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J Am Dent Assoc, Vol 137, No 11, 1582-1591.
© 2006 American Dental Association
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TRENDS

Dental caries risk in the U.S. Air Force



Joseph A. Bartoloni, DMD, MPH, Susan Y. Chao, MS, Gary C. Martin, DDS, MPH and Gerard A. Caron, DMD


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. This study describes the dental caries risk in the active duty U.S. Air Force population from October 2000 through September 2004.

Methods. The authors used data collected from two Air Force databases (personnel and dental files) by cross-referencing Social Security numbers from both databases with date.

Results. During the study period, the percentages of people at high and moderate risk of developing caries decreased by 31 percent and 12 percent, respectively, while the percentage of people at low risk of developing caries increased by 9 percent. Among Air Force members who were enrolled continuously during the study period, the percentages at high and moderate risk of developing caries decreased by 57 percent and 18 percent, respectively, while the percentage at low risk of developing caries increased by 14 percent. The authors observed improvement in caries risk in 83 percent and 73 percent of the people at high and moderate caries risk, respectively, for those continuously enrolled. High caries risk was related inversely to age, rank, education and years in service. Also, tobacco users had an elevated risk of developing caries.

Conclusions. The Air Force Dental Service has made great strides in improving the oral health of the Air Force population. The results of this study suggest that caries risk is decreasing in the Air Force population, but oral health disparities still exist and require further evaluation.

Clinical Implications. This investigation suggests that a caries risk assessment can be conducted successfully, and caries risk can be reduced by using a comprehensive population-based prevention program. This caries risk assessment also can identify factors associated with dental caries disparities in a large-scale population.

Key Words: Dental caries; caries risk assessment; military dentistry

Dental caries is a transmissible, reversible, diet-and time-dependent multifactorial bacterial disease of the oral cavity that affects people of all ages. It is the most common childhood ailment, and it continues to be a widespread, chronic disease for adults in the United States. Approximately 91 percent of dentate adults 20 years or older have experienced dental caries. The prevalence of dental caries among adults 20 years or older is continuing to decline, but the disease still affects a majority of the population and has potentially serious health outcomes.1 This disease can be reduced when science-based preventive measures are applied appropriately. The most cost-effective methods are community- or population-based.2

Many dental experts are recommending that dental providers perform a caries risk assessment (CRA) to allow for an appropriate level of prevention and treatment.3–8 Since the introduction of the CRA in the 1980s,9,10 several authors have investigated this important public health issue further. Powell11 reviewed multifactorial prediction models for adults and children, identifying the most successful and consistent methods. Bader and colleagues12 demonstrated that dentists can attain reasonable levels of reliability using a CRA. Zero and colleagues13 systematically reviewed the clinical evidence to determine the predictive validity of available multivariate CRA strategies. Bader and colleagues14 showed in a pilot study that a formal, caries risk–based prevention can be accomplished in dental offices. They showed that patients classified as being at elevated risk had received more disease-related treatment than had patients at low risk, which provided some validation for the accuracy of risk assessment. Recently, Bader and colleagues15 provided the first large-scale, generalizable evidence for the validity of dentists’ subjective assessment of caries risk.

In 1999, the Air Force Dental Service (AFDS) began collecting Dental Population Health Metrics (DPHM) during the mandated annual or periodic dental examination of all patients at U.S. Air Force dental treatment facilities. This included a CRA, a periodontal screening and recording score, and tobacco-use documentation. Each dental clinic recorded this information on a patient treatment form and forwarded these data to a central database for consolidation and report generation. The purpose of the DPHM was to facilitate understanding of the health needs of the population and improvement of the health of the Air Force population by guiding dental clinicians to use more effective preventive strategies in their practices. The AFDS senior leadership felt the collection of these data was the key to prioritizing limited resources to the oral health problems determined to be the most important. The overall strategy was to allow for efficient disease management with an emphasis on prevention, resulting in decreased percentages of the population with disease, thus decreasing costs. Analyzing these data over time would allow the Air Force to measure general oral health improvement. The goal was to raise the oral health and dental readiness of the Air Force population.

