ABSTRACT
Introduction
Many veterans qualify for health benefits but generally not dental care. This study examines differences in oral health status between veterans and nonveterans in the U.S. to determine how various factors, including socioeconomic, general health, and tobacco use, impact former service members’ oral health.
Materials and Methods
Data from 11,539 dentate adults participating in the National Health and Nutrition Examination Survey (2011-2014) were used. Outcome variables included decayed teeth (DT), missing teeth (MT), filled teeth (FT), caries experience (DMFT), and periodontitis (PD). Covariates included demographic and socioeconomic factors, deployment, smoking, depression, hypertension, hyperlipidemia, and diabetes. Logistic regression modelling was used to assess associations between these factors and oral health outcomes.
Results
Veterans represent about 9% of the U.S. population. There was a higher prevalence of PD, MT, FT, and DMFT among veterans than nonveterans. Veterans were more likely to have PD (OR, 1.8; 95% CI, 1.3 to 2.5) and higher DMFT (OR, 2.9; 95% CI, 2.4 to 3.4); however, after controlling for other covariates, military service was only associated with FT (OR, 1.3; 95% CI, 1.1 to 1.6) and higher DMFT (OR, 1.6; 95% CI, 1.2 to 1.9).
Conclusions
Because veterans are more likely to originate from groups at a higher risk for poor oral health (older adults, smokers, males, diabetics), the prevalence of adverse oral health conditions are higher among veterans compared to nonveterans. Overall, military service is not associated with PD or untreated dental caries but is associated with indicators suggesting veterans have had more dental treatment (FT and DMFT). There is substantial unmet oral health care need primarily related to periodontitis among veterans.
INTRODUCTION
Although differences in general health conditions and tobacco use between Americans who have served (veterans) and have not served (nonveterans) in the military have been well documented,1-5 only two studies have investigated differences in oral health between those with and without prior military service.6,7 One study reported that veterans (with any length of service) had fewer teeth than nonveterans and veterans had more regular dental visits in the past 12 months than nonveterans, but visitation rates decreased with age.6 In the other study, which focused on older adults, veterans who used the Veterans Affairs (VA) health care system were more likely to report poorer oral health than nonveterans.7 Both of these studies relied on self-reported data.
Previous studies have shown that smoking,8 diabetes,9 depression,10 race/ethnicity,11 income,11 and education lev-el12 can each adversely affect oral health. Socioeconomic status is a significant predictor of having ever served in the military and individuals that come from lower income families are more likely to join the military than those from higher-income families.13 A culture that promotes smoking has persisted in the military for decades, and as a result, the prevalence of smoking has remained higher within the military community than in the general U.S. civilian population.14 Although the prevalence of smoking is higher overall in the armed services, prevalence does vary substantially by service. The prevalence of depression also remains higher among active duty and older veterans.1,15,16 Since those who have served in the military are disproportionately affected by these risk factors, veterans may experience the effects of oral diseases more than nonveterans.
Military service may also increase the risk of oral diseases as it is often characterized by long deployments overseas in locations with limited access to preventive services, oral hygiene products, and comprehensive dental care. Chronic stress and fatigue from long working hours and combat can contribute to a reduction in self-care and oral hygiene habits, increased energy drink consumption and smoking, as well as increased risk for depression.17-20 Collectively, these contributing factors may increase the risk of developing adverse oral health outcomes among service members and veterans.
To be eligible for regular dental services through the VA, generally a veteran must have a 100% military service-connected disability, be a former prisoner of war, or have a service-related compensable dental disability or condition.21 Of the over 20 million veterans living in the U.S. in 2019, about half or 9 million qualify for VA medical care, of which only 907,989 qualified for dental care through the VA—representing just 4.5% of the U.S. veteran population and only 10% of veterans enrolled in VA health care system.22 Consequently, a lack of access to VA dental care for most veterans, coupled with the fact that a majority of veterans are elderly and Medicare does not cover dental care, may contribute to significant unmet need among veterans.
The objectives of this study were to (1) examine potential differences in oral health status between veterans and nonveterans using nationally representative examination data and (2) ascertain which factors are more prevalent among veterans that are supporting an increased burden of adverse oral health conditions.
METHODS
Data Source
Information from the National Health and Nutrition Examination Survey (NHANES) from years 2011-2014 was analyzed in this study. The NHANES is a cross-sectional nationally representative survey conducted by the Centers for Disease Control and Prevention National Center for Health Statistics (CDC/NCHS). Oral health data collection protocols were approved by the CDC’s NCHS Ethics Review Board (an Institutional Review Board equivalent) and all survey participants provided written informed consent. Information was collected during home interviews and health examinations which were conducted in mobile examination centers. All oral health examinations were conducted by trained dental examiners who were general dentists. Examiner performance and data quality issues have been reported elsewhere.23 Additional information about NHANES can be located at http://www.cdc.gov/nchs/nhanes.htm.
