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.

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

It’s remarkable. Despite the cost and other challenges of opening a new dental school, the numbers have risen steadily — from 53 CODA-accredited U.S. dental schools in 1996 to 70 such schools today. That’s more than one new dental school opening every two years. Another four are currently seeking CODA accreditation and at least eight more schools are in the planning stage, with for-profit entrants in the mix. Given these developments, some people wonder, “Are we at risk of having more dental schools than we need?”

Dental educators who remember the 1980s have reason for concern. In that decade, the applicant pool shrunk. With only 1.3 applicants for every first-year dental school slot, seven dental schools closed their doors, all in private universities. Many other schools reduced their class sizes dramatically. The impact was felt almost immediately. By 1990, we graduated only 4,000 dentists per year — 2,000 fewer than in 1980.

Fortunately, today’s dental school applicant pool is more robust, with 1.86 applicants per first-time, first-year enrollee in 2021, and the number of graduates has rebounded since 1990. Yet rebounding could feel like a very low bar given the opening of so many new schools. We currently graduate just a few more dentists that we did four decades ago — 6,300 graduates in 2020, up from 6,030 graduates in 1980. Meanwhile, the U.S. population has grown by 45%, from 245 to 320 million. Those numbers suggest there is continued room for growth in dental education, and they have made me far more sanguine about opening new dental schools than I was in the early 2000s.

I currently sit on the board of trustees of Kansas City University (KCU), a private, not-for-profit health sciences university, which is preparing to open a dental school in Joplin, Missouri next summer. In May 2011, an almost mile-wide tornado devastated the city and rendered its hospital unsafe. The Federal Emergency Management Agency (FEMA) erected a temporary hospital, and once a permanent replacement was complete, community leaders offered the site to medical schools as a satellite campus. KCU accepted the offer and decided to start a dental school as well to help meet the substantial need for care in Joplin and the surrounding rural communities. In Joplin proper, I’m told only one dentist accepts Medicaid insurance. According to data from the Health Resources and Services Administration (HRSA), Missouri has more HRSA designated dental shortage areas than all but one other state.

The university has already raised $40 million in philanthropic contributions and invested $10 million of its own to construct a 92-chair clinical facility and an 84-chair simulation lab at the new College of Dental Medicine. Founding Dean Linda Niessen, DMD, MPH, MPP, and her academic team are also putting together a competency-based curriculum with a strong public and community health orientation.

“We are looking for students who can become excellent clinicians, but we also want them to become leaders in their communities,” Linda told me. “We’re going to have the students engage with the community through various outreach programs early in their education. This will help them understand the important role oral health plays in children’s learning and adults’ employment. Students may provide oral health education and conduct screenings in school settings and/or health fairs to learn about the community’s oral health needs and understand their responsibilities as a dentist.”

These experiences are essential, because as critics of new schools have noted, just producing more dentists won’t solve the problem of their maldistribution — the tendency of dentists to cluster in urban areas with a high density of patients who can afford dental care rather than to practice throughout less affluent, rural regions.

Two of the dental schools that opened in this century provide models for educating dentists who are prepared to work in rural settings. A high proportion of the dentists who graduated from the Arizona School of Dentistry and Oral Health and East Carolina University have chosen to serve populations in need. Their success reflects the schools’ cultures, but also their locations and the students they recruit. KCU hopes to achieve similar success by recruiting students from its rural environs, including members of Oklahoma’s Eastern Shawnee tribe, and giving students outreach opportunities in community health centers, among them those affiliated with the Indian Health Service. Overall, about half of the new schools are in rural areas or have a commitment to caring for rural populations.

Critics of new schools also worry about their potential impact on the dental faculty shortage. Their concerns are understandable, but faculty now play considerably different roles than they did in the past. Much of the course content once delivered through in-person lectures now reaches students digitally, and some of it comes from faculty at collaborating institutions. In preclinical classes, haptics, artificial intelligence, and other digital technologies are giving students more precise feedback on their hand skills than any human observer could provide. And in dental school clinics, the faculty ranks are increasingly supplemented by late career private practitioners who serve in clinical faculty roles.

The late Art Dugoni, DDS, a legend in dental education, once fought the opening of new dental schools. Many were being planned in the early 2000s, and he was understandably concerned about competition for applicants at that time. Yet once the decision to open new schools was made, Art was among the first to say our community should do everything it could to support their development. His priority shifted to ensuring that the newest schools graduated qualified dentists.

I admire Art’s decision to rise above his own institution’s interests and to focus on the greater good. This should be the attitude of all dental educators, whether they support or oppose the opening of more schools. Linda Niessen, for instance, while firmly committed to the launch of her own institution, appreciates, and even shares, some of the concerns raised by new school critics.

“You can’t start a dental school without sufficient resources,” she told me. “You need more than just financial resources, you need physical facilities, educational resources, research experiences, and interprofessional opportunities. There are schools opening now that don’t have a medical or a nursing school associated with them, and that’s a concern. Where will these new schools find what they need to develop a quality program and meet CODA standards?”

While I don’t think we need to worry about having too many dental schools right now, I want to be sure each and every dental school is prepared to produce graduates with the skills, knowledge, and attitudes that will allow them to meet high standards for care. If they also enter our profession ready to care for the underserved, engage in their communities, and contribute to the creation of new knowledge that makes dentistry a learned profession, so much the better.

