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There are many students who are now in dental schools who could not continue their education without loans under this program.

We believe, consequently, that funds should be appropriated under present arrangements until such time as this new proposal be implemented without interruption of the program.

Mr. Chairman, the American Dental Association and the American Association of Dental Schools are grateful for this opportunity to appear before your committee on these vital matters. We would be glad now to try and answer any questions you or committee members may have.

(The complete statement of the American Dental Association and the American Association of Dental Schools follows:)

STATEMENT OF THE AMERICAN DENTAL ASSOCIATION AND THE AMERICAN ASSOCIATION OF DENTAL SCHOOLS

Mr. Chairman and members of the committee, my name is Dr. Homer D. Rovelstad of Grand Forks, N. Dak. In addition to maintaining a private practice, I am a member of the American Dental Association's Council on Legislation. With me here today are Dr. William R. Mann, dean of the University of Michigan School of Dentistry; Mr. Ben F. Miller III, assistant secretary of the American Dental Association's Council on Dental Education, and Mr. Bernard J. Conway, chief legal officer of the American Dental Association. We are testifying on behalf of the American Dental Association and the American Association of Dental Schools.

The associations we represent, Mr. Chairman, believe that passage of H.R. 13196 can be of some benefit in improving the quality of training of dental auxiliary personnel. There can be no question but that assuring an adequate supply of highly trained health personnel in the years to come is one of the most pressing responsibilities facing the Nation. The proposal presently before you is a step in the total effort to meet this responsibility. With your permission, I will ask Dr. Mann to comment in detail on the provisions of H.R. 13196.

Dr. MANN (commenting). For some 5 years now, this committee has been deeply immersed in the plans being made cooperatively by private and public agencies to increase the Nation's overall capability, both qualitatively and quantitatively, for training health professionals. Throughout this time, the committee has exercised its leadership in a prudent yet vigorous way, making real progress possible. The passage of the Health Professions Educational Assistance Act in 1963, and the amendments to it passed in 1965, are landmarks in the history of health legislation. Together with the Nurses Training Act, it constitutes the heart of our effort to assure that the American Nation has an adequate supply of highly qualified professional health manpower.

The legislation passed thus far, however, has related primarily to what might be called the major professions, those who bear the ultimate responsibility for the well-being of the patient himself. I refer here especially to the dentist and the physician. We have, of course, long recognized that the dentist and the physician are not the only professional workers in the health field. They receive vital assistance, assistance they must have, from many allied or auxiliary personnel. In the field of dentistry, three such categories of personnel can be identified. First of all, there is the dental hygienist. The dental hygienist, who is licensed in every State, is trained to carry out certain procedures inside the mouth that are necessary to the maintenance of oral health such as oral prophylaxis, taking X-rays, and applying topical fluorides and these aspects of the hygienist's work is done under the supervision and direction of a dentist. Education of the dental hygienist is conducted at the college level. In 1965, there were 56 2- and 4-year dental hygiene curriculums and enrollment was approximately 3,850. Thirty of these programs are in dental schools; 12 are in 4-year institutions and 14 are in junior colleges.

The second of the three dental auxiliaries is the dental assistant. Her responsi bilities are more directly related to the functions of the dentist himself. She works at this side, assisting him in providing dental care to each patient. In addition, the dental assistant typically will have some tasks to discharge in the area of office management. In 1965, there were 64 1- and 2-year post-high-school technical-training programs for dental assistants. Approximately half are located in junior or community colleges. The total enrollment was approximately 2,800.

Given what we know about the new number of programs now being readied, by the end of this year we can estimate that enrollment will be raised to between 3,400 to 3,800 students.

Finally, there is the dental laboratory technician who has as his primary responsibility the fabrication of prosthetic devices, such as fabrication being carried out on the basis of detailed specifications ordered by the dentist. There were, in 1965, five accredited schools of dental technology with a training capacity of 334 students. Seven additional schools have applied for and are in the process of accredition. In the instance of all three auxiliaries, it should be noted, the accreditation is by the Council on Dental Education of the American Dental Association. The American Dental Association and the American Association of Dental Schools have long recognized the important role that these auxiliary personnel play in enabling dentists to provide better dental service and to care for more people on a more efficient and economical basis. Indeed, if there has been a change in the character of dental practice within the past decade or so, it is because many dentists have been able to accomplish this result by employing formally trained auxiliaries to whom can be delegated necessary services that do not need the dentist's personal attention.

There is a shortage of formally trained auxiliaries in all three categories. While the dental profession and other interested groups have been involved for some time in vigorous efforts to remedy these shortages, it has become increasingly clear that more intensive assistance is needed.

H.R. 13196, as we understand it, would authorize a new 3-year program providing grants for construction of training centers for the allied health professions, grants to improve the quality of such centers, traineeships for advanced training to prepare personnel for teaching, supervision and other specialized functions and project grants to training centers to develop, demonstrate, or evaluate curriculums for training of new types of health technologists. The bill is limited in applicability to training centers that provide programs "leading to a baccalaureate or equivalent degree or to a higher degree" with priority going to those that provide three or more of the curriculums to be specified in regulations of the Surgeon General.