Matching prevention strategies to people at risk of developing caries can reduce unnecessary preventive services for people at low risk.

A significant component of the DPHM is the consistent performance of a CRA on all patients. The CRA performed by the Air Force is based on the American Dental Association (ADA) recommendation that dental providers should manage patients according to their risk of developing caries.16 The ADA suggested classifying patients into low-, medium- and high-risk categories. A special supplement to The Journal of the American Dental Association emphasized that dental caries was a chronic, infectious, multifactorial disease process, and that patients should be evaluated routinely for the presence or absence of risk indicators for the disease process.16 The CRA increases the likelihood of predicting future caries, identifying patients or groups that may benefit from prevention and identifying early stages of disease. In this manner, prevention and a treatment plan would be formulated that could vary according to the risk estimates. The assessment can increase the efficacy and efficiency of preventive interventions.17 Patients or groups identified as being at high risk of developing caries would be prescribed a more intense prevention program, potentially achieving a clinically significant impact. Matching prevention strategies to people at risk of developing caries can reduce unnecessary preventive services for people at low risk. The ADA emphasized that targeting interventions has implications for the costs of services to patients, employers and publicly supported programs. Individualized "risk-based" approaches to caries prevention are justified scientifically given current caries patterns.

The purpose of our investigation was to describe the dental caries risk of active duty Air Force (ADAF) members from October 2000 through September 2004 (fiscal year 2001 [FY01] through FY 2004 [FY04]) across selected demographic variables. Previous studies have shown that demographic variables are associated with dental caries, and discrepancies exist in oral health status based on demographic variables.18–20


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We obtained data for our study by cross-referencing two databases: the ADAF monthly dental files provided by the Population Health Support Division, Brooks City-Base, Texas, and the ADAF monthly personnel files provided by the U.S. Air Force Personnel Center, Randolph Air Force Base, Texas. We included ADAF members who had an annual dental examination within a study year (FY01, fiscal year 2002 [FY02], fiscal year 2003 [FY03] or FY04) in that year’s analysis. For people with multiple dental records within a year, we used results from the last examination. Thus, we constructed a sample consisting of one record per person for each of the study years (annual samples).

We used dental files as the source for caries risk (high, moderate, low) and tobacco-use status (nonsmoker, smokeless tobacco user, smoker, smoker using smokeless tobacco). We used personnel files as the source for sex (male, female), age (< 20, 20–24, 25–29, 30–34, 35–39, 40–44, ≥ 45 years), rank group (junior enlisted, E1–E4; senior enlisted, E5–E9; junior officer, O1–O3; senior officer, O4–O10), education level (high school graduate, attended college, college graduate), race (white, black, other), marital status (married, not married), years of military service (≤ 4, 5–8, 9–12, 13–16, 17–20, > 20) and career field (flyer, nonflyer).

To assess within-person changes in caries risk over the study period, we constructed a cohort consisting of ADAF members who had an annual dental examination in each of the four study years (four-year cohort). We performed separate analyses on the four annual samples and the four-year cohort. For the annual samples we performed analyses to determine the distribution of caries risk by year and by demographic characteristics and tobacco-use status. For the four-year cohort, we performed additional analyses to assess the change in caries risk within each person over time. We evaluated significance of the change using the Bhapkar test at {alpha} =.05 level.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Sample sizes ranged from 273,145 ADAF personnel in FY01 to 336,141 in FY04 (total ADAF personnel size ranged from 349,842 to 378,502, respectively), indicating an increase from 78 to 89 percent in the percentage of ADAF members with records in the dental database. This increase probably was due to gradual improvement in data collection in the dental data system.

