MANAGING THE IMPOSSIBLE LESSONS FROM THE DEFENCE DENTAL SERVICES

1. MANAGING THE IMPOSSIBLELESSONS FROM THE DEFENCE DENTAL SERVICES • LT COL SARAH RAMAGE • MSc, BDS, MFDS RCPS(Glasg), RADC • Senior Dental Officer Catterick 1

2. MILITARY DENTISTRY 2

3. DEFENCE DENTAL SERVICES • The Defence Dental Services mission is to contribute to military capability by delivering quality dental care for the Armed Forces on operations and during peacetime.

4. Military Clinical Dentistry • Good dentistry “by any standards”. • Ordinary dentistry, done extraordinarily well. • Placed in the occupational context. • Why define? SJC

5. Military Dentistry – Working Definition • “Military dentistry specifically addresses the occupational needs of the Service community as a whole by providing treatment that is at low risk of degradation in order to achieve a level of dental health that is at low risk of morbidity in the operational environment”.

6. Delivery of Care by the DDS • Clinical dentistry for force preparation • Occupational health service • Community dental service

7. Military (Clinical) Dentistry • Avoid • Inappropriately complex treatment plans (KISS!). • Treatment with a high risk of failure. • Especially in patients with high caries-susceptibility. • When complex treatment fails, a complex solution is required > Restorative Consultant.

8. Military (Clinical) Dentistry • Does this mean “dumbing-down” the treatment that we provide for our patients? • ABSOLUTELY NOT • It does mean providing treatment appropriate to patients’ caries risk. • In the high-caries risk patient, high quality treatment is often simple.

9. Military (Clinical) Dentistry • It does not mean: • Low quality • Low tech • Compromising your clinical standards • Never making crowns or bridges

10. Military (Occupational) Dentistry • It does mean: • Knowing exactly what occupational group each patient is in. • Providing treatment appropriate to each patient’s occupation. • Providing treatment appropriate to the patient’s clinical condition.

11. INFANTRY RECRUITS 11

12. SCHOOL OF INFANTRY • MISSION • “Train Officers and Soldiers in appropriate close combat skills to the standards and in the quantities directed by the Training and Development Agency and Training Requirements Analysis in order to meet the operational requirements of the Army and Defence”

13. INFANTRY TRAINING CENTRE CATTERICK • Operating since 1995 • Creation of ITC(C) centralised training on a scale not seen since National Service. • Output • 3200 trainees per year. • Combat Infantry Course (CIC) delivered over 26 weeks.

14. INFANTRY TRAINING CENTRE CATTERICK • Syllabus • Skill at Arms – weapon handling and shooting. • Fieldcraft – how to move, survive and fight on the battlefield by day and night. • First Aid • Radio communications • Drill • Chemical, Biological, Radiological & Nuclear. • Basic map reading. • Fitness

16. RECTRUIT TRAINING PROGRAMME

17. Unavailable Periods in an average ITC(C) Training Programme

18. AVERAGE INFANTRY RECRUIT • 17-25yrs old. • Often never seen the dentist. • Low expectations of dental care. • High dental treatment needs

19. PROJECT MOLAR CONCEPT

20. WHY PROJECT MOLAR ? • 10 year continuing decline in Army Dental Health. • Director Clinical Services DDS in Jan 05 • Lack of Access – • Operational tempo • No ability to provide routine care to recruits “Give us access to the recruits and we will resource” Clinical Services DDS Jun 05 Project MOLAR Initiation Meeting

21. IMPROVED ACCESS REQUIRED Ops Field Army ? Phase 2 Training School Phase 1 Training School Recruit Selection Centre Careers Office

22. SITUATION • 30% of all recruits enter trained Army with extensive oral disease • 90% of recruit population have an identified TN at enlistment that can be completed within 2 hrs (TN-4) • 70%of Army join with a high prevalence of disease. • Require an average of 2.1 hours of treatment. • During P1 and P2 training 50% of recruits require 1.2 hrs emergency treatment. • Recruits enter trained Army with: • more dental disease than when they enlisted • TN 2x that of the trained force • require 4.4 hrs of treatment • Access to routine care on average 14 months post-enlistment

23. Army Recruits - Evidence • Army recruits have double the decay levels of RAF recruits1 • Caries incidence on Service entry2: • 33% of Army recruits are free from decay on entry • <10% of Infantry recruits at ITC Catterick are caries free • Compared to 50% for RN and RAF3 • MPH Project: Surg Cdr T Elmer 2010. • Hurley and Tuck: Military Medicine. 01 November 2007; 172(11): 1182-1185. • RAF Recruit Courses 446 (18/10/10) and 448 (6/10/10).

