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SCOPE OF DENTAL RESEARCH

Dental research addresses all the diseases and disorders that affect the dental, oral, and facial structures. Dental caries and periodontal disease have come under increasing control as a result of dental research. Some of the lesser known areas of research include birth defects such as cleft lip and palate, oral cancer, viral conditions of soft tissues, AIDS, chronic pain, disorders of jaw movement, swallowing, taste, and smell.

Many Americans have oral complications from underlying medical or handicapping conditions that further diminishes the quality of life. These people require special help.

COST OF THE PROBLEM

The monetary cost to society of oral disease is high. Americans spent approximately $36 billion on dental care in 1989 and this cost is rising every year. However, the research effort conducted in this country has allowed the introduction of preventive measures which resulted in $5 billion worth of savings in the nation's dental health costs in 1989 alone.

THE FUTURE OF DENTAL SCIENCE

Mr. Chairman, the 1990's mark a turning point in the history of dental science. The opportunities for continued progress in improving the oral health of our people is outlined in the long-range plan developed jointly by the National Institute of Dental Research and the research community. This plan has now been published and is titled "Broadening the Scope". With your permission, Mr. Chairman, I would like to leave a copy with the Committee.

Over the last four decades, with the support of this subcommittee, our research efforts have changed the picture of dental disease, and brought the two major conditions affecting teeth, dental caries and periodontal disease, to more manageable levels. As we move into the nineties, dental researchers will use modern techniques and approaches to develop sensitive and specific diagnostic tools. New information in cell biology will make it possible not only to control disease but to reverse pathol°Y would like to briefly review a few of the exciting areas covered in the long range and regenerate lost tissues.

plan for improving the oral health of our society.

DENTAL CARIES

A remarkable decline in tooth decay has occurred over recent decades and currently 50 percent of children have no cavities in their teeth. Despite this progress, dental caries remains the principal cause of tooth loss. Special efforts are now made to identify and reduce dental caries in high risk groups. A program to assist older Americans to retain their teeth has been put in place as this group continues to be affected by dental caries.

PERIODONTAL DISEASE

Diseases of the periodontal tissues the gums and underlying jawbone had affected the majority of Americans. It is still a prime public health problem. However, improved diagnostic techniques, preventive methods and earlier treatment have reduced the number of affected people and the severity of their disease. Continued research into the cause of periodontal disease, the mechanisms of tissue destruction and regeneration are providing leads to new and more effective treatments.

ORAL SOFT TISSUES

Each year 30,000 Americans are diagnosed with oral cancer and almost 10,000 die from it. In fact, there are more new cases of oral cancer than leukemia. Dental researchers are heavily involved in studies of various factors, such as viruses, tobacco and alcohol that contribute to the cause of this condition. Advances have been made in the treatment of herpes virus, fungal diseases and salivary dysfunctions. Dental researchers are also participating in AIDS research since the mouth is one of the first affected sites.

CRANIOFACIAL BIRTH DEFECTS

Seven percent of the babies born each year in the U.S. have some defect evident at birth. Prominent among these are structural, functional, and developmental ab

normalities involving the head or face. The most common of these malformations are cleft lip and palate.

The nineties has brought a new era in biomedical research. For the first time there is the real possibility of understanding the human genetic makeup, of tracking what each gene does, and what can go wrong when there is an error in the genetic code-and then correcting it. These questions concern leading oral health scientists investigating the development of the craniofacial complex-the head, face and mouth. These studies should yield better treatments for those already affected and eventually, provide the means of preventing or reversing these conditions.

DENTAL MATERIALS

There has been a revolution in dental materials that shows no sign of stopping. New alloys for fillings have been developed that are as durable as the silver and gold material they will be replacing, and much less costly.

Not only have new materials been added to restorative dentistry, but new and exciting materials are being used in preventive dentistry as well. For example, certain dental materials can be designed to act as reservoirs that permit the slow release of fluoride, antibacterials, saliva-stimulating agents, and other trierapeutic agents in the mouth. These applications will be especially important for individuals at high risk for dental disease, including older Americans.

DENTAL IMPLANTS

Dental implants have become one of the most exciting and rapidly growing areas of dental research and treatment. New biological and technological advances in implants are benefiting more Americans. In the future it is expected that implants will largely replace dentures and reduce the need for bridges to replace single missing teeth. To take full advantage of these new forms of therapy, research is needed to improve the surgical placement and long term maintenance of implants.

