managing the impossible lessons from the defence dental services

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MANAGING THE MANAGING THE IMPOSSIBLEIMPOSSIBLE

LESSONS FROM THE DEFENCE DENTAL LESSONS FROM THE DEFENCE DENTAL SERVICESSERVICES

LT COL SARAH RAMAGEMSc, BDS, MFDS RCPS(Glasg), RADC

Senior Dental Officer Catterick

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MILITARY DENTISTRYMILITARY DENTISTRY

The Defence Dental Services mission is The Defence Dental Services mission is to contribute to military capability by to contribute to military capability by delivering quality dental care for the delivering quality dental care for the

Armed Forces on operations and during Armed Forces on operations and during peacetime.peacetime.

DEFENCE DENTAL DEFENCE DENTAL SERVICESSERVICES

Good dentistry “by any standards”. Ordinary dentistry, done extraordinarily well. Placed in the occupational context. Why define?

Military Clinical DentistryMilitary Clinical Dentistry

SJC

““Military dentistry specifically addresses Military dentistry specifically addresses the occupational needs of the Service the occupational needs of the Service community as a whole by providing community as a whole by providing

treatment that is at low risk of treatment that is at low risk of degradation in order to achieve a level degradation in order to achieve a level of dental health that is at low risk of of dental health that is at low risk of

morbidity in the operational morbidity in the operational environment”.environment”.

Military Dentistry – Working Military Dentistry – Working DefinitionDefinition

Clinical dentistry for force preparation Occupational health service Community dental service

Delivery of Care by the Delivery of Care by the DDSDDS

Military (Clinical) DentistryMilitary (Clinical) Dentistry

AvoidInappropriately complex

treatment plans (KISS!).Treatment with a high risk of

failure.Especially in patients with

high caries-susceptibility.When complex treatment

fails, a complex solution is required > Restorative Consultant.


Does this mean “dumbing-down” the treatment that we provide for our patients?

ABSOLUTELY NOT It does mean providing

treatment appropriate to patients’ caries risk.

In the high-caries risk patient, high quality treatment is often simple.


It does not mean:Low qualityLow techCompromising your clinical standards

Never making crowns or bridges

It does mean:◦ Knowing exactly what occupational group each

patient is in.◦ Providing treatment appropriate to each

patient’s occupation.◦ Providing treatment appropriate to the patient’s

clinical condition.

Military (Occupational) Military (Occupational) DentistryDentistry

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INFANTRY RECRUITSINFANTRY RECRUITS

MISSION“Train Officers and Soldiers in appropriate close combat skills to the standards and in the quantities directed by the Training and

Development Agency and Training Requirements Analysis in order to meet the operational requirements of the Army and

Defence”

SCHOOL OF INFANTRY SCHOOL OF INFANTRY

Operating since 1995 Creation of ITC(C) centralised training on a

scale not seen since National Service. Output

◦ 3200 trainees per year. Combat Infantry Course (CIC) delivered over

26 weeks.

INFANTRY TRAINING CENTRE INFANTRY TRAINING CENTRE CATTERICKCATTERICK

Syllabus◦ Skill at Arms – weapon handling and shooting.◦ Fieldcraft – how to move, survive and fight on the

battlefield by day and night.◦ First Aid◦ Radio communications◦ Drill◦ Chemical, Biological, Radiological & Nuclear.◦ Basic map reading.◦ Fitness

INFANTRY TRAINING CENTRE INFANTRY TRAINING CENTRE CATTERICKCATTERICK

RECTRUIT TRAINING RECTRUIT TRAINING PROGRAMMEPROGRAMME

Unavailable Periods in an average Unavailable Periods in an average ITC(C) Training ProgrammeITC(C) Training Programme

Wk 1- Initial Admin (Dental, Medical, QMs) 5 days

Wk 4 - Intro Ex 2 days

Wk 6 - Long Weekend 2 days

Wk 6 - Intro Ex 2.5 days

Wk 8 - Fieldcraft Tests 1 day

Wk 8- Live Firing 1 day

Wk 10 - Live Firing 1.5 days

Wk 11 - Live firing 1 day

Wk 12 - Adv. Trg 5 days

Wk 13 - Ranges 5 days

Wk 14 - Tac Ex 3 days

Wk 15 - Battle lessons on Trg area 5 days

Wk 15 - Live Firing 1.5 days

Wk 16 - Battle Camp 4 days


Wk 19 - Bsic Urban Combat Skills 2 days


Wk 21 - Long weekend 1.5 days

Wk 23 - Final Ex 5 days

Wk 24 - Battlecamp 5 days

Wk 25 - Final tests & NVQ Key Skills portfolio 5 days

Wk 26 - Pass out -----------------------------------------

17-25yrs old. Often never seen the dentist. Low expectations of dental care. High dental treatment needs

AVERAGE INFANTRY AVERAGE INFANTRY RECRUITRECRUIT

PROJECT MOLAR PROJECT MOLAR CONCEPTCONCEPT

10 year continuing decline in Army Dental Health.

