[Senate Hearing 108-248]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-248
 
                         AGEISM IN HEALTH CARE:
      ARE OUR NATION'S SENIORS RECEIVING PROPER ORAL HEALTH CARE?

=======================================================================

                                 FORUM

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           SEPTEMBER 22, 2003

                               __________

                           Serial No. 108-22

         Printed for the use of the Special Committee on Aging


                      U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2004
91-118 PDF

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                       SPECIAL COMMITTEE ON AGING

                      LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama              JOHN B. BREAUX, Louisiana, Ranking 
SUSAN COLLINS, Maine                     Member
MIKE ENZI, Wyoming                   HARRY REID, Nevada
GORDON SMITH, Oregon                 HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri            JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois        RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah                 RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska                  EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania          THOMAS R. CARPER, Delaware
                                     DEBBIE STABENOW, Michigan
                      Lupe Wissel, Staff Director
             Michelle Easton, Ranking Member Staff Director

                                  (ii)




                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator John Breaux.........................     1

                           Panel of Witnesses

Vice Admiral Richard H. Carmona, Surgeon General, U.S. Department 
  of Health and Human Services, Washington, DC...................     3
Greg J. Folse, Lafayette, LA.....................................    19

                                Appendix

Testimony of Daniel Perry, Executive Director, Alliance for Aging 
  Research.......................................................    61
Statement of Dr. Robert Collins, American Association for Dental 
  Research (AADR)................................................    66
Statement by Teresa Dolan, American Association of Public Health 
  Dentistry......................................................    72
Statement submitted by James Harrell, American Dental Association    78
Statement of Dr. Paula K. Friedman, Professor and Associate Dean 
  of Administration, Boston University Goldman School of Dental 
  Medicine, and President American Dental Education Association..    83
Written statement of Karen Sealander, American Dental Hygienists' 
  Association....................................................    98
Testimony of Jonathan Musher, MD, on behalf of the American 
  Health Care Association........................................   124
Statement of Dr. Robert Barsley, Oral Health America.............   127
Statement of Robert J. Klaus, President and CEO, Oral Health 
  America........................................................   132
Testimony of Dr. Paul Glassman, Associate Dean, Co-Director 
  Center for Oral Health for People with Special Needs, 
  University of the Pacific School of Denstitry, President, 
  Special Care Dentistry.........................................   137
Statement submitted by The Apple Tree Dental Model...............   143
Testimony of Kim Volk, President and CEO, Delta Dental Plans 
  Association....................................................   150

                                 (iii)




  FORUM ON AGEISM IN HEALTH CARE: ARE OUR NATION'S SENIORS RECEIVING 
                        PROPER ORAL HEALTH CARE?

                              ----------                              


                       MONDAY, SEPTEMBER 22, 2003

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Forum convened, pursuant to notice, at 2:05 p.m., in 
room SD-628, Dirksen Senate Office Building, Hon. John Breaux, 
presiding.
    Present: Senator Breaux.

            OPENING STATEMENT OF SENATOR JOHN BREAUX

    Senator Breaux. If everybody would please find a seat, we 
can begin our afternoon session, and I will do so by welcoming 
everyone to what is really a forum this afternoon; it is not a 
formal Aging Committee hearing, but it is an opportunity for 
all of us who are interested in the question of health care for 
our Nation's seniors to focus in on one particular aspect of 
our Nation's health concerns and particularly dealing with our 
Nation's older Americans, and that is the whole question of 
proper oral health care, dental care, for our Nation's senior 
citizens.
    So I would like to welcome everyone to this session this 
afternoon, and I want to thank the Chairman of the Aging 
Committee, Senator Craig, for his cooperation and support and 
assistance for allowing us to meet and have this discussion.
    This afternoon we will focus on the question of whether 
older Americans are receiving proper oral health care. I think 
the purpose is really threefold--first, to define the oral 
health issues that are facing our Nation's seniors today, and 
second, to try to develop and discuss some potential solutions 
to the problems that exist; and third, to alert Americans about 
the opportunities they have to help improve health care, 
particularly oral health care, for America's elderly.
    Although there have clearly been dramatic improvements in 
oral health care during the last 50 years, profound disparities 
continue to exist for those without the knowledge, the 
resources, or the capability to achieve good-quality oral 
health care.
    This certainly includes our poor and vulnerable elderly and 
disabled adults, and poor oral health care causes suffering to 
millions of Americans and obviously particularly to our most 
vulnerable population.
    Twenty-three percent of the 65- to 74-year-olds have severe 
periodontal or gum disease. The percentage of risk increases, 
of course, as people age. People at the lowest socioeconomic 
levels have even more severe periodontal disease. Oral and 
pharyngeal cancers are diagnosed in about 30,000 Americans 
annually, and 8,000 die from these diseases every year, which 
are primarily diagnosed in the elderly, and their prognosis is 
very poor.
    Fewer than 2 out of every 10 older Americans are covered by 
private dental insurance. Uninsured Americans with severe oral 
disease often end up in hospital emergency rooms, where the 
problem is addressed with painkillers and/or tooth extractions, 
both of which are obviously only a temporary fix, wasting 
millions of taxpayer dollars every year.
    Recent research has further highlighted the results of poor 
oral health care. Studies have shown a connection between 
chronic oral infections and heart and lung disease and stroke 
and diabetes and premature birth. Infections resulting from 
oral infections place individuals at serious risk of death. 
Infectious diseases of the mouth left untreated can cause undue 
pain and suffering and poor quality of life, and even death.
    Clearly, all Americans need to be aware of the need for 
good oral health. However, our emphasis today is on grappling 
with how best to ensure that our older Americans receive proper 
oral health care. It is my hope that this forum will accentuate 
the importance of oral health.
    Thanks to the generous support of Oral Health America, we 
are releasing a report today entitled ``A State of Decay: Oral 
Health of Older Americans.'' As you can see from the charts 
behind me, Oral Health America surveyed all 50 States and the 
District of Columbia on the extent of the oral health care 
services for Medicaid adults. As a part of this study, a report 
card was developed that reflects predominantly failing grades 
in all jurisdictions, giving the United States a score of ``D'' 
as our national average. It is very alarming, considering the 
severe health consequences and resulting cost of poor oral 
health care.
    I thank each and every one of you for being with us and for 
your participation and look forward to hearing from you as we 
discuss this issue.
    I would first like to welcome the Surgeon General, who is a 
surgeon but not a general, but he is an admiral, and we are 
very pleased to welcome Vice Admiral Richard Carmona, who is 
our Surgeon General. Vice Admiral Carmona was sworn in as the 
17th Surgeon General of the United States Public Health Service 
in August 2002. He is a decorated veteran and graduate of the 
University of California Medical School. Dr. Carmona has 
published extensively and received numerous awards, 
decorations, and local and national recognition for his 
achievements. We thank him for participating and for his 
support.
    I would also like to introduce Dr. Greg Folse, who is a 
practicing dentist from Lafayette, in my State of Louisiana. He 
was instrumental in drawing my attention in the beginning to 
the critical issues surrounding oral health of the elderly. He 
has a mobile geriatric dental practice and also works with the 
American Dental Association and Special Care Dentistry to 
improve oral access for special needs patients. He is really 
very passionate about caring for the oral health of the elderly 
and carries out that mission every day of his life.
    I have seen the slide presentation that Greg will make to 
us this afternoon. It is most impressive in highlighting the 
serious nature of the problem that we face as a Nation.
    I would also like to say thanks to all of the organizations 
represented here this afternoon. I am pleased to introduce 
these organizations and the representatives who are here today. 
Your biographies are all included in our official record, and I 
will simply recognize you for the sake of brevity:
    From the Alliance for Aging Research, Dan Perry. Dan, thank 
you for being with us; from the American Association for Dental 
Research, Dr. Robert Collins; from the American Association of 
Public Health Dentistry, Dr. Teresa Dolan; from the American 
Dental Association, Dr. James Harrell; from the American Dental 
Education Association, Dr. Paula Friedman; from the American 
Dental Hygienists' Association, Karen Sealander; from the 
American Health Care Association, Dr. Jonathan Musher; the 
CMMS-HHS chief dental officer, Dr. Conan Davis; from Louisiana 
State Dental Medicaid Services, Dr. Robert Barsley; from Oral 
Health America--thank you for the good work--Dr. Robert Klaus; 
from Special Care Dentistry, Dr. Paul Glassman.
    Thank you all.
    I would like to also introduce Janet Heinrich, who is with 
GAO, the Government Accounting Office's Director of Health Care 
and Public Health Issues. She has put together and led many of 
the health studies that we have utilized, both in the Finance 
Committee and in our committee on elderly issues, for the U.S. 
Senate and for the Congress, and we appreciate once again her 
doing the work. We are going to ask her to moderate if I have 
to leave some of the discussion, Janet, if that would be all 
right with you.
    Ms. Heinrich. Yes.
    Senator Breaux. Our format will be to first hear from our 
Surgeon General, Dr. Carmona. If you would go ahead and lead us 
off, we would appreciate hearing from you, and then we will go 
to Dr. Folse and his slide presentation.
    Mr. Surgeon General, we are delighted to have you with us.

STATEMENT OF VICE ADMIRAL RICHARD H. CARMONA, SURGEON GENERAL, 
  U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC

