By Rick Valachovic, DMD, MPH, Clinical Professor and Co-Executive Director of the NYU Dentistry Center for Oral Health Policy and Management

Academic dentistry faces a perfect storm. Multiple policy changes have converged simultaneously, creating a cascade of challenges that individually would be manageable, but together represent an existential threat to how dental schools have operated for decades. 

This isn’t about any single policy decision. It’s about the cumulative impact of fundamental shifts in educational financing, research funding, clinic revenue, and regulatory frameworks all happening at once.

Anatomy of the Perfect Storm

The convergence began in January with a series of federal policy changes that have created overlapping pressures across every aspect of dental school operations. 

• To start, Congress eliminated GRAD Plus loans and implemented strict borrowing caps on federally subsidized loans of $50,000 annually and $200,000 total. These changes strike at dental education’s financial foundation. Urban Institute data reveals that more than half of dental students have historically borrowed above these new limits. Some prospective students will turn to the private market, but others will be unable to secure adequate financing, creating an immediate enrollment crisis at many of our schools.
• Simultaneously, proposals to curtail research funding introduced another source of financial instability. The proposed 15% cap on indirect costs associated with National Institutes of Health (NIH) grants threatens the research infrastructure that supports faculty positions and institutional operations. The cap is currently blocked in the courts, but it signals the likely arrival of future constraints. Schools heavily dependent on federal research funding face potential budget shortfalls in the millions.
• Disruptions in clinic revenue represent the third element of this storm. Medicaid cuts nearing $1 trillion will force states to reduce benefits, with adult dental coverage—already optional in most states—facing elimination or severe restrictions. Since Medicaid patients account for roughly one-third of most dental school clinic populations, program cuts will disrupt educational case mix in addition to generating revenue loss.
• Lastly, new mandates on accreditors introduce regulatory uncertainty at exactly the moment when schools need regulatory stability to manage other challenges. The  elimination of diversity-related accreditation standards is concerning to many in our community. Meanwhile, the mandate to report student outcomes without demographic disaggregation directly contradicts existing federal reporting requirements, complicating compliance.

What makes these separate stressors a perfect storm is how they amplify each other, creating a cascade of financial pressures. Reduced student loan availability will inevitably force schools to increase scholarship spending just as research and clinic revenue decline. New accreditation requirements will complicate operations, demanding more administrative resources exactly when budget pressures require cost reduction. The simultaneous arrival of these changes will make it difficult to prioritize and sequence our responses. The likely outcome? Strategic paralysis.

Weathering the Storm

Perfect storms require comprehensive responses that address the interconnected nature and escalating complexity of multiple challenges. It’s tempting to try and fight on all fronts simultaneously, but a more effective response must unfold in phases, with each building on the previous one.

Step 1. Stabilization. 

Over the next six months, schools must take immediate action to preserve their revenue sources.  Tuition income could be bolstered by initiating emergency campaigns to raise scholarship dollars; negotiating bridge financing from banks and credit unions; establishing corporate partnerships to guarantee student loans; and restructuring tuition payment plans. On the clinic side, schools can protect revenue through aggressive marketing to expand cash-pay patient volumes and by negotiating contracts with health systems for clinical services. To hedge against the loss of research dollars, schools can accelerate the formation of industry-sponsored research partnerships while implementing cost reduction measures that don’t compromise educational quality. To retain their accreditation, schools must also document evolving regulatory requirements and develop compliance strategies.

Step 2. Adaptation.

As their immediate finances stabilize, schools must also begin developing new financial models to carry them forward with fewer traditional federal sources of support. On the tuition front, schools can consider launching income-sharing agreements in which graduates agree to pay a portion of their tuition through a percentage of future earnings; developing corporate-sponsored dental education tracks with employment guarantees; creating extended residency programs that generate clinic revenue while providing advanced training; and building continuing education programs for which practicing dentists will pay a premium. To diversify revenue streams schools could look to license intellectual property from dental research, create specialized clinical services that generate premium margins, or establish satellite clinics in underserved areas with sustainable payment models.

Step 3. Sustainability. 

Establishing substantial endowments for student financial aid and creating self-sustaining clinical networks that provide diverse training sites, will be key to sustaining dental schools that survive the current storm. Developing faculty practice plans that generate significant revenue and building alumni networks that provide ongoing financial and professional support are also essential to ensuring institutional resilience.

In the long run, schools must position themselves as the solution to demonstrable problems. Addressing workforce shortages in underserved areas, generating research with clinical applications, and streamlining the delivery of dental education will help dental schools build a foundation for long-term success.

Schools must take these steps with the urgency a perfect storm demands. A swift response  will require creating crisis management teams, developing contingency plans for multiple revenue loss scenarios, and establishing protocols for regular stakeholder communication protocols.  

Addressing the Workforce Imperative

Even amid this perfect storm, the need for a diverse dental workforce that can serve all Americans remains critical. The Sullivan Commission’s findings about healthcare disparities haven’t changed: Diverse healthcare teams produce better outcomes for underserved populations. This represents both a challenge and an opportunity that must be addressed strategically.

