TY - JOUR
AU - USN, Wayne M. Deutsch, DC
AB - ABSTRACT Background: Planning of dental support for populations serving in isolation is essential. Many programs of national or scientific interest such as U.S. Navy submarine missions, the manned space program, and research in Antarctica require long periods where dental care is not available. Submariners make an excellent study population due to their relatively large numbers, good health, excellent dental screening, and professional status. Methods: This study examines dental events occurring while underway on 240 submarine patrols from January 1, 1997 to September 30, 2000. A health events database contains medical encounter notes, demographic information, crew rosters, and medical evacuation reports. A special survey database contains information from three surveys conducted aboard 1 submarine during a 101-day submergence. The evacuation database contains medical evacuation data from the Atlantic and Pacific submarine fleets from 1991 through 1999. Results: One hundred nine initial dental emergency visits and 45 revisits were recorded during these patrols. Of these visits, 48.6% were for an emergency related to an endodontic or caries problem. The incidence rate for all dental problems was 5.0 per 100,000 person-days at sea. Smoking was significantly associated with the occurrence of a periodontal-related emergency and also with the occurrence of any dental emergency. The rate of dental emergencies per 100,000 person-days decreased over time with the rate for the first 7 days being 7.5, days 8 through 14 being 5.5, and after day 14 being 4.6. Dental problems accounted for 6.9–9.3% of all medical evacuations from submarines between 1991 and 1999. The special survey of self-reported dental problems was designed to obtain information on minor conditions that might not be recorded in the medical encounter database. Of the problems reported, 13.1% had a dental problem during the 101-day submergence, 9.8% had a canker sore, and 4.1% had a gum problem. INTRODUCTION The planning of dental support for populations serving in an isolated or contained environment is essential. With the expansion of the manned space program, research in Antarctica, and continuing U.S. Navy submarine missions, the need to plan for emergent conditions is critical. Although this study has important military significance, it also has significance for the general population. Only a handful of studies have addressed the rate at which dental emergencies occur, and there is very little published literature on the rate of emergencies in a population as carefully screened as sailors embarked on an underway submarine. If risk factors for an emergency can be determined, it should be possible to address those factors and decrease the risk of emergencies. On a submarine deployment, the entire crew could be placed at great risk if a dental emergency required the submarine to surface, disclose its position, and await emergency evacuation. Although the risk for the civilian population might not be so extreme, significant discomfort and dental morbidity can possibly be avoided. When other endeavors requiring long periods of isolation, such as interplanetary space flight or isolated research in Antarctica, are encountered, this information could significantly improve the chances of success of those endeavors. Finally, from a health services administration point of view, administrators can better plan what amount of dental emergency services should be available with the additional information this will place at their disposal. In 1974, Ludwick et al.1 reported a monthly average of 13.1 dental emergency visits per 1,000 personnel serving in Vietnam during 1970. They defined caries related as all conditions resulting from caries, including endodontic conditions. One-half of all emergency visits were caries related. They reported a wide variety in what individual dental officers considered an emergency and recommended indoctrination for consistency among the dentists. In 1981, Payne and Posey2 analyzed dental casualties in 24-day and 15-day prolonged field exercises conducted under simulated combat conditions. The average number of emergency visits per 1,000 troops over the 39 days was 19.39. Fifty-two percent of emergencies were described as due to caries and 22% as due to gingival conditions. Of all medical sick call visits, 21.5% were for dental problems. They felt that 74% of all dental emergencies are preventable. In 1983, Grover et al.3 described the distribution and frequency of dental emergencies in U.S. Army recruits during January to June 1980. Of the emergency visits, 40.4% were attributable to caries. Of all of the recruits, 26% reported to dental sick call for a dental emergency. In 1987, Teweles and King4 described the impact of troop dental health on combat readiness. Before deployment, “an intensive program was conducted to improve the dental health of the troops being deployed.” Soldiers deployed were categorized by dental status. Category A meant they had no dental treatment needs. Category B meant they had some routine nonurgent needs. Category PE indicated a high potential for a dental emergency in the next year. During the deployment, 160 dental emergency visits occurred, of which 106 were deemed preventable. For patients in category A, they reported an incidence of 67 dental emergencies per 1,000 troops per year. In category B, the reported incidence was 145 dental emergencies per 1,000 troops per year. In category PE, the reported incidence was 530 dental emergencies per 1,000 troops per year. They reported an annualized 160 dental emergencies per 1,000 Army personnel on a 6-month noncombat deployment to the Sinai Peninsula. In 1988, Keller5 reported the reduction of dental emergencies through dental readiness. Data were gathered in one dental clinic at Fort Bragg over 10 months in 1981–1982 and 10 months in 1983–1984. Keller5 believed that between 67 and 71% of the emergency visits could have been prevented. There was an 8% decrease in patients entering the dental clinic for emergency treatment during the second 10-month period. Keller5 estimated 324 annual emergency visits per 1,000 troops for the first period and 272 for the second. In 1987, Nice6 reported a 9-month survey of medical communications and evacuations at sea for U.S. Navy ships and submarines and Military Sealift Command ships. On ships with physicians, the MEDEVAC rate was 1.5 per 1,000 patient visits; for ships and submarines with independent duty corpsmen (IDCs), the MEDEVAC rate was 3.5 per 1,000 patient visits. The diagnostic category digestive problem was associated with 17% of the evacuations, and dental problems were the reason for 7% of the MEDEVACS. The corpsmen on submarines had less than half as many medical communications as corpsmen on ships. Telecommunications technologies to prevent some MEDEVACS were endorsed by 44% of the corpsmen. In 1988, Norman et al.7 described medical evacuations from offshore structures. Norman et al.7 studied medical evacuations from the installations of four major U.K. oil companies between 1976 and 1984. One hundred twelve (14%) of 790 medical evacuations were for dental problems. In 1992, Calderara and Zuccari8 published the first data on the frequency and reasons for dental emergencies in the Italian Army. They described soldiers' dental complaints for 5 months in 1991 and compared the soldiers' perception with clinical findings. Patients correctly identified the type of emergency between 38.6 and 62% of the time. The majority (37.1%) of dental emergencies were due to endodontic problems. In 1993, Chisick and King9 described dental epidemiology of military operations. They discussed seven previous studies that indicated a “rate” for dental emergencies. Actually, these studies provided a number of emergency visits per 1,000 service members over a period of time, but the studies did not distinguish between an initial visit and subsequent visits. None of these studies can be used in calculating an incidence rate. They noted that the category caries as a cause of dental emergencies has been described differently in the seven studies.”Some investigators grouped periapical abscesses, decay, and defective fillings as caries.