    Dr. Carmona. Thank you, Senator. It is nice to be here. 
Thank you for taking the leadership in this very important 
area.
    My name is Richard Carmona. I am the United States Surgeon 
General, and as an American, I want to take this opportunity to 
thank all of you for the service that you have provided to the 
Nation in keeping this very important issue on the forefront.
    I have had the honor of working with many of you during my 
first year as Surgeon General and look forward to strengthening 
our partnerships to improve the health and well-being of all 
Americans.
    Senator, you have been a leader in addressing the health 
needs of America in general and its seniors, and I thank you so 
much for continuing to take the lead in those issues. It was a 
pleasure participating with Senator Craig, another leader, just 
recently in a Montana Health Summit, and Senator Burns, who 
also understand the value of public health and keeping our 
citizens healthy.
    Today I welcome the opportunity to talk with this committee 
about the oral health of America's seniors. While oral health 
is tremendously important, I am sure I do not have to tell you 
that it does not receive much attention. For that reason, I 
appreciate the focus of this forum, especially in the context 
of a holistic approach to disease prevention.
    Poor oral health adversely affects all aspects of life. 
Kids cannot learn in school if they are in pain. Adults miss 
work due to dental pain and tooth and gum decay. Twenty-two 
percent of adults report having some oral pain in the past 6 
months. Oral and pharyngeal cancers, primarily found in the 
elderly, are diagnosed in about 30,000 Americans annually. 
Tragically, 8,000 Americans die from these diseases each year.
    ``Oral Health in America,'' a report of the Surgeon 
General, recognizes that such oral health is essential to 
general well-being and that the oral health of America's 
seniors is today an acute problem. The facts are staggering. 
About 30 percent of individuals 65 years and older have lost 
all their teeth. The rate of oral and pharyngeal cancers is 
higher among seniors than for any other age group. Americans 65 
years and older are seven times more likely to be diagnosed 
with oral cancer than younger individuals.
    The vast majority of payment for dental services is out-of-
pocket for older people, with only rare exceptions. Medicare 
does not cover the cost of oral health services. This results 
in compromised access for our seniors. While 61 percent of the 
general population reports having a dental visit in the past 
year, only 45 percent of seniors 75 years and older report 
seeing a dental professional in that same time period.
    A number of HHS programs focus on oral health needs of 
seniors. HRSA's oral health program is increasing access to 
oral health care through its 843 health center grantees. 
Seventy-two percent of these centers offer preventive dental 
care. Also, NIH's National Institute of Dental Health of Dental 
and Craniofacial Research reports many clinical trials related 
to the oral health of seniors.
    In addition, CDC's division of oral health supports oral 
health projects in predominantly poor, ethnically diverse 
communities. These projects include: mobilizing community 
health workers to improve oral health practices in rural 
Alabama; setting up an oral health training program for nurses 
who care for homebound seniors in Harlem, which is my old 
neighborhood; and in Washington State, training seniors to be 
oral health educators for children, which improves the health 
of the kids and the seniors.
    As you know, in April of this year, I released a National 
Call to Action to Promote Oral Health. The Call to Action is a 
guide for our efforts to improve oral health. It outlines five 
action areas.
    First, we need to change the perceptions of oral health. We 
can no longer afford to have Americans believe that oral health 
is separate from general health and well-being. Improving 
health literacy is key to improving America's oral health.
    Second is to replicate effective programs and proven 
efforts. Best practices in oral health must be recognized and 
replicated in every State.
    Third is to build the science base. Biomedical and 
behavioral research is transforming our knowledge of 
prevention, diagnosis, and treatment of oral diseases. This 
knowledge must be turned into action.
    Fourth is to increase oral health workforce diversity, 
capacity, and flexibility. Women and minorities are under 
represented in the dental profession. We must encourage 
diversity and use culturally competent messages to eliminate 
disparities in oral health.
    Fifth and finally is to increase collaborations. Disease 
prevention and health promotion campaigns that affect oral 
health, such as proper brushing and flossing and regular 
checkups, as well as tobacco control and nutrition counseling, 
can lead to improved oral health for all Americans.
    The prevention message that President Bush, Secretary 
Thompson and I have been emphasizing is applicable to ensuring 
good oral health. For example, there are simple steps that any 
person can take to prevent dental diseases. They are: proper 
brushing and flossing; use of fluoride rinse or toothpaste; 
regular visits to the dentist; healthy eating; limiting alcohol 
use and avoiding tobacco.
    In particular, tobacco use, whether cigarettes, cigar, or 
smokeless tobacco, frequently results in oral cancers. Most 
people, even many health professionals, do not know that 
smoking causes over 50 percent of the periodontal disease in 
the United States.
    We need to get this information to the public and to health 
professionals. Again, it is an issue of health literacy. It is 
a battle in many areas of public health that I find, increasing 
health literacy so that people understand the good science that 
we have already available and we are not using it fully.
    In closing, I will add that today must be a day of change. 
Today must be a day when our work is a catalyst for better oral 
health. I thank you for many efforts on behalf of seniors, and 
I promise to work with you to improve the health and well-being 
of all Americans.
    With that, I will end my oral remarks. I would ask to be 
able to submit my entire written statement into the record, and 
I would also be happy to answer any questions, Senator.
    Thank you very much.
    Senator Breaux. Thank you, Dr. Carmona.
    I understand that you need to catch a plane, so we are not 
going to keep you too long. I am going to let you be excused 
whenever you feel that you have to.
    Dr. Carmona. Thank you, sir.
    Senator Breaux. But I want to thank you for your 
participation. I think that a lot of people do not understand 
the serious nature of the problem, and I think that you as the 
Surgeon General obviously have the capacity to highlight the 
serious nature of oral health care for seniors at a time when 
many Americans seem to be more concerned about the color of 
their teeth; they want to make them whiter, and there are more 
and more products for whiter teeth and how you can get them to 
be brighter and brighter. There are many older Americans who 
are suffering very severe health problems, not because of lack 
of white teeth but because of severe infections and other 
problems that they have.
    So in your capacity as Surgeon General, I think it is 
important that you make the statement that you made today and 
continue to try to highlight this as a particular problem and a 
particular concern.
    So we thank you for being with us and hope you can continue 
helping to educate the American public about this very serious 
problem.
    You may be excused whenever you have to go because you have 
told me that you need to catch a plane for a trip.
    Dr. Carmona. Thank you, Senator.
    I would just add that, as I said when we released the 
report, you have my full commitment as does the American public 
in keeping this area of oral health on the forefront.
    Thank you, sir.
    Senator Breaux. Thank you, Admiral.
    [The prepared statement of Dr. Carmona follows:]
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    Senator Breaux. Now let us ask Greg to make his slide 
presentation, and then we will be able to begin the dialog that 
I hope we can get on trying to find out what we need to be 
doing.
    Dr. Folse.

