RESEARCH WITH A BITE
The Dental and Biomedical Research Conducts Biomedical
and Dental Research Aimed at Improving the
Medical and Dental Care Provided to Warfighters.
by David G. Charlton, D.D.S.,
Diane R. Bienek, Ph.D.,
Captain A. Dale Ehrlich, M.S., D.D.S, DC, USN
The Naval Institute for Dental and Biomedical Research (NIDBR) recently celebrated its 60th year of operation. Established in 1947, NIDBR has carried out a wide range of research focused on identifying needs inherent to dental and operational health care and developing products that speak to those needs.
NIDBR is co-located with the U.S. Air Force Dental Evaluation and Consultation Service and the U.S. Army Dental and Trauma Research Detachment at Great Lakes, Ill. Each of these units conducts biomedical and dental research aimed at improving the medical and dental care provided to warfighters.
BEING RESPONSIVE TO CHANGING NEEDS
Although the basic principle of warfare has remained essentially the same over the years, the conditions under which it is fought and the nature of the weaponry have changed dramatically. As these changes occur, NIDBR has proactively redirected its focus, always maintaining its goal of producing productoriented, scientifically-sound, militarilyfocused research directed at meeting the real-time needs of the warfighter. Some of these needs result from the type and location of the conflict being fought. For example, conflicts in Iraq and Afghanistan have resulted in a significant number of casualties with craniofacial and traumatic brain injuries.
While improvements in body armor have saved many lives, the head and neck remain vulnerable areas. Consequently, there has been an increase in the number of craniofacial injuries and, hence, a growing need for maxillofacial reconstruction. Although currently available prosthetic materials and techniques for reconstruction are successful in restoring function and esthetics to injured warfighters, NIDBR’s Clinical Sciences Department has sought ways of improving these materials and techniques to provide even more satisfactory results. Currently, surgical reconstruction of the soft and hard tissues of the head and neck are based on post-traumatic 3-dimensional CT scans and requires multiple visits to the operating room. NIDBR is currently collaborating with the Naval Dental School Bethesda to develop a method of using low-dose 3-D cone-beam CT scans to assist in the design and fabrication of craniofacial prostheses. If the technique is successful, predeployment scans would be made and available should the warfighter be injured during his/her deployment. At some point in the future, scans might routinely be made of all personnel prior to deployment to facilitate treatment should it be necessary during an individual’s military career. Also related to craniofacial reconstruction, NIDBR is beginning a study to measure the range of skin shades to assist in the development of new materials for more life-like prostheses.
In an attempt to utilize new technologies for military biomedical purposes, nanotechnology has been added to NIDBR’s capabilities. Nanoparticles are being studied to determine if they can act as drug delivery systems to prevent postsurgical infections that can occur with reconstructive cranial implants. Applied to the surface of the implant, the antibioticcontaining nanoparticles in light-cured resin would slowly release antibiotics to the soft tissues surrounding the implant. This could prevent post-operative infections of the soft tissues of the scalp. Another advantage of this type of localized delivery system would be to reduce or eliminate side-effects observed during systemic antibiotic treatment.
Different locations around the world present health care problems for warfighters because they may be exposed to pathogens not normally seen in the United States. In recent years, a growing number of deployed military personnel in the Middle East have been infected with cutaneous leishmaniasis. Currently, no reliable topical treatment for use in field operations has been cleared by the Food and Drug Administration. As such, infected personnel must be evacuated for treatment at great expense. NIDBR has developed and is currently testing a topical skin treatment for Leishmania infection which appears to holds promise for treating the condition in the field. A related project involves the screening of a variety of metallic salts of fluoride to develop new methods to manage bacterial and fungal growth in open wounds. Topical treatments resulting from this project are envisioned to augment conventional antibiotic regimens, especially where multidrug resistance occurs.
ASSESSING THE EFFECTS OF ENVIRONMENTAL CONDITIONS ON MEDICAL/DENTAL PRODUCTS
Environmental conditions in the Middle East have also provided fertile ground for NIDBR research. Medical and dental materials and devices are commonly transported and stored under conditions of high temperature and low humidity, although many manufacturers recommend that their products be stored from 4ºC to 30ºC (39ºF to 86ºF). To assess the effects of environmental conditions on such products, NIDBR’s Applied Laboratory Sciences personnel are testing commercially available rapid-diagnostic kits (i.e., blood typing and pathogen identification devices) before and after their exposure to various temperature and humidity conditions in NIDBR’s walk-in environmental chamber. The chamber makes it possible to subject products to conditions ranging from -40°C to 65°C (-40°F to 150°F) and from 15 percent to 95 percent relative humidity. As part of an extensive program of dental field equipment testing, NIDBR has also evaluated the effects of environmental conditions on dental equipment. An active program of laboratory and user testing of many types of field dental equipment has been in place since 2003. As part of the program, NIDBR has subjected the equipment to performance testing before and after environmental chamber exposure. The equipment was then sent to sites in Okinawa, Kuwait, and Barrow, Alaska. At these locations, the U.S. Navy, U.S. Marine Corps and U.S. Public Health Service dentists have worked with the equipment under actualuse conditions to assess their performance and capability to withstand transport, set-up, use and disassembly. Using these varied locations assures that the equipment will be exposed to and used under a number of different environmental conditions. NIDBR is also collaborating with USAF optical engineers at Wright-Patterson AFB, Ohio, to develop a high-efficiency, long-lasting dental examination/treatment light that uses lightemitting diodes.
