quent success in living, working and functioning as members of society. As a result, oral health has become recognized as an essential to total physiologic and psychological health of patients served by the VA health care system, and its effective practice has helped establish dentists as coequal partners with their physician colleagues in

that system.

With authorization and funding supplied by the Congress, the Dental Service of the Veterans' Administration's Department of Medicine and Surgery now operates the largest single oral health care system in the United States. To serve the needs of eligible veterans, each of the 168 VA hospitals operates its own dental service with a full-time staff of dentists and auxiliary personnel. In addition to the hospital-based dental services, there are dental clinics in a number of separate outpatient facilities.

In fiscal year 1972, with a dental budget of some $88.5 millionabout 4 percent of the total budget for medical care allocated to the VA health care system that year-more than 396,000 veterans received a full range of dental treatment. Of this number, 231,000 were provided that care within the VA facilities themselves, and the other 165,000 were treated on a fee-for-service basis by some 45,000 private dental practitioners.

In its ability to operate these extensive facilities and provide this enormous amount of care at a level of quality comparable to, or better than, that received by most Americans, a number of important—if not indispensable-attributes of the VA dental service both as part of its own system and as it relates to the total health care system of this country are demonstrated. I should like to point up some of these activities, and make some related observations for the consideration of this committee.

When viewed in its entirety, the VA dental health care system is, in fact, a national resource. It has a great potential to not only deliver dental health care to eligible veterans, but to help the country meet the total dental health care needs of all of its citizens in two ways. First, the VA dental service operates an important and critical manpower training and development resource; and, second, through its dental research programs, contributions are made to new knowledge and techniques in the sciences of dental medicine and dental practice. The Veterans' Administration today occupies a leadership role in the practice of hospital dentistry. This concept is in contrast to the traditional solo office practice carried on by many dentists in the private sector.

The special environment of the hospital and the resource it provides permit a unique approach to the diagnosis, treatment, and care of oral health conditions-for the veteran population. Under this concept, complete oral examinations have been established as an essential part of a complete physical examination. As a result, oral conditions requiring treatment are identified so that both the patient and physician are alerted to the problems and needs. It is an unfortunate reality, however, that these needs cannot always be met, and that an estimated one-half of all patients are being treated for acute conditions by prehospital or posthospital care, or are being discharged from the hospitals still in need of further dental care.

It is for these reasons that I am not only in favor of the outpatient provisions included in Senate bill 59, but would urge that those provisions specifically include dental examinations, care, and treatment and authorize sufficient funds to support such an effort. To illustrate the benefits of this concept, I would point out that through the oral examination of veteran patients during the past 10 years, some 5,000 oral malignancies have been detected in their early stages, thereby enhancing the opportunity for cure in a large number of instances.

To meet the dental needs of its current patients, VA hospitals now employ about 800 full-time dentists, 700 dental assistants, 70 dental hygienists, and 400 dental laboratory technicians. The number of dentists and auxiliary staff varies in each facility according to the size of the hospital and the number of patients it serves.

The ratio of supporting personnel, however, is not always adequate. Despite the growth of team dentistry, only about one-third of VA hospital dental services have hygienists, and there is an average of less than one dental assistant per dentist. As a result, the full potential productivity of VA dentistry is often limited, and the most effective cost-benefit ratio per patient is not realized.

As I have indicated, the hospital dental service was initially developed to provide oral health care as an integral part of medical care for hospitalized patients. However, the recognition of the benefits of ambulatory care for patients not needing hospitalization, the demand for dental care by Vietnam veterans, as provided by a recent law, and the potential of Senate bill 59 can be expected to create even greater demands on the hospital dental programs. As a result, there will be a greater need for dental manpower. This need can only be realized by authority to hire such people or contract for their services, and funds to cover those costs-and I would urge your support for such authorization and funds.