Study Population
All dentate adults over the age of 18, who participated in the interview and completed the oral and general clinical examination, were included in the analysis. Participants 18 to 39 years old were excluded from analyses assessing periodontitis because NHANES did not administer periodontal examinations on individuals under 30 years old during this survey period. We identified 11,970 adults age 18 and older participating in the home interview, and among these individuals, 10,026 completed an oral health exam. After excluding persons with no income information, there were 9,556 adults in the final analytical sample.
Outcome Variables
Dental caries experience was determined by the number of decayed, missing, and filled permanent teeth (DMFT), excluding third molars. Participants were classified as either below the mean or at/above the mean for each component that makes up the DMFT. Results of univariate analysis of DMFT for the study population indicated that the mean DMFT was approximately 11; consequently, this was used as the cutoff point for a dichotomous subject-level presence of dental caries experience. Similarly, the cutoff point for decayed teeth (DT) was determined to be 1, and 5 for each missing teeth (MT) and filled teeth (FT). Periodontal status was determined by probing depth (PD) and clinical attachment loss (AL), measured at six sites around each tooth (excluding third molars). Persons were assigned into two periodontal status groups: no periodontitis-to-mild periodontitis and moderate-to-severe periodontitis. Based on CDC/AAP guidelines, moderate-severe periodontitis was defined as two or more interproximal sites with ≥4 mm clinical AL (not on the same tooth) or two or more interproximal sites with PD ≥ 5 mm, also not on the same tooth.24
Independent Variable and Covariates
The main independent variable was self-reported prior active duty service (defined as a veteran) in the U.S. Armed Forces. Demographic variables included gender (male or female), age (18-39, 40–59, and 60+ years old), race/ethnicity (non-Hispanic Whites, Hispanics, non-Hispanic Blacks, and Others including multiracial). Socioeconomic variables were median annual household income-level (lower-income < $55,000/year and upper-income ≥ $55,000/year) based on U.S. Census Bureau data,25 and education-level (less than or equal to high school degree or greater than or equal to some college education). Health insurance coverage status was classified as private health insurance, military health care (Tricare, VA or Champ-VA), public health care coverage (Medicare, Medicaid, Indian Health Service, or other government insurance), or no health insurance.
Tobacco use was classified into three groups: current cigarette smokers (smoked at least 100 cigarettes and presently smoke), former smokers (smoked at least 100 cigarettes previously but do not currently smoke), and nonsmokers. General health indicators investigated were hypertension (self-reported use of antihypertensive medication or the average of the four clinical measurements by a systolic blood pressure ≥ 140 mm Hg or a diastolic blood pressure ≥ 90 mm Hg),26 hyperlipidemia (use of lipid-lowering medication, a blood test showing total cholesterol concentration ≥ 240 mg/dL or a fasting LDL cholesterol concentration ≥ 160 mg/dL),27 and diabetes (current use of insulin or diabetic oral hypoglycemic medication, or a blood test showing a fasting plasma glucose level ≥ 126 mg/dL).27 Mental health status was assessed for depression-related symptoms using the Patient Health Questionaire-9. Those who had a score of ≥10 were characterized as having moderate-severe depression, a cut point that has been validated and commonly used in clinical studies that measure depression.10,28
Data Analysis
Descriptive statistics were calculated for all study variables by veteran and nonveteran status. Multivariable logistic regression analyses were conducted to assess the association between oral health status and veteran status while controlling for key covariates. Unadjusted and adjusted regression models were produced to calculate odds ratios (OR) and 95% confidence intervals (CI) using SAS survey procedures (SAS version 9.4) to account for the non-equal probability of selection. Full models were built comprised of all covariates of interest and final (parsimonious) models were produced using a step-wise process of backwards selection of nonsignificant covariates starting with full models yielding only significant (P<.05) covariates in the remaining models. Based on significant interactions observed by income, stratified modelling was performed by income level to assess for effect modification.
RESULTS
In 2011-2014, approximately 9% of the U.S. adult population had served in the military, while the vast majority, 91%, had not served. Our estimate of the proportion of the adult population who were veterans (9.1%) roughly corresponds to the 9.9% reported for 2012 by the U.S. Bureau of Labor Statistics.29 Among adults age 60 and older in the U.S., 21% had served in the military whereas only 3% of adults from age 18-39 had served. Nearly 11% of non-Hispanic whites, 10% of non-Hispanic blacks, and 4% of Hispanics had served (Table I). The prevalence of high- and low-income adults serving in the military was the same (9%). Approximately 17% of former smokers and 8% of current smokers had served in the military. Among adults with some college experience who had periodontitis, 22% were veterans. Similarly, among those with higher income and periodontitis, 19% were veterans. Nearly 26% of former smokers with moderate-severe periodontitis had served in the military. Among males with above average caries experience, nearly 28% were veterans and for men with above average missing teeth, 30% were veterans.
