Related to the fuller use of auxiliaries in dental practice, the continuing analysis of the Nation's dental practice acts and the modifications they are undergoing has provided the basis for the development of a model dental practice act which will be proposed for adoption next year by the Council of State Governments. In the interim, the information available provides an effective tool for providing consultation to states considering changes in their practice acts. Finally, a major six-nation study, conducted cooperatively by DDH and the World Health Organization, is underway in an effort to learn from other nations which have had long experience in providing dental services for their citizens. The study will analyze the characteristics of the methods employed for dental care delivery, stressing the manpower components of the systems and the effectiveness and efficiency of the systems when viewed from the perspective of the consumers and providers. In HSMHA, among the numerous programs making contributions to the Department's total manpower effort, Regional Medical Programs Service supports continuing education programs. In early 1971, for example, eleven projects costing $1.3 million were being supported. It is estimated that in FY 1970, some 12,000 dentists received training through these projects. Among other HSMHA manpower activities, the Federal Health Programs Service provides training through its facilities, which includes dental residencies and dental auxiliary development while the National Center for Health Services Research & Development supports projects that, for example, serve to evaluate dental auxiliary development and demonstration programs. RESEARCH Unlike the dental service and manpower functions of the Department which are fragmented, the disease-oriented dental research function falls almost exclusively within the province of the National Institute of Dental Research. FY 1971 expenditures were estimated at $35 million, some 3 percent of the $1.118 billion obligated for NIH's research activities. The FY 1972 budget was increased to $43 million. The National Institute of Dental Research was established by the National Dental Research Act of 1948 and, under the authority of this Act, conducts and supports basic, clinical, and applied research and training in the causes, diagnosis, prevention and cure of oral diseases and disorders. Specifically, the Institute (1) conducts intramural laboratory, clinical and field research; (2) supports dental and medically related research and research training by assisting individuals, universities, and agencies through grants-in-aid for research projects, training, fellowships, and dental research institutes, and (3) conducts and supports collaborative and developmental research programs aimed at specific dental problems where major advance seems clearly possible. The state of the art for dental caries, periodontal disease, and other major oral-facial problems and the potential for significantly advancing knowledge within a five-year period are described in a report prepared at the request of the appropriation committees of the U. S. House of Representatives and Senate 16 Dental caries: The National Caries Program-initiated with a $5 million add-on budget and now with a budget approximating $9 million-was implemented in order to find ways to reduce the incidence of caries and to extend the capability of dentists and other members of the dental team to prevent decay. Because of the complex nature of caries, it is unlikely that any one approach will completely solve problems of its prevention and control. Therefore, in the National Caries Program, efforts are directed to depressing the effects of all factors to a minimum through a combination of techniques. This concerted research effort offers prospects for making the universal problem of caries largely preventable before 1980. Progress is already being made in such areas as the development of an effective anti-caries sealant, new approaches to topical uses of fluorides, and the exploration of the caries-inhibiting effect of enzymes The research is conducted through contracts with public and private research and development organizations and through epidemiological and field investigations conducted by the Institute's staff. Periodontal disease: New initiatives to advance understanding of the causes and means of preventing periodontal disease also are underway. With current support approximating $5 million, a diversified program of research is conducted, including studies of the roles of enzymes in the destruction of periodontal tissues, observations on bone metabolism, and projects to explore important immunological aspects of periodontal disease. These activities are directed to a fuller understanding of the complicated biology and chemistry of the inflammatory process and ultimately the development of new preventive measures against at least some forms of the disease Other disease-oriented research: Other research supported or conducted intramurally by the Institute includes that related to the development of improved restorative materials; achieving greater understanding of the cause of dental and oral-facial anomalies and improved methods for their treatment; development of effective means for preventing herpetic lesions; and finding better ways to control pain and relieve anxiety connected with the provision of dental services. The Institute also supports five dental research institutes and centers which, as opportunity presents, emphasize targeted approaches to the development and application of knowledge toward the prevention, cure, or control of dental and oral disease. Initiated five years ago, the program seeks to attract the knowledge and skills of scientists in disciplines not heretofore involved in dental research They build on and extend existing institutional strengths, provide for participation of multiple disciplines, facilitate the cooperation of a broad range of biological, physical, and social sciences in the study of problems of common interest and interact with the education program of the parent university. This emerging network of dental research centers not only contributes new knowledge but also provides stimulating environments for training researchers and teachers. The program is already demonstrating its potential for helping to reduce the long existing lag between dental and other biomedical research. 