PREVENTION: ELIMINATING PROBLEMS BEFORE THEY OCCUR
A key aspect of NIDBR’s work has been in the area of prevention and public health dentistry. NIDBR’s Clinical Sciences Department has been involved in several areas of research including developing evidencebased assessment tools to help identify personnel with a high risk of experiencing acute dental emergencies. Preventing such emergencies keeps warfighters with their units and prevents disruption of the mission. NIDBR has also played a key role in dealing with environmental issues related to the use of mercury in amalgam fillings and its proper disposal. As the lead agent for the Navy’s Dental Mercury Abatement Program, NIDBR works on evaluating commercial devices that remove mercury from dental wastewater. When these products have proven too costly or are inadequate for Navy use, NIDBR has developed systems to reduce mercury from clinic wastewater and reduce dentistry’s environmental footprint.
THE FUTURE OF U.S. NAVY DENTAL RESEARCH
Future research will continue to focus on providing improved treatment modalities and maxillofacial prostheses for the injured warfighter. Work will also be done to develop databases to identify the types of reconstructive implants being placed and their maintenance schedules in order to ensure that the highest quality of care is being delivered to the injured soldier, sailor, airman and marine. NIDBR has an active ongoing program for evaluating the use of computer-aided design/computeraided manufacturing (CAD/CAM) technology for quickly and accurately producing dental restorations such as crowns and bridges. As software and hardware used by CAD/CAM equipment improve, NIDBR will monitor the improvements to determine if the equipment can be used in forward locations to provide these types of permanent restorations to the warfighter.
In the near future, NIDBR and its sister service’s dental research organizations will relocate from Great Lakes, IL to Fort Sam Houston in San Antonio, Texas, as a result of a recent Base Realignment and Closure Commission decision. With this move will come change. NIDBR will become part of the Naval Medical Research Unit–San Antonio after arriving in Texas and will take up residence at the Joint Center of Excellence for Battlefield Health and Trauma Research. Joining with the other Department of Defense combat casualty care and trauma research organizations in San Antonio will bring cohesion to this vital part of military medical research and maximize its benefits for America’s warfighters. •
For more information, contact MMT Editor Jeff McKaughan or search our online archives for related stories.
NIDBR is co-located with the U.S. Air Force Dental Evaluation and Consultation Service and the U.S. Army Dental and Trauma Research Detachment at Great Lakes, Ill. Each of these units conducts biomedical and dental research aimed at improving the medical and dental care provided to warfighters.
BEING RESPONSIVE TO CHANGING NEEDS
Although the basic principle of warfare has remained essentially the same over the years, the conditions under which it is fought and the nature of the weaponry have changed dramatically. As these changes occur, NIDBR has proactively redirected its focus, always maintaining its goal of producing productoriented, scientifically-sound, militarilyfocused research directed at meeting the real-time needs of the warfighter. Some of these needs result from the type and location of the conflict being fought. For example, conflicts in Iraq and Afghanistan have resulted in a significant number of casualties with craniofacial and traumatic brain injuries.
While improvements in body armor have saved many lives, the head and neck remain vulnerable areas. Consequently, there has been an increase in the number of craniofacial injuries and, hence, a growing need for maxillofacial reconstruction. Although currently available prosthetic materials and techniques for reconstruction are successful in restoring function and esthetics to injured warfighters, NIDBR’s Clinical Sciences Department has sought ways of improving these materials and techniques to provide even more satisfactory results. Currently, surgical reconstruction of the soft and hard tissues of the head and neck are based on post-traumatic 3-dimensional CT scans and requires multiple visits to the operating room. NIDBR is currently collaborating with the Naval Dental School Bethesda to develop a method of using low-dose 3-D cone-beam CT scans to assist in the design and fabrication of craniofacial prostheses. If the technique is successful, predeployment scans would be made and available should the warfighter be injured during his/her deployment. At some point in the future, scans might routinely be made of all personnel prior to deployment to facilitate treatment should it be necessary during an individual’s military career. Also related to craniofacial reconstruction, NIDBR is beginning a study to measure the range of skin shades to assist in the development of new materials for more life-like prostheses.