TABLE I.
Prevalence of Selected Characteristics by Moderate-Severe Periodontitis, Dental Caries Experience (DMFT), Untreated Caries Experience (DT), Missing Teeth Experience (MT), and Filled Teeth Experience (FT) for Veterans in the U.S., 2011-2014a,b
| Total | Moderate/severe Periodontitisc | DMFTd | DTe | MTf | FTg | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | %h (SE)i | n | %8 (SE)9 | n | %h (SE)i | n | %h (SE)i | n | %h (SE)i | n | %h (SE)i | |
| Total | 858 | 9.1 (0.4) | 393 | 16.5 (1.2) | 631 | 13.7 (0.4) | 241 | 8.1 (0.7) | 407 | 14.9 (0.6) | 471 | 10.6 (0.5) |
| Age | ||||||||||||
| 18-39 40-59 >60 |
103 229 526 |
3.1 (0.4) 8.0 (0.7) 21.0 (1.0) |
N/A 112 281 |
N/A 10.2 (1.3) 24.4 (1.7) |
26 137 468 |
4.2 (1.1) 9.0 (1.0) 22.1 (1.0) |
26 79 136 |
2.4 (0.6) 9.5 (1.6) 20.8 (1.7) |
6 67 334 |
4.4 (2.0) 8.1 (1.4) 20.9 (1.2) |
45 136 290 |
3.7 (0.8) 8.2 (0.9) 21.9 (1.2) |
| Gender | ||||||||||||
| Female Male |
55 803 |
1.4 (0.3) 17.1 (0.7) |
17 376 |
1.5 (0.5) 27.9 (2.0) |
33 598 |
1.4 (0.3) 27.8 (1.0) |
9 232 |
0.5 (0.2) 14.7 (1.4) |
18 389 |
1.4 (0.5) 30.0 (1.1) |
38 433 |
1.6 (0.4) 21.6 (1.0) |
| Race/ethnicity | ||||||||||||
| Non-Hispanic White Hispanic Non-Hispanic Black Other |
474 86 253 45 |
10.6 (0.5) 3.7 (0.5) 9.7 (0.8) 5.8 (0.9) |
201 46 134 12 |
19.7 (1.8) 6.6 (1.1) 16.6 (1.6) 9.4 (3.3) |
377 53 176 25 |
15.4 (0.6) 5.1 (0.7) 14.0 (1.1) 10.1 (2.0) |
119 23 90 9 |
10.3 (1.1) 2.4 (0.6) 7.8 (1.1) 6.3 (3.1) |
216 40 135 16 |
17.6 (0.9) 7.1 (1.4) 13.3 (1.3) 8.3 (3.2) |
285 43 119 24 |
11.6 (0.7) 4.1 (0.6) 13.6 (1.2) 7.9 (1.9) |
| Income levelj | ||||||||||||
| High Low |
369 489 |
9.1 (0.6) 9.0 (0.4) |
163 230 |
19.1 (1.9) 14.6 (1.5) |
251 380 |
13.7 (0.7) 13.8 (0.7) |
77 164 |
8.2 (1.4) 8.0 (0.8) |
119 288 |
15.2 (1.7) 14.8 (1.0) |
256 215 |
10.6 (0.7) 10.7 (0.7) |
| Education Level | ||||||||||||
| ≥Some College ≤High School Degree |
554 304 |
10.5 (0.6) 6.8 (0.4) |
246 147 |
21.8 (1.7) 10.8 (1.4) |
385 246 |
16.1 (0.8) 10.4 (0.7) |
144 97 |
10.8 (1.2) 5.8 (0.9) |
208 199 |
20.5 (1.4) 11.0 (0.9) |
344 127 |
11.6 (0.7) 8.2 (0.9) |
| Health Insurance Coveragek | ||||||||||||
| Private health insurance Military health insurance Public health insurance No health insurance |
436 150 175 97 |
8.2 (0.4) 63.9 (4.1) 10.0 (0.8) 5.5 (0.7) |
194 64 90 45 |
15.7 (1.2) 80.2 (5.1) 14.9 (2.3) 12.4 (1.7) |
320 104 153 54 |
12.2 (0.5) 65.2 (4.4) 14.5 (1.3) 9.5 (1.5) |
96 57 46 42 |
7.8 (1.0) 79.5 (4.4) 5.9 (1.1) 5.2 (1.4) |
182 77 118 30 |
14.8 (1.0) 66.4 (5.6) 13.6 (1.8) 7.4 (2.0) |
271 66 82 52 |
9.2 (0.6) 54.6 (5.4) 12.5 (1.7) 9.5 (1.5) |
| Smoking Status | ||||||||||||
| Never Smoked Former Smoker Current Smoker |
324 363 169 |
6.5 (0.6) 16.8 (1.1) 8.2 (0.8) |
123 190 78 |
11.5 (1.3) 26.3 (2.4) 12.4 (2.4) |
203 301 125 |
9.6 (1.0) 22.0 (1.7) 11.3 (1.2) |
71 98 70 |
5.6 (1.0) 16.5 (1.8) 6.8 (1.6) |
96 207 103 |
9.3 (1.2) 24.1 (1.6) 11.8 (1.4) |
