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important to the nation's health care delivery systems today and for the foreseeable future, that the system will, of necessity, be continued. Dental care will be included as a major element of that system.

-The dental service of the Veterans Administration constitutes an unequaled national resource of service, education, and research. Over and above its current capacity, there exists a great potential for expanding that dental service as a means of providing quality dental care to veterans (and perhaps the dependents of some); the education and the production of professional and auxiliary dental manpower; research; and community service through cooperative programs in which these activities can be shared.

-The advantages derived from the interrelationship between the Veterans Administration Dental Service and the dental education system are not only of benefit to patients who are the responsibility of the Veterans Administration, but to dental educational institutions, the profession they serve, and the people served by that profession in the private sector. Maximum advantage has not yet been realized in terms of the potential these cooperative and reciprocal arrangements represent.

Current status of the

Veterans Administration Dental Service

The dental service of the Veterans Administration's Department of Medicine and Surgery operates the largest oral health care system in the United States. Each of the 168 Veterans Administration hospitals operates its own dental service with a full-time dental staff, supported by auxiliary personnel. In addition to the hospital-based dental services, there are dental clinics in a number of separate outpatient facilities.

In fiscal year 1971, more than 236,000 veterans received outpatient dental treatment within this system. Of these, 145,000 were treated on a fee-for-service basis by some 45,000 private practitioners under a hometown dental care program. If this is coupled with the inpatient program, a total of more than $74 millionabout 3.6% of the total budget for medical care -was spent to provide a full range of dental care including restorative, prosthetic, and oral surgical procedures.

When viewed in its entirety, the Veterans Administration dental health care system is, in fact, a national resource with great potential to help the country meet its total dental health care needs. Through its education and research programs, the Veterans Administration Dental Service operates an important manpower training and development resource and contributes to new knowledge and techniques in the sciences of dental medicine and dental practice.

However, although the Veterans Administration has made major strides in integrating the dental service into its total health care programs, much remains to be accomplished if the dental service is to meet its own obligations and realize its full potential in concert with the private sector. This includes the recruitment of additional top-quality professionals who can assume leadership roles not only in education and research, but in developing the acceptance of oral health care as an inseparable part of total health care.

■ Hospital dentistry: 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 most dentists in the private sector. The special environment of the hospital and the resources it provides permit a unique approach to the diagnosis, treatment, and care of oral health conditions.

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 half of all patients are being discharged from Veterans Administration hospitals still in need of further dental care. However, through this oral examination process during the past ten years, about 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 hospitalized patients, Veterans Administration 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. Only about a third of Veterans Administration hospital dental services have a hygienist, and there is an average of less than one dental assistant per dentist. As a result, the full potential productivity of the dentist is limited, and the most effective costbenefit ratio per patient is not realized.

The hospital dental service was initially developed to provide oral health care as an integral part of medical care for hospitalized patients. However, the demand for outpatient care by Vietnam veterans as provided by a recent law, has created serious overdemands on the hospital dental program. As a result, during the past year Veterans Administration hospital dentists have had to divert a large portion of their time and effort from hospitalized patients to provide outpatient services for an additional 55,000 Vietnam veterans.

■ Education and training: The Veterans Administration Dental Service has established active affiliations with 55 of the country's 56 dental schools. Thus, in addition to providing clinical training of dental students, about a third of all of the country's available rotating dental internships and a fifth of all dental residencies are provided in Veterans Administration hospitals. In 1971, all 94 full-time internships and 132 residencies were filled in those hospitals, and additional training was provided in rotating internships and residencies for persons enrolled in other affiliated programs.

The Veterans Administration also conducts 74 separate training programs for dental assistants, hygienists, and technicians. These programs provided training for more than 2,000 persons during 1971, and during the past five years all or a portion of such training was provided to some 8,700 students in Veterans Administration facilities that participate in approved educational programs.

Although the quality and magnitude of these accomplishments are significant, it is recognized that these educational activities have a potential for considerable expansion to help meet the critical needs that have been identified for dental health manpower in the country's total health care system.

To fulfill the extensive requirements for continuing education of its own staff, a dental training center has been established at the Veterans

Administration Hospital in Washington, DC. In this facility special educational and training opportunities are offered for both professional and ancillary dental personnel. It has a fully equipped closed-circuit television system and modern equipment for the production of training films. By utilizing its own faculty and consultants, the center has not only provided continuing education for onsite professionals, but has produced more than 140 single-concept motion pictures that are widely used throughout the United States by other dental training and educational centers.

■Research: The Veterans Administration encourages research in oral diseases, and supports such research efforts in one of every five of its hospitals. Annually during the past five 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 International Association for Dental Research meeting in 1971, 35 such papers generated within the dental service were read as compared with only two at the same meeting in 1955.

