longitudinal trends in restorative treatment needs among a cohort of U.S. naval personnel. J Dent Res 2003 ; 82 (Spec Iss A), Abstract Diefenderfer KE, Simecek JW, Ahlf RL, Ragain JC, Jr : Relationship between caries status and dental emergencies among U.S. naval personnel. J Dent Res 2002 ; 81 (Spec Iss A): 95, Abstract American Dental Association Council on Access, Prevention, and Interprofessional Relations : Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc 1995 ; 126 (Suppl) : 1S 24S. 17. American Dental Association Council on Scientific Affairs : Professionally applied topical fluoride: evidence-based clinical recommendations. J Dent Educ 2007 ; 71 (3) : Chief, U.S. Navy Dental Corps : Oral Disease Risk Management Protocol. Weekly Dental Update. Washington, DC, U.S. Navy Bureau of Medicine and Surgery, July 2, Chief, U.S. Navy Bureau of Medicine and Surgery : Oral Disease Risk Management Protocols in the Navy Medical Health Care System. BUMEDINST Washington, DC, U.S. Navy Bureau of Medicine and Surgery, July 1, MILITARY MEDICINE, Vol. 175, November 2010