Comparison of Dental Emergencies Among U.S. Military and Civilian Personnel During Combat Operations in 2007-2009

ABSTRACT

Introduction

Information from published studies describing dental treatment of nonmilitary personnel in a military theater of operations is sparse. The primary objective of this study is to determine the number of dental emergencies (DEs) and the types of dental treatment rendered on non-U.S. military (civilian) personnel treated by Navy dentists in 2007-2008 in Iraq and 2009 in Afghanistan. The second objective is to compare the type of DE treatment procedures provided to civilian personnel to the type of DE treatment procedures performed on U.S. military personnel.

Materials and Methods

Navy Dental Officers documented the diagnoses of unscheduled DEs. All treatment provided was described at the time of treatment using the Current Dental Terminology codes of the American Dental Association. Current Dental Terminology Code A0145 (2007 and earlier) and A0199 (2008 onward) in the patient encounter indicated a DE. This study is limited to DE occurring in (1) patient categories: U.S. civilian employees, other beneficiaries of the U.S. Government, foreign national civilian/dependents, and civilian, no government connection and (2) U.S. military service members. Chi-square analysis was performed to compare the proportion of dental treatment category procedures on civilian patients compared to those on U.S. military patients.

Results

During the reporting period, 308 patients were treated for DE in Afghanistan. Civilians treated accounted for 18.5% (n = 57) of all DEs. Nearly 93.0% of civilians who were treated were U.S. (DoD) civilian employees. Of the 57 civilian patients treated for DE, 61.4% of patients (n = 35) received oral surgery. There were 251 U.S. military patient encounters (81.5% of all DEs). Restorative dentistry was the most common dental procedure for military personnel DE. When comparing civilian and military patients, civilian patients are statistically more likely than military patients to receive oral surgery treatment for DE (P < .00001). In Iraq, 3,198 patients were treated for DE during the reporting period. Civilians treated accounted for 18.8% (n = 601) of all DEs. About 56.9% (n = 342) of civilians who were treated were U.S. contract employees. Of the 601 civilian patients treated for DE, 37.1% (n = 223) received oral surgery. There were 2,597 U.S. military patient DE encounters, and restorative dentistry was the most common dental procedure. When comparing civilian and U.S. military patients in Iraq, civilians are statistically less likely to have their DE treated by restorative dentistry (P < .00001) and are more likely have it treated by oral surgery/extractions (P < .00001). It is significantly more likely for civilians to have multiple categories of DE that must be treated (P< .00001).

Conclusions

The primary group of civilians treated for DE in Afghanistan was U.S. civilian employees. The primary group of civilians treated for DE in Iraq were contract employees of the U.S. Government. The primary dental treatment of civilian beneficiaries in both the theaters of operation was oral surgery. This brings into question what dental fitness standards are there for primarily U.S. civilian and contract employees.

INTRODUCTION

Civilian personnel, such as DoD employees, contractors, volunteers, and foreign nationals, play key roles in worldwide military and peacekeeping operations, combat exercises, and humanitarian assistance—disaster response missions—and maintaining their dental health in these forward deployed environments can prove to be challenging. Very little published data currently exist that describe the dental needs or the occurrence of dental emergencies (DEs) of civilians during past operations, yet this information could prove to be invaluable to planners and policy makers for future operations.

Existing data on DEs during conflicts typically delineate either the types of DE patients seen or procedures performed, but not both. Such data do not offer a comprehensive assessment of which treatments are more common in what populations during military operations. Past health records of emergency presentations during Operation Iraqi Freedom (OIF), for example, reveal that dental-related issues comprised 19% of patients seen; however, the types of procedures performed between civilian and military patients are not delineated, leaving the question of who is requiring DE treatment unanswered.¹ Another study of DEs in British troops in OIF in 2003 found that British military dentists treated 1,800 patients for DEs, of which 7 were civilians (6 from United Kingdom and 1 from United States). However, yet again, the types of procedures performed between civilian and military patients were not delineated.² In a study of DEs in the French Armed Forces during Operation Enduring Freedom (OEF), 28% of patients presenting with DEs were “civilians and personnel from other foreign military services.”³ However, there was no further breakdown into whether these patients were local Afghanis, French civilians, contractors, or foreign nationals.³ As with the previously mentioned reports, there was no description of what type of treatment they received for their DEs. Overall, reviewing existing data from historical operations, it seems that the contribution of civilian DEs to the military dental burden during forward deployed operations, such as in OIF and OEF, remains largely unknown.

