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

Muscle atrophy. Trouble breathing. Paralysis. Death.

To members of my parents’ generation, these manifestations of polio were familiar and terrifying. By the time I came of age, few Americans gave them any thought. My generation was the first to receive the polio vaccine developed by Jonas Salk. Licensed in 1955, it reduced annual U.S. cases of polio from 58,000 to 5,600 in just two years. By 1961, only 161 U.S. cases remained.

But now we are facing a new challenge to the value of vaccines.  Even before the COVID-19 pandemic, vaccine hesitancy had become so prevalent that the World Health Organization added it to its list of global health threats. As with any medicine, vaccines are not without risks, but most of these are minor — a sore arm, fatigue, a low-grade fever. Serious side effects can and do occur, but they are very rare. Nevertheless, fear of these risks — and a belief that they are worse than the risks of contracting the diseases they prevent — has led to a steady decline in U.S. and worldwide vaccination rates, with devastating consequences.

• In 2022 — 28 years after the Americas were declared polio free — polio reappeared in an unvaccinated U.S. adult.
• In 2023, Europe had 42,200 measles cases — 42 times as many as it had in 2022.
• In 2024, England experienced a measles outbreak after vaccination rates fell to 85% nationwide and dropped to 73% in London.
• The U.S. eliminated measles in 2000, only to see outbreaks return at Disneyland in 2014 and in under-vaccinated communities in New York in 2019.
• During the COVID-19 pandemic, misinformation and fear led many Americans to refuse vaccination against the novel disease. The Peterson-KFF Health System Tracker Project estimates that 234,000 U.S. deaths could have been prevented between June 2021 and April 2022 if more people had chosen to be vaccinated.

Last fall, Scott Gottlieb, MD, who headed the Food and Drug Administration during Trump’s first term as president, told CNBC that he doesn’t think the president wants to see a resurgence of measles, whooping cough, or “God forbid, cases of polio in this country.” I hope Gottlieb is right, and that the new administration will recognize the value of vaccination in preventing such eventualities.

Social media is rife with misinformation, and the recent decision by Meta to stop fact-checking content on Facebook, Threads, and Instagram suggests the problem will only get worse. Interestingly, a U.S./UK-based nonprofit that tracked anti-vaccine content on Facebook and Twitter in the first year of the COVID-19 pandemic found that 65% of it originated with just 12 individuals and their advocacy groups. Banning these misinformation “super-spreaders” from popular platforms could go a long way to counter their influence, but it’s not clear where pressure to do so would originate.  

Of particular interest to our community, five lawsuits have been filed against Gardasil, the vaccine that protects against the human papillomavirus (HPV). In addition to nearly all cervical cancers, HPV is thought to cause 70% of oropharyngeal cancers (OPCs). While these cancers are rare, they are extraordinarily painful and often deadly — two excellent reasons to get this particular vaccine.

Sharing information of this type more widely is essential in countering misinformation, but as we’ve learned in the past few years, facts alone are not necessarily persuasive. Often, the relationship the listener has with the person who delivers the facts is more influential than the facts themselves. A just published KFF poll found a significant drop in trust in public health agencies and vaccines since 2023. Restoring trust in health authorities will be key to increasing vaccination rates.

What the Dental Community Can Do

One bright spot in the KFF poll: 85% of respondents have either a great deal or a fair amount of trust in their doctors. Given this finding, health professionals may need to take the lead in informing the public about the value of vaccines. Here are some steps dental professionals can take to build trust in vaccines and make them available to people who might not seek them out.

1. Talk to our patients. Let them know about the benefits of vaccination for themselves and their children. Research shows that anticipatory guidance from a trusted health professional is effective in encouraging vaccination, even among parents who have initially declinedit for their children.
2. Talk to parents about HPV. They might be more inclined to vaccinate their children against HPV if they knew the vaccine existed and understood how deadly OPCs can be.
3. Speak to our communities. An op-ed in the local paper or a Q&A with a local PTA — even private conversations with friends and neighbors — help to inform the public, counter misinformation circulating online and build trust in our profession’s commitment to serving the public.
4. Volunteer at vaccination clinics. Dental professionals are skilled at giving injections. They can put those skills to use and serve their communities by heeding the call to volunteer during public health emergencies, as they did during the COVID-19 pandemic.
5. Don’t get distracted. There is talk of a renewed federal focus on processed food consumption and chronic diseases. That’s all to the good, but we mustn’t lose sight of the potentially deadly threat posed by preventable infectious diseases.