Director Clinical Services DDS in Jan 05◦ Lack of Access –

Operational tempo No ability to provide routine care to recruits

WHY PROJECT MOLAR ?WHY PROJECT MOLAR ?

““Give us access to the recruits and we will resource”Give us access to the recruits and we will resource” Clinical Services DDS Jun 05 Clinical Services DDS Jun 05

Project MOLAR Initiation MeetingProject MOLAR Initiation Meeting

Careers Office

Phase 1Training School

FieldArmy

Phase 2 Training School

Recruit Selection Centre

Ops

??

IMPROVED IMPROVED ACCESSACCESS

REQUIREDREQUIRED

30% of all recruits enter trained Army with extensive oral disease

90% of recruit population have an identified TN at enlistment that can be completed within 2 hrs (TN-4)

70%of Army join with a high prevalence of disease. Require an average of 2.1 hours of treatment. During P1 and P2 training 50% of recruits require

1.2 hrs emergency treatment. Recruits enter trained Army with:

◦ more dental disease than when they enlisted◦ TN 2x that of the trained force◦ require 4.4 hrs of treatment

Access to routine care on average 14 months post-enlistment

SITUATIONSITUATION

Army recruits have double the decay levels of RAF recruits1

Caries incidence on Service entry2:◦ 33% of Army recruits are free from decay on

entry◦ <10% of Infantry recruits at ITC Catterick are

caries free◦ Compared to 50% for RN and RAF3

Army Recruits - EvidenceArmy Recruits - Evidence

1. MPH Project: Surg Cdr T Elmer 2010.

2. Hurley and Tuck: Military Medicine. 01 November 2007; 172(11): 1182-1185.

3. RAF Recruit Courses 446 (18/10/10) and 448 (6/10/10).

PROBLEMPROBLEM Lack of access to recruits during P1 and P2

training

SOLUTIONSOLUTION Access

◦ 2 hours per recruit (P1 & P2) Dentistry

◦ 1200 hrs of dentistry per established DO post per year

Military Oral Liability Army Recruits In place since 01 Apr 2006 Address high levels of dental disease in

ARs:◦ Early intervention◦ Stop ‘small holes becoming big holes’◦ Reduce burden on Fd Army

Project MOLARProject MOLAR

PROJECT MOLAR BENEFITSPROJECT MOLAR BENEFITS Major reductions in TN entering trained

Army Improved sustainability of population

dental fitness Improving and maintaining the whole force

dental risk profile Limiting necessity and extent of surges of

treatment pre-deployment Reduced rates of dental emergencies and

subsequent impacts on capability Reduction in time lost from military duties

and force preparation

FORECASTSFORECASTS 5 YEAR

◦ Do Nothing: 57% moderate to high risk 23% unfit for task

◦ MOLAR 61% dental fitness (improvement of 21%) Deployable risk reduced from 57% to 38%

15 YEAR◦ Do Nothing

64% at moderate to high risk 27% unfit for task

◦ MOLAR 70-75% dental fitness Deployable risk reduces to 30% iaw internationally recognised

levels for well-prepared force

Intensive nature of training

Heavy reliance on civilian work force

Dental care provision should have a minimal impact on delivery of training.

CONSTRAINTSCONSTRAINTS

OPTIMAL TREATMENT TIMEOPTIMAL TREATMENT TIME

90% of recruit population have an identified TN at enlistment that can be completed within 2 hrs

ASSESSMENT OF TN ON ENLISTMENTASSESSMENT OF TN ON ENLISTMENT (Based on records of 1121 recruits from a typical Army Training (Based on records of 1121 recruits from a typical Army Training Regiment Regiment

TN - hrs

% pop2003-2004

Av Intake 100 recruits

TN hrs for Av Intake of 100 recruits

0 24.5% 24 0

0.5 27.3% 27 13.5

1 19.98% 20 20

1.5 11.75% 12 18

2 6.69% 7 14

>2 10.4% 10 20

Total 85.5hrs to get 90% of recruit population dentally fit (incl 2 hrs remedial for those with TN>2hrs) over 12 -14 week period.