We know what works:  

• Pipeline programs such as the Summer Health Professions Education Program (SHPEP).
• Creating community-based clinical training sites in underserved areas. 
• Developing post-baccalaureate programs that prepare career changers for dental education.
• Establishing mentorship networks and comprehensive support systems that foster student success regardless of background.

The key is to frame these efforts as a matter of operational excellence. Schools that effectively recruit and graduate students from all backgrounds will have larger applicant pools, stronger community connections, and better positioning for future growth, giving them a competitive advantage in attracting students and strategic partnerships.

The Choice Before Us

Will we allow this perfect storm to overwhelm us or use it as the catalyst for overdue transformation? Perfect storms create windows of opportunity alongside their challenges. The current model of dental education—high-cost, federally dependent, operationally inflexible—was already under stress before the storm arrived. Will this moment of adversity spur us to confront structural issues we have long delayed addressing?

Opportunities abound. Schools could implement competency-based advancement to reduce time-to-degree, establish partnerships with community colleges for pre-dental pipeline programs, expand simulation-based training to optimize clinical efficiency, develop cost-saving hybrid online/residential programs, or create accelerated programs for career-changers. The schools that welcome change will emerge from this storm more efficient, more innovative, and more responsive to community needs. They will have diversified revenue streams, sustainable financing models, and educational approaches that prepare graduates for evolving practice realities. I suspect we will discover that crisis-driven innovation often produces better solutions than gradual evolution ever could.

As Dr. David Thomas, the former president of Morehouse College, recently said, this moment calls for being “bold in aligning mission with innovation, unapologetic in asserting our value, and vigilant in protecting our autonomy.” I agree. The institutions that act decisively, comprehensively, and boldly will not just weather this storm—they will be positioned to lead dental education’s future. 

The NYU community is grieving the loss of Michael Alfano. When we decided to launch the Center for Oral Health Policy and Management with a symposium in 2021, Mike was the first speaker I thought of. The Center’s very existence owes a debt to his legacy. Mike’s visionary leadership brought an entrepreneurial spirit and commitment to interprofessional practice and overall health to the dental school, which informs the center’s work to advance policy and practice in support of oral health. Dean Charles Bertolami wrote a moving obituary, which will tell you more about Mike’s lasting impact at NYU and beyond. If you didn’t know Mike, I hope you will take a moment to learn more. If you were fortunate enough to make his acquaintance, I hope you will take a moment to reflect on his remarkable contributions to our community.

In May, I had the honor of delivering the commencement address at the Missouri School of Dentistry and Oral Health (MSDOH). The school is part of A.T. Still University (ATSU) of Health Sciences, home to the world’s first osteopathic medical school, founded in 1892. More than a century later, ATSU established dental schools in Arizona and later Missouri. Among their many distinctions, ATSU dental schools require their students to earn a certificate of public health alongside their DMD degrees. I reminded the graduates that their university emphasized the importance of serving underserved populations and challenged them to shape the future of dentistry. “As graduates of this institution,” I told them, “you carry forward that legacy, uniquely prepared to address the inequities in dental care that persist today.” Here are additional excerpts of my remarks.

You are entering a profession that is not only respected but also dynamic and filled with opportunities. From advances in robotic implant dentistry and artificial intelligence in treatment planning to innovations in public health and access to care, dentistry is at the forefront of improving both individual lives and community well-being. But with these opportunities come challenges. Think about the world you are stepping into as professionals: a world still grappling with the effects of a global pandemic, where health inequities have been laid bare. Nearly half of the U.S. population lacks dental insurance, and rural areas like many in Missouri face critical shortages of dental care providers.

So, I pose these questions to you:

• What will you contribute to advancing oral health equity?
• How will you define success beyond clinical outcomes?
• Will it be the number of lives you touch, the innovations you bring to the field, or the way you inspire others to join our profession?

Reflecting on these questions will help you chart your course as leaders and changemakers in dentistry.

To Those Entering Clinical Practice

I want to take a moment to speak directly to those of you entering clinical careers today. When you receive your license to practice dentistry, you are granted extraordinary privileges and responsibilities—privileges that, without the context of your education and training, could be considered unthinkable, even criminal. Think about it. With your dental license, society entrusts you to perform acts that would otherwise result in severe legal consequences. Using a 12B scalpel blade to make an incision, administering medications to alleviate pain, or prescribing controlled substances—actions like these, in the absence of your expertise, might be seen as assault, battery, or even drug trafficking.

 As a dentist, you will have the privilege of being trusted with your patients’ lives and well-being. Your education, training, and commitment to ethical practice have prepared you to meet those expectations. But remember, the power of your license lies not only in the legal rights it grants but also in the moral obligations it carries. It is a symbol of the dedication, expertise, and compassion that define our profession. Respect it, cherish it, and use it to make a meaningful impact on the lives of your patients and the communities you serve.

The Role of Role Models

As practicing dentists, you will also become role models. Unfortunately, the media often portrays dentists unfairly or focuses on exaggerated caricatures. From the maniacal dentist in Little Shop of Horrors to the infamous torture scene in Marathon Man, and even more recently, the quirky and overly enthusiastic Dr. Sherman in Finding Nemo, these portrayals do little justice to the professionalism and compassion of real-life dentists. Even newer films like Horrible Bosses feature outlandish characters like a dentist portrayed by Jennifer Aniston, who veers so far into absurdity that it’s comedic—but still unrepresentative of who we are as professionals.