In an attempt to utilize new technologies for military biomedical purposes, nanotechnology has been added to NIDBR’s capabilities. Nanoparticles are being studied to determine if they can act as drug delivery systems to prevent postsurgical infections that can occur with reconstructive cranial implants. Applied to the surface of the implant, the antibioticcontaining nanoparticles in light-cured resin would slowly release antibiotics to the soft tissues surrounding the implant. This could prevent post-operative infections of the soft tissues of the scalp. Another advantage of this type of localized delivery system would be to reduce or eliminate side-effects observed during systemic antibiotic treatment.
Different locations around the world present health care problems for warfighters because they may be exposed to pathogens not normally seen in the United States. In recent years, a growing number of deployed military personnel in the Middle East have been infected with cutaneous leishmaniasis. Currently, no reliable topical treatment for use in field operations has been cleared by the Food and Drug Administration. As such, infected personnel must be evacuated for treatment at great expense. NIDBR has developed and is currently testing a topical skin treatment for Leishmania infection which appears to holds promise for treating the condition in the field. A related project involves the screening of a variety of metallic salts of fluoride to develop new methods to manage bacterial and fungal growth in open wounds. Topical treatments resulting from this project are envisioned to augment conventional antibiotic regimens, especially where multidrug resistance occurs.
ASSESSING THE EFFECTS OF ENVIRONMENTAL CONDITIONS ON MEDICAL/DENTAL PRODUCTS
Environmental conditions in the Middle East have also provided fertile ground for NIDBR research. Medical and dental materials and devices are commonly transported and stored under conditions of high temperature and low humidity, although many manufacturers recommend that their products be stored from 4ºC to 30ºC (39ºF to 86ºF). To assess the effects of environmental conditions on such products, NIDBR’s Applied Laboratory Sciences personnel are testing commercially available rapid-diagnostic kits (i.e., blood typing and pathogen identification devices) before and after their exposure to various temperature and humidity conditions in NIDBR’s walk-in environmental chamber. The chamber makes it possible to subject products to conditions ranging from -40°C to 65°C (-40°F to 150°F) and from 15 percent to 95 percent relative humidity. As part of an extensive program of dental field equipment testing, NIDBR has also evaluated the effects of environmental conditions on dental equipment. An active program of laboratory and user testing of many types of field dental equipment has been in place since 2003. As part of the program, NIDBR has subjected the equipment to performance testing before and after environmental chamber exposure. The equipment was then sent to sites in Okinawa, Kuwait, and Barrow, Alaska. At these locations, the U.S. Navy, U.S. Marine Corps and U.S. Public Health Service dentists have worked with the equipment under actualuse conditions to assess their performance and capability to withstand transport, set-up, use and disassembly. Using these varied locations assures that the equipment will be exposed to and used under a number of different environmental conditions. NIDBR is also collaborating with USAF optical engineers at Wright-Patterson AFB, Ohio, to develop a high-efficiency, long-lasting dental examination/treatment light that uses lightemitting diodes.
PREVENTION: ELIMINATING PROBLEMS BEFORE THEY OCCUR
A key aspect of NIDBR’s work has been in the area of prevention and public health dentistry. NIDBR’s Clinical Sciences Department has been involved in several areas of research including developing evidencebased assessment tools to help identify personnel with a high risk of experiencing acute dental emergencies. Preventing such emergencies keeps warfighters with their units and prevents disruption of the mission. NIDBR has also played a key role in dealing with environmental issues related to the use of mercury in amalgam fillings and its proper disposal. As the lead agent for the Navy’s Dental Mercury Abatement Program, NIDBR works on evaluating commercial devices that remove mercury from dental wastewater. When these products have proven too costly or are inadequate for Navy use, NIDBR has developed systems to reduce mercury from clinic wastewater and reduce dentistry’s environmental footprint.
THE FUTURE OF U.S. NAVY DENTAL RESEARCH
Future research will continue to focus on providing improved treatment modalities and maxillofacial prostheses for the injured warfighter. Work will also be done to develop databases to identify the types of reconstructive implants being placed and their maintenance schedules in order to ensure that the highest quality of care is being delivered to the injured soldier, sailor, airman and marine. NIDBR has an active ongoing program for evaluating the use of computer-aided design/computeraided manufacturing (CAD/CAM) technology for quickly and accurately producing dental restorations such as crowns and bridges. As software and hardware used by CAD/CAM equipment improve, NIDBR will monitor the improvements to determine if the equipment can be used in forward locations to provide these types of permanent restorations to the warfighter.
In the near future, NIDBR and its sister service’s dental research organizations will relocate from Great Lakes, IL to Fort Sam Houston in San Antonio, Texas, as a result of a recent Base Realignment and Closure Commission decision. With this move will come change. NIDBR will become part of the Naval Medical Research Unit–San Antonio after arriving in Texas and will take up residence at the Joint Center of Excellence for Battlefield Health and Trauma Research. Joining with the other Department of Defense combat casualty care and trauma research organizations in San Antonio will bring cohesion to this vital part of military medical research and maximize its benefits for America’s warfighters. •
For more information, contact MMT Editor Jeff McKaughan or search our online archives for related stories.