Military Dentistry: Terrain, Trends and Training Paramjit Singh, Vimal Arora
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1INDIA
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Army Dental Services
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The Army Dental Corps in India is a successor of the Royal Army Dental Corps of the United Kingdom which was born out of necessity to prevent the massive wastage of manpower during the wars. It is therefore, pertinent to delve into the past of the Corps, of nearly four hundred years to the early 17th century, when western style of medicine came to Indian shores by way of five British ships of the East India Company which carried on board, two barber surgeons each.
Prior to 1678, the condition of soldier's teeth was of little concern, but in the 18th century the army created a dental standard of sorts. Grenades and cartridges had to be bit open prior to firing and unless grenadiers and infantrymen had sound anterior teeth for this operation, they were not considered suitable material for these particular branches of the army. One of the causes of the 1857 War of Independence of India was the repugnance of the Indian soldiers to the biting of these cartridges and grenades, which they suspected contained beef or pork fat. It can therefore, be inferred that it was the ‘an issue of teeth’ that struck the first blow for Indian Independence!
In 1857, just at the height of the uprising, officers of the medical service were requested to conserve teeth rather than extract them in every case. However, the army issue of instruments was so inadequate that medical officers could not use them and soldiers' teeth remained largely neglected. Even during the Boer War (1899-1902), the soldiers' teeth were no better. There was simply no provision for dental treatment in the field and little chance for tooth conservation, and the food ration of bully beef with biscuits of tooth shattering solidity, did little to help matters.
Regular provision for dental treatment to the British troops in India dates back to 1905, when specialist pay was granted to certain medical officers, including those practicing dentistry, below the rank of Colonel. Gradually the importance of having healthy teeth and gums was recognized by the army which led to the concept of Army Dental Corps in the UK, while in India for the first time 3 civilian dentists became part of the Army, only for the treatment of British personnel.
In 1914, when World War I brokeout, the facilities provided for dental treatment were minimal; however, a beginning was made in 1915, when an American dentist Varstad Horahnnes Kazanjian was commissioned in the Royal Army Medical Corps. He developed the principles of maxillofacial war injuries, preservation and restoration of the 4facial skeleton foundation, proper dental occlusion and precise soft tissue reconstruction. It was mainly due to the remarkable pioneering work of Dr. Kazanjian that the British Government became aware of significance of dental health of a soldier. There was no Dental Corps in the British Army then, but by that time there were only 15 dentists serving the troops. The government started intensive recruitment of dentists for the field service and by 1918; the number had grown to 850, as part of the Royal Army Medical Corps (RAMC).
 
FORMATION OF ARMY DENTAL CORPS (BRITISH)
The near total disbandment of the army by 1920-21, left only 21 dental officers in the British Army who formed the nucleus of post-war Army Dental Corps for the British Army. Before and during the early years of WW II, there was only a skeletal dental service in India, which catered to the British troops and was manned by officers of the AD Corps, which was a part of the British Army in India.
Indian troops suffered because of lack of dental facilities and the oft-repeated belief that Indian food and Indian methods of maintaining oral hygiene reduced the need for regular dental treatment. In actual practice, the conditions were quite the contrary. The Indian Commissioned officers were entitled to dental treatment at the British Dental Centres. The Indian soldiers however, were not entitled to dental treatment from service sources, resulting in considerable wastage of manpower. This raised a question of dental services for the Indian troops. To start with, civilian dentists were employed on contractual basis for the Indian troops. But these civilian dentists employed locally could not be sent overseas for field duty, hence emergency commission was granted to civilian dentists.