Let’s face it: The bar isn’t set very high. We don’t even have a dentist superhero yet. It’s up to you to change that narrative. By embodying professionalism, compassion, and ethical excellence, you can serve as the true representation of what it means to be a dentist. You have the opportunity to counter these fictional portrayals with reality: trusted caregivers who transform lives, not just smiles.

Dentistry as a Moral Community

As graduates of the Missouri School of Dentistry and Oral Health, you are not only entering a profession; you are joining a moral community—a concept that lies at the very heart of what it means to be a dental professional. At its essence, a moral community is a group of individuals bound together by shared values, ethical commitments, and a dedication to serving a greater good.

In dentistry, this means we are united by a collective responsibility to prioritize patient welfare, uphold the highest standards of care, and advocate for equitable access to oral health for all. Our work is profoundly personal. Patients come to us in vulnerable states—seeking relief from pain, treatment for disease, or simply the assurance that they are cared for. The trust they place in us is sacred, and it requires that we act with integrity, compassion, and a steadfast commitment to doing what is right, even when it is not easy.

Being part of a moral community also extends to addressing broader issues like health equity and underserved populations. It means asking tough questions about the disparities that still exist and using your skills to help close those gaps.

A Call to Action

As you cross the stage to receive your diploma, let the moment remind you of the deeply personal nature of our profession. You have worked hard for this achievement, but it is only the beginning. Commit to lifelong learning, to serving underserved communities, and to becoming leaders in the field. Be the kind of professional who makes a patient feel heard, a colleague feel supported, and a community feel valued. The world of dentistry is rapidly evolving, and you have the opportunity—and the responsibility—to shape its future.

At the graduation ceremony at MSDOH, I was honored to receive an honorary Doctor of Humane Letters degree. I am grateful for the recognition.

By Rick Valachovic, DMD, MPH, Clinical Professor and Co-Executive Director of the NYU Dentistry Center for Oral Health Policy and Management

In May, I watched 400 NYU Dentistry DDS graduates walk across the stage at Madison Square Garden and couldn’t help reflecting on what awaits them out there in the “real world” beyond our teaching clinics. Today’s workplace is a far cry from the practice environment my classmates and I first encountered after graduation, and the pace of change is such that even some younger faculty members may have little first-hand experience in today’s private practices.  This got me thinking about curricular changes dental schools might want to make to ensure our graduates function well in the current environment and adapt in the decades ahead.

Those changes amount to a stronger focus on meeting three core goals:

• Today’s graduates must be comfortable with digital dentistry and open to advances powered by artificial intelligence (AI).
• They need to understand how the business of dentistry is evolving to favor more efficient and less costly models of service delivery.
• They need a strong ethical foundation and moral compass to ensure they live up to their social responsibilities as health professionals while navigating the changes ahead.

And they need to develop sophisticated communication skills, effectively engaging with patients, colleagues, staff members, third party payors, referring specialists, dental laboratories, regulatory bodies, community health organizations, and professional associations.

Digital Dentistry

Electronic health records (EHRs). Digital radiography. Intraoral scanners. These technologies are well established in U.S. dental schools, but already their use is being augmented.

• Traditional dental health records, which transformed patient record keeping in dental schools in the late 1990s, are being supplanted by EHRs that integrate patients’ dental and medical records and streamline administrative and communications functions.
• Digital radiography is being paired with artificial intelligence (AI) to better diagnose disease. AI is also being integrated into treatment planning software and ultimately may enhance clinical decision-making for entire populations through advanced data analysis and predictive analytics.
• Intraoral scanning is just the first step in a digital workflow that incorporates computer-assisted design and manufacturing (CAD/CAM). CAD/CAM renderings may still be sent to a dental lab, but with the latest in-office equipment, some practices are milling crowns and using 3D printers, allowing patients to complete treatment in a single visit.
• Robotics are also expected to play a growing role in dentistry. At NYU, we expose DDS students to this technology by giving them the chance to practice implant placement using Yomi, a dental surgery robot.

“These are must haves,” says Ken Allen, DDS, MBA, clinical professor and vice chair of the Department of General Dentistry & Comprehensive Care at NYU Dentistry. He notes that a growing percentage of graduates will be working in large group practices affiliated with dental support organizations (DSOs). “They are going to insist that their new staff dentists know these technologies now. They may not use all of them yet, but they’re going to expect dentists to be familiar with them.”

That’s adding a lot to an already packed DDS curriculum, but as Ken points out, students only need to be proficient in some of these technologies. It’s enough for them to graduate with knowledge of the most advanced tools, so they are prepared to learn how to use them proficiently on the job. Do we also need to prepare students to adapt to the latest innovations as dental practice evolves, I asked Ken. “Today’s students are digital natives,” he pointed out. “They’re used to their phones being upgraded every two years, so I think they are ready to understand that things are going to change.”

