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.

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

You’ve heard me say this before, and you’ve likely said it yourself: The traditional separation of dentistry from medicine hasn’t been good for our oral health. That’s true not only in the United States but also globally, a point underscored this past September when the WHO Collaborating Center for Quality Improvement & Evidence-based Dentistry at NYU Dentistry hosted an Oral Health Side Event during the meeting of the United Nations General Assembly.

The presenters shared many encouraging developments that are advancing oral health around the world, but they didn’t shy away from sharing some hard realities, either. Speakers noted that almost half of the world’s people suffer from oral diseases, and the case numbers continue to rise in all regions of the globe. The World Health Organization (WHO) lays much of the blame on the lack of access to affordable dental care, but Richard Horton, editor-in-chief of The Lancet, which co-sponsored the event, also called out “the global sugar industry” for “working hard … to oppose, to deflect, and to undermine messages about oral public health.” 

Dentists and dental hygienists have long counseled their patients to avoid sugary foods, brush after meals, and chew only sugar-free gum, but as a community, we haven’t always considered the value of policy solutions to discourage sugar consumption. Some of my colleagues want to see that change. 

Taxing Sugar-sweetened Beverages

In November 2021, Lauren Feldman, DMD, MPH, clinical assistant professor and director of NYU Dentistry’s postdoctoral program in pediatric dentistry called on the American Dental Association (ADA) to join many of its sister organizations and the WHO in supporting the taxation of sugar-sweetened beverages (SSBs). In a commentary in the Journal of the American Dental Association, Lauren shared the growing body of evidence showing that SSB taxes reduce sugar consumption, especially in lower-income and minority communities that are disproportionately affected by diet-related chronic diseases — tooth decay among them.

Results from the United Kingdom (UK) sugar reduction effort are striking. The nation put a tiered Soft Drinks Industry Levy in place in 2018 to tackle childhood obesity. According to a government progress report, “the sales weighted average total sugar content” of SSBs fell by 46% from 2015 to 2020, due to an increase in sales of the lowest tier drinks, “those containing less than 5g of sugar per 100ml.” 

Closer to home, the city of Philadelphia, which instituted an SSB tax in 2016 to raise money for universal preschool, obtained similar results. Researchers calculated the tax reduced SSB sales by 38% in the first year, even after accounting for purchases made in neighboring districts to avoid the tax. A few more U.S. cities and some Canadian provinces have instituted SSB taxes, but overall, North America lags behind other parts of the world. Only Mexico has a nationwide SSB tax. Globally 66% of people in low-income and 74% in lower middle-income countries are subject to SSB taxes compared to less than a third of people in wealthier nations.

Other Sweeteners

Philadelphia’s SSB tax also applies to beverages that contain nonnutritive sweeteners such as aspartame, saccharin, and stevia. To be clear, these beverages do not feed the bacteria that produce tooth decay, but they can contribute to enamel erosion. Proponents of including them in SSB taxes say their inclusion discourages consumers from substituting them for sugar-sweetened beverages. 

That said, many in the dental community value nonnutritive sweeteners as a practical alternative to more harmful substances, and research suggests they also have a role to play in combating tooth decay. For example, chewing sugarless gum after meals increases the flow of saliva, neutralizing acids in the mouth. As a result, the ADA has given its seal of approval to a variety of chewing gum products that use aspartame, xylitol, sorbitol, or mannitol as sweeteners.

It’s also critical that public health policies be firmly rooted in high-quality evidence. A recent editorial in STAT raised this point in response to a statement this past summer from the WHO’s International Agency for Research on Cancer (IARC), which suggested a potential link between nonnutritive sweeteners and cancer. The author, a dentist, expressed concern that policymakers and the public might seize on this weak association to reduce access to aspartame, a sugar substitute approved by the Food and Drug Administration (FDA) back in 1974. The FDA also responded to the IARC announcement, saying the FDA disagreed with the IARC’s conclusion and pointing out that regulatory and scientific authorities in Europe and Canada have also evaluated aspartame and found it to be safe.

A Global Focus on Sugar?

