A toothache is painful enough for anyone, but imagine how agonizing it might be for an active-duty serviceman on the frontlines, thousands of miles from the nearest dentist's office.

An untimely need for a root canal isn't just unfortunate for airmen, soldiers, sailors and Marines. It has a detrimental effect on the military's overall need for force-readiness, according to Col. (Dr.) David Stanczyk, a consultant to the U.S. Air Force Surgeon General for dental technology integration.

"One of the top causes of non-battle- related disease is the dental problems that troops have in the field, and it quickly impairs their performance and requires significant resources to address the problem," he said. "They might need to be air vac-ed out and then they lose time from their mission because they had to take care of some dental issue that could have been prevented."

That is one of the main reasons why the Air Force recently rolled out an integrated digital dental radiography system that can zap digital x-rays across 80 Air Force dental clinics treating active duty and Air Reserve and Air National Guard personnel worldwide, and why the Army and Navy have their own digital dental initiatives underway.

"Imagine if you will, that all the dentists in the U.S. were connected and could share images. No patient would ever have to worry about whether their x-rays were available for their care," said Col. (Dr.) Dennis D. Stuckey, USAF (ret.), a senior consultant on Air Force Digital Dental Radiology. "That's what we are offering our military personnel."

In the case of the Air Force, the new system completely replaces film x-rays with digital radiography, which means that Air Force dentists can view patient images in near real-time or they can store or share them with other dental providers and specialists across the Web.

The use of digital x-rays provides significant benefits to both patients and the Air Force. Digital radiographs are more environmentally friendly and more cost-effective because they don't require chemicals to aid the film development process. They are ready for viewing more quickly, with digital radiographs up on the screen within 30 seconds vs. the upto- six-minutes it can take for film-based x-rays.

The images also can be displayed on large computer monitors, making them easier to see, which allows for more accurate diagnosis and better patient education. And they cut the amount of radiation exposure to the patient and technician by up to 50 percent.

Moreover, the new system will enable the Air Force to more easily meet the Department of Defense's recently created dental health standard, which requires that at least 65 percent of all service members are orally healthy. That means they don't have any cavities and they've had a recent cleaning. "Bottom line: This probably is the single biggest change and enhancement that we've made to the Air Force Dental Service in its history," said Stanczyk. "Virtually 100 percent of all dental appointments from now on will rely on this technology."

Looking down the road
Just as importantly, the new system is a foundation for future enhancements. Stanczyk says that the Air Force will eventually tie in its new solution with the forthcoming Navy and Army systems, as well as the digital radiography system and EHR systems already in use by the Department of Veterans Affairs.

"The military is becoming so [interconnected], with more and more joint operations and joint basing, which is why integration is so critical," said Stuckey. "Say there's an airman in Afghanistan; he can have a tele-consultation with a dental specialist in Germany, or if he's injured, his dental images will be at the location where's he's going to be treated before he arrives."

In fact, early on, the three services worked together to make sure that all of the budding systems were compliant with the Digital Imaging and Communications in Medicine (DICOM) industry standard to ensure that any dentist— regardless of their branch of service— could access and view the digital x-rays of any of their patients. The three teams have even conducted some joint tests to make sure that x-ray images can be successfully shared.

Michael Fortier, a team member of the Navy Picture Archiving and Communications System (PACS) Office, said that the DICOM standard was chosen very carefully.

"It didn't require any proprietary hardware and that allows us to utilize what is already in existence, but also to expand in the future," he said. "Medical and dental technology is constantly improving, so we wanted to make sure we are always in a position to take advantage of that."

A Navy-wide system is expected to be in place by the end of 2011, but a larger military-wide network that includes all three service systems is at least a couple of years away, according to Navy and Air Force officials.

The challenges include working out the connections between the three different systems, making sure that the systems are secure enough to protect personal identifiable information and that the system is compliant with HIPAA rules and regulations.

"That type of integration and the trust we'll need to have is going to take just a little bit longer," said Fortier.

Once in place, though, a service-wide network will ensure much better patient care. "For dentists to have that information at their fingertips at the moment they have that patient in the chair is important to better diagnosis and treatment," he said.
And it will better serve all military personnel for the entirety of their military careers and beyond, according to Stuckey. "Our goal ultimately is to have these high-quality images available any place in the world, 24/7, and that will keep our personnel mission-ready," he said. "Then when our service members leave active duty, we will be able to seamlessly transfer their dental images into the VA system."
 
How it works
The military has lagged behind its civilian counterparts in the adoption of digital dental x-rays—which rely on digital sensors and software to generate images that can be sent to a PC and viewed immediately—but it is jumping ahead with its ability to share those x-rays among and between its dentists, no matter where they're located.

The Air Force Digital Dental Radiography Solution, which was built by Force 3, an IT services firm based in Crofton, Md., and rolled out in October, relies on Medicor Imaging MiPACS digital imaging software and various digital imaging capture devices.

The x-rays are stored in one of two central archives: one located at Wright-Patterson Air Force Base and the other at Robbins Air Force Base. Air Force dentists can then access those images over NI PRN et, the military's secure, encrypted network for sensitive data.

The Navy also is building a digital dental system that will store and share patient x-rays. According to Michael Fortier, a team member within the Navy Picture and Communication Systems (PACS) office, the Navy is installing an Apteryx Imaging solution within 165 dental clinics (and more than 1,000 dental treatment rooms) across the Navy and has now completed 96 percent of that effort.

Initially, dental clinics will transmit images to a central archive at their local medical center via local networks, which will be fully operational in March. By the end of the year, when the global Navy system is expected to be completed, dental images can also be transmitted to and stored in four regional archives—two in the United States, one in Europe and one in Japan.

A Navy dentist will log onto the system using multi-factor authentication and then conduct a search for a specific patient's records. The system will automatically query the local database first, and then if it's not found, move out to the regional archives.