Mike Chisick, LTC, DC, USA

U.S. Army Center for Health Promotion and Preventive Dentistry

Aberdeen Proving Ground, MD

Pamila Richter

U.S. Army Dental Command

Fort Sam Houston, Texas

Put More “Bite” Into Health Promotion

“Bite”

A campaign to re-vitalize Health Promotion in the Army Dental

Care System.

“Bite”

A joint effort between

USACHPPM and DENCOM

ADCS Vision

The Army’s dental care system of choice, focused on readiness, health promotion and

exceeding our customer’s expectations.

“Put more dental into health promotion and more health promotion into the Army

Dental Care System.”

MG Patrick Sculley

Partnerships

USADENCOM - USACHPPM

DENTAC - MEDDAC

DC - TMC

“Bite” puts more DENTAL into health promotion through patient-oriented initiatives for:

Sealants

Mouthguards

Lip and Oral Cancer

Nursing Bottle Caries

“Bite” puts more HEALTH PROMOTION in the dental care system through patient-oriented initiatives for:

Skin Cancer

Tobacco Cessation/Interdiction

Nutrition

Blood Pressure Screening & Referral

PPIP

“Bite” puts more HEALTH PROMOTION in the dental care system through provider-oriented initiatives for:

Ergonomics

Stress Management

Guidelines Used in Developing “Bite”

Mindful of provider curative workload

Mindful of need for provider buy-in

Craft a well-focused, narrow, doable, acceptable agenda

Make initiatives evidence-based

Rationale for “Bite” Initiatives

Put More “Bite” IntoHealth Promotion

S e a la n t In it ia t iv e

Why Sealants?

High need in military population

Potential to greatly reduce future operative workload

Why Oral Cancer?

30,000 cases in U.S. annually

8,000 deaths in U.S. annually

90% occur in individuals > 45 y.o.

Risk factors

– Tobacco

– Sun Exposure

– Alcohol

– Diet

Why Oral Cancer?

Tobacco & alcohol account for 75% of all oral cancers

Smokers 2-18x greater risk

Heavy drinkers who smoke > 1 pack cigarettes/day 24x greater risk

Military population has high exposure to oral cancer risk factors

Why Skin Cancer

800,000 new cases annually

Incidence of skin cancer has dramatically increased over past few decades

Everybody is susceptible

Military is high risk occupation for skin cancer

Lifetime Risk of Malignant MelanomaRigel, et al. J. Am. Acad. Derm. 17(6):1050-1053, 1987

0

4

8

1 2

1 6

1 9 3 5 1 9 5 0 1 9 8 0 2 0 0 0

/10

0,0

00

Rate

Why Tobacco Cessation/Interdiction?

Tobacco Kills...

over 400,000 people each year.

Tobacco Kills...

more people than heroin, cocaine, alcohol, AIDS, fires, homicides, suicides, and automobile accidents COMBINED.

Why Tobacco Intervention?

Active duty compared to recruits

Limited to enlisted only with < 5 years service

Standardized for age, sex, and race

Cross-sectional design; no causation

(TSOHS)

Cigarette Smoking

21

43

5

20

0

5

10

15

20

25

30

35

40

45

Whites Blacks

Recruits

Active Duty

SLT Use

11

24

0

5

10

15

20

25

White Males

Recruits

Active Duty

Put More ‘Bite’ Into Health Promotion

Tobacco cessation advisement by dentists to their patients

The American Dental Association has recommended tobacco education for

patients since 1964.

Percent of Active Duty Military Seeing a Dentist within the Past Year

86%

(‘94-’95 TSCOHS)

Tobacco Cessation Advisement

5 76 2

6 8

6 8

7 2

0 15 30 45 60 75

Snuf f

Chewing Tobacco

Cigaret t es

Cigars

Pipes

Law M, Tang JL (1995): An Analysis of the Effictiveness of Interventions Intended to Help People Stop Smoking.

Arch Intern Med. 155:1933-41

Reviewed findings from 188 controlled clinical trials on smoking cessation.

Minimum 2 year duration.

Minimal intervention effective.

Despite low success rate, still cost effective.

On- and Off-the-jobOn- and Off-the-job

Injury PreventionInjury Preventionis one of the top priorities ofis one of the top priorities of

LTG Blanck, the Army Surgeon GeneralLTG Blanck, the Army Surgeon General

Why Mouthguards?

Military population is highly athletic

Am. Academy for Sports Dentistry recommends MGs for 40 sports

During any sports season, athletes have a 10% chance of sustaining an injury to the face or mouth

Why Mouthguards?

