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

Fluoride has been in the headlines — tens of thousands of headlines this past month alone. Even before President-elect Donald Trump nominated a fierce opponent of community water fluoridation to be secretary of health and human services, the popular press was busily examining the mineral’s purported benefits and harms. In September, a federal judge’s decision that community water fluoridation “poses an unreasonable risk of injury to health” appeared to confirm public fears. These were already heightened by the summer release of a monograph by the National Toxicology Program (NTP), which showed an inverse association between high levels of fluoride exposure and neurodevelopment and cognition.

These events triggered what has since become an avalanche of media coverage. Happily, much of it focused on setting the record straight. Reporters and commentators were quick to point out that, as with any medicine, dose matters. The negative effects of fluoride cited in the NTP monograph came from studies performed in regions with high levels of naturally occurring fluoride in the water supply. Fluoride exposure in these studies (all conducted overseas) was at or above 1.5 milligrams per liter — more than double the amount in U.S. fluoridated water systems.

So, should Americans be concerned that community water fluoridation is a risk to their health?

There is no evidence to suggest that community water fluoridation at 0.7 milligrams per liter — the current standard — is harmful. Quite the contrary. According to the Centers for Disease Control and Prevention (CDC), community water fluoridation safely and inexpensively reduced dental caries in children by 40%-70% and tooth loss in adults by 40%-60% between 1945 and 1999. You don’t get much more effective than that, which is why the agency listed community water fluoridation among the top 10 public health achievements of the 20th century.

That said, a lot has changed since community water fluoridation was first introduced in the United States. If those of us in the public health community want to preserve our credibility and continue to influence policy, we should consider the latest evidence on the value of community water fluoridation and talk honestly with our patients who are seeking alternative ways of protecting the health of their teeth. 

Evolving Evidence

The movement to fluoridate U.S. community water supplies was born out of an auspicious 15-year study. Following the introduction of fluoride in the Grand Rapids, Michigan, water system in 1945, scientists at the then-named National Institute of Dental Research monitored the dental health of 30,000 impacted school children. The results were dramatic. The dental caries rate among children born after the introduction of community water fluoridation was more than 60% lower than that of their older peers.

The success of community water fluoridation in preventing dental caries in Grand Rapids led other communities to adopt the practice and spurred businesses to develop new products to prevent tooth decay. Fluoridated toothpaste entered the marketplace in 1975, and mouth rinses containing fluoride were also introduced, becoming widely available on supermarket and drugstore shelves.

Given these developments, should Americans be concerned about ingesting too much fluoride?

In most cases, no, but there is one group of Americans who may have cause to avoid products containing fluoride: the 1.9 million people living in communities with naturally occurring fluoride in the water supply above the 1.5-milligrams-per-liter level considered safe by the World Health Organization. According to the CDC, these communities made up less than 1% of the U.S. population in 2020, and since they don’t live in areas with community water fluoridation, they are unlikely to be affected by any new federal policy recommendations. It will be up to local policymakers and public health officials to mitigate the health risks children in these regions may face.

As for the 72.5% of U.S. residents living in areas with community water fluoridation, the current evidence suggests that community water fluoridation is strengthening their teeth without harming their overall health. That said, 80 years after its introduction, is there still a strong case for implementing community water fluoridation?

The Cochrane Database of Systematic Reviews released a review in October that sheds light on this question. The reviewers examined 157 studies comparing dental caries in populations receiving community water fluoridation with populations consuming naturally low-fluoridated water. They found that as the use of fluoride-containing products became commonplace among consumers, the relative impact of community water fluoridation declined. Prior to 1975, the reduction in the number of decayed, missing or filled teeth resulting from community water fluoridation averaged 2.1 teeth per person. In studies conducted after 1975, the effect size had dropped to one quarter of a tooth.

Looking Ahead

So, where does the evidence leave us?

We should continue to inform policymakers and our patients about the safety and efficacy of fluoride at recommended doses, but we also need to acknowledge that community water fluoridation is not the indispensable intervention it once was and accept the fact that public sentiment may be shifting against it. If that occurs, how else can we protect the oral health of our most vulnerable populations?

Encourage good oral hygiene. Brushing with fluoridated toothpaste and flossing remain the first line of defense in preventing cavities in teeth.

Encourage the use of sealants to protect children’s teeth. Sealing molars has been shown to reduce the risk of dental caries by almost 80%. Best of all, sealants can be applied in school settings, making it possible to reach children who may not have a routine provider of dental care. 

