At any rate, regardless of whether there are enough dentists or not, there is a vast shortage of certain types of auxiliaries-mainly dental hygienists or their equivalent. We have approximately 100,000 active dentists in the United States but only 8,000 dental hygienists. We probably need as many hygienists as dentists since prophylaxis is one of the most important preventive procedures. For example, past age 35 most teeth are lost from pyorrhea which has its origins for the most part from tartar deposits on the teeth. Therefore, preventive oral hygienic procedures are directly related to the ultimate dental health of the aged, provided they are begun early in life and continued periodically.

There is also a shortage of skilled dental technicians. This would become worse with the expansion of prepaid group practices, especially if technicians were to be employed on the staffs. Currently, most training of dental technicians is by commercial firms, vocational schools, and apprenticeship. I would like to see Federal support given to the development of dental technician training schools in university dental schools so that dental technicians and dental students can learn to work together from the beginning of their careers.

But again, all of these suggestions are based upon a higher degree of organization of health care services, mainly through development of group practices. Training of more personnel will be wasted if there do not exist organizations capable of employing them. Solo practice is too inefficient to employ the variety and numbers of auxiliary personnel that are necessary to maximize productive efficiency.

MEDICAL AND DENTAL NEEDS OF ELDERLY

7. "How well do you think Medicaid (Title XIX) is serving the dental needs of the elderly, and what, if any, recommendations would you have for making this program more responsive to the dental needs of this age group?" Medicaid is not serving very well for the simple reason that the majority of eligible persons fail to utilize the programs. In California, for example, probably not more than 15 percent of eligibles seek dental care in any one year, and California has one of the best programs in the nation. Those that seek care do not necessarily receive the best care since preventive services often are valued lower (re: fees) than prosthetic services such as dentures. Dentists can make three or four times as much per hour on dentures as compared with filling and cleaning of teeth! Another problem relating to elderly persons eligible for Medicaid is the maldistribution of dentists. Dentists tend to locate in the middle class areas, not the urban ghettos where most of the aged poor reside. Therefore, programs should be developed to bring dentists to these areas. The best way would be for the state and/or federal government to establish group practice programs in these areas. The key to the success of these programs is good administration. Unfortunately, there appears to be a dearth of good dental administrators in this country. We urgently need training programs developed in schools of public health in dental care administration. These programs require Federal financing since the universities do not have the funds to support them locally.

8. "To what extent do you believe that failure or inability to receive proper dental care results in medical conditions covered by Medicare, thus forcing Medicare expenditures by the government and individual which could have been prevented?" Not much. I am enclosing the complete paper on "Dentistry in the Geriatric Patient: Mutilation by Consensus" which expressed my views on this matter quite completely. (The article brought to your attention was abstracted from this paper).

I am not satisfied with these brief responses. But your questions were so comprehensive that anything less than a dissertation with background and supporting data for the opinions expressed would be unsatisfactory. Nonetheless, I hope you will find these remarks for some interest and value. Needless to say, I would be glad to offer assistance (and opinions) in the future since we share common concern for the well-being of our compatriots-old and young together.

Sincerely,

JAY W. FRIEDMAN, D.D.S., M.P.H.,
Associate Researcher.

[Enclosure]

EXHIBIT A. DENTISTRY IN THE GERIATRIC PATIENT*

MUTILATION BY CONSENSUS

(By Jay W. Friedman, D.D.S., M.P.H.)

Approximately 50% of Americans have lost all their teeth by age 65. More than two-thirds are totally edentulous by age 75.1 It is obvious that dental care for the geriatric patient is overwhelmingly characterized by the extraction of his teeth. This massive destruction of the mouth is not the result of an insidious, unpreventable disease process of aging. Rather, it is the result of little concern by the public for the preservation of teeth, and the regressive social character of the dental profession which has the technical knowledge but has failed to develop the manpower necessary to apply it on a universal scale. To be sure, there are degenerative processes of the oral mechanism with aging. But these processes can be modified to such an extent that the vast majority of the population could retain teeth throughout life.