218 199 53 |
8.3 (0.7) 17.4 (1.5) 8.5 (1.3) |
| Hypertensionl | ||||||||||||
| No Yes |
413 445 |
6.9 (0.4) 14.5 (0.8) |
149 244 |
13.8 (1.4) 19.3 (2.0) |
262 369 |
11.2 (0.6) 17.2 (0.9) |
112 129 |
6.2 (0.9) 12.8 (1.7) |
149 258 |
13.6 (1.3) 16.1 (1.0) |
226 245 |
8.2 (0.7) 15.9 (1.3) |
| Hyperlipidemiam | ||||||||||||
| No Yes |
535 323 |
7.3 (0.4) 16.2 (1.1) |
236 157 |
14.6 (1.3) 20.4 (2.0) |
365 266 |
11.4 (0.7) 19.0 (1.3) |
162 79 |
6.7 (0.9) 15.3 (2.3) |
232 175 |
13.5 (1.0) 17.3 (1.2) |
290 181 |
8.7 (0.7) 16.9 (1.8) |
| Diabetesn | ||||||||||||
| No Yes |
688 170 |
8.3 (0.4) 16.6 (1.6) |
301 92 |
15.9 (1.1) 18.9 (3.3) |
486 145 |
12.6 21.2 |
191 50 |
7.3 (0.8) 15.1 (2.6) |
306 101 |
14.0 (0.7) 18.7 (2.5) |
384 87 |
9.9 (0.6) 17.8 (2.4) |
| Moderate-Severe Depressiono | ||||||||||||
| No Yes |
761 58 |
9.5 (0.4) 6.6 (0.9) |
353 23 |
17.4 (1.4) 9.9 (2.5) |
559 41 |
14.5 (0.5) 8.6 (1.5) |
207 21 |
8.9 (0.9) 4.6 (1.3) |
352 29 |
16.1 (0.7) 7.5 (1.2) |
430 28 |
11.1 (0.6) 7.8 (1.6) |
Source: National Health and Nutrition Examination Survey, 2011-2014.
Dentate population only.
Moderate-severe periodontitis defined as: two or more interproximal sites with ≥4 mm clinical AL (not on the same tooth) or two or more interproximal sites with PD ≥ 5 mm, also not on the same tooth, in population ≥ 40 years old only.
Decayed, Filled, or Missing teeth experience at/above the mean defined as ≥11 DMFT.
Untreated caries at/above the mean defined as ≥1 DT (decayed teeth).
Missing teeth experience at/above the mean defined as ≥5 MT.
Filled teeth experience at/above the mean defined as ≥5 FT.
Weighted percent.
Standard error of weighted percent.
Income level categorized as: High: ≥$55,000/year household income, Low: <$55,000/year household income.
Health insurance coverage categorized as: self-reported private health insurance, military health care (Tricare, VA, or Champ-VA), Public health care coverage (Medicare, Medicaid, Indian Health Service, or other government insurance), or no health insurance coverage.
Hypertension defined as either self-reported use of antihypertensive medication or a clinical diagnosis measured by a systolic blood pressure > 140 mm Hg or a diastolic blood pressure > 90 mm Hg (by averaging out the three measurements taken).
Hyperlipidemia defined as self-reported use of lipid-lowering medication or a blood test showing total cholesterol concentration ≥ 240 mg/dL (6.22 mmol/L) or a fasting LDL cholesterol concentration ≥ 160 mg/dL (4.14 mmol/L).
Diabetes defined as either self-reported current use of insulin or diabetic pill (oral hypoglycemic) medication or blood test showing a fasting plasma glucose level ≥ 126 mg/dL (6.99 mmol/L).
Moderate-severe depression defined as having a score of ≥10 on the PSQ-9 based on depressive symptoms in the past 2 weeks.
N/A: Not available—NHANES collected periodontal data in population ≥30 years old.
