@@@ ' 11 1. * January 9, 1969 DENTISTRY AND REGIONAL IEDICAL PROG@ Dentistry's role in new national By the expansion of hospital dental services, the establishment of treatment centers for maxillo- facial rehabilitation, emphasis on programs for health legislation: continuing dental education, and other projects, dentistry can become an important part of the Regional Medical Programs Regional Medical Programs that provide better care for more patients. Rudolph H. Friedrich, DDS, New York Reproduced here because of its rele- vance to Regional Medical Programs -- A review of the development of the National In- and especially because of one of the stitutes of Health, which began in 1939 with the Amendments to P.L. 89-239 relative to National Cancer Institute, and the appropriations that have been made to them indicates that den- dentists -- is a paper entitled "Den- tistry's Role in New National Health tistry consistently has been far behind. the rest of Legislation: Regional Medical Proszrams" the institutes in time and financial support for the given by Rudolph H. Friedrich, DDS, development of its research activities. The great Director of the Division of Oral Sur- strides made since 1956 to bring dental research gery of the Department of Dental and to its present position, where research in the den- Oral Surgery of Columbia University. tal schools is one of the outstanding aspects of Dr. Friedrich presented this paper to dental education, must be attributed directly to the 19th National Dental Health Con- the legislative and research development program ference sponsored by the Councils on of the American Dental Association. Dental Health and Dental Care Programs In 1960, Congress authorized the establishment of the American Dental Association in of the second program, namely, the Center Grant Chicago April 8 - 10, 1968. It was Program, through which the Institutes of Health subsequently published in the Journal could improve the quality of health care for the the American Dental Association in population. Briefly, the purpose of this program was to establish in appropriate institutions the capability for translating basic research into ap- U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE @nfhl A district, and the state dental professions. Of plied research, that is, to convert the discoveries growing out of basic research programs into bet- course, there is much that the ADA can and will ter treatment of disease or its prevention. Den- do to provide guidance. The National Dental tistry has made considerable progress, and in Health Conferences are examples of such support. 1966, the University of Washington and the Uni- The language of public law 89-239 permits versity of Pennsylvania received grants'to estab- and even urges indirectly that dentistry. be in- lish centers for applied dental research. In 1967, cluded in the policy structure of the Regional grants were approved for the Universities of Medical Programs, although it does not mandate North Carolina, Michigan, and Alabama. such inclusion. Dental schools and dental soci- lic law 89-239 eties should have no difficulty in obtaining repre- In 1965, Congress amended pub to establish what is most commonly known- as sentation on the advisory committees of Region- the Regional Medical Programs. This third . ele- al Medical Programs or the establishment of a ment of the health programs of the National In- subcommittee on dentistry. If they understand the stitutes of Health is designed to improve the care concept of Regional Medical Programs and are available to the general public by taking the de- prepared to recommend, develop, and see to the veloprnents of the center grant programs to the proper establishment and operation of programs health professionals and all health agencies in that will irnprove,the health care of patients with direct contact with the general public. In the heart disease, cancer, stroke, or such related dis- words of Russell Nelson at Johns Hopkins Uni- eases as diabetes, renal disease, and pulmonary versity: "We have great resources of cake medi- disease, their participation and contribution will cine in this country but a dearth of bread medical be welcome. care." Since the beginning of the planning for Region- Concomitant with the development of Region- al Medical Programs, there has been little formal al Medical Programs has been the establishment inclusion of dentists in the programs and little of two other federal programs that include exten- project development by dental agencies. Part of sive programs for the provision of health care. The this delay arises from the desire to make the Re- general provisions of the Office of Economic 0 - gional Medical Programs reflect the particular p portunity (OEO) legislation authorize the estab- characteristics and requirements of the regions lishment of Neighborhood Health Centers that with a minimum of direction and definition from must include dental care in their operation. Under the federal level. In addition, in the initial year Title 11 of public law 89-97, which also requires of the program, there was some confusion regard- s ing what the programs could do, how they could the development of the state Medicaid program under' its Title XIX, the Children's Bureau was do it, and who would be involved