A beginning in the dental treatment of the Indian troops was made in Feb. 1941, when seven Indian dental surgeons were granted Emergency Commission in the newly formed branch of the Indian Medical Services (IMS), designated as the IMS (D). The Corps formed as IMS (D), as an emergency cadre of seven officers, had its teething troubles. Though these officers were commissioned on 01 Feb. 1941, there was no dental equipment available in the country. The ship carrying the equipment from UK sank, delaying the actual establishment of facilities for the Indian troops till July 1941. After two weeks of military training along with IMS officers and two weeks at British Military Dental Centers for instructions in technical administration, these officers were posted to raise Army Dental Centres for Indian troops at various military stations.
The professional work done by this nucleus organisation was highly appreciated and by the end of 1942 their strength was raised. Side by side many Dental Centers for Indian troops were raised in most of the big garrisons. In addition to this, many field dental units were also raised to cater to the requirements of the Indian troops in field areas and operated in different theatres of war, viz. Middle East, Burma, and Ceylon. Thus, with the increase in the demand for dental treatment, the end of the war saw an increase in the number of dental officers from 7 in 1941 to 131 in 1945. As a result, the question of disbandment of the organisation did not arise.
 
INDIAN ARMY DENTAL CORPS
In April 1943, the dental element of the IMS (D) was separated and the Indian Army Dental Corps (IADC) came into being.
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Fig. 1.1: Indian Army Dental Corps
Subsequently all officers of the IMS (D) were transferred to the IADC. In 1947, after independence the letter (I) was removed and the abbreviation ‘ADC’ came into use to denote Army Dental Corps. This abbreviation caused considerable confusion with the term ‘aide-de-camp’, and was duly changed to AD Corps in 1951.
In April 1943, the Corps got its own distinctive badge, which had a laurel wreath surmounted by a crown and a five-pointed star with the initials IADC. The authorized colour of the Corps was green and so was the colour of the lanyard. Much later, after independence, in 1950, a new badge was designed which had within a lotus wreath surmounted by a five-pointed star, crossed elephant tusks, with a lotus flower at the base and a scroll containing the words ‘Army Dental Corps’. Later, the Ashoka lions replaced the star and the authorized colour was changed to dull cherry, as was the colour of the Army Medical Corps (Fig. 1.1).
 
ORGANISATION OF ARMY DENTAL CORPS
At the time of raising of the dental service for the Indian troops in 1941, the service was controlled by the Director of Dental Services (Major General) in UK, through a Deputy Director of Dental Services (DDDS) a Colonel, posted in the General Headquarters of the army in New Delhi, who was assisted by DADDS (Major). For local administrative matters regarding Dental Services, he was responsible to the Director of Medical Services in India. As the dental services expanded, an Assistant Director Dental Services (ADDS) was appointed in each Command from 1942. The Promulgation of an Army Instruction on the formation of Indian Army Dental Corps promulgated in 1943 is reproduced below:
 
 
Indian Army Dental Corps
  1. The Governor General in Council is pleased to sanction with effect from Third April, the formation of an Indian Army Dental Corps.
  2. The Indian Army Dental Corps will be formed by the transfer of all ranks of the Dental Branch, Military Cadre to the new Corps subject to the provision of para 6 below.
  3. The terms and condition of service will be those laid down in Annexure to AI 155 of 1941, as amended from time to time.
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  4. The Corps will be prescribed as Corps under both Army and Indian Army Acts.
  5. The DMS in India will be the head of the Indian Army Dental Corps and will administer it through the Deputy Director, Dental Services.
  6. Dental Officers commissioned under the terms of IAO 155 of 1941 who possess medical qualifications recognised by the Medical Council of India will be seconded to the Indian Army Dental Corps; those with purely dental qualifications will be transferred to the new Corps.
  7. Recruiting and Records of the new Corps will be responsibility of DMS in India.
  8. Separate orders regarding dress will be issued by the DMS in India.
  9. No additional measure is involved in this measure.
In March 1947, the posts of ADsDS were abolished following demobilisation. Command Military Dental Centres (CMDC) were established in each Command and the duties of the erstwhile ADsDS were given to the OC of the CMDC.