As former US surgeon general Jerome Adams, MD, MPH, FASA, posted on social media, “Cardiovascular disease and cancer are now the top killers in our country. But that’s only because vaccine-preventable diseases and infections stopped being top killers long ago.” Let’s keep it that way.

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.

Use of SDF may offer an attractive alternative approach to school-based caries prevention.

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

Inexpensive, easy to use, effective. The value of silver diamine fluoride (SDF) is becoming harder to dispute thanks to a growing body of research, led in part by my colleagues here at NYU Dentistry.

Since 2014, SDF has been approved as a desensitizing agent for teeth, but pediatric dentists in particular have found other off-label uses for the substance. A hydrophilic liquid that can be painted onto teeth, SDF lends itself to use in children who are too young to cooperate with traditional dental care. With silver to kill bacteria and fluoride to remineralize teeth, SDF can stabilize decay until children are mature enough to sit through a dental procedure.

The catch? SDF leaves a black stain on the teeth that clashes with our image of a healthy smile. The common assumption has been that patients, or their parents, will not accept that discoloration.

“I think there’s a misconception that parents won’t want a black stain on their kids’ teeth,” says Lauren Feldman, DMD, MPH, clinical assistant professor and director of NYU Dentistry’s postdoctoral program in pediatric dentistry. “I do not have that issue, even in my private practice. When you explain to a parent, here are our options, many parents are very happy to avoid general anesthesia, even if it means black staining.”

Traditionally, very young children with severe dental decay have often been treated in hospitals under general anesthesia. That comes with risks, not to mention a hefty price tag. SDF is not a substitute for routine dental procedures, but its ability to arrest the progression of carious lesions makes it an exceptional tool, not just for young patients, but also for dental patients who sometimes wait up to a year for access to a facility offering sedation or general anesthesia. Applying SDF means their cavities won’t get bigger, allowing the dentist to employ more conservative treatment. “You’re able to save teeth rather than just extract teeth, which is extremely beneficial,” Lauren says.

The evidence on effectiveness

In 2017, the American Academy of Pediatric Dentistry (AAPD) recommended that SDF be used “for the arrest of cavitated caries lesions in primary teeth as part of a comprehensive caries management program.” The AAPD’s guidance also noted that the recommendation was “conditional” and based on “low-quality evidence.”

Since then, the evidence in support of SDF has mounted, and a recent study provides strong support for its ability to arrest dental caries. Over the past six years, researchers at NYU Dentistry and the University of Michigan School of Dentistry conducted the first randomized controlled trial in the United States of SDF against placebo. With funding from the National Institutes of Health (NIH), the researchers studied SDF’s ability to arrest severe cavitated lesions in very young children. The initial results quantify SDF’s efficacy. Six months after its application, 54% of lesions had not progressed compared to 21% of lesions treated with water, the placebo.

“SDF is very effective in arresting decay in these very young children with severely decayed teeth,” says Amr Moursi, DDS, PhD, professor and chair of the Department of Pediatric Dentistry and principal investigator (PI) for the NYU arm of the study. “On the other hand, it wasn’t 90%,” he adds. “I think the take-home message is: We have to be strategic about how we use it.”

Amr’s team and their colleagues in Michigan, where is overall study PI, will continue to analyze their data to determine how best to use SDF moving forward. They will be asking, Do the results differ at eight months follow up? Do they differ by the children’s ages, or by the size, severity, or position of the lesions in the mouth? These analyses may also help explain why earlier studies suggested the effectiveness of SDF could be as high as 90%. “Many of those studies were actually done on adults,” Amr told me, so perhaps age is a critical variable.

Federal interest

The U.S. Food and Drug Administration (FDA), which wants to know if SDF merits a caries-arrest claim for SDF, will be reviewing the Michigan/NYU data as well. If the agency finds the data support the claim, the use of SDF outside of pediatric dental offices could increase significantly.