Utilizing data from 2 military campaigns, OIF in Iraq (2007-2008) and OEF in Afghanistan (2009), this retrospective epidemiological study seeks (1) to determine the proportion of DEs contributed to civilian personnel and (2) compare the types of presentations and DEs between civilian and U.S. military personnel. (Note: the terms “non-US military” and “civilian” are used interchangeably.)

METHODS

Literature Review

PubMed and Google Scholar were used to make multiple queries of published literature related to DEs occurring in civilian U.S. beneficiaries and local population civilians in war zones. The first step of this report was to identify studies that quantified and categorized DEs in a deployed setting since 2001 (e.g., OEF and OIF) focusing on civilian beneficiaries (such as DoD employees and contract employees of the U.S. Government) and local population civilians. Various synonyms for DEs have been used by authors, and therefore, the search approach used “U.S.,” “dental,” “dental emergency,” “disease non-battle injury,” and “dental casualty” as key words. To search for studies on DEs in non-U.S. military personnel, the search approach included a combination of various other key words, including “dental treatment,” “beneficiaries,” “war zones,” “civilians,” “civilian workers,” “humanitarian,” “theater of operation,” “military,” and “US military.” From these searches, only one peer-reviewed article mentioned non-U.S. military or civilian personnel receiving dental treatment from U.S. military dentists in OIF.¹ Two other peer-reviewed articles mentioned civilian personnel receiving dental treatment from foreign military dentists (UK-OIF and French-OEF).^2,3 Overall, the literature confirmed that scant documentation exists on civilians treated in wartime theaters.

Data Collection

Data describing the treatment provided to eligible beneficiaries in OEF and OIF were routinely documented at the point of care by deployed Navy Dental Officers. Furthermore, Navy Dental Officers documented the diagnoses of unscheduled DEs occurring in deployed Navy and Marine Corps personnel, as well as others eligible for treatment using 7 major etiologic categories (E-Codes).⁴ Dental Officers documented the diagnoses of unscheduled DEs using E-Codes to clinically define the types of DEs seen. All treatments provided were described at the time of treatment using the Current Dental Terminology (CDT) codes of the American Dental Association.^5–8 CDT Code A0145 (used until the end of calendar year 2007) and A0199 (used calendar year 2008 onward) defined the patient encounter as a DE.

Using the aforementioned guidelines, Navy Dental Officers collected data and documented routine and emergency treatment for >29,000 active duty personnel and >1,400 other eligible beneficiaries from 2007 to 2009. Use of these data for research purposes was approved by the Naval Medical Research Unit San Antonio (NAMRU-SA) Institutional Review Board (IRB)—NAMRU-SA.2011.0003. After approval, the data were transferred to the primary investigator of the aforesaid protocol and deidentified. Two previous publications used these data to describe the incidence and severity of DEs experienced by military personnel, but did not cover civilian DEs.^4,9,10

A subset of the original data collected during 2007, 2008, and 2009 served as the basis of this report. The subset contained the following variables: Combat Zone (Iraq or Afghanistan), Month (from beginning of data collection) of Treatment, ID (nonidentifiable), Beneficiary Code, Number of Procedures Performed, Dental Weighted Value, CDT Code, and Emergency Type (E-Code). This report utilized the CDT Codes to classify the DEs according to dental treatment categories. These dental treatment categories were then adapted from the “categories of service” that the American Dental Association uses to organize the CDT Codes (Fig. 1).^11,12 This report was conducted under a protocol reviewed and approved by the NAMRU-SA IRB, NAMRU-SA.2023.0002.

