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.

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

The world is changing at a breathtaking pace, yet as the first quarter of the 21^st century draws to a close, it feels as though the dental education community is still struggling to achieve consensus on what constitutes a 21^st-century dental education.

Beginning in 2005, the ADEA Commission on Change and Innovation in Dental Education (ADEA CCI) created a framework for supporting efforts to modernize our enterprise and disseminate promising practices. Many of our colleagues launched ground-breaking initiatives, published their results, and presented at conferences. Substantial progress was made, but despite these advances, our community still faces some perennial challenges. Chief among these, we need more faculty and innovative ways to develop the skills they will need to successfully lead our institutions.

Whatever the obstacles, dental education must adapt to the current environment, but something seems to be holding us back. I’ve come to believe that the problem is not a lack of ideas but rather a reticence to act in the face of uncertainty. As academics, we are trained to approach our research methodically and to test our results through repeated experimentation. Those steps are critical for building a scientific evidence base, but it takes 17 years on average for research evidence to be implemented in clinical practice.

Where health and even lives are at stake, that level of caution is critically protective, but does it make sense in clinical education? What would happen if we adopted a “fail forward” mindset instead?

“Failing forward” is the idea of creating or implementing something before it is perfected to see how it works in practice and then iterate from there. Such an approach could help us accelerate the pace of educational change. Faculty and staff throughout our community have already conceived dozens of strategies and piloted tools that are ready for replication or adaptation. Not every one of these 21^st-century approaches will stand the test of time, but by rapidly implementing them, we would gain insight into what works, what doesn’t, and what can be refined to deliver the best dental education possible today and in the future.

As we consider where to put our energies to ensure that dental education remains strong in the years ahead, do we really need another systematic review before implementing practices that have shown promise over the last two decades? I would argue that we have more than enough evidence to justify embracing some core strategies. Here are ten that stand out to me.

1. Focus on core biomedical sciences. Technologies and treatments are constantly evolving – just think of how artificial intelligence and machine learning have evolved since IBM’s Watson debuted on Jeopardy! in 2011 – but the human body and its vulnerabilities change little over time. Strong education in anatomy, physiology, pathology, and pharmacology will remain the foundation of a dental education.
2. Teach research and critical thinking skills. Dentists must possess the skills to critically evaluate new science and practice models as they emerge. Schools can prepare students for evidence-based practice by teaching literature review techniques and encouraging participation in research.
3. Incorporate technology and innovation. Students’ clinical experiences should prepare them for real-world practice. Schools should endeavor to introduce students to telemedicine, innovative electronic health records, the use of artificial intelligence in diagnosis, robotic surgery, and the other technologies they will likely encounter in state-of-the-art health care environments.
4. Offer simulation-based learning. Simulation has proven its effectiveness as a tool for learning and practice. Schools should employ simulation to facilitate the development of various competencies and to fill gaps in students’ clinical experience, such as exposure to certain rare or complex conditions.
5. Develop soft skills. Fewer and fewer dentists are working on their own. In today’s health care environment, solid communication and teamwork skills are essential, and leadership is prized. Developing empathy is also critical for delivering culturally respectful, patient-centered care. Schools should strive to foster all these traits.
6. Engage in interprofessional education and practice. Create opportunities for learning with students from other health professions (nursing, pharmacy, etc.) to promote collaboration and foster an understanding and appreciation of each profession’s role in patient care.
7. Promote adaptability and resilience. Health professionals need the ability to adapt to change and handle stress effectively, a fact driven home by the COVID-19 pandemic. Even under the best of circumstances, it is vital that schools prepare students to adjust as procedures, guidelines, or health care systems undergo change.
8. Emphasize ethics and patient-centered care. Schools should strive to acculturate students to their future professional roles throughout their education, teaching them strategies for navigating ethical dilemmas and emphasizing their responsibilities to patients, the profession, and their communities.
9. Provide a global health perspective. Whatever the field, a global perspective is an asset in an interconnected world. Schools can find ways to expose students to health and health care beyond the local community. Knowledge of global oral health challenges and alternate models of care delivery will deepen students’ awareness of the value and duties of the dental professions.
10. Encourage lifelong learning. Time doesn’t stand still, and neither should working professionals. Because scientific discovery and technological change will continue to reshape dental practice throughout the 21^st century, schools should stress the importance of continually updating their graduates’ knowledge and skills. Beyond simple encouragement, schools can offer continuing education to alumni on preferred terms.