“A lot of dentists, especially general dentists, don’t feel comfortable using something off label, especially on children,” Amr says. The FDA’s assessment would increase general dentists’ comfort level with using SDF and likely spur more insurance companies to pay for the treatment. It could also encourage more manufacturers to enter the market. According to Amr, only two U.S. companies currently market SDF, but others are expected to follow suit if the FDA approves/supports a caries-arrest claim for the substance. Such developments could spur innovation, and over time, Amr hopes, the development of a non-staining SDF formula.

SDF for prevention

A separate research team at NYU released findings this year on the use of SDF for a different purpose: caries prevention. The “CariedAway” study, published in JAMA Network Open, compared the effectiveness of two cavity-prevention techniques—a “simple” treatment using SDF and fluoride varnish, and a “complex” treatment using traditional glass ionomer sealants and fluoride varnish. The study population was children 5 to 12 years old in New York City and New Hampshire schools where at least 80% of students received free or reduced-cost lunch. Study funding was provided by the NIH and the Patient-Centered Outcomes Research Institute (PCORI).

The results suggest that SDF, which is much easier to apply than traditional glass ionomer sealants, may be just as good as glass ionomer in preventing and arresting dental caries. Based on a population-level review of the data, the researchers found a single dose of either topical treatment had prevented roughly 80% of cavities in healthy teeth and arrested 50% of existing cavities when children were examined two years later, an interval resulting from the COVID-19 pandemic. “As school-based dental sealant programs are limited by burdening costs and lack of available, trained clinicians, use of SDF may offer an attractive alternative approach to school-based caries prevention,” the researchers concluded.

One notable aspect of the CariedAway study was the use of non-dental professionals to apply SDF. “One of the questions we asked is, ‘Is a nurse as effective as a hygienist in delivering fluoride varnish and silver diamine fluoride?’” says Rick Niederman, DMD, a professor in the Department of Epidemiology and Health Promotion who conducted the study with our departmental colleagues, Ryan Richard Ruff, PhD, and Tamarinda Barry-Godín, DDS, MPH. Their answer: Yes. A recent interview with Dr. Barry-Godin filmed at one of the New York City school sites affirms their stance.   

Rick’s interest in SDF springs from the persistent growth in childhood caries rates—from 5% at age 5 to 25% at age 20—despite a steady increase in dental spending over the last 30 years. He sees the application of SDF as a powerful preventive tool, not just because of its medicinal properties, but because it is inexpensive and easy to apply outside traditional dental settings. Borrowing a metaphor from the COVID-19 pandemic, he asks, “If physicians and nurses could administer SDF independently, could we flatten that curve? I think using non-dental professionals in this way is absolutely doable,” he told me, “but you have two barriers: practice acts and finances.”

The financial barrier appears to be surmountable. Reimbursement rates for SDF application are far lower than for traditional fillings, but a dentist can apply many SDF treatments in the time it takes to restore a single tooth. Because Lauren uses SDF as a stabilizing medium, she says the treatment is usually in addition to rather than in place of traditional care, which her patients receive at a later time. Rick knows of one pediatric dentist who no longer treats his patients in the operating room, but instead employs six to eight dental hygienists to apply SDF while he focuses on diagnosis. “On a scale like that, he is making a good living,” Rick says.

Lauren agrees increasing the number of people trained to provide SDF could be very beneficial to vulnerable populations. She would like to see greater efforts to engage general dentists in this work. In her professional encounters, she’s been surprised to learn how few dentists use SDF in their practices. 

Some oral health advocates would like to see non-dental professionals apply SDF in other healthcare and community settings as well. That possibility troubles some dentists. They fear SDF could be applied ineffectively or in situations where it is contraindicated, e.g., when a nerve is exposed or a tooth is infected.

Amr shares these concerns. “There are some pediatricians who are really enthusiastic about using SDF outside the dental office because its application is very easy. They argue it’s an access to care issue,” he says. “I get it, but the argument that it’s better than nothing is not true. You can actually cause harm. Trying to diagnose a cavity is not as easy as some may think, and if you can’t make a definitive diagnosis, then you really need to be careful about applying some treatment.”

Rick has heard these concerns before, but counters that his experience does not bear them out. His study team found nurses were fully capable of recognizing when SDF should and should not be applied, and the team reported no adverse events.

