Australian Defence Force Health Status Report

CHAPTER 5
DENTAL HEALTH AND FITNESS 5
INTRODUCTION 5.1
5.1 Dental fitness is an important aspect of personnel readiness. Personnel who are not dentally
fit when they deploy are much more likely to become non-battle casualties as a result of dental disease
which requires emergency treatment or evacuation.
5.2 The policy on Australian Defence Force (ADF) dental classification is contained in Health
Policy Directive (HPD) 402The ADF Dental Classification System. The dental classification system
indicates a members level of dental fitness based on treatment required and indicates whether they are
deployable.
5.3 Each classification recording consists of a number and the with effect date. Table 51,
extracted from HPD 402, summarises dental fitness criteria.
Note
(a) Waivers may apply (see paragraph 5 of HPD 402)
Table 51: Criteria for dental classifications
5.4 A Service members classification is reviewed after treatment and after an annual dental
examination. Personnel with a dental classification of either 1 or 2 are deemed to be deployable. Those
classed 3 or 4 require further treatment to prevent themfrombeing a dental casualty, and are considered
as temporarily downgraded. Waivers for deployability for members classed 3 or 4 can be granted by the
Force Commander, in consultation with a senior dental officer.
5.5 A classification reflects the oral condition at a particular date and must be considered
progressively less reliable with the passage of time. The method of classification is essentially based on
a risk management approach. A members dental fitness can be affected by a number of factors,
including genetics, diet, use of fluoridated water/toothpaste (particularly as a child), personal dental
hygiene, and protection from traumatic injury (eg during sport). The tendency will be toward a decrease
in fitness (or an increase in the likelihood of need for prophylactic or restorative treatment) over time, but
good oral hygiene and diet play a major role in maintaining dental fitness.
Class Meaning Amplification Deployable/Sea
Duty
1. Fully dentally fit No treatment necessary plus no
active oral disease plus adequate
home care
Yes
2. Requires treatment which could
be deferred for 12 months
Expected not to become a dental
casualty
Yes
3. Requires dental treatment
within 12 months
Routine conditions No
(a)
4. Requires early treatment As a guide, early means within
approximately one month.
Examples are ongoing RCT,
deep caries, or insertion of a
prosthesis before imminent
posting.
No
(a)
5. Unclassified Not yet classified (equates to
blank in a non-automated
system)
No
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5.6 One year is the maximum amount of time that should elapse prior to an individual receiving a
dental examination to assess the state of dental health and the need for prophylactic or restorative care.
This is based on a risk management approach. Some individuals could potentially go for longer than one
year without receiving dental care and not become a dental casualty. Others with more advanced oral
disease may need to be seen more frequently than once a year. However, the only way to determine the
specific level of deterioration in oral health is to conduct a dental examination. All personnel who are
undergoing routine dental treatment are classified as Class 3 or 4.
DATA COLLECTION AND STORAGE 5.7
Royal Australian Navy 5.7
5.7 The Royal Australian Navy (RAN) captures data for Navy personnel in the Navy Dental Fitness
database maintained by the dental clinic at HMAS KUTTABUL. Individual dental clinics submit
summaries of dental classification statistics on a monthly basis via floppy disk or email to HMAS
KUTTABUL for compilation of a monthly summary report. Data sent by mail may lead to late data entries,
which may contribute to a 510 per cent error in the reporting of dental fitness for deployability.
Army 5.8
5.8 The Royal Australian Army Dental Corps (RAADC) has published Oral Hygiene Surveys from
1982 to 1996. The last three surveys were compiled electronically on DENSYSTEM (an electronic dental
reporting system) with previous reports being compiled manually. At present it is not possible to collate
data for Army personnel centrally, with reports only being compiled at DENSYSTEM locations.
Royal Australian Air Force 5.9
5.9 Royal Australian Air Force (RAAF) dental facilities submit monthly returns on dental
classification for the members they treat. This data is entered into the AFMANS database from which a
SNODENS (developed over 20 years ago) report on dental fitness is generated. This produces a printout
indicating dental fitness of the RAAF on a unit or cumulative basis.
DENTAL FITNESS LEVELS BY SERVICE 5.10
Royal Australian Navy 5.10
5.10 Figure 51 depicts a summary of RAN cumulative dental fitness, as at December 1998, over
the last four complete calendar years. The dental fitness shown in figure 51 is in terms of percentage
of members who are dentally fit using the number of records held at RAN dental establishments.
Figure 51: Royal Australian Navy dental fitness status
% Dental Fit
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
1995 1996 1997 1998
Australian Defence Force Health Status Report
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5.11 An average of 51.2 per cent of RAN personnel for whom data is held at RAN clinics were
identified as Class 1 (dentally fit) in the period 1995 to 1998. The percentage of RAN personnel assessed
dentally fit (Class 1), increased by 16.9 per cent from 1995 to 1997. However, in 1998, the percentage
of dentally fit personnel decreased by 11.1 per cent. The RAN reporting system only reports on those
members who are Class 1 and have had an examination in the previous 12 monthsClass 2 statistics
are not captured. Although data on the frequency of dental examinations is not collected, it has been
estimated that the average time between examinations is 15 to 18 months.