           STATEMENT OF GREG J. FOLSE, LAFAYETTE, LA

    Dr. Folse. I want to thank you very much, Senator Breaux, 
for bringing us all together today.
    You talked about the whitening--I think the color that my 
patients would really like to have their teeth is ``some.'' 
Unfortunately, that is where we are.
    That is one of the things that Louisiana happens to do 
well, actually. We have a good denture program for our elderly, 
but we do not pay for a lot of other things.
    I also want to thank Dr. Carmona in his absence for his 
call to action. I think it is already affecting lives. But we 
have a long way to go.
    Ageism and oral health--are our Nation's seniors receiving 
proper oral health care? The answer is resoundingly no--they 
are not receiving it right now when you look across the board.
    The Surgeon General's report in 2000 called it ``a silent 
epidemic'' for our elderly. I think that when you really look 
at it, and you see the patients that I see--and let me back up 
a little bit. I have a mobile geriatric practice, and I go to 
nursing homes every day; I am in there day in and day out. When 
you see what I see, it is not silent--it screams. It screams 
for us to take action on the issue.
    This is Miss Sylvia. I am going to introduce you today to a 
few patients of mine, and if you cannot see, please get up and 
move around; that is fine with me. Ms. Sylvia was the mother of 
a nursing home administrator. She had just arrived at the 
facility. She was poor. She had been in the community. You will 
notice her hair is pretty; she has it all combed. She was 
really trying to take care of herself. She has lipstick and 
rouge, and everything was Cadillac-ing for her--except when you 
looked in her mouth.
    She did not have access to oral health services. She did 
not go and have her teeth cleaned. She had gum disease. She had 
broken teeth. She had abscesses in the back of her mouth. She 
had infection.
    We cannot stand for this. Her daughter cared dearly for her 
and did not really realize that this was going on.
    This is Mr. Joe, an old man in a facility--I work in 
facilities all day, and I love nursing facilities. It is not 
that he was there, but there is a great burden of disease when 
these patients get into nursing facilities, and that burden is 
difficult for us to deal with.
    He had a tooth, which you can see right her, that they 
asked me to take a look at. When I did, they told me his story. 
He was a grumpy guy who would sit in his wheelchair and 
literally run the wheelchair into your ankles. He was ornery 
and hated everybody, and nobody liked him.
    Well, when I looked in his mouth, under his lip was this 
huge squamous cell carcinoma. This guy thought he was dying; 
his face was rotting off. This cannot be. Had he had one dental 
evaluation, one cleaning, while he was getting older, someone 
would have picked this up.
    We did radiation therapy, this became a little scar, and 
the guy did very well. He started going to bingo and became a 
good part of the facility.
    Who are these patients? When I look at the country, I had 
this term introduced to me not too long ago--the ``aged, blind, 
and disabled.'' If we can think about our seniors and our 
vulnerable adult population and use this term, we will be ahead 
of the game, because this term is defined in Social Security 
law, so it is a great place to hang our access hat.
    This gentleman, Mr. Charles, is a good representative of 
``aged, blind, and disabled.'' He is all three of them. He was 
in a facility, and I told him 2 months ago, ``I am going to 
Washington. I am going to try to get some help for your 
teeth.'' He was all happy, and he gave me this kind of 
convoluted smile that you can see here. He was happy about it.
    He allowed me to take photographs of his mouth, and today 
he sits in this facility with no access to oral health care 
with these teeth. This is how he eats every day. He has broken 
teeth, he has gum disease, he has abscesses. These are teeth 
that are broken off at the gum line, for those of you who do 
not know.
    When I told him that I was going to Washington just to 
talk, he thought I was going to take his teeth out that day, 
and he got angry; and when he did, this was the face he made, 
and I just quickly took a shot of it. I am with you, Mr. 
Charles; I feel the same way. Let us do something.
    How many of them are there? In my written testimony, I have 
some actual numbers of disabled adults, but we all know that 
the number of seniors in our country is going through the roof.
    Just like Miss Marsha--these slides I took a month ago--6 
months ago, she had an abscess for this little tooth, right 
here. This tooth needed extraction 6 months ago. There is no 
access in our State, along with other States--I will tell you 
how many in a little while. I put her on antibiotics. Someone 
else put her on antibiotics a month later, and someone else 
again a month after that.
    A $100 extraction would have taken care of this. The fourth 
time she got infected, she got an MRSA infection, which is a 
staph infection that is resistant to antibiotics. She had to go 
in the hospital--and that is where these pictures were taken--
so that they could do a little surgical procedure, a drainage 
here. During the procedure, she was septic, and her heart 
stopped beating, so she went into the ICU for 4 days. One 
hundred dollars for an extraction, $30,000 for a surgery and 
ICU stay. It does not make a lot of sense, besides the 
suffering that this lady had to go through.
    As a practitioner, it kills me, because they sit and they 
rot under my care, and I hate it. Guys like me all across the 
country see the oral health of our seniors is neglected.
    The report from the Surgeon General said there are many 
disparities, and there are. The elderly take the brunt of it. 
If you have money, you can get care--until you get medically or 
functionally disabled, or until you get institutionalized or 
you spend all of your money. Then you start losing that access 
that we all have as functional adults.
    Within the ``age, blind, and disabled''--and I realize this 
is not quite as on-point--but we have mentally retarded adults 
in our country who sit in facilities or who sit at home with no 
access to oral health care. This is a sin that our mentally 
retarded do not have access.
    This poor gentleman sits--he is losing his teeth, he has 
gum disease, he has abscesses--and there is nothing I can do 
about it. There are hundreds and thousands of them across the 
country like this. We have to do something on a national level.
    I wish the Surgeon General was here for this. We need a 
statement from him saying that oral health services are 
medically necessary for this vulnerable population. I think 
that is going to be a key to the advocacy or the push to get 
services.
    It goes on and on, people. I saw this guy, and 2 years 
before I took this photograph, these four teeth were in perfect 
shape; he had a $900 partial hooked to it that he was eating 
with. Two years later, after a stroke, he has gum disease, he 
bleeds every time he eats--and no access to care.
    This is the old tooth in the lung, another $100 extraction 
that turned into a $40,000 or $50,000 surgical procedure and 
hospital stay with all these complications. A loose tooth--she 
rolled over, hit her mouth on the bed rail, and it went into 
her lung.
    This is a birth mark. Miss Mary had this birth mark all her 
life. But what I want you to look at are her eyes. Do you see 
that? Two weeks before I took these photographs, Miss Mary was 
walking and talking. She developed a dental abscess. Had she 
had any access over the last few years of her life, they would 
have caught something.
    Miss Mary, you can see, is swollen here; actually, she has 
some purulent drainage down on her bib. This was in the front 
of her mouth. I would think that this tumor would have been 
caught by somebody had we had access to oral health for an 
aged, blind, and disabled adult. She could have gone somewhere.
    Miss Mary died from the infection that got into this tumor. 
They could not take care of it. Seven days after I took these 
photographs, she passed away and really has solidly put the 
need for what we are doing here today in me.
    My wife will kill me, but I offer my services to all of you 
as we go through this process of getting access for these 
patients to help in any way I can.
    What benefits are available? The Surgeon General talked 
about it. There is virtually nothing until you get down to 
Medicaid--virtually no Medicare, private insurance, applied 
income laws. Medicaid has optional programs for every State. 
States can individually choose whether they want dental 
services or not.
    This is what our country looks like--blue is a B; New York 
gets a B--as far as Medicaid services go. The green States are 
C's. The yellow States are D's, and the red States are F's. I 
got to pick the colors, too--it is pus yellow and blood red--
and I am not going to apologize for it. It is a sin.
    We have 45 States with a D or an F, and when you look at 
the service reimbursements--and all of this is included in the 
Oral Health Report Card from Oral Health America, which I thank 
you guys for doing; it was great to be a part of that--when you 
look at the service reimbursements for the providers out there, 
all States except one get a D or an F.
    So when I couple the D-minus grade for Medicaid with the 
vulnerability of the ``aged, blind, and disabled,'' I give our 
country an F on how we are doing.
    Do we get it yet? There is nothing out there for these 
adults. The system of optional Medicaid oral health benefits is 
not working. We have in essence designated treatment of pain, 
pus, infection, and swelling as ``optional,'' and it does not 
make sense, and I know you all agree with me.
    So nationally, unfortunately, we have no infrastructure for 
oral health for ``aged, blind, and disabled.'' We do, however, 
have an infrastructure for children under EPSDT, and this is 
where I really think the solution can come. I believe that if 
we could take the ``aged, blind, and disabled'' who are already 
approved for Medicaid and put them into coverage under EPSDT or 
in a system like that, I really believe that that would work.
    National solutions--again, we need a bill, and I know that 
you will be open to helping us with that with the ABD patients. 
Within my testimony, I have included kind of the guts of that 
idea of the ``aged, blind, and disabled oral health access 
proposal''; it is in my written testimony. I would love to see 
a declaration that oral health services are definitely 
medically necessary. I would like to see the formation of a 
National Oral Health Coalition for Special Needs Adults, and a 
dental director in every nursing home.
    It can be done well. This is Miss Daisy. I made these 
dentures for her when she was 103 years old. Miss Daisy lost 
them 4 years later, and I remade them. Miss Daisy wore those 
dentures until she was 112 before she passed away. She had good 
oral health, and it meant a lot to her. We can do that on a 
national level.
    I thank you all very much for being here, and I thank you 
for participating in this event.
    Thank you, Senator Breaux. [Applause.]
    [The prepared statement of Dr. Folse follows:]
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    Senator Breaux. Thank you very much, Greg.
    I met with Greg previous, and I had seen his presentation 
back in Louisiana, and it was what really got me interested in 
trying to figure out where we are as a Nation with regard to 
oral health care for seniors.
    Let me just start--and I want you all to enter into 
discussion, not me--I would rather just sit and listen--but 
Greg, you made a statement that Louisiana has a good program.
    Dr. Folse. For denture care only.
    Senator Breaux. Oh, for denture care. Explain the 
difference between oral health care and just denture care that 
we have in Louisiana.
    Dr. Folse. Oral health care would include extractions, 
would include all the preventive services, exams, x-rays, 
getting teeth cleaned, gum disease treatment, fillings. That is 
an oral health care program.
    What we do is only the prosthetic side, which is a piece 
and an important piece of oral health, but we make dentures. We 
do not take out bad teeth to give you dentures, but we do 
provide dentures for patients whose teeth are already gone.
    Senator Breaux. That is really interesting; we are after 
the fact.
    Dr. Folse. The program was started years ago when most of 
our elders--in our State, probably 65, 70 percent of our elders 
had no teeth. Now I am seeing only about 40 percent; so I am 
seeing 60 percent with teeth now. So back then when they 
started that program, a majority of the population was affected 
by it in a positive way. So it made sense back then.
    Senator Breaux. So the State Medicaid program covers the 
dentures?
    Dr. Folse. Yes, sir, they do.
    Senator Breaux. You are really pointing out something. 
Older citizens, like my grandparents' generation, were just 
expected to lose their teeth and never to have all of their 
teeth.
    Dr. Folse. Exactly, yes, sir.
    Senator Breaux. OK. The information is obviously very 
graphic. I think we have a problem, and the question is how 
extensive is the problem. Can anybody talk about that a little 
bit? I have seen Lafayette, and I have seen Louisiana, but what 
about the study that we did with oral health?
    Robert, do you want to comment on that? How did you all do 
the survey?
    Dr. Klaus. We surveyed Medicaid dental contacts across the 
United States. I would suggest that the study results that we 
see here today are really the tip of the iceberg, that the 
problem is probably far more serious than even we would come 
out and say.
    Senator Breaux. What kinds of programs do we have for oral 
health care among the States? I guess the States' obligation 
would be under the Medicaid program for the low-income.
    Dr. Klaus. Medicaid--but under the Medicaid program, the 
first thing to be cut when times get tough in State 
legislatures as they are now, with States facing huge deficits, 
is the dental benefits of Medicaid. Recently, Michigan cut all 
Medicaid benefits except for those that relate to emergencies.
    We think that this pattern is going to continue. I just 
heard this morning from people in Georgia that next year, they 
think they are going to cut back on their dental benefits for 
Medicaid.
    Senator Breaux. Is the best that any State has under 
Medicaid an optional program that covers dental?
    Dr. Klaus. Yes. They are all optional.
    Senator Breaux. They are all optional, and many of them do 
not even have them as an option.
    Dr. Klaus. No, many of they do not have them as an option.
    Senator Breaux. Greg.
    Dr. Folse. Correct. The children's program is not optional, 
but all programs for adults are. You get a range of different 
types of programs. Minnesota right now is doing very well with 
their program. There are little problems within individual 
programs, and as a whole, you have Medicaid issues nationally. 
But it is optional versus non-optional.
    So from Minnesota, which is doing well, treating a lot of 
nursing home patients and a lot of elderly across the State, it 
goes down to States with absolutely nothing, not even a denture 
program; so you have us all in the range.
    The effectiveness of those programs, though, comes in when 
you really grade it, and that is what the report card did. We 
cut out five different procedures and looked at the 
reimbursement rates and said what dentist is going to do this 
for these types of fees, and that is where we got all the D's 
and F's. It was just way below what is out there.