Discuss the role of diet in maintaining oral health. As long as Americans continue to consume large amounts of sugar and other processed foods, their oral health will be at risk. Public health measures that influence people’s dietary choices can help lay a foundation for better oral and overall health.

Stay informed about alternative remineralizing agents. A growing body of evidence supports the safety and efficacy of hydroxyapatite in reducing dental caries. Since it was first tested in Japan in the late 1980s, a variety of oral care products containing the compound mineral have come on the market, but one recent survey suggests few dentists practicing in this country are familiar enough with these products to recommend them to patients.

Offer fluoride treatments. Varnishes, gels and other topical fluoride products are another effective means of preventing dental caries for those at higher risk, whether applied during a dental visit or as part of a school-based program. Dietary fluoride supplements can also benefit these patients. Even individuals who do not want to consume fluoride in their drinking water may be open to using fluoride mouth rinses to control decay.

Ironically, the public resistance to fluoride coincides with two developments that showcase the mineral’s value:

• The 2021 World Health Organization decision to update its list of essential medicines to include fluoride toothpaste for the first time.
• The growth in evidence supporting the use of silver diamine fluoride to arrest decay and prevent dental caries.

Members of the dental community should use their influence to ensure these tools remain in our collective toolbox as the debates about fluoride continue in Washington and the public square.

Americans continue to make over 2,000,000 emergency department visits each year for dental pain. The vast majority of these visits arise from untreated dental caries and their consequences. Community water fluoridation — and other proven preventive measures — can mitigate that risk, especially for the most vulnerable among us. As we reconsider the evidence on fluoride and appraise the latest research, let’s keep their well-being top of mind.

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

Each Veterans Day, many dental schools and some private dental offices open their doors to veterans and honor their service by providing free dental care. These acts of generosity are welcome and impactful, but they point to a shameful reality: For too many veterans, access to dental care is often a matter of charity and chance.

Roughly 15% of veterans are eligible for dental benefits through the Veterans Administration (VA), and many of the ineligible veterans can’t afford to pay for care on their own. This gap in care has persisted for decades, despite the fact that veterans have higher rates of dental caries (56% versus 37%) and periodontal disease (42% versus 27%) than their civilian counterparts.

“They sacrifice. Their families sacrifice. They shouldn’t have to struggle to get dental care,” says Gabriela Gonzalez, MPA, director of the VOCARE (Veterans Oral Care Access Resource) program at NYU Dentistry. The VOCARE initiative provides free dental care to U.S. military veterans from the five boroughs of New York City who are registered with the VA and are not eligible for dental benefits through the VA. Enrollment in VOCARE is based on referrals received from providers at the VA New York Harbor Healthcare System, the VA Bronx Health Care, and the Leukemia & Lymphoma Society.

Since its inception in 2021, VOCARE has made a significant dent in the access to dental care problem for veterans living in our region. Between July 1, 2021, and June 30, 2024, 3,253 veterans received care in our clinics. Over the course of 29,473 visits, 58,040 procedures were performed. The program currently gets about 20 to 25 referrals each day.

“VOCARE is having an impact in New York City and New York State,” says Michael O’Connor, EdD, MPA, who serves as executive vice dean and oversees the VOCARE program. He says the NYC VA directors are “thrilled” that they now have a place to refer their patients for free dental care. So are VA leaders in Washington. During a visit to NYU earlier this year, U.S. Secretary of Veterans Affairs Denis McDonough presented Gabriela with a military challenge coin in recognition of the VOCARE program.

On the Policy Front

As we celebrate VOCARE’s success, we are acutely aware that beyond our immediate region, millions of veterans still struggle to receive dental care. According to a June article in Military Times, only 1.8 million of the nation’s 9 million veterans were eligible for dental care through the VA in 2023. To qualify, veterans must demonstrate their oral health needs are either connected to their military service or medically necessary to prepare the veteran for a covered hospital admission. Routine dental care is not a covered benefit.

The VA also provides dental care for veterans who are considered 100% disabled as a result of service injuries. The 2022 PACT Act, which created health benefits for veterans exposed to burn pit smoke and other toxins, has made it easier to qualify for the 100% rating. This should increase the number of veterans eligible for dental benefits, but shouldn’t all veterans have access to dental care, whether or not they have a service-related disability?