Maximum level of fitness Target Population TN<2hrs – 90%, 65.5hrs.

Av Annual Intake of 1500 recruits presents an Annual TN – 1325 hrs.

( not accounting for 20% drop out)

ITC CATTERICK

ITC Catterick – ITC Catterick – Av annual intake Av annual intake 3200 recruits recruits

TN - hrs

% pop2003-2004

Av Intake 100 recruits

TN hrs for Av Intake of 100 recruits

0 8.85% 8 0

0.5 23.89% 24 12

1 24.78% 25 25

1.5 14.34% 15 22.5

2 12.92% 13 26

>2 15.22% 15 30

Total 115.5hrs to provide 2 hrs for every recruit for intake over 26 week period

Maximum level of fitness Target Population TN<2hrs – 85%, 95.5hrs

Annual TN – 2319 hrs ( not accounting for up to 35% drop out)

Comparison of StrategiesComparison of StrategiesClinical Resources – 10hrsClinical Resources – 10hrs

Patient TN Traditional MOLAR

Hrs req’d Fit Hrs expended

Hrsexpended

A 6 6 2

B 4 4 2

C 2 0 2

D 2 0 2

E 1 0 1

F 1 0 1

Review clinical hrs available Coincide clinical hrs with max availability of

recruits within limit of working week – flexibility Creation of Appointment schedule based on Trg

programme. Lists of prioritised personnel and appointment

slots to Directing Staff – responsibility with Chain of Command.

Daily reminders Communication between Dental Centre PMs

inter/intra unit

DDS action at the local DDS action at the local level level

FOB SHAWQAT- Home of Part of 1-Lancs FOB SHAWQAT- Home of Part of 1-Lancs Battle GrpBattle GrpWe are seeing roughly 15 - 20 dental patients a week. This is over the entire AO which is about 1250 at present. This is all medical staff seeing the patients not just at my facility. Of these there are about 5 CAT C(24hr request) CASEVACS per week for dental issues and probably the same again for sent back on next routine flight - tend not to have full sight of these as they are co-ordinated locally and as not medically evacuated remain non medical. Most presentations are either ongoing problems flaringup, loss of fillings and bizarrely a lot of abscesses.

Unless a guy is returned to Camp Bastion (BSN) he tends to remain effective. However, there is a low cut off for sending to BSN - i.e. pain over 36hrs. I will treat for probably 72hrs with ABs and higher dose PKs but PBs do not have that luxury and to be honest they should be reviewed. The average time for a solider to be off work pending flight, time for Tx and then return to front line is about 5 days. This is highly dependant on flights and could as short as 2-3 days and as long as 7-10 days. Major Chris Baird- Clarke- Regimental Medical

Officer 1st Battalion Duke of Lancaster Regiment- April 2010

MOLAR - The EvidenceMOLAR - The Evidence

Oral Health on Oral Health on OperationsOperations

Disease and Non-Battle Injury (DNBI).

Dental DNBI is a major contributor Current rates much higher than acceptable

Dental DNBIDental DNBI

• The DDS Future Vision with central focus on morbidity reduction andthe delivery of key healthcare outputs

• New model for the delivery of care• Action plan and implementation

timetable.

The Oral Health Strategic PlanThe Oral Health Strategic Plan

OBJECTIVESOBJECTIVES

◦A reduction in dental morbidity on operations

◦Planned re-orientation of our activity towards disease control and prevention.

◦Gain the evidence of effectiveness and cost effectiveness for interventions

Traditional Target Groupsfor Prevention of Caries

Caries Prone - Early Childhood CariesHandicapped - Medical, Physical etcSocially Deprived - Low Socio-economicImmigrant Groups - Inner Cities

Army Recruits

The Future Rapid treatment of tri-service initial

recruit needs, along with initial oral health education.

Orientation of activity towards more disease control and prevention

Conduct the required applied research on effectiveness and cost effectiveness

Dental DMICP is essential for this Needed for expanding the evidence

base

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MAXIMISING CLINICAL MAXIMISING CLINICAL EFFICIENCYEFFICIENCY

3 ASPECTS3 ASPECTS

Be there

Have patients there

Maximize what you get done when there

Be there- Boring but Be there- Boring but essential!essential! 200 clinical days a year 32 clinical hours a week (minimum) Each clinical session am or pm costs a lot to the DDS◦ Is the admin done in “an admin afternoon” worth

that much?◦ Are you doing enough dentistry to EARN your

keep?