“ In their article, Chisick and King9 adjusted all of the studies to create an adjusted percent due to caries for the seven studies. Percentages ranged from 40.9 to 60%. The number of dental emergency visits per 1,000 troops per year ranged from 65.8 to 259. They described the most common treatment across the studies as prescriptions and the second most common treatment as extractions. Chisick and King9 believed reporting of time trends would be valuable. In King's article,10 he noted that the number of dental emergency visits during Operations Desert Shield/Storm were highest (713 per 1,000 troops per year) in the months before and subsequent to the ground war. The lowest monthly number of visits was 217 per 1,000 troops per year. In 1996, Deutsch and Simecek11 described dental emergencies among Marines ashore in Operations Desert Shield/ Storm. This study described a large number (4,776) of dental emergencies and the weekly number of emergency visits per 1,000 Marines over 35 weeks during Operations Desert Shield/Storm. Using the previous criteria, the combination of caries, defective restorations, and endodontic complaints accounted for 54.3% of the emergency visits. The annual number of emergency visits was estimated to be 149.3 per 1,000 personnel. The same seven categories of dental emergencies were also used in this study: “(1) caries, broken/lost/defective restorations, postrestorative complications (caries); (2) pericoronitis and other third-molar pain (P-Cor); (3) postendodontic complications, pulpitis, periapical abscess (Endo); (4) periodontal other than pericoronitis (Perio); (5) surgical postoperative (Post-Op); (6) trauma (Trauma); (7) other (Other).” The number of dental emergency visits per unit time was only 5% less than that in the study of Ludwick et al.1 20 years earlier, even though treatment needs had decreased. In 1998, McKee et al.12 described disease and nonbattle injury among U.S. soldiers deployed in Bosnia-Herzegovina during 1997. During Operation Joint Guard, dental disease accounted for 10% of soldier visits to medical treatment facilities. The authors counted International Classification of Disease, 10th Revision (ICD-10) codes K00-K14 as dental disease. Reporting this way, the authors found 0.84 cases per week (as compared to 0.29 for Operation Desert Storm). After Operations Desert Shield/Storm, the U.S. Joint Chiefs of Staff mandated structured medical surveillance. The authors believed that some of the high disease, nonbattle injuries (DNBI) were due to referrals. They noted a similar decreasing trend of the weekly number of dental emergencies per 100 soldiers over time as in Operations Desert Shield/ Storm. In 1979, Tansey et al.13 analyzed 10 years of health data collected on Polaris submarines from 1963 through 1973. They estimated the rate for all medical conditions by collecting numerator data and using assumed crew size and cruise length to estimate the man-days used for the denominator. In 10 years, there were 50 dental problems that resulted in 105 lost days of work and one transfer at sea. Those 50 dental problems accounted for 3% of the 1,685 cases of illness and 1/37 or 3% of the transfers at sea. In 2000, Thomas et al.14 described a method for monitoring the health of U.S. Navy submarine crew members during periods of isolation. The International Classification of Diseases, 9th Revision, Clinical Modification codes used to define a dental condition were 520 through 523 and 525, and only initial visits were counted in the numerator for the rates. The rate for those conditions was 3.1 per 100,000 person-days. In addition, IDC rather than dentists did the diagnosis and treatment and description of the dental emergency was by international Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) code and SOAP (subjective findings, objective findings, assessment of the patient's complaint, and plan for treatment) notes. The latter two studies did not investigate dental emergencies in detail. MATERIALS AND METHODS Health Events among Submarine Crew Members Description of the Database Historically, there was no Central Repository for Shipboard Non-Tactical ADP Program Automated Medical System (SAMS) Submarine data. Thomas et al.14 combined SAMS data for all submarine patrols of 10 days or longer beginning January 1, 1997. For each underway period, crew members not onboard for the patrol were manually deleted from the automated roster using the hard copy of the official sailing list submitted with the data. SOAP notes were reviewed to ensure accuracy and internal consistency with ICD-9 coding. SAMS has a place for only one ICD-9 code and does not use procedure codes. Study investigators reviewed all of the SOAP notes to ensure consistency of coding and to add up to two additional ICD-9 codes as well as up to two procedure codes. The database on health among submarine crew members contains medical encounter data and demographic information on 240 submarine patrols from January 1, 1997 to September 30, 2000, when data collection stopped. These data primarily come from the SAMS and a small amount of supplemental information or missing demographic data comes from the Naval Health Research Center. SAMS is a software program that contains clinical and administrative information on crew. The data are stored in an onboard computer. Crew member information is added/deleted when the crew member is assigned to the submarine. The IDC is required to make an entry for medical consults that involve: a prescription medication, procedure, or lost time from work. Corpsmen record findings in a format called SOAP. Data include: date, SOAP notes, vitals/laboratory results, accident yes/no, number of days on full/light/no duty status, and other, including requests for assistance. In addition, SAMS includes the ICD-9 code. Smoking status was recorded by the IDC in each crew member's most recent physical examination as “yes” or “no.” Naval Health Research Center records are used to confirm demographic information and add level of education and length of military service to SAMS. If rank and race data are missing from the SAMS data, Naval Health Research Center information is used. For this analysis, only events with an ICD-9 code in the following categories were considered: 520 through 528 and 873.6 and 873.7. A dentist (W.M.D.) reviewed all SOAP notes with ICD-9 codes in considered categories and assigned the dental codes consistent with the study conducted by Deutsch and Simecek.11 Codes assigned that conform to the ODS/S study2 were Caries, P-Cor, Endo, Perio, Post-Op, Trauma, and Other. In addition, prosthetic-type emergencies were broken out from the “Other” category. Statistical Analysis For purposes of these analyses, each submarine patrol was considered a separate cohort; however, there were multiple submarines and a single submarine may go out more than once. The numerator is the number of initial visits for each of the selected ICD-9 codes and dental codes and the denominator is the total number of person-days at sea. The measure used for analysis is incidence density rates per 100,000 person-days at sea for the period January 1, 1997 to September 30, 2000. To determine the rates, the number of initial visits for a dental problem was the numerator and the total number of person-days underway was the denominator. Rates were calculated for all crew members combined and were also stratified by rank, age, and smoking status. Rates were calculated for each emergency type (ICD-9 categories and dental codes) as well as for total emergencies combined. Revisits for the same problem are not included in the numerators for any of the rates. They are examined separately as the average number of revisits for each dental code category. To compare the risk of dental emergencies in crew members <25 years old/enlisted rank/smoker with crew members 25 years old and older/officer rank/nonsmoker, the measure of association used was relative risk (RR). RR is the ratio of risk of disease in one group of individuals to the risk of disease in a referent group of individuals. For age, crew members that were 25 years old and older served as the referent category. For rank, officers served as the referent category. For smoking status, nonsmoking was the referent. For categories with less than four events, RR was not calculated. The EpiInfo Statcalc program was used to calculate RRs and the corresponding 95% confidence intervals (CI). A stepwise logistic model was used to determine which variables were significantly associated with having a dental event. The full model included rank, ethnicity, age, length of service, education, smoking status, a