Some in Congress think so, and they have introduced legislation that would expand access to dental care for millions of veterans. The Dental Care for Veterans Act, introduced in 2023, has garnered 68 co-sponsors. It would eliminate the current eligibility restrictions for VA dental care. A separate bill introduced the same year would provide dental care to veterans diagnosed with diabetes and ischemic heart disease. With only 14 cosponsors, its chances of immediate passage are less promising.

Nevertheless, Michael believes momentum in favor of expanding veterans’ oral health benefits is building. “Will it be full oral health care? Not this round,” he says. “But will there be some enhancement to current plans? I think so. One idea is to have a voucher system in which each living veteran receives $1,000 to $2,000 a year to spend on dental care, and they decide how best to spend it,” he suggests.

Each spring, we take 20-25 students to Washington, D.C., in conjunction with our Global Health Care Leaders program. As part of this leadership experience, our students have been able to speak on behalf of pending legislation related to oral health priorities in meetings at our Congressional representatives’ offices on Capitol Hill. During one such encounter, a member of the New Jersey delegation asked one of our students, Anthony Allison, DDS (a 2024 NYU Dentistry grad), if he would serve as an advisor on veterans’ oral health policy. As an active-duty member of the U.S. Army, Anthony was only too happy to oblige. With such committed and knowledgeable advocates, the momentum Michael has observed can only grow.

A Role for the Private Sector

The success of VOCARE would not be possible without NYU Dentistry’s in-kind contributions and additional donations to cover the cost of care. A generous donation from the United Concordia Dental Charitable Fund helped us launch the program, and the Leukemia & Lymphoma Society, which underwrites dental care for veterans with blood cancers, soon followed suit. Subsequently, support arrived from the New York State Assembly, the New York State Senate, and the New York City Council.

Faculty, students, and alumni at NYU Dentistry have also been moved to contribute. Of special note is a $1 million donation announced earlier this week, from NYU dental alumni Dr. Nazish Jafri and Dr. Noel Liu. Their gift will sustain the program and allow us to expand the dental services the college provides to deserving veterans. The Chicago-based couple are talking with other area alumni about ways to support veterans’ oral health, and we hope their example will spur alumni all over the country to think about serving veterans in their locales.

So does Dianne Sefo, RDH, MEd, who chairs our Dental Hygiene & Dental Assisting Department. Dianne is also the daughter of a veteran and a VOCARE donor. She introduced everyone to the Wounded Veterans Relief Fund, which provides financial assistance and dental care to wounded veterans in Florida. A burgeoning relationship has formed.

“My hope is that the relationship will raise more awareness and get more Florida alumni involved, whether it’s volunteering their work or providing monetary support,” she says. As she points out, NYU graduates 10% of all dentists in the country, so the impact our alumni could have in this one area is vast.

Of course, dentists do not need to be NYU Dentistry graduates to join in providing veterans with free or reduced cost dental care. Michael is particularly eager to see how the American Dental Association (ADA) Foundation’s Give Veterans A Smile program, launched last month, impacts veterans’ care. “As advocates for veterans to get more oral health care, they have the capacity and the influence to make a major difference across the country,” he believes. I hope the organization will use that clout with their members and with lawmakers.

As someone who has worked with the Veterans Administration Outpatient Clinic in Boston and served as a technical expert to the VA on veterans’ oral health care, I’m heartened to see policy moving in the right direction. Veterans and their families sacrifice a lot to serve this country. We shouldn’t be leaving their dental care to chance.

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

The health professions face an urgent challenge — a significant shortage of leaders amid an overarching shortage of health professionals — and dentistry is no exception. Anyone following demographic trends has long known this day would come. Baby boomers have been aging out of the health professions for about a decade now, and they are joining the ranks of older Americans, the heaviest consumers of health care.

These two developments amplify one another, and they have been further exacerbated by recent changes in healthcare delivery and the lasting impacts of the COVID-19 pandemic. Medicine, nursing, and dentistry have all seen an exodus of professionals from clinical roles, driven by burnout, job dissatisfaction, and a reevaluation of career paths. The result is a pressing need for leadership that can guide the professions through both immediate hardships and longer-term challenges.