Evolving Models of Care Delivery

Alongside technological change, the structure of the workplace and the composition of the dental team are also evolving. The scope of practice for dental hygienists has expanded considerably in most states; dental therapists (DTs) are poised to expand the capacity of the dental team in coming years; and some dental care is migrating outside the dental office. Primary care physicians have begun administering fluoride varnish in response to a 2021 recommendation by the U.S. Preventive Services Task Force. Last year, the governor of New York signed a law allowing dental assistants and licensed practical nurses to do the same, and two additional bills pending in New York would extend the privilege to parents and guardians under the telehealth supervision of authorized providers. In a concerning trend, more complex dental care, such as mail-order aligners, is also occurring in the home, as new business models encourage consumers to engage in do-it-yourself dentistry.

The demographic make-up of the workforce has also changed, with women making up a majority of current DDS graduates. Female dentists have traditionally worked fewer hours than their male counterparts and are more likely to choose part-time employment. This preference may preclude solo practice for some new dentists and partially explains the rise of large group practices, which can accommodate part-time providers while still meeting their business objectives. Over 28% of recent graduates chose employment at DSO-affiliated practices in 2023, almost doubling the number of dentists in this sector to 13.8%, up from 7.4% in 2015.

Given these trends, it is incumbent upon dental schools to make sure their practice-management curricula evolve with the times. Don Gallo, DMD, retired chief clinical officer for Dental Care Alliance, a DSO, sits on NYU Dentistry’s Dean’s Strategic Advisory Council and teaches in the college’s practice management course. When I asked him what DSO-affiliated practices want their new hires to know by the time they graduate, Don had a short list of priorities at the ready. In his view, dental students should know:

1. How to engage in comprehensive treatment planning. In Don’s experience, new dentists are so focused on addressing their patient’s immediate complaints that they often miss the opportunity to evaluate the entire dentition and recommend treatments that can stave off future problems.
2. How to use visual aids to present treatment plans to patients. “People retain about 20% of what they hear. They retain 65% or 70% of what they see,” Don told me. Knowing this can help dentists communicate more effectively with patients.
3. How to engage the bur longer to increase their efficiency. “It’s not about working faster,” Don insists. “Speed comes with confidence. It’s a product of understanding and visualizing what the end looks like.”
4. That the quality of customer service is what drives business success. “There are a lot of dentists that are phenomenal technicians that just aren’t successful because they’re not good at managing people and managing their practice,” Don observed.
5. Basic facts about group practice employment.

“I think there’s this perception, even inside organized dentistry, that employed dentists somehow work for the DSOs, which they don’t,” Don told me. There is considerable variation in how state laws address DSO affiliation, but in most cases, dental practices must be owned by dentists, and DSO-affiliated group practices may offer a path to practice partnership, should a dentist choose to pursue it.

How can graduates make the best choice of where to start their careers? Don suggests that dental schools coach students in contract negotiation and provide education or assistance to graduates in understanding the offers they receive. Those sound like good ideas to me.

Social Responsibility

The rise of DSOs has been controversial at times, with some affiliated dentists and hygienists reporting they feel pressured to alter how they practice in order to meet corporate goals. The use of AI in health care also poses ethical concerns that our profession is just beginning to analyze. Threats to public health — from hostility toward community water fluoridation to a rapidly changing climate — also call on dentists to live up to their social responsibilities. For these reasons and more, our graduates need a strong ethical foundation and moral compass to help them navigate the practice landscape that awaits them.

As I wrote in March, members of the dental profession are obligated to do no harm and to act in the best interests of their patients. Dental schools must imbue their curricula with this North Star and encourage their graduates to be leaders in shaping our collective future. Given the rapid pace of change, we might also offer certificate programs to help practicing dentists stay up to speed on the latest techniques, equipment, workplace practices, and ethical and legal matters. Such robust CDE offerings could have the added benefit of ensuring that faculty are also well acquainted with the challenges their students will face in the practice environment.

As stewards of the profession, we’ve done a good job of ensuring our graduates are competent clinicians in the here and now, but a lot can happen in 40 years; they will likely still be practicing in 2065.  Given the pace of change, it’s more urgent than ever that we give them the knowledge they need to adapt as the practice of dentistry evolves.

By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

It’s expensive to become a dentist. Students typically must finance a minimum of eight years of higher education and forgo eight years of earnings before entering the profession. For those who specialize, the costs incurred and lost income are considerably higher. Future physicians, pharmacists, and advanced practice nurses face similar burdens.  Even students considering health professions with a shorter educational trajectory often find the tuition costs and the lost earnings prohibitive.

Such concerns prompted the National Academies of Sciences, Engineering, and Medicine in Washington, D.C., to convene a series of workshops this spring on the affordability of health professions education. I spoke on a panel that looked at the impact of cost on students’ intention to practice primary care or work in rural settings and listened to others over the course of several days. An international roster of educators, clinicians, and economists considered ways to make entry into the health professions more affordable, here and abroad. Among the ideas they raised:

• Shift some costs to employers,
• Train a cost lens on innovation, and
• Restructure health professions education to meet community needs.