Recruitment of dentists and allied dental health personnel in the VA system has a built-in factor stemming from its extensive education and training programs. At the present time, most VA hospitals are affiliated with 57 of the Nation's 58 schools of dentistry. These affiliations have been progressively strengthened and become increasingly interdependent over the years. They now include a full range of educational activities in the training of not only dentists, but dental specialists, hygienists, assistants, and laboratory technicians. Some 52 other universities and community colleges utilize the unique capability of VA hospitals to provide practical experience for their students engaged in the auxiliary career disciplines of dentistry, and have entered into training agreements with those VA hospitals. A number of other educational institutions have also expressed a desire to develop similar affiliations, and plans for extending these activities are now underway.

Concurrent with the expanded role that the VA dental services have played in the educational efforts of affiliated educational institutions, there has been a steady improvement in the quality of the dental professional staffing of VA clinics. One of the best evidences of this improvement in quality of staff has been the success of VA's career development and specialty training programs in dentistry. In 1955, there were approximately 20 certified dental specialists in the entire VA system. Currently, there are 72 such board-certified spe

cialists, plus an additional 77 who have completed advanced specialty training, and 96 who have received postdoctoral training in general practice as career interns.

The recent special recruiting efforts of the dental service have begun to attract young, highly qualified general dentists, as well as board certified specialists to careers in the VA dental service. This is evidenced by the fact that the average age of all dentists in the Veterans' Administration in 1972 was 45.9 years. This is a reduction of nearly 3 years from the average in 1969, and compares favorably with the median age of 46 for all practicing dentists in the United States. Since 1970, the VA has been able to recruit 198 staff dentists, whose average age is under 33. Obviously, these accomplishments have a direct bearing on providing better quality of patient care to the Nation's veterans. Salaries of VA dentists are on a parity with those of physicians in the system, and have a direct bearing on the successful recruiting efforts I have reported.

Although the quality and magnitude of these accomplishments are significant, it is recognized that these educational activities have a potential for considerable expansion. In this way, the increased needs of the VA can not only be met, but so can the critical needs that have been identified for dental health manpower in the country's total health care system.

Only if sufficient funding is provided for VA educational resources, can all of these potentials be realized. It should also be clearly noted in this regard that such funds can not only be considered as important in producing dental health manpower, but by being invested in an ongoing educational system, will provide the most effective cost-benefit ratio.

It is unfortunate that Public Law 92-541 did not provide funds for dental schools, as such. However, my colleagues and I are interpreting the term "medical schools" to be a generic one and meant to include schools of dental medicine. It is conceivable that if funds are appropriated for the implementation of that law-and I would ask that this committee encourage such action-dental schools and those involved with allied dental health personnel can become involved under both subchapters II and III-and I would hope they would.

Since education and research are inextricably tied together, the Veterans' Administration encourages research in oral diseases, and supports such efforts in its hospitals. Annually, during the past 5 years, Veterans' Administration dentists and other scientists engaged in research projects have presented and published an ever-increasing number of scientific papers. For example, at the recent International Association for Dental Research meeting, completed here last week, 33 such papers generated within the dental service were read, as compared with only two at the meeting of the same association in 1955. The VA Dental Service is continuing its efforts to attract and develop research-oriented personnel. However, success in this effort is severely limited by the availability of funds. The fact is that support for research in oral diseases currently amounts to less than 2 percent of the Agency's total research budget. I would suggest that the budget be increased.

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The Veterans' Administration's dental facilities and equipment are adequate, but in need of modernization. Outmoded equipment is gradually being replaced and further progress is being made as funding permits. Included in this program are newly designed operatories, featuring modern cabinetry, instrument panels, and contour chairs, that are being installed to facilitate the practice of sit-down team dentistry now being taught in all dental schools.

This critical assessment of the current status of the Veterans' Administration Dental Service is presented primarily to serve as a basis on which this committee can make a projection of immediate and long-range objectives. In my belief, such considerations should be made in the expectation that they cannot only contribute to improved care of patients, but help establish new directions that will permit the VA health care system to utilize its existing affiliations with the country's dental schools and other educational institutions to make a maximum contribution to expanding its own available dental services and in helping to solve the country's critical dental health care needs.