24. PROBLEM • Lack of access to recruits during P1 and P2 training

25. SOLUTION • Access • 2 hours per recruit (P1 & P2) • Dentistry • 1200 hrs of dentistry per established DO post per year

26. Project MOLAR • Military Oral Liability Army Recruits • In place since 01 Apr 2006 • Address high levels of dental disease in ARs: • Early intervention • Stop ‘small holes becoming big holes’ • Reduce burden on Fd Army

27. PROJECT MOLAR BENEFITS • Major reductions in TN entering trained Army • Improved sustainability of population dental fitness • Improving and maintaining the whole force dental risk profile • Limiting necessity and extent of surges of treatment pre-deployment • Reduced rates of dental emergencies and subsequent impacts on capability • Reduction in time lost from military duties and force preparation

28. FORECASTS • 5 YEAR • Do Nothing: • 57% moderate to high risk • 23% unfit for task • MOLAR • 61% dental fitness (improvement of 21%) • Deployable risk reduced from 57% to 38% • 15 YEAR • Do Nothing • 64% at moderate to high risk • 27% unfit for task • MOLAR • 70-75% dental fitness • Deployable risk reduces to 30% iaw internationally recognised levels for well-prepared force

29. CONSTRAINTS • Intensive nature of training • Heavy reliance on civilian work force • Dental care provision should have a minimal impact on delivery of training.

30. OPTIMAL TREATMENT TIME • 90% of recruit population have an identified TN at enlistment that can be completed within 2 hrs

31. ASSESSMENT OF TN ON ENLISTMENT (Based on records of 1121 recruits from a typical Army Training Regiment Total 85.5hrs to get 90% of recruit population dentally fit (incl 2 hrs remedial for those with TN>2hrs) over 12 -14 week period. Maximum level of fitness Target Population TN<2hrs – 90%, 65.5hrs. Av Annual Intake of 1500 recruits presents an Annual TN – 1325 hrs. ( not accounting for 20% drop out)

32. ITC CATTERICK

33. ITC Catterick – Av annual intake 3200 recruits Total 115.5hrs to provide 2 hrs for every recruit for intake over 26 week period Maximum level of fitness Target Population TN<2hrs – 85%, 95.5hrs Annual TN – 2319 hrs ( not accounting for up to 35% drop out)

34. Comparison of StrategiesClinical Resources – 10hrs

35. DDS action at the local level • Review clinical hrs available • Coincide clinical hrs with max availability of recruits within limit of working week – flexibility • Creation of Appointment schedule based on Trg programme. • Lists of prioritised personnel and appointment slots to Directing Staff – responsibility with Chain of Command. • Daily reminders • Communication between Dental Centre PMs inter/intra unit

36. FOB SHAWQAT- Home of Part of 1-Lancs Battle Grp We are seeing roughly 15 - 20 dental patients a week. This is over the entire AO which is about 1250 at present. This is all medical staff seeing the patients not just at my facility. Of these there are about 5 CAT C(24hr request) CASEVACS per week for dental issues and probably the same again for sent back on next routine flight - tend not to have full sight of these as they are co-ordinated locally and as not medically evacuated remain non medical. Most presentations are either ongoing problems flaringup, loss of fillings and bizarrely a lot of abscesses.Unless a guy is returned to Camp Bastion (BSN) he tends to remain effective. However, there is a low cut off for sending to BSN - i.e. pain over 36hrs. I will treat for probably 72hrs with ABs and higher dose PKs but PBs do not have that luxury and to be honest they should be reviewed. The average time for a solider to be off work pending flight, time for Tx and then return to front line is about 5 days. This is highly dependant on flights and could as short as 2-3 days and as long as 7-10 days.   Major Chris Baird- Clarke- Regimental Medical Officer 1st Battalion Duke of Lancaster Regiment- April 2010

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38. MOLAR - The Evidence

39. Oral Health on Operations • Disease and Non-Battle Injury (DNBI). • Dental DNBI is a • major contributor • Current rates much • higher than acceptable

40. Dental DNBI

41. The Oral Health Strategic Plan • The DDS Future Vision with central focus on morbidity reduction and • the delivery of key healthcare outputs • New model for the delivery of care • Action plan and implementation timetable.

42. OBJECTIVES • A reduction in dental morbidity on operations • Planned re-orientation of our activity towards disease control and prevention. • Gain the evidence of effectiveness and cost effectiveness for interventions

43. Traditional Target Groups for Prevention of Caries Caries Prone - Early Childhood Caries Handicapped - Medical, Physical etc Socially Deprived - Low Socio-economic Immigrant Groups - Inner Cities Army Recruits

44. The Future • Rapid treatment of tri-service initial recruit needs, along with initial oral health education. • Orientation of activity towards more disease control and prevention • Conduct the required applied research on effectiveness and cost effectiveness • Dental DMICP is essential for this • Needed for expanding the evidence base

45. MAXIMISING CLINICAL EFFICIENCY 45

47. 3 ASPECTS • Be there • Have patients there • Maximize what you get done when there

48. Be there- Boring but essential! • 200 clinical days a year • 32 clinical hours a week (minimum) • Each clinical session am or pm costs a lot to the DDS • Is the admin done in “an admin afternoon” worth that much? • Are you doing enough dentistry to EARN your keep?

49. ALTERNATIVE ADMIN TIMES • Between patients • At lunch • After work • When patients Fail to Attend • Power cuts- Volcano’s- Maundy Thursday pm • Defer to PM- let the Practice Manager manage

50. ALTERNATIVE ADMIN TIMES • Meetings- do you have to go- could Practice Manager attend?? • Visits to Units • - could they visit you • put them in the Dental Chair- • Undertake their dental inspection and then Brief • Position of Power- puts them on edge • Shows we are busy • One less inspection to do!!!!!!!!