Army 5.12
5.12 The RAADC Oral Health Program (OHP) aims to achieve and maintain acceptable oral health
through the cooperative efforts of dental officers, dental hygienists, and individual Service members. A
personalised one-to-one educational approach is an integral part of all completed dental treatments.
Reports from the OHP provide information on the Dental Fitness status of Australian Regular Army
(ARA) members to RAADC sub-units and commanders at all levels. Data from the last three reports are
shown in figure 52. Data from more recent reports are currently being collated and will be included in
the next Health Status Report. The following goals were set under the OHP: members receiving dental
services should exceed 90 per cent of the Army; members receiving an Annual Dental Examination
should exceed 80 per cent of the Army; and the highest dental fitness status (Class 1 or DF1) should
exceed 75 per cent of all members treated.
Figure 52: Summary of Army dental fitness from June 1994 to June 1996
5.13 It should be noted that the figures represent all members, regardless of whether they were
examined in the last 12 months. Of these, 18 per cent had not been seen by a dentist in the last
12 months, which increases the likelihood of these members becoming a dental casualty or requiring
predeployment treatment.
Royal Australian Air Force 5.14
5.14 No goals for dental fitness in the RAAF have been published, however, 90 per cent of RAAF
personnel should be dentally fit (Class 1 and 2) and no more than 10 per cent should be overdue for their
annual dental examination. A summary of RAAF dental fitness as of January 1999 indicates that at that
time, 87.2 per cent of RAAF personnel were dentally fit for deployment. A total of 10.1 per cent were not
dentally fit for deployment, and a further 1.8 per cent had not been classified. Therefore, the percentage
dentally fit for deployment was close to the goal of 90 per cent. The percentage overdue for annual
examinations was nine per cent, thus the goal of no more than 10 per cent overdue was achieved as of
January 1999.
0
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DF1 Examined in last
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DF1 Examined in
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Australian Defence Force Health Status Report
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5.15 The change in the percentage of RAAF members dentally fit over the period from July 1992 to
December 1997 is shown in figure 53. Only during a brief time (January to February 1995) was RAAF
dental deployability above 90 per cent, reaching a peak of 92 per cent. The lowest percentage of
personnel in Class 1 and 2 occurred in November 1996, when the percentage was 85.2. The sudden
rise in dental fitness in 1994 was attributed to a change in the method of defining the dental classification,
which occurred in early 1994. However, the trend since that time has been toward a slight reduction in
dental fitness despite the relaxation of dental fitness requirements for deployment.
Figure 53: Royal Australian Air Force members dentally fit to deploy from 199297
5.16 Figure 54 depicts the trend in RAAF personnel who are overdue for annual assessment. The
high value in early 1998 was attributed to an administrative change in the method of data call-up, which
did not truly reflect the overdue status.
Figure 54: Proportion of Royal Australian Air Force personnel overdue for annual examinations
RAAF Dental Fitness Levels
85.0
86.0
87.0
88.0
89.0
90.0
91.0
92.0
93.0
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Australian Defence Force Health Status Report
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5.17 Periodontal status. The ADF Periodontal Assessment (ADFPA) provides clinicians and
planners with a guide to periodontal treatment requirements for individuals and groups.
HPD 409Australian Defence Force Periodontal Assessment, summarises policy for the ADFPA.
ADFPA categories correspond to periodontal treatment needs as shown in table 52. The ADFPA is a
modified version of the World Health Organisation Community Periodontal Index of Treatment Needs.
Data on the ADFPA was presented in the 1996 OHP Survey and is summarised in table 52. The large
percentage of ADF members requiring plaque control, oral hygiene instruction and professional tooth
cleaning, is indicative of the requirement for dental hygienists in the ADF to maintain dental health.
Table 52: Summary of periodontal assessment results for Army and Royal Australian Air Force
personnel for December 1996
5.18 Qualitative indicators. In addition to the quantitative data presented above, the Army OHP
surveys in 1995 and 1996 used the Soldier Attitude and Opinion Survey and the Officer Attitude and
Opinion Survey questions regarding satisfaction with dental care received, as a qualitative indicator.
Results from the 1994 surveys (captured in the 1995 OHP survey) showed at least 90 per cent of ARA
members indicated that the standard of dental care provided by the Army was good, and only five per
cent indicated it was not good. Results from the surveys in 1995 (captured in the 1996 OHP survey)
showed at least 87 per cent of ARA members indicated that the standard of dental care provided in the
Army was good, and less than five per cent indicated that it was not good.
BENCHMARKING 5.19
Comparison with other military forces 5.19
5.19 As previously discussed, the dental classification system used by the ADF is focused on dental
fitness for deployability. Therefore, such a system would only have relevance within a military context.