My colleague Habib Benzian, PhD, who co-directs the WHO Collaborating Center, located within the Department of Epidemiology & Health Promotion here at NYU Dentistry, recently published a commentary in The Lancet advocating for the incorporation of oral diseases and sugars in the WHO framework of non-communicable diseases (NCDs). This tool for setting WHO priorities originally focused on four conditions (cardiovascular diseases, cancers, chronic respiratory diseases, diabetes) and four modifiable risk factors (tobacco use, unhealthy diet, unhealthy use of alcohol, physical inactivity). Mental disorders and air pollution were added to the matrix in 2018. The proposed “6×6” framework would elevate oral diseases to the same level as other NCDs and highlight the importance of reducing sugar consumption.

I hope the WHO will adopt the new framework. I saw the effects of sugar firsthand as a pediatric dental resident at Children’s Hospital in Boston. It’s hard to imagine now, but the city lacked community water fluoridation at that time, and we saw high levels of childhood caries as a result. Fluoridation remains an essential tool in preventing tooth decay, but as the WHO’s Global Oral Health Status Report released in November 2022 pointed out, “Sugar consumption is the main cause of dental caries, showing a clear dose–effect relationship.” 

The WHO recommends limiting sugar consumption, whether added to foods or naturally occurring, to less than 10% of daily calories. People in high- and middle-income countries routinely exceed this guideline, and consumption is rising in low-income countries as well. The report also cited “the very high level of free sugars found in commercial foods for infants and young children” as another cause for concern.

Taking Action

Not everyone supports the idea of taxing SSBs. Some people take issue with the idea of governments having any say in what people eat or drink. Others argue that educating individuals to take personal responsibility for what they consume is a better way to improve health. In a written response to one such critic, Lauren pointed out that individuals don’t make choices in a vacuum. “Choice architecture influences personal decisions in beverage selection through marketing, packaging, store placement, and pricing,” she wrote. “The food and beverage industry designs our choice architecture to maximize profits. Sugar-sweetened beverage (SSB) taxes are an effective tool to redesign our choice architecture to maximize health.”

Over the years, states and the federal government have used the same rationale to justify taxing alcohol and tobacco and to limit where these products may be sold. Government interventions to mitigate the potential harms of these so-called commercial determinants of health may be uncomfortable in a society that prizes the free market. That said, it’s hard to imagine anyone arguing that we would be better off today without cigarette taxation and the other public health measures that disrupted the status quo. A 2018 study on the relationship of cigarette taxes and smoking prevalence found a decline of 0.6% for every 25-cent rise in per-pack cigarette taxes, and an even greater drop of 1.5% in smoking among young people aged 18 to 24. Collectively, various U.S. efforts to curb cigarette use reduced youth smoking from 23% in 2000 to less than 3% today.

As a profession, we’ve long supported community water fluoridation, another evidence-based government intervention to support oral health. It’s time for us to seek a similar consensus regarding SSBs. To quote Lauren’s commentary, “The ADA and oral health care professionals are uniquely positioned to help shift the public conversation in recognition of sweetened beverage taxes as an effective policy tool for oral and general health promotion.” I agree and hope our community will take advantage of the WHO’s current focus on oral health to advocate for policy changes that can improve oral health on a global scale.

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

This past June, the Supreme Court issued its long anticipated ruling placing strict limits on the consideration of race in college admissions. Though not unexpected, the Court’s decision is concerning, not least of all for the effect it will have on efforts to diversify the health professions. 

In 2004, the Sullivan Commission on Diversity in the Healthcare Workforce released a landmark report: Missing Persons: Minorities in the Health Professions. The report asserted that the increasing diversity of the U.S. population had been accompanied by “glaring disparities in the quality of care, especially for racial and ethnic minorities,” leading to “thousands of premature deaths each year and incalculable hours of lost productivity, pain, and suffering.” The report laid a significant portion of the blame on “the imbalance in the makeup of the nation’s health care workforce” and called diversity among health professionals “a key to excellence in health care.” 

Progress

Over the past three decades, the American Dental Education Association (ADEA) and its sister organizations have devoted tremendous energy and resources to addressing this imbalance. While I was president and CEO of ADEA, we built on the work of the Association of American Medical Colleges (AAMC) to promote the use of holistic review in admissions at our member institutions and provide them with technical assistance. We also worked to integrate dentistry into the nation’s leading pre-medical preparation program for students from demographic groups underrepresented in the health professions. Known today as the Summer Health Professions Education Program (SHPEP), the Robert Wood Johnson Foundation funded program currently includes five additional health professions.

