NIDCR Director's Statement for the Senate Appropriations Subcommittee Regarding the FY 2014 Budget Request

Mr. Chairman and Members of the Committee:

I am pleased to present the President's Budget request for the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH). The fiscal year (FY) 2014 NIDCR budget of $411,515,000 includes an increase of $1,568,000 over the comparable FY 2012 level of $409,947,000.

When NIDCR was established as a research home for oral health in the mid-20th century, it focused primarily on oral infectious diseases like tooth decay and periodontal disease. Today, the Institute maintains a diverse and productive research portfolio that extends beyond infections in the mouth. In keeping with its mission to improve the nation's oral health, the breadth of NIDCR-funded research includes basic science studies aiming to understand development, maintenance, and regeneration of tissues of the face and head; novel preventive, diagnostic, and treatment approaches for oral infections and oral cancer; investigating the role the mouth plays as an indicator of overall health; and community-led studies of issues related to dental care.

Realizing personalized oral health

Personalized health, aiming to individualize care based on a person's unique genetic, environmental, and clinical profile, is not new: dentists and physicians have long recognized variations among patients, and they have provided customized care based on the history, environmental exposure, and behavioral components that shape a person's health. However, new technologies offer additional strategies. For example, the NIDCR investment in molecular diagnostics using saliva is a key step toward advancing personalized care. As a diagnostic fluid, saliva has long been recognized to have many advantages over blood. These include simple, non-invasive collection; the potential for lower testing costs; portability; and application at or near the site of patient care, maximizing convenience and allowing the results to be available immediately to the patient. Recent progress comes from NIDCR-supported scientists that developed a miniaturized, portable biochip that can analyze small volumes of saliva. During the first phase of this project, the researchers found promising predictive markers for cardiac events. Other research identified the presence, in saliva, of disease-related proteins and RNAs for oral cancers, Sjögren's syndrome, and conditions such as periodontal disease.

Beyond supporting the development of molecular-based tools to individualize care, NIDCR appreciates the important role of behavior and environment in determining an individual's health status. As trusted providers in a private setting, dentists have an extraordinary opportunity to communicate to their patients the health risks of behaviors such as alcohol and tobacco use. NIDCR-funded projects are currently exploring how dental providers can help their patients by providing smoking-cessation advice.

Progress in oral diseases: cancer

The five-year relative survival rate for oral and pharyngeal cancer is approximately 60 percent, which is among the lowest for all major cancers¹. This outlook is significantly worse for African Americans, who face a five-year relative survival rate close to 40 percent. In addition to bringing behavioral science tools and expertise to bear on this problem, NIDCR aims to initiate and lead an NIH-wide effort in oral premalignancy identification and oral cancer prevention. The multi-pronged approach weaves together scientific advances in molecular profiling with clinical testing of the FDA-approved drug rapamycin for its effectiveness against certain cancers of the head and neck. Also, in FY 2014 NIDCR will launch an initiative supporting research on a unique type of cell capable of initiating oral cancer, as therapies targeting these cells could potentially eliminate the ‘root' of the cancer.

Infection with human papillomavirus (HPV) is an increasingly recognized risk factor for distinct forms of oral and pharyngeal cancer. NIDCR remains vigilant to this rising public health concern. The incidence of HPV-linked oral cancers in the United States has been increasing at a rapid rate-by 225 percent from 1998 to 2004, and now 37% of oral and pharyngeal cancers are HPV-associated cancers². Because the FDA-approved HPV vaccine Gardasil is effective against the particular strains of HPV implicated in oral cancers, NIDCR is supporting efforts to determine the potential benefit of this vaccine in preventing these terrible diseases.

Progress in oral diseases: pain

NIDCR has a long-standing interest in the understanding and management of chronic pain. In 2012, the Institute launched the second phase of Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA), the first-ever large, prospective clinical study to identify risk factors for temporomandibular joint disorder (TMJD). OPPERA II will follow more than 3,000 initially pain-free individuals for three to five years. OPPERA II will build upon OPPERA I and further explore risk factors and genome-wide markers for chronic TMJD as well as for several frequently overlapping pain conditions. Also in 2012, NIDCR partnered with the National Institute of Neurological Disorders and Stroke to host a workshop focused on identifying innovative scientific approaches to the study of chronic overlapping pain conditions. Together, these efforts are expected to have an impact not only on TMJD, but also on other chronic pain conditions including fibromyalgia, irritable bowel syndrome, chronic headache, vulvodynia, and chronic fatigue syndrome. In addition, NIDCR co-sponsored a meeting in 2013 with two other NIH Institutes to explore opportunities to utilize contemporary and integrative approaches in understanding TMJ structure and function, including novel imaging and molecular diagnostic techniques.

