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AIDS is one of the more dramatic examples of a systemic disease that compromises oral health. The first signs of infection with the human Immunodeficiency virus often appear in the mouth as candidiasis, Kaposi's sarcoma, or other soft tissue lesions. These early clinical observations have spurred NIDR AIDS research that is contributing to the basic understanding of the virus and immune responses, the development of non-invasive methods of

diagnosis, treatments for AIDS-related oral lesions, and epidemiological

studies of the natural history of oral signs and symptoms. Currently, intensive efforts are under way to identify a factor in saliva that inhibits the AIDS virus from infecting cells. Such a factor would explain why it is very difficult to recover HIV from saliva samples and why the virus is not transmitted by casual contact with infected patients. Salivary spread of HIV might occur in situations of prolonged sexual contact, however, as in deep mouth kissing, and for that reason avoidance of such behavior is warranted.

Many other diseases and disease treatments directly or indirectly affect oral health-common diseases such as diabetes and arthritis; less common diseases such as the condition of dry mouth and dry eyes known as Sjögren's syndrome, the excruciatingly painful neuralgias associated with tic douloureux and shingles, and the unpleasant, dysfunctional problems caused by disorders of taste, smell, and swallowing. NIDR expansion in these areas has occurred naturally as our investigators have employed the new biology techniques to discover the cell or molecular events underlying the symptoms and use these findings to develop new treatments.

Our past surveys indicate that mature adults and older Americans are the age groups at highest risk for oral health problems --with over 40 percent of those over 65 missing all their teeth. We are addressing the needs of these older-age groups in an initiative we have previously described to the Committee: the NIDR Research and Action Program for Improving the Oral Health of Older Americans and Other Adults at High Risk. In a move to facilitate oral health research at the Federal level, the Assistant Secretary for Health last year established an Oral Health Coordinating Committee composed of dental representatives from all the Public Health Service agencies. The committee's first order of business was to endorse the Research and Action Program and define objectives and implementation plans for each agency. Also in 1990, a

private foundation began plans for a national oral health initiative. A

steering committee has been formed whose members include former Surgeon

General C. Everett Koop, former Assistant Secretary for Health Julius

Richmond, a representative from the American Association for Retired Persons,

and leaders from the dental profession and private Industry. The steering

committee will guide development of a national consortium to conduct oral

health promotion activities for a wide range of groups, including the elderly.

Our concern for individuals at high risk extends beyond the medically

compromised and elderly to include those of limited education or access to

care:

a group which will number many members of minority populations. To

address issues of minority health and assistance, we have developed a three

part program to enhance minority research, research training, and staff

recruitment,

With regard to research, NIDR is planning epidemiological

studies of the oral health of various subgroups of black, native American,

Hispanic and Asian-American populations to establish baseline data and assess

risk factors.

In this endeavor we have contracted with a minority firm to

develop a plan for the study of black Americans,

Research will also increase

on disorders found to be more prevalent in minorities, such as diabetes, oral

STANFORD LIBRARIES

cancer, facial clefts, and a rare but particularly severe fora of periodontal

disease prevalent in young black males.

In the second part of the program we are increasing activities to

encourage minority members to pursue careers in research through such

mechanisms as minority supplements to existing research grants and special

research training initiatives.

NIDR has proposed an expansion of its small

grant (R03) program, inviting young minority investigators to apply for these

awards.

Finally, NIDR administrators are increasing efforts to attract

applicants among minority members and women to staff positions as research

Investigators or mid- and senior-level administrative positions. We have

estabished a subcommittee of our national advisory council to review these

activities and provide periodic reports and recommendations.

Overall, 1990 was a year in which we saw progress in our efforts to

broaden the NIDR mission and research efforts--affirmed in the title of our

plan, Broadening the Scope.

The year was not without controversy, however, as

three dental-health-related issues received widespread publicity.

The first issue concerned fluoride and emerged following the release of a

study of the carcinogenicity of fluoride in drinking water. The study, conducted by the National Toxicology Program of the National Institute of Environmental Health Sciences, found "equivocal" evidence of bone cancer in 3 male rats fed high dosages of fluoride and 1 male rat fed a mid-high dosage.

However, no bone cancers were found in female rats or male and female mice in

the same study.

The Assistant Secretary for Health subsequently established an expert

subcommittee of his Committee to Coordinate Environmental Health and Related

Programs (CCHERP), asking it to conduct a searching review of the world literature and include new studies being conducted by the National Cancer Institute. The Committee's report was issued in February. Its most important

finding, based on animal experiments and over 50 epidemiological studies including the latest NCI study, is that there is no evidence that optimal levels of fluoride cause cancer of any kind in animals or human beings. Furthermore, it supports the use of water fluoridation as the most cost

effective and equitable method of preventing tooth decay, benefiting rich and poor alike. The report found that mild forms of dental fluorosis (a staining and mottling of enamel) have increased, probably because of widespread availability of fluoride products and their inappropriate use in some cases. The report concludes with research recommendations which generally parallel

those in the NIDR long-range plan.

A second issue to emerge in 1990 raised the question of whether toxic amounts of mercury can accumulate in the body as a result of the placement of mercury-containing amalgam fillings and the subsequent release of mercury vapor during chewing or toothbrushing. Research to date has not proved that mercury-containing fillings are harmful to anyone except those rare individuals hypersensitive to the metal. However, we will continue to Investigate the health effects of mercury, including the possibility of conducting population studies. A technology asessment conference on the biocompatibility of all dental materials is scheduled for July, and we are continuing research to develop alternative materials.-ones that will be as durable as amalgams, but esthetically preferable, and also requiring less drilling and removal of sound tooth substance. Finally, a new CCHERP

subcommittee has been formed and charged by the Assistant Secretary to conduct

a complete investigation.