On withdrawal of Royal Army Dental Corps officers' cadre in Sep. 1947, the appointment of DDS at Army HQ's and Command Dental Adviser at the command level was taken over by the Indian officers in the rank of Major. The appointment at Army HQ was designated as DADDS. Two years later, the ranks of these appointments were raised to Lt Col and the appointment at Army HQ was upgraded to ADDS. In 1950, Lt Col Kartar Singh was appointed as Assistant Director of Dental Services. In 1971, he retired as Director of Dental Services in the rank of Maj Gen after a distinguished tenure of 21 years as head of the service. In Sept. 1956, the appointment of ADDS at Army HQ was upgraded to DDS (Colonel). The appointments at Army HQ and Command Dental Centres were further upgraded to that of Brigadier and Colonel respectively in the year 1961. In the year 1966, as a befitting recognition of the services rendered by the Corps, the then Director of Dental Services was appointed as Honorary Dental Surgeon to the President of India who is the Supreme Commander of the Indian Armed Forces.
In 1960, a committee under the chairmanship of DMS (Director Medical Services) Navy, Surgeon Commander AK Dev was constituted to recommend reorganisation of the Armed Forces Medical Services. As a result, rank of the head of the AD Corps was upgraded to Major General in 1967. In 1985, the change in the designation of DMS (Army) to DGMS also led to a change in the designation of the DDS to Additional DGDS during the tenure of Maj Gen PC Kochhar, AVSM.
In 1992, the Chief of the Army Staff constituted a committee under the chairmanship of Lt Gen Foley to review the functioning of the Armed Forces Medical Services. It was felt that, the dental profession is distinctively different from the medical profession with a separate governing council, i.e the Dental Council of India. Hence the Additional DGDS was recommended to be placed directly under the Adjutant General. This major achievement was the result of concerted and dedicated effort by Maj Gen AK Varma, AVSM, who was at the helm of affairs of the Armed Forces Dental Services.
As a result of the recommendations, Additional Directorate General of Dental Services (Addl DGDS) working as a section (DGMS-6) under the Director General Medical Services, Army became a separate Directorate like any other independent Service Headquarters, in the year 1998.
On 04 Dec. 2001, the vision of AD Corps to have an independent Directorate General 7headed by a Lt Gen was accomplished due to the sustained efforts of Maj Gen PN Awasthi VSM, Addl DGDS during his short stint at the headquarters and the office of Addl DGDS was further upgraded to DGDS. This post was made tenable by a LIEUTENANT GENERAL.
Lt Gen J L Sharma, AVSM, VSM became the first Director General of Dental Services. This achievement was the result of a long struggle that started in 1986, when it was principally agreed that the head of Army Dental Corps should hold the rank of Lt Gen, but the same could not be implemented for ‘technical’ reasons.
As of today, the Army Dental Corps has a cadre of over 400 officers who look after the dental health of troops of the Army, Navy, and Air Force including more than 100 specialists.
 
DENTAL UNITS AND TRAINING ESTABLISHMENTS
Dental establishments were raised on the basis of peace and war requirements. During the last World War, separate dental centres and dental units existed for Indian and British troops. The dental centres/units for the Indian troops had no arrangement for dental laboratory work, hence they were attached to dental centres/units for British troops. In Jan. 1947, all Indian Army Dental Centres (Indian and British troops alike) were redesignated as Military Dental Centres (MDCs) as static units in peace. One MDC in each Command was reorganised as Command Military Dental Centre, which besides providing dental cover to the local garrison had a centralised prosthetic laboratory for denture work. This unit also provided specialist cover and training facilities for personnel of AD Corps. In the present setup, there are one/two/three chair MDCs according to the garrison strength of the station. All two/three chair dental centres have been authorized a dental laboratory over a period of time.