Systems approaches to understanding oral health

Oral tissues and fluids have remarkable protective roles, dependent on human components and those of oral bacteria. The NIH Human Microbiome Project (HMP) has created unprecedented opportunity to learn much more. NIDCR is harnessing HMP knowledge and tools to define the overlapping and unique roles of the oral microbiota in oral diseases and immune function - such as in susceptibility to autoimmune diseases and cancer - and in other systemic conditions like metabolic syndrome, a cluster of co-occurring conditions including increased blood pressure, blood sugar levels, body fat, and cholesterol levels that can raise the risk of heart disease, stroke, and diabetes. NIDCR is investing resources in new approaches to understand the properties of the vast majority (more than 80 percent) of the microbial universe in our mouths that cannot be grown in the laboratory. These studies will provide insights into interactions among microbes and with human cells, potentially leading to the development of novel strategies for prevention, diagnosis, and treatment of oral diseases.

Genome-wide association studies, or GWAS, are another example of the broad utility of systems approaches for investigating oral health biology. GWAS methods combine human genome sequencing and high-speed computing, to scan the entire genome for disease triggers and factors. In the realm of oral health, GWAS suggest that the risk for dental caries arises from interplay between genetic factors, home fluoride exposure levels, and in some cases, taste preferences. Further analyses may point to common risk factors for dental caries and other conditions such as diabetes and cardiovascular disease. NIDCR-funded genetic studies of craniofacial development and birth defects have yielded information on the causes of cleft lip and palate and craniosynostosis, and this research will continue to be a focus moving forward.

NEW DIRECTIONS IN ORAL HEALTH RESEARCH

Minding workforce trends and the importance of interdisciplinary science to health promotion, NIDCR recognizes the need for investigators representing a range of scientific areas to conduct research in dental, oral, and craniofacial health. NIDCR is particularly engaged with the needs and contributions of practitioners, whose participation in research could cut the time it takes for laboratory research to be applied for patients. In 2005, NIDCR launched the Practice-Based Research Network, or PBRN, and the second, seven-year phase began in April 2012. This powerful "real world" research network is recruiting practitioners in every state-with a goal of involving at least 5,000-to propose and perform clinical studies on topics important to dentistry. Because the research is conducted by clinicians in their own practices, dentists are more likely to accept and adopt the findings. The expected result is nothing short of a transformation of dental practice-one that will yield more individualized and evidence-based treatment and prevention, to the benefit of millions of Americans.

Martha J. Somerman, D.D.S., Ph.D.M

Director, National Institute of Dental and Craniofacial Research

Dr. Martha J. Somerman is the Director of the National Institute of Dental and Craniofacial Research, National Institutes of Health. She also is Chief of the Laboratory of Oral Connective Tissue Biology at the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Prior to becoming NIDCR's director, Dr. Somerman was dean of the University of Washington School of Dentistry, Seattle, a position she held from 2002-2011. Before joining the University of Washington, she was on the faculty of the University of Michigan School of Dentistry, Ann Arbor, from 1991 to 2002, and University of Maryland, 1984-1990. An internationally known researcher and educator, Dr. Somerman's research has focused on defining the key regulators controlling development, maintenance and regeneration of dental-oral-craniofacial tissues and has been a recipient of numerous honors and awards throughout her academic career.

Dr. Somerman holds a D.D.S. from New York University, a certificate in Periodontology from Eastman Dental Center, Rochester, New York and a Ph.D. in Pharmacology from the University of Rochester, School of Medicine and Dentistry.

¹Siegel et al.,(2013) Cancer statistics, 2013. CA: A Cancer Journal for Clinicians. 63 (1) 11–30.
²Gillison ML et al. (2012) JAMA;307,693-703; Jemal A et al. (2013)J Natl Cancer Inst