Results From The2000 Tri-Service Recruit Oral

Health Survey

Lt Col Gary “Chad” Martin, USAF, DC LTC Bruce B Brehm, USA, DC

CDR Thomas M Leiendecker, DC,USN

Tri-Service Center for Oral Health StudiesUniformed Services University of the Health Sciences

Epidemiological Studies Evaluating Oral Health

Department of Health and Human Services (DHHS) National Health and Nutrition Examination Survey (NHANES II)

began 1976 The National Survey of Oral Health in US Employed Adults and

Seniors:1985 - 1986

Department of Defense (DoD) The 1994 Tri-Service Comprehensive Oral Health Survey

Contained a recruit component

Congress mandated a Comprehensive Study of Military

Medical Care System. National Defense Authorization Act for Fiscal Years 1992 and 1993

PUBLIC LAW 102-190 (SEC.733)

2000 Tri-Service Recruit Oral Health SurveyBackground

Cross-Sectional Study Design for both 1994 and 2000 Recruit Surveys

Constraints of time, personnel and money Same basic study design for both surveys allows for

comparability Comparisons of cross-sectional surveys conducted at

different times can demonstrate trends in disease

prevalence and distribution

2000 Tri-Service Recruit Oral Health SurveyStudy Design

Determine the prevalence of various oral diseases, specific treatment needs and tobacco use

Assess their impact on DoD Dental Readiness

Classification

Compare findings to those from the 1994 Tri-

Service Oral Health Survey

2000 Tri-Service Recruit Oral Health SurveyObjectives

Recruits randomly selected to participate in Survey

4,346 recruits for the 2000 Survey

2,711 recruits for the 1994 Survey

Survey included a comprehensive oral examination by a calibrated dental officer and a patient questionnaire

Samples were weighted prior to analysis, the statistical software program SPSS v10.0 was used for all calculations

Significance was calculated to the .01 level (CI=99%)

A single asterisk (*) will appear next to a value or item when statistically significant changes are noted.

2000 Tri-Service Recruit Oral Health SurveyMethods

Simple stratified random sampling Stratified by gender and race/ethnicity Sample size of 4,346 DoD Recruits (about 5% of pop.) Time frame - 6 months with quotas for each month

Variations by month evident in 1994 data

Why not 12 months? Data Collection

Clinical exam data recorded on laptop computer

Data recorded for each tooth down to the surface level Patient questionnaire completed on scannable form

2000 Tri-Service Recruit Oral Health SurveySampling and Data Collection

Eight examiners attended 3 day course (Dec 1999) Calibrated on Caries Diagnosis, PSR and Dental Readiness

Classification Not calibrated on treatment planning Scientific evidence of re-mineralization of early carious lesions

Created dilemma on which technique to use in 2000 Survey

Inter-examiner reliability Determining the Kappa statistic

Very misleading to report “percent agreement”

Agreement beyond chance divided by amount of agreement possible beyond chance

Calibration checks during site visits

2000 Tri-Service Recruit Oral Health SurveyCalibration of Examiners

Patients used for the calibration course get sick or child has an emergency at school Unexpected difficulty in recruiting individuals into the military

results in weeks where very few recruits enter basic training Brand new lap top computer had significant power problems Unexpected TDY or PCS of examiner Access and Excel unable to accept data base in total due to number of fields exceeding the limit of 256, total fields = 258

2000 Tri-Service Recruit Oral Health SurveyFog of War

2000 Tri-Service Recruit Oral Health SurveyDental Readiness

Comparison: Percent Dental Readiness for Service

1 0

48.450.633.6*

66.4*

0

20

40

60

80

100

Class1 Class2 Class3

Dental Readiness

Per

cen

t o

f R

ecru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Dental Readiness for DoD

50.7

0.6

50.149.3

1.8*

47.5

0

20

40

60

80

100

Class1 Class2 Class3

Dental Readiness

Per

cent

of R

ecru

itsDoD Recruits(1994)DoD Recruits(2000)

The percent of 2000 USAF Recruits in dental readiness class 3 has significantly decreased compared to 1994 USAF Recruits

No real change in 2000 DoD Recruits vs. 1994 DoD Recruits

Comparison: Percent Distribution of Missing Teeth per Recruit for Service

91.4

1.52.24.9

0.71.44.7

93.3

0

20

40

60

80

100

None 1 2 3 or >

Number of Missing Teeth (Excluding Third Molars)