The majority of veterans were older (54.5%) and were predominantly male (92.4%) (Fig. 1). There was no difference between veterans and nonveterans based on income level, and nonveterans were more likely to have lower education attainment than veterans (39.5% vs. 28.7%). Although non-Hispanic whites made up 65.5% of the nonveteran U.S. population, they made up a larger proportion of the U.S. veteran population (77.3%). Hispanics made up 15.2% of the nonveteran U.S. population, but just 5.8% of the veteran population. Among veterans, 59.8% were current or former smokers, compared to just 41.4% among nonveterans (Fig. 1). The prevalence of moderate-severe periodontitis was higher among veterans compared to nonveterans (55.0% vs. 40.0%) and caries experience was higher among veterans as well (72.3% vs. 45.4%). The prevalence of having above average missing teeth and filled teeth was also higher among veterans than nonveterans.
FIGURE 1.
Distribution of select demographic, socioeconomic status, general health, and oral health conditions by veteran status: U.S., 2011-2014.
Estimates shown are weighted percent and standard error (error bars).
Table II shows the association (unadjusted ORs) between oral health outcomes of interest and key characteristics in the U.S., including military service, before controlling for confounding factors. Unadjusted modeling results show that veterans were nearly three times more likely to have caries experience (OR, 2.9; 95% CI, 2.4 to 3.4), twice as likely to have missing teeth (OR, 2.2; 95% CI, 1.9 to 2.6), and 50% more likely to have filled teeth (OR, 1.5; 95% CI, 1.3 to 1.8) than nonveterans. Veterans were nearly twice as likely to have moderate-severe periodontitis (OR, 1.8; 95% CI, 1.3 to 2.5) than nonveterans as well. In addition, persons with military (VA) health insurance were 70% more likely to suffer from untreated caries or moderate-severe periodontal disease (OR, 1.7; 95% CI 1.1 to 2.5), and three times more likely to have missing teeth (OR, 3.1; 95% CI 2.2 to 4.3) than those with private health insurance. After controlling for other demographic and health-related covariates in the final multivariable models, military service was only associated with above average caries experience (OR, 1.6; 95% CI, 1.2 to 1.9) and above average filled teeth (OR, 1.3; 95% CI, 1.1 to 1.6), and was not associated with having moderate-severe periodontitis, above average missing teeth, or untreated dental caries experience.
TABLE II.
Association (Unadjusted and Final Multivariable Models) of Select Characteristics and Military Service with Periodontitis, Dental Caries, Missing Teeth, and Filled Teeth: U.S., 2011-2014
| Have Moderate-Severe Periodontitis | Have caries experience (DMFT) | Have untreated caries (DT) | Have missing teeth (MT) | Have filled teeth (FT) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Unadjusted Model OR (95% CI) |
Final Model OR (95% CI) |
Unadjusted Model OR (95% CI) |
Final Model OR (95% CI) |
Unadjusted Model OR (95% CI) |
Final Model OR (95% CI) |
Unadjusted Model OR (95% CI) |
Final Model OR (95% CI) |
Unadjusted Model OR (95% CI) |
Final Model OR (95% CI) |
|
| Age | ||||||||||
| 40-59a >60 |
n/a 1.8 (1.5-2.1) |