High school football injuries to mouth and face

- 50% prior to 1962

- 1.4% today

Impact of official game rules mandating use of mouthguards

Squash surfing skate boarding shot putt skydiving trampoline tennis volleyball wrestling weight lifting water polo

Academy for Sports Dentistry endorses mouthguard use for the following sports:

acrobatics baseball basketball boxing cycling discus equestrian sports field hockey football gymnastics handball

ice hockey judo karate lacrosse motorcross martial arts parachuting rugby racquetball skiing soccer

(Johnsen & Winters, Dent Clinics N Amer 35:657-66, 1991)

13% - 39% of all dental injuries are sport-related

(Hayrinen-Immonen et al., Endod Dent Traumatol 6:208, 1990)

(San, Proc Finn Dent Soc 84:Supplement IV, 1988)

Ankle injuries and HEAD TRAUMA tie as the leading cause of MAJOR injuries in IDF paratroopers.

Overall injury rate 0.89% or 9/1000 plane jumps.

Earlier studies show injury rates of 0.3-1.4 % or 3.1-14/1000 plane jumps.

(Bar-Dyan, Bar-Dyan, & Shemer, Milit Med 163:1-2, 1998)

Although the injury rate for parachuting may Although the injury rate for parachuting may be low, the cost of a single major parachuting be low, the cost of a single major parachuting injury could be prohibitive in both lost injury could be prohibitive in both lost productive time and medical costs.productive time and medical costs.

CHPPM ankle brace, now in mandatory use CHPPM ankle brace, now in mandatory use in airborne training, has cut the incidence of in airborne training, has cut the incidence of ankle injuries in half.ankle injuries in half.

Reducing injuries 10 % in the Army Reducing injuries 10 % in the Army

would save an estimated would save an estimated $35m.$35m.

(COL Bruce Jones, MD, USACHPPM)(COL Bruce Jones, MD, USACHPPM)

Key Challenges to Changing Health-Related Behaviors

“Everybody loves to learn but nobody likes to be taught.”

- Winston Churchill

“We don’t need no education. We don’t need no thought control”

- Pink Floyd

The most treasured of all American liberties is the right to be left alone.

- Samuel Warren and Louis Brandeis

The Right to Privacy. Harvard Law Review.

15 December 1890.

Time Pressures

Fragmented Audience

General Principles to Follow When Counseling on Health

Behaviors

“TEAM” Approach

Clinic Waiting Room

– Video Loops from ADA, ACS, TDA, etc

– Posters

– Pamphlets

– Static Displays

“TEAM” Approach

Clinical Staff

– Patient Interviews

– Reinforce Positive Lifestyles & Healthy Decisions

– Reinforce Oral Message with Written Materials

– Referrals

Old Clinical Axiom:

What is said is not

what is heard.

Deliver the Message Through Multiple Channels

Oral

Written

Visual

Why educate people who can’t benefit from a service?

Raise awareness

Diffuse knowledge

May influence others as a parent, relative, or peer

The only thing harder than getting an old idea out of the military mind is getting a new one in.

- Liddell Hart

‘97 Dental Health Promotion Practices Survey

606 full-time clinically assigned dentists

Queried on:

– Frequency of delivering 20 dental health promotion/preventive services

– Type and source of patient educational materials

Dental Health Promotion/Preventive Services Delivered Frequently

PSR Education 69%

Tobacco Counseling 75%

Blood Pressure Screening 79%

Oral Cancer Screening 84%

Individual Oral Hygiene Instruction 88%

Dental Health Promotion/Preventive Services Delivered Infrequently

Nursing Caries 8%

Make Mouthguards 21%

Mouthguard Education 24%

Place Sealants 25%

Sealant Education 28%

Sources of Patient Education Materials

Internet 2%

Tobacco-Free 3% Steering Committee

NOHICH 4%

Other 7%

Amer. Heart Association 12%

Insurance Company 16%

Amer. Cancer Society 23%

Self-Designed 25%

Army 38%

ADA 49%

Media used to deliver dental health promotion messages is

almost exclusively oral counseling.

“Bite” Interventions Include: Screening and referral

- Skin, lip, & oral cancer

Clinical services- Mouthguards

- Sealants

Patient Education– Sealants– Mouthguards– Skin, lip, & oral cancer

– Tobacco cessation/interdiction

You can resist an invading Army; you cannot resist an idea whose time has come.

- Victor Hugo

Points of Contact

Pamila T. Richter, USADENCOM DSN 471-8241, COM (210)221-8241

MAJ Mark Piotrowski, USACHPPM DSN 584-7390, COM (410)436-7390