Amr, who is past president of AAPD, and his departmental colleague Divya Khera, DDS, are working with the AAPD and the American Academy of Pediatrics to develop SDF application guidelines that address the concerns of pediatric dentists while allowing other professionals to use SDF outside the dental office, as Rick would like to see. “We have done modeling that indicates that, were the whole country to do prevention using SDF and provide it to every child in the United States, it would cost about half of what Medicaid currently spends for children’s oral health,” Rick says.

My colleagues here at NYU make persuasive arguments for harnessing SDF’s potential to improve both individuals’ and the public’s oral health. I look forward to seeing what the FDA concludes after reviewing the latest research on caries arrest and whether the AAPD or American Dental Association guidelines, which do not currently recommend SDF for prevention, evolve in response to the CariedAway study findings. Wherever the evidence takes us, these developments underscore the value of research and the role of policy in advancing oral health. It’s exciting to see these contributions to the growing body of evidence get the attention they deserve.

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

If you could protect your children from most oral cancers with a vaccine, would you make sure they got it? You just might — if you knew the vaccine existed and understood how deadly these cancers can be.

I’m talking, of course, about the human papilloma virus (HPV), which is thought to cause 70% of oropharyngeal cancers (OPCs). Although these cancers of the tongue and throat are relatively rare, their prognosis is bleak. They kill an estimated 40% of OPC patients within five years and can be extraordinarily painful. The good news is that many of these cancers are preventable if people are vaccinated against HPV before they are exposed to the cancer-causing pathogen.

“I counsel my patients starting at age nine, and I ask, ‘Has your pediatrician spoken to you about the HPV vaccine?’” says Lauren Feldman, DMD, MPH, clinical assistant professor at NYU Dentistry and pediatric dentistry postdoctoral program director. She informs families that HPV is the leading cause of OPCs and tells them, “As your dental health professional, I recommend that you’re vaccinated to prevent against this.”

When I was practicing pediatric dentistry earlier in my career, this vaccine was not at our disposal. Had it been, I would have eagerly recommended it. Research shows that anticipatory guidance from a trusted health professional is an effective tool for encouraging vaccination, even among parents who have initially declined it for their children.

The HPV Vaccine: Effective but Underutilized

In 2006, the Food and Drug Administration approved the first HPV vaccine. It was developed to prevent cervical cancer and originally offered to girls and young women. Less than two decades later, research shows just how effective the vaccine has been. One study found cervical HPV infection was significantly less prevalent in the first generation of U.S. women aged 18 to 32 who received the vaccine than in their counterparts born 10 years earlier (5.6% vs. 12.5%). A separate study found an 87% reduction in cervical cancer rates among the first generation of girls aged 12-13 in England who received the vaccine.

Not surprisingly, vaccination has affected the rates of oral cancer as well. The Centers for Disease Control and Prevention (CDC) reported that women accounted for 3,617 HPV-related OPCs from 2015 to 2019 while finding 17,000—more than 4.5 times as many—cases among men. “We’re seeing a decrease in women because of vaccination,” Lauren told me. “This is a public health win.”

The CDC now recommends the HPV vaccine for 11- to 12-year-olds of both sexes and for everyone through the age of 26 who has not already been immunized. HPV vaccination rates are inching up, but they are considerably lower than the immunization rates for some other common childhood diseases. In 2021, the CDC estimated that only 62% of 13- to 17-year-olds had received all recommended doses of the HPV vaccine. In contrast, the rates of immunization against tetanus, diphtheria, chickenpox, the measles, and several other diseases met or exceeded 90%. Since the likelihood of HPV exposure increases as adolescents age, the CDC website now states the vaccine may be given as early as age 9.

What Dental Professionals Can Do

What can dental professionals and dental schools do to increase HPV vaccine uptake? Lauren believes we can be most effective by starting conversations. “We should be asking our patients, ‘Did you get your first dose? When’s your next dose scheduled?’” she argues. “We need to reinforce the need to go back and to finish the course.”