These are but a few of the exciting challenges facing dental scientists in the nineties. Many others are described in the NIDR long-range plan.

BUDGETARY NEEDS

We are fully aware of the difficult budgetary pressures facing the Congress, however, we believe that adequate funding of the Nation's biomedical research enterprise will pay dividends to the citizens of this country-through reduced mortality, improved quality of life, and improved productivity through a reduction in days lost from work due to illness. We urge the Committee to consider providing $247 million for the National Institute of Dental Research in 1992. This funding level reflects a balanced research program in dental and oral science by supporting regular research grants, research centers, training, and intramural research.

We wish to note that the American Association for Dental Research supports the work of the ad hoc group for medical research funding and their funding recommendation of $9.7 billion for all components of NIH in fiscal year 1992.

Mr. Chairman, there are two additional items I wish to comment on-the budgets for the Biomedical Research Support Grants (BRSG) and the Agency for Health Care Policy and Research.

The President's budget proposes to eliminate funding for the BRSG program. This program is designed to meet emerging opportunities in research, to pursue new ideas, and to develop young scientific talent. In the dental research field these funds have played a particularly important role in launching young and unproven investigators. Without these funds many young investigators would not have advanced in their chosen field of research. We urge the Committee to provide $96 million for this program.

With regard to the budget for the Agency for Health Policy and Research—we support the level provided by the President. This agency has the important task of researching the most efficient and effective way to organize and finance our health care system.

This concludes my testimony. I will be happy to answer any questions. Again, thank you for this opportunity to testify.

STATEMENT OF DR. RAYMOND FONSECA, DEAN, SCHOOL OF DENTAL MEDICINE, UNIVERSITY OF PENNSYLVANIA, ON BEHALF OF AMERICAN ASSOCIATION OF DENTAL SCHOOLS

Senator HARKIN. I have at least one question for you. Let me go to Dr. Raymond Fonseca, Dean of the School of Dental Medicine, University of Pennsylvania.

Dr. FONSECA. Thank you, Mr. Chairman. I am here testifying on behalf of the American Association of Dental Schools. Our top priorities in fiscal year 1992 are increased funding for the AIDS dental reimbursement program and enhanced support of the general dentistry program. We appreciate the fiscal year 1991 funding made available by Congress to offset some of the costs incurred by dental schools in providing oral health services to AIDS patients. Many of the first physical manifestations of AIDS infection are found in the mouth. Severe pain in the oral cavity is frequently the symptom that leads HIV-positive patients to seek care. Therefore, a dentist is often the first diagnostician to see the AIDS patient. This month's Journal of the American Dental Association, for example, reports a woman with no history of IV drug use who became infected with HIV through heterosexual transmission. The diagnosis of AIDS was made when a specific cancer was found on the roof of her mouth. The recent study showed that younger dentists were more willing to treat AIDS patients than older dentists, as were those who spent more time in hospitals compared to those who did not. These findings illustrate the importance of education. and improving access to care and changing attitudes.

The AIDS Dental Reimbursement Program is supported by the National Organizations Responding to AIDS which notes the dif ficulty of persons with HIV obtaining access to dental care and how this program will help assure that the patients will receive necessary treatment.

We urge an appropriation of $7 million in fiscal year 1992 for this much-needed program.

Second, the general dentistry residencies provide training in the skills needed to provide comprehensive care to a wide variety of patients, including the elderly and the medically compromised. Dentists who complete this advanced training rely less on specialists, which is especially important for indigent urban and underserved rural populations. Demand continues to outpay supply for this training. Today, one of three applicants is still unable to find a general dentistry residency position.

We urge the subcommittee to appropriate $8 million for general dentistry in fiscal year 1992 to support expansion of these primary care residencies.

As with Dr. Listgarten, we are especially concerned about the Biomedical Research Support Grant Program which provides flexible funds for pilot and student research projects and interim funding for researchers who are between grants. AADS urges an appropriation of $96 million for the BRSG Program in 1992.

AADS is very concerned that the Health Education Assistance Loan Program remain a viable loan of the last resort for dental students. With HEAL loans, many students would be forced to discontinue their dental education. AADS urges the subcommittee to

lift the credit ceiling for the remainder of this fiscal year as well as for the fiscal year 1992.