17 Research training: The Institute serves as the principal source of support for the development of investigators in the dental sciences. The research training programs of NIDR also have contributed substantially to the development of trained faculty for dental schools. The proportion of full-time faculty in dental schools has grown from 25 percent to slightly more than 40 percent over the past eleven years. The number of full-time dental school faculty members engaged in research at least 10 percent of their time has grown nearly threefold since 1958-59 from a low of 400 to over 1100 in the 1969-70 school year. A notable impact has been in such important disciplines as materials science and corrective speech therapy, which had been woefully deficient in dental schools. Dentallyoriented training has also been provided in other major basic disciplines to provide the kind of broad research effort needed to generate productive answers to oral health problems. In recognition of the serious shortage of trained clinical investigators, a greater share of the training program is now being directed toward strengthening clinical research capabilities. PROGRAM PROBLEMS, ISSUES AND RECOMMENDATIONS The Advisory Committee, after reviewing the current dental programs of the Department against the backdrop of the major dental health problems of the Nation, felt it appropriate to make comments and recommendations for strengthening the overall program effort. Inasmuch as the Committee was unable to ascertain that the Department had any general philosophy or policies which guided the development of its dental health programs, the Committee, to guide its own deliberations, adopted the philosophy that dental services are an essential part of total health services and that every individual-whatever his situation-should have access to the services he requires. The Committee also is of the opinion that the Secretary of HEW is in a unique position to help make this right a reality, and moreover, that he has a responsibility to use all appropriate means to do so. Therefore, to establish a sound base for all program development within HEW, the Committee recommends that: I. The Department should squarely face the fact that the human suffering and disability resulting from oral and dental disease is of staggering proportions; it should acknowledge by adoption of appropriate policies that dental care is an essential part of total health care and that every person has a right of access to necessary dental services; and it should establish national dental health goals and formulate a plan and programs essential to their achievement. Other comments and recommendations which follow relate to specific program elements: manpower, prevention, biomedical research, delivery of dental services, national health insurance, attention to children and concern for minorities and other groups having special needs. MANPOWER The prospect of providing sufficient dental care of high quality intensifies a most serious problem facing dentistry: the limited supply of dental manpower and its distribution. Already acute in some areas, the shortage of dentists and dental auxiliaries will inevitably become worse unless dental and allied schools continue at full capacity and solutions are found to the maldistribution of available resources. Consequently, there is a paramount need to modernize, expand and develop the facilities where students are educated, improve the educational programs and increase the productivity of all members of the dental health team. Progress is being made by federally-supported programs in the use of self-teaching machines, closed circuit television and computer-assisted teaching programs for dental students, auxiliaries and for the continuing education of dental practitioners outside the university setting. Dental research institutes in university settings also give attention to research training in applied dental science, research fellowships for students in those centers, and accordingly, act as hubs for disseminating continuing education to private practitioners Programs related to the recruitment of well-qualified teachers and researchers are paying off. Efforts by private and public agencies to attract young people from minority groups to careers in dentistry show promising results and should be expanded. The most efficient use of scarce dental skills can be secured through the extended use of dental auxiliaries. Dentists today are employing larger numbers of auxiliaries and, in so doing, are increasing the amount of services they can provide and the number of patients they schedule each year. Statistics from the American Dental Association show that dentists, through the greater use of auxiliaries, are scheduling many more patient visits per year than a decade ago. And the trend of employing multiple auxiliaries is continuing In addition, the dental profession is using auxiliary personnel in more efficient ways than formerly as more dental graduates are better prepared and more practicing dentists learn the new methods of working with auxiliaries who possess advanced and additional skills. Even more recent than these developments, and of major significance, are the new Division of Dental Health-supported TEAM (Training In Expanded Auxiliary Management) programs in many dental schools. This further increases the productivity of newly-trained dentists by teaching them to make better use of auxiliaries with expanded clinical duties. As encouraging as these advances in the development of dental manpower and services have been over the past decade, the very difficult problem of balanced distribution of dental services remains largely unsolved. Financial incentives to encourage recent graduates to practice in underserved areas have not proved attractive enough. The National Health Service Corps Program is too new to evaluate. Certainly this major problem of distribution of manpower is one that requires intensive study, experimentation and development. Regarding dental manpower, the Committee makes the following recommendation: As part of this recommendation: a. Intensive research should be undertaken and supported by governmental funds to determine factors that influence the distribution of dental manpower, to design possible solutions to the maldistribution problem, and to experiment with methods that would alleviate and solve these critical problems. b. Support should be continued and increased for the improvement of educational programs and the development of new teaching methods in schools for dental students and auxiliaries. c. Efforts by private and public agencies to attract promising young people, especially from minority groups, to dental careers should be encouraged and strengthened. Efforts to bring more women into the profession of dentistry should also be intensified. d. Federal support should be continued and increased for the development and operation of more dental auxiliary training programs, especially expanded function auxiliaries, in community colleges and other post-high school programs, and commensurate attention should be given to the development of teachers for these programs. e. Greater emphasis should be given to training expanded function auxiliary concepts for dental students as well as for dentists and auxiliaries already in the work force. f. Greater efforts should be made to recruit military-trained dental auxiliaries upon the discharge from the military and to make full use of their skills. |