The degenerative dental condition of the geriatric patient generally is a product of cumulative neglect which begins in childhood and progresses to a state of partial and then total edentulatism (Fig. 1). But neglect is not a simple function of disinterest or negativism, although both these attitudes are present to an alarming degree. It is also a function of relative social, economic, and health values. Little social stigma is attached to loss of teeth even though we have advanced beyond the stage where it is viewed as a "coming of age." Economically, dental care is relatively low on the priority of expenditures. The simple fact is that the United States is a commodity culture in which the acquisition and consumption of manufactured goods are conditioned needs taking precedence over what are considered nonessential health care services. Although dental neglect inevitably leads to pain and infection which require treatment. the loss of teeth either singly or totally does not represent a significant health hazard. Conditions leading to the loss of teeth may be hazardous to health, but once the teeth are lost the person is nearly the same physiologically. However, there may be serious social and psychological hazards which have untoward effects on the person's well-being.

To place these remarks in perspective, the function of the dentition, the diseases that ravage it, and the knowledge and techniques that are known to preserve it are reviewed.2

Function of the dentition

The most obvious function of teeth is the mastication of food in preparation for digestion. Incisors are designed for tearing and cutting up food and molars for shredding and grinding it prior to swallowing. Saliva lubricates the food bolus and supplies enzymes which begin the digestive process in the mouth. Prior to forks and knives, this process undoubtedly was of great importance. But with the development of processed foods and the emphasis on the soft texture of cooked foods the physiologic importance of mastication has declined. Edentulous persons do not necessarily suffer from an inability to masticate foods properly. Prehistorically, human teeth also functioned as weapons of aggression and defense as they do presently among the lower animals. However, man has subsequently developed more efficient weapons. Teeth also are sexual symbols as evidenced by their implied virility in the advertising media. Loss of teeth can be equated with loss of virility which is certainly an important psychological factor in the process of aging. Therefore, the geriatric patient may accept the loss of his teeth, but want them replaced with an esthetically attractive artificial denture. Teeth also are important in speech. Many sounds are dependent upon the position of the tongue and lips against the dentition. Yet it is apparent that edentulous patients are not at a loss for words, so this function also should not be overemphasized. In short, teeth have their functions but they are not essential to the longevity of the species in the modern world. It would be a grievous error, however, to view the dentition as a dispensable vestige with little more significance than the appendix.

* Reprinted from Geriatrics, Vol. 23, pp. 98-107, August 1968. Copyright 1968, by Lancert Publications, Inc. 1 Loss of Teeth. Health Statistics from the U.S. National Health Survev: U.S. Department of Health, Education, and Welfare, Public Health Service, PHS Publ. No. 585-B22. Wash

2 Current Therapy in Dentistry. Vols. 1 and 2. Edited by H. M. Goldman. S. P. Forrest, D. C. Byrd, and R. E. McDonald. St. Louis: The C. V. Mosby Co., 1964.

FIG. 1. Rate of edentulous persons per 100 population by sex and age*

*U.S. DEFARTMENT OF HEALTH, EDUCATION. AND WELFARE. PUBLIC HEALTH SERVICE. HEALTH STATISTICS FROM THE U.S. NATIONAL HEALTH SURVEY: LOSS OF TEETH P.H.S. PUB.584-822

Diseases of the dentition

Although many systemic diseases manifest symptoms in the oral cavity, the science and art of dentistry is mainly concerned with diseases of the dentition, foremost of which are dental caries and pyorrhea. Dental caries occurs commonly in children with the eruption of the primary molars. It continues throughout life and is the greatest cause of tooth loss up to age 35.3 Periodontal disturbances also occur early in life, mainly as gingivitis. But gingivitis in childhood and early adolescence usually is without clinical significance. With the increased deposition on teeth of calivary calculus that occurs during late adolescence and continues throughout life, the gingiva become irritated and eroded. If the calculus is not removed periodically, irreversible degenerative changes in the periodontium-gingival and bony tissues and the periodontal attachment-may occur which lead to loosening and eventual loss of the teeth.

3 Pelton, W. J., Pennell, E. H., and Druziną, A.: Tooth morbidity experience of adults. J. Amer. dent. Ass. 49 :439, 1954.