Since dentistry’s inclusion in 2006, 929 SHPEP participants have graduated from dental school. Two-thirds are women, and almost half come from underrepresented minority (URM) groups. According to a report ADEA issued last year, the enrollment rate at U.S. dental schools in 2020 was 14.5% higher for URM students who took part in SHPEP than for those who did not. ADEA data also suggest that efforts to recruit and prepare more URM students for dental careers are paying off, at least for some groups. The number of Black first-time, first-year enrollees rose steadily from 300 in 2015 to 435 in 2021, and the number of Hispanic enrollees grew at a notably faster pace, from 318 in 2009 to 695 in 2021.

Many dental schools, including NYU, have their own programs to expose young people to the health professions and help them understand what it will take to apply and gain admission to a program in their chosen field. Throughout the United States, numerous programs at the college, high school, and even elementary school levels also strive to interest students in health careers and prepare them to be successful applicants to college or professional schools. These so-called pipeline programs will be critical tools for diversifying the healthcare workforce in the wake of the Supreme Court’s decision, but we will need additional tools to accelerate change. 

More Is Needed

Even prior to this summer, when admissions teams were still able to consider race as one factor in admissions in order to build diverse classes, the proportion of URM enrollments in dental schools lagged behind these groups’ representation in the population. Black students made up 6.4% of 2022 dental school enrollees, and Hispanic students made up 10.1%—roughly half of their representation in the U.S. population as a whole. The situation for American Indian/Alaska Native and Native Hawaiian/Pacific Islander students was even worse, with fewer than two dozen students from each of these groups even applying to dental school in 2022.

As someone who spent two decades at ADEA working on this issue, I too am troubled and searching for strategies that can allow us to continue to advance the work of building a more representative healthcare workforce. ADEA continues to be concerned about the dearth of Black men in dentistry and the health professions and hosted a summit in 2022 and a webinar this past February to inform members about ways schools can support Black men pursuing careers in the health professions. I’m also heartened by a recent partnership between AAMC and the National Medical Association (NMA): the Action Collaborative for Black Men in Medicine. Together, these organizations are developing measurable solutions to reduce barriers to medical school enrollment and boost Black men’s interest in a medical career starting in high school. 

Similarly, nursing has focused on diversifying its workforce as a strategy for advancing health equity. With support from the Robert Wood Johnson Foundation, AARP, and the AARP Foundation, the Future of Nursing: Campaign for Action launched a series of workshops in 2019 to train faculty at minority-serving academic institutions in mentoring best practices. The goal is to ensure more URM students graduate from nursing school and pass their licensure exams. The Campaign has also established learning collaboratives to assist participants in establishing or strengthening their mentorship programs and student supports.

One additional strategy we might adopt comes from the Action Collaborative. It has suggested that training pre-health advisors could open the door to a more diverse applicant pool. These professionals lack standardized preparation or credentials for their role, yet they often function as conduits to our professions. Some observers believe that advisors trained to focus more on students’ strengths than their deficits could encourage more Black men to pursue health careers. They could also be instrumental in getting URM students to apply earlier to dental school.

A Historical Perspective

To get a historical perspective on the current situation, I reached out to Lisa Tedesco, PhD, a psychologist who has focused her career on promoting oral health. Lisa became associate dean for academic affairs at the University of Michigan (U-M) School of Dentistry. She was moved to join the faculty in part by the university president’s commitment to diversifying U-M’s faculty, administration, and student body. Subsequently, Lisa led a team evaluating campus outcomes related to diversity, which included a focus on the advancement of women.

Lisa shares my disappointment with the recent Supreme Court ruling, but I was pleased to learn that she is feeling “resolved” rather than demoralized. “We just can’t lose sight of what the goals are,” she told me. “As licensed representatives of the learned professions with a mandate to advance the health of the public, we have a professional obligation to advance equity and social justice, and we need to hold ourselves accountable.”

Lisa has seen challenges to diversity initiatives before. She was U-M vice president and secretary when U-M’s affirmative-action admissions practices met with resistance in the form of two lawsuits that made their way to the U.S. Supreme Court. The Court’s decision in Grutter v. Bollinger affirmed the legality of the university’s consideration of race in admissions, calling student body diversity “a compelling state interest.” In the second case, the Court found the practice at one U-M college of awarding points to URM applicants unconstitutional, reminding institutions to pay close attention to the details of their admissions processes, as well.

