The World Of Military Orthodontics
by Dr. Casey J. Burns Captain, Dental Corps, United States Navy Specialty Leader for Navy Orthodontics to the Chief, Bureau of Medicine and Surgery
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government. This article will focus on military treatment by the Air Force, Army, and Navy. The Public Health Service also has dental officers and a small number of orthodontists.
Oftentimes, while attending orthodontic meetings or speaking with other dental professionals, patients or even friends and family, I am greeted with surprise—“There are orthodontists in the military?!” Some may wonder why we exist and what our contributions are to the overall mission of the Department of Defense. How are our practices managed? What is our focus? Who are our patients? Rest assured, we do have a unique purpose that enhances the lethality of the United States Military as well as a proven track record as outstanding clinicians and servant leaders.
Who Are We?
Military orthodontists are fairly unique—we are a small community of about 80 officers. Many of us entered the military shortly after dental school and spent time as general dentists before attending orthodontic residency. A smaller number are direct accessions from private practice or took a nontraditional path in a nonmedical military community. Currently, most of us train at the TriService Orthodontic Residency Program (TORP) in San Antonio, Texas, a 2-year program that leads to a master’s degree from the Uniformed Services University. Approximately 88% of us are presently board certified. Although some of our military dental colleagues have limited orthodontic privileges, we are the only specialists who provide comprehensive orthodontic treatment. We are from many diverse backgrounds, but we all proudly wear the uniform of the United States Military and have sworn to support and defend the Constitution.
We have two primary roles: first, as Military Officers who wear the cloth of the Nation and, secondly, as dedicated orthodontic providers seeking clinical mastery. In addition to treating patients, we function in many nonclinical jobs throughout the military. As officers, we have annual military trainings, deployments, leadership expectations, collateral duties, and frequent moves just like other members of the military. Air Force, Army, and Navy orthodontists are more connected than most other military dental specialties because we train together, transfer patients to each other, and maintain ongoing relationships through the American Association of Military Orthodontists.
Military Orthodontics is led by Specialty Leaders (Navy) and Specialty Consultants (Air Force and Army) who are tasked with advising the service Surgeon General as well as the Defense Health Agency on everything related to orthodontics and the community at large. This includes but is not limited to clinical practice guidelines, military instructions, duty assignments, career development, new technology, bonuses, cuts, retention, and resident selection.
Our Mission
Our overall mission is to support military training and readiness as well as provide warfighter support by rendering high-quality orthodontic treatment for our beneficiaries. What exactly does this mean? To break it down more clearly, it is important to understand the differences in the goals of our stateside versus overseas practices. Typically, military dental treatment facilities located in the United States do not accept family members for care, except for specific circumstances, like craniofacial anomalies or specific types of cases for the residency programs. These practices focus on adult treatment. When stationed stateside, we feed orthognathic cases to military oral surgeons and oral surgery residents, making the surgical case load upwards of 80%–90%. Surgeons who are proficient at putting faces together can and will save lives during wartime conflict—which is a big reason why military orthodontics exists. Additionally, we treat adult restorative patients, mentor and teach at Advanced Education in General Dentistry Programs (AEGD) and General Practice Residencies (GPR), and serve as faculty members at Military Postgraduate Dental Schools and the TORP. These contributions can clearly make a difference in the skillsets and readiness of our oral surgeons and dentists who deploy on ships or to austere locations. We have a direct impact in creating stronger clinical teams and better-educated clinicians, who in turn provide important care to our warfighters.
In contrast, our overseas focus is to support the military family. Transitioning to an overseas duty location can be daunting, and the last thing our Sailors, Airmen, Solders, and Marines should have to worry about is their kids’ teeth while they are deployed or stationed in a foreign country. Identification of orthodontic issues and timing for treatment can be crucial for some children. Many overseas areas totally lack a civilian network for this service, do not have the same types of orthodontic care as the United States, or do not designate orthodontic specialists. Many military families do not necessarily choose an overseas duty station and sometimes receive orders to move earlier than expected while their children are undergoing active orthodontics. Children and adolescents accepted for treatment in overseas locations include transfer patients from U.S. civilian orthodontists (higher priority for continued orthodontic care Outside the Continental United States goes to those who had braces before the orders were cut), those with crossbites, excessive overjet, severe crowding, impacted teeth, eruption issues, and Class III children in mixed dentition. In addition, we treat adult multidisciplinary and orthognathic surgery cases, while also mentoring other dental specialists and general dentists on orthodontic diagnosis. These functions are very important to provider development—many of the general dentists are quite junior clinicians and have just come from an installation in the States that does not treat children. Looking at a child’s Panorex for the first time since dental school can be intimidating! Consequently, the mentorship of these dentists becomes crucial in overseas locations.