Research efforts in oral diseases are primarily involved in studies of bacterial products and their relationship to oral diseases; mechanisms for suppressing toxic products; radiation effect on bone metabolism; a search for metallic alloys to improve partial dentures; and studies to improve and maintain the health of oral and related tissues. In this connection, it is of some interest to note that the nonfoaming ingestible dentifrice used in the Apollo space flights was developed at the Veterans Administration Oral Physiology Research Laboratory in Houston. This product is being used at present to maintain the oral health of seriously handicapped patients in whom foamy dentifrices, by contributing to nausea and choking, would pose complex medical and nursing problems.

The Veterans Administration 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% of the agency's research budget.

Personnel: The recent special recruiting efforts of the dental service have begun to attract young, highly qualified dentists to careers in the

Veterans Administration. This is evident in the fact that the average age of all dentists in the Veterans Administration in 1972 is 45.9. This is a reduction of nearly three years from the average in 1969 and compares favorably with the median age of 46 for all practicing dentists in the United States. Salaries of Veterans Administration dentists are on a parity with those of physicians in the system, a concept which the council strongly supports.

■ Facilities: 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, four-handed dentistry.

Summary: This critical assessment of the current status of the Veterans Administration Dental Service is presented primarily to serve as a basis on which a projection of immediate and long-range objectives can be made. Such considerations will be made in the expectation that they can contribute to improved care of patients and establish new directions that will permit the Veterans Administration to make a maximum contribution, not only by expanding its own available dental services, but in helping to solve the country's critical dental health care needs.

Long-range objectives

Within the framework of the initial assumptions as they relate to the current status of the Veterans Administration Dental Service, the Advisory Council on Dentistry believes there are identifiable and reasonable long-range objectives that can form the basis for the development of plans.

The major dual thrust of the long-range effort in the coming years should be the achievement of an expanded dental service to ensure quality and availability within the Veterans Administration dental health care system and a functional integration of that system with the mainstream of American dentistry. Both of these efforts should include patient care, the development of existing and new professional and auxil

iary manpower, and dental research, both scientific and in terms of oral health care delivery. It is recognized that a significant start toward both goals has already been made. Some steps that can be taken immediately and subsequently will be identified; this section outlines some broad directions for the Veterans Administration Dental Service in the evolutionary process to provide the base for achieving both goals.

■ Expansion of function: Because of legal eligibility limitations of whom it may serve, the Veterans Administration health care system has not yet developed some services that must necessarily be part of any comprehensive health care program. Three of the most important are pedodontics, orthodontics, and the dental care of women. In order to expand its function into a full range of services similar to those provided in the private practice of dentistry or by a community hospital providing such services, plans will have to be developed for additional oral health facilities and personnel to provide such services.

The extension of services to nonveteran women should pose no great technical problems. It will only essentially require a change in attitudes to accept other female patients and meet their dental needs.

The possible extension of eligibility of dependent children, coupled with the likelihood that a national dental health program will initially give attention to children and teenagers, will require a more extensive plan. This will require that provisions be made not only for general pediatric dentistry, but also for orthodontics and preventive dentistry to meet the needs of this age group. An initial period must include not only the development of appropriate facilities and equipment, but provisions for adequately prepared specialized personnel, faculty and student rotation from dental schools, and the development of postdoctoral programs for internships, residencies, and graduate and continuing education in these new areas.

With such a capacity, the Veterans Administration system should be able to make a significant contribution to the oral health care of the children of indigent families. This might occur even before a national health program is adopted, and could be an important first step in a national expansion of pediatric dentistry. Because the Veterans Administration health care system is so extensive, its dental service can provide a major leadership role in contributing to solving

this important national health problem.

Most dental schools could improve their educational programs by increased access to more extensive medical facilities, specialists, and services. By their affiliation with Veterans Administration hospitals, a significant portion of this critical ingredient is provided. This arrangement also enhances the opportunity for frequent consultation and cooperation with the medical colleagues of dentists and dental students in not only general areas, but in such related special services as radiology, anesthesiology, and pathology.

In developing its long-range plans for both expansion and cooperation with community programs, the Veterans Administration Dental Service must make every effort to supplement rather than duplicate existing facilities and services. The authority for this latter effort exists in the sharing law, Public Law 89-785. Under its provisions, Veterans Administration health care facilities are authorized and, indeed, encouraged to provide to the community those services that are not otherwise available to it, or to arrange to utilize those community services that the Veterans Administration hospitals themselves do not have for the diagnosis and treatment of their patients. Thus by using such an exchange, all services can be made equitably available to Veterans Administration patients as well as those served by the private sector.

■ Hospital dentistry: As already pointed out, the Veterans Administration dental health care system has played a unique role in the development of hospital dentistry, and should include new developments in this area in its future plans. This idea is predicated on the belief that there will be a significant shift in emphasis in both the educational and patient-care aspects of dentistry. This will require an ever-increasing closer relationship to hospitals. If properly and adequately pursued, such efforts can provide models for the future, and can begin to do so sufficiently in advance to make a significant contribution to both dental education and the practice of dentistry in the years to come.

