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. ." 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.

cated. With or without sores or dissatisfaction, most dentures require rebasing or replacement about every five years to readapt them to changes in the supporting tissues caused by alveolar resorption. It is generally believed that less alveolar resorption occurs under well-fitting dentures.

Alternate choices

For the most part, the upper dentures are easily constructed and well tolerated by patients. When there are only a few sound maxillary teeth left few dentists would hesitate to recommend a complete denture. Such is not the case for mandibular dentures. In contrast to the board, relatively immobile maxilla which provides a wide base of support for denture stability and retention, the mandible forms a narrow horseshoe shape. In addition, the peripheral mucobuccal fold of the mandible is far more active as a consequence of the greater mobility of the mandible. The lower lip, the tongue, and the sublingual musculature are in vigorous motion during speech and swallowing. The effect of these actions is to unseat the lower denture. For this reason, mandibular teeth should be maintained as long as possible to provide anchors of retention for partial dentures. Even if there are only two cuspids remaining they should be retained rather than removed for a complete lower denture. The reason for citing the cuspids is that they tend to be least susceptible to pyorrhea by virtue of their long, strong roots, and are more likely to be present in the geriatric patient.

In this brief review of the major dental problems of the aged, mention of fixed bridges has been omitted. Certainly, fixed bridges are indicated for the replacement of natural teeth wherever possible. When too many teeth have been lost or the cost of fixed restorations is prohibitive, partial dentures should be constructed. Full dentures are a last resort, and are the consequence of oral failure." When the cost may run into thousands of dollars, alternative treatment plans rather than full dentures are frequently little more than exercises in fantasy. Locales of treatment-the private office and the hospital

The preceding discussion is intended to provide a broad background of common conditions that are applicable to the population at any age and to indicate that the main geriadontic problems result not from aging but from neglect. Responsibility for this neglect falls upon the public which readily accedes to its consequences. But it must be shared also by the dental profession which has in the past opposed the development of auxiliary manpower and methods of financing care to meet the needs of the population. Only within the last few years has the profession seriously addressed itself to this problem of auxiliaries, although the level of experimentation is often ludicrous in light of known accomplishments elsewhere. Thus, the vast majority of the population arrives at old age with the complete destruction of its natural dentition despite the fact that the dental profession has the scientific knowledge and technological ability to avoid it. A revolution in our social values is required to overcome this mutilation by

consensus.

Meanwhile, there are some practical considerations that are of special concern for the dental care of the geriatric patient. Foremost of these is his state of ambulation. Dental care is most effectively performed in a well-equipped office. The responsibility of the physician is to ensure that his patients seek and receive necessary dental care, especially with regard to elimination of present and potential oral infections. The relatively well ambulatory patient is easily referred to a private dentist, provided he can afford treatment. The nonambulatory patient presents a special problem. Since many of these patients have been, will be, or are hospitalized, they should receive needed care before being discharged from the hospital. Therefore, every hospital should have completely equipped and staffed dental facilities.14 All patients should be required to have a dental examination and necessary treatment should be provided before discharge to those who are unlikely to receive it afterwards because of anticipated immobility. For the geriatric patient, the treatment most likely needed is removal of infected teeth. It would be easier and safer to perform this minor surgery in a hospital rather than to await an acute toothache or infection in a nursing home that lacks adequate facilities. 15 Also, the hospital concentrates patients, thereby making best

12 Friedman, J. W.: A Basic Guide to Qualitative Standards for the Evaluation of Dental Care Programs (mimeo). Los Angeles: UCLA School of Public Health, 1965.

13 Hillenbrand, H.: Keynotes: an address to dental examiners and dental educators. J. Amer. dent. Ass. 74: 1464, 1967.

14 Weyer. I. E., and Casey, G. J.: Planning the dental unit. Am. Hosp. A. J. 41: 69, 1967. For methods of practice. see B. L. Douglas and G. J. Casey, eds. A guide to hospital dental procedure. Chicago, Am. Dent. Assoc., 1964. 195 pp.

15 Douglas, B. L.: Dental care for the aged. N. Y. J. Dent. 29: 53, 151, 1963.

use of dentists' time. Programs have been developed for the provision of care in nursing homes and the patient's home.10 17 I consider them inordinately wasteful of dental manpower which is already in short supply.