Our Patients
We serve a very deserving population who sacrifice many liberties to keep us safe, so we do our best to hold our practices together and treat as many patients as we are able. As you might imagine, this is a very diverse patient population from all walks of life, from every State, and even other countries. Many folks want or could benefit from our services, especially when they hear that braces are “free.” In fact, they are not really free—we are stewards of the American taxpayer dollar and are required to use keen discernment when accepting patients for treatment. Unfortunately, we cannot offer orthodontic therapy to every beneficiary. So, how do we determine who is eligible? Luckily, we have a lot of guidance when it comes to patient selection; specifically, military instructions. The Defense Health Agency, as well as each individual service, manages instructions which provide clinical practice guidelines that mirror the American Association of Orthodontists as well as issue selection criteria for eligible patients. The big criteria utilized are:
1. Time Remaining at a Duty Station: In general, patients must have sufficient time remaining in their present assignment (generally 24 months or more), with the goal being completion of treatment prior to patient transfer to a new duty station. There are case-by-case exceptions for interceptive or limited treatment that would take less time to complete or that is critical during windows of growth or eruption of teeth. Unfortunately, having a malocclusion does not qualify someone to extend their time on station for medical reasons to obtain, nor can orthodontic therapy be used to justify staying longer than the scheduled rotation date.
2. Deployablity Status: Although all military members have the potential to deploy, there are some specific contraindications for the initiation of orthodontic therapy when active-duty members are placed on deployable platforms, such as ships or frequently deploying units. Patients may be in situations where they do not have access to even a general dentist for an extended amount of time. Because connectivity of the Internet can be difficult in some areas, teledentistry is inadequate in these cases. Anyone undergoing orthodontic therapy who is assigned to such a unit for longer than 6 months must have their appliances removed. For shorter deployments, the clinician will seriously assess compliance and oral hygiene to determine if the therapy should be stopped altogether or the appliances made passive.
3. Eligible Patients Must Be Active-Duty Military Personnel or Their Command-Sponsored Child Dependents (While Overseas, Rarely While Stateside): There is a hierarchy of eligibility for each type of patient we may encounter, but due to the overwhelming demand of care, we rarely get beyond the active-duty member and their dependents. TORP will typically accept the children of retirees more readily because they need pediatric patients for the residency program.
4. Patients Must Have a Current Exam and No Active Caries, Periodontal Disease, or Active Temporomandibular Joint Issues: Orthodontists will verify these items during evaluation.
5. Tobacco Use or Vaping as well as Poor Oral Hygiene Are Disqualifiers.
Our general dentists do an overall great job ensuring that patients meet the above criteria before generating a referral, which helps prevent evaluations from easily overwhelming our schedules. Even with this tiered approach, the truth is we often have to say no due to demand for treatment exceeding the threshold of what we can handle. This situation tests our abilities to balance being a clinician and an officer, and we ensure that we are doing our best to not only take as many patients as possible but also to perform our military duties well. The added challenge is that our military and leadership performance is critical for promotion, so to move up in the ranks, we must learn to strike a good balance. Patients are welcome to see civilian providers if they do not qualify for military care. We still recommend they have the appropriate time on station, if possible, to complete treatment, unless there is a growth, eruption, or timing issue. Active-duty patients are required to have approval from their chain of command, and if assigned to a deployable unit they should not initiate or continue any orthodontic therapy, including aligners. Their assignments can be unpredictable, and they may not have access to help if there is a problem. Orthodontists have some autonomy on how they manage their referrals and score severity, but all services use some version of a discrepancy index. The Army and Air Force utilize the HIM but have some flexibility if there is another system they prefer. The Navy uses a modified version of the ABO discrepancy index which is part of the Navy Orthodontics Instruction. This information is pivotal
for not only selecting the most severe patients but also those who are impacted by timing of growth or eruption of teeth. Once the information is collected, it is taken to a patient selection board led by the orthodontist. The frequency of the board depends on the orthodontist, but most meet monthly. It is encouraged to have a pediatric dentist and oral surgeon on the board, if possible, but other dentists also participate. I personally use this as an opportunity to educate and mentor our clinicians, taking time to walk through the diagnostic process, and find it improves the quality of referrals sent. The board evaluates patient time on station, severity, oral hygiene, how many patients are being treated currently, and how many patients can reasonable be added to that number. This process ensures that patient selection is as fair and unbiased as possible.