ALTERNATIVE ADMIN TIMESALTERNATIVE ADMIN TIMES Between patients At lunch After work When patients Fail to Attend Power cuts- Volcano’s- Maundy Thursday

pm Defer to PM- let the Practice Manager

manage

ALTERNATIVE ADMIN TIMESALTERNATIVE ADMIN TIMES Meetings- do you have to go- could Practice

Manager attend?? Visits to Units

◦ - could they visit you◦ put them in the Dental Chair- ◦ Undertake their dental inspection and then Brief

Position of Power- puts them on edge Shows we are busy One less inspection to do!!!!!!!!

ALTERNATIVE ADMIN TIMESALTERNATIVE ADMIN TIMES

“Practice Managers and reception staff have Admin afternoons and Admin mornings every

day”

Maj Mike Twamley RADC

DENTAL TEAMWORKDENTAL TEAMWORK

You don’t have to be a Dental superhero

An ExampleAn Example

The ProblemThe Problem

Practice Manager, Lt Col Ramage and the Principal Dental Officer want toast.

Grill can toast two pieces at a time

Perfect toast needs 30 seconds each side under the grill.

How long to Grill all three How long to Grill all three slices to perfection?slices to perfection?

2 minutes?


Slice 1

Side A

0 Seconds under Grill

Slice 2

Side A


Slice 1

Side A


Slice 2

Side A

Slice 1

Side B

Slice 3

Side A


Slice 1 complete & slices 2+3 ½ toasted

At 60 secondsWhat do we have?


Slice 1

Side B


Slice 3

Side A

Slice 2

Side B

Slice 3

Side B


Slice 2

Side B


Slice 3

Side B

90 seconds

25% time reduction

Critical path Critical path analysisanalysis

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Time saving Time saving documentsdocuments

Dental Downgrading documentation shortens a lot of discussions about need for treatment

IOTNIOTN

Keeping the IOTN close to hand eliminates long conversations about what constitutes orthodontic need.

Less instruments on the tray

Plan the day out at the start of Plan the day out at the start of the daythe day

• Know what’s coming inKnow what’s coming in

1)1) How long you need/ can you How long you need/ can you run over?run over?

2)2) If DMICP crashes can fight onIf DMICP crashes can fight on

3)3) Endo WL’s can be annotated Endo WL’s can be annotated and medical problemsand medical problems

4)4) Nurses knows what stage Nurses knows what stage treatment is at and can get treatment is at and can get out what is needed.out what is needed.

Don’t fear IT - Understand it and use it

Big burs to remove Big burs to remove caries- Size 9 caries- Size 9 roseheadrosehead

I also have medium I also have medium and small.and small.

Ultrasonic scaler to cut Ultrasonic scaler to cut GP, less thing to get out GP, less thing to get out and less fire risk!!and less fire risk!!

Clean instruments as go along, when material set it takes Clean instruments as go along, when material set it takes the nurse time to clean at the end.the nurse time to clean at the end.

BPE Probe doubles as a BPE Probe doubles as a Dycal/Vitrebond applicator Dycal/Vitrebond applicator - one less instrument.- one less instrument.

BUR STANDBUR STAND

Oral SurgeryOral Surgery

• Have surgical kit (complete) Have surgical kit (complete) made up in advance.made up in advance.

• If not confident visit Regional If not confident visit Regional Oral Surgery Clinic for training.Oral Surgery Clinic for training.

• If tooth not out in 10 minutes - If tooth not out in 10 minutes - its time for a surgical. its time for a surgical.

• With practice a surgical should With practice a surgical should be relatively quick.be relatively quick.

• Big flaps heal as quick as little Big flaps heal as quick as little flaps.flaps.

• Try to be confident.Try to be confident.

ExtirpationsExtirpations

• Take WL PA on extirpation - it Take WL PA on extirpation - it takes seconds and saves takes seconds and saves minutes.minutes.

• Get on with it - max 20 mins.Get on with it - max 20 mins.

RCTRCT

• Only start RCT on restorable Only start RCT on restorable teeth- its not your fault if a teeth- its not your fault if a tooth can’t be fixed- (get tooth tooth can’t be fixed- (get tooth extracted)extracted)

• Be confidentBe confident

• BrilliantBrilliant

• I rarely take I rarely take them off.them off.

