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

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.

A Review of Medical Evacuations Related to Dental Emergencies and Oral-Maxillofacial Injuries.

A literature review was performed to determine the frequency of medical evacuations (MEDEVAC) that are required for dental emergencies (DE) and oral-maxillofacial (OMF) injuries. Fourteen studies were reviewed altogether - eight which quantified evacuation of DEs or OMF injuries in military personnel (from 1982-2013) and six studies that discussed medical evacuation of DEs occurring in civilians working in offshore oil and gas rigs and wilderness expeditions (from 1976-2015). Among military personnel, DE/OMF issues were frequently among one of the top categories of medical evacuations, ranging from 2-16% of all evacuations. Among oil and gas industry workers, 5.3-14.6% of evacuations were dental-related, while one study of wilderness expeditions found that DEs ranked as the third most frequent type of injury that required evacuation. Previous studies have shown that dental and OMF problems often account for one of most frequently cited reasons for evacuation. However, due to the limited study base of DE/OMF medical evacuations, further research is needed to determine their impact on the cost of health care delivery.

Mouthguards for the Prevention of Orofacial Injuries in Military and Sports Activities: Part 2, Effectiveness of Mouthguard for Protection From Orofacial Injuries.

This is second of a two-part series on the history and effectiveness of mouthguards (MGs) for protection from orofacial injuries. MGs are hypothesized to reduce orofacial injuries by separating the upper and lower dentation, preventing tooth fractures, redistributing and absorbing the force of direct blows to the mouth, and separating teeth from soft tissue which helps prevent lacerations and bruises. The single study on MG use in military training found that when boil-and-bite MGs were required for four training activities, orofacial injury rates were reduced 56% compared with when MGs were required for just one training activity. A recent systematic review on the effectiveness of MGs for prevention of orofacial injuries included 23 studies involving MG users and nonusers and a wide variety of sports. For cohort studies that directly collected injury data, the risk of an orofacial injury was 2.33 times higher among MG nonusers (95% confidence interval, 1.59-3.44). More well-designed studies are needed on the effectiveness of MGs during military training. Despite some methodological limitations, the current data suggest that MGs can substantially reduce the risk of orofacial injuries in sport activities. MGs should be used in activities where there is a significant risk of orofacial injuries.

Mouthguards for the Prevention of Orofacial Injuries in Military and Sports Activities: Part 1: History of Mouthguard Use.

This is the first of a two-part series on the history and effectiveness of mouthguards (MGs) for orofacial injury protection. Military studies have shown that approximately 60% of orofacial injuries are associated with military training activities and 20% to 30% with sports. MGs are hypothesized to reduce orofacial injuries by separating the upper and lower dentation, preventing tooth fractures, redistributing and absorbing the force of direct blows to the mouth, and separating teeth from soft tissue, preventing lacerations and bruises. In 1975, CPT Leonard Barber was the first to advocate MGs for military sports activities. In 1998, Army health promotion campaigns promoted MG education and fabrication. A US Army basic training study in 2000-2003 showed that more MG use could reduce orofacial injuries and the Army Training and Doctrine Command subsequently required that basic trainees be issued and use MGs. Army Regulation 600-63 currently directs commanders to enforce MG use during training and sports activities that could involve orofacial injuries. In the civilian sector, MGs were first used by boxers and then were required for football. MGs are currently required nationally for high school and college football, field hockey, ice hockey, and lacrosse, and are recommended for 29 sport and exercise activities.

Causes of Oral-Maxillofacial Injury of U.S. Military Personnel in Iraq and Afghanistan, 2001-2014.