Three Ideas Worth Exploring

1. Shift some costs to employers

As health systems scramble to recruit and retain staff, some employers are investing upfront in the education of future hires. Norton Healthcare in Louisville, KY, created a first-of-its-kind program for pre-licensure nurses that is paying off with impressive results. The Student Nurse Apprenticeship Program (SNAP) provides the region’s top nursing students with paid opportunities for on-site clinical learning. Students gain income, skills, and confidence in the nursing role, while the health system gains practice-ready employees. Nine out of ten participants choose to work for Norton after graduation, with 92% staying at the organization for at least one year. The result? Norton saved $47 million in avoided turnover costs in the program’s first decade.

Several other hospital systems have adopted the SNAP model, and several states are promoting and funding similar efforts to help meet their health workforce needs. Dentistry doesn’t have hospitals, but a growing number of dentists work for large group practices and dental support organizations. Might these practices invest in the education of their future employees?

2. Train a cost lens on innovation

Several presenters talked about the potential of innovation to make our enterprise more efficient and increase the return on investment (ROI) of health professions education. They also highlighted the need to justify innovation’s costs. Even when a newer approach is demonstrably better, one workshop participant suggested, we need to ask if the improvement is sufficient to justify passing along the cost to our students.

Innovative loan and repayment programs would almost certainly meet that standard. So might pruning the curriculum; using AI and other tools to allow students to learn independently; sharing faculty and facilities; and continuing education (CE) that extends the learning process after a degree is conferred. One participant mentioned an emergency department that reduced readmissions by 30% among patients at the health system’s skilled nursing facilities by introducing simulation-based CE for its employees. Simulation can be expensive, but in this case it more than paid for itself, and at no cost to those who took part.

3. Restructure health professions education

Here’s a provocative question: Rather than measuring the knowledge, skills, and attitudes of our graduates, what if we measured our success by examining the health of our populations?

This perspective suggests a radical restructuring of our entire educational endeavor, a proposition raised during Day 2 of the workshop. Rather than graduating fully formed health professionals who are prepared for a variety of types of independent practice, one speaker asked, what if we shortened education for some by creating different exit points for generalists and specialists? What if we redefined entry-level practice and continued the educational journey through paid apprenticeships or residencies? What if we started from the needs of the community and developed shorter and narrower programs in response?

It’s been done before. Barefoot doctors with roughly a year of basic medical training deployed to rural villages in China during the Cultural Revolution and significantly improved infection control, morbidity and mortality. If this example sounds a little extreme, consider the University of Global Health Equity in Rwanda, which currently offers a combined bachelor’s degree in medicine and surgery and master’s in global health in just six and half years.

In the United States, we have two successful examples of community-driven education as well. The University of Colorado created the first nurse practitioner (NP) program in 1965 to keep rural Colorado children healthy through vaccination, health education, and other preventive services. In the early 2000s, the Alaska Native Tribal Health Consortium responded to the poor oral health of rural Alaskans by sending a handful of community members to New Zealand for two years of post-high school dental education, which was unavailable then in the United States. These pioneers became the first U.S. dental therapists (DTs). Programs for NPs are now ubiquitous, and programs for DTs have taken root in several states, but degree requirements for both health professions have expanded since their earliest days. There may be lessons here as we consider bold approaches to restructuring health professions programs.

At NYU

Affordability is an especially salient issue here at NYU Dentistry. That’s not surprising, given our location in the nation’s most expensive city. Nonetheless, we are eager to find ways to reduce the economic burden on our students.

One approach we’ve taken is to offer early admission to undergraduates who can meet our requirements in three years of college study through the NYU BA/DDS program. These students arrive well prepared and possess the maturity needed to pursue professional studies. Their experience is in line with that of many of my own dental school classmates, who started their professional studies after just two years of college. Similarly, most of our colleagues from overseas specialize right out of high school. Although their dental education lasts a year or two longer than ours, they enter the dental workforce years in advance of their U.S. peers. 

To my mind, encouraging students to seek early admission is a sensible first step all dental schools can take while our community explores potentially disruptive ways to increase the affordability of becoming a dentist. At NYU, we are using our Brooklyn clinic as a pilot site for one such model: High Efficiency Education in Dentistry (HEED). A select group of our D-4s will practice in this location alongside faculty. HEED employs a mentor-protégé model akin to a preceptorship or residen­cy model of clinical teaching.

Education’s Return on Investment

Those of us in dentistry know that dental education continues to provide a strong ROI, and the same is true for our colleagues in dental hygiene. In fact, the job prospects for dental hygienists are excellent right now, with a third of surveyed dentists actively recruiting, and almost 90% reporting that finding hygienists is very or extremely challenging. Dental assistants and lab technicians are also in demand, yet the value of entering the health professions may be far less apparent to young people deciding on future careers. They hear about the cost of education rising but don’t always grasp how their future earnings would offset those costs. Even government statistics don’t paint a full picture. They often measure ROI as debt vs. first-year earnings, a calculation that doesn’t factor in the substantial income growth most dentists experience over time.

Anecdotal accounts in the media can also be discouraging. The example of billionaires who dropped out of college offers a tantalizing alternative to the traditional career path. Meanwhile, the specter of debt and indebted students who never finish their degrees provides a cautionary tale. There’s also this sobering news: The size of the lifetime-earnings advantage that a college degree confers is no longer growing, and unemployment rates for recent college grads are on the rise.