Dental education is also witnessing a critical shortage of leaders. The expansion of the number of dental schools and the increase in student enrollment have created a demand for experienced deans, faculty members, and administrators. Unfortunately, the traditional pipeline for seasoned professionals has been disrupted both by baby-boomer retirements and by a slower-than-anticipated influx of new graduates stepping into leadership roles. In this context, cultivating a new generation of leaders who are prepared to navigate and address these complexities has become imperative.

Developing Tomorrow’s Leaders

These concerns propelled NYU Dentistry to establish the Center for Oral Health Policy and Management in 2021. When Dean Charles Bertolami asked me to direct the Center along with Executive Vice Dean Michael O’Connor, we decided that creating a portfolio of student leadership opportunities would be one of our highest priorities. We launched several innovative initiatives that year, and these were so successful that we soon heard from faculty and staff saying, “I want in!”

This thirst for leadership development speaks volumes. Clearly all generations within dental education are eager to step up to leadership roles and recognize the value of preparation. So how can we cultivate this latent talent? Here’s what we’re offering at NYU Dentistry.

• The NYU Dentistry Leadership Track. This twice-monthly lecture series focused on character-based leadership was initially designed exclusively for dental students. Enthusiastic demand from other members of our community led us to open these talks to faculty and staff. This initiative highlights the value of leadership training throughout the dental education ecosystem.
• Student Leadership Mock Congressional Hearing. Each spring, students are invited to apply for this competitive program, which enhances students’ public speaking and advocacy skills. Participants prepare and deliver testimony on a health policy topic before a mock congressional panel, gaining valuable experience in policy-related leadership.
• The Dental Student Leadership Institute (DDSLI). Each year, up to 35 D1 students are selected to take part in the DDSLI, an intensive leadership development experience. Over the next three years, participants are given access to seminars, workshops, internships, mentoring, and other opportunities designed to prepare them to manage the complex challenges of advancing oral health in the 21st century. The program culminates in a capstone project during their fourth year, ensuring that students can apply their leadership skills in a real-world context.
• Global Health Care Leaders: Washington, DC. Students from across the College of Dentistry, including advanced standing students and dental hygiene students, are eligible to apply for this professional development experience. Participants visit NYU’s DC campus to gain insights into policymaking and legislative processes through meetings with oral health advocates and federal lawmakers.
• Global Health Care Leaders: NYU Global Academic Centers. D4 students are eligible to apply for this international experience. Selected students travel to one of NYU’s Global Campuses each year to explore complex policy issues with overseas leaders in government and oral health advocacy. In fall 2023, the experience took place at NYU’s Villa LaPietra in Florence, Italy. This October, 25 students will travel to NYU’s Prague campus to participate in a program entitled, “From the Velvet Revolution to Health Equity: Using Dissent and Hope to Reframe Oral Health Care.”

The students in these programs are thriving. Just one example: Two of my mentees in the DDSLI — Sam Al Safarjalani and Natalie Ralston — were elected to serve on the NYU Dentistry Student Government Executive Board as president and vice president this year.

Last year, we created a second leadership development program specifically aimed at faculty. It launched this past June with twenty-five full-time faculty taking part. Over three days, they developed skills that can accelerate their ability to move into leadership roles in higher education. The experience inspired some of the participants to begin working together to recruit DDS applicants from underrepresented groups and address other compelling issues in dental education. If their efforts bear fruit, they will have shown true leadership — paying it forward as they continue to pursue their own leadership journeys.

Looking to the Future

The dental profession is encountering a host of contemporary challenges that require innovative leadership. Whether addressing disparities in access to care, integrating advanced technologies such as artificial intelligence and personalized medicine, or managing public health crises such as the opioid epidemic, leaders will be needed to drive the dental professions forward in a rapidly changing environment. By integrating leadership development into dental education, we can ensure that the profession remains resilient and capable of meeting the needs of the populations it serves.

The example set by NYU College of Dentistry provides a valuable roadmap for how dental schools can prepare their students for future leadership roles. While such initiatives could take many forms, leadership development is essential for equipping students to succeed in a complex and evolving healthcare landscape. It is imperative that dental educators commit to fostering the next generation of dental leaders. As we look to the future, let us commit to empowering and supporting the leaders of tomorrow, so that they are well-equipped to address the challenges and opportunities that lie ahead in the dental professions.

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

The age of value-based care has begun. The result will be an overhaul of how we think about, deliver, and are reimbursed for health care. These sweeping changes represent an extraordinary opportunity for dentistry—not only to define what value-based care means for oral health, but also to reshape health care to include what medicine has so often overlooked: the mouth.