where. authorized to develop programs for children and The establishment of the categories of heart youth. In these programs for the provision of corn- disease, cancer, stroke, and related diseases as prehensive heaIIth care for children from birth the irtimediate targets of the program tended to to age 18, the inclusion of dental care is man- center attention on the disease entities themselves dated. The programs also include medical care, rather than, on the patient who had the disease. mental health, health education, and social su-r- It was difficult for the medical people, health, a ency people, and dentists themselves to relate vice. .9 Under the direction of the OEO, Neighborhood dentistry's efforts in any significant measure to Health Centers are being established as satellites the acute processes of these diseases. The First direction of the National Conference on Regional Medical Pro- of teaching hospitals. Under the Children's Bureau, children and youth programs grams reflected this confusion. To the dentists are being established in voluntary and city hos- who attended the conference it seemed that the pitals. primary objective of the conference was to stimu- In all of these developments, dentistry's active late the medical schools and medical centers participation is mandated or definitely permitted. through the medical deans to develop programs to wait while the ADA wages, that would increase the knowledge and skills of There is no need a long campaign to open the way for dentistry to the health professionals and hospitals in the corn- make its impact in Regional Medical Programs, munity, that is, to open the doors of these cen- ters of advanced knowled OEO programs, or Title 11 Children's Bureau' ge and skills and take being involved the benefits out into the communities for the programs. The responsibility for in these programs rests with the community, the health professionals and agencies that provide the Friedrich: DENTISTRY AND NATIONAL HEALTH LEGISLATION 865 2- actual health care to the general public. The con- utable to these continuing education progralliz5. tribution of the dental profession did not receive The rapid developments in head and neck sur- any significant attention at that conference. gery in the management of head, neck, and oral The Second National Conference on Region- cancer has increased the number of oral def6rmi-' al Medical Programs was devoted to the descrip- ties resulting from the removal of malignant le- tion of the experiences of the Regional Medical sions more rapidly than the dental profession has Program headquarters during the developmental been able to provide well-trained niaxillofacial phase. The development (if operating programs, prosthodontists or develop sufficient maxillofa operational projects, and programs for which cial prosthetic rehabilitation centers for training concepts were being converted to project proto- and rehabilitative treatment. Radiation of the cols were described in a large number of short salivary glands during radiation therapy for ma- papers. lignant lesio.ns of the face, mouth, and jaws causes One came away from the second conference a loss of the caries-immunity factor i@ saliva and with the conviction that: in too many instances a complete melting away of m Dentistry could be an integral component the remaining natural teeth and the subsequent of Regional Medical Programs if it were involved roblems of osteoradionecrosis, dental infection, p in the policy structure on the advisory committee massive loss of tissue, and speech defects. and if a dental subcommittee were established. Until recent years, the patient with a stroke, This information evolved from many personal isolated from society as a major problem in n4rs- discussions with individual directors of Region- ing care, seldom became a serious problem for al Programs. the dental profession except for the removal of Dentistry must consider the essential lifetime teeth that were causing acute symptoms. With the dental care for patients who have been treated rapid advances made in the stabilization and re- for heart disease, cancer, stroke, or related dis- habilitation of this patient, the dental problems eases, and even more important, consider the po- are clear and unavoidable. The acute stages of tential role for dentistry in the early recognition his cerebrovascular episode and the long recov- of signs and symptoms and through this, the pre- ery periods in nursing homes must be recognized 'vention of heart disease, cancer , stroke, and re- as periods when maximum preventive dental ser- lated diseases. The patients, in fact, require con- vices must be provided. The patient should re- siderable dental rehabilitation and maintenance ceive at least oral hygiene preventive services as patients on a total health basis for the rest of during the period of medical rehabilitation to their lives. avoid the unnecessary loss of the remaining natu- The patient with heart disease has been a prob- ral teeth and the subsequent construction of corn- lem in the dental office throughout history. The plete upper and lower dentures as an additional management of pain, dental disease, and infec- burden to an already formidable program of tion in these patients has been so difficult that motor and speech rehabilitation. until