I hope today’s dentists will follow her advice, but many will encounter parents whose skepticism about the value of the HPV vaccine may have been exacerbated during the COVID-19 pandemic. When the HPV vaccine first became available, the media focused on parental fears that vaccination might encourage children to become sexually active. Research suggests this was (and remains) a minority view. Nevertheless, a quarter of parents believe the vaccine is unnecessary, and almost as many parents refused the vaccine in 2018 over concerns about safety. This finding is especially troubling because only 13% of parents listed safety as a concern in 2015, and reported adverse events associated with its administration fell dramatically over the same time period. Given documented links between vaccine refusal rates and exposure to misinformation via social media, the researchers speculate that misinformation may be responsible for the rise in safety concerns.

Despite the availability of patient education resources on the American Academy of Pediatrics website, many parents clearly remain unaware of the vaccine’s value and its availability. Judging from what Lauren has heard in her private practice, few pediatricians offer patients the vaccine before age 12. She’s also heard anecdotally that some don’t recommend HPV vaccination to their male patients despite offering it to girls in their care.

Can these barriers be overcome? Lauren believes they can.

“The HPV vaccine is unique because it’s cancer prevention,” she reasons. “If somebody is hesitant to get one vaccine, I wouldn’t assume that means that they’re hesitant against all vaccines.” As she points out, most immunocompetent people will recover from influenza, and the flu vaccine has a much lower rate of efficacy than the HPV vaccine does. In contrast, “cancer’s ‘big C’ scary,” she says.

I hope people take HPV-caused cancer as seriously as Lauren does and see the vaccine for the lifeline that it is. In the meantime, dental professionals can use their influence to inform patients about the vaccine’s benefits and the cancers it prevents. We owe it to our patients to talk about HPV.

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

Dentists are all too familiar with the realities of pain. It motivates many patients to walk through our doors, and it results from many of the procedures we do. In short, pain mitigation is essential to our practice.

Most of us were taught to treat dental pain with opioids. These drugs are highly effective, but as we’ve learned, they are also addictive and even deadly. According to the National Institute on Drug Abuse, opioid overdoses killed more than 106,000 people in the United States in 2021 alone.

How did we get here? While dentists are not responsible for the opioid epidemic, we contributed to the problem. Dental pain requires strong medicine, and in the late 1990s, dentists were among the top specialty prescribers of opioids. Especially troubling, research suggests that opioid use and abuse among teenagers may be linked to having their “wisdom teeth” removed. Many teens received their first opioid prescription from the dentist who extracted their third molars.

Dentists prescribe a lot fewer opioids today, thanks in large part to a group of Boston dental educators who developed strategies for preventing and managing prescription drug misuse in dental settings. The Commission on Dental Accreditation has also helped reduce opioid use by revising its standards to emphasize dental students’ competencies in local anesthesia, pain, and anxiety control. (You can learn more about these initiatives and other steps dentists have taken to curb the opioid epidemic in a 2020 issue of Dental Clinics of North America, to which I contributed.)

What hasn’t occurred is the discovery of a treatment for pain that can rival opioid’s effectiveness. “As dentists we should be spearheading the research to understand this problem, especially when it relates to dental pain or any pain in the head and neck,” says my colleague Brian Schmidt, DDS, MD, PhD, senior vice dean for research development and academic affairs at NYU Dentistry. “It’s on us to try to figure out better solutions.”

Seizing the Moment

Brian’s interest in pain is not purely scientific. An oral and maxillofacial surgeon specializing in oral cancer, Brian sees pain up close on a regular basis. Because oral cancers are located in the mouth and throat, they trigger pain in the course of chewing, speaking, and even swallowing – unavoidable activities that occur throughout the day. As a result, oral cancer patients report more pain and more severe pain than other cancer patients.

Brian is now part of an interdisciplinary effort to tackle pain at NYU Dentistry: the NYU Pain Research Center. The brainchild of Nigel Bunnett, BSc, PhD, who chairs our department of molecular pathobiology, the Center was launched in 2022 to spur the development of novel therapies that can replace opioids.

Both Brian and Dean Charles Bertolami saw the proposed Center’s potential to build on the College’s unparalleled expertise in oral cancer pain at a time when federal concern about the opioid crisis has elevated pain research at the National Institutes of Health (NIH). By adding world-class researchers investigating pharmacology, bioengineering, the gut-brain connection, and the neurobiology of pain to the NYU Dentistry faculty, the Center is poised to play a leading role in this national effort.

