The Advisory Council on Dentistry recognizes the critical need for identifying the short- and long-range goals of the Veterans Administration Dental Service within the context of its current activities in the health care system of the United States. It does so in the belief that dentistry is recognized as an integral component of health and the systems that deliver health care.

In preparing for its study, the council reviewed the report prepared for the Administrator of Veterans Affairs by the Special Medical Advisory Group of the Veterans Administration entitled: "Helping to Meet the Health Care Needs of the Nation-The Potential Role of the Veterans Administration's Health Care System." In so doing, the council expressed its support and endorsed the general concepts and philosophy set forth by the Special Medical Advisory Group. However, the general concepts contained in that report were thought not to consistently or adequately cover or completely apply to dentistry in general, and the Veterans Administration Dental Service, in particular. As a result, the council has assumed responsibility of presenting the case more adequately, developing a more specific position, and offering recommendations related to both the future of the dental service and its potential relationship to the country's health care system. Therefore, this report goes beyond that of the Special Medical Advisory Group in the particular area of dentistry, and contains specific proposals applicable to the dental service of the Department of Medicine and Surgery.

The major premise underlying this report is that oral health and disease are inseparable from general systemic health and disease. Yet, the fact is that the practice of dental medicine in America has evolved as a distinct professional entity. In so doing, it has demonstrated that oral pathology, the treatment of dental anomalies, and the prevention of oral diseases are no less important or critical than diseases and conditions of other parts or systems of the body. Indeed, all evidence suggests that diseases of the orofacial complex are some of the most prevalent, the most time-consuming to repair and, in many instances, the most debilitating of all the ills of mankind. In human and social terms a healthy mouth is critical to every individual's comfort, personality, self-confidence, and success. Not only does the orofacial complex serve an individual's essential need as the central portal of communication, but also registers appear

ance, personality, individuality, and sensitivity, and most importantly, provides the means by which nutrition is brought to the body. As an essential to total psychological and physiological health, the problems of the mouth and the orofacial complex must have high priority and require that dentists must be coequal partners with their medical and surgical colleagues in planning any health system of the future.

With this premise as a base for its report, the Advisory Council on Dentistry makes the following assumptions to support its view of the future. Although the Veterans Administration Dental Service has all of the attributes listed, the thrust and content of this report recognize the need to carry them beyond those that already exist.

-Some system to ensure that health care will be made available to all Americans will be adopted by the Congress in the next few years. Virtually every individual, national group, or organization that has examined the existing health care system has reached that conclusion. The variety of legislative proposals in the Congress indicates bipartisan support for several alternative systems. There is no longer any doubt whether there will be a national program for health care. Rather, the questions are: What kind of program will it be? How extensive shall it be? How will it be financed?

-Few dental benefits will be authorized in the initial stages of a national program. Although a possible exception is the availability of service to children, it is expected that dental benefits will be added to the program on a time-phased basis as public demand for increased health care grows, and as funds and manpower permit.

-Establishment of a national program will directly effect the Veterans Administration's Department of Medicine and Surgery, including the dental service. Under such a program, veterans can be expected to have the option of obtaining care in Veterans Administration health facilities or in the private sector. The exercise of that option will inevitably have an influence on the utilization, organization, and operation of all existing federal health service systems, as well as those of the private sector.

-The health care programs of the Veterans Administration will continue to exist as an organizational entity. The existing network of Veterans Administration health facilities and resources and the system it represents are so extensive, well distributed, and have become so

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 million— about 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