first in the intermediate school clinics. Good work, however, can and is being done with present facilities. South Australia The Australian plans tend to emphasize a closer control of auxiliaries than the New Zealand plan. In Adelaide, South Australia, the school dental service of the Department of Public Health runs a school for dental therapists along the lines of the New Zealand schools for dental nurses. Four classes have been graduated from this school (as of 1972), giving a working force of about 50 therapists. These therapists operate 23 field clinics on elementary school grounds, and serve about 25,000 of the 180,000 children who make up the total eligible child population. The typical deployment within a given area involves a regional dental officer, who works with two dental therapists and two chairside assistants in a three-chair clinic (Fig 6). He supervises two satellite clinics, at which two therapists and one dental assistant work. These clinics usually are located within 2 miles and almost always within 20 miles of the regional clinic. So far, regional and satellite clinics have been established only in city or town areas. The regional dental officer performs annual dental examinations for the children in the first 622 JADA, Vol. 85. September 1972 grade and in alternate grades (three, five, and seven). He must approve all treatment plans, but the therapist performs screening at such midyear recalls as seem necessary, and annually for children in grades two, four, and six. The dental officer performs any dental treatment for children that is beyond the scope of the therapist. He makes a quality control check and counsels the therapists at the third-, fifth-, and seventh-grade recall examinations, and sees their work on many other occasions as well. When the children's problems are controlled, he also treats pensioners of various ages and categories, who are eligible for dental care through a plan that is similar to Medicare in the United States. The clinics in South Australia resemble those in New Zealand, but equipment differs. Japanese reclining dental chairs are used, and the operators are seated for every aspect of their work except extractions. Dental units with high-speed equipment have been pieced together by local manufacturers, as shown in Figure 7. A new three-chair clinic, fully equipped and supplied for operation, is estimated to cost about $50,000. (The Australian and New Zealand dollars are approximately equal in value.) The scope of activity of the dental therapists in South Australia is similar to that of dental nurses in New Zealand, except that they are trained to take radiographs, and ordinarily will have X-ray machines and developing facilities to fluoridated city in the area, took this step only within the two past years. Therapists are now being placed where they have responsibility for approximately 500 eligible schoolchildren. The New Zealand dental nurses and the South Australian therapists work only for the government. This limitation is written into both statutes. South Australia is a large state, more than 700 miles in both width and length. More than three quarters of its population is concentrated in the Adelaide metropolitan area; the other widely separated groups of people live on ranches or in very small towns. The Department of Public Health, therefore, owns 12 mobile dental clinics (trailers), of which 6 are operational at the present time. Each is staffed by a school dental officer with one assistant. Before the advent of therapists, these mobile clinics, "exiled to the out-back," provided the only government-sponsored children's dental service in the state, except the service at the dental department of the Royal Adelaide Hospital. The new town and city clinics, therefore, fill a real need. Much further expansion, of course, is necessary before the South Australian program will approach the degree of coverage now found in New Zealand. Tasmania The state of Tasmania, Australia, developed a dental nurse program in 1966, one year ahead of the plan in South Australia. I was unable to visit this program, but have been informed that it resembles the New Zealand dental nurse pro Dunning DENTAL AUXILIARIES IN NEW ZEALAND AND AUSTRALIA 623 gram more closely than the dental therapist program in South Australia. The dental equipment used in Tasmania is naturally more modern than most equipment found in the New Zealand program. Western Australia In Perth, Western Australia, a new school for dental therapists has graduated its first class of 16 women this year (1972). In curriculum and scope of activity, this therapist program resembles the plan in South Australia, but differs sharply in the fact that the dental therapists will be permitted by law to enter private practice, as well as government service. The people in New Zealand and in other parts of Australia are apprehensive about this permission; the dental profession in the United States seems relatively unconcerned about the matter. The Western Australian program, therefore, must be watched carefully in the future, to note the settings that prove practical in private practice and the degree, if any, to which