STATEMENT OF THE AMERICAN DENTAL ASSOCIATION TO THE SUBCOMMITTEE ON DEFENSE COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE ON SUPPORT OF DENTAL AND ORAL HEALTH-RELATED PROGRAMS IN THE DEPARTMENT OF DEFENSE
SUBMITTED BY JAMES B. BRAMSON, D.D.S. EXECUTIVE DIRECTOR
MAY 5, 2004
Good morning, Mr. Chairman and members of the subcommittee. I am Dr. James Bramson, Executive Director of the American Dental Association (ADA), which represents over 149,000 dentists nationwide. As of September 30, 2003, there were 3,126 dentists in the military services. Thank you for the opportunity to testify to discuss appropriations for Department of Defense dental and oral-health related programs. My primary purpose today is to bring to your attention programs that directly relate to the dental readiness of our men and women in uniform and the efforts being made to achieve and maintain their dental health.
The Public Health Service’s first study of the military draft in World War II determined that more than 20 percent of the two million selectees did not meet Selective Service dental requirements. At the time of Pearl Harbor, “dental defects” led all physical reasons for rejection of recruits. Dental disease today continues to have an impact on military deployment in the Global War On Terrorism. General Peter J. Schoomaker, Army Chief of Staff, testified before the Senate Armed Services Committee on November 19, 2003 and stated “…quite frankly we [have] real problems in dental readiness…” as he discussed the rotation of troops and the activation of Army Guard and Reserve personnel. The DoD’s 2002 Survey of Health Related Behaviors Among Military Personnel reported that 34 percent of military personnel on active duty required dental care prior to deployment. What isn’t said in the report is whether the dental care was completed prior to deployment and whether the treatment was of a temporary nature.
An abscessed tooth may be one on mankind’s most painful experiences. While most Americans have been fortunate enough to have never experienced a toothache, those who have know that there is little else that one can think about when it happens. Imagine that toothache in a combat zone, or while flying a fighter, or in a submarine. The ADA is concerned that too many soldiers, sailors, airmen and marines are being deployed at risk for these problems - not only because of the unnecessary pain they may have to endure but also the impact of that pain on their ability to complete their mission.
Funding for Dental Readiness
Since the late 1990s, the dental corps have had difficulty in recruiting and retaining dental officers. One reason is the pay differential between uniform and civilian dentists. The Center for Naval Analysis Health Professions Retention-Accession Study I stated that: “…the uniformed-civilian pay gap in 2000 dollars was substantial, averaging $69,000 per year for general dentists and $113,000 per year for specialists…” A second reason is student loan debt. Many junior officers carry more than $100,000 (the national average is $116,000) in loans. Without loan repayment, dentists have a hard time making monthly payments on an 03’s pay. The result is that all the dental corps are operating below their authorized manpower levels. The Department of Defense reported that all three services are below strength by almost 12 percent (September 2003). This figure masks the fact that over the past few years unfilled dental officer authorizations are often transferred to other medical officer corps.
This comes at a time when dental care needed by the troops has not substantially decreased. In fact, with the activation of Guard and Reserve personnel, the demand has increased. As a result of these demands there has been a substantial increase in payments, in the millions of dollars, to private practice dentists paid through the Military Medical Support Office at Great Lakes Naval Training Center (primarily for active duty personnel) and the Federal Strategic Health Alliance Program known as Feds-HEAL (for activated Guard and Reservists). In FY 2000, the military purchased $13 million of dental care for active duty personnel. That account is projected to reach $49 million in FY 2004. While some of this additional expense is a result of the activation of Guard and Reserve personnel, a significant portion of these expenses is a direct result of the reduction of dental officers required to maintain the dental readiness of the active duty members. The ADA is aware that the issue of recruiting and retention special pays and bonuses has been studied within the Department of Defense, but currently nothing is being developed in response to these previous reports.
The ADA believes it is time to address dental officer authorizations before the damage to the military dental corps reaches a crisis level. We, therefore, recommend additional targeted funding for Health Professions Scholarship Program (HPSP) dental scholarships to attract new dentist recruits. This additional funding could also be used for loan repayment to retain current military dentist as allowed by law.
Military Dental Research
The Army first began formal dental research with the establishment of the Army Dental School in 1922, which was a precursor to the establishment of the US Army Institute of Dental Research in 1962. The Navy Dental Research Facility at Great Lakes was established in 1947, which subsequently became the Naval Dental Research Institute in 1967 (now known as the Naval Institute for Dental and Biomedical Research). In 1997, both activities were co-located at Great Lakes as a result of the Base Realignment and Closure activities of 1991. These research programs share common federal funding and a common goal to reduce the incidence and impact of dental diseases on deployed troops. This is unique research that is not duplicated by the National Institutes of Health or in the civilian community.
The Army focuses on improving materials to protect the troops, not only from the effects of oral disease but also from injury or hostile fire. Almost half of the injuries reported in Iraq and Afghanistan are head, neck and eye trauma. Army researchers are developing a lighter, thinner anti-ballistic face shield to replace the current headgear that weighs almost 8 pounds and is hot to wear. This is analogous to the development of the lighter and more effective body armor currently being used by our ground troops in Afghanistan and Iraq.
Plaque-related oral disease, including trench mouth, account for as much as 75 percent of the daily dental sick call rate in deployed troops. Even soldiers who ship out in good oral health can become vulnerable to these severe gum diseases if stationed in combat areas where access to good oral hygiene is difficult. An easy and cost effective way to address these conditions is the development of an anti-plaque chewing gum, which could be included in every meals ready to eat (MRE) or mess kit.