Background: Few studies have examined the causes or mechanisms of oral-maxillofacial (OMF) injury among deployed military populations. This study reports causes of OMF injuries to U.S. Department of Defense personnel deployed to Afghanistan in Operation Enduring Freedom (OEF) or to Iraq in Operation Iraqi Freedom (OIF) and Operation New Dawn (OND). This study provides follow-on analysis of a previous report of OMF injury rates among U.S. military personnel in Iraq and Afghanistan from 2001 to 2014. Methods: The populations studied were military personnel deployed to Afghanistan in OEF or Iraq in OIF and OND, who sought care at a level III military treatment facility for one or more OMF injuries. Injuries were identified in the Department of Defense Trauma Registry using diagnosis codes associated with OMF battle and non-battle injuries. Causes associated with these injuries were identified by evaluation of the data field "dominant injury mechanism." All OMF injuries incurred from October 19, 2001, to June 30, 2014, were included. Findings/Results: Approximately 89% of all OMF battle injuries in both OIF/OND and OEF were due to explosives or explosive devices. The three leading causes of OMF non-battle injuries for both OIF/OND and OEF were motor vehicle crashes/accidents (MVCs), falls, and "other blunt" trauma. MVCs as well as other blunt trauma accounted for a greater percentage of OMF non-battle injuries in OIF/OND than in OEF (p < 0.01). OMF non-battle injuries due to falls were more likely to occur in OEF (p = 0.05). Helicopter/plane crashes were responsible for a significantly higher percentage of OMF non-battle injuries in OEF compared with OIF/OND (p < 0.01). Discussion/Impact/Recommendations: Across both theaters of war, Iraq and Afghanistan, the main causes of OMF battle and non-battle injuries were consistent. Battle injuries were primarily due to explosives or explosive devices and the three main causes of non-battle injuries were MVCs, falls, and other blunt trauma. However, the distribution of causes differed by war theater. Future studies should focus on potential reasons for cause distribution disparities in MVCs and helicopter/plane crashes as they can only be partially explained by topography and infrastructure differences between Iraq and Afghanistan. Further surveillance is needed to understand the scope of OMF injuries in military-armed conflicts and operations.

Oral-Maxillofacial Injury Surveillance of U.S. Military Personnel in Iraq and Afghanistan, 2001 to 2014.

BACKGROUND: Cranial and oral-maxillofacial injuries accounted for 33% of military visits to in-theater (Level III) military treatment facilities for battle injuries during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Even after years of conflict, the size and scope of oral-maxillofacial injuries in military armed conflict is still not fully understood. This study reports U.S. Department of Defense (DoD) rates of oral-maxillofacial injuries that can be used for further surveillance and research. METHODS: The populations studied were military personnel deployed to Afghanistan in OEF or Iraq in OIF and Operation New Dawn (OND), who sought care at a Level III military treatment facility for one or more oral-maxillofacial injuries. Injuries were identified in the DoD Trauma Registry (DoDTR) using diagnosis codes associated with oral-maxillofacial battle and nonbattle injuries. All oral-maxillofacial injuries incurred from October 19, 2001, to June 30, 2014, were included. The Defense Manpower Data Center provided DoD troop strength numbers to serve as the study denominators. RESULTS: Battle injuries accounted for 80% of oral-maxillofacial injuries in OEF. There were 2,504 oral-maxillofacial injuries in OEF. The Army accounted for 1,820 (72.7%), the Marines 535 (21.3%), the Air Force 75 (3.0%), and the Navy 74 (3.0%). The oral-maxillofacial injury rates in OEF for the Army ranged from 1.10 to 4.90/1,000 person years (PY), for the Marines from 0.57 to 9.39/1,000 PY, for the Navy from 0 to 3.29/1,000 PY, and for the Air Force from 0 to 3.38/1,000 PY. The Army tended to have the highest incidence of all services in the early and latter part of the conflict, whereas Marines tended to have the highest incidence in the middle years. The Marines, Army, and Navy all had their individual highest incidences in 2009, the first year of the 2009 to 2011 OEF troop surge. Battle injuries accounted for 75% of oral-maxillofacial injuries in OIF/OND. There were 3,676 oral-maxillofacial injuries in OIF/OND. The Army accounted for 2,798 (76.1%), the Marines 731 (19.9%), the Navy 91 (2.5%), and the Air Force 56 (1.5%). The injury rates in OIF/OND for the Army ranged from 0.66 to 8.69/1,000 PY, for the Marines from 0.88 to 42.7/1,000 PY, for the Navy from 0.35 to 19.16/1,000 PY, and for the Air Force from 0.24 to 1.13/1,000 PY. In OIF/OND, the Marines had the highest overall oral-maxillofacial injury rate (42.70/1,000 PY) in 2003. The other services had their individual peak incidences in either 2003 or 2004. DISCUSSION/IMPACT/RECOMMENDATIONS: This is the first study, which quantified the incidence of oral-maxillofacial injury in theaters of conflict over prolonged periods. The Army has the highest number of injuries. The Marines had the highest incidences during the initial stages of OIF and the OEF troop surge. Intensity of the conflict could account for the upswing in rates. These increases in injury rates highlight the need for additional health care personnel to be deployed near the battlefield to treat these injuries.