Since the study samples represented approximately 80 to 90 percent of all ADAF members, we compared demographic characteristics of each year’s sample to those of the mid-year ADAF population to assess the generalizability of the study sample. We observed similarities in demographic characteristics between the study sample and mid-year ADAF population in each of the four study years. Since the results of the comparison were similar among the four study years and the demographic composition in ADAF personnel was stable over the study years, we present only distributions from FY04 (Table 1Go). The majority of the sample was white, male, younger than 30 years and had attended college. A little more than one-fourth of the sample used tobacco products. We did not include tobacco-use status for the ADAF population because it was not available in the personnel files.


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  		TABLE 1 Demographic characteristics and tobacco-use status for study sample with comparison to mid-year FY04* ADAF{dagger} population.

 
Figure 1Go (page 1586) summarizes the distribution of caries risk from FY01 through FY04. Over the four-year study period, the percentages of people at high and moderate risk of developing caries declined steadily from 11.0 to 7.6 percent and from 19.7 to 17.3 percent, respectively, while the percentage of people at low risk of developing caries increased from 69.2 to 75.1 percent.


Figure 1
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  		Figure 1. Distribution of caries risk from fiscal year (FY) 2001 through FY 2004.

 
We selected high caries risk from among the three risk categories to show the results by year and demographic characteristic (Table 2Go, page 1587). Among the demographic characteristics and tobacco-use status variables, we selected age and tobacco-use status to show distributions for all three caries risk categories (Figure 2Go and Figure 3Go, page 1588).


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  		TABLE 2 Percentage of patients at high risk of developing caries risk, by year, demographic characteristics and tobacco-use status.

 

Figure 2
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  		Figure 2. Distribution of caries risk fiscal year (FY) 2001 through FY 2004 by age group. L: Low risk. M: Moderate risk. H: High risk.

 

Figure 3
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  		Figure 3. Distribution of caries risk fiscal year (FY) 2001 through FY 2004 by tobacco-use status. L: Low risk. M: Moderate risk. H: High risk.

 
As shown in Table 2Go, we observed a downward trend in high caries risk in the overall sample in demographic groups. In addition to the downward trend in percentage of high caries risk over the study period, for most demographic characteristics the percentage also varied substantially across subgroups. The only two demographic characteristics that showed similar results across subgroups were sex and race. Higher percentages of people at high risk of developing caries were found in groups with younger age, lower rank, less education, fewer years in military service, unmarried people, tobacco users and nonflyers. Demographic and tobacco-use status groups that were consistent with more than 10 percent of people at high caries risk over the study period were people younger than 25 years, junior enlisted members, high school graduates, unmarried people, and smokers and smokers using smokeless tobacco, in addition to people who had less than four years of military service.

Figure 2Go shows that distributions for the last four age groups (older than 29 years) were similar. Changes over time within these groups were more prominent than changes across age groups. Among the first four age groups (younger than 35 years), we observed steady rises in the percentage of people at low risk and decreases in the percentage of people at high risk, both over time and across age groups.

In addition, Figure 3Go revealed that tobacco-use status also was associated with high caries risk. Compared with non-smokers, the percentage of low caries risk was lower and the percentage of high caries risk was higher in any of the three tobacco user groups throughout the study period. Among the three tobacco user groups, smokers using smokeless tobacco had the highest percentage of people at high risk of developing caries and the lowest percentage of people at low risk.

Demographic distributions of the four-year cohort in FY01 were similar to those of the FY01 annual sample. However, since people in the four-year cohort were older in FY04 than they were in FY01, distributions of those demographic characteristics affected by age progression (for example, rank, education level, marital status and years of service) changed in the four-year cohort and differed from the distributions in the FY04 annual sample. In FY04, there were higher percentages of older, higher-ranked, college-educated and married people in the four-year cohort than in the annual sample. All of the people in the four-year cohort also had been in the Air Force for at least four years by FY04.