Value-Based Care in a Nutshell

For anyone new to this discussion, at its core, value-based care aims to reward the quality rather than the quantity of care delivered. This prevention-focused approach incentivizes providers to improve the health of their patient populations by using personalized preventive care to ward off disease before it happens. This approach represents a sea change from the typical fee-for-service model that rewards providers for the number of procedures or treatments delivered after a patient becomes ill or experiences pain. Reimbursement models that focus on quality are person-centered and risk-based, so they inherently promote equity, target social determinants, and reduce health care disparities. The result is a healthier overall population at a reduced cost.

Value-Based Care and Oral Health Care

The value-based care movement is international, making strides in countries such as Brazil and the Netherlands, as well as in the United States. In 2022, 41% of U.S. health care payments involved alternative payment models, and another 18% of payments linked quality and value to fee-for-service reimbursements. Alternative payment models have gained the greatest traction in Medicare Advantage followed by Medicare and Medicaid—public programs which play much larger roles in medicine than in dentistry. Do our professions risk being left behind?

In 2020, the CareQuest Institute for Oral Health surveyed almost 3,000 dental providers in more than 20 states. It found 51% of respondents had never heard of alternative payment models in dentistry. Their report noted an increase in dental payments linked to alternative payment models from 27% of all Medicaid dental claims in 2013 to 33% in 2017. Additionally, some federally qualified health centers have implemented an integrated dental model emphasizing value-based care.

That represents progress but on the margins. Traditional Medicare does not cover most adult dental care, and in many states, fewer than half of dentists are enrolled as Medicaid providers and many of those are not seeing any Medicaid patients. We need to do more to push dentistry in the right direction.

Academic dentistry could help, but our commitment to value-based care also lags behind that of our medical peers. In a 2022 survey of dental school deans, 65% of respondents reported that value-based care was not currently in the didactic curriculum and only 25% said their schools were considering implementing value-based care in their clinics. Similarly, a 2022 study showed a need for more training and guidance among dental school faculty to effectively bring value-based care into didactic and clinical instruction.

An Opportunity at Our Fingertips

In addition to its potential to reduce health care spending, value-based care blazes a path for medical-dental integration. The focus on value gives oral health professionals an opportunity to demonstrate how the integration of dental and primary care can improve patient outcomes. You might say it is our chance to show that the money is where the mouth is.

Control of type 2 diabetes is one case in point. A recent study in The Journal of the American Dental Association showed that overall health care spending for Medicaid patients with the disease decreased by 14% when they regularly received periodontal treatment. A decrease of 12% occurred for similar patients with commercial insurance. Value-based care should incentivize this type of integrated care and make it the rule, rather than the exception.

In a recent article in JAMA Internal Medicine, Ira Lamster, DDS, MMSc, clinical professor, Stony Brook School of Dental Medicine, and Lisa Simon, MD, DMD, fellow in oral health and medicine integration, Harvard School of Dental Medicine, suggest some specific ways dentists could enhance primary care by seizing the opportunities latent in our unique access to patients who come in for regular dental cleanings. They note past successes with screening for tobacco use and poor diet, adding that dentists can perform services such as hypertension and depression screenings without additional infrastructure. Further, screenings for conditions such as colorectal cancer, HIV, and type 2 diabetes can occur with minimal additional resources.

The shift to value-based care in health care primes the landscape for this kind of thinking. When conversations occur about shaping value-based care, we need to be sure we are present and ready to make the case for medical-dental integration.

Barriers to Value-Based Care in Oral Health Care

Of course, implementation of value-based care in oral health care is not without its challenges. The predominance of small dental practices, compatibility issues with electronic health records, the limited use of diagnostic codes in dentistry, and the current structure of dental insurance all present barriers. Most significantly, state and federal quality and reporting programs lack standardized oral health measures that would help us define what we mean by “quality,” hindering our ability to develop uniform ways of addressing such things as compensation and accountability. But these barriers are not insurmountable—and they are not new. The rise of value-based care has simply brought them to the fore.

Embracing the Value-Based Care Paradigm

The barriers we face leave us with quite a to-do list that includes devising outcome measures, increasing our use of diagnostic codes, and developing collaborative partnerships to foster interprofessional care. But the first order of business is to increase understanding and acceptance of value-based care among those in our own community. This is where dental education can play an essential role. We must incorporate value-based care into our curricula, determining what to teach and how to teach it. If we take these steps, the next generation of dentists will be prepared to practice in a value-based care environment enhanced by medical-dental integration. The sooner we embrace this paradigm shift, the sooner we can make it a reality.