As more adequate provisions are developed to ensure dental care for all, it is anticipated that such care will come to be recognized as an integral part of total health care. By strengthening the Veterans Administration's unique ties with university dental schools, the relationship between dentistry and medicine will be enhanced; the study and care of oral conditions

in physically and mentally handicapped patients will be improved; and, indeed, the prevention and treatment of all of the various oral conditions will be ensured.

With the fuller development of the Veterans Administration model of hospital dentistry, one of the most significant national resources for both community service and the training of appropriate dental manpower can be utilized. Concomitant with increased hospital facilities and staff, teamwork between the physicians and dentists operating in and out of a hospital setting can be further developed.

■ The Veterans Administration's role in education of dental students: Extensive clinical facilities are required by universities to establish a fully rounded dental degree program. This need opens the possibility for the Veterans Administration to explore the increased role it might play in the clinical education of dental students. Over and above contributing to the expansion of classes in existing dental schools, the potential for providing new schools with clinical facilities might be studied. The schools themselves could offer the basic biological sciences curriculum for students; the affiliated Veterans Administration hospitals could then provide the setting for technological and clinical aspects of the dental students' education, including both outpatient and inpatient practice. Such training in a hospital setting will become an increasingly more important part of dental education of the future, thus emphasizing hospital dentistry. The current sharing of certain activities with dental schools, which has only been tested on a small scale in a few areas, could be expanded. As their contribution to the sharing effort, more dental schools could utilize their own specialized facilities and members of their faculty, when appropriate, to give veteran patients the special services that only the schools are capable of providing.

■ Improved patient flow: In this latter connection, there have existed certain barriers to the easy exchange of patients and professionals between the Veterans Administration systems and the university teaching hospitals and clinics. To ensure greater quality and availability of care offered by such an exchange, there should be better integration of Veterans Administration dental services with dental care systems operating in the academic and nonacademic community. Unfortunately, there have been

only isolated examples in which veteran patients were transferred to a university teaching hospital or clinic for special study and care. With a greater sharing effort catalyzed by closer affiliations, there should be a freer flow of patients and professionals in both directions.

Related to this problem are certain existing differences in reimbursement systems; these pose financial problems and thus, all too often, prevent Veterans Administration patients from receiving care in the most appropriate facility. The Veterans Administration should begin a study of methods by which the free flow of patients to those facilities best suited to their needs can be achieved.

■ Veterans Administration models for dental care delivery systems: As suggested, the dental service of the Department of Medicine and Surgery of the Veterans Administration is in a unique position to develop models of dental health care systems. The facilities and staff of no other system, institution, or agency have the potential freedom to conduct such service experiments by using their existing resources and authorizations as those of the Veterans Administration.

Many of the limitations placed on institutions and agencies by the dental practice acts of the various states do not exist in the Veterans Administration. As a result, the Veterans Administration Dental Service can undertake any number of experimental programs in the delivery of services in its various locations.

If the current thinking that is directed toward a national dental health program is to be realized, there will have to be a significant improvement of the current systems and development of new systems for the delivery of dental care. It can be expected that these will include not only new and expanded technical facilities, services, and utilization of personnel, but also new approaches in utilizing such supporting services as clinical and dental laboratories, supplies, record keeping, patient motivation, and public education. Although financing will undoubtedly be provided by some mechanism, cost and quality controls will also be necessary, as already demonstrated by the experience in Medicare and Medicaid.

The Veterans Administration Dental Service, having the opportunity to move both vertically and laterally with only limited restraints, has an unequaled opportunity. By experimenting with new models it can demonstrate improved and new expeditious systems of delivery that

are most economical and effective to serve the greatest number of people. Pursuing this idea, the Veterans Administration can begin to design and develop a series of such demonstration models. As these pilot projects are developed, however, it will be important to build into them objective methods of evaluation to determine their relative merits or applicability in various circumstances.

■ Data monitoring in the Veterans Administration: Because it has uniquely available information on the health status of a veteran population of nearly 29 million in its data bank, the Veterans Administration is capable of providing critically needed data on oral health in the nation. This base can be enhanced if the data bank can be extended to include statistical and epidemiological information for others and especially children and women. When correlated, these data can provide a more complete understanding of the country's oral health problems and needs. Therefore, the Veterans Administration should continue to collect, analyze, publish, and distribute its existing data so that they can be shared and used by other planners and providers of health care who, in turn, can begin to plan to build a resource of additional relevant data.

Immediate goals and recommendations

Having examined the current activities of the Veterans Administration Dental Service and considered what might appropriately be its longrange goals, the Advisory Council on Dentistry concluded that there is a series of specific actions that could be taken immediately to start the process toward those goals. Since certain of the immediate goals discussed in this section of the report are closely related to the long-range goals, each is presented in combination with a specific recommendation of the council.

■Role of oral health care in the hospital setting: In its introductory comments, the Advisory Council on Dentistry set forth the premise that oral health care is an integral part of total health care in both hospital and ambulatory patient environments. However, it recognizes that in reality this premise has not always been accepted in general medical and surgical hospitals—

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