    Senator Breaux. We sent all of you some questions, and I 
want to try to keep it focused to a certain extent. The first 
question is: What is the greatest problem that seniors face 
where oral health is concerned?
    If you are poor, the greatest problem is you do not have 
it. Anybody can start to comment on this. My father fortunately 
has access to his employer's retirement health program that 
covers dental care. He probably also has enough money that if 
he did not have that insurance, he could afford to go to a 
dentist and pay the bill.
    But that is probably not the situation for most Americans. 
Let us talk about that.
    Paula.
    Dr. Friedman. Senator, thank you for this opportunity to 
comment. I think that this is a tremendously important issue, 
and I would suggest that we consider, in additional to the 
financial means to access care, the dearth of qualified 
providers. One of the reasons that there is a problem certainly 
is financial, but another level of problem is that there are so 
very few qualified people trained in geriatric dentistry. A few 
of them happen to be seated around this table. But I would ask 
you to think about how many dentists are trained annually to 
provide the special training to provide care to senior 
citizens. I am not going to put you on the spot, but I am sure 
you would not imagine. Under HRSA--and we are grateful for the 
support that HRSA provides toward training geriatric physicians 
and dentists--less than 10 dentists a year for the entire 
country are trained in providing special services to this frail 
elderly population with medically compromised, complex medical 
conditions.
    So I certainly recognize the financial aspect, no question 
about that, but I am sure that my friend and colleague Dr. 
Folse would agree with me that access is also a function of 
having qualified providers.
    Dr. Folse. Without a doubt. It is kind of what comes first, 
the chicken or the egg, because I have had 3 years of extra 
training so that I could take literally a 50 percent pay cut 
over my colleagues. So what is going to come first? I do not 
think we could get the--you almost have to have the financial 
infrastructure at the same time. I do not care which one gets 
there faster. We have got to do both of them, and you are 
exactly right.
    Dr. Friedman. You certainly have to address both. I happen 
to be one of the dental directors of one of the HRSA-funded 
geriatric dentistry and medicine training programs, so I can 
tell you that there are only five to seven dentists per year in 
the entire country.
    Senator Breaux. Well, we only have five medical schools, 
and we just recently picked up two more, but out of all the 
medical schools in the country, 113 or so, there are only five 
that offer graduate programs in geriatrics. It is the fastest 
growing segment of our population in America, and yet only five 
medical schools offer advanced degrees in geriatric 
specialties. So when you break it down to subspecialties of 
dentistry, you can understand why we only have 10 graduates a 
year.
    Yes, Mr. Harrell.
    Dr. Harrell. I am a consultant to a nursing home, which I 
do mostly on a free basis--I take a 100 percent cut--and we 
have a Medicaid program that covers adults, although the 
reimbursement rates are extremely low, sometimes as low as 14 
to 16 percent of cost.
    Senator Breaux. Who has the program?
    Dr. Harrell. North Carolina.
    Senator Breaux. Oh, the State does--under the Medicaid 
program?
    Dr. Harrell. Although we fear we are going to lose it. I 
think the only reason we came out so well this year was the 
one-time Medicaid reimbursement to the States which saved us 
from probably a lot of lobbying and a lot of heartache. But 
this is going to come back again next year. But it is a 
financial issue. As a family dentist, I see geriatric patients 
in my office on a daily basis. A lot of them have insurance or 
can afford it otherwise, or they would have Medicaid. But going 
into a nursing home facility--I serve three--there are no 
facilities, no equipment. The nurses and staff know very little 
about oral health, and most of the time you are doing 
extraction in the middle of the night with a weak flashlight 
battery, and they always feed them right before you get there. 
I do not understand that. So I know we need geriatric 
dentists--I am not underplaying that--but we need to stimulate 
family dentists.
    Senator Breaux. I would think--and I am obviously not a 
medical doctor--but it would seem to me that the fact that we 
do not have a lot of geriatric dental specialists, it seems to 
me that any doctor of general dentistry can look at these 
seniors and the problems they have are no different than those 
of a young child who has not been to a dentist in 15 years of 
his life. I mean, a practicing dentist would be able to look at 
an elderly person just like he does a person who has never seen 
a dentist who is 20 years old as the same types of problems 
develop. There are a lot of other problems, particularly mental 
illness and others, that seem to be a lot different among the 
elderly and more difficult to recognize that it is a problem of 
aging.
    Dr. Harrell. There are special needs patients that you 
cannot treat without some type of facilities, and in a lot of 
places, we do not have those.
    Senator Breaux. I would bet you there is not a nursing home 
anywhere in the country that has a resident dentist.
    Dr. Folse. I am actually a dental director in 14 nursing 
homes now, and I am there usually a time or two a week, and we 
do all of our services. I do do some extractions and cleanings 
and those kinds of things at the facility----
    Senator Breaux. But how many other dentists do that?
    Dr. Folse. Not many. To build the infrastructure that we 
are going to need to get people doing those kinds of services, 
one of the things is to take away the yearly budgetary threat 
that we get from Medicaid on a State-by-State basis. That has a 
significant impact when you have a system built to treat 
vulnerable adults, but it is always on target. I have trouble 
getting other dentists to do that when the States pull the rug 
out from under us every year.
    Senator Breaux. But what kind of compensation does a 
dentist who does what you do get? Is he reimbursed anywhere?
    Dr. Folse. I am reimbursed for the denture care, and a lot 
of the other stuff is donated.
    Senator Breaux. We know these other problems are not 
denture problems; they are just gum disease problems. You are 
not going to be reimbursed zip for that.
    Dr. Folse. But I am not treating it, either. It is sad. I 
have 2,500 patients, and 1,600 patients have cavities and gum 
disease under my watch, and they do not get treated. I put the 
fires out as much as I can. I treat the ones that the families 
will let me treat. But as a whole, having an infrastructure 
where guys in an office could get paid to see these patients 
and I could refer them to you would be great.
    Senator Breaux. Are there any other comments from anybody?
    Dr. Barsley.
    Dr. Barsley. Senator Breaux, I appreciate the opportunity 
to be here today.
    I have worked with Dr. Folse over the years in Louisiana, 
and one of our problems has been I have pulled the rug out from 
under Greg more than once when our State ran out of funds; I 
have reduced the amount of money that we can pay to him. 
Fortunately this year, we were able to increase that amount of 
money, and one thing we thought about doing was increasing the 
services that were offered. Our problem was that the pent-up 
demand is so vast that once we increase the range of services 
we can offer, we have no way to judge how much pent-up demand 
there would be; if we had to extract just one tooth in every 
person in Louisiana who is Medicaid-eligible, that is one 
million teeth.
    Senator Breaux. How much do we pay for dentures?
    Dr. Barsley. We pay roughly $1,000 in Louisiana.
    Senator Breaux. I mean what is the total cost.
    Dr. Barsley. In Louisiana, our budget for adult services is 
about $4 million.
    Senator Breaux. Four million dollars for dentures.
    Dr. Barsley. For dentures only and the exams that go with 
them, yes, Senator.
    Senator Breaux. Suppose we just did not do dentures, and we 
used the $4 million for oral health?
    Dr. Barsley. That is what I am looking at.
    Dr. Folse. Yes.
    Senator Breaux. Is there any prohibition--I mean, could a 
State do that if it wanted to?
    Dr. Barsley. Senator, we could, but I am very much afraid--
in fact, we are discussing this very weekend adding dental care 
for adult pregnant women to help decrease low birth-weight 
children. We are estimating that adding extractions and 
cleaning their teeth will probably cost about $3 to $4 million 
for the 30,000 women who would be covered in the next year. So 
if we were to cover all the Medicaid-eligible people in 
Louisiana and cover a range of services limited just to that--
--
    Senator Breaux. Does anybody know if any other States just 
cover dentures?
    Dr. Folse. That is optional. I mean, you can cover whatever 
set of benefits you want.
    Senator Breaux. Yes, I know, but I think it is unusual that 
we cover dentures but not oral health.
    Dr. Folse. Yes.
    Dr. Dolan. Senator, the State of Florida had an adult 
denture program until about 2 years ago, and when they had 
Medicaid cuts, they eliminated that program. That is why my 
State is a ``red'' State on Dr. Folse's chart, because 
actually, we have one of the highest proportions of older 
adults in the United States, and yet we do not have the ability 
to serve the needs of those individuals.
    Senator Breaux. So Florida is not able to do dentures or 
anything else in oral health?
    Dr. Dolan. No. In fact, I was the dental director for four 
nursing facilities in Florida as part of my teaching 
responsibilities at the University of Florida and was faced 
with the same frustrations that you face every day in that you 
try to do the right thing for these individuals, and yet there 
was not the public or private financing to meet the needs of 
the residents of these facilities.
    Dr. Folse. Senator, I beg your forgiveness for the 
interruption. You are talking about cost. In special care 
dentistry, we looked at the problem of including oral health 
for adults in Medicaid, and when you cover the whole 
population, it costs a lot of money. You are really in a jam. 
You are not able under Medicaid to carve out like ``aged, 
blind, and disabled.''
    If we could carve out ``aged, blind, and disabled,'' which 
is the most vulnerable population, and cover them under 
Medicaid, that is a doable thing. We put together as part of my 
written testimony the proposal--we looked at what California 
spent on ``aged, blind, and disabled''--and they have full 
dental benefits there--and we extrapolated that out to the 
country, and it looked like about $1.2 billion a year if you 
put those patients under the dental programs that are currently 
there. That is pretty much a max, because some of those 
patients are already being treated, so the ones like California 
would be included in that $1.2 billion, so we are already 
spending that. It would probably add from our estimation about 
$700 million a year to the country to treat ``aged, blind, and 
disabled'' under Medicaid. It just makes sense.
    Senator Breaux. Would you have to drop others--aren't 
children included?
    Dr. Folse. Children are covered now under Medicaid; 
correct.
    Senator Breaux. You are not talking about dropping them.
    Dr. Folse. No. I am talking about just adding ABD adults 
into the EPSDT program that is already existing in all the 
States.
    Senator Breaux. Does anybody have any thoughts about that?
    Yes, Paul?
    Dr. Glassman. Paul Glassman, from Special Care Dentistry. 
Thank you for the opportunity to be here.
    Greg is referring to some data that we did collect in 
California, where the people who were in that category, adults 
who are ``aged, blind, and disabled,'' account for 33 percent 
of the Medicaid population in California and currently use 
about 20 percent of the Medicaid dollars. So that is where the 
numbers came from to extrapolate what it would cost nationally. 
California actually received a C-plus on the chart, which was 
one of the three highest States because of that program--
although that program has been threatened and almost went away 
this year. Again, the one-time block grants to the States saved 
it from being removed this year.
    I also wanted to comment that--you asked earlier about 
data--in the recent Surgeon General's Report on Oral Health in 
America, it actually says in the report that one of the 
problems when you are talking about special populations is that 
there really is not any good data, and it actually talks about 
that in the report.
    I am president this year of Special Care Dentistry, and we 
have 1,000 members, which is a small group of very dedicated 
people who spend their lives treating people who are aged, 
blind, and disabled, and each one of those people has a 
thousand stories. So there is no question in our minds that 
this is a huge problem. The numbers are staggering, but as Greg 
says, it tends to be a silent epidemic because the people who 
are suffering really do not have a voice to let their suffering 
be known.
    Senator Breaux. Tell me again what is your situation in 
California. The aged, blind, and disabled constitute about 33 
percent?
    Dr. Glassman. We have an adult Medicaid program for 
dentistry, so adult Medicaid recipients are covered by dental 
benefits. Of those who are covered, about 25 percent fall into 
the category of ``aged, blind, and disabled,'' and they use 
about 20 percent of the Medicaid expenditures.
    Senator Breaux. What does the program in California cover?
    Dr. Glassman. I cover all the kinds of things that Dr. 
Folse was talking about--basic examinations, cleanings, 
fillings, extractions, treatment of infections, screening for 
oral cancer. It does cover dentures. Some people say that it 
does not cover enough, but I actually think it is a very good 
program for basic services.
    Senator Breaux. But how did they only get a C if they cover 
all that?
    Dr. Klaus. Because they missed in other major--I do not 
have the report right in front of me, Senator--but they missed 
in other major categories. Paul, you probably know those better 
than I do.
    Dr. Glassman. I think it is actually a good program 
compared to many States in the country. It certainly has its 
problems, and I think that is where the C came from.
    Senator Breaux. So you miss seniors who are not aged or 
disabled or blind; they are not covered?
    Dr. Glassman. Yes, that is right. Low-income seniors are 
covered.
    Senator Breaux. All low-income seniors eligible for 
Medicaid have dentistry as an option.
    Dr. Glassman. Right, yes. Most people who are eligible for 
Medicaid gets dental benefits, right.
    Dr. Folse. Their low grade came from real low reimbursement 
rates.
    Senator Breaux. Other than that, they have a good program. 
It is just a question of the reimbursement rates--because the 
services are provided.
    Dr. Folse. Yes. A lot of the States have full coverage is 
what they say, but when you look at the effectiveness of that 
coverage, because it is below the tenth percentile of what 
dentists charge, it is real hard to get the infrastructure.
    Senator Breaux. That is true of everything--in the CHIP 
program in my State of Louisiana, we have insurance for 
children under the Medicaid program, but the reimbursement rate 
is so low that many doctors refuse to take children as patients 
because of the reimbursement rate. It is all a question of 
money, isn't it?
    Dr. Folse. Yes.
    Senator Breaux. Is there other discussion on this?