term for the interaction between age and length of service, and a term for the interaction between rank and education. The outcome variable was all dental events; dental events were defined as ICD-9 codes 520 through 528 and 873.6 and 873.7. For analysis of how the rate of emergencies changes over time within a deployment, each deployment was divided into three periods. The first period was days 1 through 7. The second period was days 8 through 14. The final period included all emergencies occurring after day 14. The number of person-days at sea was partitioned by each period so that a rate could be determined using the events as the numerator and the partitioned person-days at sea as the denominator. The measure used for analysis is cumulative incidence, i.e., the number of events divided by the total number of survey respondents. To determine the rates, the numbers of yes answers for a dental problem was the numerator and the total number of respondents was the denominator. Rates were not stratified because of small numbers. Medical Evacuations from Submarines Description of the Database The evacuation database contains all of the medical evacuation information from the Atlantic fleet between 1991 and 1999, except for 1998, and the Pacific fleet from 1991 through 1999. Data from 1998 for the Atlantic Fleet are not available. The medical evacuation database contains all requests for medical assistance sent by the IDC to Force Medical. Some requests do not result in an evacuation; thus, only those resulting in an evacuation were included in the analysis. This database includes the following information: identifying information on the patient, the suspected condition, whether an evacuation took place, the date of the event, and which submarine. We counted the event as dental when a request for medical assistance using ICD-9 codes 520 through 528 and 873.6 and 873.7 was made. Statistical Analysis The frequency of dental events and the proportion of all evacuations due to dental events were determined. Survey of Crew Members Aboard a Submarine during a 101-day Submergence Description of the Database The special survey database contains data from a special survey that was conducted to obtain information of some of the minor conditions that might not be recorded in SAMS. In addition, habit information was reported over time. Three surveys were conducted aboard one submarine during a 101-day submergence. Beginning, midpoint, and end information was obtained on dental habits and how they changed during the deployment. The special dental survey contains self-reported dental problems that occurred during that deployment. Statistical Analysis The measure used for analysis is cumulative incidence; i.e., the number of events divided by the total number of survey respondents. To determine the rates, the numbers of yes answers for a dental problem was the numerator and the total number of respondents was the denominator. Questions from the beginning, middle, and end surveys are in Appendix A (Table XVII). Additional questions from the special survey are in Appendix B (Table XVIII). Rates were not stratified because of small numbers. TABLE XVII Questions from Beginning, Middle, and End Surveys Dental Survey While on shore, how many times a week do you brush your teeth?  While on shore, how many times a week do you floss your teeth?  During the past year, while on shore did you ever have a toothache? Did you seek medical care?  While on shore, how many times a week do you brush your teeth?  While on shore, how many times a week do you floss your teeth?  During the past year, while on shore did you ever have a toothache? Did you seek medical care?  View Large TABLE XVII Questions from Beginning, Middle, and End Surveys Dental Survey While on shore, how many times a week do you brush your teeth?  While on shore, how many times a week do you floss your teeth?  During the past year, while on shore did you ever have a toothache? Did you seek medical care?  While on shore, how many times a week do you brush your teeth?  While on shore, how many times a week do you floss your teeth?  During the past year, while on shore did you ever have a toothache? Did you seek medical care?  View Large TABLE XVIII Questions from Special Dental Survey Year of last dental examination 19XX  Month of last dental examination  Classification at last examination  During this underway period did you have any dental problems?  Did you experience a toothache?   Did you have pain?   Did you see a corpsman?   What types of medications were given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling while eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling due to trauma?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling not due to trauma or eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a canker sore?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a gum problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a jaw joint problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience any other problems?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?   What was the dental problem?  Year of last dental examination 19XX  Month of last dental examination  Classification at last examination  During this underway period did you have any dental problems?  Did you experience a toothache?   Did you have pain?   Did you see a corpsman?   What types of medications were given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling while eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling due to trauma?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling not due to trauma or eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a canker sore?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a gum problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a jaw joint problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience any other problems?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?   What was the dental problem?  View Large TABLE XVIII Questions from Special Dental Survey Year of last dental examination 19XX  Month of last dental examination  Classification at last examination  During this underway period did you have any dental problems?  Did you experience a toothache?   Did you have pain?   Did you see a corpsman?   What types of medications were given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling while eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling due to trauma?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling not due to trauma or eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a canker sore?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a gum problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a jaw joint problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience any other problems?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?   What was the dental problem?  Year of last dental examination 19XX  Month of last dental examination  Classification at last examination  During this underway period did you have any dental problems?  Did you experience a toothache?   Did you have pain?   Did you see a corpsman?   What types of medications were given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling while eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling due to trauma?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you break/crack a tooth or loose/crack a filling not due to trauma or eating?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a canker sore?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a gum problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience a jaw joint problem?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?  Did you experience any other problems?   Did you have pain?   Did you see a corpsman?   What types of medications were you given for the problem?   How many workdays were lost?   What was the dental problem?  View Large RESULTS The total number of person-days at sea for the patrols included in the study was 2,170,607. The distribution of submariners by demographic characteristics, January 1, 1997 to September 30, 2000, are shown in Table I. All of the submarine crew members were male and 88.5% were Caucasian. Only 10.3% were officers and 70.5% were 25 years old or older. Submarine crew members are generally more senior than the average sailor. The 240 submarine patrols from January 1, 1997 to September 30, 2000, resulted in 2.2 million person-days at sea. TABLE 1. Distribution of Submariners by Demographic Characteristics, January 1, 1997 to September 30, 2000   Survey  Full Study          No.  