Time for Change

If we want to see a steady flow of new entrants into our professions, we need to do a better job of conveying the ROI message. We also need to make entry into our professions less burdensome. The ideas mentioned above include concrete steps our schools can take today. As for more radical change, recent federal actions that are shaking up the status quo in higher education, health care, and research could provide the impetus for our institutions to seriously consider new approaches to preparing the next generation of health professionals.  The way forward may take time to emerge, but I suspect bold actions that reduce costs and increase value — to society as well as individuals — will likely carry the day.

By Rick Valachovic, DMD, MPH, Clinical Professor and Co-Executive Director of the NYU Dentistry Center for Oral Health Policy and Management

The community water fluoridation (CWF) tide is turning and it’s happening fast.

• In late March, Utah became the first state to ban CWF.
• Last week, Florida became the second state to ban the practice.
• Bills are pending in at least three more states and circulating in many more to reverse CWF mandates.
• At the federal level, the Environmental Protection Agency announcedit would review the evidence on CWF’s potential risks, and the Centers for Disease Control and Prevention and the Community Preventive Services Task Force are expected to reverse their recommendations in favor of CWF.
• In a related move, the Food and Drug Administration announced last week it will take steps to stop the marketing of ingestible fluoride products aimed at children.

Members of our community are speaking out in response. The American Dental Association, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics issued a joint statement affirming the safety and efficacy of CWF, and the American Dental Education Association released a separate statement supporting the practice.

While some have argued that CWF is no longer essential given the widespread availability of fluoride via toothpaste and other consumer products, the evidence from communities that have discontinued CWF underscore its continued relevance. In fact, studies strongly indicate that the practice still has a meaningful role to play in preventing tooth decay, especially among children.

The Evidence

Take Calgary, Alberta. When the city’s fluoride injection system broke in 2011 necessitating millions of dollars in repairs, city councilors saw removing fluoride from the water supply as a way to avoid a major expense and respond to public sentiment opposing fluoridation. From a political standpoint, halting CWF was clearly the smart choice. Ten years later, a marked rise in childhood caries shifted public opinion and the political winds. A 2021 ballot measure to reintroduce CWF passed with 62% of the vote.

In Juneau, Alaska, CWF was stopped in 2007. Researchers studying Medicaid data observed a statistically significant increase in caries-related dental procedures and treatment costs for children from low-income families between 2003 and 2012. The increase was most pronounced in children under 7 who had almost no exposure to fluoridated community water during their lifetimes.

A similar rise in decay occurred in Israel after the minister of health ended mandatory water fluoridation in communities of 5,000 or more in 2014. This policy change occurred despite strong evidence that children 3 to 12 years of age in Israeli communities with no fluoride in the water had almost twice as many dental restorations as their counterparts in communities with CWF. What was the effect of eliminating the mandate? Not surprisingly, a study comparing the dental records of military recruits who entered service between 2012 and 2021 found higher rates of caries-related treatment among those with less exposure to CWF during their childhoods. What might surprise some is that the study also found no association between access to free, universal pediatric dental care (introduced in 2010 and extended to teenagers in 2018) and the recruits’ oral health. It appears access to treatment is no substitute for community-based prevention when it comes to dental caries.

Where We Stand Today

Less than a year after changing its fluoridation policy, Israel’s Ministry of Health decided to reverse it. The Knesset approved the change, but funding has yet to be appropriated to support fluoridation’s reintroduction. Calgary is in a similar holding pattern. Four years after voting to restore fluoridation, the city is still working to upgrade its infrastructure to achieve that goal, and the initial estimated cost has almost tripled. Juneau has no plans to reintroduce CWF, so local dental professionals rely on topical fluoride treatments to protect their patients’ teeth.

I hope dental professionals and other clinicians will continue to advocate for CWF at the state and community levels, but in communities where fluoridation is halted, we will need to take other steps to protect our patients’ health.

What We Can Do Moving Forward

In my December post on this topic, I described a variety of steps dental professionals can take to protect our patients’ oral health. These included:

Oral hygiene education. We should make sure our patients know how to properly brush and floss and understand the role of diet in tooth decay.

Encouraging the use of sealants to protect children’s teeth. We need to inform families of their value, especially in communities that discontinue CWF.

Introducing silver diamine fluoride (SDF) in your practice. This effective tool for caries treatment and prevention has yet to be widely adopted. Its wider use could make a major contribution to mitigating the harm to children’s oral health that we anticipate.

Employing other fluoride treatments. Fluoride-containing toothpastes, varnishes, gels, and rinses can also benefit our patients — at least for now. Some of these are also under attack. At the end of April, the Texas Attorney General filed suit against Colgate and Proctor & Gamble claiming that their practice of marketing flavored toothpastes containing fluoride to children and parents is “misleading, deceptive, and dangerous.” 

Sugar taxes are another public health measure that has substantially reduced childhood caries, but Americans have often balked at efforts to reduce their sugar consumption. When then New York City Mayor Michael Bloomberg attempted to restrict the sale of soda in large containers, the backlash was fierce, and two years later, the regulation was overturned by the courts.