No data regarding dental fitness levels in other countries was gathered for this report. However, given
that similar systems are used in other military forces, it may be worthwhile for future ADF Health Status
Reports to contain a comparison with dental fitness in other defence forces.
ADFPA
Category
Periodontal Treatment Required RAN
(No stats
available)
ARA
(Dec 96)
RAAF
(Dec 96)
A No need for periodontal treatment 24 15.7
B Plaque control measures including
improvement in personal oral hygiene and
dietary practices
76 17.7
C As for B plus professional tooth cleaning
and removal of overhanging restoration
margins
55 59.4
D As for C plus complete periodontal
charting and likely to involve root planing
and recall appointments
4 3.8
E As for D plus likely to involve deep scaling,
root planing, specialist referral and complex
surgical procedures
<1 0.8
N Edentulousno periodontal treatment
needed
U Uncategorised
Australian Defence Force Health Status Report
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To Australian population 5.20
5.20 Australias Health 1998
1
provides a summary of oral health for Australians. However, the main
measures of oral health presented are the number of decayed, missing, and filled teeth in the permanent
dentition index and the prevalence of edentulism (total tooth loss). These indicators of oral health are not
useful from a military perspective where fitness for deployment is of primary concern. The dental health
of Australian children has clearly improved over the last 20 years with children experiencing less dental
caries. Oral health gains in children have been associated substantially with exposure to fluoride through
both water fluoridation and use of fluoride toothpaste. Capital cities in Australia began to fluoridate water
in 1964 and between that time and 1971, six of the capital cities introduced water fluoridation. Melbourne
was not fluoridated until 1977. Brisbane and most locations in Queensland still do not fluoridate public
water supplies. Improvements in children are obviously the starting point for improvements in the oral
health of adults, however, there are indications that the only improvement in adults in recent years has
been the reduction of the number of missing teeth. One study
2
indicated a three fold increase in caries
experience from a group of 12 year olds to a group aged between 18 and 24 years. This latter group is
from where the ADF draws its recruits.
Strategies for improvement and prevention 5.21
5.21 Dental fitness is achieved and maintained by a combination of professional services, personal
oral hygiene, and a balanced diet. Methods of increasing dental fitness levels for deployment are
increasing the number of hours of professional dental services being provided to ADF members, and
increasing the number of dental staff to facilitate the delivery of dental services. To ensure Service
personnel have their dental fitness maintained at an optimal level, measures need to be taken to ensure
all members are examined annually, and receive treatment in a timely manner.
5.22 Dental hygienists play an important role in maintaining the periodontal health of ADF
personnel. Periodontal assessments for the RAAF and Army indicate that a high proportion of ADF
personnel will require periodontal treatment each year. In addition to prophylactic treatment services,
dental hygienists play an important role in training personnel on how to achieve better oral hygiene.
5.23 There is no common dental fitness database within the ADF, although such a system is
currently being sought. There is no reason to have separate systems for each Service. A common
database would operate more efficiently and allow direct comparisons between the Services. However,
the current Personnel Systems for the three Services make this difficult to achieve.
CONCLUSIONS 5.24
5.24 Approximately half of RAN personnel are classed as being dentally fit for deployment. The
Army and RAAF have approximately 87 per cent of their personnel classed as dentally fit for deployment.
However, the figures cannot be compared due the differences in reporting.
5.25 In the most recent surveys, 18 per cent of Army personnel had not been seen for an
examination or treatment in the previous 12 months. As at January 1999, the RAAF reported that
nine per cent of personnel had not had an annual dental examination in the previous 12 months. These
figures would actually reduce the number of personnel considered dentally fit in the Army and RAAF.
However, although a member is classed dentally unfit, this is only temporary in nature, as most
personnel who are Class 3 or 4 can be made dentally fit in a short period of time.
5.26 The Army is the only Service to have published goals for dental fitness and the proportion of
personnel receiving annual dental examinations. The Army has been able to meet most of its goals,
however the goal for annual dental examinations has rarely been achieved.
5.27 The RAN database does not record information on a member's periodontal health. The Army
database currently cannot collect data globally, however data can be collected at individual dental
facilities. An earlier RAAF database was not Y2K compliant and has been discontinued. A replacement
database will be developed into the tri-Service HEALTHKEYS project for data collection.
1 Australias Health 1998, Australian Institute of Health and Welfare, p 128.
2 Commonwealth Dental Health Program Evaluation Report 199498.
Australian Defence Force Health Status Report
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5.28 The major ways to increase dental fitness for deployment are to increase provision of dental
services, increase dental staffing to facilitate this, and/or develop better procedures to ensure that ADF
personnel receive dental examination and treatment in a timely way.
5.29 Detailed data on dental emergencies in the National Support Area and during deployments are
not readily available. Such data would be an important means of assessing the adequacy of dental risk
management in the ADF.