Per

cent

of R

ecru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Distribution of Missing Teeth per Recruit for DoD

2.23.36.8

87.7 91.2*

1.61.8*5.4

0

20

40

60

80

100

None 1 2 3 or >

Number of Missing Teeth (Excluding Third Molars)

Per

cent

of R

ecru

itsDoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyMissing Teeth

No real change in 2000 USAF Recruits compared to 1994 USAF Recruits

Significant increase in the percent of 2000 DoD Recruits who are not missing any teeth compared to 1994 DoD Recruits

Comparison: Percent Intensity of Restorative Treatment Needs for Service

25.926.235.7

12.2

38.232.3*

13.4*16.1*

0

20

40

60

None 1 to 3 4 to 6 7 or >

Number of Restorations Needed per Recruit

Per

cen

t o

f R

ecru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Intensity of Restorative Treatment Needs for DoD

39.5

21.4 18.520.6

34.4*

13.6*15.8*

36.2*

0

20

40

60

None 1 to 3 4 to 6 7 or >

Number of Restorations Needed per Recruit

Per

cen

t o

f R

ecru

its

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyRestorations Needed Per Recruit

Significant increase in percent of 2000 USAF Recruits who have no restorative needs compared to 1994 USAF Recruits

Significant decrease in percent of 2000 USAF Recruits who require 4 to 6 or > 7 restorations compared to 1994 USAF Recruits

2000 DoD Recruits have significantly less restorative needs compared to 1994 DoD Recruits

Comparison: Mean Number of Restorations Needed (by Type) per Recruit for Service

0

0.5

1

1.5

2

2.5

3

1 Sur

face

2 Sur

face

3 Sur

face

4 Sur

face

5 Sur

face

Number of Restorations Needed per Recruit (1 Surf*)

# o

f R

esto

rati

on

s

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Mean Number of Restorations Needed (by Type) per Recruit for DoD

00.5

11.5

22.5

3

1 Sur

face

2 Sur

face

3 Sur

face

4 Sur

face

5 Sur

face

Number of Restorations Needed per Recruit (1 Surf* 2Surf*)

# o

f R

es

tora

tio

ns

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyRestorations Needed Per Recruit (By Type)

Significant decrease in mean number of 1 Surface Restorations required by 2000 USAF Recruits compared to 1994 USAF Recruits

Significant decrease in mean number of 1&2 Surface Restorations required by 2000 DoD Recruits compared to 1994 DoD Recruits

Percent Distribution of Dental Readiness Classification Based Only on Restorative Treatment Needs for Air Force Recruits

(1994)

Class112%

Class264%

Class324%

Percent Distribution of Dental Readiness Classification Based Only on Restorative Treatment Needs for Air Force Recruits

(2000)

Class322%

Class2 *46%

Class1 *32%

Percent Distribution of Dental Readiness Classification Based Only on Restorative Treatment Needs for DoD Recruits

(1994)

Class121%

Class242%

Class337%

Percent Distribution of Dental Readiness Classification Based Only on Restorative Treatment Needs for DoD Recruits

(2000)

Class3 *27%

Class2 *38%

Class1 *35%

2000 Tri-Service Recruit Oral Health Survey Dental Readiness Classification Based Only On Restorative Needs

Comparison: Percent Distribution of Class 3 Teeth Among Those who are Readiness Class 3 for

Restorative Reasons (Service)

3.610.8

11.9 312.9

61.4

124.7*

23.4*

56.3*

0

20

40

60

80

1 2 3 4 5 or >Number of Class 3 Teeth per

Class 3 Recruit

Per

cent

of

Rec

ruits

Air Force Recruits(1994)Air Force Recruits(2000)

Comparison: Percent Distribution of Class 3 Teeth Among Those who are Readiness Class 3 for

Restorative Reasons (DoD)

25.8

6.711.812.4

43.3

9.55.51123.3

50.7*

0

20

40

60

80

1 2 3 4 5 or >Number of Class 3 Teeth per

Class 3 Recruit

Per

cen

t o

f R

ecru

its

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health Survey Percent Distribution Of Class 3 Teeth Among Those Who

Are Readiness Class 3 For Restorative Reasons

Significant decrease in percent of 2000 USAF Recruits who have 5 or more Class 3 Teeth compared to 1994 USAF Recruits