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

It’s a cliché to say that traveling opens our eyes to new ways of seeing things. That doesn’t mean it’s not true. My frequent interactions with internationally educated dentists — both overseas and here at NYU — have me thinking about how we first decided it should take eight years after high school to produce a dentist and whether we can do it more efficiently moving forward. Are there ways to shorten the total time to a dental degree and make it more affordable without compromising the quality of education and patient care? The evidence points to a resounding, “Yes!”

It is in just a few countries — the United States, Australia, New Zealand, and some Canadian provinces among them — that most dental schools require a four-year university degree for admission. Almost every other country does not. If you live in China, Japan, Brazil, or most of Europe, you can apply to dental school directly from high school. The time these students spend in dental school is a year or two longer than the time spent here, but they enter the dental workforce years in advance of their U.S. peers. 

Could the United States adopt a similar model? The four-year undergraduate degree has become such an established first step on the U.S. career ladder for all professions that it is hard to imagine an alternate path, but there are precedents. Before the 1970s, most people entered dental school after just two years in college. That was still the case for many of my dental school classmates, some of whom were veterans during the Vietnam War era. The increase in applicants resulting from the Baby Boom changed that. When the numbers of applicants competing for 6,000 first-year slots swelled to 16,000, some dental schools began requiring bachelor’s degrees for admission. 

Those dental students who lacked four years of undergraduate preparation were able to graduate and obtain licensure, and I suspect there are many students today who could also succeed in U.S. dental schools without first completing a traditional bachelor’s degree. The undergraduate classes students take in subjects not directly related to dentistry may have value in and of themselves, but they cost money—more and more each year. For some students, the return on investment of accumulating credits outside their chosen area of study may be marginal at best. 

Whatever benefit students derive, it’s difficult to see how those additional courses necessarily contribute to preparing students for dental school. Meanwhile, the cost of obtaining those credits has skyrocketed, while burgeoning student debt has prompted Americans to question the value of higher education. Might there be benefit in allowing students who can demonstrate their knowledge and skills in the prerequisite sciences, math, and English to enter dental school without a four-year undergraduate degree?

The ROI on a dental education remains strong, but some potential applicants are hesitant to take on more educational debt. Replacing a year or two of college with a year or two of earnings would certainly be a win from their vantage point. That said, I realize this line of thinking may be anathema to some. If nothing else, it flies in the face of recent trends in some of the other health professions. 

• Physical therapy moved from a two-year degree in the 1930s to a four-year degree in the 1960s. Today a six-year Doctor of Physical Therapy degree is the standard for entry into practice.
• Pharmacy has followed a similar path. In the 1990s, the six-year Doctor of Pharmacy (PharmD) degree replaced the four-year Bachelor of Science degree, which reigned throughout the preceding half century.
• Nursing has also encouraged higher levels of education. Although the profession still accepts a variety of degrees for entry into practice, many hospitals have been preferentially hiring nurses with bachelor’s degrees over those prepared at the associate-degree level, and more and more advanced practice registered nurses enter their fields with practice doctorates rather than master’s degrees. 

At the same time, a countervailing trend aims to shorten the time it takes to earn a professional degree. For instance, nursing schools now offer a host of accelerated degree programs at both the undergraduate and graduate levels to speed entry into the workforce. The Association of American Medical Colleges is working to implement a competency-based educational model, which would lay a foundation for self-paced medical education. In 2013, the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education recommended the creation of a competency-based model for educating primary care physicians. These moves suggest broad agreement that the value of education is not accrued through seat-time alone.

In dentistry, many schools have replaced numerical requirements with other ways of demonstrating clinical competence and readiness for practice. And some dental schools have opted for year-round education so their students can enter the workforce in three years rather than four. At NYU, we offer early admission to undergraduates who can meet our requirements in three years of college study. These students arrive well prepared and possess the maturity needed to pursue professional studies. 

These are steps in the right direction, but could we be doing more? Is it time for all U.S. dental schools to consider alternatives to the eight-year path? The answer seems obvious to some of my internationally trained colleagues. I personally find my encounters with our seven-year students persuasive. They are thriving in dental school and will soon be treating patients outside our clinic walls. The sooner they get there, the better. 