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

“Having a healthy mouth means everything.”

Those are Leonard’s words, not mine. He’s a patient at NYU Dentistry and one of the millions of U.S. military veterans who are not eligible to receive dental care through the U.S. Department of Veterans Affairs (VA).

Leonard says he looked everywhere for help with his teeth but couldn’t find it until the VA referred him to VOCARE (Veterans Oral Care Access Resource) at NYU Dentistry.  The program serves veterans who are not eligible to receive oral health care through the VA. In its first year alone, VOCARE provided more than 10,000 dental procedures — free of charge — to 1,022 veterans.

That pent-up demand stems from the nature of VA health coverage. Nine million veterans get their health care through the VA, but only 1.4 million of them are eligible to receive dental care at the VA’s expense. To qualify, veterans’ oral health needs must be connected to their military service or be medically necessary to prepare the veteran for a covered hospital admission. Just as in traditional Medicare and many private plans, routine dental care is not a covered benefit.

Michael O’Connor, co-director with me at the Center for Oral Health Policy and Management and executive vice dean of NYU Dentistry, also co-directs VOCARE, and he’s passionate about serving this population. He vividly recalls a decades-old encounter with his father, a veteran of World War II. He didn’t look well, and knowing of his struggles with alcoholism, Michael feared his father had scurvy.

Michael took him to the VA, where the reception they got was far from welcoming. When the staff tried to release his father without providing care, Michael took down names and made it clear he would hold the staff responsible if his father’s condition worsened. They agreed to keep him overnight and soon learned he did have scurvy, one of many debilitating conditions (including cancer, heart disease, vision problems, diabetes, and a stroke), which Michael would help him manage over the next two decades.

At every VA facility where his father sought care, Michael fought the system and was able to secure great health care for his father. “I kept him alive for 20 years,” but Michael was unable to get his father treatment for one critical concern: his broken and missing teeth.

“I wonder what would have happened to my father if I was able to get him teeth. Would that have changed his life? Would he have no longer been a recluse, ashamed to go out? Would he have gone back to work? Would he have tried to turn himself around? Those questions will never be answered,” Michael says.

VOCARE is part of a VA pilot program, VETSmile, which aims to fill the gap in veterans’ access to dental care by connecting them with dentists in their communities. In July 2021, the VA selected NYU Dentistry to pilot the program in an urban setting. I sit on a technical expert panel advising VETSmile, and in my role at NYU Dentistry, I’m delighted that VOCARE resides within the Center for Oral Health Policy and Management. That connection forces us to also think about policies that can further extend veterans’ access to oral health care.

Although VETSmile is a VA initiative, pilot sites such as NYU Dentistry are responsible for funding the care. To date, the College has raised $900,000 from a mix of public and private sources. The New York State Assembly and New York City Council have allocated funds, and charitable donations have come in from the United Concordia Dental Charitable Fund and the Leukemia & Lymphoma Society, which provides funding specifically for dental care for veterans with blood cancer. Faculty and students at NYU Dentistry have also been moved to contribute.

VOCARE co-director Gabriela Gonzalez, MPA, shares their passion for providing care to former members of the nation’s military services. As the younger sister of a veteran who served in Iraq and Afghanistan, her compassion for this population is rooted in her personal experience as well as her patriotism. She’s been attending national meetings on veterans’ oral health, including the American Dental Association’s Give Veterans A Smile Summit in May. She told me the willingness to treat veterans at no cost is growing, but no one is committing resources on the scale of VOCARE.

According to Gabriela, “Some dental practices set aside part of a day each week to provide pro bono care to veterans, but more often, including at dental schools, it’s one day a year, usually Veterans Day. After a recent presentation at which I spoke about VOCARE, everybody thanked us for providing free dental care to veterans year-round.”

The veterans we’ve treated have also shown their gratitude. “I am so grateful that Brooklyn VA Hospital [connected me to] NYU Dentistry,” Leonard told us. “Coming here, just meeting the staff, was breathtaking, and they guarantee me that they can help me, and they are helping me.” He’s confident many others in his community will benefit as well.

Michael shares his conviction that VOCARE will improve the oral health — and the lives — of today’s veterans. Thinking back on his father’s situation, Michael observes, “One thing I know is, no one feels good about themselves if they can’t smile. No one gets a job if they don’t have teeth. There is a stigma associated with people missing or having no teeth. VOCARE will help in this regard.”

NYU has a five-year partnership with the VA to continue VOCARE, and Michael and Gabriela are now looking at ways to help other dental schools and federally qualified health centers adopt the model. Making more charitable care available is a step in the right direction, but with his background in public health policy, Michael won’t be satisfied until he sees government action to address the root of the problem: the lack of a universal dental benefit for veterans. He is looking forward to a day when he and VA representatives testify before Congress, explaining the importance of dental treatment and preventive care to veterans’ oral, mental, and overall health.

“This care shouldn’t be at the largesse of private institutions like the NYU College of Dentistry. It should be a taxpayer-funded benefit appropriated by Congress,” Michael insists. “Our goal is for Congress to fund dental care at all the VAs across the country, so that these veterans get the care that they deserve — simple as that.”

I couldn’t agree more.