Data analysis was limited to DEs occurring in the following Defense Health Agency patient categories: (1) K51-K92: “US civilian employees, other beneficiaries of the US government, foreign nationals/dependents, and civilian, no government connection” and (2) “US military service members: F11-F12 Air Force; A11, A12, A15 Army; N11-N12 Navy; M11-M12 Marines.”^13–15 Data analyzed for this study were documented during OIF for 4 months in 2007 and 10 months in 2008 and for 4 months during OEF in 2009.

Chi-square analysis was performed to determine if any significant differences occurred between the number of U.S. military and civilian patients seen as well as any significant differences between the proportion of dental treatment categories. Significance was set at α = 0.05.

RESULTS

OEF—Afghanistan

A total of 308 patients were treated for DEs during the 4-month reporting period during 2009. Civilians treated who had an E-code and a CDT Code A0199 accounted for 18.5% (n = 57) of all DEs (Table I). Nearly 93.0% of civilians who were seen and treated were “US [DoD] civilian employees (K53).” Of the 57 civilian patients treated for DE, 61.4% of patients (n = 35) received oral surgery (primarily exodontia or extractions), 28.1% received restorative (operative) dentistry, 8.8% received examinations/diagnostics, and 1.8% received periodontal treatment.

There were 251 U.S. military patient encounters that had an E-code and a CDT Code A0199, which accounted for 81.5% of all DEs (Table II). Restorative dentistry was the most common emergency dental procedure for military personnel at 42.2%. Oral surgery procedures—primarily exodontia—accounted for 19.9% of DE procedures. A total of 12.4% of military patients received only adjunctive services for DEs such as the application of desensitizing medication, occlusal adjustments, or receiving medications. Examinations/diagnostic services/preventive services accounted for 10.8% of emergency procedures. Finally, 9.2% of military DE patients had dental procedures from multiple categories (excluding adjunctive, diagnostic, and preventive services). All other DE categories were below 3.0% and totaled around 4.5%.

When comparing patients, civilians were statistically more likely than U.S. military patients to receive oral surgery treatment for DEs (P< .00001). For all other dental treatment categories, the P-values failed to show a statistically significant difference between U.S. military dental patients and civilian patients.

OIF—Iraq

A total of 3,198 patients were treated for DEs for the reporting period during 2007-2008. Civilians treated who had an E-code and a CDT Code A0145 or A0199 accounted for 18.8% (n = 601) of all DEs (Table I). Around 56.9% (n = 342) of civilians seen and treated were “other beneficiary of the U.S. government/contract employee” (K65). “Foreign national/foreign civilian” (K76) accounted for 18.5% of civilians seen and treated for DEs, and “civilian, no government connection, emergency” (K92) accounted for 17.0%. All other categories of civilians treated for DEs (n = 46) accounted for 7.6% of the civilians seen and treated. Of the 601 civilian patients treated for DEs, 37.1% of patients (n = 223) received oral surgery, 20.6% received restorative dentistry, and 14.3% received examinations/diagnostics/preventive treatment only. Subsequently, 11.5% received adjunctive services for DEs, such as application of desensitizing medication, occlusal adjustments, or medications dispensed, 5.3% received endodontic treatment, and 4.7% received periodontal treatment. Also, 5.0% of civilian DE patients were categorized with dental procedures from multiple categories (excluding adjunctive, diagnostic, and preventive services). All other categories of DE totaled 1.5%.

There were 2,597 U.S. military patient encounters (81.0% of all DEs) that had an E-code and a CDT Code of A0145 or A0199 (Table II). Restorative dentistry was the most common DE procedure for military personnel at 40.3%. Examinations/diagnostic services/preventive services accounted for 21.3% of DE procedures, whereas 14.3% of military patients received only adjunctive services for DEs. Oral surgery procedures, such as exodontia, accounted for 11.6% of dental procedures performed to treat DEs. Endodontic procedures accounted for 6.9% of emergency dental procedures on military patients. All other categories of DEs were below 2.5% and totaled 5.3%.