Significant increase in percent of 2000 DoD Recruits who have 1 Class 3 Tooth compared to 1994 DoD Recruits

Comparison: Percent Distribution of Number of Teeth Requiring Extraction for Service

25.7

0.2

32

42.1

10.6*2.4

30.7*

56.3*

0

10

20

30

40

50

60

None 1 or 2 3 or 4 5 or >

Number of Teeth per Recruit

Pe

rce

nt

of

Re

cru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Distribution of Number of Teeth Requiring Extraction for DoD

38.7

23.8

2

35.5

4*

48.5*

15.5*

32*

0

10

20

30

40

50

60

None 1 or 2 3 or 4 5 or >

Number of Teeth per Recruit

Pe

rce

nt

of

Re

cru

its DoD Recruits

(1994)DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyNumber Of Teeth Requiring Extraction

Significant increase in percent of 2000 USAF Recruits who require 3 or 4 teeth extracted compared to 1994 USAF Recruits

Significant decrease in percent of 2000 USAF Recruits who require “No” teeth to be extracted and “1 or 2” teeth extracted compared to 1994 DoD Recruits

Identical findings for DoD Recruits

Comparison: Mean Number, by Type, of Surgical Procedure Needed by Recruits with OS Treatment

Needs for Service

0.4

1.6

0.9 0.8

2.6*

0.1*

0

0.5

1

1.5

2

2.5

3

Simple Complex Impaction

Types of Surgical Extractions

# o

f T

eeth

per

Rec

ruit

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Mean Number, by Type, of Surgical Procedure Needed by Recruits with OS Treatment

Needs for DoD

0.5 0.60.4

2

0.8*

2.2

0

0.5

1

1.5

2

2.5

3

Simple Complex Impaction

Types of Surgical Extractions

# o

f Tee

th p

er R

ecru

it

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyTypes Of Surgical Extractions For Recruits

With OS Treatment Needs Significant increase in mean number of “Impaction” Surgical Extractions for 2000 USAF Recruits compared to 1994 USAF Recruits

Significant increase in mean number of “Simple” Surgical Extractions for 2000 DoD Recruits compared to 1994 DoD Recruits

Percent Distribution of Dental Readiness Classification Based Only on Oral Surgery Treatment Needs for Air Force

Recruits (1994)

Class142%

Class229%

Class329%

Percent Distribution of Dental Readiness Classification Based Only on Oral Surgery Treatment Needs for Air Force Recruits

(2000)

Class3 *12%

Class2 *57%

Class1 *31%

Percent Distribution of Dental Readiness Classification Based Only on Oral Surgery Treatment Needs for DoD Recruits

(1994)

Class139%

Class239%

Class322%

Percent Distribution of Dental Readiness Classification Based Only on Oral Surgery Treatment Needs for DoD Recruits

(2000)

Class240%

Class3 *27% Class1 *

33%

2000 Tri-Service Recruit Oral Health Survey Dental Readiness Classification Based Only On Oral Surgery Needs

Comparison: Percent Distribution of Recruits by PSR Code for Service

5 1 13

63

4

32

61

30

0*0

20

40

60

80

PSR 0 PSR 1 PSR 2 PSR 3 PSR 4

Recruits' PSR Code

Per

cen

t o

f R

ecru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Distribution of Recruits by PSR Code for DoD

3

54

34 5

31

9

25*20*

46*

0

20

40

60

80

PSR 0 PSR 1 PSR 2 PSR 3 PSR 4

Recruits' PSR Code

Per

cen

t o

f R

ecru

its

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health Survey Percent Distribution Of Recruits By PSR Code

Significant decrease in percent of 2000 USAF Recruits with PSR Code 0 compared to 1994 USAF Recruits

Significant decrease in percent of 2000 DoD Recruits with PSR Code 2 & 3 compared to 1994 DoD Recruits

Percent Distribution of Dental Readiness Classification Based Only on Periodontal Treatment Needs for Air Force

Recruits (1994)

Class15%

Class278%

Class317%

Percent Distribution of Dental Readiness Classification Based Only on Periodontal Treatment Needs for Air Force Recruits

(2000)

Class2 *95%

Class1 *0%

Class3 *5%

Percent Distribution of Dental Readiness Classif ication Based Only on Periodontal Treatment Needs for DoD

Recruits (1994)

Class293%

Class13%

Class34%

Percent Distribution of Dental Readiness Classification Based Only on Periodontal Treatment Needs for DoD Recruits (2000)