This process-pyorrhea-is the greatest cause of tooth loss after the third decade of life. Most pyorrhea is produced by the physical presence of calculus. It is therefore preventable by early and periodic removal of calculus. Another form of pyorrhea, periodontosis, appears to be unrelated to calculus deposits. It is characterized by rapid dissolution of the dental alveolar bone, the cause of which is unknown, in contrast to the slow progress of calculus-induced pyorrhea. Fortunately, periodontosis is a relatively uncommon dental disease. Many other diseases of the hard and soft tissues of the mouth, including cysts and carcinomas, affect the teeth and other oral structures." Functional conditions such as malocclusion, temperomandibular joint disturbances, and pernicious habits involving the tongue, lips, and swallowing process may require corrective dental treatment. Also, traumatic injuries and fractures of the jaws come under the purview of the dental profession.

Systemic diseases such as blood dyscrasias, diabetes, and epilepsy under DilantinR therapy commonly cause inflammation and hypertrophy of the periodontal tissues. Avitaminosis, a frequent occurrence in the aged, may be associated with cheilosis. Also, individuals suffering from vitamin deficiencies as well as those who have recently completed antibiotic therapy may be more susceptible to acute and chronic monilial infections. Localized diseases of the periodontium, such as trench mouth and dental abscesses, may produce generalized systemic infection which is characterized by fever and, if untreated, septicemia. Dental extractions or even gingival curettage-cleaning of the teeth-produce transient bacteremias which can cause subacute bacterial endocarditis in those patients with a history of heart damage due to rheumatic fever.""

While some dental diseases occur more commonly at different ages in life, few can be considered age-specific. However, physiological and functional changes occur with aging that may affect the course and the success of dental treatment. The oral mucosal lining tends to become thinner and less resilient and thereby more susceptible to pressure ulceration from artificial dentures. Salivary flow may decrease, causing dryness of the mouth which makes denture retention more difficult. The enamel of teeth may be worn off the occlusal and buccal surfaces, creating sensitivities and greater susceptibility to dental caries. The temperomandibular joint is subject to wear, especially the articulating disc. Also, decrease in vertical dimension, the distance separating the mandible from the maxilla, occurs with loss or excessive wear of teeth. The resultant change in the articulation of the mandible may be accompanied by temperomandibular joint pain and, in extreme cases, impairment of hearing. When teeth are lost, the alveolar bone forming the supporting ridges for dentures is gradually resorbed. Thus the elderly patient's jaws frequently present flat ridges that are inadequate for the stabilization of artificial dentures.

Of particular interest to physicians caring for geriatric patients is the "theory of focal infection" as it pertains to the teeth. A few decades ago it was not uncommon to have physicians and dentists recommend the removal of suspicious teeth in the hope of curing rheumatism and arthritis. But it has long since been demonstrated that asymptomatic teeth, including those that are nonvital or have been devitalized by root canal therapy, do not serve as foci of infection. Therefore, teeth should only be removed for sound dental reasons and not on the presumptive hope that cures for systemic diseases will be effected.

Prevention and treatment

The most common dental diseases of caries and pyorrhea cannot be entirely prevented. However, the incidence of dental caries can be reduced by 60% through the fluoridation of public water supplies. A further decrease can be effected by the reduction in the consumption of refined carbohydrates." Unfor

• Peridontal Disease in Adults. U.S. Department of Health, Education, and Welfare, Public Health Service, PHS Publication No. 1000 Series 11, No. 12, Washington, D.C.: Government Printing Office, 1965.

5 Bhaskar, S. N.: Synopsis of Oral Pathology. St. Louis: The C. V. Mosby Co., 1961. 6 Brandt, C. L.. Korn, Ñ. A., and Schaffer, E. M.: Bacteremias from ultrasonic and hand instrumentation. J. Periodont. 35 :214, 1965.