Figure 4Go (page 1588) shows the distribution of caries risk in the four-year cohort over the study period. Compared with the annual sample results shown in Figure 1Go, we observed a similar downward trend in high and moderate caries risks and an upward trend in low caries risk in the four-year cohort; however, the changes over time were more prominent in the four-year cohort. The distributions of caries risk in the FY01 annual sample and the four-year cohort in FY01 were similar (approximately 69 percent at low, 20 percent at moderate, and 11 percent at high). In FY04, however, the percentage of people at high risk of developing caries was lower (4.8 percent versus 7.6 percent) and the percentage of people at low risk was higher (79.2 percent versus 75.1 percent) in the four-year cohort than they were in the annual sample.


Figure 4
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  		Figure 4. Distribution of caries risk fiscal year (FY) 2001 through FY 2004 for the four-year cohort.

 
We found a significant change (P <.05) in the distribution of caries risk from FY01 through FY04 in the four-year cohort (Table 3Go, page 1589). The majority of people at moderate or high risk of developing caries in FY01 showed improvement in FY04. Among the people at low risk in FY01, 84.4 percent remained at low risk in FY04, and 15.6 percent had elevated risk in FY04.


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  		TABLE 3 Changes in caries risk from FY01–FY04* for the four-year cohort.

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
During this study period, caries risk in the Air Force decreased. These results could be due to the general trend of reduced caries prevalence in the United States or to dental population health improvement approaches in the Air Force. The additional reduction seen in the four-year cohort in FY04, as compared with the reduction in the annual samples from FY01 through FY04, could be due to the changes of those demographic characteristics affected by age progression in the four-year cohort. The higher percentage of older, higher-ranked, more college-educated and married people in the four-year cohort in FY04 was associated with a lower prevalence of caries risk. Furthermore, all the people in the four-year cohort had been in the Air Force for at least four years and, thus, had received at least four years of dental treatment from the Air Force by FY04. While it is beyond the scope of this study to examine how much of the reduction seen in the annual samples was due to a general trend and how much of the additional reduction seen in the four-year cohort was due to changes in demographics, we believe that the extensive efforts of the entire AFDS played an important role in the caries risk reduction within-person and across the Air Force over the study years. These efforts included AFDS senior leadership’s support of population health principles including CRA, periodic inspection of preventive dentistry programs at all Air Force dental clinics by the Air Force Inspection Agency, comprehensive training provided to dental providers and technicians, and local dental clinic health promotion activities.

The AFDS senior leadership implemented the collection of DPHM in 1999. AFDS leadership assigned an American Board of Dental Public Health–certified ADAF public health dentist (J.A.B. and a predecessor) to this task, and the dentist developed a comprehensive program that involved data collection and report generation. Each month, all dental treatment facilities receive an updated listing of their patients who are at high risk of developing caries to aid in prevention, intervention and treatment. This expedites care for patients at the highest risk, ultimately improving dental readiness in the Air Force. The AFDS believes the benefits of this program include providing a healthy, fit and ready force; improving the health status of the Air Force population; and managing an effective and efficient health care delivery system.

The Air Force Inspection Agency periodically inspects every Air Force dental clinic. This agency is responsible for internal investigatory oversight and evaluation of all Air Force operations, including dental and medical operations.21 This independently assigned group represents the eyes and ears of the senior leadership in the Air Force. Its goal is to answer the question "How are we doing?" Dental inspectors work in close coordination with surveyors from the Joint Commission on the Accreditation of Healthcare Organizations to evaluate the performance and compliance of all aspects of Air Force health care operations via on-site surveys. This includes a complete review of each dental clinic’s preventive dentistry program. On completion of the inspection, each clinic receives a written report of positive and negative findings. The dental clinics use the information to further improve care over time. The Air Force Inspection Agency also has published on its Web site specific components of outstanding caries management programs to assist dental clinics in the proper management of the patient at high risk of developing caries.

The AFDS provides nearly 22,000 hours of dental officer and dental technician continuing education every year,21 which includes the U.S. Air Force Preventive Dentistry Course. This course is offered annually and provides cutting-edge knowledge on the latest in dental public health, including managing the care of patients at high risk of developing caries. Dental providers are trained in early diagnosis, prevention, timely intervention and conservative treatment as part of the U.S. Air Force Preventive Dentistry Course. From FY01 through FY04, approximately 10 percent of dental officers attended the U.S. Air Force Preventive Dentistry Course.