    Yes?
    Dr. Harrell. I wanted to bring up the reimbursement to make 
sure you are clear. States have programs; it does not 
necessarily mean they fund those at a reimbursement level 
adequate enough for people to have access. In North Carolina, 
by a funny twist, the State was just successfully sued by a 
children's advocacy group because they did not raise the fees, 
the reimbursement, enough to allow the required access. The 
funny thing is--not funny--but the nice irony is that they did 
it by codes, and a lot of those codes are also adult codes. So 
that is going to help our geriatric Medicaid population also. 
But just because you have children's Medicaid or a Medicaid 
program does not necessarily mean you are providing access.
    Senator Breaux. Let me understand. How many States have 
dentistry covered under the Medicaid program, regardless of the 
reimbursement rates?
    Dr. Folse. Virtually all of them.
    Senator Breaux. So all of them do--Louisiana, too? I 
thought we just covered dentures.
    Dr. Folse. There are I believe eight States with no 
services at all, and this is from some data that I had about a 
year ago, so I am doing it by memory. I think we had eight with 
none and 22 with either limited or emergency only, and the rest 
of the States had what they considered full coverage for 
adults. For children, everyone is required to have full 
coverage.
    So the heart of this would be taking ``aged, blind, and 
disabled'' and saying you must cover them also, and that is 
where ageism comes in to me. We have a vulnerable child 
population, and we have the same issues on a vulnerable adult 
population, but we do not have the same requirements. I would 
love to see that as a requirement.
    We could increase the FMAP for the States, too, the Federal 
matching dollars. If we increased that for that program, it 
would be a really nice thing that would fly politically--with a 
big question mark.
    Senator Breaux. I'm not sure what flies politically today.
    Dr. Davis, what about CMMS? Can you comment on what we have 
been listening to here?
    Mr. Davis. The latest number that I have on the number of 
States that do provide adult dental care is 8 for full 
benefits, 16 for limited benefits, 18 for emergency-only 
benefits, and 9 that have no coverage at all. Those are the 
current numbers right now on the Medicaid side.
    Senator Breaux. Karen.
    Ms. Sealander. Karen Sealander with the American Dental 
Hygienists Association.
    While there are many inevitable declines in seniors' 
health, a decline in oral health is preventable, and that is 
why it is such a tragedy to see Dr. Folse's slides; because if 
seniors receive regular preventive services, we could prevent 
all of these horrible oral health tragedies.
    While the profession of dental hygiene was founded back in 
1923 as a school-based profession, over the years, hygienists 
have lost many outreach opportunities. One solution to the oral 
health care crisis that ADHA would like to see is increased 
entry points into the oral health care delivery system. Even 
seniors who have insurance, whether it is Medicaid or private 
insurance, often cannot get access to care because they cannot 
travel to a dental office. So we need to go out and reach these 
seniors where they are, and ADHA would like to see dental 
hygienists play an increasingly important role in delivering 
care to people where they are, whether that be in a nursing 
home or an assisted living facility.
    In many States, there are restrictive supervision 
requirements, but there are some States pioneering less 
restrictive requirements, and ADHA would like to see that 
encouraged.
    Presently 25 States allow hygienists to provide services in 
nursing homes; 12 States recognize hygienists' ability to 
provide services to homebound patients; and 10 States recognize 
hygienists as Medicaid providers. ADHA would like to be part of 
this solution in a collaborative way. Dental hygienists cannot 
provide all oral health services--we need to work in 
conjunction with dentists--but hygienists would like to be able 
to reach more seniors with our services.
    Senator Breaux. Let us talk a little bit about that. I do 
not want to get into a battle between dentists and hygienists, 
like we have done over the years with psychiatrists and 
psychologists and chiropractors and medical doctors, et cetera, 
et cetera. But there are two questions. No. 1, how much help 
can dental hygienists provide if they were involved in 
treatment of our elderly citizens, and No. 2, if they can be of 
help, how many of them would be available considering the 
shortage of dentists that we have?
    Can anybody talk to me about how much help they could be?
    Ms. Sealander. Senator Breaux, with respect to the historic 
turf battle, there is more than enough unmet need for all of us 
to play a significant role, so there is really no need to 
squabble over turf.
    With respect to the workforce issue, the number of dental 
hygienists in the workforce has grown steadily and is expected 
to increase by 37 percent between 2000 and 2010. Dentists, on 
the other hand, are among the five health professionals with 
the slowest rate of job growth, a 5.7 percent increase 
projected between 2000 and 2010.
    Right now, approximately 5,500 dental hygienists graduate 
each year and about 4,300 dentists graduate each year. Morever, 
dental hygienists are educated to care for geriatric patients; 
geriatric care is a required part of the dental hygiene 
accreditation standard.
    Because dental hygienists provide preventive oral health 
services; and do not provide restorative services, hygienists 
to work in connection with dentists, and hygienists can serve 
as a pipeline to dentists. One hygienist in Portland, OR 
provides services in a nursing home in an onsite dental clinic 
that was built with donated equipment. She works there one day 
a week, and then, one day a month, a dentist comes in and 
provides the needed restorative care.
    Dr. Folse. They would be an integral part of the team, and 
I think hygienists are going to be integral in the final 
solution of this; they are going to be a big part of it.
    Senator Breaux. Anybody else?
    Paul, and then Jim.
    Dr. Glassman. You are touching now on workforce issues, 
which I think are going to become a major problem. This problem 
that we are talking about now with elderly and disabled people 
having difficulty getting access to care is going to get worse 
because of workforce problems.
    It certainly is true that the number of hygienists is 
growing faster than the number of dentists. Dentists who are 
retiring now went to school at a time when there were 6,000 
dentists a year being produced, and they are being replaced by 
today's 4,000 graduates.
    The thing I want to point out, though, is in all of the 
estimates about how critical this workforce shortage is going 
to be, all those estimates if you look at them carefully are 
based on an underlying assumption, and that assumption is that 
those people who are currently left out of the oral health 
system who do not have access to oral health are going to 
continue not to have access to oral health. All the analyses on 
workforce are based on that assumption
    Senator Breaux. Dr. Harrell.
    Dr. Harrell. The American Dental Association has 
consistently studied the workforce issue, and there are some 
problems with some of the data, and it is hard to project the 
needs in the future. We recognize the value of hygienists, 
particularly as Greg said in a team concept, where the dentist 
does the diagnosis but the hygienists particularly are 
extremely valuable, I think, on the education end of this 
thing.
    I looked the other day, and there are 44 States--our policy 
in the American Dental Association is that it is sort of a 
States' issue, but 44 States have chosen to give some laxity of 
supervision to hygienists in nursing homes. Whether that has 
increased the care, I do not know. The only concern is that the 
diagnosis is done so that we do not just polish decay but that 
we really give treatment.
    Senator Breaux. Yes. It seems to me that some of these 
people who are institutionalized, not to mention those who are 
not in institutions, but all those who are in assisted living 
facilities or nursing homes, never really have anyone look into 
their mouths to see what kind of oral health they have. A 
dental hygienist could certainly help identify serious problems 
that necessitate a dentist to do the extra work that may be 
required, but there is an awful lot that could be done just to 
help identify the problem and help with at least a partial 
solution to the problem.
    Dr. Collins.
    Dr. Collins. Thanks, Senator.
    Like others, I appreciate the opportunity to be here. For 
the moment, I would like to make three points.
    One is about the reimbursement issue, which is obviously a 
complex one, and you have heard a lot of different statistics 
about what is covered and what is not covered. The key issue to 
me is that the service is an optional one regardless of where 
you are in the United States, so that when times get tough, 
things that are optional tend to disappear. This is the 
solution that Greg is offering as an attempt to address that.
    The second point I want to make is about education and 
training, looking at alternate solutions--not necessarily 
training an entire workforce of geriatric specialists--that is 
probably very impractical, although I would certainly encourage 
us to have a core of them; certainly we need them as faculty to 
teach, we need them in programs where they can take referrals 
for the more difficult, and we need them to educate of general 
dentists in order to get treatment to these older patients, who 
yes, may have the same kind of disease, as younger patients but 
they also have many co-morbid conditions that make it difficult 
to treat them and that add special conditions that require 
consideration.
    In some of the material that was provided in advance of the 
hearing, it has been reported the dental schools, that have 
made considerable progress in offering didactic material--in 
geriatrics nearly all of them do now--but clinical training has 
lagged behind.
    I graduated from dental school in Philadelphia in 1971, and 
there was no geriatrics in my course of study; there was very 
little public health. Downstairs in a little, obscur room, 
there was something called a special patients' clinic, and I 
had an instructor who by chance got me involved in that clinic, 
and I think it made a big difference in my interest in this 
area and in public health in general, because you got an 
opportunity to understand that these people had needs like 
everybody else, and they were eminently treatable if you had 
the right skills and you understood that.
    So that is definitely one of the three legs of the stool. 
You have to have practitioners who understand that whether they 
are dentists, whether they are auxiliaries, whether they are 
hygienists.
    The third point I want to make is in the area of research. 
In the Surgeon General's Report, he talks about science being 
the lead and the connection for us to make progress in this 
area and many other areas in oral health. I definitely think 
there are many opportunities, some of them linking the 
reimbursement and workforce issues, maybe done through the 
universities, looking at different distributions of personnel 
and how well they can address problems, whether the elderly 
patients are in the community or they are in the institutional 
setting, because in either situation, it is not a matter of one 
size fits all. We used to make assumptions--and I think that is 
why there are so many denture programs or priority on 
dentures--that people were going to lose their teeth, and if 
they lost all of their teeth, then they were going to need 
dentures. Our other priority was kids. So we had denture 
programs, and we had basic programs for kids.
    Times have changed rapidly as dental insurance has grown. 
We have people with complex medical problems, but they also 
have complex dental problems; they are moving into old age, and 
suddenly, they do not have reimbursement for this care, and as 
they develop other kinds of co-morbid conditions, they have 
problems.
    There is a vast opportunity for us, I think, in the 
research arena, delivering care in many cases at the same time, 
to find solutions that use resources wisely--give patients what 
they need; do not give them more than what they need.
    Senator Breaux. A good point.
    Paula.
    Dr. Friedman. Thank you, Senator.
    I wanted to point out a workforce issue agenda that is 
actually interdisciplinary, and it speaks to the need for 
increased education in oral health across all health care 
disciplines, and the invisibility, if you will, of oral health 
care among other health care providers.
    I brought with me for the purposes of this hearing two 
publications that just came out. One is a Public Policy and 
Aging Report produced and published by the Gerontological 
Society of America called ``Emerging Crisis: The Geriatric Care 
Workforce,'' which speaks about the dearth of health care 
providers across all health care professions, except that oral 
health is not even mentioned here. There is no mention of oral 
health in this well-respected association's publication on the 
workforce crisis.
    The second one is a joint publication by the Merck 
Institute of Aging and Health, and again, the Gerontological 
Society of America, called ``The State of Aging and Health in 
America,'' which again does not mention oral health at all.
    So I think that when we talk about workforce issues and 
about increasing awareness of oral health as an important and 
critical component of overall health, which was mentioned by 
Surgeon Everett Koop many years ago, it is very important to 
not only consider the oral health professions but 
interdisciplinary professions as well.
    Senator Breaux. That raises a question, Greg, with your 
slides, and I am sure that any State you go to, you could go to 
a senior facility and see the same problem, maybe some even 
worse certainly, maybe some not as bad. But why doesn't a 
regular medical doctor when doing a normal check on an elderly 
American--anybody can look into someone's mouth and say look, 
they have a dental problem. I mean, I could look in there and 
say this is a dental problem before it got to the point where 
it got there. You did not need a dentist to tell those folks in 
your slides that they had a problem long before it got to that 
point.
    Do doctors not notice this, or ignore it, or just do not 
look?
    Dr. Folse. I have had a lot of interaction with the 
American Medical Directors' Association. They are the doctors 
who go into the nursing homes. I teach them about this, and I 
called it ``the forehead slap''--when you talk about it and 
they go, ``Oh, my God--I am not even looking.'' I see that time 
and time again. I call it ``the forehead slap factor,'' and I 
have it on an additional slide.
    We have a long way to go in that regard. I think, though, 
that as we gear up as I have in my area and as other dentists 
have around the country, when you gear up an oral health 
program, they start thinking about it. Then, when you have a 
few patients who have complex problems and you point it out to 
them, they start looking. But it needs to be part of the normal 
routine, and it is not right now.
    Senator Breaux. Teresa.
    Dr. Dolan. Senator, I had the good fortune as a recent 
dental graduate to participate in a VA fellowship training 
program which was multidisciplinary, where I worked with the 
nurses and physicians and physical and occupational therapists, 
and we learned from each other. That was one way of sensitizing 