n/a 2.4 (2.0-2.8) |
4.3 (3.6-5.0) 17.2 (14.8-20.1) |
3.8 (3.3-4.4) 12.9 (10.7-15.7) |
0.8 (0.7-0.9) 0.5 (0.5-0.6) |
0.9 (0.8-1.1) 0.6 (0.5-0.7) |
5.9 (4.8-7.3) 20.8 (17.2-25.2) |
6.5 (5.6-7.6) 25.3 (20.3-31.6) |
2.7 (2.4-3.1) 2.6 (2.3-3.1) |
2.7 (2.4-3.1) 2.4 (2.0-2.8) |
| Gender | ||||||||||
| Male | 1.8 (1.6-2.1) | 1.9 (1.7-2.2) | 0.9 (0.8-1.0) | 0.8 (0.7-0.9) | 1.3 (1.2-1.5) | 1.3 (1.1-1.5) | 0.9 (0.8-1.1) | - | 0.7 (0.7-0.8) | 0.7 (0.6-0.8) |
| Race/ethnicity | ||||||||||
| Hispanic Black Other |
2.3 (1.8-2.9) 2.5 (2.0-3.2) 1.6 (1.2-2.2) |
2.0 (1.6-2.5) 2.4 (1.9-3.1) 1.9 (1.4-2.6) |
0.5 (0.5-0.6) 0.7 (0.6-0.8) 0.6 (0.4-0.7) |
- | 1.7 (1.4-2.1) 2.3 (1.9-2.7) 1.1 (0.9-1.2) |
1.1 (0.9-1.4) 1.8 (1.5-2.2) 1.0 (0.8-1.2) |
0.8 (0.7-1.0) 1.6 (1.3-1.9) 0.9 (0.7-1.1) |
1.1 (0.9-1.4) 2.2 (1.8-2.6) 1.5 (1.2-1.8) |
0.5 (0.4-0.6) 0.3 (0.3-0.4) 0.5 (0.4-0.6) |
0.8 (0.7-1.0) 0.4 (0.3-0.5) 0.5 (0.5-0.7) |
| Income level | ||||||||||
| Low | 2.9 (2.5-3.3) | 1.8 (1.5-2.2) | 1.3 (1.1-1.5) | - | 2.4 (2.1-2.8) | 1.6 (1.4-1.9) | 2.6 (2.3-3.0) | 1.8 (1.6-2.0) | 0.5 (0.4-0.5) | 0.7 (0.6-0.8) |
| Education Level | ||||||||||
| ≤High School Degree | 2.7 (2.3-3.2) | 1.8 (1.4-2.2) | 1.2 (1.1-1.3) | 1.2 (1.1-1.3) | 2.2 (1.9-2.6) | 1.5 (1.2-1.8) | 2.7 (2.4-3.1) | 2.2 (1.9-2.6) | 0.4 (0.4-0.5) | 0.6 (0.5-0.7) |
| Health Insurance Coverage | ||||||||||
| Military Insurance Public Insurance No Insurance |
1.9 (1.0-3.4) 2.4 (2.0-2.8) 3.0 (2.5-3.6) |
0.8 (0.4-1.8) 1.3 (1.0-1.6) 1.8 (1.4-2.2) |
1.9 (1.3-2.8) 1.7 (1.5-1.9) 0.7 (0.5-0.8) |
- | 1.7 (1.1-2.5) 2.1 (1.8-2.5) 3.6 (3.1-4.3) |
1.5 (0.9-2.3) 1.4 (1.2-1.7) 2.2 (1.9-2.7) |
3.1 (2.2-4.3) 3.1 (2.7-3.5) 1.2 (1.0-1.5) |
1.7 (1.2-2.5) 1.5 (1.3-1.8) 1.3 (1.0-1.8) |
0.8 (0.5-1.1) 0.5 (0.5-0.6) 0.4 (0.3-0.4) |
0.7 (0.5-1.0) 0.7 (0.6-0.8) 0.7 (0.6-0.8) |
| Military Service | ||||||||||
| Veteran | 1.8 (1.3-2.5) | - | 2.9 (2.4-3.4) | 1.6 (1.2-1.9) | 0.9 (0.7-1.1) | - | 2.2 (1.9-2.6) | - | 1.5 (1.3-1.8) | 1.3 (1.1-1.6) |
| Smoker status | ||||||||||
| Former smoker Current smoker |
1.8 (1.5-2.1) 4.3 (3.4-5.3) |
1.6 (1.4-2.0) 4.1 (3.2-5.2) |
2.4 (2.1-2.7) 1.6 (1.4-1.8) |
1.7 (1.5-2.0) 2.0 (1.6-2.3) |
1.0 (0.9-1.2) 2.7 (2.2-3.2) |
1.1 (0.9-1.3) 2.0 (1.7-2.4) |
2.6 (2.3-2.9) 2.9 (2.4-3.4) |
1.8 (1.5-2.1) 3.7 (2.9-4.6) |
1.3 (1.1-1.4) 0.5 (0.4-0.6) |
1.1 (1.0-1.2) 0.6 (0.5-0.8) |
| Hypertension | ||||||||||
| Yes | 1.6 (1.3-1.9) | - | 3.4 (3.1-3.8) | 1.2 (1.0-1.4) | 1.0 (0.9-1.1) | - | 3.9 (3.4-4.4) | 1.3 (1.1-1.5) | 1.3 (1.2-1.5) | - |
| Hyperlipidemia | ||||||||||
| Yes | 1.2 (1.0-1.4) | - | 3.3 (3.0-3.8) | 1.3 (1.1-1.5) | 0.7 (0.6-0.8) | - | 3.0 (2.5-3.5) | - | 1.5 (1.3-1.8) | - |
| Diabetes | ||||||||||
| Yes | 2.0 (1.6-2.4) | 1.5 (1.3-1.9) | 2.3 (1.9-2.7) | - | 1.1 (0.9-1.3) | - | 3.2 (2.8-3.6) | 1.3 (1.1-1.6) | 0.9 (0.8-1.2) | - |
| Moderate-Severe Depression | ||||||||||
| Yes | 1.2 (0.9-1.7) | - | 1.5 (1.2-1.7) | 1.3 (1.0-1.6) | 1.8 (1.5-2.3) | 1.3 (1.0-1.6) | 2.2 (1.8-2.7) | 1.6 (1.3-2.0) | 0.7 (0.6-0.9) | - |
Reference groups: Age group 18-39 (aAge 40-59 for periodontitis); Female gender; Non-Hispanic white; ≥Some college; Private health insurance; Nonveteran; Never smoked; No hypertension; No hyperlipidemia; No diabetes; No moderate-severe depression.
