need hospital care and can be taken care of with skilled nursing in the nursing home.

Senator MCNAMARA. Some of these places that refer to themselves as nursing homes, and they may not be truly nursing homes, as you point out, have a problem of somebody coming in who needs nursing care and needs medical care and then having no place to go. They just stayed there and take up considerable space. And they are asking for some relief in this area. You have not run into this in any great degree?

Mrs. BALTZ. We know there are many in so-called nursing homes that are really room and board and the patients that become in need of nursing care should be transferred to a skilled nursing home.

Senator MCNAMARA. Thanks again. We appreciate very much your cooperation.

Mrs. BALTZ. Thank you.

Senator MCNAMARA. Now, we are down to Dr. Rudolph Friedrich.

STATEMENT OF DR. RUDOLPH H. FRIEDRICH, AMERICAN DENTAL ASSOCIATION

Dr. FRIEDRICH. Mr. Chairman, and members of the committee, I am Dr. Rudolph H. Friedrich of Chicago, Ill. I am secretary of the council on dental health of the American Dental Association.

The association has a membership of more than 90,000 and represents about 85 percent of the Nation's dentists. With me is Mr. Bernard J. Conway of Chicago, Ill., the secretary of the association's council on legislation.

We are here today to discuss the dental-health problems of our elderly citizens.

I can summarize our statement in about 5 minutes, I think. Senator MCNAMARA. Go right ahead. The statement will be printed in its entirety in the record at this point.

Dr. FRIEDRICH. Thank you, sir.

(The prepared statement of Dr. Friedrich follows:)

PREPARED STATEMENT OF DR. RUDOLPH H. FRIEDRICH, AMERICAN DENTAL

ASSOCIATION

Mr. Chairman and members of the committee, I am Dr. Rudolph H. Friedrich, of Chicago, Ill. I am secretary of the council on dental health of the American Dental Association. The association has a membership of more than 90,000 and represents about 85 percent of the Nation's dentists. With me is Mr. Bernard J. Conway, of Chicago, Ill., the secretary of the association's council on legislation. We are here today to discuss the dental-health problems of our elderly citizens.

THE AGING PROCESS

In order to focus on the problems of the aged and aging, one must necessarily use the recognized baseline, that is age 65 and older as defining our elderly population. Although for practical purposes it can be assumed that aging conforms in general with chronology, this assumption should not lead to the conclusion that at a particular age most humans are not fit to continue in productive occupations.

I believe that it is universally accepted by those who treat human ailments that the process of aging does not always follow a consistent chronological pattern. For some persons who reach age 65 the process has advanced to the extent that the marked physiological characteristics of aging are obvious. For others the aging process is retarded so that these characteristics are negligible. One person of 65 years may look and act like an 80-year-old; another like a 50-yearold.

To the dental and medical practitioner age 65 as the dividing line between usefulness and obsolescence for humans is arbitrary and unacceptable. The physician or dentist is especially aware of the individuality of his patients and their physiological and psychological resources. He is also aware, however, of the rapidity with which senescence can develop and advance. Although the dentist or physician may not know exactly how the physiological and psychological quick changes of aging are triggered, he does know that good health, physical and mental, can retard aging significantly. The physician and dentist also know that physiological and psychological changes are many times a series of causes and effects. The loss of teeth, for example, may cause the elderly person to withdraw from activity in society; this in turn can readily bring about actual physical changes, even impairments, which accelerate the aging process. The oral anatomy is a clear reflector of many disease processes which are prevalent in other organs and areas of the body. It is also subject to local impairments which contribute greatly to the aging process. The nonrestored edentulous mouth, for example, may make a 40-year-old person who is so afflicted look 20 years older. If this person, as a result of lack of adequate masticatory function, cannot digest his food properly, or cannot partake of essential foods, he may start the cycle of cause and effect that contributes to the acceleration of the aging process. He will, at the least, have predisposed himself to a more rapid advance toward physiological senescence.

cer.

THE DENTIST'S ROLE IN STEMMING THE AGING PROCESS

The dentist is educated and trained not only to diagnose dental disorders, but also to recognize all anomalies which can be detected either visually, digitally, or by X-ray within the oral cavity. He may, for example, be in a position to detect not only the several types of oral malignancies but also the conditions which are precursors to malignancy. The adult who visits his dentist frequently is, in effect, exposing himself to a course of preventive medical treatment that may well prolong his life. (I call your attention to a pamphlet recently published by the American Cancer Society entitled "The Challenge of Oral Cancer." It describes the importance of the dentist in preventing and detecting oral canI ask that this be included in the record following my statement.) To illustrate how important a thorough and detailed examination of the oral cavity can be, let us concentrate just on the tongue. The following conditions might be evident: the shiny, smooth appearance in anemias; the increased pigmentation in Addison's disease; the extreme paleness in severe anemias; the cyanosis in heart conditions; the dryness in diabetes mellitus, fevers, and cases of dehydration; canker sores in allergies; ulcerations of acute leukemia; the characteristic lesions in metallic or drug poisoning; the yellow pigmentation most evident along the margins of the tongue in obstructive jaundice; the tremors of paralysis; the scars resulting from bites in epilepsy; and many other manifestations of systemic disease.