McKesson mouth props.McKesson mouth props.

• Small mouthsSmall mouths

• Can’t keep mouth openCan’t keep mouth open

• Keep falling asleepKeep falling asleep

Advantages:Advantages:

• Increased visibility/ accessIncreased visibility/ access

• Can make suction easier.Can make suction easier.

• Pts like- its hard keeping your Pts like- its hard keeping your mouth open.mouth open.

Disadvantages:Disadvantages:

• Time taken to explain/ fit.Time taken to explain/ fit.

Local anaesthetic timeLocal anaesthetic time

• Scale teethScale teeth

• Do notes/ Emails/ AdminDo notes/ Emails/ Admin

• Can give Oral Health Education Can give Oral Health Education tend to do upper and lower tend to do upper and lower cons at the same time and so cons at the same time and so start drilling uppers as lowers start drilling uppers as lowers go numb.go numb.

Cons tipsCons tips

• Matrix bands tight and wedged-Matrix bands tight and wedged-prevents ledgesprevents ledges

• Fill MO’s and DO’s before Fill MO’s and DO’s before occlusals to give them more occlusals to give them more time to set before carving.time to set before carving.

Team work with Nurse - No waiting Team work with Nurse - No waiting

• Dentist aspirates as DN mixes RothsDentist aspirates as DN mixes Roths

• DN starts mixing VB as I start drying DN starts mixing VB as I start drying cavitiycavitiy

• DN starts Amalgamator as I start DN starts Amalgamator as I start curing VB.curing VB.

More TipsMore Tips

• Have a inspection before sick slot or Have a inspection before sick slot or big cons so if not filled time not big cons so if not filled time not wasted.wasted.

• Try to fit that extra Cons into an Try to fit that extra Cons into an appointment.appointment.

• If an emergency pt presents with sore If an emergency pt presents with sore gums etc treat – then do a cons (if gums etc treat – then do a cons (if needed) as well!needed) as well!

More top tips More top tips

• Don’t do unnecessary treatment, i.e. if Don’t do unnecessary treatment, i.e. if pt happy with caries free anterior pt happy with caries free anterior composite being wrong shade then so composite being wrong shade then so am I.am I.

• Don’t speak too much/ waste time.Don’t speak too much/ waste time.

• Don’t keep checking things, check Don’t keep checking things, check once then move on.once then move on.

• Cast your own impressions- it will stop Cast your own impressions- it will stop you taking unnecessary impressions. you taking unnecessary impressions.

• See the greater good, not always that See the greater good, not always that patients individual welfare - we make patients individual welfare - we make soldiers combat fit in order to support soldiers combat fit in order to support the infantry in closing-in and killing the infantry in closing-in and killing the enemythe enemy

More top tips More top tips

• After giving IDB start cons on After giving IDB start cons on most mesial tooth and work most mesial tooth and work distally. distally.

• Each Patient is a six pointer. Each Patient is a six pointer. Bringing back denies another pt Bringing back denies another pt that slotthat slot

• Seal root canals with VB after Seal root canals with VB after filing takes seconds- eliminates filing takes seconds- eliminates microleakage- Dental Update microleakage- Dental Update April 10.April 10.

More top tips

• Establish a treatment plan – not Establish a treatment plan – not a treatment list list it makes a treatment list list it makes things quicker easier and less things quicker easier and less complex.complex.

• Aim for 6 PDI’s a day every dayAim for 6 PDI’s a day every day

• Keep an eye on the clock- don’t Keep an eye on the clock- don’t run over unless you know you run over unless you know you can get away with it.can get away with it.

• Always finish on time at the end Always finish on time at the end of the day and at lunch.of the day and at lunch.

• Always thank your nurse for Always thank your nurse for working hard.working hard.

TREATMENT LISTTREATMENT LIST

TREATMENT PLANTREATMENT PLAN

The number of filling done The number of filling done is less important than the is less important than the number of patients made number of patients made fit. fit.

The Key is making The Key is making patients dentally fit with patients dentally fit with as little clinical time as as little clinical time as possible.possible.

Adjust appointment Adjust appointment length to maximise output length to maximise output for that patientfor that patient.