For dental care to be incorporated into hospital practice the physician must pay more than lip service to the concept of treating the whole patient rather than the admitting diagnosis. Many hospital staffs govern themselves according to the by-laws of the medical and dental staff. But even in those hospitals that have rather highly developed medical staff organizations, dental participation is most often limited to oral surgeons with the consequent emphasis on maxillofacial and interoral surgery rather than preventive and restorative dentistry. More recently, a number of hospitals have instituted well-equipped dental facilities for restorative treatment of patients under general anesthesia, especially those suffering from cerebral palsy and similar disabilities. However, only a few of the larger governmental hospitals such as those operated by the Veterans Administration include normal dental care in the total medical care program. In these hospitals newly admitted patients are screened by dentists and care is provided where it is deemed supportive of the general medical condition. For example, a long-term diabetic patient may receive dental treatment whereas a short-stay patient with a limb fracture may not. For this approach to be effective, general dental practitioners and prosthodontists must be present on the hospital staff and directly involved in diagnosis and treatment. The manpower problem

Concerning the larger issue of dental manpower and especially the creation and expansion of duties of auxiliaries, the medical profession's passive attitude toward dentistry requires alteration. Dentistry is, after all, a specialty of medieine. What is true of medicine generally therefore is applicable to dentistry. As a corollary, the orthopedist is not expected to construct and fit prosthetic appliances or to personally train the patient in their use. Put another way, state medical practice acts do not specifically prohibit medical technicians from looking at, much less touching, patients. Yet, that is the status of dental practice legislation in this country. The law specifically prohibits dental technicians and assistants from taking impressions and fitting dentures. Laboratory technicians are even prohibited from taking the shade of the patient's natural teeth in order to match the color of prosthetic appliances, a process that requires visual but hardly physical contact. In order to remove tartar and stains from the exposed surfaces of the teeth, one must be either a licensed dentist or hygienist. There are historical reasons for these restrictions, but abuses of the past do not necessarily form a rational basis for present practices. Certainly it is not proposed that inadequately trained or unlicensed individuals be allowed to practice dentistry, rather that more rational practices be adopted in accord with present needs. Given adequate organization and surveillance controls, lesser trained auxiliaries can perform many dental tasks without jeopardy to the public. Indeed, this has been the experience of medical practice and there is no reason why it should not be applied to the practice of dentistry. Without this application there is absolutely no possibility of preventing the destruction of the natural dentition with or without the consensus of the public.

As stated previously, the American dental profession no longer opposes the expansion of the role of auxiliaries as such. It is even engaged in experiments to determine the feasible parameters of this expansion. Hundreds of thousands of dollars are being expended to discover if dental assistants can take study impressions as well as dentists or place amalgam in prepared cavities. Many elements of the profession consider these experiments audacious if not outrageous, whereas others cite them as indicative of a progressive posture. However, these experiments are little more than simple demonstrations of the obvious, which has been known for nearly half a century. To be specific, New Zealand has been training school dental nurses since the 1920s." These nurses are trained in a two-year course to perform fillings, extractions, and other procedures for children. They work independently in dental operatories located in public schools. Parentheti

16 Douglas, B. L.: Dental care for the special patient (handicapped-chronically ill— aged.) Practical Dent. Monographs, Jan.-Feb. 1966. 28 pp. 17 Waldman, H. B., and Stein, M. For the Chronically Ill and Aged A Plan for Total Dental Services (mimeo). Cleveland: Western Reserve University School of Dentistry, 1967.

18 Hammons, P. E., and Jamison, H. C.: Expanded functions for dental auxiliaries. J. Amer. dent. Ass. 75: 658, 1967.

19 Fulton, J. T.: Experiment in Dental Care; Results of New Zealand's Use of School Dental Nurses. (WHO Monograph Series No. 4) Geneva: World Health Organization 1951. 24-798-69-pt. 3—11

cally, restriction of their services to children represents an economic concession to the dental profession rather than being based on differential skills, since children are often more difficult to work on than adults. Thus, New Zealand's school dental nurse program has not advanced internally much beyond its original design. But it has demonstrated that lesser trained auxiliaries can effectively perform many dental procedures far more sophisticated than those presently under consideration in the United States.

Other countries are responding to the dental needs of their populations by adopting the New Zealand approach." While most of these countries are designated as underdeveloped such as Ceylon, Singapore, Malaya, Thailand, Indonesia, and Ghana, it is also being adopted in more advanced nations such as Great Britain and Canada. However, by dental standards, all nations are underdeveloped and it is only a matter of time before the New Zealand pattern is adopted universally. Concerning the major needs of the geriatric population, such as dentures, Canada already has legalized denturists who are specially trained and licensed technicians.

The future

What do these developments portend for the future of dental practice? With the expansion of the numbers and duties of auxiliaries, dentists will be relieved of the vast bulk of simple mechanical procedures that presently consume most of their time. They will be able to devote themselves to the practice of dental medicine. Problems of growth and development of the oral structures will receive greater attention, resulting in more preventive and interceptive treatment. Oral and maxillofacial surgery, advanced periodontal therapy, and orthodontics will most certainly remain the prerogatives of the dentist. Prosthodontics will be more concerned with the correction of oral clefts, traumatic injuries, and defects caused by cancer than with the construction of dentures for edentulous persons. As a consequence of these developments, more dentists will practice in hospitals. Also, more group practice clinics will be developed which employ auxiliaries to perform the simpler tasks under the direction and surveillance of fully qualified dentists. In view of these prognostications, it is possible that the current concern over the shortage of dentists is misplaced. What may be needed is not more dentists per unit of population but more and better trained dental auxiliaries. Otherwise we must place our hope in the discovery of immunization against dental decay and pyorrhea, or else consign the majority of the population to the eventuality of edentulism. Though hope springs eternal, the stuff of progress is pragmatism.