Our Practices Imagine moving and joining a new practice every 2–4 years, having a different experience every time. This is the life of a Military Orthodontist! Although we try to streamline as many of our processes as possible, no two military practices are exactly alike—variability in the training and experience level of the orthodontist, the size of the base population, the number of potential patients, the quality of the civilian network, the number of chairs or assistants, the skillset of the assistants and lab, IT knowledge on our systems, whether or not there is administrative/front-desk staff (you may have to do it yourself!), and even the availability of certain supplies. We are limited by what we are given—and we do the best with it that we can. Most administrative burdens rest on our shoulders, and many times our assistants are young and inexperienced. All of this can be frustrating, but it forces us to be flexible and learn to troubleshoot a lot of interesting challenges. It also encourages us to lean on each other for advice.
Because patients can move with short notice, it is imperative that we focus on mechanics. Maintaining continuity also means a mostly streamlined bracket size and prescription (0.022 slot MBT) across the military, with quality metal twin brackets and bands. Money for supplies is regulated by each individual facility, and each practice maintains and orders its own supplies through its chain of command. We often must think ahead and be prepared in case of continuing resolution or budget cuts. Lab support can be hit or miss due to the experience or capabilities of the lab staff, so we might have to make more complex appliances ourselves. We typically do not order from labs outside of the military due to budgetary constraints and the complexity of contracts. For the most part, we either train the lab staff or fabricate them ourselves! As a note, we still get a lot of success with headgear—because it works! Unfortunately, we do not have very many options for aligner therapy due to security network limitations that may compromise patient information stored by the aligner company’s Cloud. In addition, aligners can be very time consuming for us to make in-house. We will continue to look towards potential future options.
Transfer Cases
Especially overseas, we gain numerous transfer cases. This is where the private practice orthodontist can really help the patient and the gaining military provider. As has been mentioned, we do not have the ability to offer orthodontics to everyone referred or everyone who can benefit. Transfer patients can be very difficult, regardless, but military practices do not have practice managers, orthodontic-concentrated front-desk staff, or treatment coordinators. The administrative burden usually falls on the orthodontists themselves, so transfer cases are much easier to accept if the patient or parent has the American Association of Orthodontics (AAO) Transfer Form along with initial and transfer records when they arrive at their new place of duty. This cannot be understated—ensuring the AAO Transfer Form is completely filled out with type of brackets or slot sizes and basic treatment plan or treatment progression is beneficial. Military transfer patients must have the correct documents to make their transition easier for them and for us! It is also important to note that the only patients who are automatically accepted are those treated by other military providers—but we do our best to accept as many transfer patients as we can. When the situation is reversed, we try to provide good transfer paperwork. Patients should contact the local military treatment facility for information on the availability of orthodontics at their next installation!
Retention
Retention policies, like those in private practice, are up to the individual orthodontist. We have to weigh several factors when it comes to which retainer we will provide to the patient. If bonded retainers come loose, it can be difficult to repair them if the patient is deployed. At the same time, retainers can be lost in a move or while on a ship. We do our best, but I will be honest that retention is very difficult for military practices. Another major factor that contributes to the choice of retention is the skill and availability of the lab. Hawley retainers can be difficult and time consuming for military labs to fabricate because most of their training focuses on other restorative aspects of dentistry. Additionally, many active-duty lab technicians have not been stationed with an orthodontist before and may be inexperienced in making not only retainers but other appliances as well. If the lab is robust and busy, their timetable to make and return a Hawley retainer can be upwards of a month or longer, which can be difficult if a patient is moving shortly after they are debonded. Retention continues to be one of the most difficult aspects of orthodontics, especially since our providers and patients move so much.
The Future
The military is constantly evolving—luckily, Military Orthodontists are resilient and accustomed to change. This is not without sacrifice, not without frustration. However, the path we have chosen as Military Officers has many levels of purpose that can be incredibly fulfilling, and one shining constant is the joy and compassion we bring as we serve the most deserving patients out there!