From the Lab to the Clinic

“Drug discovery is a long, expensive, and complex path, so we can’t count our chickens before they hatch,” says Rajesh Khanna, PhD, MSc, the Center’s director and a professor of molecular pathobiology, “but if something comes out of these investigations to find non-opioid solutions to pain, that could be useful on a global scale.” Rajesh and his colleagues at the Center are exploring how pain signals travel through the body and how those signals might be disrupted by a diverse array of therapies. These include the use of biologics (drugs derived from living organisms), green LED light, and allosteric modulators (drugs that bind with their targets in a way that produces fewer side effects). The Center’s researchers are also working to build on the knowledge of pain signaling derived from rodent models by mapping those pathways in humans.

These efforts are not only fascinating; they also hold promise for improving the lives of millions of people with chronic pain, but only if they are translated into clinical applications. That’s where the Center’s associate director for clinical and translational research, Kara Margolis, MD, comes in. Kara is pursuing yet another avenue of research: the gut-brain connection. As a pediatric gastroenterologist, she studies disorders that affects both the brain and the gastrointestinal (G.I.) tract in children.

“I am looking at which comes first, gastrointestinal problems and pain, or anxiety, depression, and related behavior disorders. If we can figure that out, we may know how to target treatment better,” she says.

Promising Investments

Although an estimated 50 million U.S. adults live with chronic pain, the NIH has never had an institute devoted to its study, but the NIH has created opportunities for pain research. Investigators inside and outside NYU learned about these efforts on March 7, when the Center held a day-long symposium featuring Rena D’Souza, DDS, MS, PhD, director of the National Institute of Dental and Craniofacial Research and Rebecca G. Baker, PhD, director of the NIH HEAL Initiative, a trans-agency effort to speed scientific solutions to stem the opioid crisis.

NIH funding will be critical to supporting the Center’s research. Its investigators currently have $44 million in federal funding, $19 million of which is focused on oral cancer pain research occurring in collaboration with the NYU Dentistry Translational Research Center and the NYU Oral Cancer Center, both of which Brian directs. These investments, coupled with NYU Dentistry’s investment in top research talent and the Center’s focus on interdisciplinary collaboration, hold tremendous promise. On the educational side, the Center should prove influential in how pain mitigation is taught throughout NYU’s health professions’ programs. On the clinical side, it should advance changes in practice.

The Center’s creation has also raised Brian’s hopes that after his 20 years of oral pain research, substantial progress may be in sight. “I now have access to experts who have no idea about oral cancer, but they’re trying to understand all cancer pain. That’s a step that I never thought would happen in my career. If one of their discoveries from our basic science laboratories advances to a clinical trial, that would be a huge success,” Brian says.

We’ve made some progress since the 19^th century, when physicians treated Ulysses S. Grant’s oral cancer with regular doses of cocaine, but most of the task of finding non-addictive treatments for oral and other types of pain lies before us. Exposing scientists to patients with pain and clinicians to pain research is one way in which the Center can accelerate this progress. That work is urgently needed to bring promising therapies into routine care.

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

“The status of global oral health is alarming.” That’s the conclusion of the first-ever Global Oral Health Status Report. Issued last November by the World Health Organization (WHO), the report documents a global population burdened by widespread oral disease.

• An estimated 2.5 billion people had untreated dental caries in 2019,
• Roughly 1 billion people had severe periodontal disease,
• 370 million people were missing permanent teeth, and
• 370,000 had oral cancer, a highly lethal disease that kills roughly 170,000 people globally each year.

“No other disease group affects humanity across the life cycle and across all countries in the way that oral diseases do,” the report declares.

How is it that policymakers throughout the world have paid so little attention to oral diseases when they affect so many? Part of the answer may be the tendency of public health officials to favor prevalence data when deciding where to focus their efforts. In comparing oral disease prevalence in 1990 with 2019 figures, the report’s authors found that the estimated age-standardized global prevalence of oral diseases had increased by 3.2% during the preceding three decades. That sounds like a modest increase, but the report’s startling case numbers lead to another conclusion. There are 1 billion more cases of oral disease today than in 1990. “Those are real people who are in pain and who need care because they have untreated disease,” says Habib Benzian, DDS, MScDPH, PhD, a research professor at NYU College of Dentistry who served on the team that produced the WHO report.