During World War II, the Mobile Dental Units were raised to provide dental cover during war. These were designated as Indian Dental Units and equipped with lighter equipment for service with field formations and 84 of such units were sent to various theatres of war. These were raised to provide in a scale of one Dental Unit for each Brigade and one for each Division troops. With the increase in the number of field Dental Units, a Corps Dental Unit (CDU) was sanctioned in 1958 to each Corps. The CDUs provided specialist cover and prosthetic laboratory cover for dental services in the field. Subsequently, on the reorganisation of the field medical units into Medical Battalions and later Field Ambulances, the dental units were incorporated in their establishment as Dental platoon/section with a dental laboratory. The Commanding Officer of the CDU was also designated as the Corps Dental Adviser to DDMS of respective Corps Zone.
 
COMMAND MILITARY DENTAL CENTRES
The history of the Command Military Dental Centres dates back to 1942, when recruitment to the IMS (D) was picking up momentum. There were adequate arrangements for imparting basic military training to the newly commissioned dental officers but no infrastructure existed to train them in professional and administrative matters pertaining to the dental services. Therefore, four major British Army Dental Centres at Pune, Ranchi, Delhi, and Rawalpindi were designed and equipped for training purposes and were staffed by experienced British Dental Officers. With the 8partitioning of the country and the departure of the British Officers including the DDDS at General Headquarters in 1947, these Dental Centres at Pune, Ranchi, and Delhi were reorganised into Command Military Dental Centres. Their Officers' Commanding were also designated as Command Dental Advisers to their respective Commands.
Command Military Dental Centres at Pune and Ranchi came into existence in 1947 followed by the one at Delhi. Their Officers' Commanding were granted the acting rank of Major, which over a period of five decades have been upgraded to Brigadier. The rank of Commandant, Command Military Dental Centre, Lucknow, was later upgraded to Major General in 1999.
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Fig. 1.2: CMDC (Eastern Command)
In 1954, Headquarters, Eastern Command along with its Command Military Dental Centre moved from Ranchi to Lucknow. In 1963, after the Indo-Chinese conflict, an Army Command was raised at Calcutta with the designation of Headquarters, Eastern Command. The assets of the existing two-chair Military Dental Centre at Calcutta were utilized to raise a new Command Military Dental Centre for this Command (Fig. 1.2). The Command Headquarters at Lucknow was redesignated as Headquarters, Central Command and its Command Military Dental Centre as Command Military Dental Centre, Central Command.
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Fig. 1.3: CMDC (Northern Command)
In 1972, Western Command split into two to form Western and Northern Commands. New Command Military Dental Centres were accordingly raised in Western and Northern Commands (Fig. 1.3) respectively.
 
DEPARTMENT OF DENTAL SURGERY, AFMC, PUNE
Department of Dental Surgery is an integral part of the Armed Forces Medical College (AFMC). AFMC is the premier professional training institute of the Armed Forces Medical Services through whose portals hundreds of dental officers and thousands of medical officers have passed over the years. The events that led to the creation of this institution need a special mention.
The Army Medical Training Centre (AMTC) established in Jan. 1942, was the forerunner of the present Armed Forces Medical College, which was raised on 01 May 1948 in the immediate post-World War period. On the recommendations of the BC Roy Committee, remnants of the Indian Army Medical Corps units were amalgamated into one unit to create the Armed Forces Medical College. Over the past 50 years, it has grown in its functions and has become one of the premier medical colleges of the country.
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Fig. 1.4: Armed Forces Medical College, Pune
The college started its undergraduate wing on 04 Aug. 1962.
The Armed Forces Medical College (Fig. 1.4) has multiple roles to perform. These are primarily training of medical undergraduates and postgraduates, dental postgraduates, nursing cadets and paramedical staff. Patient care forms an integral part of its training curriculum and the attached hospitals benefit from the expertise available at AFMC. The institution is responsible for providing a major part of the specialists' pool and super specialists to Armed Forces by giving them training. The AFMC forms the backbone of high quality professional medical care being provided to the clientele, which in the ultimate analysis, affects considerable financial saving to the Government besides contributing largely to the morale of the fighting forces. The college is also involved in conducting research in various dental subjects as well as those aspects, which would affect the morale and performance of the Armed Forces both in war and peace.
