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June 22, iyi

technical procedures on the patient which are now done by the dentist. But, then what will the dentist do? The usual answer is that he will serve as the leader and coordinator of a team delivering oral health care. Although this probably will be his role, the dentist of today is uneasy over the prospect of being very little different from the "Associate Dentist" of the future, and I believe this unease contributes to the resistance of many dentists toward greater utilization of auxiliaries. To paraphrase the Dean of Harvard Dental School--the dentist of today is overtrained for what he does and undertrained for what he should be doing.

There are many possible pictures of the dentist of the future; I shall attempt to paint one of them.

The dentist of the future should be:

1. 2.

3.

4.

As competent technically as he is now.
Better able to direct and coordinate a team of auxiliaries in pre-
vention and treatment.
More sensitive to problems of society, particularly those involving
the delivery of health care.
Better able to evaluate and manage his patient's non-dental oral
disease.
Better able to manage his patients with known systemic disease--e.g.,
diabetes, high blood pressure.
Better able to evaluate his patients for the presence of unsuspected
systemic disease.

5.

6.

Point l--it is my belief that it is possible to train a dentist to be technically competent in far less time than is now consumed. For example, when I taught at the University of California, a small percentage of the dental students were switched to an orthodontic curriculum some time during their freshman year. During their four-year curriculum they had about one-half to two-thirds the experience in restorative dentistry (fillings, dentures, etc.) as did their classmates--yet they were as successful in passing state board examinations.

Point 2--He will need slightly more time than at present to learn directing and coordinating skills. It might be noted here that, although prevention of oral disease should occupy a sizeable proportion of the practice of dentistry, the dentist himself need spend only a minimal amount of time on this aspect, with well-trained auxiliaries actually performing the preventive procedures.

Point 3--To become more socially sensitive, the dental student will have to spend part of his time working in deprived areas, as well as taking more formal course work.

Point 4.-As an oral pathologist | can state that generally neither dentists nor physicians are adequately prepared in the diagnosis and treatment of oral lesions, ranging from oral cancer to "canker sores." Nor is either professional sufficientiy familiar with the many oral manifestations of systemic disease.

Point 5--Most dentists are not adequately prepared to optimally manage patients who also suffer from known conditions such as cardiovascular or kidney disease, or to properly consider the cffects of drugs thcsc patients may be taking.

Point 6--| feel most strongly on this point--that most dentists do not know how to evaluate patients for unsuspected diabetes, cardiovascular, or other systemic diseases--conditions which might well be aggravated by dental procedures such as oral surgery or periodontal treatment. Dentists are in the unenviable position of performing procedures potentially harmful to certain patients, without the training to suspect these conditions. This situation is one of the causes of great friction between physicians and dentists on equality of hospital privileges for the two professions. (Unfortunately, another reason, I believe, is economic control--so that many well-qualified oral surgeons are not permitted parity with their medical colleagues, merely because their initial training was in dentistry-even though their residency training has resulted in superb surgeons.) Health care of the mouth is restricted to a very small anatomic area, similar to the eye.

We find that there are two classes of eye specialists: 1) the optometrist, who although he has a good biological background, only refracts eyes for glasses--he does no surgery nor does he prescribe drugs and, therefore, cannot harm the patient systemically and 2) the ophthamologist, who does everything the optometrist does and, in addition, performs surgical procedures and prescribes drugs. The training of both is adequate for what they do (although if they worked as a team instead of separate professions, I believe, the ophthamologist could spend his time much more profitably). Contrast this with the training of the general dentist, which is inadequate because he does perform surgery and he does prescribe drugs. in some European countries there are two separate groups of professionals engaged in oral health care: 1) dental mechanics (analogous to the optometrist) and 2) stomatologists (physicians who are concerned primarily with the medical and surgical aspects of oral disease and not restorative procedures). These professionals do not work together either, and as a result, dentistry in these countries is not of the highest quality. To the not-too-distant future I should like to see the dentist have as much training and experience in internal medicine as the ophthamologist. This should adequately fulfill points five and six and could take place within the frarework of dental education with cooperation from associated medical schools. Then, the dentist may, if he wishes, take additional training in one of the specialties, such as orthodontics, oral surgery or oral pathology. The bulk of dentists would probably elect to practice as the leader of an effective group of auxiliaries, perhaps associated in a group practice with other dentists (generalists and/or specialists) and physicians. As a half-way step, we at the University of Oregon Dental School are attempting to teach dental students to screen patients (by questionnaire, simple laboratory tests and physical examination) for the presence of important systemic disease with subsequent referral of patients with positive findings to the proper physician.

i wonder how many realize the potential that the more than 100,000 dentists enjoy as case-finders of early and presumably more readily treatable disease. This alone could benefit the country tremendously in terms of the prevention of serious disease with its attendant burden on our health facilities and lost man-hours of work. Many investigations have demonstrated the relatively high yield of early disease detectable in the dental office. (in one of our investisations we found at least 20% of patients over age 35 to be afflicted with unsuspected significant discase.) One critical consideration here is that póto ients usually visit their dentists when they feel well, whereas they usually seek out their physician only when they are ill.

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Many health plans are now being considered by Congress. I am by no means familiar with all of them, but the stimulus for this letter came from a news item describing Senator Magnuson's latest proposal which is primarily aimed at the improvement of the oral health of children. A portion of it does provide for pilot projects, and I wonder whether this portion or a portion of some other legislation (perhaps new legislation should be introduced) might not be used to support an experimental educational program with the six objectives mentioned above. I would envision that only a small percentage of each class would go through the experimental curriculum, until its products could be evaluated. The program could stop with the foregoing, but if one wished to really dream, one could ask for support for an experimental oral health delivery facility as well. This facility could include the graduates of the new curriculum, oider general dentists with additional training in internal medicine, a whole team of dental auxiliaries and dental specialists. Ideally this whole group would be integrated into an ongoing medical group, such as the permanente Foundation. Then, if the whole set-up proved to be very effective in delivering oral health care of high quality and quantity at a reasonable cost, it might become a national pattern.

I also note that Senator Magnuson's bill calls for a dental advisory committee. If I can be of service on this committee, or in any other way, I should be very happy to discuss the possibility.

Completely aside from the foregoing, I note that you will be traveling to the Middle East shortly. As you can see in my curriculum vitae, I did spend an exciting 1966-1967 sabbatical year as a Fulbright Professor in Israel, about which I wrote the enclosed letter to friends after our return. I'm sure that you have more information available now from the State Department and others than you can absorb; but, I should be most pleased to comment on any questions you might wish to put to me.

My experience in the Middle East has so enriched my life that I would we icone occasional assignments in any area of my competence in other parts of the world in order to contribute to my capacity.

I am looking forward to your comments with anticipation. In any event, please have a good trip to the Middle East--I hope that your visit will help bring those unhappy nations together; I'm certain that if left to themselves the peoples would have no difficulty in living together.

Very sincerely yours,

دے د عا م کی بنی تیرسنز

Norman H. Rickles, D.D.S., M.S.
Chairman, Department of Pathology

NHR: bdw

Senator KENNEDY. The subcommittee stands in recess subject to the call of the Chair.

(Whereupon, at 5:10 p.m., the subcommittee was recessed subject to the call of the Chair.)

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