When comparing civilian and U.S. military patients, civilians were statistically less likely to have their DEs treated by restorative dentistry (P< .00001) and were more likely to have DEs treated by oral surgery (P< .00001). It was also significantly more likely for civilians to have multiple categories of DEs that must be treated (P< .00001). Furthermore, civilians are more likely to receive periodontal treatment for their DEs (P= .0007) than U.S. military patients, and military patients are much more likely than civilians to be treated for DEs with “diagnostic and preventive” procedures only (P= .0001).

DISCUSSION

The most common patient category of civilians receiving treatment in 2009 from Navy Dental Officers during OEF were overwhelmingly (>93%) DoD civilian employees. When looking at the dental treatment categories of civilian patients, >60% of these patients received oral surgery as the treatment for their DEs. Compared to U.S. military personnel (19.9% + 5.5%, as part of treatment for multiple DEs), civilian patients were statistically more likely than military patients to receive oral surgery treatment for DEs. From the raw data, the overall dental health of the civilian patients that presented to Navy dentists cannot be discerned. It is not known if these patients presented with conditions such as poor oral hygiene and/or rampant and nonrestorable caries. However, based on the overall rate of DEs in the civilian cohort, it can be surmised that civilian personnel presented in theater in a worse and/or more risky dental condition than U.S. military personnel.

The most common patient category of civilians seeking treatment in Iraq during OIF in 2007-2008 was contract employees of the U.S. Government (∼57%). As in Afghanistan, civilian patients were statistically more likely than military patients to receive oral surgery treatment for DEs. However, in Iraq, there appeared some nuanced differences from Afghanistan. In Iraq, civilians were statistically less likely to receive restorative dentistry for treatment of their DEs. Also, civilians were statistically more likely to have multiple categories of DEs that had to be treated. Many of these involved oral surgery and other treatments such as endodontics, periodontics, and restorative dentistry. Civilians were more likely to receive periodontal treatment for their DEs and statistically less likely than military to receive “diagnostic and preventive” procedures only. This stands to reason because less severe periodontal conditions commonly seen in young military personnel are treated by preventive procedures such as prophylaxis, whereas more severe periodontal conditions require more robust periodontal treatment rather than only prophylaxis. As stated earlier, the raw data for Iraq did not provide information on factors as such age or the overall oral condition of civilian patients’ dental health.

When comparing civilian patients treated for DEs in Afghanistan and Iraq, variation existed among patient categories within the civilian denomination. In Afghanistan, DoD civilian employees overwhelmingly comprised the civilian patient population seen. No foreign nationals/foreign civilians or local civilians were seen—only one contract employee of the U.S. Government was seen and treated. In contrast, in Iraq, more than half of civilian patients were contract employees. There were a sizable percentage of both “foreign nationals/foreign civilians” (18.5%) and “civilians, no government connection, emergency” (local civilians) (17.0%) seen and treated. The percentage of DoD civilian employees treated in Iraq was substantially less (5.0%) than that in Afghanistan (93.1%). Differences in patient categories for civilian personnel may be attributed to differences in rules of engagement in different areas within a theater of operation (for instance, different regions in Iraq) or differences in rules of engagement between different theaters of operation (Afghanistan-OEF vs. Iraq-OIF). Differences in the makeup of the population being treated and variations in access to care because of geography may have influenced the observed differences. Age may play a role in the number and type of DEs. Civilians were likely generally older, and their advanced age potentially explains their higher numbers of DEs, but age qualifying data were not available to substantiate this. Iraq possessed a semideveloped road system, which made transportation via land-based motorized vehicles more achievable.¹⁶ Having some semblance of a transportation system makes it conducive to allow different civilian employee types to be inserted into theater for mission support. Not only could more patients access dental care on their own in Iraq, but also dentists were able to travel further distances with their equipment to increase the catchment area for patient treatment and humanitarian efforts. On the other hand, Afghanistan possesses a mountainous topography with a rudimentary road system. Fewer personnel and supply transport and movement occurred via land-based motorized vehicles.¹⁶ The differences in topography could have limited the U.S. Military’s use of civilian personnel and could have caused the U.S. Military to rely more on DoD civilian employees and not so much on contract employees and foreign nationals/foreign civilians. The rugged terrain in Afghanistan may have acted as a hindrance, making it difficult to perform humanitarian efforts for local populations. This could account for the fewer types of civilian personnel treated in Afghanistan: mostly U.S. civilians, almost no contract employees, no foreign nationals/foreign civilians, and no local civilians.