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Clinical Case 1Clinical Case 1Best place to start

Before

Session 1Session 2

Session 3

Lower cons Lower cons

If cons needed in all If cons needed in all four quadrants – do four quadrants – do cons in one of lower cons in one of lower quadrants firstquadrants first

After session 1After session 1

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Clinical Case 2Clinical Case 2Multi-tasking clinical timeMulti-tasking clinical time

Needed –cons Needed –cons 12MB, RCT 12 + 12MB, RCT 12 + pal cons and pal cons and RPD.RPD.

1)1)As the WL PA going through As the WL PA going through cons 12MB done. cons 12MB done.

2)2)Endo completed and U+L imps Endo completed and U+L imps taken as final PA goes through. taken as final PA goes through.

3)3)Silicone base imp technique Silicone base imp technique used due to high palate to get used due to high palate to get around need for special trayaround need for special tray

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Clinical Case 3Clinical Case 3Less can be moreLess can be more

Sometimes its just about slogging Sometimes its just about slogging through the work to get it donethrough the work to get it done

• Cross archCross arch

• Amalgam and CompositeAmalgam and Composite

Before

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Clinical Case 4Clinical Case 4A Hard CaseA Hard Case

Some cases are complicatedSome cases are complicated

• Nervous Pt- seemed weak at IDINervous Pt- seemed weak at IDI

• Sent day after IDI to see OHE - Sent day after IDI to see OHE - a bit aggressive with her. I a bit aggressive with her. I explained the “way of the world explained the “way of the world to him”to him”

• Wanted all restorations placed Wanted all restorations placed one at a time if he was going to one at a time if he was going to get the work done.get the work done.

• Was told that would mean 24 Was told that would mean 24 appointments denied to fellow appointments denied to fellow recruits or an unfair burden on recruits or an unfair burden on receiving unit. receiving unit.

Pte B- a reformed character???

After first cons appointment- Pt initially After first cons appointment- Pt initially given choice RHS or Centre.given choice RHS or Centre.

• Nature of choice - area not number Nature of choice - area not number fillings.fillings.

• Next pt FTA’d therefore ran over into next Next pt FTA’d therefore ran over into next slot all restorations completed. slot all restorations completed.

A happy Pte B

15 spills of amalgam and

2 composite capsules later

He coped well and will get himself dentally fit.

100

Clinical Case 5Clinical Case 5Breaking a massive case downBreaking a massive case down

Session 1 IDI

Session 2

Session 3Session 3

Session 4

Session 5Session 6

• Session 1+2 done for me Session 1+2 done for me

• Session 3 able to expand out to Session 3 able to expand out to upper leftupper left

• Session 4 anterior’s improved Session 4 anterior’s improved (to be crowned eventually)(to be crowned eventually)

• Session 5 21/11 RCT- two as Session 5 21/11 RCT- two as quick as 1 and XLA as final PA quick as 1 and XLA as final PA goes through.goes through.

• Session 6 Final RCT - Pt Session 6 Final RCT - Pt stabilisedstabilised

• NB deploys October 2010NB deploys October 2010

Everything except- 22M/27O/44MO +RCT12

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Clinical Case 6Clinical Case 6Early FinishEarly Finish

• Pt booked in for cons 40 Pt booked in for cons 40

• Checking ahead showed next pt Checking ahead showed next pt didn’t need an appointment.didn’t need an appointment.

• Pt again deploying in OctPt again deploying in Oct..

• McKesson prop in.McKesson prop in.

• Pt asleep.Pt asleep.

• 80 min session all cons 80 min session all cons complete.complete.

• Time fully utilised.Time fully utilised.

• 3-6 -> 1-0! Job Done3-6 -> 1-0! Job Done

• Inspection - Col Watson Inspection - Col Watson

• Oral Surgery – Maj DaviesOral Surgery – Maj Davies

• OHE- Mrs S ThompsonOHE- Mrs S Thompson

• Cons- Maj TwamleyCons- Maj Twamley

• 4 Jobs done-> 1 fit Pt4 Jobs done-> 1 fit Pt

• Time fully utilisedTime fully utilised

WHY?WHY? We get soldiers fit to allow them to

deploy at low risk of becoming a dental casualty, preventing them from putting lives at risk being CASEVAC’d and leaving their Section one man down on a patrol.

QUESTIONS?QUESTIONS?

managing the impossible lessons from the defence dental services

Documents

qms5 dayswk

battlecamp5 dayswk

trg5 dayswk

tac ex5 dayswk

tac ex4 dayswk

tac ex3 dayswk

final ex5 dayswk

battle camp4 dayswk