The dentist is, of course, educated and trained principally to maintain the health of the human oral anatomy; that is to prevent, treat, and cure infections and disorders of the mouth and to preserve the intricate and critical function of the teeth and jaws. Let us look at this latter objective; it is the one most commonly recognized as the dentist's professional objective.

The teeth and jaws must function correctly for many reasons. One of these is to convert our food to a state where it can be swallowed easily and then digested readily. Mastication and digestion of food are dependent on dental function. The importance of the masticatory function, furthermore, increases with age. This is so because the aging process usually reduces the ability of the gastrointestinal system to perform its function. Unless the masticatory operation is kept efficient, then, the result may well be digestive disorders if the person affected tries to consume a normal diet, or nutritional deficiency if that person consumes only soft foods which do not need mastication.

The prevention and treatment of infections and diseases within the oral cavity also directly contribute to preserving the dental function. The periodontal or gum diseases, for example, ordinarily cause the teeth to loosen. This will certainly impair the efficiency of mastication at the point when chewing becomes painful. Unless the infected gums are treated in time, moreover, the dentist will have no choice but to extract the teeth and substitute an artificial

restoration. It should be kept in mind that more teeth are lost because of gum diseases than because of cavities in the teeth. It is also significant to realize that the teeth that escape the ravages of dental decay may be lost in late adulthood because of infected gums which are unable to retain those healthy teeth. It is regrettable that so many people in this country do not heed the best advice the dental profession can offer: "See your dentist regularly and frequently." This is as necessary for those of us who are 50 or 60 as it is for those 20 or 30 years of age. The preservation of the natural dentition not only is of benefit directly to the overall health of the individual; it also contributes greatly to slowing down the aging process, both physiologically and psychologically. In like manner, for those of us who lose our natural dentition, the prosthetic replacements which the dentist designs are capable of restoring dental function to an exceptional degree and facial appearance to the same remarkable extent. Again, professional dental care is needed periodically even after full dentures are inserted. Unless the dentures are checked on a regular schedule as indicated by the dentist, the occurrence of normal changes in the tissues of the mouth may gradually cause loss of proper function and failure of the tissues to support and retain the dentures. For the person who has well-fitting dentures, and who visits his dentist to assure that his dental function is maintained, there will also be a considerable lessening of the aging process, both physiologically and psychologically.

FACILITIES FOR PROVIDING DENTAL CARE TO THE AGING

The American Dental Association believes that dentists in private practice are doing a commendable job in making their services available to persons over 65 years of age. The critical problem in dental care for the elderly is in caring for those in institutions such as nursing homes and in caring for those who are homebound. The association recognizes that much needs to be done to make dental care available to these persons. It must also be recognized by all those interested in making dental care available to the elderly that many aged persons will not cooperate and some will actually refuse needed dental care. would like at this point to portray a recent study of the dental conditions of persons living in 26 nursing homes in Fulton County, Ga. This study was conducted in 1957 by the dental health service of the Georgia Department of Public Health. It is typical of the excellent projects being launched by some of our State dental health directors. I shall quote at length from this report, entitled "Survey of Dental Conditions in the Nursing Homes in Fulton County."

I

"In the 26 homes visited, 855 patients were examined. They ranged in age from 23 years to over 99, with 284 male and 571 female. The number of nonambulatory patients (255) was surprisingly high, which is almost one-third of those in the homes. If those confined to wheelchairs are included, it is safe to estimate that about one-half are nonambulatory.

"While these patients came from all walks of life, the majority were housewives, farmers, or mechanics. Those individuals with private income, other than welfare or social security, were relatively small. Five hundred and eleven patients indicated they have no other income, 305 had from 1 to a few dollars per week and a very limited number indicated they were economically secure.

"In only a few instances was a plan mentioned by those in charge of the homes for the routine oral home care such as daily washing and cleaning of dentures, toothbrushing or mouth rinsing *

"The condition of each tooth was classified in one of eight categories-normal, missing, replaced, filled, decayed, filled and decayed, indicated for extraction due to decay or indicated for extraction due to condition of gums or supporting tissues. For these people, relatively few teeth were found to be normal. Most of their teeth were missing and many had been replaced by dentures. Many of the dentures were too old for use and often extremely unsanitary. It was unusual to find a full upper or lower denture that was not in need of repair or replacement. In fact, it was difficult to understand how many of the patients could use their ill-fitting dentures at all due to looseness, lost teeth, or their own physical or

1 Georgia Dental Journal, January 1958, vol. XXXI, No. 3.

physiological condition. A considerable number of the older patients had discarded their dentures or had lost them when they were confined to the home or at one of the hospitals when they received treatment. It was evident that dental health of the patients was neglected in most of the homes.