Medical surveillance of injuries in the u.s. Military descriptive epidemiology and recommendations for improvement.

INTRODUCTION: Injury surveillance is the first and most critical step of the injury prevention process. Without it, successful injury prevention could not be sustained. The purpose of this paper is to describe advances in military medical surveillance, compare the incidence of injuries with other illnesses, define the size and causes of the injury problem for the military, and make recommendations for improved surveillance and injury prevention. METHODS: Medical and personnel data for nondeployed active duty personnel were obtained from the Armed Forces Health Surveillance Center for 2000-2006. Rates of nonfatal injuries and injury-related musculoskeletal conditions, frequencies of injury types, and causes of injury hospitalizations are described. RESULTS: Injuries were the leading cause of medical encounters among military personnel. The rate of hospitalization for injuries was approximately 1000 per 100,000 person-years and, for injuries treated in outpatient clinics, 999 per 1000 person-years. The leading injury type resulting in hospitalization was fractures (40%) and the leading injury type resulting in outpatient visits was sprains and strains (49%). Leading causes of hospitalization were falls/near falls (17.5%), motor vehicle mishaps (15.4%), and sports (13.1%). CONCLUSIONS: Injuries are the biggest health problem of the military services. Military medical surveillance data are useful for determining the magnitude and causes of the injury problem, identifying possible prevention targets, and monitoring of trends among military personnel.

Epidemiology of hearing impairment and noise-induced hearing injury among U.S. military personnel, 2003-2005.

INTRODUCTION: Rates of noise-induced hearing injury (NIHI) among U.S. active duty military have not been previously described using available military medical surveillance data. METHODS: NIHI were identified in the Defense Medical Surveillance System (DMSS) using a list of ICD-9-CM diagnosis codes selected in collaboration with military audiologists. To provide a more comprehensive view of the NIHI problem, NIHI-related ICD-9 codes beyond the traditional 388 noise injury-code set were included. Visit rates by gender and age group are reported by quarter, 2003-2005. Overall frequencies and rates by occupational specialty, 2003-2005, are also described. RESULTS: From 2003 to 2005, rates for men were significantly higher than rates for women, with rate ratios (RR) ranging from 1.15 (95% CI =1.07, 1.23) to 1.78 (95% CI= 1.62, 1.93). Rates among women ranged from 2.9 to 6.2 per 1000 person-years; rates among men ranged from 4.5 to 6.7 per 1000 person-years. NIHI rates were highest among those aged > or =40 years and lowest among those aged 17-19 years, with RRs ranging from 3.06 (95% CI=2.77, 3.40) to 5.51 (95% CI=4.88, 6.30) during this time period. Among occupational groups, general officers/executives had the highest NIHI rate over this time period (29.5/1000 person-years), followed by enlisted personnel in training (14.3/1000 person-years) and scientists and professionals (12.8/1000 person-years). CONCLUSIONS: While data on outpatient injury causes and use of hearing protection are also needed to guide the future design and/or modification of interventions, existing military medical surveillance provides essential information for tracking NIHI and monitoring NIHI intervention effects.

Eye injury surveillance in the U.S. Department of Defense, 1996-2005.