them to oral health issues that they were probably never 
exposed to during their usual curricula.
    Also in the VA, they had dental operatorie in the nursing 
facility, and we provided preventive and restorative care with 
dental hygienists, and it was a wonderful model.
    Over time, those programs disappeared, so we had probably 
fewer than 30 trained geriatric dentists who had that 
experience.
    Senator Breaux. In VA facilities?
    Dr. Dolan. In VA facilities. Many of those VA trainees are 
in this room and have become the academic leaders in geriatric 
dentistry.
    When I joined the University of Florida, we had a 6-year 
HRSA training program, also multidisciplinary, with physicians, 
dentists, and other health care providers, where we learned 
from each other. Physicians learned about oral health. We 
learned from physicians about medical complications that were 
important in dental therapy. Again, those programs were 
severely cut in Federal budget cuts. I believe that now there 
are fewer than 10 individuals being trained in those programs. 
We no longer have a program in the State of Florida.
    I think models have been tried and have been successful, 
but they require commitment and resources. I think we do have a 
lot to learn from each other. If you look at the medical 
education curriculum right now, there are probably less than 10 
total hours of instruction, in a good school, about oral health 
issues.
    So I think there are many, many areas that need to be 
addressed. We have had models in the past that have worked and 
for one reason or another are no longer funded and supported.
    Senator Breaux. Yes, Dr. Musher.
    Dr. Musher. Senator, I am a physician. I am board-certified 
in family practice, and I am a fellowship-trained geriatrician. 
I am also a past president of the American Medical Directors' 
Association, so I was happy to hear comment about that.
    One of the things that that organization has been trying to 
do is help educate our medical directors who by law have to be 
in nursing homes related to the different issues that are 
important in nursing homes, and one of them is oral care.
    But I do want to mention in my training as a fellow that I 
was trained in oral care. I reach a point, just as anyone else, 
where I would find a problem in oral care and I would need to 
find a dentist or an oral surgeon to help care for that 
problem.
    But I think we are saying two important things here. One is 
the team approach, and the second part is education. In the 
nursing homes, we have what is called the minimum dataset, and 
in part of that, we are supposed to be assessing for oral care 
and looking in our residents' mouths, our patients' mouths, and 
assessing for certain problems.
    I have heard a lot of people have advocate for education, 
and I think that is critical. I think we have to better educate 
the staff in the nursing homes all the way down to the CNA 
level what to look for and then how to plug that patient into 
the system, and I think they can be educated. They are with the 
patients every day. They are helping brush their teeth, taking 
care of their dentures, et cetera, et cetera, so I think that 
would be important.
    I think educating physicians to work with dentists and 
other health professionals is part of that. I think there are a 
lot of physicians who are still in nursing homes that are not 
as well-trained or feel as comfortable, if you will, looking in 
patients mouths.
    I also wanted to comment that, for example, a lot of the 
patients we are seeing now in the nursing homes are frail, they 
are demented, they are a little harder to care for in some of 
these ways, but there are some simple things besides what we 
have heard today that I struggle with every day such as 
xerostomia, which is just a dry mouth, either from medicines or 
just from the aging process, which has huge repercussions. I 
have had patients who were going to get gastric feeding tubes 
because they stopped eating because you need saliva to taste 
the food. My patients were not tasting the food, and they 
stopped eating. As soon as that was brought to my attention, I 
realized it was a dry mouth.
    That is something simple that anybody could hopefully 
recognize and correct. So I think it underlines again that more 
education is critical.
    I guess one side comment because I also have a private 
practice, and one of the things that has frustrated me--and 
maybe it gets to the financial issue a little bit--is that I 
think if there were less paperwork related to billing issues, 
maybe the health care system would not be as costly.
    Senator Breaux. Thanks, Jonathan.
    Robert.
    Dr. Klaus. It seems to me and to Oral Health America that 
there are two chapters in health history in the United States. 
One is overall health, and then there is oral health. This has 
contributed to the problems of oral health being perceived in 
almost abject isolation and what we call almost a militant 
indifference--and it is not just us. Listen to how the 
Frameworks Institute, a think tank in Washington, DC., 
describes the problem.
    ``You cannot solve a problem that is not perceived to exist 
by the public. To say that this issue has not emerged in public 
discourse is to greatly understate the issue. It is 
invisible.'' I would suggest just looking around the room--and 
I do not know everybody here--but we are all part of the oral 
health family, and the solutions to this problem will not be 
advanced, Senator, until we begin to get outside and get 
coalitions that speak to this issue as passionately as we do.
    Senator Breaux. That is a good point. I have always said 
that in solving problems, first, people have to understand that 
there is a problem, and after you realize there is a problem, 
you can talk about possible solutions to the problem. The third 
part of any program is to convince people that these solutions 
are worth pursuing and worth investing a financial commitment 
to help pay for what you think is the right solution.
    So first, you have got to recognize that there is a 
problem, and that is what we are trying to do and to try to let 
more people know that the oral health of our Nation's seniors 
is a severe problem and is one that can be corrected.
    Then, we have got to come up with some ideas of what should 
we be doing. Greg suggested trying to make sure we at least 
cover aged, blind, and disabled seniors. We could start in that 
area.
    Then, you have got to have the political wherewithal to go 
out and sell that proposal.
    So it is a three-step process. It is not rocket science, 
but it takes some commitment on the part of people.
    Somebody else had a point. Paul, first.
    Dr. Glassman. Just to extend this discussion about 
awareness and are people seeing things or not seeing them or 
ignoring them, I think it is a combination of both. It 
certainly is a gigantic awareness problem where people look 
right past the mouth and sometimes do extensive medical tests, 
workups running to thousands of dollars for somebody and it 
turns out to be a dental problem.
    I spent 20 years working in a hospital dental clinic where 
that would happen time and time again. You would have someone 
who was in the ICU and had been there for a week and had had 
all kinds of expensive tests and then finally, in frustration, 
giving up and saying, ``Let us call a dentist in,'' and you 
would look, and sure enough, there would be a dental infection, 
and that was what was causing the problem.
    I supplied a videotape to your staff of an adult lady who 
was not verbal and mentally retarded who was admitted to a 
locked psychiatric facility in California at a cost of $150,000 
a year to the State of California because she was exhibit 
bizarre behaviors and lashing out at people around here. 
Luckily, there was a dental hygienist in our State who was 
connected through a program we have who came in and saw her and 
thought maybe this was a dental problem. Because we have adult 
benefits in California for this group, they were able to see 
her, and within 24 hours after dental treatment, she was back 
to her normal behavior and back living in the community again.
    That was a pretty dramatic story. So I think we have a 
giant awareness problem, but I think we also have a giant 
frustration problem, which is imagine that you are a physician 
or a social worker or a nurse and you are in a nursing home or 
working with a group of disabled people, and you look in the 
mouth and you recognize there is something wrong, and you try 
to get someone to come in and see that person. How many times 
are you going to try? You dial the phone, and you call 20 
dentists, and after a while, you give up, and you stop looking, 
and you stop trying to even bother because you know you are not 
going to get anyone to come in and see them.
    So we need awareness, and when someone does become aware, 
we need to have something that they can do that is going to 
work.
    Senator Breaux. That is a very dramatic story from a cost 
standpoint.
    Dr. Harrell. Senator, we appreciate you taking your time 
this afternoon, by the way.
    I want to make two points. I just participated in an 
Interfaces Conference which dealt with children's dentistry, 
sponsored by the American Association of Pediatric Dentistry, 
and they had a group similar to this. The physicians in the 
group did state pretty overwhelmingly that--I think they would 
have caught some of the slides that Greg had--but especially a 
lot of the subtleties of oral health, they were not trained in. 
In fact, none of the doctors present were. I thought that was 
interesting.
    Second, with Dr. Folse and some of the people who are 
sitting here, we are developing an oral health assessment and 
survey process for nursing homes, and CMS is reviewing that 
right now. Basically, we would like to at least have the right 
questions asked, hoping to raise awareness on oral health 
needs.
    Senator Breaux. Tell me about what. What are you all 
submitting?
    Dr. Harrell. It is called an oral health assessment and 
survey. It is for nursing home patients, and the nursing home 
fills it out. That is being produced right now; CMS I think is 
reviewing it.
    Senator Breaux. Do they do that now, or not? Is it a 
requirement to do that now when a patient enters into a nursing 
home?
    Dr. Folse. Yes, yes. In every nursing home chart, there is 
a health questionnaire called the MDS, and on the MDS are seven 
different oral health questions, and those questions have a lot 
of problems.
    Senator Breaux, you have been instrumental, whether you 
know it or not, in helping me to expose that at CMS. It was 
from some of the letters and correspondence that you had with 
CMS about oral health a few years back; so I had it down to 
thank you for that, actually.
    We have submitted the actual new questions that will be in 
every chart across the country, which are going to be good 
questions.
    Senator Breaux. How do they differ from what the existing 
program requires?
    Dr. Folse. The existing questions had the four main 
diseases--oral cancer, tooth-borne gum disease, and 
prosthetics--all mixed into a bunch of jumbled questions, so 
when you tried to answer one, you had to look at three 
different things.
    We separated out those four areas, and by separating them, 
we will be able to use some of the national data that we have 
about cavities and gum disease for the gum disease questions.
    Also, again because of your efforts at CMS, we did the 
National Surveyor Training Session about a year and a half ago, 
where we trained the nursing home inspectors. It was pretty 
much based on the MDS, and the video from that has been 
dispersed--there were a lot of responses from our facilities 
across the country looking at oral health. They got this 
videotape, and they looked at it because they wanted to know 
what the surveyors were going to be looking for.
    We are still pretty deeply involved in it, and special care 
dentistry has really been teaming up with ADA and CMS to have a 
real good result with that.
    Senator Breaux. Can Mr. Davis comment on that? That survey 
will indicate the potential problem that senior has coming into 
a nursing home.
    Dr. Folse. Correct.
    Senator Breaux. It does not provide any treatment, but it 
at least recognizes that there is a problem.
    Dr. Folse. Correct.
    Senator Breaux. Can you comment on the use of that data?
    Mr. Davis. That data is collected on each patient, and it 
is actually collected in the nursing homes. It is expanded now. 
Dr. Folse spoke recently to a group that CMS participated in. 
It is a contracting group, and they are looking at this 
expansion of questions for a minimum dataset for dentistry. 
That is still under review. It is not finalized yet. But it is 
an expansion.
    Senator Breaux. That does not do anything for the patient. 
It is just sort of let us go to the wreck site and see how many 
people are hurt.
    Dr. Folse. Correct.
    Mr. Davis. Right. Surveyors used that as a part of their 
review. It is part of the things that they look at. They do 
look at medical records, and they do have interviews with the 
patients and with the families and with the staff, and they do 
have observation.
    Senator Breaux. Where does that MDS go?
    Dr. Folse. If somebody has a cavity--the new question says, 
``Does the resident have a cavity?'' If they check ``Yes,'' 
that goes onto the care plan. Once it is on the care plan, they 
are supposed to refer that patient to a dentist or get 
appropriate care.
    That is actually the way that it is supposed to happen now. 
The problem has been in the actual assessments. We have not had 
enough training to get those done correctly, and where I found 
40 percent of my patients had a ``Yes'' trigger to the gum 
disease question, we found across the country out of 3.6 
million MDS's 0.8 percent that were being triggered. So we were 
missing 39.2 percent of the population, according to my 
records.
    Once that got exposed to CMS, they did make a commitment to 
us and to you to get the new questions and also to put in a 
quality indicator for oral health, which means not only will 
that information be used at the nursing home level; they 
receive all of those data electronically, and if an individual 
facility would have, say, greater than 60 percent gum disease, 
or they would report less than 20 percent gum disease, it would 
trigger the quality indicator for oral health, which would let 
the surveyors inspect specifically for oral health issues.
    Right now, the MDS questions are not tied to a quality 
indicator, so you can check them all of or you can check none 
of them off, and no survey question will come because of the 
MDS questions. So we are changing that.
    Senator Breaux. My next question was who makes that 
assessment. When you are admitting someone into a nursing home, 
is it a registered nurse, a practical nurse? Is it just an 
administrator who is on duty that night, who takes a look at 
the patient and says ``Yes'' or ``No''?
    Dr. Folse. In my facility, it is a range. Some facilities 
have licensed practical nurses do it; some have RN's do it. I 
have one facility--I do not go there anymore--where the social 
director was doing it, which was not that appropriate.
    Having the training to get them up-to-speed will help. I 
think the way that we handled that broad case was ``This is 
normal'' and ``This is abnormal.'' If it is abnormal, you check 
it, and you refer it. We tried to make it real simple, get out 
the big dental terms--that is not going to work.
    The problem with the personnel who are doing it now is that 
every time they check this stuff off, they have to refer, and 
there is no infrastructure to refer them to. So it is a round-
robin thing.