A report is expected later this year.

The third issue concerns the case of the Florida dentist who allegedly

was responsible for the transmission of the AIDS virus to three of his

patients.

We may never know how this transmission occurred, but the Centers

for Disease Control suspects that there were lapses in Infectivity control procedures. We have formed an internal working group to explore this issue. While there are complex regulatory, legal, and ethical concerns involved,

there are also research issues relating to infection control and compliance.

Mr. Chairman, the FY 1992 request for the National Institute of Dental

Research is $160,939,000. I will be pleased to answer any questions.

BIOGRAPHICAL SKETCH OF DR. HARALD LÖE

Current Position: Director, National Institute of Dental Research

Birthplace and Date: July 19, 1926, Steinkjer, Norway

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Education: Oslo University, Norway, D.D.S., 1952; Dr. Odont, 1961
Professional History: 1974-1982, Dean and Professor of Periodontology, School of
Dental Medicine, University of Connecticut, Farmington. 1972-1974, Professor of
Dentistry and Director of the Dental Research Institute, University of Michigan,
Ann Arbor. 1962-1972, Professor of Dentistry and Chairman, Department of
Periodontology, Royal Dental College, Aarhus. 1971-1972, Associate Dean and
Dean-elect, Royal Dental College, Aarhus. 1966-1967, Visiting Professor of
Periodontics, Hebrew University, Jerusalem. 1956-1962, Research Associate,
Norwegian Institute for Dental Research, Oslo. 1960-1962, Associate Professor,
Department of Periodontology, School of Dentistry, Oslo University, Oslo. 1959-
1962, University Research Fellow, Oslo University, Oslo. 1957-1958, Fulbright
Research Fellow and Research Associate, Department of Oral Pathology, University
of Illinois, Chicago. 1952-1955, Instructor in Operative Dentistry, School of
Dentistry, Oslo University, Oslo.
Honorary Doctorate Degrees: University of Detroit, 1990; Medical University of
South Carolina, 1990; University of Toronto, 1989; Royal Dental College,
Copenhagen, 1988; University of Medicine & Dentistry of New Jersey, 1987;
University of Maryland, 1986; University of Bergen, Norway, 1985; Georgetown
University School of Dentistry, Washington, D.C., 1983; University of Lund,
Sweden, 1983; Catholic University of Leuven, Belgium, 1980; University of Athens,
Greece, 1980; Royal Dental College, Aarhus, Denmark, 1980; University of
Gothenburg, Sweden, 1973.

Honors. Awards: Honored by His Majesty the King of Norway (Royal Norwegian Order
of Merit), 1989; U.S. Surgeon General's Exemplary Award Medal, 1988; Swedish
Dental Society International Prize, 1988; Honorary Professorship, Medical
Sciences University of Beijing, 1987; The Royal Dental College, Copenhagen,
Denmark, 1987; Goldstein Lecture, Emory University, 1986; Member, National
Academy of Sciences, Institute of Medicine, 1985; Benjamin J. Robinson Lecture,
University of Maryland, 1985; Alfred C. Fones Medal for Outstanding Achievement
in the Service of Humanity, 1984; International Award of the Friends of the
University of Connecticut School of Dental Medicine, 1983; Lister Hill Memorial
Lecture, University of Alabama, 1983; Daniel F. Lynch Award, Dental Society of
Greater Waterbury, 1983; International Lecturer of the Year Award, Academy of

International Dental Studies, 1983; Gold Medal, University of Ghent, 1982; Centennial Award, University of California School of Dentistry, 1982; Award of Merit, Hartford Dental Society, 1982; Irving Glickman Memorial Lecture, Turts University, 1979; William J. Gies Award, American Academy of Periodontology, 1978; Arthur Merritt Memorial Lecture, Baylor University, 1977; Certificate of Achievement, Connecticut Society of Periodontists, 1976; Massachusetts Dental Society International Award, 1973; honored by Her Majesty the Queen of Denmark (Knight of Danebrog), 1972; International Association for Dental Research Award for Basic Research in Periodontics, 1969; Honorary memberships in several professional societies around the world. Other Professional Activities: Author of more than 275 scientific articles; International lecturer; honorary member and elected fellow of scientific and learned societies here and abroad.

GUIDELINES FOR HEALTH CARE PROVIDERS Senator HARKIN. Thank you very much, Dr. Löe.

Obviously, one of the questions I had was on the silver fillings, and you have answered that, and I appreciate that. We look forward to that study toward the end of this year.

The other question that we hear a lot about, of course, is AIDS and the transmission of AIDS, the dentist in Florida. Is there a need for any additional guidelines in this area?

Dr. LÕE. At this point CDC is examining the issues. They have already had two meetings on this particular problem and to explore the possibility of issuing new regulations. Both the American Dental Association and the American Medical Association have issued guidelines for their professions on the management of patients by health providers who are HIV positive. So, I think we are in the middle of discussing the issues at the moment.

For our part, when you look back on it, we have had 10 years of experience with AIDS, and so far we know of only one practice where the disease was transmitted from health provider to patient. The evidence for that is also circumstantial, by the way, and no one really has a fix on how this happened. This is another area we need to know more about before we issue firm and severe guidelines or regulate health providers in practice.

Senator HARKIN. Dr. Löe, thank you very much.
Dr. LÕE. You are welcome.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE Senator HARKIN. There will be some additional questions which will be submitted for your response in the record.

[The following questions were not asked at the hearing, but were submitted to the Institute for response subsequent to the hearing:)

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