recent improvements in the medical man- Dental students and the practicing dentist agement of the patient with heart disease, any must be trained to evaluate the soft and hard, tis- but absolutely essential dental care was avoided sues of the mouth and at least observe gross ab- as constituting an impossible burden for the pa- normalities in a patient's physical functions. The tient. At present, the young dentist, trained on a dentist can and should be qualified to refer pa- total patient-total health concept, is accustomed tients to the physician for an overdue physical to relating the treatment to the medical charac- examination. The early symptoms of diabetes in teristics of the patient. For the patient with heart the mouth and the relationship of diabetes to dif- disease, we still need to develop the most effec- ficulty in bringing periodontal disease under con- tive system for assuring the availability of ade- trol has been well established in dentistry. The quate dental care at the most propitious time and early symptoms of congestive heart failure, sub- place during his recovery and rehabilitation. acute bacterial endocarditis, and coro nary dis- The patient with cancer has been of particular tress can often be elicited or disclosed during a concern to the dental profession during the past history taken by the dentist who is trained in the 20 years since the profession and the American fundamentals of physical diagnosis as an integral Cancer Society instituted continuing education function of his patient-evaluation program. for the early recognition of cancer. The best cure Because of the need for the r@lief of pain, the statistics for oral malignancy are directly attrib- prevention of dental disease, and the periodic re- 866 a JADA, Vol. 77, October 1968 3- call systems that are effective in most dental of- -is one of the bright spots in dentistry's future. fices, patients come to the dental office much The expansion of the hospital dental service more regularly than they seek the services of a through federal support of the OEO, Children's physician, Still, the influence of the dentist iii Bureau, Medicaid, or Regional Medical Pro- health education and his stimulation of periodic grams is the responsibility of the dental schools,. health examination has been virtually untapped. dental societies, specialty societies, hospital den- What, then, are some of the programs or tal staffs, or individual dentists who have the projects that dental agencies, institutions, or in- imagination to use the forces of federal, state, and dividual dentists should consider for their com- local governmental health programs. They can munities with the support of Regional Medical guide the local health agencies and hospitals in Programs? the establishment of effective hospital dental ser- vices and develop the utilization of such services to the mutual advantage of public and private patients, the dental community, and the hospital. Promotion and expansion of hospital dental services The modem hospital has evolved through con- Dental education stantly changing functions and objectives from a warehouse for the illnesses that were an abomina- Undergraduate and advanced dental education tion to society to the place where it at present must consider the expansion of clinical training in has the responsibility of centralizing the expen- the hospital environment. The key to this develop- sive hardware of health care, administering the ment is the formal affiliation of dental schools efficient production and distribution of compre- with the dental services of teaching hospitals and hensive health care, coordinating a complex the assumption of joint responsibilities by the myriad of professional skills, and conducting a schools and the hospitals for the operation of broad scope of health education and extensive clinical clerkship programs for undergraduate programs in clinical research and community dental students as well as internship and resi- public health. dency training programs in the various specialty The expansion of hospital dental services is areas of dental practice. Although this is a deep- being stimulated by such governmental programs er extension into the educati onal process than is as the OEO and the Children's Bureau. The Vet- generally considered in Regional Medical Pro- erans Administration is expanding the role of its grams, the hospital training for undergraduate hospitals in undergraduate, advanced, and con- and advanced trainees in medicine has a long es- tinuing dental education. To quote from Doctor tablished history. The future dentist must receive Coggeshall, in what has become known as the more of his training in the hos ital environment p . Coggeshall report prepared under the auspices of if he is to properly contribute to the new delivery the American Association of Medical Colleges: systems of health care which in the future will be "Continued expansion of government activity in the centered almost entirely in the hospital. There health field can be anticipated. Institutions and or- can be no question about the value of clinical ganizations concerned with health care as well as clerkships in stimulating the dental student Vol- with health education-including both instruction untarily to seek productive and challenging, and @esearch-will need to act responsibly and mixed or limited dental internships and subse- effectively to make the fullest use of government quent resident training. The early exposure of assistance and to avoid the government becoming the undergraduate student to the hospital environ- dominant as a consequence of their -own default or ment has demonstrated its value in orienting him the default of others.',' Ll- to interprofessional contact as well as total For dentistry, then, the opportunity exists to health-total patient concepts. guide, promote, and utilize the expansion of hos- The availability of expanded hospital dental pital dental service. Their potential in basic den_ services as training facilities for undergraduate tal education, advanced dental education, and and advanced denial education will ' alter the continuing education-all of which are essential economics of dental education in the future. The to the improvement of the -dental care available understanding of the medical status of patients to the atient with heart disease, cancer, or stroke will be increased when a dentist is trained in a p Friedrich: DENTISTRY AND NATIONAL HEALTH LEGISLATION m 867 *I. -4 - ic,it atnios- greater degree of integration of dental care with hospital instead of tile sterile outpat ill and with other health pliere, with the ,veil-screened patients, of the the totil he@ittli progra dental school. professionals. o Provide the dental profession with a greater understanding of tile medical problems of the pa- tieiit, particularly in tile areas of heart disease, Continuing dental education cancer, stroke, and related a Improve tile Licllti,.,t's understanding of the A discussion of continuing education pro(yrams total, organized liciltil care progran, of the na- 0 under Regional Medical Pro(yrani,-, must differ- nor,, the state, :tlicl tile common), in order that entiate between the requirements tor physicians he [iiaN, Lliicterst@iilLt tile cii%@irotinicnt in %vhich his to 55% of the services, K'110%%'ICLIV illl(.t skills are to be dis- and dentists. For a lonc., time, 50" _,C, physicians have had continuing education through tributed. iN 's uiitier,.,taiiding of new their hospital affiliations and the requirements liicre@ise the (teilt I for attendance at hospital acti@'itic@ such as staff systems and ;trriiigciiieilt-,; of practice as the evolu- patholo-a% conferences tit)li ot' tie%% for health care pro- meetings and clinical -job which constitute excellent ways tor on-the cee,.Is, pirtictilirl@ pitii (.Iciitat practice, continuing education. @rotil) practice, or ciiii1t)itlltiolis of both. The continuing education programs in niedi a llilprt)%C tile geti(:ritl lc%el of dental care by cine included in the Regional Medical Programs kccpili@v kll details of present concepts are directed to those physicians who do not h@i\,e Ot'LiCtIt.ki practice. e disciplinary tif.Ict tile oil tile ilierits of the addi- hospital affiliations or, therefore, th a A I pressure of a hospital affiliation regarding the hotel and skill gained from the con- continuing education activities. turning cLltlc..ttit)li 1)rt)gr;kiii and be designed to Hospitals have had little effect on the COntitILl- iiiect Iii% liccLl., I% cletcniiiiiett by his practice in ing education of the dentist except for that small %%ill Iw co(lvctiicllt. percentage of dentists who participate actively in the relatively few effective hospital dental ser- vices. The AD@A has long and actively promoted Design and development of new concepts lithe cause of continuing education. Detitit soci- for the delivery of dental care eties have conducted well-organized continuing education programs. Dental schools lllvc otic ti( tile niijor objectives of Regional Medical contributions to continuing education with Post- tort)gr;xni@ ii the cxiwriiiictitiitioti in and develop- graduate courses and seminars. Continuing Ctill- nictit o( iii(itc cf(intivc delivery systems of health cation in dentistry has not been effective oil 41 citi:. t-ot dentistry, this provides an opportunity mass basis in any of these areas. t4l C%1;3bli-Ji demonstration projects that will re- in go%,crtinient p continuing dcn- rograms, such There has been an interest in latc the @t (;tctor% ioti of the rcgu- tlw 01-0 -.end Cllildren;s Bureau children and tal education with the proniulgat rations by the New York State Dep;trtiiicill of ),nuth pftljccts. A,itli those of the hospital admin- Health which require that a dentist have 25 hours c@it)ility ind the professional capability of continuing education per ),car to maintain ti( tire default pr-,tcticiiig in the fullest concept of eligibility to treat patients under the st-itc Ni@- intellectual and professional freedom. caid program. There is also evidence that ttic Ststc l@ demonstration projects should keep the Department of Education is studying the Pft)blcm prt-)(m-.ional fictors in dental care within the con- of requiring evidence of continuing education for tM o( the professional dental group. They will renewal of dental license. al-4 mwrc tile highest quality of professional care Regional Medical Programs Prt)@,idc an cxcti- @c@ in the public practice administered by ivc and met dw @pitat and the private-group practice con- lent opportunity for the crcat . ductive development of