freedom of action, found in private practice, is conducive to illegal practice among the therapists. Discussion The differences between deployment and control of auxiliaries in New Zealand and Australia, compared with the proposed deployment and control of similar auxiliaries in the United States, leads to speculation along several different lines. Perhaps the first consideration is the dental manpower that is required to mount large-scale programs of child care. In New Zealand, the diversion of only a small number of dentists to the school dental service has permitted a large increase in the availability of dental care to children between the ages of 21⁄2 and 132. Their systematic approach to incremental care is unequaled elsewhere in the world, unless perhaps in the Scandinavian countries. When the various supervisory and administrative positions that require the employment of dentists are added, it appears that less than 25 dental graduates, exclusive of those teaching in the training schools, can control a working force of 1,350 auxiliaries. In Australia, the ratio is about one dental graduate to six therapists, with the dentist free 624 JADA, Vol. 85. September 1972 to perform many dental procedures for children and patients of other ages. In the United States, one dentist is likely to be able to employ no more than four expanded duty dental auxiliaries, though again, he will accomplish many of the dental procedures himself. The productivity of the American teams, such as those at Louisville, 5.6 may surpass that of the Australian teams, though detailed time studies have not as yet been made in Australia. On the debit side, however, the manpower problem in the United States will be complicated by the difficulty of recruiting congenial teams for the intimate coordination that will be required, the difficulty of scheduling a suitable patient flow, and the disruption that will occur to the work of any team if a member is unexpectedly absent. In a period when the United States is concerned about the delivery of incremental care to children, the most important consideration is the relation of the New Zealand and Australian plans to their environment in the accomplishment of incremental care. The New Zealand plan has a sufficient staff to reach the entire child population of that country. Even so, we cannot necessarily equate availability of staff and completion of care in the entire eligible population. Usually, however, enrollment of a child in the program is taken as the equivalent of completion of dental care. The dental nurses have such continuous access to their enrolled children and such determination to work out a satisfactory plan of treatment that failure to control caries to at least a reasonable extent seems to be almost unknown. This situation is so different from that found in most incremental programs in the United States that I made a careful effort to assess the cultural and the environmental factors that might have contributed to such a result. Several factors were obvious. Dental care is brought to the schools throughout New Zealand with a minimum reliance on busing. This provides maximum accessibility to the child population and a small logistic problem. The dental nurse is a full-time resident teacher, without competition in the health field in her personal relationship with the children. She sees the children as individuals in the clinic, as groups in the classroom and in sports. New Zealand society is relatively homogeneous and well-disciplined. Military service and sports-both of which require discipline-are respected. Each nurse is given a numerically controlled population whose care she is able to complete. The New Zealand program is so extensive that movement of families from one area to another interferes little with incremental care. The program gives such real and challenging responsibilities to the nurse that her occupation has become prestigious. The service attracts above-average young women and good leaders. There is an excellent esprit de corps. The New Zealand people are by nature hardworking, and must work to maintain a civilized society. Kaula's said, "As a do-it-yourself man, a New Zealander has no equal. A New Zealander will undertake any job around the house from building a new wing to installing the plumbing. . . . Even women and girls have an all-around talent for fixing things." Dentistry fits well with this temperament. The direction of the nurses, although distant, is good and a minimum of time and manpower is expended in supervision. The dental nurses have reacted well to this sytem, fulfilling their responsibilities without exceeding them. Written rules are clear and their enforcement thorough. The responsible contacts the women have with their patients and with other members of the school staff, however, compensate for the rigidity of the rules. The New Zealand people think dental care is worth the support, through taxes, of one fulltime paraprofessional worker in their school system for the care of about every 500 children 13 years of age and under. In sharp contrast to the New Zealand program, most incremental dental care programs in the United States