Senator CRANSTON. Thank you very, very much, Doctor. I know that you are universally recognized as among the outstanding leaders in dental education and knowlege in our country, and it was particularly helpful to have you with us.

I have quite a few questions I want to ask you, but I want to declare a 2-minute recess so I can see a legislator from California who has to see me. I will be right back.

[Whereupon, a short recess was taken.]

Senator CRANSTON. The hearing will now resume.

Doctor, do you have an estimate of the funding needed to provide the level of dental care you believe is needed currently in VA facilities? Dr. ROBINSON. No, but I can supply the information for the record, Senator.

[Dr. Robinson subsequently supplied the following information :] Dental care for hospitalized veterans is not identified as a line item in the budget. From my personal experience as a consultant at several VA hospitals, I believe that at least a 25 percent to 35 percent increase in facilities and personnel would be needed to reach the level of dental care I feel to be adequate. I would suggest that the committee might obtain more detailed information in dollars from the Administrator.

Senator CRANSTON. Would you also specifically indicate how much new staff would be needed, and how much new equipment, and how much of this patient care load could be met through supervised utilization of these students in training as dental assistants and dental hygienists?

Dr. ROBINSON. I will have to furnish that information for you, too. [Dr. Robinson subsequently supplied the following information:] In order to plan an adequate number of dental students in training at hospitals and helping to provide additional care, there is need for at least six operatories in every hospital participating with dental schools in this program. In larger hospitals and schools as many as 20 operatories could be used to advantage. There would be need for auxiliary personnel and supervision. The supervision could be a joint budgeting responsibility of the VA hospital and the affiliated school. Some may feel that the productivity of the students would be so low and the cost of supervision so high that they might offset each other. Our experience in our community hospital does not support this concept.

Senator CRANSTON. Do you feel that the VA has shortages in the dental field currently?

Dr. ROBINSON. Yes, I do. They have been training their own people through the career residency program, and have been able to train large numbers of them. It is relatively recent that the program got underway, but they have a very high retention factor.

Senator CRANSTON. Do you have any idea of the estimated number of dental schools that could effectively expand their programs if funds became available next year for implementation of Public Law 92-541?

Dr. ROBINSON. I could not think of one that could not expand its program if funds were available.

Senator CRANSTON. You think every school could?

Dr. ROBINSON. I think everyone could.

Senator CRANSTON. Isn't one of the major problems in expanding enrollment the lack of chairs for teaching purposes which the VA can help make available?

Dr. ROBINSON. That's true. I might point out that in our own instance, we are affiliated with the Veterans' Administration Hospital in Kansas City and in Leavenworth, Kans., and partially with Topeka and Wichita. There are not adequate chairs for our students who work there.

On the other hand, the Jackson County Public Hospital recently added 22 chairs to their hospital, and these are manned everyday, 5 days a week by dental students, which certainly expands their treatment program at a very minimal expense.

Senator CRANSTON. How much leadtime do dental schools require to develop such expanded programs?

Dr. ROBINSON. I think most of them have them on blueprints and could have them going within 1 year.

Senator CRANSTON. You recommend that the funds allocated to dental research be increased. Do you have an estimate of the amount of additional funds that could be effectively utilized?

Dr. ROBINSON. Again, I will have to get that figure for you in an exact way.

[Dr. Robinson subsequently supplied the following information:] I believe that a graduated increase in dental research funding over the next 5 years could allow recruitment of qualified scientists and development of cooperative programs with dental schools. By 1978 the amount allocated for research in oral disease and its prevention should be at least 8 percent of the total VA research budget.

Senator CRANSTON. You were a member of the Advisory Council on Dentistry that reported to the Medical Director of the VA, and made several recommendations that would strengthen and expand the VA dental services provided veterans. I found that a very interesting series of recommendations. I would like to run through the main ones, and if you have any comments or expansion on any of these, I would be very interested in hearing them. If you can advise of any action or response made to the suggestions of the council, by the Administrator, I would be very interested in that.

The main recommendations were, (a) that the VA develop a dental health system for ambulatory patients in conjunction with those being provided for other medical services.

Has anything happened on that, thus far?