will add, rather, a new dimension to dental research by engaging the broad base of the universities and a rich cross fertilization and interaction of various disciplines. In this way we believe we will add to the dental environment and to the solution of dental problems, the knowledge and skill of a variety of personnel trained in the basic biological and other life sciences who are not now located in institutions engaged in dental research. For these activities, and anticipating our needs for fiscal 1968, a budget of $30,307,000 is before you as compared with $28,404,000 for the current fiscal year, representing an increase of $1,903,000. The increase will permit us to expand those areas of laboratory, clinical, epidemiological and applied research where needs and opportunities are greatest for productive work. I would be very happy to do my best to answer any questions you and your associates might have.

SUMMARY OF BUDGET REQUEST FOR NATIONAL DENTAL INSTITUTE

Mr. FLOOD. What we call the adjusted appropriation for 1967 is $28,447,000 and the request for 1968 is $30,307,000. That is an increase of $1,860,000.

Dr. KRESHOVER. Yes, sir.

Mr. FLOOD. If that is so, you must have stretched your imagination a little to try to show that this would cover more than the increased costs. For instance, you indicate you can finance eight more research projects, two more training grants and seven more positions.

Dr. KRESHOVER. Yes, sir.

Mr. FLOOD. These are pretty small, but do you really think that even those small increases are possible?

Dr. KRESHOVER. We, of course, needless to say, must do our best. We believe that with the establishment of certain priorities we can keep our program with a sense of mobility, of not standing still. While in certain areas this might indeed be difficult to accomplish, as you have perceived, we do feel it absolutely urgent that we keep our program moving ahead.

Mr. FLOOD. Yes, I am sure you do. That is very commendable. I am wondering how are you going to do it? What are you going to use for money? This is only a 6-percent increase. Increases in the cost of maintaining the same program level are estimated by many experts to be more than that.

Dr. KRESHOVER. I am rather speechless to try to respond adequately to this

Mr. FLOOD. What about this man here? What do you think?

Mr. CHRISTOFERSON. Mr. Flood, this will mean in the field of research grants that we will not be able to fund as many grants as would be approved by the Research Council, among other things. This will also be true in the field of training.

Mr. FLOOD. You have to make a hard choice.

Dr. KRESHOVER. Yes, we indeed will. We are rather optimistic that a recasting of some of our programs in the context of broad gaged dental research institutes might make some impact on this objective.

UNIVERSITY-BASED RESEARCH INSTITUTES

Mr. FLOOD. Last year we gave you $3 million above the budget to set up these six university-based research institutes.

Dr. KRESHOVER. Yes, sir.

Mr. FLOOD. What about your plans for 1968?

Dr. KRESHOVER. The $3 million was a line item in our 1967 budget. As I indicated to you earlier, we have now approved and have funded two such grants.

Mr. FLOOD. That is Washington and Pennsylvania.

Dr. KRESHOVER. That is correct. The remaining three that will be considered at the next Council meeting have only thus far been reviewed in our so-called primary review mechanism. I believe it would be inappropriate for me to identify these universities. But nevertheless there are three more that we anticipate are of such quality that they will be recommended for approval and indeed will be negotiated for funding in the current fiscal year. These will be carryovers as five full-fledged institutes under varying stages of development or planning for 1968, and during the forthcoming fiscal year we anticipate funding one additional institute with the $3 million that is being requested for fiscal 1968.

GERM FACTOR IN TOOTH DECAY

Mr. FLOOD. You remember last year we spent some time telling you of our interest in research on the germ factor in tooth decay and urged that you vigorously pursue it.

Dr. KRESHOVER. Yes, sir.

Mr. FLOOD. Is this what we talked about earlier?

Dr. KRESHOVER. Yes, Mr. Flood.

Mr. FLOOD. There is no other germ factor?

Dr. KRESHOVER. I should point out that while I emphasized a specific causative organism in my earlier comments, the likelihood is that similar approaches to our research objectives might well identify additional organisms that might be causally related not only to dental caries, but other diseases as well.