For troops stationed in desert combat zones, dehydration is a serious problem. Often the soldier is not aware that there is a problem until he or she is debilitated, obviously not a good thing in a hostile environment. The Army researchers have been working on developing a sensor to monitor hydration rates that could be bonded to a soldier’s tooth. Health care personnel at a remote site could monitor the sensor and alert the deployed forces to administer fluids before the situation becomes critical.
Navy research focuses more on the immediate delivery of dental care. For instance, keeping the war fighter in the field is a high priority. Navy researchers are developing dental materials that are more compact and portable, that can be used by non-dental personnel to manage a wide variety of urgent dental problems. Last year in Iraq, a Marine line commander in the field had to have a temporary filling replaced 3 or 4 times. This required a trip to a field dental clinic and the services of a dentist, taking this commander away from his troops. A new dental material being developed by the Navy will allow a corpsman to replace these temporary fillings on the spot and without the need for the commander to spend time away from his troops and the mission. A lesson learned from this situation is that the currently available dental materials are not strong enough for the field environment, especially the desert climate. More research is needed to perfect this far-forward field dental dressing, but once perfected, it can be used by other agencies like NASA or the Indian Health Service, which also operate in remote areas.
Naval researchers have continued to make progress on the development of rapid, hand-held, non-invasive salivary tests for the detection of military relevant diseases, such as tuberculosis and dengue fever, as well as for biological warfare agents. A prototype model of such a hand-held unit developed by the Navy researchers at Great Lakes is being tested. This unit will be able to test for numerous chemical and biological agents and provide troops in the field a positive or negative determination within a matter of minutes. The implications for Homeland Security are quite obvious.
Last, but not least, the Iraqi war environment has identified an additional research area: the effects of sand on dental equipment. The unique composition of the sand in Iraq has caused dental equipment to break down and fail in the field. Because the sand in Iraq is stickier and more like talcum powder than grittier American sand, the Iraqi sand tends to cling to instruments and equipment. Navy researchers are analyzing the effects of the Iraqi sand on the portable dental equipment with the goal of developing new mobile delivery systems that can be used in the desert environment. This research has obvious implications for medical equipment or any equipment that is easily fouled by the desert sands.
These are just a few of the dental research projects being conducted at the Great Lakes facility. All have a direct relationship to combat medicine, are targeted to improve the oral health of deployed personnel and can lead to enormous cost savings for forces in the field. Furthermore, while the Army and the Navy do not duplicate the research done by the National Institute of Dental and Craniofacial Research, many of their findings will have implications within the civilian community or other Federal Agencies. The ADA strongly recommends that the funding for the Army and Navy dental research activities at Great Lakes be funded at $6 million to expedite this research for the deployed forces.
Other Military Dental Appropriations Issues
There are two other matters that the ADA would like to bring to the Committee’s attention and are related to issues discussed during the Committee’s April 28th hearing with the Surgeon Generals. First, we are concerned about the dental care for our returning troops through the Veteran’s Administration. Following Desert Storm deactivated Reserve and Guard personnel were authorized a dental benefit upon separation. Fortunately, both the length of the Gulf War and the need for activating Reserves and Guard were limited. Approximately $17 million was spent to provide this dental care. Once again, the Veteran’s Administration is anticipating that a significant number of returning Reservists and Guard personnel will require and be authorized dental care upon their release from active duty in the Global War on Terrorism. And since the Reserve and Guard activations are projected to remain significant for the foreseeable future, then the demand for dental care following deactivation will also continue. While the exact amount of money required for this care is not yet known, the ADA believes that it will easily exceed the $17 million required following Desert Storm and for a sustained basis.
The second issue relates to a military construction project for the dental clinic at Lackland Air Force Base. Some of the soldiers who have suffered head and neck injuries in Iraq are being treated at Lackland for facial reconstruction. Oral surgeons there are using the highly sophisticated computer programs to make 3-D images to recreate shattered jaws.
The proposed construction will consolidate all dental activities on Lackland AFB and Kelly AFB to the Dunn Dental Clinic. There are currently two separate dental treatment activities at Lackland: MacKown Dental Clinic and Dunn Dental Clinic. The MacKown Clinic is 44 years old and has long outlived its usefulness. It predates the current Joint Commission on Accreditation of Healthcare Organizations (JACHO), Occupational Safety and Health Administration (OSHA) and infection control standards. The MacKown Clinic also houses three of the Air Force’s dental specialty training programs that have outgrown that facility significantly over the last twenty years. The clinic at Kelly Air Force Base will be closed as a result of highway construction. The patients currently seen at Kelly will now be seen at the Dunn clinic and there is insufficient capacity to absorb these patients.
The planned addition to the existing Dunn Dental Clinic building will provide an additional 90 dental treatment rooms on two floors that meet current ambulatory surgery codes. The proposed facility will also provide space for a dental laboratory to meet regional dental workload demands, support the dental resident training, and dental research currently part of the MacKown facility. The new addition will also provide necessary classroom space and suitable audio-visual, teleconference, and distance learning capabilities. The ADA requests that the Committee appropriate $1.5 million for the design phase of this construction project.
The ADA thanks the Committee for allowing us to present these issues related to the dental and oral health of our great American service men and women.