Throughout my career, I have always looked to see what trends were on the horizon in order to help our community prepare for whatever was coming our way. The need for leaders as my generation ages into retirement is one recurring theme. If you read last year’s ADEA report, New thinking for the new century: Preparing for the next 100 years, you saw it there as well. In addition to replacing faculty, it called out the need for leaders who can fill the shoes of today’s deans and other academic leaders.

Both these challenges are among my primary concerns, and I’ve taken steps to address them in my current role. At the NYU Dentistry Center for Oral Health Policy and Management, we have developed a portfolio of leadership programs to equip students with leadership skills and instill in them a willingness to serve their communities — whether as faculty at their alma maters or policy influencers on the global stage.

As dental educators, it is incumbent upon us to help students understand the various roles they will need to play and to help them develop the resiliency to adapt to whatever they encounter. I know my colleagues at other institutions share my concerns, and I hope we can spur one another to action. Only by taking risks — and occasionally failing — can we move dental education forward.

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

College campuses are in the media spotlight these days, as they are roiled by competing views on the Israel-Hamas war and how universities should respond to world events. On some campuses, including NYU’s, students featured prominently in these debates, raising questions not just about what constitutes free speech but also about what it means to be a professional.

For decades, dental educators have contemplated how best to prepare students for practice as a professional. It’s one thing to teach students about ethics. It’s quite another to socialize them to be ethical professionals, and the challenges of preparing students for their future roles seem to be increasing by the day.

Are dental schools doing enough to ensure their students understand that being a licensed professional is a privilege that comes with certain duties? Every time I speak at a dental school’s commencement exercise or a white coat ceremony, I make this point: People will come to us in pain and suffering with an expectation that we will treat them to the best of our ability whatever we may think about them as individuals. I’m sure the audience always hears me, but is the message getting through?

21st Century Challenges

Events last year at Wake Forest University offer a case in point. A medical student bragged on social media about missing a patient’s vein after the patient questioned their display of gender pronouns. The university concluded that the student did not harm the patient intentionally but placed them on extended leave for their inappropriate use of social media.

I recently discussed the incident with NYU Dean Charles Bertolami, DDS, DMedSc. “Whatever happened in the clinic, it ended up translating into a public perception that you can’t trust doctors,” he said. The student made a public apology for their unprofessional conduct and its poor reflection on the school, but the damage to Wake Forest’s and the student’s reputations had already been done.

I also spoke with another longtime colleague of mine, Pamela Zarkowski, JD, MPH, who serves as provost and vice president for academic affairs at the University of Detroit Mercy. She is internationally recognized for her scholarship on professional, legal, and ethical issues related to the health professions. “I think students aren’t really clear about what constitutes freedom of speech,” she said.

Students aren’t the only ones who challenge professional norms in the name of free speech, as the New York Times reported in December when the chancellor of the University of Wisconsin lost his job for posting pornographic videos. The way that Pam responded is key: “One of the challenges as we go forward will be trying to educate everybody about what is legally protected speech and what is speech that reflects well on professionals.”

Ground Zero: Cheating

Discussions of ethics in dental education are often rooted in a more parochial concern: cheating. This ethical lapse is probably as old as academic grading, but smartphones, online apps, and most recently, generative AI tools, complicate the picture. Charles’ interest in ethics education began at the University of California, San Francisco (UCSF) School of Dentistry, where he served as dean when digital technologies were being widely integrated in classrooms. The outcome of an early online test at UCSF revealed evidence of dishonesty. When Charles received the news, he remembers thinking, “Aren’t our students taking courses in ethics? How does this happen?”

Academic dishonesty has also been reported at the nation’s military academies and at other dental schools. In seeking to understand why, Charles observed that conventional ethics courses informed students about ethics but rarely spurred the kinds of insights that might prompt behavior change. In a widely read 2004 article, he concluded that dental school ethics courses were “inadequate in content and form” and proposed the need to “cultivate an introspective orientation to professional life” as a possible solution.

Although ethics education was clearly falling short, it wasn’t for lack of trying. In 2009, the American Dental Education Association (ADEA) released a statement on professionalism in dental education, and a 2011 survey by the American Society for Dental Ethics (ASDE) found that 80% of dental schools offered at least one formal course on ethics. Many programs incorporated a broad range of content, and teaching methods included case-based learning, small group discussions, and reflective writing.

Necessary but not Sufficient

Pam noted these improvements when she served as a site visitor for the Commission on Dental Accreditation (CODA). She says many grading rubrics used by dental schools on the clinic floor included students’ professionalism and judgment in addition to their clinical competence. But she worries that schools may still fall short, doing enough to meet accreditation standards but not significantly impacting students’ thinking or behavior. She has seen too many idealistic students become cynical over time. “Dental School presents some challenging realities,” she observes.