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

Across the globe, millions of people lack oral health care. Others are going to great lengths to access it. Imagine traveling thousands of miles for a routine dental appointment, leaving the country to get an implant, or—unfathomably—extracting your own teeth! These things are happening to residents in the present-day United Kingdom, and they are not alone. Almost half of the world’s population experiences oral diseases, and health systems are struggling to keep up. Worse, the prevalence of disease is compounded by unequal oral health status and access, where issues such as poor service distribution hinder access to care for those individuals who most need it.

The United States is not immune to these global issues, so our next generation of leaders must look beyond their own backyards if they hope to bring the best and most innovative ideas to bear on the world’s oral health care challenges. Lessons from abroad can also help leaders see the pitfalls and limitations of seemingly promising approaches and avoid repeating others’ mistakes.

One Lesson From Abroad: The NHS

We saw the transformative power of a global outlook in real-time when students in NYU’s Global Health Care Leaders program traveled to Italy. Each fall, interested NYU D4 students apply to visit one of NYU’s Global Academic Centers where they can explore complex health policy issues with government leaders and oral health advocates.

In November 2023, students in this program met with European oral health leaders at the NYU campus in Florence, Italy. We provided educational sessions in which students learned about European oral health policy priorities and opportunities for advocacy. It was during these discussions that we learned about what’s happening in the UK, where the National Health Service (NHS) is in turmoil.

If you’re not familiar, the NHS is the UK’s public health care system. Established in 1948, it aimed to provide all medical care to all residents free of charge and has long been revered as a beacon for those who believe health care is a human right. But in recent years, the NHS has hit hard times. A combination of underfunding, privatization, and a failure to adequately grow the budget and maintain a provider pipeline have all led to what can only be described as a disaster.

The current NHS is beleaguered by strikes, long wait times, provider shortages, and debt, while private care options remain out of reach for many budgets. The failure to systematically invest in the workforce, in particular, has produced devastating results. It takes six to seven years to educate a dentist in the UK, so the problem cannot be fixed overnight. In the meantime, UK residents are left without health care.

 A Similar Challenge at Home: Medicaid  and Children’s Oral Health

This tragedy can serve as a cautionary tale for health care providers in the United States. Of course, the two health care systems differ significantly—and most U.S. dental care is delivered through private practice—but we have encountered a not-so-different issue with the provision of dental care to children on Medicaid, where insufficient investment has also undermined access.

In 1967, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit mandated comprehensive oral health care benefits for children enrolled in Medicaid. On paper, the program had extraordinary potential for addressing the needs of children living in poverty, but deeming children’s oral health care an essential benefit doesn’t equate to their having access to care. In 2020, the American Dental Association reported that only 50% of children aged 3 to 17 on Medicaid had a dental appointment in the past year.  Considering what we learned about the NHS while in Florence, our mid-20th-century legislative victory followed by a failure to follow through rings familiar. We’re left wondering: How did this happen here in the United States?

A number of factors appear to have contributed, among them a lack of awareness among Medicaid beneficiaries of the available benefits. Additionally, Medicaid’s low reimbursement rates and cumbersome paperwork requirements dissuade dentists from participating. With fewer than half of dentists in many states accepting Medicaid patients, there aren’t enough appointments to go around.

A Future Imperative: Adopting a Global Mindset

In its Global Oral Health Status Report (2022), which I wrote about last year, the World Health Organization (WHO) called for universal oral health coverage. This means all individuals across the globe should have access to affordable providers who can deliver the care they need wherever they are in the world.

While in Florence, our students felt the enormous impact of adopting a global mindset as exposure to European oral health leaders shifted and enhanced their perspectives. After hearing about other ways of delivering care, one of our students called the experience “mind-blowing” and “life changing.” Another put it better than I could when she said, “Being able to hear the other person and then create your own understanding based on their perspective is so important, because it’s not just us, it’s all of us.”

As we strive to remedy the barriers to universal access to dental care in the United States—such as those experienced by Medicaid beneficiaries—we can learn from the early successes and later missteps at the NHS. Over time, we may also see our overseas colleagues solve their current problems in ways we want to emulate in the future.

Likewise, our friends in the UK can learn from us. Together, we can expand our ability to envision solutions to oral health challenges and actively contribute to meeting the goals laid out by the WHO.