Class36%

Class2 *86%

Class1 *8%

2000 Tri-Service Recruit Oral Health Survey Dental Readiness Classification Based Only On Periodontal Needs

Comparison: Mean Number, by Readiness Class, of Periodontal Sextants for Each Recruit by

Service

1.6

3.9

0.5

5.7*

0.1*0.2*0123

456

Class 1 Class 2 Class 3Perio Sextant Readiness Class

Mea

n #

of

Sex

tan

ts

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Mean Number, by Readiness Class, of Periodontal Sextants for Each Recruit by DoD

0.1

4.7

1.20.1

4.7

1.2

0123456

Class 1 Class 2 Class 3

Perio Sextant Readiness Class

Mea

n #

of

Sex

tan

ts

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyPeriodontal Sextant Readiness Classification

The mean number of Class 3 sextants has decreased significantly for 2000 USAF Recruits compared to 1994 USAF Recruits

The mean number of Class 2 sextants has increased significantly for 2000 USAF Recruits compared to 1994 USAF Recruits

No change in 2000 DoD Recruits compared to 1994 DoD Recruits

Comparison: Percent Distribution of Recruits by Fixed Prosthodontic Needs for Service

2.26.67.8

83.485.9

1.149

0

20

40

60

80

100

None 1 to 2 3 to 6 7 or >Number of Fixed Pros Units per

Recruit

Per

cen

t o

f R

ecru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Distribution of Recruits by Fixed Prosthodontic Needs for DoD

2 0.98.68.8

80.6

4.2*9.8

85.1*

0

20

40

60

80

100

None 1 to 2 3 to 6 7 or >

Number of Fixed Pros Units per Recruit

Per

cen

t o

f R

ecru

its

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyFixed Prosthodontic Needs

No real change in 2000 USAF Recruits compared to 1994 USAF Recruits

The percent of 2000 DoD Recruits who do not require any Fixed Pros Units has significantly increased compared to 1994 DoD Recruits

Comparison: Percent Distribution of Recruits by Endodontic Needs for Service

1.2 0.25.9

92.7

0.52.36.3

90.9

0

20

40

60

80

100

None 1 2 or 3 4 or >

Number of Endo Teeth per Recruit

Per

cen

t o

f R

ecru

its

Air Force Recruits(1994)

Air Force Recruits(2000)

Comparison: Percent Distribution of Recruits by Endodontic Needs for DoD

2.3 2 0.36.6

90.8

0.15.7

92.2

0

20

40

60

80

100

None 1 2 or 3 4 or >

Number of Endo Teeth per Recruit

Per

cen

t o

f R

ecru

its

DoD Recruits(1994)

DoD Recruits(2000)

2000 Tri-Service Recruit Oral Health SurveyEndodontic Needs

No real change in 2000 USAF Recruits compared to the 1994 USAF Recruits

No real change in 2000 DoD Recruits compared to the 1994 DoD Recruits

Percent Distribution of Endodontic Needs by Type for Air Force Recruits (1994)

Anterior17%Premolar

7%

Molar76%

Percent Distribution of Endodontic Needs by Type for Air Force Recruits (2000)

Anterior18%

Premolar14%

Molar68%

Percent Distribution of Endodontic Needs by Type for DoD Recruits (1994)

Anterior16%

Premolar16%

Molar68%

Percent Distribution of Endodontic Needs by Type for DoD Recruits (2000)

Anterior17%

Premolar14%

Molar69%

2000 Tri-Service Recruit Oral Health Survey Percent Distribution Of Endodontic Needs By Type

Percentage of Total DWV Contributed by Each Clinical Discipline for Air Force Recruits (1994)

Oral Surg25%

Prost31%

Perio11%

Rest29%

Endo4%

Percentage of Total DWV Contributed by Each Clinical Discipline for Air Force Recruits (2000)

Prost20%

Perio13%

Endo6%*Rest

20% Oral Surg*41%

Percentage of Total DWV Contributed by Each Clinical Discipline for DoD Recruits (1994)

Oral Surg30%

Prost31%

Perio12%

Rest22%

Endo5%

Percentage of Total DWV Contributed by Each Clinical Discipline for DoD Recruits (2000)

