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

either within or outside the government hospitals systems-and that such acceptance must be earned through mutual appropriate performance and understanding of the concept on the part of both dental and medical staffs in the hospital.

In view of the changing concept of comprehensive health care, the need for proper utilization of hospitals, and the economics of health care, the Veterans Administration system should include dental services for not only hospitalized patients, but those who are entitled to ambulatory care as well. This service should be included as an integral element of the full range of medical, surgical, and other specialized ambulatory health services. Only by providing services for both hospitalized patients and services for ambulatory patients can total improved care and economies be realized.

Therefore, it is recommended that the Veterans Administration develop a dental health system for ambulatory patients in conjunction with those being provided for other medical services.

■ Preventive dentistry: Medical and surgical priorities are given first to the relief of pain, and then to the repair of the ravages of disease. Because most injuries to the teeth and, to a lesser extent, to the supporting structure are not selfrepairing, dentistry gives emphasis to restorative and reparative procedures. However, efforts to treat dental disease only after it occurs are expensive, wasteful of resources and manpower, and do not serve the best interest of patients.

Prevention of oral disease not only preserves the structures so they may serve individuals throughout their lives and increase their productivity, but also conserves dental health manpower and reduces the per patient cost of care. Where routine prevention leads to such efforts as the early detection of oral cancer, lives are also saved and long-term disability prevented.

Prevention of oral disease ranges from primary prevention of dental caries and periodontal disease to the forestalling of loss of teeth through periodontic, endodontic, and operative or prosthetic procedures. The Veterans Administration dentists are currently heavily committed to the secondary preventive programs and to the early detection of oral cancer. However, emphasis should also be placed on the following primary programs that help to prevent the onset of dental caries and periodontal diseases and require deliberate action such as

the fluoridation of drinking water; positive action such as oral hygiene and home-care procedures, or change in behavior in such areas as dietary control; and positive action of oral prophylaxis, topical application of fluorides, and instruction in plaque control.

By becoming involved in all three preventive areas, Veterans Administration dental personnel could help reduce future restorative costs by more than 60%. Similarly, by conducting programs in dental health education of young individuals, the Veterans Administration could reduce demands for dental care of those who will ultimately become veterans.

In addition to patient education, veterans under direct care in Veterans Administration hospitals and clinics or by private dentists paid by the Veterans Administration should receive oral prophylaxis, application of fluoride directly to the teeth, elimination of occlusal prematurities, and examination for potential or early cancer. During active treatment, the importance of plaque control and oral health care should be reinforced.

Therefore, it is recommended that an assistant to the Assistant Chief Medical Director for Dentistry be appointed to coordinate preventive dentistry programs, and that in every health facility one dentist be assigned the responsibility for effecting preventive dentistry programs.

■ Effective utilization of auxiliary personnel: Modern dental health service requires the fullest use by the dentist of members of an adequate team of auxiliary personnel. To require that dentists perform selected procedures, when they can be carried out as effectively by auxiliaries, is wasteful of existing manpower and unnecessarily costly.

The Veterans Administration has long recognized the value of dental laboratory technicians, and has made provisions for them to perform selected procedures that conserve the time of the dentist without reducing the quality of service. Similarly, dental assistants and dental hygienists have been employed to some extent, but their full potential has not yet been realized. In addition, since it has been demonstrated that one fully trained chairside dental assistant can expand the productivity of the dentist by 33%, no Veterans Administration dentist should be functioning without such an assistant.

The TEAM (Training in Expanded Auxiliary Management) approach is currently in a devel

opmental state to experiment with and demonstrate the utilization of multiple assistants with expanded functions. Already, it has shown that a dentist and dental auxiliaries working as a team at several chairs can provide increased dental service of high quality at lower unit cost. Diagnosis, treatment, prescription, and other procedures requiring full professional expertise must be reserved for the dentist. However, other selected duties, beyond those generally assigned at present, must be properly and effectively delegated to trained auxiliaries.

Dental students exposed to the TEAM concept in Veterans Administration hospitals are learning how to manage a team of auxiliaries working in a suite of operatories and taking part in new experiments. For example, the dental hygienist, with the necessary additional training, is being used to serve as a periodontal therapist, again expanding manpower potential. Dental students trained in the TEAM concept who are being graduated from dental schools are already utilizing auxiliary personnel trained in companion programs and, with some other innovations, are putting many of these practices into operation in the community.

The council believes that there is a failure to fully and effectively utilize auxiliaries in the Veterans Administration Dental Service at present.

Therefore, it is recommended that the Veterans Administration should set an immediate priority for the full utilization of auxiliaries in its facilities to increase the efficiency, practicability, and economy of its dental service; and that staffing patterns be developed to ensure that by 1975 the TEAM approach to dental health care is fully operational in all Veterans Administration dental services.