After stratifying by income as a result of the finding of an interaction, low income U.S. adults with military (VA) health insurance (OR, 2.1; 95% CI, 1.1 to 4.1) were more likely to have untreated caries but that association attenuated to nonsignificance for high-income adults in final multivariable modeling (Fig. 2). For low income U.S. adults, prior military service (OR, 1.5; 95% CI, 1.1 to 1.9) was significantly associated with an increased likelihood of filled teeth experience, but that association attenuated to nonsignificance among high income adults (Fig. 2). For low income U.S. adults, having military (VA) health insurance (OR, 1.8; 95% CI, 1.2 to 2.8) or no insurance (OR, 1.5; 95% CI, 1.0 to 2.0) was significantly associated with an increased risk of missing teeth, but those associations attenuated to nonsignificance among high-income adults (Fig. 2).
FIGURE 2.
Influence of select characteristics on untreated caries, filled teeth, missing teeth, and moderate-severe periodontitis experience of the adult population, stratified by income level, U.S. 2011-2014.
*1 OR=6.6 (5.3-8.1), *2 OR=27.1 (22.1-33.2), *3 OR=7.6 (5.1-11.3), *4 OR=36.5 (21.9-60.9). Reference groups: Age group 18-39 (*Age 40-59 for periodontitis); Female gender; Non-Hispanic white; > Some college; Private health insurance; Non-veteran; Never smoked; No hypertension; No hyperlipidemia; No diabetes; No moderate-severe depression. Odds Ratios and 95% Confidence Intervals (error bars) shown are from Final models developed during stratified (income) analyses.
DISCUSSION
Although 9.1% of the total U.S. population have served in the military, veterans make up a larger proportion of the overall U.S. population with above average caries experience (13.7%), periodontitis (16.5%), and above average tooth loss (14.9%), which contributes to a higher overall burden of oral diseases within the U.S. veteran population. However, after controlling for several important sociodemographic factors, there was no association observed between prior military service and oral health status, except for low income veterans who were 50% more likely to have filled teeth compared to other low-income adults in the U.S. Among all low-income adults, persons with military health insurance were more likely to have missing teeth compared to those with private insurance.
Caries experience is a composite measure that incorporates the sum of DT, MT, and F T. Overall, the MT and F T components contribute more to the DMFT measure for veterans than for nonveterans in the U.S. Although results of multivariable modeling indicated that veterans were 60% more likely to have greater caries experience than nonveterans, this was related to veterans having above average filled teeth compared to nonveterans. This suggests that veterans have had greater access to restorative dental care in the past, likely while previously serving on active duty, as regular dental examinations are required to ensure dental readiness.
Additionally, veterans were no more likely to have periodontitis and more tooth loss compared to nonveterans after controlling for demographic, socioeconomic, and other key factors. This suggests that military service alone does not contribute to differences in oral health observed between veterans and nonveterans, but it is very likely that other factors disproportionately affect veterans. Some of these factors include smoking, age and chronic health problems, which are more prevalent among veterans.
For example, the age distribution among veterans is significantly shifted toward older adults, compared to the nonveteran population. Older veterans commonly served in World War II, the Korean War, and the Vietnam War, and make up over a half (54.5%) of the veteran population nationwide. Because periodontitis, dental restorations and tooth loss increases with age, the larger proportion of elderly veterans may partially account for the greater burden of oral diseases and adverse conditions in the veteran community.
Chronic health problems, such as diabetes, are another factor than may underlie higher prevalence of moderate-severe periodontitis and tooth loss among veterans. Poorly controlled diabetes can contribute to increasing severity of periodontitis and, if severe enough, may lead to tooth loss. Because the prevalence of diabetes is nearly twice as high among veterans (17.3%) versus nonveterans (8.7%), veterans may be at increased risk for periodontitis and tooth loss. Previous studies also have shown that veteran dental visitation rates decrease with age, which may partially explain why periodontitis and caries experience is higher among veterans, which are predominantly older (60+ years old).6
Smoking is another factor that can explain why the prevalence of poor oral health is higher in veterans. Smoking is associated with periodontitis, tooth loss, and increasing caries risk. Because the prevalence of current and former smoking (59.8%) among veterans is substantially higher than for those who have not served (41.4%), this greater smoking exposure over one’s lifetime can lead to increased risk for periodontitis, restorative care, and tooth loss. The significant impact of smoking on veteran’s oral health underscores the importance of improved tobacco use policy and programs that target current service members. This could lead to substantial oral health care expenditure savings in the long-run for the military and VA health systems, improve military dental readiness, and prevent the Post 9/11 generation of service members from developing the same burden of oral disease as previous generations as they advance in age.