at present are pilot programs that serve small segments of a heterogeneous, highly mobile population. Our society is less disciplined than that in New Zealand, and none of our plans for deployment of dental auxiliaries gives the women as responsible a place in the community as the New Zealand dental nurse has found. As a result, our programs have developed slowly and possess little prestige. They seldom provide incremental care to large, stable groups of children. Our clinic schedules, particularly those in the neighborhood health centers serving disadvantaged populations, are built on demand care." We find it most efficient to work first with those members of the community who seek us out and give promise of becoming regular recipients of incremental care. We cannot alter our society in any brief time, nor can we perhaps ever modify it to the extent that it will duplicate that in New Zealand. Our problem, therefore, is to select as many of the good qualities of the New Zealand and Australian programs as may be reasonably well applied in this country. Despite the environmental and cultural differences between Australia and New Zealand, and the United States, one conclusion seems clear. Any large-scale incremental care plan for young children if it is to succeed, must be brought to them in their schools. This concept implies the unsuitability of private dental offices alone for a nationwide program, except for the care of adolescents, at which time a transfer from care at schools to private offices should occur for those children not already being handled in private offices. In this respect, the New Zealand contract plan for adolescents offers an attractive example. The mechanisms for implementing it are already developing here in those states where Medicaid offers comprehensive dental care. Where private practice cannot carry the adolescent and adult patient load unaided, as in disadvantaged areas, the Australian plan has merit. Treatment of adults in school dental clinics points to the desirability of establishing neighborhood dental facilities on school premises to avoid duplication of facilities. Again, a precedent exists in the United States. An increasing number of cities and towns are opening their school buildings to adult health care and other adult activities after school hours. This is sometimes called a community school program, and may be arranged through a local hospital or a Model Cities program. Another conclusion seems clear: expanded duty dental auxiliaries do fit well into a school dental care program. More than one control and deployment mechanism for them has been shown to succeed. The United States must plan carefully the control and deployment mechanism best suited to its own people. Last and most important is the lesson to be learned in timing. New Zealand, after 50 years, now has a mature school dental service well adjusted to its designed load. South Australia, with 23 clinics established in four years, modestly calls its program a pilot one. About 300 more therapists are needed in service to cover 180,000 eligible children in a state with a total population less than that of Nebraska. They will require many more years to reach this working force, even if they enlarge their training program. Dunning: DENTAL AUXILIARIES IN NEW ZEALAND AND AUSTRALIA 625 The United States, if it goes a similar road, cannot develop overnight the corps of over 50,000 auxiliaries needed to care for its 37 million children 5 through 13 years of age. The author is indebted to R K. Logan, director. New Zealand Division of Dental Health, and to H. D. Kennare, superintendent, school dental service. South Australia, for valuable assistance in editing the manuscript of this paper. Dr. Dunning is professor of ecological dentistry, Harvard School of Dental Medicine, 188 Longwood Ave, Boston, 02115. 1. Fulton, J.T. Experiment in dental care: results of New Zealand's use of school dental nurses Monograph senes no. 4. Geneva, World Health Organization, 1951 2. Gruebbel, A.O. A study of dental public health services in New Zealand Chicago, American Dental Association, 1950. 3. Dunning, JM. Dental caries experience in New Zealand contrasted with that in certain parts of the United States. New Eng Dent J 4 10 July 1951 4. Kennedy, D.P. New Zealand's dental auxiliary programme. WHO Chron 25:65 Feb 1970. 5 Lotzkar, S.; Johnson, DW., and Thompson, M.B. Experi mental program in expanded functions for dental assistants. phase 1 base line and phase 2 training JADA 82:101 Jan 1971 6 Lotzkar, S., Johnson, DW, and Thompson, M B. Experimental program in expanded functions for dental assistants: phase 3 experiment with dental teams. JADA 82:1067 May 1971. 7. Soricelli, DA Practical experience in peer review controlling quality in the delivery of dental care. Am J Pub Health 61:2046 Oct 1971. 8. Friedman, JW New Zealand School Dental Service lesson in radical conservatism. JADA 85 609 Sept 1972. 9. Logan, R.K. Personal communication, Feb 23, 1972. 10. Leslie, G.H. Personal communication, Feb 21, 1972. 11. Berman, D.S. Utilization of the dental auxiliary-school dental nurse. 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