The results of this study bring into question what, if any, dental fitness standards exist for civilian U.S. beneficiaries. It also brings into question if there is a need for better preassignment dental screening and treatment protocols for civilians sent into military theaters. A study of oil rig workers showed that dental fitness standards were put in place by the oil company, but not enforced.¹⁷ This nonenforcement resulted in 12.6% of medical evacuations from company oil rigs because of DEs and a yearly DE rate of 21.6/1000.¹⁸ An application (with enforcement) of dental fitness standards like the U.S. Military for U.S. DoD employees and contract employees could reduce DEs and medical evacuations, streamline DE care, and reduce the equipment needed in the field.¹⁸

There appear to be limitations to this study. Because of the operational tempo experienced within combat environments and the potential for lack of digital access for data input, under-reporting of the actual numbers of all patients treated in either Afghanistan or Iraq is always possible.

Another limitation of this study could be the difference in the length of the study periods for OEF and OIF. The timeframe for data collection in OEF in 2009 (4 months) was shorter than that for OIF from 2007to 2008 (14 months nonconsecutively). This may have partially accounted for the much larger numbers of DEs in OIF. However, it should be noted that lengthening the OEF data gathering period likely has little effect on the types of DEs.

A final limitation is that ages of patients were unavailable. The original source of the data did not provide this before it was presented to the authors. If present, the ages (especially of the civilian patients) could have contributed to better inferences and conclusions.

CONCLUSION

The study of DEs and treatment related to civilians in a military theater of operations is limited. The primary groups of civilians treated for DEs were U.S. DoD civilian employees in Afghanistan and U.S. Government contractors in Iraq. The primary dental treatment of civilian beneficiaries in both theaters was oral surgery—specifically exodontia. Findings of this study may indicate that in future operations, military dentists will likely (1) need the skill sets to perform more complex treatments associated with oral surgery/exodontia and (2) need to have provisions to provide forms of periodontal treatment beyond simple prophylaxis. Military dental leaders will need to provide their dental officers with the training and the appropriate supplies and equipment to properly treat these patients.

The concluding recommendation from this study is that civilians participating in military operations should meet a baseline standard dental health requirement via appropriately enforced screening protocols aligning with their military counterparts, and military dentists should be prepared (trained and supplied) to treat the cadre of dental conditions that are correlated with civilian DEs. In the future, better, standardized, and more complete documentation of the types of DE treatments rendered to both civilian and military personnel in theater will aid in further analysis and forecasting of the capabilities required to successfully win campaigns.

ACKNOWLEDGMENTS

None declared.

CLINICAL TRIAL REGISTRATION

None declared.

INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS)

This study was approved by NAMRU-SA IRB—NAMRU-SA.2011.0003.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

J.W.S. collected the data. T.A.M. analyzed the data and drafted the original manuscript. J.W.S. and T.A.M. designed this research. W.B.A. and J.W.S. reviewed and edited the manuscript. All authors read and approved the final manuscript.

INSTITUTIONAL CLEARANCE

Institutional clearance (Ethics Review) approved.

FUNDING

This work was supported/funded by Defense Health Agency (DHA) work unit number G1804.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The data underlying this article were provided by NAMRU-SA by permission. Data will be shared on request to the corresponding author with permission of the Commander, NAMRU-SA.

REFERENCES

Author notes