"Due to abnormalities in or around the oral cavity, patients, ambulatory and nonambulatory, often did not use their dentures. These abnormalities ranged from pathological conditions, flat bridges and closed bite to ill-fitting or broken dentures. As the individual patient progresses in years, in numerous cases an emotional condition develops which sometimes makes it impossible to have any prosthetic appliance in the mouth. Statements were frequently made by patients that 'I can't wear dentures because they worry me.' * * * A number of those patients without dentures are those who would not wear them even if they were provided. These patients have been without dentures for years and stated they would be unwilling to wear them. This fact necessarily would have to be taken into consideration in determining the specific needs in a treatment program

"Contrary to the usual findings in younger age groups, these old people needed relatively few fillings. The high number of lost teeth, due to extraction, accounts for the small number of teeth in need of fillings. While some fillings are needed, this does not constitute a major problem. Due to loss of so many teeth, the number of fillings present was also small as compared to the younger person outside these institutions.

"The most urgent need was noted in the number of teeth indicated for extraction either due to decay or due to disease of the supporting tissues. The number of oral infections was appalling. Practically all of the patients with natural teeth had some oral pathology ranging in severity from suspicion of cancer to mild gingivitis or gum diseases. * **

"Of the 289 patients having 1 or more natural teeth present, periodontal or gum treatment was indicated for 119. Of the few patients with teeth present, 203 teeth need filling, and 1,404 teeth need extracting. Extraction would do more to clear up oral infection for these people than most any other treatment that could be provided. Several cases were designated for oral surgery in preparation for dentures while others were indicated for surgery due to ill-fitting dentures that had been in place for long periods of time and were causing chronic irritation of mucous tissues.

"The most time consuming and probably the most expensive treatments were the large number of dentures needed, 511 original dentures, and 363 replacement or repair of existing dentures ***.

"Despite the overall lack of services, a few of the homes showed an unusual ability to provide adequate services in every respect. Two of the larger homes were equipped with dental clinic facilities and a few of the other homes have arranged with private dentists to provide emergency dental service."

TABLE 3.-Number of nursing homes with patients by age groups and sex and percent receiving dental care within last 5 years, Fulton County, October 1957 Number of homes..

Number of patients:

26

TABLE 4.-Condition of teeth and dental treatment recommendations for nursing home patients, Fulton County, October 1957

This 1957 survey of dental conditions in the 26 Georgia nursing homes is not intended to typify a normal situation among the elderly. One of the findings, for example, showed that only 18 percent of the residents had seen a dentist in the last 5 years. This is somewhat less favorable than has been reported for the general public in similar age groups.

The survey did, however, disclose a need for dental attention among a large group of low-income, institutionalized elderly persons. It discloses also that steps are being taken to find out what are the dental problems of the elderly groups. The fact that this survey was reported in the official publication of the Georgia State Dental Association, accompanied by an editorial promising action by the State's dentists, clearly indicated that State and local groups are ready to cooperate in all reasonable efforts for improving the availability of dental care for the aging.

GOVERNMENT'S ROLE IN PROBLEMS OF DENTAL CARE FOR THE AGED

The Federal Government has three existing, effective means for cooperating in the improvement of the dental health of our elderly citizens. The first of these is the rapidly expanding research program conducted and supported by the National Institute of Dental Research. Federal grants administered by the Institute now support 40 research projects related to oral health problems of the aged. A list of these projects now being carried on in the dental schools and major dental research centers is attached to this statement. The association urges this committee to recommend additional Federal support for dental research projects.

The Federal Government has, through the Dental Division of the Public Health Service, furnished leadership and expert advice to our State and local dental public health teams in their effort to identify and evaluate the dental problems of our aged groups. This is the second area for additional Federal action. The pilot programs now being carried out in New York City and Kansas City, Mo., by the Public Health Service in conjunction with the State and local dental societies are excellent examples of appropriate Federal leadership. These programs are designed to illustrate modern means for making dental care available to the elderly, including the use of specially designed portable dental equipment to bring care to the institutionalized and, in particular, to the homebound elderly patients.

It is the association's conviction that the Federal Government should establish a separate category of grants-in-aid funds, under the Public Health Service Act, earmarked for support of State dental public health activities. The public health programs needed to help assure the availability of dental care to the elderly would be among the several measures that cannot today be initiated in many States because of insufficient funds. The American Dental Association urges this committee to recommend a Federal grant-in-aid authorization under