“You see a situation where the prevalence is stable and your conclusion is, our interventions seem to work,” Habib told me. “That view is a fallacy.” First, within the global prevalence statistics, modest decreases in high-income countries mask increases in prevalence in low- and middle-income countries, and even within countries, population groups are affected differently. Moreover, the persistent prevalence of oral diseases over 30 years — despite billions spent on dental care — constitutes an indictment of the status quo. As Habib put it, “We were not able to make a significant dent in oral disease using our current approaches.”

Universal Health Coverage

If the status quo is unacceptable, what should we be doing differently? In May 2022, the WHO adopted a global strategy, which put forth Universal Health Coverage (UHC) by 2030 as a means for enabling all people to enjoy the highest attainable state of oral health. To American ears, UHC may sound like dental insurance for all, but the WHO imbues the term “coverage” with a broader meaning. The WHO defines UHC as a state in which “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.” Applied to oral health, global UHC would mean all countries made health promotion, prevention, treatment, and rehabilitation services readily available to individuals and communities at an affordable cost.

In tandem with the recent report, the WHO released profiles of the oral health status of 194 WHO member countries. These profiles make clear that UHC is achievable, even in countries with emerging economies. Thailand stands out for having managed to provide essential oral health services to its population. Oral health benefits are integrated in all its insurance programs, and a school-based oral health program helps children develop good oral habits early in life.

Challenges at Home

In contrast, the report’s authors are openly critical of countries, including the United States, that they say “are embroiled in heated professional and political debates around offering limited oral health coverage for some disadvantaged population groups.” (See my recent posts on Medicaid dental benefits and care for veterans and people with disabilities for some specifics.) In a commentary, which appeared in The Lancet, the authors wrote that oral health is frequently viewed in these nations as “non-essential” and “a private matter,” with workforce shortages, unequal geographic distribution of oral health professionals, over-reliance on dentists, and little integration of oral health and primary care contributing to a lack of access.

I asked Habib if he thought the United States was on track to achieve UHC by 2030 as the report recommends. “I think the U.S. is heavily off track in many ways,” he said, noting the challenges inherent in changing policy in a nation with 50 largely autonomous states. He sees the focus on deriving profit from providing care as another barrier to reaching UHC. “We have a system that spends more on health care per capita than any country in the world with mediocre outcomes, so the situation of oral health is one symptom of bigger system issues,” he believes.

Where NYU Dentistry Fits In

Before joining NYU, Habib worked with the World Dental Federation (FDI) in Geneva, Switzerland, and then as a consultant for the WHO and other international agencies. This established relationship positioned NYU Dentistry’s Department of Epidemiology & Health Promotion, which I currently serve as interim chair, to become a WHO Collaborating Center for Quality Improvement, Evidence-based Dentistry in December 2016 with Professor Richard Niederman, DMD, as its first director. Habib and his colleague Eugenio Beltrán, DMD, DrPH, MPH, currently co-direct the Collaborating Center, which is the only one of its kind in the Americas.

Department faculty support the WHO’s oral health mission in a variety of ways. In addition to raising awareness and advocating for oral health and they work with colleagues internationally to determine which oral health interventions are most cost-effective. The Collaborating Center’s success in its early years led to a renewal of the WHO agreement in 2021.

Moving ahead, the Collaborating Center will continue to work with the WHO as it develops a comprehensive global oral health action plan and a framework for monitoring its implementation. The Global Oral Health Status Report presents a foundation for these efforts by providing baseline data that can be used to monitor progress. Although the report is not focused on policy solutions, its advocacy message is clear and strong: “Continuing with ‘business as usual’ is not an option,” it states, echoing a point Habib made when we spoke. “We need to move away from the idea that all diseases can be treated away because they cannot. We will never have enough oral health professionals to seal every tooth or treat every case of dental caries.”

I agree. Continuing to pour billions of dollars into established models of clinical care without also taking concerted steps to improve access and prevent disease will merely reinforce an unacceptable status quo. In showing that nearly half the world’s people have some form of oral disease, the WHO report reveals the magnitude of the problem. In sounding the alarm, its authors challenge us to muster the political will to move beyond the current state of global oral health and shift policy, both at home and globally.