Percent  No.  Percent  Age (years)           <25  36  29.5  4,573  34.4   25 +  86  70.5  8,676  65.3   Unknown  0  0  49  0.4  Ethnic background           Caucasian      11,773  88.5   Non-Caucasian      1,310  9.9   Unknown      215  1.6  Rank           Officer  13  10.7  1,375  10.3   Enlisted  109  89.3  11,898  89.5   Unknown  0  0  25  0.2  Total  122  100.0  13,298  100.0    Survey  Full Study          No.  Percent  No.  Percent  Age (years)           <25  36  29.5  4,573  34.4   25 +  86  70.5  8,676  65.3   Unknown  0  0  49  0.4  Ethnic background           Caucasian      11,773  88.5   Non-Caucasian      1,310  9.9   Unknown      215  1.6  Rank           Officer  13  10.7  1,375  10.3   Enlisted  109  89.3  11,898  89.5   Unknown  0  0  25  0.2  Total  122  100.0  13,298  100.0  View Large TABLE 1. Distribution of Submariners by Demographic Characteristics, January 1, 1997 to September 30, 2000   Survey  Full Study          No.  Percent  No.  Percent  Age (years)           <25  36  29.5  4,573  34.4   25 +  86  70.5  8,676  65.3   Unknown  0  0  49  0.4  Ethnic background           Caucasian      11,773  88.5   Non-Caucasian      1,310  9.9   Unknown      215  1.6  Rank           Officer  13  10.7  1,375  10.3   Enlisted  109  89.3  11,898  89.5   Unknown  0  0  25  0.2  Total  122  100.0  13,298  100.0    Survey  Full Study          No.  Percent  No.  Percent  Age (years)           <25  36  29.5  4,573  34.4   25 +  86  70.5  8,676  65.3   Unknown  0  0  49  0.4  Ethnic background           Caucasian      11,773  88.5   Non-Caucasian      1,310  9.9   Unknown      215  1.6  Rank           Officer  13  10.7  1,375  10.3   Enlisted  109  89.3  11,898  89.5   Unknown  0  0  25  0.2  Total  122  100.0  13,298  100.0  View Large For the 240 submarine patrols from between January 1, 1997 and September 30, 2000, there were 5,187 visits to an IDC for a medical consultation that involved a prescription medication, medical procedure, or lost time from work (Table II). Three percent of these events were for dental conditions. When excluding revisits, 109 (3%) of 3,562 visits were for dental conditions. TABLE II. Proportion of Events due to Dental Emergencies from January 1, 1997 to September 30, 2000   Dental Events  All Events  % Due to Dental  Initial visits  109  3,562  3  Initial and revisits  154  5,187  3    Dental Events  All Events  % Due to Dental  Initial visits  109  3,562  3  Initial and revisits  154  5,187  3  View Large TABLE II. Proportion of Events due to Dental Emergencies from January 1, 1997 to September 30, 2000   Dental Events  All Events  % Due to Dental  Initial visits  109  3,562  3  Initial and revisits  154  5,187  3    Dental Events  All Events  % Due to Dental  Initial visits  109  3,562  3  Initial and revisits  154  5,187  3  View Large Endodontic emergencies accounted for 22.0% of initial visits for dental emergencies and 57.8% of all revisits to the IDC (Table III). Caries accounted for 26.6% of initial visits and 11.1% of all revisits. Initial visits due to periodontal problems accounted for 9.2% and trauma accounted for 8.3%. Third molar-related emergencies only accounted for 2.8%, but required as many revisits as initial visits; this is less than one-quarter of rates reported in other studies and could be due to aggressive removal of any suspicious wisdom teeth. The “other” category was quite large and accounted for 27 of 109 initial visits. In this category were: cyst, aphthae, baby tooth, tooth pain from sinus, temporomandibular joint (TMJ), lip infection, tongue, and one simply listed as broken tooth that did not have enough information to categorize further. The incidence rate for all dental problems was 5.0 per 100,000 person-days at sea. TABLE III. Rates of Dental Conditions from January 1, 1997 to September 30, 2000   No. of Initial Visits  Initial Visit Rate/100,000 Person-Days at Sea  No. of revisits  Average No. of Revisits/ Initial Visit  Third molar  3  0.1  3  1.0  Endodontic  24  1.1  26  1.1  Caries  29  1.3  5  0.2  Periodontal  10  0.5  5  0.5  Surgical postoperative  4  0.2  0  0.0  Prosthodontic  3  0.1  0  0.0  Trauma  9  0.4  3  0.3  Other  27  1.2  3  0.1  Total  109  5.0  45  0.4    No. of Initial Visits  Initial Visit Rate/100,000 Person-Days at Sea  No. of revisits  Average No. of Revisits/ Initial Visit  Third molar  3  0.1  3  1.0  Endodontic  24  1.1  26  1.1  Caries  29  1.3  5  0.2  Periodontal  10  0.5  5  0.5  Surgical postoperative  4  0.2  0  0.0  Prosthodontic  3  0.1  0  0.0  Trauma  9  0.4  3  0.3  Other  27  1.2  3  0.1  Total  109  5.0  45  0.4  Other: cyst, aphthae, baby tooth, tooth pain from sinus, J, lip infection, tongue (unable to categorize one initial and one revisit listed as broken teeth). View Large TABLE III. Rates of Dental Conditions from January 1, 1997 to September 30, 2000   No. of Initial Visits  Initial Visit Rate/100,000 Person-Days at Sea  No. of revisits  Average No. of Revisits/ Initial Visit  Third molar  3  0.1  3  1.0  Endodontic  24  1.1  26  1.1  Caries  29  1.3  5  0.2  Periodontal  10  0.5  5  0.5  Surgical postoperative  4  0.2  0  0.0  Prosthodontic  3  0.1  0  0.0  Trauma  9  0.4  3  0.3  Other  27  1.2  3  0.1  Total  109  5.0  45  0.4    No. of Initial Visits  Initial Visit Rate/100,000 Person-Days at Sea  No. of revisits  Average No. of Revisits/ Initial Visit  Third molar  3  0.1  3  1.0  Endodontic  24  1.1  26  1.1  Caries  29  1.3  5  0.2  Periodontal  10  0.5  5  0.5  Surgical postoperative  4  0.2  0  0.0  Prosthodontic  3  0.1  0  0.0  Trauma  9  0.4  3  0.3  Other  27  1.2  3  0.1  Total  109  5.0  45  0.4  Other: cyst, aphthae, baby tooth, tooth pain from sinus, J, lip infection, tongue (unable to categorize one initial and one revisit listed as broken teeth). View Large Age was not a significant risk factor for developing a dental emergency (Table IV). The risk of any dental problem approached significance with sailors >25 years old, more likely to have a dental emergency. TABLE IV. Incidence Rates by Age from January 1, 1997 to September 30, 2000   Age (years)                <25  25 +                  No.  Rate  No.  Rate  RR  95% CI  Third molar    1  0.1    2  0.1      Endodontic  12  1.6  11  0.8  1.94  0.85–4.39  Caries    8  1.0  21  1.5  0.68  0.30–1.53  Periodontal    4  0.5    6  0.4  1.18  0.33–4.19  Surgical postoperative    3  0.4    1  0.1      Prosthodontic    2  0.3    1  0.1      Trauma    5  0.6    4  0.3  2.22  0.60–8.26  Other  12  1.4  15  1.1      Total  47  5.8  61  4.4  1.37  0.94–2.00    Age (years)                <25  25 +                  No.  Rate  No.  Rate  RR  95% CI  Third molar    1  0.1    2  0.1      Endodontic  12  1.6  11  0.8  1.94  0.85–4.39  Caries    8  1.0  21  1.5  0.68  0.30–1.53  Periodontal    4  0.5    6  0.4  1.18  0.33–4.19  Surgical postoperative    3  0.4    1  0.1      Prosthodontic    2  0.3    1  0.1      Trauma    5  0.6    4  0.3  2.22  0.60–8.26  Other  12  1.4  15  1.1      Total  47  5.8  61  4.4  1.37  0.94–2.00  * Does not include one patient of unknown age with one endodontic emergency. View Large TABLE IV. Incidence Rates by Age from January 1, 1997 to September 30, 2000   Age (years)                <25  25 +                  No.  Rate  No.  Rate  RR  95% CI  Third molar    1  0.1    2  0.1      Endodontic  12  1.6  11  0.8  1.94  0.85–4.39  Caries    8  1.0  21  1.5  0.68  0.30–1.53  Periodontal    4  0.5    6  0.4  1.18  0.33–4.19  Surgical postoperative    3  0.4    1  0.1      Prosthodontic    2  0.3    1  0.1      Trauma    5  0.6    4  0.3  2.22  0.60–8.26  Other  12  1.4  15  1.1      Total  47  5.8  61  4.4  1.37  0.94–2.00    Age (years)                <25  25 +                  No.  Rate  No.  