BACKGROUND: Consistent with the public health approach to prevention, surveillance analyses are needed to fully understand a health problem. U.S. military eye injury rates have not been fully described using medical surveillance data. METHODS: Medical visit data on active duty personnel, 1996-2005, and causes of eye injury hospitalizations (identified by Standard NATO Agreement injury cause codes) were obtained from the Defense Medical Surveillance System. Eye injury-related ICD-9-CM codes beyond the traditional 800-999 injury code set were included. Rates by age and gender are reported for 1996-2005, along with the frequency of causes of injury hospitalizations and leading eye injury diagnoses for 2005. RESULTS: Eye injury rates among active duty military personnel increased from 1996 to 2005 among both men and women (p<0.001), with the highest rates in 2004 (26/1000 person-years and 21/1000 person-years, women and men, respectively). Women consistently had 7%-21% higher rates than men (rate ratios=1.07; 95% CI=1.04, 1.11) to 1.21 (95% CI= 1.17, 1.25). From 1996-2005, eye injury rates increased among all age groups (p<0.001). From 2002-2005, rates were highest for those aged > or =40 years compared to those aged 17-19 years (rate ratios=1.17 [95% CI=1.11, 1.24] to 1.24 [95% CI=1.18, 1.31]). Leading causes of eye injury hospitalizations were ordnance handling (16.9%), enemy action (13.1%), and fighting (11.9%). CONCLUSIONS: Medical surveillance data enable the assessment and monitoring of overall active duty eye injury rates, trends, and causes. Outpatient data could be improved with the addition of cause of injury codes and eye protection use. Current data suggest that continued use of eye protection during ordnance handling, combat, motor vehicle use, and sports could help reduce eye injury rates.

Oral-maxillofacial injury surveillance in the Department of Defense, 1996-2005.

INTRODUCTION: Oral-maxillofacial injuries can lead to deformity and malfunction, greatly diminishing quality of life and worker productivity. Data suggest that over 10% of civilian emergency room visits are due to craniofacial injuries. The size and scope of oral-maxillofacial injuries in the military is not well understood. This study reports U.S. military rates of oral-maxillofacial injuries, causes of oral-maxillofacial hospitalizations, and recommends approaches to improving surveillance, research, and prevention. METHODS: Active duty U.S. military personnel who sought inpatient or outpatient treatment for one or more oral-maxillofacial injuries from 1996 to 2005 were identified in the Defense Medical Surveillance System using ICD-9-CM diagnosis codes associated with oral-maxillofacial injuries. ICD-9-CM diagnosis codes were divided into two categories: oral-maxillofacial wounds and oral-maxillofacial fractures. RESULTS: The oral-maxillofacial fracture rates for men were consistently 1.5 to 2 times higher than those for women, with 2000-2005 rates between 1.2 and 1.5/1000 person-years for men and between 0.7 and 1.0/1000 person-years for women. Wound rates for men were similar to those for women for all years examined (p<0.001), with 2000-2005 rates ranging from 11.0 to 14.6/1000 person-years for men and 12.2-14.8/1000 person-years for women. Compared to the over-40 age group, active duty personnel under age 25 had the highest rates of both oral-maxillofacial fractures and wounds (p<0.001). Among those injuries with a cause recorded, fighting (13.5%) was the leading cause of oral-maxillofacial injury hospitalizations in 2005. CONCLUSIONS: Oral-maxillofacial injuries can and should be monitored using military medical surveillance data. Surveillance efforts would be enhanced by the addition of dental care data. There is also a need for additional quality intervention studies on the strategies to prevent oral and craniofacial injury.

Air medical evacuations of soldiers for oral-facial disease and injuries, 2005, Operations Enduring Freedom/Iraqi Freedom.

This retrospective study was conducted to assess the nature and causes of serious oral-facial illnesses and injuries among U.S. Army personnel deployed to Iraq and Afghanistan in 2005. Information for this study came from the U.S. Air Force Transportation Regulating and Command and Control Evacuation System (TRAC2ES) database for medical evacuations (MEDEVACS) for 2005. The study found 171 oral-facial MEDEVACS out of Iraq (cumulative incidence: 13.3/10,000 soldiers per year) and 35 out of Afghanistan (cumulative incidence: 21.6/10,000 soldiers per year), a total of 206 MEDEVACS. Fifty-three percent (n = 109) of oral-facial MEDEVACS were for battle injuries caused by acts of war. Thirty-one percent of all oral-facial MEDEVACS (n = 64) were for diseases of the oral cavity, salivary glands, and jaw. Sixteen percent (n = 33) of oral-facial MEDEVACS were for nonbattle injuries, primarily fractures of the face bones, for the most part because of motor vehicle accidents.