Perio13%

Endo5%*Rest

20%

Prost*21%

Oral Surg*41%

1994 Air Force Recruits 2000 Air Force Recruits 1994 DoD Recruits 2000 DoD RecruitsOral Surgery 332.6 [290.9-374.3] 550.2 [509.5-590.7] 420.6 [400.1-441.0] 510.6 [493.5-527.6]

Prosthodontics 397.4 [238.9-555.9] 271.4 [180.8-361.9] 443.2 [383.8-502.5] 269.3 [233.9-304.7]Periodontics 148.4 [123.5-173.3] 181.6 [158.0-205.1] 169.4 [156.9-181.9] 162.1 [151.8-172.4]

Restorative 384.5 [339.6-429.4] 264.5 [230.5-298.5] 307.7 [291.7-323.6] 255.2 [241.8-268.7]Endodontics 52.7 [25.3-80.1] 81.2 [50.6-111.8] 74.3 [60.7-87.9] 63.1 [52.8-73.3]

Totals 1315.7 [1114.1-1517.3] 1348.8 [1212.4-1485.3] 1415.1 [1331.2-1499.0] 1260.3 [1206.6-1313.9]

Comparison: Mean Dental Weighted Values (DWV) In Each Clinical Discipline For Air Force And DoD Recruits

2000 Tri-Service Recruit Oral Health SurveyDWV’s By Discipline

1994 Air Force Recruits 2000 Air Force Recruits 1994 DoD Recruits 2000 DoD RecruitsANUG 0.0% 0.5% 0.3% 0.3%

Aphthous Ulcer 0.2% 0.5% 2.2% 0.7%*Herpetic Lesion 0.7% 0.0% 0.6% 0.2%Tobacco Lesion 0.7% 0.1% 1.4% 1.1%

Pericoronitis 20.8% 5%* 4.1% 2.9%Other Lesions 1.7% 5.7%* 0.9% 4.1%*

Sig. TMD Findings 6.1% 0.7%* 2.1% 0.3%*Sig. Malocclsion 2.4% 2.7% 1.4% 1.4%

Percent Distribution of Various Oral Health Status MeasuresOral Conditions

Significant decrease in percent of 2000 USAF Recruits identified with pericoronitis and TMD Findings compared to 1994 USAF Recruits

Significant decrease in the percent of 2000 DoD Recruits identified with TMD Findings compared to 1994 DoD Recruits

2000 Tri-Service Recruit Oral Health SurveyOral Soft Tissue/TMD/Malocclusion Conditions

Cumulative caries experience measured using DMFT IndexSimple count of the (D)ecayed, (M)issing and (F)illed Teeth for each patient

Usually reported as the mean DMFT for a given populationThe DMFT for 2000 Air Force Recruits is significantly lower compared to 1994 Air Force RecruitsSimilar findings for DoD Recruits

2000 Tri-Service Recruit Oral Health SurveyDMFT Index

1994 AF Recruits 2000 AF RecruitsDMFT 6.9 [6.8-7.0] 5.3 [5.2-5.4]*

D 3.6 [3.5-3.7] 2.6 [2.5-2.7]*M 0.17 [.15-.19] 0.09 [.07-.11]*F 3.2 [3.1-3.3] 2.7 [2.6-2.8]*

Comparison: Mean DMFT For Air Force Recruits

1994 DoD Recruits 2000 DoD RecruitsDMFT 6.6 [6.5-6.7] 5.4 [5.3-5.5]*

D 3.1 [3.0-3.2] 2.6 [2.5-2.7]*M 0.24 [.22-.26] 0.16 [.14-.18]*F 3.3 [3.2-3.4] 2.6 [2.5-2.7]*

Comparison: Mean DMFT For DoD Recruits

2000 Tri-Service Recruit Oral Health SurveyOther Findings

Three fold increase in percent of 2000 Marine Recruits who had a smokeless tobacco lesion (5.3%) compared to 1994 Marine Recruits (1.6%)

Significant increase in percent of 2000 DoD Recruits who smoked at least 100 cigs in their lifetime (47.2%) compared to 1994 DoD Recruits (37.2%)

Significant increase in percent of 2000 DoD Recruits who smoked daily prior to entering the military (35.0%) compared to 1994 DoD Recruits (16.7%)

Of those Recruits who smoked daily prior to entering the military there was a significant increase in percent of 2000 DoD Recruits who had made a serious attempt to stop smoking cigarettes (61.3%) compared to 1994 DoD Recruits (49.4%)