On the outbreak of WW II the demand for medical and dental officers rose sharply. To meet this requirement a medical wing of the Officer's Training School (OTS) Mhow was opened in 1941, however this arrangement was not enough. It was decided to start an Army Medical Training Centre (AMTC) at Pune in 1943. In August 1945, a wing for officers and other ranks of the Indian Army Dental Corps was added. At the end of the war, demobilisation replaced recruitment. A number of departments including the dental wing were closed down. In 1948, AMTC was reorganised into Armed Forces Medical College.
The dental wing after closing down in AMTC in 1945, resurrected itself in 1949 in AFMC. The AFMC shifted to a new location in 1956 and the new building of the Department of Dental Surgery came into being in 1966, as an extension wing of the main building.
The primary role of the department was to conduct senior dental officer's courses, courses for dental operating room assistants and the dental refresher courses. In 1958, for the first time ever, advanced specialist courses of 52 weeks duration, in Oral Surgery and Dental Prosthetics were introduced. In 1974, the department was affiliated to the Mumbai University for grant of MDS degree and the duration was increased to 104 weeks. In 1975, two more subjects i.e. Periodontia and Orthodontia were added. In order to meet the clinical requirements of the trainees, Government's sanction was obtained in 1980, to open an outpatient department for civilian patients. This obviated the necessity of sending the trainees to CMDCs for the practical phase of the courses. Presently, the course duration is 152 weeks for each post graduate course. Operative Dentistry has recently been included among the dental specialties. The appointment of Associate Professor was upgraded to Professor in the rank of Colonel in 1961 and later upgraded to Brigadier in 1985. However, due to reorganisation, the rank of Professor and Head of the Department of Dental Surgery was reverted back to Colonel in the year 2000.10
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Fig. 1.5: Armed Forces Dental Clinic, New Delhi
 
ARMED FORCES DENTAL CLINIC
The Armed Forces Dental Clinic (AFDC) was raised in the year 1947 as Military Dental Centre, New Delhi. On 24th April 1978, the unit moved to its present location at Tyagraj Marg, New Delhi in close proximity to the Rashtrapati Bhawan which is also the official residence of the President of India. AFDC, which started as a 5 chair dental centre on the same lines as the CMDCs, has emerged as the single largest defence dental clinic in the country where 14 dental officers drawn from various specialties are providing state of the art dental care under one roof (Fig. 1.5).
AFDC is a multi specialty premier dental institution with its prime role to provide routine and specialised dental care to the service population of all the three service headquarters. The unit is commanded by a Brigadier and is the largest dental establishment of its kind in the Armed Forces.
Over the years, technologically advanced equipment has been inducted to upgrade the infrastructure with a view to provide comprehensive dental care to its clientele. The outstanding feature of AFDC is its activity in the field of research and Continuing Dental Education programmes. AFDC is regularly holding hands-on courses on clinical dentis-try on subjects ranging from Esthetic Dentistry, Fixed Prosthetic Rehabilitation, Implant Dentistry and Autogenous Bone Grafts (Fig. 1.6).
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Fig. 1.6: Implant surgery in AFDC, New Delhi
In addition, workshops on various disciplines of dentistry are held regularly which are open to the civil fraternity as well. The AFDC has come to be recognised as an Institute par excellence in the professional circles of the country.
 
ARMY DENTAL CENTRE (RESEARCH AND REFERRAL)
Army Dental Centre, Research and Referral (Fig. 1.7) is a specialist dental centre raised on 01 May 1999 for exclusive management of all cases requiring advanced specialist care in the fields of Maxillofacial Surgery, Orthodontics, Prosthodontics and Periodontics.