■ Increasing training programs for auxiliaries: If the Veterans Administration adopts the TEAM approach for oral health care, it will become the country's largest single employer of dental auxiliaries, including assistants, hygienists, and new ancillary personnel who are qualified to perform expanded functions. Therefore, the Veterans Administration must undertake the expansion of its own or the development of new cooperative training programs. Since such individuals have a greater tendency to remain nearer to their homes than dentists and physicians, such training centers should be established throughout the country. Also, because large numbers of veterans serve as dental auxiliaries during their

military duty, the Veterans Administration is in an unusually favorable position to attract and retrain these veterans. Such a program would provide benefits to the veterans involved by assuring them of employment in work they have enjoyed and for which they are especially prepared, and to the Veterans Administration Dental Service which needs their talent.

Therefore, it is recommended that the Veterans Administration immediately establish recruitment and training programs for dental auxiliaries, with special emphasis on veterans who have had experience as dental auxiliaries during their military service.

■ Developing research as an integral activity: Research activities of the dental service should not be isolated from the mainstream of other biomedical or health service research in the Veterans Administration. Oral research facilities should be a resource to be shared with and appropriately utilized by all other related services. Research programs should be directed toward solving oral health problems that are particularly related to the conditions that are most prevalent among the part of the population represented by Veterans Administration beneficiaries.

Such research may be concerned with a wide range of activities. It may, for example, be devoted to the further study and development of preventive techniques and the early detection of disease; or it could include studies of the epidemiologic characteristics of oral conditions and diseases, correlations between oral and systemic disease, or the study of bone and the effect of disease and aging on the oral tissue. The Veterans Administration Dental Service is in a unique position to undertake such studies and to make these kinds of correlations.

Other areas of investigation relevant to the mission of the dental service, as described in this document, include research in the use of expanded functions of auxiliary personnel, equipment design, and utilization, and economic implementation of various health care delivery systems. High priority should be given to the development of improved biomaterials for tissue replacement. The dental service might also provide treatment facilities that can serve as the interface between work relating to prostheses and research in biologic materials.

Therefore, it is recommended that support be provided to the dental service for immediately expanding its research and development activities and that those activities be directed to

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ward the solution of oral and related health problems that are most prevalent in the patients in the Veterans Administration system, but which have direct applicability to the private sector.

■ Enhance collaboration between Veterans Administration hospitals and other teaching hospitals and educational institutions: The primary function of the Veterans Administration hospital system is the provision of patient care, and this responsibility must continue to be maximized both qualitatively and quantitatively.

Since educational activities have demonstrated a direct relationship to quality care, dental schools affiliated with Veterans Administration hospitals have a long history of helping to improve the quality of dental patient care. Conversely, these affiliations have proved advantageous to the dental education programs of the schools. Members of the faculty of dental schools have provided much of the biomedical and dental science education, both at the hospitals and at the schools in intern and residency programs in Veterans Administration hospitals. However, as already noted, the clinical facilities of the schools have not been fully utilized for dental treatment of veteran patients.

In view of the shortage of facilities and manpower to deliver oral health care, the current potential of these relationships appears to have serious limitations in terms of service. Therefore, consideration should be given to fuller collaborative use of the facilities of these affiliates. Provisions should be made for an increased number of veterans to receive treatment in dental school clinics as needed, and for an increased number of dental students to be assigned to Veterans Administration hospitals to help deliver oral health service under supervision of the Veterans Administration dentists and faculty members. The Veterans Administration also should develop collaborative efforts with other community hospitals in dental patient care to utilize those that are best qualified in each discipline or specialty for the benefit of all patients. Recognized dental specialties of Veterans Administration dental training programs are generally affiliated with the dental schools of the region. These affiliations should be expanded in the best interest of the Veterans Administration hospitals, the residents in training, and the schools themselves. Since the programs are primarily teaching programs, the educational responsibility must, of necessity, be centered in the accredited school. In regions where more

than one Veterans Administration hospital is involved, plans should be developed to have one advanced dental educational program under the dental school's aegis with residents in a common program. Where feasible, dental residents from other community hospitals in the region should be included in the same program to facilitate the rotation among all of the institutions involved. For example, a dental school with an accredited advanced education program in oral surgery might have residents rotating through a Veterans Administration general hospital, a Veterans Administration psychiatric hospital, a community pediatric hospital, and an active city hospital with an emergency service. Under such a program, the Veterans Administration residents would receive the broadest possible experience. This is, in effect, regionalization of educational and health care service that can enhance efficiency and economy.

Therefore, it is recommended that Veterans Administration hospitals expand cooperative programs for patient care and residency training programs for dental students with dental schools and hospitals in the private sector.

■ Understanding, acceptance, and support of the Veterans Administration Dental Service: It is imperative that understanding, acceptance, and support of the mission and activities of the Veterans Administration Dental Service be developed. Only in this way can patients, whether hospitalized or ambulatory, have full confidence that they are receiving high-quality care by thoroughly trained and competent staff working in well-equipped facilities. Similarly, only with recognition of the major role played by the Veterans Administration Dental Service in dental education and research can recognition be achieved at the professional, congressional, and community level.

The establishment of an understood and accepted identity for the Veterans Administration Dental Service in these areas is an integral part of the total goal of the Veterans Administration's Department of Medicine and Surgery and consistent with its need to be included as an integral part of the country's total health care system. With the advent of some type of national health program, the options open to veterans for dental care, like other health services, could become many and varied. Also, with the options for available support to dental schools becoming more and more limited along with availability of research funds, it is important that the