Each Air Force dental clinic is responsible for developing a program for treating its patients at high risk of developing caries; monitoring this program development is part of the inspection process by the Air Force Inspection Agency. After identifying patients who are at risk, each clinic offers these patients the added benefits of entering a high caries-risk program established at each facility. Dental providers trained to treat the patients at high risk of developing caries use the medical model for treating bacterial infection.22 This model involves the use of intensive measures that are applied more rigorously than for a preventive regimen. Treatment is short-term and intense and is carried out to a defined endpoint.8 Caries control measures include patient education, oral hygiene instruction, diet counseling, restorative procedures, and use of sealants, fluorides, xylitol and chlorhexidine. The dental provider tailors scheduled recall appointments to the patient due to variations in rate of caries advancement and presence of caries risk factors. The boxGo (page 1589) shows a sample protocol for the patient at high risk of developing caries.


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  		BOX Sample protocol for the patient at high risk of developing caries.

 
Dental population health principles are taught yearly at several intermediate and senior leadership symposiums to reinforce the need for preventive dentistry support at the dental clinic level. Dental public health policy issues and updates also are provided annually in a dental public health newsletter that is distributed to all Air Force dental clinics. Overall, the goal of Air Force continuing education programs is to ensure that patients receive the best quality care possible from highly trained dentists and technicians to support dental readiness and operational missions.

Each dental clinic is responsible for developing its own health promotion policies based on the monthly DPHM received; this also is inspected by the Air Force Inspection Agency. Some examples of these health promotion activities include giving presentations on caries risk and prevention, oral health and tobacco use, promoting the proper use of protective mouthguards to newly assigned younger personnel, having scheduled fluoride days and publishing articles on dental caries in the local Air Force base newspaper.

Other findings from our investigation showed that high risk of developing caries was inversely related to age, rank, education and years in service. We also found that tobacco users have an elevated risk of developing caries. These findings are connected closely to each other in this population. We found high risk of developing caries to be more prevalent in junior enlisted troops who tend to be younger, have less education and are new to the Air Force. Our finding agrees with those of Sgan-Cohen and colleagues,23 who noted disparities in caries experience by age, education and military rank in the Israeli military personnel. Szmyd and McCall24 in 1960 found a trend that continues today: the younger the Air Force recruit, the greater the need for restorative care, and people who enter the Air Force need more dental care than do civilians of the same age. Caries risk for many of the younger Air Force members probably relates to the level of dental care that they received before entry into the military. Hyman25 found in a U.S. Navy population that most restorative work included lesions present at the time of entry into the service. On a positive note, caries risk in our study was reduced for those who had extended time in the service. This probably is due to the cumulative effect of mandatory periodic dental examinations and comprehensive dental treatment performed by military dentists.

It appears that caries risk status probably is influenced heavily by the socioeconomic status (SES) of personnel before they enter military service. Graves and Stamm26 stated that SES had a strong influence on the tendency of populations to seek care, with SES inversely related to caries experience. Graves and Stamm stressed that the caries experience of military populations is not representative of the U.S. population. They believe the military population has a somewhat lower SES and includes a higher proportion of minorities and men than does the civilian population. Compared with the U.S. general population estimates from 2004,27,28 our sample had a significantly higher proportion of men (80.2 percent versus 49.2 percent), a similar proportion of whites (79.9 percent versus 80.4 percent), a slightly higher proportion of blacks (16.5 percent versus 12.8 percent) and a slightly lower proportion of other races (3.5 percent versus 6.8 percent). Several authors have shown that there was an increase in caries experience with decreasing SES in military recruits worldwide.29–31 Interestingly, our sample comparing results from FY01 through FY04 showed a 39 percent, 26 percent and 53 percent decrease in high-risk caries status across the three education categories (high school, attended college, college graduate), respectively, and virtually no difference due to race (Table 2Go).