Rate  RR  95% CI  Third molar    1  0.1    2  0.1      Endodontic  12  1.6  11  0.8  1.94  0.85–4.39  Caries    8  1.0  21  1.5  0.68  0.30–1.53  Periodontal    4  0.5    6  0.4  1.18  0.33–4.19  Surgical postoperative    3  0.4    1  0.1      Prosthodontic    2  0.3    1  0.1      Trauma    5  0.6    4  0.3  2.22  0.60–8.26  Other  12  1.4  15  1.1      Total  47  5.8  61  4.4  1.37  0.94–2.00  * Does not include one patient of unknown age with one endodontic emergency. View Large Enlisted submariners were 2.3 times more likely than officers to have a dental emergency (Table V), but the RR was not significant. TABLE V Incidence Rates by Rank from January 1, 1997 to September 30, 2000   Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Third molar    3  0.2    0        Endodontic  23  1.2    0        Caries  25  1.3    4  1.9  0.7  0.2–3.0  Periodontal  10    0.5    0        Surgical postoperative    4  0.2    0        Prosthodontic    3  0.2    0        Trauma    9  0.5    0        Other  26  1.3    1  0.5      Total  103    5.3    5  2.3  2.3  0.9–5.5    Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Third molar    3  0.2    0        Endodontic  23  1.2    0        Caries  25  1.3    4  1.9  0.7  0.2–3.0  Periodontal  10    0.5    0        Surgical postoperative    4  0.2    0        Prosthodontic    3  0.2    0        Trauma    9  0.5    0        Other  26  1.3    1  0.5      Total  103    5.3    5  2.3  2.3  0.9–5.5  Does not include one patient of unknown rank with one endodontic emergency. View Large TABLE V Incidence Rates by Rank from January 1, 1997 to September 30, 2000   Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Third molar    3  0.2    0        Endodontic  23  1.2    0        Caries  25  1.3    4  1.9  0.7  0.2–3.0  Periodontal  10    0.5    0        Surgical postoperative    4  0.2    0        Prosthodontic    3  0.2    0        Trauma    9  0.5    0        Other  26  1.3    1  0.5      Total  103    5.3    5  2.3  2.3  0.9–5.5    Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Third molar    3  0.2    0        Endodontic  23  1.2    0        Caries  25  1.3    4  1.9  0.7  0.2–3.0  Periodontal  10    0.5    0        Surgical postoperative    4  0.2    0        Prosthodontic    3  0.2    0        Trauma    9  0.5    0        Other  26  1.3    1  0.5      Total  103    5.3    5  2.3  2.3  0.9–5.5  Does not include one patient of unknown rank with one endodontic emergency. View Large Smokers were five times more likely to have a periodontal emergency than nonsmokers and 1.85 times more likely to have any dental emergency (Table VI). TABLE VI. Incidence Rates per 100,000 person-days at Sea by Smoking Status from January 1, 1997 to September 30, 2000   Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Third molar   1  0.3   2  0.1      Endodontic   3  1.0  19  1.0      Caries   5  1.7  21  1.2  1.49  0.56–3.96  Periodontal   4  1.4   5  0.3  5.01a  1.35–18.67  Surgical postoperative   2  0.7   2  0.1      Prosthodontic   0     3  0.2      Trauma   1  0.3   8  0.4      Other   7  2.4  18  1.0      Total  23  7.6  78  4.3  1.85a  1.16–2.94    Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Third molar   1  0.3   2  0.1      Endodontic   3  1.0  19  1.0      Caries   5  1.7  21  1.2  1.49  0.56–3.96  Periodontal   4  1.4   5  0.3  5.01a  1.35–18.67  Surgical postoperative   2  0.7   2  0.1      Prosthodontic   0     3  0.2      Trauma   1  0.3   8  0.4      Other   7  2.4  18  1.0      Total  23  7.6  78  4.3  1.85a  1.16–2.94  Does not include emergencies for 8 patients with unknown smoking status. View Large TABLE VI. Incidence Rates per 100,000 person-days at Sea by Smoking Status from January 1, 1997 to September 30, 2000   Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Third molar   1  0.3   2  0.1      Endodontic   3  1.0  19  1.0      Caries   5  1.7  21  1.2  1.49  0.56–3.96  Periodontal   4  1.4   5  0.3  5.01a  1.35–18.67  Surgical postoperative   2  0.7   2  0.1      Prosthodontic   0     3  0.2      Trauma   1  0.3   8  0.4      Other   7  2.4  18  1.0      Total  23  7.6  78  4.3  1.85a  1.16–2.94    Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Third molar   1  0.3   2  0.1      Endodontic   3  1.0  19  1.0      Caries   5  1.7  21  1.2  1.49  0.56–3.96  Periodontal   4  1.4   5  0.3  5.01a  1.35–18.67  Surgical postoperative   2  0.7   2  0.1      Prosthodontic   0     3  0.2      Trauma   1  0.3   8  0.4      Other   7  2.4  18  1.0      Total  23  7.6  78  4.3  1.85a  1.16–2.94  Does not include emergencies for 8 patients with unknown smoking status. View Large Tables VII through X present the results of this study using medical ICD-9 codes. Since ICD-9 codes are site codes, they may not give the level of detail equal to a dental emergency code. In terms of dental health, ICD-9 codes are not as meaningful as a term descriptive of a dental emergency. TABLE VII. Rates of Dental Conditions by ICD-9 Code from January 1, 1997 to September 30, 2000 Diagnosis (ICD-9 code)  No. of Initial Visits  Initial Visit Rate per 100,000 Person-Days at Sea  Tooth eruption (520)   3  0.1  Pulp and periapical (522)  21  1.0  Hard tissues and caries (521)   4  0.2  Gingival and periodontal (523)  10  0.5  Malocclusion and J (524)   4  0.2  Other and tooth loss (525)  30  1.4  Jaw diseases and osteitis (526)   0    Salivary glands diseases (527)   2  0.1  Oral soft tissue diseases except aphthae (528)   3  0.1  Aphthae (528.2)   6  0.3  Injury to mouth (873.6, 873.7)  18  0.8  Total  101  4.7  Diagnosis (ICD-9 code)  No. of Initial Visits  Initial Visit Rate per 100,000 Person-Days at Sea  Tooth eruption (520)   3  0.1  Pulp and periapical (522)  21  1.0  Hard tissues and caries (521)   4  0.2  Gingival and periodontal (523)  10  0.5  Malocclusion and J (524)   4  0.2  Other and tooth loss (525)  30  1.4  Jaw diseases and osteitis (526)   0    Salivary glands diseases (527)   2  0.1  Oral soft tissue diseases except aphthae (528)   3  0.1  Aphthae (528.2)   6  0.3  Injury to mouth (873.6, 873.7)  18  0.8  Total  101  4.7  Eight dental events were not the primary complaint and were excluded. View Large TABLE VII. Rates of Dental Conditions by ICD-9 Code from January 1, 1997 to September 30, 2000 Diagnosis (ICD-9 code)  No. of Initial Visits  Initial Visit Rate per 100,000 Person-Days at Sea  Tooth eruption (520)   3  0.1  Pulp and periapical (522)  21  1.0  Hard tissues and caries (521)   4  0.2  Gingival and periodontal (523)  10  0.5  Malocclusion and J (524)   4  0.2  Other and tooth loss (525)  30  1.4  Jaw diseases and osteitis (526)   0    Salivary glands diseases (527)   2  0.1  Oral soft tissue diseases except aphthae (528)   3  0.1  Aphthae (528.2)   6  0.3  Injury to mouth (873.6, 873.7)  18  0.8  Total  101  4.7  Diagnosis (ICD-9 code)  No. of Initial Visits  Initial Visit Rate per 100,000 Person-Days at Sea  Tooth eruption (520)   3  0.1  Pulp and periapical (522)  21  1.0  Hard tissues and caries (521)   4  0.2  Gingival and periodontal (523)  10  0.5  Malocclusion and J (524)   4  0.2  Other and tooth loss (525)  30  1.4  Jaw diseases and osteitis (526)   0    Salivary glands diseases (527)   2  0.1  Oral soft tissue diseases except aphthae (528)   3  0.1  Aphthae (528.2)   6  0.3  Injury to mouth (873.6, 873.7)  18  0.8  Total  101  4.7  Eight dental events were not the primary complaint and were excluded. View Large The ICD-9 code 528 is for oral soft tissues diseases. Two-thirds of these “emergencies” are due to oral aphthae. Dental emergency studies do not consider aphthae to be a dental emergency. For this analysis, code 528.2 was separated out from all 528 codes. The rate of dental emergencies for the first 7 days of deployment was 7.5 per 100,000 person-days (Table XI). This was 27% higher than the subsequent 7 days and 49% higher than the rate for the remainder of the patrol. TABLE VIII. Incidence Rates by ICD-9 Codes and Age from January 1, 1997 to September 30, 2000   Age (years)                <25  25+                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  1  0.1  2  0.1      Pulp and periapical (522)  10  1.3  11  0.8  1.61  0.69–3.80  Hard tissues and caries (521)  4  0.5  0        Gingival and periodontal (523)  4  0.5  6  0.4  1.18  0.33–4.19  Malocclusion and J (524)  2  0.3  2  0.1      Other and tooth loss (525)  8  1.0  22  1.6      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  1  0.1  1  0.1      Oral soft tissue diseases except aphthae (528)  3  0.4  0        Aphthae (528.2)  3  0.4  3  0.2      Injury to mouth (873.6, 873.7)  8  1.0  9  0.6  15.68  6.05–40.63  Total  44  5.6  56  4.0  1.39  0.94–2.07    Age (years)                <25  25+                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  1  0.1  2  0.1      Pulp and periapical (522)  10  1.3  11  0.8  1.61  0.69–3.80  Hard tissues and caries (521)  4  0.5  0        Gingival and periodontal (523)  4  0.5  6  0.4  1.18  0.33–4.19  Malocclusion and J (524)  2  0.3  2  0.1      Other and tooth loss (525)  8  1.0  22  1.6      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  