Q&A with Dr. Rena D’Souza, NIDCR Director

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Dear HEAL Community,

Those who read this monthly message know that the HEAL community is committed to using our large and diverse set of research equities to end addiction long-term. HEAL currently funds more than 600 research projects across the United States spanning basic and translational science to implementation research. Many of the different NIH Institutes and Centers are involved with HEAL, funding science and advising us on research directions, connecting us to stakeholders, and guiding us through emerging challenges.

The breadth of our science is vast, and I’d like to take time periodically to focus in on particular areas. This month, we’re spotlighting how HEAL research connects with oral health through a Q&A with Dr. Rena D’Souza, who leads the National Institute of Dental and Craniofacial Research (NIDCR).

RB: Thanks for joining me, Rena. Many people might not recognize the relevance of oral health in opioid use and pain. Can you give us some examples of NIDCR HEAL projects and recent findings?

RD: Rebecca, thanks for the opportunity to have this conversation. Managing and treating dental, oral, and craniofacial pain is central to NIDCR’s vision to improve oral health and well-being for all people. So there’s an obvious connection. NIDCR HEAL projects include research to discover new, non-addictive ways to prevent and treat orofacial pain disorders such as temporomandibular disorders, inflammatory and neuropathic pain, and oral cancer-associated pain. NIDCR HEAL researchers are also in the early stages of developing a material that can seal surgical wounds and deliver pain medicine on-site to help reduce the need for opioids after oral surgery. In addition, our institute is interested in how socioeconomic status, race, ethnicity, and other social determinants of health play a role in chronic pain, pain management, and patient outcomes.

RB: NIH recently published a report, Oral Health in America: Advances and Challenges, in which you highlight several areas of concern related to the opioid crisis. Can you elaborate?

RD: Certainly. Opioid prescribing by dental practitioners decreased by 55% between 2012 and 2019, according to recent evidence. However, opioids are still commonly prescribed for patients who lack access to dental care and go to hospital emergency rooms to seek treatment for painful dental problems. The oral health community is also giving special attention to opioid-prescribing practices for wisdom tooth extraction, which is often the first time many adolescents and young adults are exposed to prescription opioids. That’s an area where managing risk is an important prevention opportunity. Another area of concern relates to the direct effects of opioids on oral health. When overused, opioids can reduce saliva flow, which increases the risk of tooth decay and other detrimental oral conditions.

RB: That same report notes that many people are prescribed opioids for dental pain in the emergency department, putting them at risk for harmful use and addiction. Do you see an opportunity to change this?

RD: This information reveals a couple of opportunities for intervention. The first is access to dental care. More than 48 million people in the United States have minimal or no access to dental services. As a result, many must resort to finding care for painful dental problems in emergency departments. Dental expertise may not be available in these settings, making it difficult to address the source of the problem and increasing the likelihood that a patient will receive opioid prescriptions. Second, medical training is relevant. Training emergency clinicians to inquire about patients’ histories of pain, substance dependence, mental health conditions, and oral health can help them make informed opioid-prescribing decisions. Additionally, this group can help link patients to dental care. With enhanced training for clinicians and development of non-opioid pain therapies, which HEAL is supporting, we can improve our safety net for dental emergencies.

RB: What about prevention more broadly?

RD: We know through an NIDCR-supported study that higher opioid prescribing by dentists is associated with less-consistent use of strategies to mitigate opioid risks. The study team pointed to the need for outreach efforts to dental schools and through professional networks to encourage consistent use of prescription drug monitoring programs, which are electronic databases that track controlled substance prescriptions. The researchers also recommended that dentists help patients understand potential side effects of opioids, as well as how to store and dispose of prescriptions safely.

We also have an opportunity to provide dental clinicians with training in pain, substance misuse and dependence, and mental health to help them identify patients who are at risk. Additionally, putting in place electronic health records that integrate patients’ dental and medical data would allow dentists to collaborate with medical and behavioral health professionals and pharmacists to identify substance use disorders and link patients to treatment. These are the kinds of opportunities that can enable dentists to best support patients and manage their pain safely and effectively.      

RB: One constant feature of the opioid crisis is that it continues to change. Given recent increases in polysubstance use including methamphetamine, is there more we can do to understand its effects on oral health – and to design treatments?

RD: Yes, staying on top of this evolving public health challenge can be tough. One thing to keep in mind is that the mouth is in many ways a window into the whole body. Signs of certain substance use disorders can show up in the mouth, and dental practitioners are in a prime position to help flag these issues. For example, the chronic use of methamphetamine can result in rampant tooth decay. Consuming alcohol, tobacco, marijuana, and other substances can increase the risk of oral cancers, gum disease, low saliva flow and related cavities, tooth loss, and other oral conditions. Whether the joint use of these substances can have negative compounding effects on oral health and well-being is a topic that needs more research investigation.

RB: Yes, that’s a good example of how substance use can have serious consequences for oral health. Another issue that’s just coming into focus is the recent FDA advisory about effects of buprenorphine on oral health. This medication is a key tool for treating both opioid addiction and pain – what more do we need to know about this side effect?

RD: Yes, this is an issue we’re paying very close attention to. There are a few things we do know. For example, for many people who take buprenorphine that dissolves in the mouth, which is a very common way to take it, the medication could worsen dental problems such as tooth decay, oral infections, and tooth loss. That’s because buprenorphine makes the mouth temporarily more acidic. People should take extra steps to take care of their oral health by gently rinsing the mouth with water and waiting at least an hour to brush their teeth with fluoride-based toothpaste and oral rinse after taking buprenorphine. Health care professionals are encouraged to refer people who are taking buprenorphine to dental clinics for assessments and preventative plans to counter potential dental problems. NIDCR encourages more research on this topic.

RB: Thank you, Rena, for sharing these exciting plans and information from the dental community. HEAL as a whole is much larger than its many parts and benefits from the collective wisdom of you and your colleagues.

I’ll close by saying that oral health is just one of so many areas that intersect with both pain and opioid use disorder. Just a few weeks ago, we gathered the entire HEAL research community for our third annual meeting. Other health issues discussed at length include mental illness and emotional pain, trauma, patient-friendly medications, stigma, and many others. Stay tuned for more messages from me on those topics in the coming months.

Ending addiction long-term is a group effort that benefits from strong partnerships, including close linkages with the NIH Institutes and Centers who support this vital research. I encourage you to share information about HEAL with your networks and remember that we want to hear from you. It just takes a quick email to [email protected].