    Senator Breaux. Dr. Musher?
    Mr. Musher. Yes, just a couple of comments. One, I can 
assure you that the MDS is taken very seriously in the nursing 
home, but I think it is more of the stick than the carrot is 
what you are hearing, and it is also data. I think what 
everybody is saying--and usually in facilities, it is an LPN, 
licensed practical nurse, not usually RN level, who is filling 
out this information--it is supposed to point out where we have 
concerns or problems to then lead into other things. It used to 
lead into what we called the RAPs, which were resident 
assessment protocols, or guidelines or other things--in other 
words, there may be a problem, how do we now approach that.
    I think that is good, but I think what everybody is saying 
is that if it just becomes filling out the form and moving on, 
then we really have not accomplished what we need to 
accomplish. What we need to do is use that form as a guide, if 
you will, or a screen to say that we may have some problems, 
but we need to give the individual, whether it is the nurse or 
the other individuals in the facility, the education and the 
means to then go to the next step--because normally, as you are 
pointing out--and I have been pretty fortunate in most of my 
facilities to have dentists and dentistry available--but if 
there is a problem, I usually get the call. You are absolutely 
right--sometimes it is very frustrating to sit there and say 
well, I think there may be an abscess or a problem, I know the 
best treatment for an abscess is to take care of it, not just 
to treat with antibiotics--how do we then get to the next step?
    Dr. Folse. I actually as the dental director in my 
facilities do the MDS for them, and that is one reason why I 
really like the dental director model, because I am part of 
that process, I am part of the team.
    Senator Breaux. Yes, Daniel?
    Mr. Perry. Thank you, Senator.
    On one level, obviously, what we are talking about is the 
deplorable state of oral health in America, especially for our 
seniors. But just beneath the surface are two threads that are 
coming together. One is the thread of ageism which is endemic 
throughout the American health care system at all levels, where 
older patients tend to get fewer preventive treatments, less 
screening, fewer interventions than younger people would; and 
on the other end--and this, too, is part of ageism in our 
health care--is the failure of our professional health 
education schools to be able to provide some access to 
geriatric content for everyone who passes through them.
    For those on the committee who may not know it, Senator 
Breaux has taken the leadership on both of these, and you and 
your staff are to be commended for full-scale hearings within 
the last 18 months, both on the shortage of academic training 
in geriatrics and on ageism.
    I cannot offer today a simple solution to ageism, because 
it is part of our society; it is part of the fabric of who we 
are, and it has terrible effects on older people in health 
care. We ought to bring attention to it as you have been doing, 
Senator.
    On the issue of greater envelopment of health professionals 
in their training in geriatrics, we can do something about 
that, and I am urging you and your staff to look at what we 
might do through HRSA to improve professional health education 
with geriatric content and most promising to create some 
department-level centers in our academic health centers where 
not only physicians and nurses and pharmacists, but dentists 
and all allied health professions, have to rotate and receive 
some of the basics in good geriatric care before they are out 
treating a patient population that increasingly is 50 percent 
age 60 and older in this country.
    Senator Breaux. I think that is a helpful suggestion, and I 
think we have heard a number of them. I am trying to figure 
out, if you had the ability to write a recommendation to the 
Congress and to the U.S. Senate as to how we can improve the 
quality of dental care for our Nation's elderly. I have heard 
the suggestion of the greater use of dental hygienists because 
of the shortage of dentists in many areas. I have heard the 
suggestion of trying to increase Medicaid coverage for the 
aged, blind, and disabled, at least move in that area with a 
limited amount of money.
    Are there other suggestions that may be appropriate that we 
have not put down?
    Paula.
    Dr. Friedman. Thank you, Senator.
    I have four recommendations that, with your permission, I 
would like to read into the record.
    ``One, broaden grantee eligibility for geriatric training 
programs. Dental education institutions currently may only 
compete for geriatric education center grants. ADEA recommends 
that grantee criteria be revised to include dental education 
institutions as the responsible applicant for the geriatric 
training for physicians, dentists, and behavioral/mental health 
professionals program. We further recommend that the criteria 
be broadened so that faculty members employed by U.S. dental 
schools are eligible to compete for geriatric academic career 
awards, which are currently limited only to physicians.'' While 
I certainly agree that we do not need to train a huge cohort of 
specialists, as you indicated earlier, we need to train enough 
to, as we call it, train the trainers, so that they can train 
general dentists and dental students.
    ``No. 2, authorize a new geriatric dentistry residency 
training program. ADEA recommends that a new Federal grant 
program modeled on the general and pediatric dentistry 
residency programs be authorized by Congress to prepare the 
dental workforce to meet the growing needs of an aging 
population.'' This might be a component of an existing general 
dentistry training program or indeed a second year added onto a 
1-year training program in general dentistry with emphasis on 
geriatrics.
    ``No. 3, authorize a new NIH loan repayment program for 
research on the elderly and other special needs populations.'' 
I think that is self-explanatory.
    ``No. 4 and finally''--I believe this fourth one 
encompasses both an access issue and the fiscal piece that we 
all agree is an important component of geriatric oral health 
care, and that is ``authorize a new reimbursement program for 
elderly dental care at academic dental institutions. Dental 
schools and their satellite clinics provide a significant 
amount of oral health care to the elderly. We are considered 
the safety net for people with limited fiscal resources. We 
cannot expand services beyond what is being done if Federal 
assistance is not made available to assist in paying for 
unreimbursed care.''
    Dr. Folse talked about the large degree that all dental 
schools certainly are providing in terms of unreimbursed care.
    ``ADEA urges Congress to authorize a dental reimbursement 
program for poor elderly obtaining treatment at the Nation's 
dental education institutions.''
    That certainly could include dental hygiene institutions. 
For your information, Senator--I imagine you know this, but 
just for the record--the fees at dental schools are generally a 
fraction of fees in private offices, so that a relationship 
with a dental education institution would be by extension a 
fraction of the cost of a private practice program.
    Senator Breaux. Those are good suggestions, and we would 
like to make sure we get a copy of that and the whole 
presentation.
    Paul.
    Dr. Glassman. I think that in addition to funding and 
training systems, there needs to be a support system, and let 
me tell you what I mean by that.
    We are just finishing up now a grant program that we have 
had in California. We have been working in eight communities 
around the State where we have had what we call a community-
based system that is involved using people that we call dental 
coordinators. They are mostly dental hygienists, actually, who 
have played this role. Their role is to actually act as a 
liaison between the social support agencies that exist in every 
community that deal with the special populations we are 
interested in and the dental professionals.
    They do screening and triage; they get people into dental 
offices; they entice dentists to be willing to say ``Yes'' when 
they get a referral. They do preventive education.
    I will give you an example of how it might work. Let us say 
you are a dentist, and you have a busy practice, and your 
practice is pretty full with people who can come in and pay 
full fare and sit in your chair and do not have a lot of 
complicated medical problems. So someone calls and says, ``My 
mother has dementia. Can I bring her in to see you?''
    You think, well, things are kind of busy, but sure, I want 
to do my part. So the person shows up, and you find that the 
daughter who brings the person in does not really know about 
their medical history or the medications they are taking, and 
their behavior is such that there is just no way you are going 
to treat them, and you spend a frustrating half an hour or 45 
minutes trying.
    The next time you get a call like that, what do you think 
you are going to say? You are going to say, ``No, I really 
cannot do that.''
    Now picture situation No. 2. You have a dental coordinator 
in the community who calls up and says, ``I have just done a 
screening on this individual. I was out to see them. I know 
your office because I have talked with you before, and I know 
the kinds of things that you are able to do in your office, and 
I think this person would work pretty well in your office. When 
they get there, I am going to make sure that you have all the 
medical history information you need, and we are going to take 
care of the consent issues, because I am going to work with the 
social service agency who knows how to get consent.''
    When the person gets there, they are going to have the 
medical history, the consent is going to be taken care of, they 
are going to be matched to the dental office. Now, the chances 
of that referral being successful are infinitely better than 
the first one.
    So in that kind of program, our 3-year results are now 
showing that people have significantly less dental disease. 
There are numbers of dentists in these communities who are now 
willing to say yes under the circumstances I just described who 
were not willing to say yes before. In fact, the amount of 
dental disease in the population we are talking about, the 
burden of dental disease, the cost of providing treatment for 
that dental disease has gone down to a degree that it is more 
than the salaries that we are paying to these dental hygienists 
who are providing these services.
    So I think there needs to be a support system that goes 
along with funding and training.
    Senator Breaux. So your suggestion is--are you trying to do 
this in California, or----
    Dr. Glassman. We are just finishing up a 3-year 
demonstration and demonstrating the effects of this, and we are 
showing great results.
    Senator Breaux. So is there a dental coordinator for 
seniors?
    Dr. Glassman. We picked eight communities throughout the 
State. We have a dental coordinator who works with social 
service agencies in those communities and plays this role of 
acting as a liaison between these agencies and the dental 
community, helps to bridge the gap, helps to make the kinds of 
referrals that we talked about, does preventive education and 
preventive programs, does screenings and gets people into care.
    Senator Breaux. A good idea.
    Jim.
    Dr. Harrell. The only thing that would worry me is that in 
North Carolina, we have a shortage of dental hygienists, so I 
cannot tell you where you are going to get them--do not take 
them from my office.
    Also on the manpower issue, as I said, we have studied 
that, and the term ``shortage'' has been used a couple of 
times. I do not know--and there again, the data is kind of 
squirrely--but I do not know that we have a shortage, but we 
definitely have a maldistribution.
    I think the Surgeon General mentioned diversity of the 
dental work force. The University of North Carolina is starting 
to give preference to students from rural areas, hoping that 
they will return to rural areas when they graduate, because 
they tend to go to the metropolitan areas. So it is hard to 
know, but I do not know that we definitely have a shortage.
    Senator Breaux. We have had some good suggestions, and this 
is the first thing that we have ever focused on a particular 
problem area of seniors in terms of a disease. We have held 
hearing on senior problems with people who were scamming them 
from an insurance standpoint, people who discriminate against 
them in the job market, actual care and treatment that they get 
in nursing homes, and have looked at alternative means of 
caring for seniors. But I think this is really the first time 
we have actually had a discussion on a particular ailment of 
seniors that has not been noticed as much as it should or 
treated as adequately as it could be. I think it has been very 
helpful to do this, because this really is sort of a silent 
illness out there that people are ignoring, and it leads to 
much more serious problems, much more expensive problems, and a 
lot of suffering that in many cases is unnecessary in today's 
society.
    The question is how do we go about trying to fix it and how 
do we go about trying to solve it. We have gotten some good 
suggestions on the table, and I would like to see if anybody 
has any closing comments, perhaps, to help us summarize.
    I want to try to bring the information we get from here to 
maybe do some statements on the floor of the Senate to try to 
get some other Members interested in this, because when you 
find out that most States are not doing a very good job of 
paying attention to the oral health of our Nation's seniors 
within their States, it is a serious problem, and it should not 
go neglected as we have neglected it in the past.
    Does anybody have any final suggestions that may be 
helpful?
    Robert.
    Dr. Collins. Thanks, Senator.
    This has been a wonderful hearing. There is an awful lot of 
information that is out there, and many people around this 
table and others have had an opportunity to contribute to that. 
I think this is one more step in the Surgeon General's Call to 
Action booklet which he kind of modestly talked about today, 
but I think is increasing the involvement of a larger community 
of people.
    I had a mentor as I came along in public health who used to 
talk about ERAs of expectation in regard to oral health. The 
first one, which I guess covers a large portion of history, was 
resignation. You had pain, and you just found out a way to deal 
with it, and maybe you had somebody who could relieve it by 
knocking your tooth out.
    We went into a second period of rehabilitation where you 
had dentures available, crude in the beginning, more 
sophisticated as time went on, where people could still expect 
to lose all their teeth, but now they had some sort of 
replacement.
    The third era, which we are really still in and coming out 
of as a whole is the restorative area. These are the 77 million 
that you are talking about in your question, people who have a 
lot of complex dentistry who are moving into older age.
    The final era is one of prevention.
    So, we have some conflicts here with people who are in an 
era where they are beginning to expect that a lot of these 
problems that Dr. Folse so nicely illustrated today should not 
be there--they should be prevented. We have research that can 
go a long way toward pointing the way to do that, yet we have a 
system that I would say in many cases is not even in 
rehabilitation in terms of responding; it is back in 
resignation.
    So there are lots of ways that we can point forward to the 