ITEM 6: STATEMENT OF SEYMOUR E. HARRIS, UNIVERSITY OF CALIFORNIA, SAN DIEGO

October 28, 1968. In reply to Senator Williams invitation, I comment on some aspects of the health problems of the aged.

MEDICARE

Of course Medicare greatly improves and extends health services for the old. The net effect of Medicare is to pour several billion dollars into the pool of medical resources available to the old. In 1968, thru OASDHI (health insurance for the aged) $42 billion in benefits were received. (S.S.B., September, 1968, p. 3). Before the introduction of Medicare, the old accounted for about 9 per cent of the population and considerably more than 9 per cent of medical costs; but also obtained considerably less than the medical needs of this age group. Should, for example, $5 billion additional be made available to the old, then total medical resources for this age group might well double.

DRAIN OF HOSPITALS

Unfortunately the net gain to the elderly is much less than might be suggested by the additional funds thus being made available under Medicare. One reason for this result is the diversion of part of the additional funds to the hospitals which use medicare as a means of improving their financial position. The disposition now is to increase charges for the elderly and thus reduce the excess of hospital costs over charges. The additional resources thus obtained by the hos

20 Grayland, E.: The Colombo plan brings dental health to Asia's children. CAL Magazine 29: 8, 1967.

pitals reduce the net gains of the elderly. Medicare has in part become an institution for making hospitals financially viable.

The availability of several billions additional per year also tends to increase costs of operating hospitals and thus cuts gains of the elderly. With hospital costs rising by about 15 per cent a year, the recovery of additional costs is facilitated by payments under Medicare. But the new resources made available also tends to make possible large rises in pay of hospital workers.

The Somers in their recent book on "Medicare and the Hospitals" have raised a vital question. Hospitals are guaranteed recovery of costs. With such guarantees and with no other restraints, are not costs likely to rise at an unacceptable rate? Indeed, the major reason for the current rise in hospital costs may well be the low pay of the past which is not easily tolerated in a full employment economy. But surely the inflow of medicare cash facilitates the rise in pay of hospital help. The new resources, however, do not merely facilitate increases in pay scale; they also assure a greater supply of labor for the hospital and hence to that extent facilitates improved service. Without the increase of funds and the accompanying rise of pay scales, the hospitals would be confronted with serious shortages of labor in a full employment economy.

Doctors and other health personnel necessarily profit from the increased cash thus being injected into the system. The large rise of income for physicians postmedicare is explained to a considerable extent by the billions being poured into medicare. The physicians' incomes rise as with slow response of supply of doctors to rising demand, incomes automatically rise. On top of that many physicians seek higher rate of pay by pushing for direct reimbursement by patients rather than obtaining compensation thru the intermediary of the hospital. Hence with the inflow of medicare dollars, the struggle between hospitals and physicians for a greater share of the medical dollar is intensified.

DOCTORS' COMPENSATION

In the discussion of recent advances in medical costs, there is some disposition to adhere to the position that medicare has not improved the economic status of the doctors.1

I do not subscribe to this interpretation. The rise of costs for service of physicians has recently been much greater than in the premedicare period.

Senator Robert Kennedy commented thus on the costs of doctors' services preand post-medicare: "

2

"There have been some studies made in the State. I don't want to take too much time, we have a lot of witnesses, but here is an article from Watertown which shows that an office call before the passage of this legislation was $3; afterwards it was $6.50; a home call, $4; afterwards $8; special service, initial visit, $7.50; after the passage of the bill, it was $20."

This excess is not by any means explained merely by the general inflationary trends. Nor am I convinced by the argument that costs of physicians' services recently have not risen more than the costs of services generally relevant especially for the younger population. The crucial point is that billions of additional funds are being channelled into the medical stream. Doctors' income accounts for about one quarter of the total medical income. In view of this fact and the large rise of costs per doctors' services, and of physicians' income and the inelastic supply of doctors, the only conclusion I can draw is that medicare has indeed raised costs of physicians' services, and the income of physicians.

That Medicare operates through fee for services is also unfortunate. This method of payment induces excessive services. The costs are compounded because of the absence of adequate quality control.

Another inflationary factor derives from the opposition of doctors to assignments. By refusing assignment (fees based on current practice) the doctor can impose much higher fees and with the patient recovering only part from the government.

DENTISTRY

Improved economic status has accrued not only to physicians and hospital personnel. Medicare has especially been effective in stimulating services previously greatly under-supplied. One significant area has been dentistry. The pro

1 Senate Hearings, Costs and Delivery of Health Services to Americans, 1968, pp. 370–71. 2 Costs and Delivery of Health Services to Older Americans, Hearings, Subcommittee on Aging of U.S. Senate, p. 371.