Given this latter limitation, it is obvious that the bill will not be applicable to the dental assistant, the dental laboratory technician or, immediately, to all dental hygienists. It would be a mistake, then, to view H.R. 13196 as a mounting program for the allied professions parallel in scope to that provided dentistry and medicine by the Health Professions Educational Assistance Act. The thrust of the Allied Health Professions Personnel Act of 1966 is toward supplying more teachers and administrators to staff existing and projected educational programs and will not substantially affect the present and growing shortage of dental auxiliaries.

There are at present 16 universities that have well-defined health science centers that probably would qualify immediately under H.R. 13196 as training centers for dental hygienists. In addition, we would judge that some of the other existing programs would be able to qualify within a short period of time.

With regard to new programs, it should be noted that the American Dental Association and the American Association of Dental Schools both have policy urging that all dental schools establish dental hygiene programs. About 20 of the schools do not now have such programs but some of these might be expected to react to the stimulus provided by this bill.

While precise statistics are not available, it is believed that the 4-year dental hygiene programs contribute substantially to providing the personnel needed for teaching and dental public health. At the present time, there are three graduate programs in dental hygiene that are primarily designed to prepare supervisors and administrators for both 4- and 2-year curriculums.

Of the six exclusively 4-year curriculums, only one is structured and designed as a total of 4 years of dental hygiene education. The others represent the completion of 2 years of dental hygiene education and 2 years of additional general education in the arts and sciences. Experimentation in the design of the 4-year curriculum is, then, desirable and the provisions of H. R. 13196 for curriculum design and experimentation seem appropriate to this purpose. Such experimental programs could include:

1. Teacher training programs for the development of instructors and teachers in 2-year dental hygiene, dental assisting, and dental technology programs; 2. Four-year curriculum development for the training of public health dental hygienists;

3. Experimental investigations into the expansion of the duties of presently recognized auxiliaries, based upon the educational experience of graduates from 2-year dental hygiene programs.

With regard to the improvement grants section, we believe that the availability of such funds will prove useful in enabling the schools to enhance the quality of their offerings. Similarly, the traineeship provision should have the effect of broadening the opportunities of selected dental hygienists and make it possible for these superior students to prepare themselves for specialized service in the educational and administrative fields.

H.R. 13196, then, is well designed to make some contribution to the health manpower needs of the Nation and we support these aspects of the bill.

In addition to these comments on the Allied Health Professions Training Act, Mr. Chairman, the American Dental Association would like to direct the committee's attention to section 4 of H.R. 13196, which is concerned with loan repayments by health personnel. This section would amend existing provisions of the Public Health Service Act to increase annually from 10 to 15 percent the amount of a student loan that will be canceled for each year a physician practices in a rural area characterized by low income. It also allows the total amount of the loan, rather than 50 percent, to be canceled. The association opposes this amendment in its present form as being discriminatory.

The purpose of the loan cancellation provision, as we understand it, is to help persuade health practitioners to establish practices in an area where there is now a shortage. Setting different cancellation rates for physicians, as compared to dentists, is unjustified without a clear showing that there is a substantially more serious shortage of medical practitioners than dental practitioners.

We know from our own surveys that there is a serious problem with respect to the geographical distribution of dentists. For example, in a State such as California, with a very favorable dentist-to-population ratio of 1 to 1,600, four counties range from 1: 4,500 to 1: 6,600. Again in Illinois, where there is a favorable statewide ratio of 1:1,600, 14 counties range from 1:3,500 to 1:9,300. Similar situations exist in most States.

Finally, we would like to comment on section 5 of H.R. 13196. While our associations do not feel competent to comment on the relative fiscal merits involved in these alternate forms of financing, we are concerned that nothing be done to jeopardize the continuing provision of loans to dental students. There are many students now in dental schools who could not continue their education without loans under this program. We believe, consequently, that funds should be appropriated under present arrangements until such time as this new proposal be implemented without interruption of the program.

Mr. Chairman, the American Dental Association and the American Association of Dental Schools are grateful for this opportunity to appear before your committee on these vital matters. We would be glad now to try and answer any questions you or committee members may have.

Mr. ROGERS of Texas. Thank you very much, Dr. Mann. Dr. Rovelstad, there is one question I would like to ask now. We are speaking of the American Dental Association. How many other dental societies or professional associations are there in America, in the dental profession?

Dr. ROVELSTAD. There are two, I believe. Is that right, Mr. Miller?

Mr. MILLER. I think there are a number of allied dental organizations. You mean organizations such as the American Academy of Dental Practice and general organizations, such as the American College of Dentists?

Mr. ROGERS of Texas. What I mean are the other groups. Wasn't there an American Association of Dentists that was formed, made up of dentists who disagreed with the legislative policies of the American Dental Association?

Dr. ROVELSTAD. Yes, sir.

Mr. ROGERS of Texas. How many of those groups are theredifferent groups?

Dr. ROVELSTAD. May I refer that to Mr. Conway, please?