1  0.1  1  0.1      Oral soft tissue diseases except aphthae (528)  3  0.4  0        Aphthae (528.2)  3  0.4  3  0.2      Injury to mouth (873.6, 873.7)  8  1.0  9  0.6  15.68  6.05–40.63  Total  44  5.6  56  4.0  1.39  0.94–2.07  Does not include one patient of unknown with one endodontic emergency. View Large TABLE VIII. Incidence Rates by ICD-9 Codes and Age from January 1, 1997 to September 30, 2000   Age (years)                <25  25+                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  1  0.1  2  0.1      Pulp and periapical (522)  10  1.3  11  0.8  1.61  0.69–3.80  Hard tissues and caries (521)  4  0.5  0        Gingival and periodontal (523)  4  0.5  6  0.4  1.18  0.33–4.19  Malocclusion and J (524)  2  0.3  2  0.1      Other and tooth loss (525)  8  1.0  22  1.6      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  1  0.1  1  0.1      Oral soft tissue diseases except aphthae (528)  3  0.4  0        Aphthae (528.2)  3  0.4  3  0.2      Injury to mouth (873.6, 873.7)  8  1.0  9  0.6  15.68  6.05–40.63  Total  44  5.6  56  4.0  1.39  0.94–2.07    Age (years)                <25  25+                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  1  0.1  2  0.1      Pulp and periapical (522)  10  1.3  11  0.8  1.61  0.69–3.80  Hard tissues and caries (521)  4  0.5  0        Gingival and periodontal (523)  4  0.5  6  0.4  1.18  0.33–4.19  Malocclusion and J (524)  2  0.3  2  0.1      Other and tooth loss (525)  8  1.0  22  1.6      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  1  0.1  1  0.1      Oral soft tissue diseases except aphthae (528)  3  0.4  0        Aphthae (528.2)  3  0.4  3  0.2      Injury to mouth (873.6, 873.7)  8  1.0  9  0.6  15.68  6.05–40.63  Total  44  5.6  56  4.0  1.39  0.94–2.07  Does not include one patient of unknown with one endodontic emergency. View Large TABLE IX. Incidence Rates by ICD-9 Code and Rank from January 1, 1997 to September 30, 2000   Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  3  0.2  0        Pulp and periapical (522)  20  1.0  1  0.5      Hard tissues and caries (521)  4  0.2  0        Gingival and periodontal (523)  10  0.5  0        Malocclusion and J (524)  4  0.2  0        Other and tooth loss (525)  26  1.3  4  1.9      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  2  0.1  0        Oral soft tissue diseases except aphthae (528)  3  0.2  0        Aphthae (528,2)  6  0.3  0        Injury to mouth (873.6, 873.7)  17  0.9  0        Total  95  4.7  5  2.3  2.08  0.85–5.12    Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  3  0.2  0        Pulp and periapical (522)  20  1.0  1  0.5      Hard tissues and caries (521)  4  0.2  0        Gingival and periodontal (523)  10  0.5  0        Malocclusion and J (524)  4  0.2  0        Other and tooth loss (525)  26  1.3  4  1.9      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  2  0.1  0        Oral soft tissue diseases except aphthae (528)  3  0.2  0        Aphthae (528,2)  6  0.3  0        Injury to mouth (873.6, 873.7)  17  0.9  0        Total  95  4.7  5  2.3  2.08  0.85–5.12  Does not include one patient of unknown rank with one endodontic emergency. View Large TABLE IX. Incidence Rates by ICD-9 Code and Rank from January 1, 1997 to September 30, 2000   Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  3  0.2  0        Pulp and periapical (522)  20  1.0  1  0.5      Hard tissues and caries (521)  4  0.2  0        Gingival and periodontal (523)  10  0.5  0        Malocclusion and J (524)  4  0.2  0        Other and tooth loss (525)  26  1.3  4  1.9      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  2  0.1  0        Oral soft tissue diseases except aphthae (528)  3  0.2  0        Aphthae (528,2)  6  0.3  0        Injury to mouth (873.6, 873.7)  17  0.9  0        Total  95  4.7  5  2.3  2.08  0.85–5.12    Rank                Enlisted  Officer                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  3  0.2  0        Pulp and periapical (522)  20  1.0  1  0.5      Hard tissues and caries (521)  4  0.2  0        Gingival and periodontal (523)  10  0.5  0        Malocclusion and J (524)  4  0.2  0        Other and tooth loss (525)  26  1.3  4  1.9      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  2  0.1  0        Oral soft tissue diseases except aphthae (528)  3  0.2  0        Aphthae (528,2)  6  0.3  0        Injury to mouth (873.6, 873.7)  17  0.9  0        Total  95  4.7  5  2.3  2.08  0.85–5.12  Does not include one patient of unknown rank with one endodontic emergency. View Large TABLE X. Incidence Rates by ICD-9 Codes and Smoking Status from January 1, 1997 to September 30, 2000   Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  2  0.7  1  0.1      Pulp and periapical (522)  3  1.0  17  0.9      Hard tissues and caries (521)  2  0.7  2  0.1      Gingival and periodontal (523)  4  1.4  5  0.3  5.01  1.35–18.67  Malocclusion and J (524)  1  0.3  2  0.1      Other and tooth loss (525)  4  1.4  24  1.3      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  0    2  0.1      Oral soft tissue diseases except aphthae (528)  1  0.3  2  0.1      Aphthae (528.2)  1  0.3  4  0.2      Injury to mouth (873.6, 873.7)  3  1.0  13  0.7      Total  21  7.2  72  4.0  1.83  1.12–2.97    Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  2  0.7  1  0.1      Pulp and periapical (522)  3  1.0  17  0.9      Hard tissues and caries (521)  2  0.7  2  0.1      Gingival and periodontal (523)  4  1.4  5  0.3  5.01  1.35–18.67  Malocclusion and J (524)  1  0.3  2  0.1      Other and tooth loss (525)  4  1.4  24  1.3      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  0    2  0.1      Oral soft tissue diseases except aphthae (528)  1  0.3  2  0.1      Aphthae (528.2)  1  0.3  4  0.2      Injury to mouth (873.6, 873.7)  3  1.0  13  0.7      Total  21  7.2  72  4.0  1.83  1.12–2.97  Does not include emergencies for eight patients with unknown smoking status. View Large TABLE X. Incidence Rates by ICD-9 Codes and Smoking Status from January 1, 1997 to September 30, 2000   Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  2  0.7  1  0.1      Pulp and periapical (522)  3  1.0  17  0.9      Hard tissues and caries (521)  2  0.7  2  0.1      Gingival and periodontal (523)  4  1.4  5  0.3  5.01  1.35–18.67  Malocclusion and J (524)  1  0.3  2  0.1      Other and tooth loss (525)  4  1.4  24  1.3      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  0    2  0.1      Oral soft tissue diseases except aphthae (528)  1  0.3  2  0.1      Aphthae (528.2)  1  0.3  4  0.2      Injury to mouth (873.6, 873.7)  3  1.0  13  0.7      Total  21  7.2  72  4.0  1.83  1.12–2.97    Smoking Status                Yes  No                  No.  Rate  No.  Rate  RR  95% CI  Tooth eruption (520)  2  0.7  1  0.1      Pulp and periapical (522)  3  1.0  17  0.9      Hard tissues and caries (521)  2  0.7  2  0.1      Gingival and periodontal (523)  4  1.4  5  0.3  5.01  1.35–18.67  Malocclusion and J (524)  1  0.3  2  0.1      Other and tooth loss (525)  4  1.4  24  1.3      Jaw diseases and osteitis (526)  0    0        Salivary glands diseases (527)  0    2  0.1      Oral soft tissue diseases except aphthae (528)  1  0.3  2  0.1      Aphthae (528.2)  1  0.3  4  0.2      Injury to mouth (873.6, 873.7)  3  1.0  13  0.7      Total  21  7.2  72  4.0  1.83  1.12–2.97  Does not include emergencies for eight patients with unknown smoking status. View Large TABLE XI. Dental Emergency Rates by Number of Days at Sea from January 1, 1997 to September 30, 2000   No. of Events  Rate/100,000 Person-Days  First 7 days  18  7.5  Days 8–14  12  5.5  After day 14  79  4.6    No. of Events  Rate/100,000 Person-Days  First 7 days  18  7.5  Days 8–14  12  5.5  After day 14  79  4.6  View Large TABLE XI. Dental Emergency Rates by Number of Days at Sea from January 1, 1997 to September 30, 2000   No. of Events  Rate/100,000 Person-Days  First 7 days  18  7.5  Days 8–14  12  5.5  After day 14  79  4.6    No. of Events  Rate/100,000 Person-Days  First 7 days  18  7.5  Days 8–14  12  5.5  After day 14  79  4.6  View Large The evacuation database covers a much larger time period (9 years) than the health events database, which covered 4 ½ years (Table XII). During the period 1991 through 1999, there were 32 requests for medical assistance for dental conditions (ICD-9 codes 520 through 528 and 873.6 and 873.7) by Pacific Fleet submarines and 58 requests from Atlantic Fleet submarines (Table XIII). Dental problems accounted for 7.4 to 7.5% of all requests for assistance. These requests for assistance resulted in 27 evacuations by Pacific Fleet submarines and 43 evacuations by Atlantic Fleet submarines. Therefore, dental problems accounted for 7 to 9% of all evacuations. TABLE XII. Proportion of Medical Evacuations due to Dental Conditions, 1991–1999   Requests for Assistance  No. Evacuated  Dental Requests  No. Evacuated  % Dental Requests  % Evacuated  SubPac 1991 to 1,999  432  392  32  27  7.4  6.9  SubLant 1991 to 1,997 (except 1998)  774  460  58  43  7.5  9.3    Requests for Assistance  No. Evacuated  Dental Requests  No. Evacuated  % Dental Requests  % Evacuated  SubPac 1991 to 1,999  432  392  32  27  7.4  6.9  SubLant 1991 to 1,997 (except 1998)  774  460  58  43  7.5  9.3  View Large TABLE XII. Proportion of Medical Evacuations due to Dental Conditions, 1991–1999   Requests for Assistance  No. Evacuated  Dental Requests  No. Evacuated  % Dental Requests  % Evacuated  SubPac 1991 to 1,999  432  392  32  27  7.4  6.9  SubLant 1991 to 1,997 (except 1998)  774  460  58  43  7.5  9.3    Requests for Assistance  No. Evacuated  Dental Requests  No. Evacuated  % Dental Requests  % Evacuated  SubPac 1991 to 1,999  432  392  32  27  7.4  6.9  SubLant 1991 to 1,997 (except 1998)  774  460  58  43  7.5  9.3  View Large TABLE XIII. Dental Habits Questionnaire during a 101-day Submergence   Begin (times/week)  Midpoint (times/week)  End (times/week)  Brush  12.5  11.1  11.1  Floss   4.4   3.9   3.6    Begin (times/week)  Midpoint (times/week)  End (times/week)  Brush  12.5  11.1  11.1  Floss   4.4   3.9   3.6  View Large TABLE XIII. Dental Habits Questionnaire during a 101-day Submergence   Begin (times/week)  Midpoint (times/week)  End (times/week)  Brush  12.5  11.1  11.1  Floss   4.4   3.9   3.6    Begin (times/week)  Midpoint (times/week)  End (times/week)  Brush  12.5  11.1  11.1  Floss   4.4   3.9   3.6  View Large Before the underway period, while ashore, the submariners reported 14 toothaches over the preceding year for which they sought care. In addition, three submariners reported a toothache for which they did not seek care and the dental condition improved without intervention (Table XIV). During the single patrol, one crew member had a toothache at mid-patrol for which he did not seek care, and one patient had a toothache during the last half of the patrol and he also did not seek care. TABLE XIV. Toothache Survey during a 101-day Submergence   On Shore Past Year  Days 1–50  Days 51–101            No.  %  No.  %  No.  %  Toothache and did seek care  14  11.5   0     0    Toothache and did not seek care   3  2.5   1  0.8   1  0.8  Total  17  13.9   1  0.8   1  0.8    On Shore Past Year  Days 1–50  Days 51–101            No.  %  No.  %  No.  %  Toothache and did seek care  14  11.5   0     0    Toothache and did not seek care   3  2.5   1  0.8   1  0.8  Total  17  13.9   1  0.8   1  0.8  For middle and end surveys, both patients reported the condition got better. View Large TABLE XIV. Toothache Survey during a 101-day Submergence   On Shore Past Year  Days 1–50  Days 51–101            No.  %  No.  %  No.  %  Toothache and did seek care  14  11.5   0     0    Toothache and did not seek care   3  2.5   1  0.8   1  0.8  Total  17  13.9   1  0.8   1  0.8    On Shore Past Year  Days 1–50  Days 51–101            No.  %  No.  %  No.  %  Toothache and did seek care  14  11.5   0     0    Toothache and did not seek care   3  2.5   1  0.8   1  0.8  Total  17  13.9   1  0.8   1  0.8  For middle and end surveys, both patients reported the condition got better. View Large The special survey of self-reported dental problems was designed to obtain information on minor conditions that might not be recorded in the medical encounter database (Table XIV). Of those reporting dental problems, 13.1% had a dental problem during the 101-day submergence, 9.8% had a canker sore, 4.1% had a gum problem, and 1.6% had a toothache. Two other dental problems reported were a possible loose crown and trouble keeping a bridge clean. Of those reporting their classification, 67.3% of submariners were class 2 when the submarine deployed and 26.5% were class 1. This is considered a dental readiness of almost 94%. Goal is 95%. In summary, RR calculations indicated smoking status was found to be significantly associated with the occurrence of periodontal emergency. Smoking status was also found to be significantly associated with the occurrence of any dental emergency. Enlisted rank was 2.3 times more likely to have a dental emergency, but was not significant at 95% CI. Age was not a significant risk factor. In the stepwise logistic regression model, the only variable significantly associated with having a dental event was smoking. DISCUSSION This study has several new and important aspects. Previous dental emergency studies combined initial visits and revisits for dental emergencies when determining rates, thus the rates calculated were actually rates of visits for dental emergencies and not rates of specific events. We have used initial visits only in determining rates. Also, this is the first dental study to describe emergencies by both dental codes and medical ICD-9 codes. This is also the first study with the specific purpose of describing dental emergency rates on submarines. The number of dental emergency visits was compared to previous studies (Table XV). Ludwick et al.1 reported 157 per 1,000 service members per year for 1969 Vietnam. Payne and Posey2 reported 167 per 1,000 service members per year for 1981 simulated combat. Teweles and King4 reported 160 per 1,000 service members per year for the Sinai/Egypt deployment. Deutsch and Simecek11 reported 149 per 1,000 service members per year for 1990–1991 Operations Desert Shield/ Storm. Using initial and subsequent visits and converting to the same terms, this study reported 26 per 1,000 service members per year for submariners between 1997 and 2000. TABLE XV. Questions from Special Dental Survey (Days 1–101 of Deployment)   No. of Yes Responses  % Yes Responses  Any dental problems?  16  13.1  Toothache?   2   1.6  Break/crack a tooth or loose/crack a filling while eating?   0    Break/crack a tooth or loose/crack a filling due to trauma?   0    Break/crack a tooth or loose/crack a filling not due to trauma or eating?   0    Canker sore?  12  9.8  Gum problem?   5  4.1  Jaw joint problem?   0    Any other problems?   2  1.6    No. of Yes Responses  % Yes Responses  Any dental problems?  16  13.1  Toothache?   2   1.6  Break/crack a tooth or loose/crack a filling while eating?   0    Break/crack a tooth or loose/crack a filling due to trauma?   0    Break/crack a tooth or loose/crack a filling not due to trauma or eating?   0    Canker sore?  12  9.8  Gum problem?   5  4.1  Jaw joint problem?   0    Any other problems?   2  1.6  View Large TABLE XV. Questions from Special Dental Survey (Days 1–101 of Deployment)   No. of Yes Responses  % Yes Responses  Any dental problems?  16  13.1  Toothache?   2   1.6  Break/crack a tooth or loose/crack a filling while eating?   0    Break/crack a tooth or loose/crack a filling due to trauma?   0    Break/crack a tooth or loose/crack a filling not due to trauma or eating?   0    Canker sore?  12  9.8  Gum problem?   5  4.1  Jaw joint problem?   0    Any other problems?   2  1.6    No. of Yes Responses  % Yes Responses  Any dental problems?  16  13.1  Toothache?   2   1.6  Break/crack a tooth or loose/crack a filling while eating?   0    Break/crack a tooth or loose/crack a filling due to trauma?   0    Break/crack a tooth or loose/crack a filling not due to trauma or eating?   0    Canker sore?  12  9.8  Gum problem?   5  4.1  Jaw joint problem?   0    Any other problems?   2  1.6  View Large When considering only initial visit rate to determine an incidence, our study found the incidence of dental conditions to be only 18 emergencies per 1,000 per year (as opposed to the total number of visits for dental emergencies being 26 per 1,000 per year). The smallest number of visits reported in previous studies was 29 emergencies per year for “class A” patients in the study of Teweles and King.4 Our rates are only ∼16% of the rates in other studies. TABLE XVI. Comparison to Other Studies Study  Ref.  Initial and Subsequent Visits for Emergencies/1,000 Service Members/ Year  Vietnam 1969  Ludwick et al.1  157  Simulated combat 1981  Payne and Posey2  167  Sinai/Egypt 1982  Tewelse and King4  160  Desert Shield/Storm 1990–1991  Deutsch and Simecek11  149  Submariners 1997–2000  Deutsch and Thomas    26  Study  Ref.  