Air medical evacuations of soldiers due to oral-facial disease and injuries, Operations Enduring Freedom/Iraqi Freedom.

This retrospective study was conducted to assess the nature and causes of serious oral-facial illnesses and injuries among U.S. Army personnel deployed to Iraq and Afghanistan in 2003 and 2004. Information for this study came from the U.S. Air Force Transportation Regulating and Command & Control Evacuation System database for medical evacuations (MEDEVACS) for 2003 to 2004. The study found 327 oral-facial MEDEVACS out of Iraq (cumulative incidence: 11/10,000 soldiers per year) and 47 out of Afghanistan (cumulative incidence: 21/10,000 soldiers per year), for a total of 374 MEDEVACS. Forty-two percent (n = 158) of all oral-facial MEDEVACS were due to diseases of the oral cavity, salivary glands, and jaw. Another 36% (n = 136) of oral-facial MEDEVACS were for battle injuries, primarily fractures of the mandible, caused by acts of war. Twenty-one percent (n = 80) of oral-facial MEDEVACS were due to nonbattle injuries, primarily fractures of the mandible, mainly caused by motor vehicle accidents and fighting.

Mouthguards in sport activities : history, physical properties and injury prevention effectiveness.

Three systematic reviews were conducted on: (i) the history of mouthguard use in sports; (ii) mouthguard material and construction; and (iii) the effectiveness of mouthguards in preventing orofacial injuries and concussions. Retrieval databases and bibliographies were explored to find studies using specific key words for each topic. The first recorded use of mouthguards was by boxers, and in the 1920s professional boxing became the first sport to require mouthguards. Advocacy by the American Dental Association led to the mandating of mouthguards for US high school football in the 1962 season. Currently, the US National Collegiate Athletic Association requires mouthguards for four sports (ice hockey, lacrosse, field hockey and football). However, the American Dental Association recommends the use of mouthguards in 29 sports/exercise activities. Mouthguard properties measured in various studies included shock-absorbing capability, hardness, stiffness (indicative of protective capability), tensile strength, tear strength (indicative of durability) and water absorption. Materials used for mouthguards included: (i) polyvinylacetate-polyethylene or ethylene vinyl acetate (EVA) copolymer; (ii) polyvinylchloride; (iii) latex rubber; (iv) acrylic resin; and (v) polyurethane. Latex rubber was a popular material used in early mouthguards but it has lower shock absorbency, lower hardness and less tear and tensile strength than EVA or polyurethane. Among the more modern materials, none seems to stand out as superior to another since the characteristics of all the modern materials can be manipulated to provide a range of favourable characteristics. Impact studies have shown that compared with no mouthguard, mouthguards composed of many types of materials reduce the number of fractured teeth and head acceleration. In mouthguard design, consideration must be given to the nature of the collision (hard or soft objects) and characteristics of the mouth (e.g. brittle incisors, more rugged occusal surfaces of molars, soft gingiva). Laminates with different shock absorbing and stress distributing (stiffness) capability may be one way to accommodate these factors.Studies comparing mouthguard users with nonusers have examined different sports, employed a variety of study designs and used widely-varying injury case definitions. Prior to the 1980s, most studies exhibited relatively low methodological quality. Despite these issues, meta-analyses indicated that the risk of an orofacial sports injury was 1.6-1.9 times higher when a mouthguard was not worn. However, the evidence that mouthguards protect against concussion was inconsistent, and no conclusion regarding the effectiveness of mouthguards in preventing concussion can be drawn at present. Mouthguards should continue to be used in sport activities where there is significant risk of orofacial injury.