future, and I just wanted to underscore my appreciation and 
support not only for what the Surgeon General is doing, because 
I think that is a terrific, terrific booklet, that little green 
booklet, but also for all the Federal agencies, in particular 
the National Institute of Dental and Cranio-Facial Research--
yes, it does support a lot of research in universities and 
across the country and funds most of the dental research and is 
therefore very important, but it also serves as probably the 
principal coordinating center in the Federal infrastructure for 
oral health and makes it possible, I would say, probably if you 
go back to the beginning, possible for all of us to be here 
today.
    Thank you.
    Senator Breaux. Thank you.
    Ms. Heinrich, do you have anything from General Accounting?
    Ms. Heinrich. I really do appreciate the opportunity to 
hear all of these ideas. It really is very thought-provoking.
    I appreciate your point that there are several ways of 
focusing on this problem, and one question I had was with the 
focus that we have put on prevention with children--
fluoridation, for example--do we anticipate that this problem 
is going to wane in the future?
    A second question--Paul, you have talked about some best 
practices in California; there might be some in New York also, 
since they got a C-plus--but has there been any effort to 
identify strategies that really do work in trying to bring 
better dental care to older populations?
    Senator Breaux. Let me interrupt. I am going to have to 
take off. But Janet, why don't you all finish up on this 
question, and let me just conclude for my part and thank each 
and every one of you. I think it has been very important, and 
we have gotten some good ideas.
    To those who have travelled, thank you, Greg and others who 
have come from other places, for being with us. It was well 
worth your effort as far as I am concerned. I am very 
appreciative of the information that we have been able to learn 
and the suggestions that we have received.
    So I thank you all, and please continue.
    Dr. Folse. Before you leave, we thank you very much. 
[Applause.]
    Dr. Glassman. Just to respond to the question about best 
practices, yes, I think there are a number of publications and 
articles and lots of information about best practices. The 
problem is that the best practices, the theoretical ones, the 
ones that have been used in demonstration projects, are not 
widely available and not widely used because of the issues we 
have already identified here--awareness and funding and 
training.
    So the best practices do exist. The American Association of 
Geriatric Dentists has a number of publications about 
guidelines for nursing home dental practice. There are 
guidelines in other areas. The next issue of the Journal of 
Special Care Dentistry is going to have the results of an 
expert panel that we brought together to look at prevention in 
disabled and elderly populations.
    So I think the information is there. The problem is taking 
that information and translating it and getting it into 
practice is where there is a gigantic chasm.
    Ms. Heinrich. In terms of Senator Breaux' interest in 
having material that people could speak to, are there some of 
those that would have information about dollar savings or costs 
that could be provided to Members of Congress?
    Dr. Glassman. I am not aware of that. I do not know if 
others are.
    Dr. Collins. I pointed out earlier that one of the things 
in the Surgeon General's report on Oral Health in America is 
that it states in that report the lack of data about both the 
oral health burden and strategies and all those things, and we 
all wish we had numbers about those kinds of things. The 
numbers are generally not available, unfortunately.
    Dr. Folse. Dr. Barsley actually did a study in Louisiana 
for Medicaid children where they used some interventions, and 
there were significant savings with just water fluoridation for 
that population.
    Dr. Barsley.
    Dr. Barsley. For children with fluoridation, we showed the 
parishes or counties that were fluoridated had significant 
savings over the counties that were not. Does that translate to 
the adult population? I am not sure.
    I would break in and answer one question--I do not see this 
problem waning at all. As people have better teeth and better 
lives, we are going to have a bigger problem. So I do not see 
any waning of the problem in any way at all; it will just 
continue to grow.
    Ms. Heinrich. Paul, and then James.
    Dr. Glassman. I just want to emphasize that point, that the 
problem is not going away. We have gone from in our country 20 
years ago, I think it was something like 56 percent of people 
over 65 being in dentures; now it is down to about 26 and 
dropping. So we are having more and more seniors who are 
becoming seniors with teeth that did not used to have that, and 
the fact that disease for certain groups of children is going 
away does not really have much impact on what happens when 
people get to be 65 and can no longer care for themselves the 
way they used to and begin to take medications and have dry 
mouth. So I think this is going to be a blossoming problem.
    Ms. Heinrich. Teresa.
    Dr. Dolan. I would just add that I certainly agree that 
this problem will not go away. It is a good news/bad news 
story, because as the younger cohorts of adults age, and we 
have retained their natural teeth--maybe we have had some 
dental fillings--but we also have higher expectations, and we 
are more vocal about our expectations, I think as those folks 
become chronically ill and perhaps end up in long-term care 
facilities, the demand for a more appropriate level of oral 
health services will grow, and if anything, the cost associated 
with that will increase. I think that what is currently a 
silent epidemic will become more prominent.
    Ms. Heinrich. Go ahead, James.
    Dr. Harrell. As we have a unique program in North Carolina, 
I will try to get any data on cost-sharing that the ADA has for 
you. I am not sure what we have.
    We do have an interesting program in North Carolina where 
we have physicians apply fluoride varnishes. We are doing 
studies on that, and I do not know the results at this point or 
whether that will be a cost saving or not; we suspect that it 
will. The problem was that by the time these children were 
seeing a dentist at 2 or 3 years of age, they already had 
decay.
    The American Dental Association has been sort of reeling 
with the punches and doing what we can to boost the Medicaid 
reimbursements or whatever. We are having a Medicaid symposium 
in December, which will hopefully be a small group similar to 
this one, to actually look at the whole system and maybe come 
up with some innovations for that system.
    Also, thinking about Paul's remarks, we have a van program 
which is mostly a nonprofit organization in North Carolina, but 
I do not want us to overlook the fact that there are multi-
millionaires in nursing homes who cannot get care because they 
have special needs, and they require treatment that they do not 
have the facilities to do--even if they can bring them to my 
office, I cannot do it. So I do not want us to overlook that 
segment of the population either.
    Ms. Heinrich. Senator Breaux was beginning to ask all of 
you for recommendations on solutions to this problem, and not 
all of you had a chance to speak, so I would ask if there are 
other ideas.
    Mr. Musher. Just a couple of points--I guess some things 
that we could do now, not to lighten the big, 10,000-foot 
view--but there are certain initiatives going on now. For 
example, there is a pain initiative. There is a collaborative 
initiative that CMS is part of concerning pain and trying to 
develop best practices. Certainly oral pain problems and 
syndromes could be better focused on through that.
    So I think there are certain programs that are going on. 
The American Medical Directors' Association has created many 
guidelines. That could certainly be something that would lend 
itself toward a guideline on how do you approach oral care in 
the nursing home.
    Again, not lightening the access to care, which is what I 
hear is a huge issue, and my frustration, as I mentioned 
earlier, is trying to get a dentist or a dental surgeon or 
extractions or certain things that I may need at some points in 
time, but I think there are areas where we could use some of 
the systems or some of the approaches that are now available to 
just better point out the need for oral care.
    I know that like no other industry--in the nursing home, if 
you focus on something, there is a very good likelihood of it 
happening, especially when you connect it with MDS and other 
survey issues. But I think that a lot of what I am seeing is if 
we could just get the word out that oral care is something that 
is urgent and important, just like we did several years ago 
with restraint reduction--there was a huge decrease in 
restraints once we put it back on the providers of services to 
say this is a huge problem, we need to work together to solve 
that problem--and we did, and I do not think there was a huge 
cost to that.
    So although there are a lot of costs and issues that we 
have talked about that I don't think lend themselves to that, I 
do think at least some focus on how we would approach oral care 
in nursing homes is important.
    The other point I would like to make--and it is no 
different from what we struggle with in other parts of medicine 
with our population, and I will use high cholesterol as an 
example. We do not treat everybody who has high cholesterol in 
the nursing home population because it is risk-benefit and it 
is quality of life issues. So at some points, I think we also 
have to look at what should we be treating and what do we not 
necessarily have to treat. The Senator mentioned earlier about 
whitening teeth. I am not really worried about cosmetic issues 
in a lot of my patients. I am not sure--and I would defer to my 
dental colleagues--whether I have to worry so much about 
dentures, because I was taught that a lot of my patients could 
actually gum their food. So I am not sure that dentures are as 
important as pain, abscess, xerostomia, which I have seen huge 
problems with. So how do we focus--the pain, the abscess, those 
kinds of things in my severely demented patients are a quality 
of life issue, so I would want to focus on the quality of life 
issue, but I think we have to break down the population, 
because the nursing home has dementia and end-stage and almost 
palliative types of care, but there are all other subsets of 
elderly in our population.
    Ms. Heinrich. Yes?
    Dr. Barsley. If I could add one thing that I do not think 
has been addressed, or only on the margins, it would be to 
increase interaction and educational interplay between 
physicians and dentists.
    I used to teach at the medical school and give lectures on 
dental health to medical students. They were amazed at what we 
brought them. Then we would bring them out to our clinic and 
have them actually look into each other's mouths, and they were 
further amazed by what was in the mouth besides the teeth.
    So I think if we start at an early time and broaden that, 
we would be benefited.
    Ms. Heinrich. Karen.
    Ms. Sealander. I think that the mere holding of this forum 
is an important signal that this committee, and hopefully the 
whole Senate, thinks that oral health is important. Hopefully 
in the future, whenever Senators think of seniors' general 
health, they will think of oral health as well.
    We know how to prevent the principal oral maladies, and 
despite this proven prevention capacity, we still have this 
silent epidemic of oral disease which disproportionately 
affects our vulnerable citizens, particularly the elderly. ADH 
wants to be part of a collaborative solution to the problem of 
oral health disparities and inadequate access to care. ADHA 
believes that with the increasing number of hygienists, the 
occupational growth, and with our focus on prevention that 
dental hygienists are well-situated to play an important role.
    One specific suggestion that ADHA offers is to ask the 
committee to direct CMS to write to State dental directors, 
asking them to facilitate the provision of Medicaid oral health 
services by hygienists, specifically to recognize hygienists as 
Medicaid providers of oral health services. Ten States already 
do recognize hygienists as Medical providers and ADHA would 
like to see the other 40 States follow suit.
    Ms. Heinrich. Anyone else?
    Dr. Folse. A couple of comments in closing for me. In 
nursing facilities, I think there is an obvious partner there. 
Some of the efforts that we have made have been along survey 
issues, and I just want to assure you that that is not my focus 
in my advocacy efforts and the work that I do with ADA and 
special care dentistry. It is not about coming in with the 
hammer; it is about we had that opportunity, so you go there. 
But at the same time, we are doing all kinds of things to help 
bring that industry up with oral health, working with the 
American Medical Director Association. I and special care 
dentistry for sure are seriously committed to working with your 
industry trying to help in any way that we can. We have 
education programs all day long that we can help you with.
    Your point about not treating everyone is really well-
taken. I have patients with really bad oral conditions who, 
because of the risk-benefit issues, I say we are not going to 
be able to take care of these patients. So I am with you 
there--education--we can all come to consensus with that.
    Again going back to a foundation medically is the medical 
necessity of oral services. I still think it is a medical 
necessity.
    Does anyone have disagreement with that? [No response.]
    So one of the things that we could say from this forum--or 
can we--is that we were all in agreement that oral health 
services for vulnerable adults was medically necessary.
    Are there any nays? I do not see any. OK. My dad was an 
auctioneer.
    Dr. Harrell. Actually, I would modify that and leave out 
the ``vulnerable adults.'' Oral health care is essentially the 
general health for anybody.
    Dr. Folse. Thank you. I limit myself unnecessarily 
sometimes.
    I think in these State budgetary woes that everybody has, 
if they would find their State problem and find some things 
that they did not want to pay for, all they have to do is put a 
set of lips on it. Once you get behind some lips, it does not 
get any money, so it seems like it would help somewhere along 
the way.
    Personally, I have been involved with this forum, and we 
have to thank Lauren Fuller who behind the scenes has done an 
awful lot of work for the last 3 or 4 months, has taken endless 
calls from Dr. Greg Folse--she probably does not want to hear 
from me for 6 months, and even then, I am not sure--but we 
really thank you for your work and your dedication to oral 
health for elders across the country. You have started 
something here, and it is going to be a fun ball to watch.
    Before I let you close this, I want to thank each and every 
one of you again for being here and participating, and those of 
you in the audience who really care about oral health services 
for our elderly, I thank you for being here also.
    Ms. Heinrich. Well, I think you did a very nice job of 
closing. I think it is easy to say that you have put 
information together in one place, and yes, it is going to be 
interesting to see how this moves forward.
    Thank you all.
    [Whereupon, at 4:05 p.m., the forum was concluded.]


                            A P P E N D I X

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