Among low-income U.S. adults, those with military (VA) health insurance were approximately twice as likely to suffer from missing teeth and untreated caries than those who had private insurance. Their likelihood of untreated caries is actually higher than among those who had some other form of public health insurance and nearly as high as those with no health insurance at all. Moreover, their risk for missing teeth is comparable to those with public insurance and in fact higher than those with no health insurance at all. This suggests that low income veterans who receive medical care have significant unmet dental need by the VA health system, likely attributable to significant limitations on access to dental care, such as requirements that veterans be 100% disabled or a prisoner of war to receive any kind of consistent dental care. Among high-income earning adults, having VA-health insurance did not translate to an increased risk for missing teeth as they were likely able to afford private-practice provided dental care.
Low-income U.S. adults with prior military service were more likely to have more filled teeth compared to those who never served. This suggests that lower income veterans may have benefited from regular access to restorative dental care while previously serving on active duty status, in contrast to other nonveteran low-income individuals who may not have access to free, consistent dental care, which is a substantial benefit of military service. Access while on active duty entitles a service member to no-fee, comprehensive dental care which is customary across many military forces globally—however, this does not extend to veterans of any military force, except those in the U.S. with access to VA dental care.30
Our study had a number of strengths, including the use of nationally representative data of adults living in the U.S., study participants who were not selected based on any preexisting condition, and standardized examinations were conducted that minimized examiner error and improved data reliability. In addition, our overall estimate of the U.S. veteran population, calculated using NHANES data, approximates published statistics from the U.S. Census Bureau. Because of the very limited questioning regarding military status on the NHANES questionnaire, the duration of active duty military exposure (4 years, 8 years, 20+ years, etc.) and veterans’ level of disability cannot be determined, which prevents additional in-depth analyses on this important issue. Because the source of the data is derived from a cross-sectional survey, temporal issues inherent to the study design prevent assessment for any causality.
This study’s findings may have important implications for the U.S., as they indicate that there are significant unmet oral health needs within the veteran community. These findings call to attention the need for additional research investigating other key factors such as disability rating and access to care issues that could be contributing to higher levels of adverse oral health conditions in veterans in contrast to nonveterans. As mentioned previously, over 9 million veterans are enrolled in VA health care and less than 1 million receive dental benefits. Because there has not been meaningful dental eligibility reform for many years, growth in the number of veterans eligible for comprehensive VA dental care grows primarily by achieving a 100% service connected disability rating (this group grew by 13.6% between FY 18-19), or by achieving a service connected rating for a dental or oral condition (this group grew by 9.7% between FY18-19).22
In summary, adverse oral health conditions are substantially greater among veterans than nonveterans. However, military service alone does not increase the likelihood of untreated dental caries, periodontitis, or tooth loss. Instead, the prevalence of these oral conditions among veterans is better attributed to other risk factors that disproportionately affect veterans, including smoking, diabetes, and advancing age. Because of a higher prevalence of smoking and diabetes among veterans, many have considerable unmet oral health care needs primarily associated with periodontitis. Consequently, health providers should consider tobacco cessation interventions and proper diabetic screening and referral for prevention and management to improve oral health outcomes for veterans. Findings from this study can help VA and Military Health System administrators better understand the prevalence and distribution of oral health care needs and how risk factors like smoking affect their current active duty and future veteran patient populations. This could facilitate discussion leading to improved allocation of dental and preventive resources and integration of oral and general health care for veterans. This may not only improve health outcomes for veterans but could reduce long-term health care expenditures for veterans.
ACKNOWLEDGMENTS
None.
Contributor Information
Maj David K Schindler, Tri-Service Center for Oral Health Studies, Uniformed Services University-Southern Region, JBSA-Ft. Sam Houston, TX 78234, USA; National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA.
Gabriela V Lopez Mitnik, National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA.
Lt Col Aida M Soliván-Ortiz, Tri-Service Center for Oral Health Studies, Uniformed Services University-Southern Region, JBSA-Ft. Sam Houston, TX 78234, USA.
Lt Col Scott P Irwin, Tri-Service Center for Oral Health Studies, Uniformed Services University-Southern Region, JBSA-Ft. Sam Houston, TX 78234, USA.
Shahdokht Boroumand, National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA.
CAPT Bruce A Dye, National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA.
FUNDING
None.
CONFLICT OF INTEREST
None declared.
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