Would a similar federal effort by the current administration be more warmly received by some previous objectors? Perhaps. As the number of communities with fluoridated water decline, we may see increased recognition that public health measures to protect American’s oral health are urgently needed.

University of Alaska Anchorage Associate Professor of Public Health Jennifer Meyer, PhD, MPH, CPH, RN, who studied the impact of Juneau’s decision to halt CWF, has eloquently made the case for adding fluoride to the water supply. “We add and supplement beneficial elements in food for many reasons,” Meyer said during a 2019 interview. “It’s an effective and equitable public health strategy. For example, we fortify wheat products with folic acid to prevent spina bifida and other neural tube defects. We add calcium and vitamin D to milk to prevent rickets, and adding iodine to salt has been a primary way of preventing iodine deficiency and goiters. Similarly, fluoride is an important mineral for the development and protection of teeth. Adjusting the availability of fluoride in the community water to an optimal level (0.7ppm) supports a population oral health benefit and mitigates risk.”

I saw the power of CWF firsthand when I was a pediatric dental resident at Children’s Hospital in Boston. When I started, we routinely saw high levels of caries in our patients. After the city introduced CWF, their oral health improved dramatically. I hope the panic surrounding fluoride will subside and efforts to remove this beneficial mineral from water supplies will be successfully countered. In the meantime, history tells us to expect a surge in tooth decay if public fear of CWF continues to dictate public policy.

By Rick Valachovic, DMD, MPH, Clinical Professor and Co-Executive Director of the NYU Dentistry Center for Oral Health Policy and Management

If you’re concerned about sustainability in dental clinics and offices, chances are you care about waste: the endless stream of plastic wrap, gowns, gloves, and all the other single use items that we throw away each day. I have to admit, until recently I hadn’t given sufficient thought to dentistry’s broader environmental footprint.

That changed in 2023, when I attended the annual meeting of the Association for Dental Education in Europe (ADEE). I was struck by how seriously the Europeans take sustainability. They aren’t just focused on disposables. They are looking at how teledentistry can reduce the profession’s carbon footprint and at prevention as the ultimate sustainability strategy. What’s more, they are implanting these ideas into the future dental workforce by adding “sustainable practice” to the list of competencies for The Graduating European Dentist, with the expectation that dental graduates will understand the environmental impact of their clinical practice, demonstrate respect for the environment, critically evaluate current practices, and seek practical solutions within an ethical framework.

Here at Home

Europeans are far ahead of the U.S. dental community, but that’s not to say that nothing is happening on this side of the pond. 

• The American Dental Education Association (ADEA) has formed a special interest group (SIG) focused on sustainability.
• And at several U.S. dental schools, concerned students and faculty have lobbied for innovative clinical practices and curricula related to sustainable dentistry.
• The American Association of Dental Office Managers offers tips on greening dental practices and has initiated a Green Leader Initiative sponsored by the Henry Schein Cares Foundation.

Jennifer Luca, DMD, MS, a Michigan-based pediatric dentist, is chair of the ADEA Sustainability SIG and was a student leader in sustainability at the Harvard School of Dental Medicine (HSDM). She cofounded and led HSDM’s “Green Team” and conducted a survey of student and faculty attitudes towards sustainability at more than a dozen dental schools. The respondents were overwhelming interested, she told me, but “no one had any idea what to do.”

At HSDM, the “Green Team” lowered the school’s carbon footprint by setting the hoods in the bench lab to close automatically when research was not taking place and transitioning from plastic to paper for patient goody bags. At Nationwide Children’s Hospital in Columbus, Ohio, where Dr. Luca did a residency in pediatric dentistry, she formed an employee resource group that attracted 120 members. “We planted trees. We picked up trash. We had green physicians and anesthesiologists and facility workers present to the group.” Dr. Luca also estimated the environmental impact of treating early childhood caries and discovered patients’ travel-related emissions and the use of nitrous oxide, a potent greenhouse gas, had the greatest impact. Now she is focusing her research and advocacy on reducing the environmental impacts of anesthesia use in pediatric dentistry.

Dentistry’s Carbon Footprint

A widely cited 2016 estimate attributes 10% of U.S. greenhouse gas emissions to the nation’s health care sector. Of that, 3% is often attributed to dental care, and a report quantifying the environmental impact of dental care in England supports that figure. That may not sound like a lot, but in the aggregate, the impact is much harder to dismiss.  An estimated one billion plastic toothbrushes are discarded each year in the United States alone, and because most are made from composites, they can’t be recycled.

The amount of waste generated by dental offices is also substantial, and dental school clinics, because they are teaching environments, generate even more. In recent months, students and faculty at NYU Dentistry have conducted waste audits in the oral surgery and some general dentistry clinics. Leena Manzoor, a third-year student, led the audit with her classmate Mona Jahangirvand and with Mahsa Salmasi, a second-year student who serves as greening representative to the college’s student government. All three are in the group practice led by Bapanaiah Penugonda, BDS, MS, an associate professor and one of the college’s most vocal advocates for sustainable practice.