continuing cducatim. TO ducted in a dental facility established and admin- accomplish this, continuing education istcrcd by the hospital. The hospitals in which the must: initial projects can best be established should be a Establish standards thakwill -givt MMIMM @ hmpitals that have a dental-teaching affilia- consideration to the n@ of pro tion, some form of government supported corn- improvement Df care to the pft@ivc care program, a progressive care fa- A. V cility where many patients with heart disease, can- elated diseases are stabilized and Regional conferences to stimulate regional cer, stroke, or r of a community action in the development rehabilitated and where the imagination of project ideas dynamic health professional core exists in the medical and dental staff, the hospital board, and the hospital administration. Consideration should be given to the use of con- The potential of dental education, continuing ferences to involve the health professionals, the dental education, dental research, and dental hospitals, the health agencies, and other pertinent care can be accommodated in such an en@iron- persons in organizing appropriate health care ment with full protection of the professional pre- projects for patients with heart disease, cancer, rogatives of the dentists involved. There is no stroke, or related diseases. question that such experimentation must develop In dentistry, it would be most desirable to hold pressures that require the utmost of good p@ofes- such a conference for adjacent communities that sional administration, patience, and willingness have common characteristics in the provision of to produce equitable and balanced results. Such dental care for patients with heart disease, can- experimentation is the only effective way in cer, stroke, or related diseases rather than the de- which the health professions and the allied agen- N@elopment of small, duplicate, expensive pro- cies can maintain their intellectual and profes- crams. If such conferences demonstrate or devel- sional freedom in a dominant position while they op the realization that a project established for make the maximum use of government support in the region which will assure adequate dental care our ever more organized society. for patients with heart disease, cancer, or stroke; that a regional project will benefit the dentists of the total region in providing continuing educa- Training and treatment centers for tion; that the project can improve and expand maxillofacial rehabilitation hospital dental services to the benefit of every- one, then dentistry and the public can gain from The increasing number of patients who have re- such a conference. If the idea is not activated at ceived head and neck surgery or radiation ther- the present time, it will progress no further in apy.for the control of cancer of the head and '-)O years. neck and the patient with a stroke who often loses all his teeth during his stroke episode and stabilization require a specialized system of oral Summary rehabilitation, including speech rehabilitation, if after the initial treatment their lives are to be There is an excellent potential for dentistry in the productive and adjusted. Reaional Medical Programs. The only limitations There are many persons who are s.eparately de- for dentistry lie within the creative imagination veloping technics and concepts for the manage- and dynamics of the dental profession. Regional ment of these problems in oral rehabilitation. Medical Programs provide opportunities for bring- There is a great need for the development of re- inc, the whole of dentistry into the future main- gional centers for the care of these patients as stream of health care in a highly organized so- well as the training of dentists for these more ciety with highly organized health services. They specialized problem-solving responsibilities. These provide an opportunity for dentistry to be in- centers should also be expected to conduct ex- N@olved from the beginning in assuring the best tensive clinical research in the area of maxillo- professional standards supported by intellectual facial rehabilitation. Another benefit of such pro- and professional freedom as the essential founda- grams would be the inclusion of such closely tion for an organized society's organized health allied problems as cleft lip and cleft palate, oral services. and speech rehabilitation, and unusual problems such as muscle spasm, temporomandibular joint Presented before the 19th National Dental Health Con- dysfunction, and the'ir relation to functional den- fare, sponsored by the Councils on Dental Health and tal occlusion. Certainly, projects to organize on a Dental Care Programs, American Dental As@ociation, at the regional basis the care, research, and training in ADA Headquarters Building, Chicago, April 8-10, 1968. Doctor Friedrich is director, division of oral surgery, de- these areas are proper functions of Regional-Mqd- partment of dental and oral surgery, Columbia University, ical Programs. New York 10032. Reprinted by permission from Friedrich: DENTISTRY AND NATIONAL P-CALTH LEGISLATION n 869 Reprinted with permission by the The Journ'al of the:@American Deiital U.S. DEPARTMENT OF HEALTH, E Association Vol-. 77, October 1968 .-6- DUCATION, AND WELFARE National Institutes of Health