Mr. FLOOD. What advance have you made in a year? We urged you to get into this thing and expressed an interest. Have you advanced or are you just digging away?

Dr. KRESHOVER. No, sir; we have advanced significantly. We can now demonstrate in selected population groups a specific causative organism in man, which now suggests for the first time that a similar process of decay, of the development of the caries lesion, exists in man as it does in the experimental animal model system.

INCIDENCE OF DENTAL CARIES RELATED TO CIVILIZATION

Mr. FLOOD. On page 9 you say :

The world-wide incidence of dental caries ranges from nearly 100 percent in this country to essentially zero in some primitive areas.

I think you mentioned Ethiopia especially.

Dr. KRESHOVER. Yes, sir.

Mr. FLOOD. How much do we know regarding the reasons for this? Why would that happen? You say you want to get into Ethiopia before the encroachment of civilization?

Dr. KRESHOVER. Yes, sir.

Mr. FLOOD. How much do we know regarding this problem among peoples?

Dr. KRESHOVER. We know that dental caries is a complex disease as is periodontal disease; being a complex disease, we recognize the fact that more than one factor certainly comes into the causative range. We know that diet, we know that hereditary factors, we know that exposure, possibly, to those with the disease might indeed excite the disease in man.

We have had evidence in a study done some few years ago in Alaska that as the inroads of civilization took place, tooth decay increased, whereas before that time caries was practically non-existent, as it is today in Ethiopia. The inroads of civilization have changed that pattern remarkably.

Dr. SHANNON. I think one might make the point-if Dr. Kreshover had not I was going to-of the transition of the Alaskan Eskimo beyond the less civilized characteristics of some Ethiopians.

If one made an epidemiologic study of this condition one would see that one of the major changes is this behavior pattern. The basic problem, as far as it has been studied in the Alaskan Eskimo, relates much more to dietary habits than to others. As Dr. Kreshover has pointed out, this is a very complex relationship of many factors-so complex that one must get population isolates that are quite different.

FLUORIDATION

Mr. FLOOD. Are there any new findings regarding fluoridation of water supplies?

Dr. KRESHOVER. Perhaps the most significant development over the course of the past year is the new technique I alluded to earlier whereby fluoride can be applied topically in a form that would provide a benefit to the child, and our experiment has been largely limited to children up to this time, in the range of some 80-percent reduction in dental caries. The other significant development with respect to fluoride, to depart momentarily from the dental caries story, is the benefit that it presumably has, according to the best evidence to date, in the attack on periodontal disease.

We have found, for an example, in communities that had been following a regimen of fluoridation for some years, that not only is there a beneficial effect on dental caries, but also in the reduction of the incidence of periodontal disease. We have found also and when I say "we" I talk now more broadly

Mr. FLOOD. What do you mean by periodontal?

Dr. KRESHOVER. Periodontal disease is an inflammatory lesion of the supporting structures of the teeth, extending beyond the superficial gum tissue, causing breakdown of the underlying membrane. structures and the underlying bone which normally holds the teeth in their sockets.

I might point our furthermore in our consideration of the fluoridation effort today that there are currently being benefited across our United States of America in the range of some 60 million people in over 3,000 communities. In addition to this total there are another 7 million who are residing in areas that are naturally fluoridated.

Mr. FLOOD. What would be the source of the natural fluorides in the water?

Dr. KRESHOVER. The natural mineral content.

Mr. FLOOD. What would they be?

Dr. KRESHOVER. The many fluoride-bearing soil minerals that come in contact with drinking water supplies.

REFERENDUMS ON FLUORIDATION

Mr. FLOOD. Did you lose any converts?

Dr. KRESHOVER. Through 1966, counting all years up to that time, the total number of referendums held in the United States were 952. The total won was in the range of 40 percent; the total lost, 60 percent. This is broken down further, if you care to have these other figures, to the number of referendums to adopt fluoridation, and the number to continue, and the number to reinstate. Would you want these figures?

Mr. FLOOD. Yes.

(The information follows:)

Number of referendums to adopt fluoridation_

Total won (40 percent) _.

Total lost (60 percent) –

Number of referendums to continue_.

