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The NIDR also has moved ahead with its new Research and Action Program. As you know, this program is aimed at eliminating toothlessness in this country and improving the oral health of adults, the elderly, and others at high risk, including members of minority populations. The program has grown to include several other Federal agencies, and we are now working with a private foundation which is about to set up a consortium of industry, academia, and the general public to mount a major oral disease prevention and oral health promotion program for the Nation.
Finally, our past successes with the prevention of disease in children and our current aspirations have led us to expand our agenda, as described in our new long-range plan for the 1990's which we have called broadening the scope. The plan speaks to finishing the job on periodontal diseases as well as getting on with all the diseases and disorders affecting the mouth, the face, and the jaws.
Mr. Chairman, for fiscal year 1992, the request for NIDR is $160,939,000.
I would be pleased to answer any questions that you may have. [The statement follows:]
STATEMENT OF DR. HARALD LÖE
Mr. Chairman, the publication of Broadening the Scope, the new NIDR LongRange Research Plan for the Nineties, marks a turning point in the history of During our earliest years, research emphasized dental caries and periodontal diseases--the costly, painful, and highly prevalent conditions that were responsible for the widespread toothlessness of our parents' and Four decades of NIDR-funded research have changed the epidemiological picture. We learned what caused these diseases and how to prevent them--knowledge that has been translated into public and professional practice. Our surveys now indicate that 50 percent of schoolchildren have no cavities in their permanent teeth. Periodontal diseases remain common, but are generally mild and no longer considered a major cause of tooth loss in adults. The resulting gains in oral health translated into savings of $5
billion in the nation's dental bill in 1989.
These advances have allowed us to evolve from an Institute with a two
disease focus to one with a broadened mission. We will continue to work to reduce the burden of caries and periodontal diseases, but our plan for the nineties establishes priorities for research that emphasize other serious and debilitating diseases that affect the mouth, the face, and the jaws.
Oral cancers constitute one of the deadliest forms of cancer known, with 30,000 new cases occurring every year and 10,000 deaths. Those who survive may face disfigurement from surgery, destruction of the salivary glands from radiation, and impairments in speaking, chewing, and swallowing. We have expanded research on oral cancers to include studies of the basic mechanisms involved in transforming the normal cells lining the mouth into aggressive and rapidly dividing malignant cells. We are exploring the role of herpes and papillomaviruses in initiating the cancer process, as well as behavioral factors that greatly heighten the risk, such as the combined use of tobacco and alcohol. Our investigators have evidence that alcohol increases the permeability of the oral tissues, making it easier for carcinogenic substances in tobacco to penetrate cells.
To facilitate this research, NIDR intramural scientists have developed a novel method for growing human cancers in mice--traditionally, an extremely difficult task. The method should greatly benefit the study of all human
cancers, enabling observation of the growth and spread of human tumor cells in the living animal, and making it possible to test new methods of diagnosis, treatment, and prevention.
A second high priority research area concerns birth defects. We have long supported research on treatment of cleft lip and cleft palate--the most common facial birth defects. Now that we can apply molecular biology methods to the study of craniofacial development, we are increasing research on the genetic and environmental factors that cause facial clefting and other developmental disorders, including the abnormalities of bone seen in osteogenesis imperfecta, the painful skin and oral ulcers that occur in epidermolysis bullosa, and the multiple defects in the development of teeth, skin, and hair that occur in the ectodermal dysplasias. The children affected by ectodermal dysplasias must be repeatedly fitted with removable dentures as they grow, a costly and hardly ideal solution considering that these are normal, active children who like to play games and participate in sports like most children their age.
We are currently conducting a clinical trial of dental implants in children with ectodermal dysplasias. The implants are small titanium screwlike devices that are surgically placed in the jawbone and allowed to heal for several months, during which time they become integrated into the natural
At the second stage of treatment, artificial teeth are attached to the implants and the patients learn to clean the teeth just as they would natural teeth. We feel that this more physiological approach--along with improvements in esthetics, efficiency, and patient satisfaction--will make implants the treatment of choice in the future. Not only will implants essentially replace dentures for patients missing all their teeth, but they will be used also for single tooth replacements. The advantage in that case is that there is no need to cap the adjacent teeth--the normal procedure in making a bridge.
The Institute's emphasis on oral cancers and birth defects underscores the priority we are placing on people at high risk for oral health problems. We think of this as a natural progression from our earlier overall concern for the oral health of the nation's schoolchildren to a concern for the special needs of people of any age whose oral health is compromised because of systemic diseases, because of age, or because of limited resources.
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.
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. address issues of minority health and assistance, we have developed a threepart program to enhance minority research, research training, and staff
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. cancer, facial clefts, and a rare but particularly severe form 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.