Mr. ROGERS of Texas. Yes.

Mr. CONWAY. That is the only organization of that type that we know of, Mr. Rogers.

Mr. ROGERS of Texas. What I am getting at is this: Percentagewise, how many of the practicing dentists in the United States does the American Dental Association represent?

Mr. CONWAY. The American Dental Association represents more than 90 percent of the practicing dentists in this country.

Mr. ROGERS of Texas. I gather some of those are simply not members of any association or any group?

Mr. CONWAY. I would assume that. I believe that even this organization which dissents from the American Dental Association policies requires its membership to be in the American Dental Association or to be ethically entitled to membership in the association. Mr. ROGERS of Texas. I wondered, have you discussed this legislation with those other groups?

Mr. CONWAY. No, we do not follow a policy of discussing with them.

Mr. ROGERS of Texas. Do you know their position on it?

Mr. CONWAY. I do not know their position on this bill. Generally, I think it is on record that they have opposed Federal aid to education in any way.

Mr. ROGERS of Texas. But 90 percent of the dentists in the United States are members of the American Dental Association and the American Dental Association is the one you are speaking for today?

Mr. CONWAY. That is true. I might point out, Mr. Chairman, that this organization, the Association of American Dentists, to which you refer, has never revealed its membership and refuses to do so for

some reason.

Mr. ROGERS of Texas. Now is the same true, Dr. Mann, of the American Association of Dental Schools? Are all the dental schools members of that association?

Dr. MANN. Yes, all the dental schools of the United States and Canada.

Mr. ROGERS of Texas. When you speak you speak for them?
Dr. MANN. That is right.

Mr. ROGERS of Texas. Mr. Rogers, do you have a question?
Mr. ROGERS of Florida. Thank you, Mr. Chairman.

You have pointed up here some of the concerns I have about this legislation. It very obviously does not meet the need of what it was implied it would, in my own mind anyhow. It is it looks like what it has turned out to be is an education bill rather than a bill to turn out some practical medical people to help solve the health problem of the Nation.

I am not sure that this has even come to the right committee if we get into jurisdiction. It might be that this ought to go to Education and Labor.

What you have pointed up I think is one of the great defects of the bill, and I hope we can get the Department of Health, Education, and Welfare to look this over and see about letting some of the other institutions participate, because, as you say, it would not get to the problem of even helping dentists really, would it?

Dr. MANN. Insofar as stimulating a significant increase in the number or supply of dental auxiliaries I agree with you. To be specific with our dental hygiene program, only about 10 percent of the people being trained now are obtaining a baccalaureate degree. So the bulk of these people are being trained in 2-year programs. Junior

colleges and community colleges are entering more and more into this training, and this would not encourage them.

Mr. ROGERS of Florida. This would not help their situation or encourage them to increase their capacity to turn out these needed people?

Dr MANN. That is right.

Mr. ROGERS of Florida. How many colleges, is it 16 dental colleges? Dr. MANN. Dental schools?

Mr. ROGERS. Dental schools.

Dr. MANN. There are 50 of them.

Mr. ROGERS of Florida. About how many dentists do you turn out a year?

Dr. MANN. I will ask Mr. Miller to answer that.

Mr. MILLER. About 3,400.

Dr. MANN. Yes.

Mr. ROGERS of Florida. What do you estimate the actual need is for dentists?

Mr. MILLER. A number of estimates have been made of need, not only for today but for up to 1970 and 1980. I think the figure that was pretty generally agreed upon, was that by 1975 or 1980 we should just about double the number of the present output of the dental schools.

Mr. ROGERS of Florida. What are the prospects for meeting that goal?

Mr. MILLER. I think currently there are some very good prospects as the result of the Health Professions Educational Assistance Act. Many of our schools are currently expanding their enrollments. Several new schools are now either in planning for new construction or about to begin construction.

Mr. ROGERS of Florida. This is encouraging.

Mr. MILLER. Yes, it is.

Dr. MANN. I think Mr. Rogers, H.R. 12 has been most helpful. My own school is in the process of expanding.

We will take 53 percent, 54 percent more students, jumping from

97 to 150.

Mr. ROGERS of Florida. Many of the medical schools have not been able to take very many new people. I think it would be helpful for the record if you could supply what the dental schools have done as a result of that legislation then and how we would meet the goal? Dr. MANN. We will be glad to supply that. (The information requested follows:)

At the end of the current fiscal year 14 applications from new or existing dental schools will have been funded under the Health Professions Educational Assistance Act program. These facilities will provide 426 new places for dental students. It is estimated that if the full amounts authorized are appropriated during the next 3 years a total of 700 new places will have been added.

Mr. ROGERS of Florida. Would you agree then that it would be well to have this legislation apply to, say, junior colleges where the 2-year schools can benefit from this construction program?

Dr. MANN. If I were writing this I would make it apply to the 2-year dental hygiene programs which would include many dental schools, junior colleges, community colleges, and I would not insist that these people who are being effectively trained in 2 years necessarily now be trained over a 4-year period.

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