Pam offered some examples:

• A staff member gossips about a patient or mocks their accent.
• A preceptor tells a student to fudge a patient’s blood pressure in the medical record so they can move ahead with a procedure.
• A D3 student fails to report a patient who is sexually or ethnically harassing a D4 student in clinic because the D4 needs the patient to complete a graduation competency.

I’ve seen similar ethical lapses over the years and often fear we are on a slippery slope. Violations of professional conduct create an institutional climate from which students learn as much or more than they do in formal ethics courses about what is acceptable in practice. This contrast can lead to cynicism and demoralization, but that doesn’t mean we should give up. Research shows that without formal instruction, the moral development of professional school students either fails to progress or erodes as they move through their programs.

What’s Next for Ethics Education?

To arrest the slide down the slippery slope, we need to become more effective at socializing our students to their professional roles and responsibilities. Recommendations include:

• Integrating ethics education throughout the curriculum, including in the clinical years,
• Assessing professionalism on an ongoing basis,
• Service-learning opportunities that stimulate reflection,
• Encouraging ongoing self-reflection
• Creating faculty development programs related to ethics and professionalism,
• Ensuring that professionalism is modeled as well as taught, and
• Addressing ethical challenges within the institutional culture so that patient and student interests do not conflict.

We might also look to the other health professions for inspiration. Medical students at the University of Rochester School of Medicine and Dentistry engage in a peer assessment process that appears to enhance students’ awareness of their professional behavior.

Pam is part of a team that will soon be fielding another ASDE survey to gauge the status of ethics education today. Here at NYU Dentistry, they’ll find our students studying ethics right out of the gate. Charles teaches our 19-session introductory course and offers small group seminars to interested D2, D3, and D4 students. The program takes full advantage of classroom technology and game theory problems to make the ideas stick. He especially likes the ultimatum bargaining game, in which half the class must decide how to share an imaginary $100 windfall with their less fortunate peers. “Seventy percent of the students offer the fairest possible amount, a 50/50 split,” Charles reports, “however, 3½% of our students offer one dollar. Because we use an anonymous audience response system, those students immediately see how different they are from their peers,” he says, and gain insight and self-awareness.

In a subsequent experiment, the imaginary $100 is awarded to half the students based on an earned but unrelated property entitlement (a grade point average in the upper half of the class). In this scenario, Charles says, generosity declines significantly. This finding aligns with research on which drivers are least likely to yield at a four-way stop—those in the most expensive cars.

Do these thought experiments change student behavior? Charles readily admits that he doesn’t know. “But our graduates are going to be folks that are in an affluent group with a title, a state license, and a degree from a prestigious university,” he argues. “All those things push toward the greed end of the spectrum, so we need to try to balance that if we can.”

I agree. Our commitment to graduating health professionals who understand that a license to practice comes with responsibilities as well as privileges must be unwavering. While maintaining high expectations of our students, we might also show them some empathic understanding. Earlier generations were able to make mistakes—socially as well as academically—and even fail spectacularly, and not have their every indiscretion immortalized in social media. Let’s remember that human beings are works in progress, especially in the first few decades of their lives, and provide them with environments as well as instruction that cultivates their best instincts. Students, their future patients, and our professions will benefit.

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

On November 7, Ohio residents voted by a wide margin to become the 24th state to legalize the recreational use of marijuana. While the drug is nominally illegal under federal law, the substance is becoming a fixture of more and more Americans’ lives. Some 17% of respondents to a 2023 Gallup poll said they smoke marijuana; among adults aged 18 to 34, the number was 29%.

In the past decade, a giant industry has sprung up to capitalize on this growing market. According to an August opinion piece in the Washington Post, legal U.S. marijuana sales equaled $30 billion in 2022, with the drug outselling both chocolate ($20 billion) and craft beer ($28 billion). These figures signal more than a cultural shift. They also reveal a remarkable commercial success that has engendered some less visible public health costs. 

Most of today’s marijuana is a far cry from the plant consumed in the 1960s and 1970s, when the drug first gained social acceptability. Market forces, coupled with a lack of federal standards for marijuana and other cannabis merchandise, have led to a proliferation of smokable, vapable, and edible products that typically have higher and even extremely high concentrations of THC (marijuana’s psychoactive compound). As a result, some people who use these products are becoming addicted, and some others, including children and teens, are experiencing psychosis. According to data from the Substance Abuse and Mental Health Services Administration, almost 800,000 drug-related emergency department visits in 2021 involved cannabis. In Colorado, the first state to legalize recreational marijuana use, marijuana-related emergency department visits quadrupled in the early years of medical and recreational marijuana legalization.