PREPARED STATEMENT

We thank the subcommittee for the opportunity to testify on fiscal year 1992 appropriations and for the substantial efforts members have undertaken to benefit the health of the American people.

Thank you.

Senator HARKIN. Thank you very much, Doctor.

[The statement follows:]

STATEMENT OF DR. RAYMOND FONSECA

I am Dr. Raymond Fonseca, Dean of the School of Dental Medicine at the University of Pennsylvania. I am here to testify on behalf of the American Association of Dental Schools (AADS), which represents all of the nation's dental schools as well as advanced education, hospital and allied dental education programs. As such, we are the one national organization that speaks exclusively for dental education.

Of the several issues discussed in this testimony, our top priorities are for increased funding for the AIDS Dental Reimbursement program and for continued and enhanced support of General Dentistry primary care training. We join other health professions groups in urging restoration of the Biomedical Research Support Grant program and lifting restrictions on access to the Health Education Assistance Loan program.

We

Acquired Immune Deficiency Syndrome (AIDS) Dental Reimbursement Program: appreciate the FY 1991 funding made available by Congress to offset some of the costs incurred by dental schools as we provide oral health services to AIDS patients. These funds will repay some of the losses we have had to absorb as We teach dental students and residents to care for HIV patients. Our school will apply for a share of the $2.9 million made available under the Secretary's discretionary fund of the Ryan White Act. We understand that the funds we receive will be proportionate to our share of the burden of unreimbursed costs, as compared with all dental education institutions.

Many of the first physical manifestations of HIV infection are found in the oral cavity. As a result of the immune system breakdown that occurs. AIDS patients are more susceptible to very severe oral herpes, rampant fungal diseases, hairy leukoplakia, as well as oral diseases found only in patients who suffer from AIDS, including an extremely painful form of gum disease that frequently involves complete oral tissue breakdown with exposure of the bone. Severe pain in the oral cavity is frequently the symptom that leads these patients to seek care; therefore, a dentist is often the first diagnostician to see the AIDS patient.

The ability to treat AIDS patients is critically linked to providing proper education and training activities. A recent study showed that 60 percent of general dentists practicing in the U.S. are willing to treat AIDS patients. This survey also showed that younger dentists were more willing to treat AIDS patients than older dentists, as were those who spent more time in hospitals compared to those who did not. This illustrates an important linkage between education and practice and highlights the importance of education in improving access to care and changing attitudes.

Partial reimbursement is critical to alleviate some of the financial burden faced by dental education treatment centers. Those schools and hospital programs that become known as referral centers for AIDS patients risk senous fiscal problems because the patients they serve have complicated treatment needs, requiring more resources than the "average" dental patient. Moreover, unlike medical services, oral health care is not covered under many private insurance programs and is seldom covered for adults under Medicare or Medicaid.

This AIDS Dental Reimbursement program is supported by the National Organizations Responding to AIDS (NORA); they note the difficulty of persons with HIV obtaining access to dental care, and how this program will help assure that the patients will receive necessary treatment. AADS urges an appropriation of $7 million in FY 1992 to allow the expansion of this much-needed program.

General Dentistry Residencies: General Dentistry programs provide dental graduates with the skills and clinical experience necessary to provide comprehensive care to a wide variety of patients requiring specialized or complex care, including the elderly and the medically compromised. Dentists who have had the benefit of this advanced residency training are better prepared to provide comprehensive dental services, and rely less on specialists. This is especially important for indigent urban and underserved rural populations.

The General Dentistry program remained at level funding of $3.8 million in FY 1991. While this allowed 4 new grants to be made to previously approved but unfunded projects, this funding level remains inadequate to meet the need for General Dentistry residencies. Demand continues to out pace supply for this primary care training. One year ago, AADS estimated one out of four dental students seeking this training were turned away today, one of three applicants is unable to find a general dentistry residency slot.

Without Federal support, it would be extremely difficult to create new programs because of the lead time needed for these programs to become self sufficient and because of the high cost of dental equipment and instrumentation. To cover expansion of current programs, as well as start-up funds for new programs, we urge the Subcommittee to appropriate $8 million for General Dentistry in FY 1992.

Research: AADS endorses the testimony of the American Association for Dental Research regarding priorities and funding of $247.5 million for the National Institute of Dental Research in FY 1992. We also request an appropriation of $150 million for the Agency for Health Care

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