Initial and Subsequent Visits for Emergencies/1,000 Service Members/ Year  Vietnam 1969  Ludwick et al.1  157  Simulated combat 1981  Payne and Posey2  167  Sinai/Egypt 1982  Tewelse and King4  160  Desert Shield/Storm 1990–1991  Deutsch and Simecek11  149  Submariners 1997–2000  Deutsch and Thomas    26  Calculations: 154 emergencies per 2,170,607 person-days = 7.1 emergencies per 100,000 person-days, or 0.025896 emergencies per person per year, or 26 emergencies per 1,000 per year. View Large TABLE XVI. Comparison to Other Studies Study  Ref.  Initial and Subsequent Visits for Emergencies/1,000 Service Members/ Year  Vietnam 1969  Ludwick et al.1  157  Simulated combat 1981  Payne and Posey2  167  Sinai/Egypt 1982  Tewelse and King4  160  Desert Shield/Storm 1990–1991  Deutsch and Simecek11  149  Submariners 1997–2000  Deutsch and Thomas    26  Study  Ref.  Initial and Subsequent Visits for Emergencies/1,000 Service Members/ Year  Vietnam 1969  Ludwick et al.1  157  Simulated combat 1981  Payne and Posey2  167  Sinai/Egypt 1982  Tewelse and King4  160  Desert Shield/Storm 1990–1991  Deutsch and Simecek11  149  Submariners 1997–2000  Deutsch and Thomas    26  Calculations: 154 emergencies per 2,170,607 person-days = 7.1 emergencies per 100,000 person-days, or 0.025896 emergencies per person per year, or 26 emergencies per 1,000 per year. View Large Implications from the rates determined are: submariners have a much lower rate of dental emergencies than other military populations. This would indicate that the intense dental screenings do result in decreased dental emergencies as Payne and Posey2 predicted in 1981. In this study, 3% of health problems requiring a visit to the IDC were for dental complaints. The percentage of medical visits attributable to a dental condition is smaller than the percent reported by McKee et al.12 Dental disease accounted for 10% of soldier visits to medical treatment facilities in the Bosnia operation. When compared to 10 years of health data collected on Polaris submarines in the study by Tansey et al.,13 the percentage of visits that were attributable to dental conditions was the same at 3%. The implications of smoking as a risk factor for dental emergencies could be screening out smokers in missions where dental care is not available, such as long-term space flights or Antarctic research. The findings are limited by the short duration of underway periods. The longest submergence was 101 days, which is still much shorter than other isolated missions. Future research is needed for a larger sample size. The rate of dental conditions requiring a visit to the independent duty corpsman while underway on submarine deployments was 5 per 100,000 person-days with an average of 0.4 revisits required. Demographic factors of age and rank were not significant risk factors; however, smoking status was a significant risk factor for a dental emergency. The rate of emergencies decreased in later time periods of a patrol. This is consistent with studies by Deutsch and Simecek11 and McKee et al.12, both of which noted this time trend.11,12 The number of dental emergency visits during 37 weeks of Operations Desert Shield/Storm decreased by 0.045 per thousand Marines each week. McKee et al.12 simply reported a trend toward decreased dental emergency visits as troops neared their rotation date. The proportion of medical evacuations due to dental conditions was 6.9% for the Pacific fleet and 9.3% for the Atlantic fleet. It is unknown if different policies, operating conditions or mix of submarine types could account for the difference. Not all evacuations are of equal urgency. If another evacuation was occurring unrelated to a submariner's dental problem, a less urgent dental patient could be evacuated at the same time for convenience. The 10-year study by Tansey et al.13 of health data collected on Polaris submarines was much smaller. In 10 years, there were only 50 dental problems that resulted in 105 lost days of work and one transfer at sea as compared to 154 emergencies in the primary database of this study. Tansey et al.13 reported the same percentage of medical events was for a dental condition as this study (3%). The Polaris submarines in this study had fewer evacuations for dental conditions (3% as compared to 6.9–9.3% in this study). The major findings of this study are: 109 initial dental emergency visits and 45 revisits were recorded during 240 submarine patrols. Of these visits, 48.6% were for an emergency related to an endodontic or caries problem. The incidence rate for all dental problems was 5.0 per 100,000 person-days at sea. Smoking was significantly associated with the occurrence of a periodontal-related emergency and also with the occurrence of any dental emergency. The rate of dental emergencies per 100,000 person-days decreased during deployment with the rate for the first 7 days being 7.5, days 8 through 14 being 5.5, and after day 14 being 4.6. Dental problems accounted for 6.9–9.3% of all medical evacuations from submarines between 1991 and 1999. A survey of self-reported dental problems was designed to obtain information on minor conditions that might not be brought to the attention of the medical care provider. Of problems reported, 13.1% had a dental problem during the 101-day submergence, 9.8% had a canker sore, and 4.1% had a gum problem. This study is limited in that it applies only to adult men. In addition, the overwhelming majority of these men are Caucasian. The small numbers of dental emergencies in some strata limit determining the significance of risk factors. ACKNOWLEDGMENTS Contributors to these databases include: Terry L. Thomas, PhD, MS, and the principal investigator for “A Method for Monitoring the Health of U.S. Navy Submarine Crewmembers during Periods of Isolation.” Collaborators include CDR Wayne Horn, MC USN, Tomoko I. Hooper, MD, MPH, CDR T.M. Leiendecker, USN, and associates, and Force Medical Officers. REFERENCES 1. ‘Ludwick W, Gendron E, Pogas J, Weldon A Dental emergencies occurring among Navy-Marine Corps personnel serving in Vietnam. Milit Med  1974; 139: 121– 3. 2. Payne TF, Posey WR Analysis of dental casualties in prolonged field exercises. Milit Med  1981; 146: 265– 71. 3. Grover PS, Carpenter WM, Allen GW Dental emergencies among United States Army Recruits. Milit Med  1983; 148: 56– 7. 4. Teweles R, King JE Impact of troop dental health on combat readiness. Milit Med  1987; 152: 233– 5. 5. Keller D Reduction of dental emergencies through dental readiness. Milit Med  1988; 153: 498– 501. 6. Nice DS U.S. Navy medical communications and evacuations at sea. Milit Med  1987; 152: 446– 51. 7. Norman JN, Ballantine BN, Brebner JA, et al.   Medical evacuations from offshore structures. Br J Indust Med  1988; 45: 619– 23. 8. Calderara PC, Zuccari A Soldiers' dental complaints compared with clinical findings in the military hospital in Bologna, Italy. Milit Med  1992; 157, 10: 542– 4. 9. Chisick MC, King JE Dental epidemiology of military operations. Milit Med  1993; 158: 581– 5. 10. King JE U.S. Army dental support for Operation Desert Shield/Storm. Dent Corps Intl  1992; 4: 4– 6. 11. Deutsch WM, Simecek J Dental emergencies among Marines ashore In Operations Desert Shield/Storm. Milit Med  1996; 161: 620– 3. 12. McKee KT Jr., Kortepeter MG, Ljaamo SK Disease and nonbattle injury among United States soldiers deployed in Bosnia-Herzegovina during 1997: Summary primary care statistics for Operation Joint Guard. Milit Med  1998; 163, 11: 733– 42. 13. Tansey WA, Wilson JM, Schaefer KE Analysis of health data from 10 years of Polaris submarine patrols, Undersea Biomed Res Submarine Suppl 1979 ; S217– 46. 14. Thomas TL, Hooper TI, Camarca M, Murray J, et al.   A method for monitoring the health of U.S. Navy submarine crewmembers during periods of isolation. Aviat Space Environ Med  2000; 71: 699– 705. Google Scholar PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Dental Events during Periods of Isolation in the U.S. Submarine Force
JF - Military Medicine
DO - 10.7205/MILMED.173.Supplement_1.29
DA - 2008-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/dental-events-during-periods-of-isolation-in-the-u-s-submarine-force-iD80ACViXc
SP - 29
EP - 37
VL - 173
IS - suppl_1
DP - DeepDyve
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