Total won (35 percent).

Total lost (65 percent).

Number of referendums to reinstate___

Total won (50 percent)

Total lost (50 percent).

Mr. FLOOD. Why would you lose a fight like that?

821

336

485

100

35

65

31

15

16

Dr. KRESHOVER. Presumably the Public Health Service still has a real challenge ahead to educate our people. The populations in our major cities must be educated to the fact that fluoride has beneficial aspects, and that the scares that have been rather abundant are, nevertheless, we hope, diminishing today and are ill-founded.

Mr. FLOOD. What are some of the worst scares? What are some of the worst indictments? Here is the Public Health Service that says you should have this for the benefit of your children's teeth. Why would anybody want to debate that? What is the point? What are they afraid of?

Dr. KRESHOVER. The interesting thing about this is that the professional judgment is sound, and by "professional judgment" I refer now not only to the Public Health Service, but also to the American Dental Association, the American Medical Association, the American Public Health Association.

Mr. FLOOD. What are they afraid it will do?

Dr. KRESHOVER. The concerns have been so wide ranging.

Mr. FLOOD. Then you should have no problem giving me two or three. What are the two most alarming things that you are supposed to be doing to people with this?

Dr. SHANNON. I think I would like to answer that question. The concerns come under two groups. In the first group of concerns, fluorides are presented as a potentially toxic substance that can have dire consequences to health, indeed, in isolated biological systems with very high concentration such toxicity can be shown to obtain. I am talking now about the test tube. In the oral ingestion of one part per million this is ridiculous. Related to this concern of toxicity are alarming things ranging from a number of diseases, actually, to the fear of

the production of cancer. The other general series of concerns relate to whether indeed it is a public responsibility to impose the will of the community upon the individuals that reside in the community or whether the individuals should have the right to elect to have fluoride

or not.

So the grouping of opinion is around these two very broad issues. The first is a wholly fallacious one in that it has no scientific basis. Much the same way, for example, there have been arguments or there were arguments earlier in the century when one started to chlorinate water. A substantial group of people felt they should have a right to determine whether their individual water supply should be chlorinated or not. There it was possible to show that the public good was at stake here because the lack of chlorination could indeed result in epidemic disease. It was a little easier to demonstrate public good there than in the case of fluorides in relation to dental caries. Again the falacious concept of toxicity and the imposing of the community will on the individual are the two centers of opposition to fluoridation. Mr. FLOOD. Mr. Natcher.

TRANSPLANTATION OF TEETH

Mr. NATCHER. Doctor, do you have underway at this time a program concerning the replacement of teeth that have been drawn or pulled? I don't know the terminology for it.

Dr. KRESHOVER. Extracted.

Mr. NATCHER. What are you doing along this line?

Dr. KRESHOVER. We are undertaking today, largely through grant supporting mechanisms, studies of a variety of reconstructive materials used to replace or repair structures lost as a result of dental disease or oral facial disease. These are largely limited to categories of restoring decayed teeth for obvious need, replacing of lost teeth, and repairing facial defects from either congenital malformation or from injury. Our research is largely directed toward the development of new and improved materials with adhesive bonding properties. Mr. NATCHER. Doctor, pardon me for interrupting you.

Dr. KRESHOVER. Yes, sir.

Mr. NATCHER. You have a tooth that is broken and you have to remove it and it is a good tooth.

Dr. KRESHOVER. Yes, sir.

Mr. NATCHER. Can you place a tooth back in that socket at this time? Does it have to be done immediately? What are you doing along that line? That is what I have in mind.

Dr. KRESHOVER. I see. What you are alluding to now is what we would call the transplantation or the implantation of teeth.

Mr. NATCHER. That is the part I am interested in. What are you doing about that?

Dr. KRESHOVER. I would say first the replacement of damaged or lost parts of tissues or organs in man, generally speaking teeth and other structures, from other humans or lower animal forms has been a long continuing chapter of interest and challenge in the history of the dental sciences as well as in the broad range of the biomedical sciences. The principal obstacle to advance has seemingly been rather insurmountable; a barrier insofar as the immunological response or