Our findings indicated that patients who use tobacco products were at higher risk of developing caries; this finding coincides with those of other studies32–35 that showed an association between tobacco-use status and dental caries. Interestingly, tobacco use was most prevalent among young enlisted troops in our study. This finding may be due to smokers’ lack of routine oral hygiene or placing less value on general health,36 which also may have contributed to the finding that the youngest age groups showed the smallest degrees of improvement (that is, positive change) during the four years of the study (Figure 2Go).


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Our study suggests that the risk of developing caries is decreasing in the Air Force, indicating a gain in oral health. It is critical that the AFDS understand the dental caries risk of its population to aid in understanding disease pattern variations and to offer opportunities to prevent disease and reduce population differences. The Air Force’s dental public health policy and planning require accurate and current information about the extent of dental caries risk because most dental emergencies in the military—both when personnel are in the U.S. and when they are deployed—are due to caries,37–40 which can significantly affect combat effectiveness and worldwide capabilities for deployment on short notice. The prevention and treatment of dental caries is essential to maintaining the Air Force’s war-fighting capability while preserving dental readiness.

The AFDS faces similar challenges as does civilian dentistry, including too few providers, rising costs and reduced access. The Air Force needs to be more efficient when treating patients owing to downsizing, limited resources and spiraling costs. The CRA emphasizes minimum intervention, proven methods of prevention and remineralization therapy, which can improve oral health and increase dental readiness, thus potentially shifting resources to other areas of the dental support mission.

The AFDS would like to prevent dental disease in the most rational manner given the disease challenges of today and believes the use of the CRA will provide for greater efficiency of dental care in terms of outcomes for money, resources and time. The CRA is essential if Air Force dental care providers are to practice efficacious and cost-effective caries prevention. Owing to changing disease patterns, Air Force dental care providers, however, need to modify practice decisions using the CRA to ultimately improve oral health.

The AFDS feels that the risk-based approach is a sound public health strategy that targets preventive and interceptive care to patients who are at risk, which potentially can reduce Department of Defense expenditures. The key is for the Air Force to use the DPHM to better educate patients who are receiving care to improve their oral health attitudes and behavior and to deliver to them more timely interventions. Air Force dental providers also need to deliver a concise message to each patient during the dental examination. This can be done by discussing the patient’s oral health problems, including tobacco use, and relating these issues to future health consequences that could have a major public health impact in the Air Force. We hope that emphasizing optimal oral health will reduce further the need for restorative dentistry and will result in a shift to diagnostic and preventive services, which may reduce the oral health burden of the Air Force.

Oral health disparities remain in the Air Force despite improvements in dental health; some ADAF members still have a disproportionate amount of dental caries. These differences require further evaluation, and additional studies are needed to confirm the trends we noted in our study. The major limitations of our investigation were lack of calibration among the dental clinicians performing the CRA and the lack of reliability and validity studies of the CRA in the Air Force population. These limitations also will require further study.


   FOOTNOTES
 

Dr. Bartoloni is a colonel, U.S. Air Force Dental Corps, and was the dental public health consultant, Population Health Support Division, Brooks City-Base, Texas, when this study was conducted. He now is the director, USAF Dental Processing Center, Lackland AFB, Texas. Address reprint requests to Dr. Bartoloni at 1993 Waterstone Parkway, Boerne, Texas 78006, e-mail "bartoloni{at}gvtc.com".


Ms. Chao is the biostatistician, Population Health Support Division, Brooks City-Base, Texas.


Dr. Martin is a colonel, U.S. Air Force Dental Corps, and is the senior consultant for dentistry to the assistant secretary of defense for health affairs, Tricare Management Activity, Falls Church, Va.


Dr. Caron is a colonel, U.S. Air Force Dental Corps, and is the chief, Dental Policy and Operations, Office of the Air Force Surgeon General, Bolling Air Force Base, Washington.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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