The students shared the results of one audit during the college’s recent Research Day, and the results were eye-opening. Their six-day audit of discarded unused materials in the oral surgery clinic found 268 burs, 244 restorative materials, 203 anesthesia components such as carpules and needles, and an assortment of other items. The estimated cost based on this brief audit? $828.

If that sounds like a lot, the audit team discovered even more waste in Dr. Penugonda’s general dentistry clinics that took part. Paul R. Baker, DDS, clinical assistant professor of oral and maxillofacial surgery and one of the professors who encouraged the waste audit, attributes his clinic’s better performance to the unit’s supply clerks, who “constantly ask students, ‘Do you need this? If you’re taking a handful, are you going to use this?’”

Even before the audit, Dr. Baker had made a point of exposing students finishing their oral surgery rotations to the unused items typically discarded in his clinic each day and their costs. While some of the students who are just starting their clinical rotations roll their eyes, he says those on the cusp of graduating are stunned by the financial implications for their future practices.

Strategies for Change

So, what can be done about all this waste?  The students who conducted the audit have made three policy recommendations, which they hope the college will adopt later this year.

1. Reduce waste by standardizing how many supplies students can access for each type of procedure.
2. Reuse discarded burs in the sim lab. These come individually wrapped, so only the packaging would need cleaning.
3. Incorporate sustainability in the curriculum throughout the four years, not just in the final practice management course.

Given our crowded curriculum and the universal sense that students feel stressed for time, this last request is particularly notable.

How can U.S. dental practices reduce waste? While plastic materials are convenient and cheap, there are alternatives. In our clinics, perhaps we can replace disposable plastic nozzles with metal ones that can be sterilized, and we can encourage our patients to use more sustainable oral hygiene products in their homes. Bamboo toothbrushes, biodegradable floss, and toothpaste tablets that obviate the need for plastic tubes are all currently being marketed, and industry heavy weights are striving to make their packaging and manufacturing processes more environmentally friendly.

In most practices, electronic health records have reduced paper waste.  Meanwhile 90% of dental practices have adopted digital radiography, eliminating the waste associated with film stock and development chemicals. A 2021 survey suggested half of dentists were also using intraoral scanners, with two-thirds of those remaining planning to acquire one.

Beyond Waste Reduction

To reduce its carbon footprint, dentistry must also examine a range of other activities that produce emissions. Chief among these is travel. The report on dental care in England I mentioned above attributed more than 60% of the country’s dental carbon footprint to patient and staff travel. The energy used in dental facilities and procurement (production and transport of materials) ranked second and third at almost 20% each.

The establishment of the LEED rating system for design and construction has helped to make many newer buildings more energy efficient, but the facilities we work in are typically beyond the control of most oral health professionals. We could, however, take steps to reduce the amount of travel associated with our provision of care. We could reduce the number of patient trips by offering telehealth consultations, scheduling family members on the same day, and completing adjacent restorations in a single visit. Larger practices can also open satellite clinics in more remote areas to take care to patients, rather than the other way around.

Most importantly, we can double down on prevention — the most sustainable form of oral health care. In some cases that will mean bucking administrative and payment systems that don’t always reimburse for patient education or give dentists flexibility in scheduling procedures for irregular blocks of time. We should take on these challenges, not just because it’s good for the environment, but because avoiding the need for restorative dental care is what’s best for our patients.

Are We Ready to Commit?

It’s hard to say how ready U.S. dentists are to embrace sustainable practices, but I was pleased to see Toni M. Roucka, DDS, MA, FACD, current editor of the Journal of the American College of Dentists, assert this spring that dentists have an ethical responsibility to practice sustainably.

As healthcare providers, dentists must consider the broader impact of their practices on their patients’ overall health and well-being, including the health of the environment and the mitigation of climate change, often described as the greatest public health challenge of the 21^st century.

Many dental students already share this view and are putting their beliefs into action. At NYU, they have petitioned the college, along with Dr. Baker and Dr. Penugonda, to create an official sustainability committee, which they anticipate will begin influencing policy this fall. They hope the integration of sustainable dentistry principles in the clinics and curriculum will not just benefit them but influence practice far beyond the dental college. As Mona Jahangirvand put it, “There are almost 380 NYU Dentistry graduates each year. So, if 400 dentists in America implement these practices, I feel like we will be able to see a change in the field even within the next decade.”

Given the enthusiasm for sustainable dentistry I’ve witnessed at NYU and read about elsewhere, I’d say that’s a strong possibility.

Learn More

The FDI World Dental Federation Sustainability in Dentistry website contains:

• A free, online, three-hour course to help oral health professionals understand the importance of sustainable practice and their own role in tackling sustainability issues
• An interactive sustainability toolkit
• Infographics and journal articles on a range of sustainability topics
• FDI’s Consensus Statement on Environmentally Sustainable Oral Healthcare
• A pledge with signatories from around the globe.

Several of my colleagues also recommend The Sustainable Dentist by Beverly Oviedo-Allison and Marylou Shockley. It provides concrete advice to practice owners on operating their businesses more sustainably.

Those working in large health systems will find additional resources on the Health Care Without Harm website, which seeks to reduce health care’s environmental footprint worldwide.