7 Handbook of Dental Practice. Edited by L. I. Grossman. Philadelphia: J. B. Lippincott Co., 1952.

8 Grossman, L. I.: Focal infection. Dent. Clin. N. Amer. Nov. 1960, p. 749. Fluoridation as a Public Health Measure. Edited by J. H. Shaw. Washington, D.C.: Amer. Ass. Advancement of Science, 1954. Also see J. Amer. dent. Ass. Vol. 71, No. 5, November 1965 for more recent papers on facts and issues in the fluoridation controversy. 10 Jay. P., Beeuwkes, A. M., and Hughey, M. J.: Dietary program for the control of dental caries. In: Lippincott's Handbook of Dental Practice. 3rd ed. Edited by L. I. Grossman. Philadelphia: J. B. Lippincott, 1958.

tunately the food industry caters to the "sweet tooth" of the populace as well as playing a determining role through advertising in the development of dietary habits. Although the modern diet may be nutritionally adequate, from the dental viewpoint it is too soft to provide proper stimulation of the gingival tissues during mastication and serves as a feeding ground for the complex bacterial and chemical decay process. Nonetheless, dental caries can be effectively treated by the removal of the areas of decay and the restoration of the teeth with fillings and crowns. Teeth need seldom be lost due to this disease.

Pyorrhea is also largely preventable, as mentioned, through the semiannual or annual removal of calculus deposits on the teeth. Relatively sophisticated techniques have also been developed for the preservation of teeth that have already experienced loss of supporting alveolar bone. But as yet, there is no public health method comparable to fluoridation for the prevention of pyorrhea. Dental prophylaxis must therefore be carried on throughout the life of the individual. Some problems of dentures

Given proper periodic dental care, there is little reason for the geriatric patient to lose his teeth. Yet, in the United States perhaps only 10% of the population receives adequate care. e." For example, in any one year it is estimated that only 40% of the population visits the dentist at least once, most likely for the removal of teeth. Half the population by age 65 has or needs artificial dentures. But far from having solved the problem, the average denture patient has a sore mouth, dissatisfaction with his chewing capacity, and the fear that his teeth will come loose at embarrassing moments. Many elderly patients have given up chewing with their dentures and use them only for appearance in social situations. Although temporary stability may be obtained by use of denture adhesives, it is very short-lived and denture wearers find these powders and pastes literally distasteful.

It is debatable if there is such a thing as a well-fitting denture, although maxillary dentures are more easily retained and provide considerably more satisfaction than mandibular dentures. The reason is that both dentures "float" in the mouth during function, and the mouth is in constant movement even during sleep. Nevertheless, there are definite criteria for the proper fit of dentures, such as the maximum area of the base support that the tissues and musculature can tolerate, the correct centric relationship of the opposing dentures, and the proper vertical dimension. Even though these criteria are met, the success of dentures is still dependent upon the individual's adaptive capacity. Generally, the younger the patient, the more successful the adaptation. The subjective element is so great that even poorly fitting dentures can be worn successfully by some individuals, whereas many have the greatest difficulty with dentures that satisfy all known functional requirements.

As the patient ages, it is important that radical changes not be introduced by the dentist simply to satisfy the textbook criteria. This error most frequently occurs when an elderly patient decides to have a new set of dentures because the teeth are cracked or the denture base looks unattractive, although he is otherwise satisfied with the fit of his ten- or twenty-year-old plates. In these cases the patient's separation of maxilla and mandible has decreased. He has what dentists call a "closed bite." It may be the result of an original error in which the artificial teeth were too short or the alveolar ridges may have been resorbed under the dentures. Proper vertical dimension is itself an arbitrary concept which may vary as much as five millimeters without violating the principles of sound denture construction. The over-enthusiastic dentist may decide to restore the geriatric patient to a 35-year-old level of vertical dimension to improve his profile and make his teeth show more. While this procedure is most likely indicated for the 50 or 60-year-old patient, it is hazardous for the very elderly who have accommodated successfully to the gradual closing of their bites.

Ill-fitting dentures can represent hazards other than occasional sores and generalized dissatisfaction. In particular, constant irritation of the oral mucosa can produce cancerous lesions. These lesions occur most commonly along the periphery of the dentures. In the early stages they cannot be distinguished from pressure sores. However, if the ulcerations persist beyond ten days or two weeks after mechanical relief or adjustment of the denture, biopsy examination is indi

11 This is based on the fact that "only one-tenth of the population accounted for about two-thirds of all dental visits." (Blue Cross Reports. Dental expenditures, utilization, and prepayment. Sept.-Oct. 1963) But whether the consumption of the bulk of dental services really implies "adequate" care must remain moot until adequacy is defined and measured.