Oral Health Implications

Even at safer levels, dental professionals should be aware that consuming marijuana and other cannabis products can have oral health effects. Research compiled by the American Dental Association (ADA) indicates that regular users have higher rates of dental caries and significantly higher rates of periodontal disease than non-users. These consumers are also more likely to experience xerostomia, a symptom also associated with smoking tobacco.

“We don’t yet know for certain if cannabis is physiologically increasing the risk of cavities,” my colleague Austin Le, DDS, MSc, told me, but there is an association between the two. Austin is an orthodontist and an assistant research scientist in the Department of Population Health, NYU Langone Health. He and his fellow investigator, Joseph J. Palamar, PhD, MPH, of NYU Grossman School of Medicine, are among the few researchers studying the oral health implications of cannabis use. His goal is not to discourage all cannabis consumption, which he acknowledges may have some positive effects. “We’re just saying, let’s be cautious,” he says. He wants the advice he and other dentists give patients to be grounded in evidence, and he can’t achieve that goal without more research.

Austin believes the association between cannabis use and caries likely results from behaviors such as the increased snacking that often accompanies marijuana use, and research supports this hypothesis. One small but interesting study comparing cannabis users and smokers in Switzerland found significantly higher decayed surface values, less frequent daily tooth brushing and dental check-ups, and much higher consumption of sugary beverages among the cannabis-using group. 

Researchers are also trying to tease out whether smoking marijuana or consuming cannabis in other forms puts people at higher risk for oral and pharyngeal cancers. While tobacco use and orally inhaling smoke are strongly associated with some cancers and malignant lesions in the mouth, the research to date on oral cancer and cannabis use is inconclusive, Austin told me.

What Can Dental Professionals Do?

While we wait for additional evidence, the ADA recommends that dental health care providers ask their patients about cannabis use and advise them accordingly, a practice Austin heartily endorses. In a 2022 commentary in the Journal of the American Dental Association, he called on dental professionals to ask at least one question about drug use when taking a health history. 

Austin says there are many reasons dentists may shy away from the question, especially in a private practice setting. It’s a very personal topic, and “a lot of clinicians are trying to foster a nice and minimally intrusive customer experience for their patients,” he says. Dentists may also worry that patients’ answers may obligate them to refer or treat something they regard as beyond the scope of their expertise. 

Despite these limitations, he would like to see dentists ask the question routinely, especially with young people, who report the highest levels of cannabis use. “We already ask, are you taking any medications? What’s another two seconds to say, are you using any cannabis, because if you are, it might affect our treatment decisions.” As a secondary benefit, asking routinely may surface patients who need referral for substance-use disorder. “I view it as low hanging fruit with potentially great benefits that could change a lot of people’s lives,” Austin told me.

Cannabis as Medicine

Further complicating the clinical picture, a growing body of research supports the use of cannabis in managing pain, including the pain of oral cancer, which can be especially severe. This is welcome news in the dental community, which is striving to reduce opioid prescriptions. My NYU Dentistry colleague Brian Schmidt, DDS, MD, PhD, senior vice dean for research development and academic affairs, is working with researchers at the UCLA School of Dentistry to develop a non-addictive cannabis-based pain medication for oral cancer patients without the addictive properties or side effects of marijuana. This could be a boon both to prescribing clinicians and to their patients.

Because of the potential benefits of cannabis for treating oral pain and other conditions, we owe it to our patients to learn more about this increasingly popular drug and to be nuanced in how we discuss cannabis and marijuana use. This may be especially tricky with older adults, who experience high levels of oral disease. Austin and Joseph Palamar have found evidence to suggest that older adults are less forthcoming about their drug use, but available surveillance data show their cannabis use trending upward, perhaps in part because people who started using marijuana in their youth are aging into this population. Given that poor oral health is linked to diabetes and cardiovascular disease, getting a full picture of these patients’ substance use may be important to managing both their oral and overall health.

Austin’s impression is that most dentists are unprepared for a conversation that goes beyond counseling abstinence, but he is still eager to see screening questions asked regularly in the dental office. “If you don’t ask anyone, then you’re going to miss everyone,” he reasons. “If you ask everyone, you might get a few who say yes and potentially change their lives and improve their health situation in a very meaningful way.” 

I couldn’t agree more. We owe it to our patients to let them know we’re open to discussing the risks and benefits of cannabis use. Kudos to Austin, Brian, and the other researchers who are helping to determine more precisely what those are.