This exclusive dental centre at New Delhi, equipped with state-of-the-art equipment has been functioning in the Army Hospital (R and R) complex, providing advanced specialist care to serving and retired personnel and their families on referral from peripheral dental centres and hospitals.
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Fig. 1.7: ADC, Army Hospital (R and R), Delhi Cantt.
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The Maxillofacial surgery unit deals with surgical management of trauma including fractures, gunshot wounds, management of cysts and tumors of the facial region, correction of facial deformities including reconstruction. The maxillofacial surgery unit is equipped with state-of-the-art armamentarium including titanium mini and micro bone plates, reconstruction plates, micro-saw system for bone cutting, distraction osteogenesis equipment etc for advanced cranio-maxillofacial surgery (Figs 1.8 and 1.9).
The Prosthodontic unit undertakes fixed rehabilitative work, like crown and bridge prostheses including cast metal and ceramo-metal restorations.
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Figs 1.8 and 1.9: Oral and Maxillofacial Surgeons of ADC (R and R) operating in the state-of-art Maxillofacial operating room
Prostheses for post surgical deformities and dento-facial residual deformities following trauma or battle injury are routinely being fabricated. Dental implants (both single and two stage) are currently being used for replacement of the teeth. Latest casting facility including Titanium casting is available.
The Orthodontic unit undertakes correction of dento-facial deformities using both functional and fixed appliances. Severe dento-alveolar discrepancies are treated with pre-adjusted edgewise appliances along with extra oral anchorage when indicated. In addition, the major treatment modality of this unit is the correction of dento-alveolar deformities of the cleft lip and palate cases. These are undertaken as a team approach involving the orthodontist, maxillofacial surgeon, prosthodontist, reconstructive surgeon and ENT specialist resulting in the achievement of comprehensive functional and aesthetic treatment goals. Deformities involving skeletal and dental structures are dealt with by the oral surgeon and the orthodontist together.
The R and R dental centre has the latest equipment like radio-visiography, intra-oral camera, ortho-pantomograph, cephalogram and a fully equipped dental laboratory having titanium as well as conventional induction casting and the metal to porcelain facilities. The most recent addition in the diagnostics for surgical and rehabilitative work has been the Maxillofacial CT. This is the only one of its kind in the country in defence services. The installation of a spiral CT in the Army Dental Centre (R and R) has proved to be a valuable adjunct to the conventional CT available in the radiology departments. Its role to carry out evaluation by 3-D re-construction as well as volumetric analysis for better diagnosis and treatment 12of maxillofacial injuries and defects has been proved beyond doubt.
The specialist work being carried out in this dental centre has set new standards in quality specialist dental care in the armed forces, thus offering the armed forces personnel, the best of facilities available in the country and abroad under one roof.
 
ARMY COLLEGE OF DENTAL SCIENCES (ACDS)
ACDS with an intake capacity of 40 students has been established at Secunderabad for the wards of army personnel, both serving and retired and war-widows. The college was started in July 2001 and is being run under the aegis of Army Welfare Education Society. Facilities for treatment in all disciplines of dentistry are open for the local civilians. Out of an annual intake of 40, four seats are reserved for the State Government. The Dental College has well developed infrastructure to look after the administrative and educational needs of the students. It is a positive step towards assuring quality material for recruitment in the Dental Corps.
The Army Dental Services has grown from its initial batch of seven stalwarts to its present strength of more than 400 dental officers and a sizeable dedicated cadre of ‘personnel below officers rank’ (PBOR). The history of AD Corps is also the history of the dental profession in India. Both have been struggling to find a place for recognition at different echelons. The Corps today stands tall with a dedicated cadre of officers and PBOR's deployed all over this diverse land existing in harmony with other services of the Indian Armed Forces. It has established a unique standing of its own over a period covering the last sixty years. Needless to say the journey through the ages can never be written comprehensively. The Corps continues to march ahead relentlessly to achieve even greater distinctions in its quest for excellence.