Three years later, Michigan voters amended the state constitution to “ban public institutions from discriminating against or giving preferential treatment to groups or individuals based on their race, gender, color, ethnicity, or national origin in public education, public employment, or public contracting.” The university responded by trying a variety of race-neutral approaches to achieve diversity, but over the next 16 years, the enrollment of URM students at U-M fell precipitously, according to an amicus brief the university filed with the Supreme Court last summer. California universities, and their medical schools in particular, observed a similar decline in URM enrollments following that state’s 1996 ban on considering race in admissions.

Moving Forward

Now that the Justices have ruled on the latest challenge to affirmative action, the ball is in our court. What more can we do to advance diversity in the health professions and dentistry in particular? The Department of Education released some guidance in August, but the document is far from comprehensive and offers no new, bold ideas for advancing diversity in higher education.

Whatever happens with undergraduate admissions, recruiting URM students to dental schools will continue to pose its own set of challenges. Lisa, who is now dean emerita of the James T. Laney School of Graduate Studies; vice provost emerita for academic affairs, graduate studies; and professor emerita of the Rollins School of Public Health at Emory University, suggested lowering the cost of a dental education when we spoke. Such a move might improve access and boost URM enrollment, but as Lisa readily acknowledged, it would require a complete overhaul of curriculum and the structure of clinical education. 

A less disruptive way to achieve the same end might be to reduce the amount of education required for entry into dental school. Other countries produce competent dentists without requiring four years of undergraduate education—something U.S. schools might consider. 

In the meantime, we need to rally our communities to remain committed to the cause of diversifying the health professions. When Justice Sandra Day O’Connor authored the Grutter decision, she wrote that the “Court expects that 25 years from now, the use of racial preferences will no longer be necessary.” Like Justice O’Connor, the Sullivan Commission believed its vision of a diverse American healthcare workforce could be achieved within the next two decades—in other words, by today. Sadly, neither of these predictions has come to pass. Let’s hope we find the will to realize them before another two decades elapse. The well-being of all Americans in our diverse society depends upon it.

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

In 1926 Dr. William J. Gies published a landmark report that created a roadmap for modern dental education. Among his recommendations was the creation of a national licensure examination that would allow licensed dentists to move among states.

Nearly 100 years later, many states and their professional licensing boards still cling fiercely to their ability to control who may practice within their borders. These policies are intended to safeguard the public, but some have argued that forcing health professionals to obtain multiple state licenses is both costly and outdated, especially at times of heightened need. This proved true during the COVID-19 pandemic, when all U.S. states implemented an emergency licensing waiver for healthcare professionals, allowing them to practice in all 50 states.

The Case for License Portability

Even under ordinary circumstances, enabling health professionals to practice in multiple states has value. According to the American Dental Association (ADA) Health Policy Institute, roughly one in 13 dentists moved across state lines between 2015 and 2020, and among dentists 40 and younger, the number was one in six.

Dental educators and academic institutions would benefit tremendously from license portability. The American Dental Education Association (ADEA) reported that 17% of dental faculty moved from one school to another during the 2021-22 academic year. How many of those folks had dentist spouses or wanted to set up their own private practices in a new state is unknown. What we do know is that faculty recruitment is always challenging, and with seven new dental schools opening soon and four more in the planning stages, it will only become more so. Anything that reduces barriers to dentists’ mobility will be welcomed by both academic dentists and their employers.

The lack of license portability for dentists and dental hygienists is also concerning to the U.S. military. Service members are regularly transferred between duty stations, and roughly a third of military spouses in the labor force work in licensed professions. The process of obtaining a new state license can be so cumbersome, costly, or time-consuming that many military spouses are forced to temporarily step out of the workforce, depriving their families of income and the public of their services. Sidelining these health professionals also impacts military morale.

One Solution: Interstate Licensure Compacts

In a country where professional licensing falls within the purview of the states, interstate licensure compacts offer one solution. In 2000, nursing became the first health profession to establish an interstate licensure compact, which 39 states and 2 territories have now enacted. Medicine launched a compact in 2017, and 37 states plus the District of Columbia and Guam have already signed on. As of 2022, six other health professions had licensure compacts as well.

Each of these agreements functions differently, but all of them create a framework for cooperation. States retain control of professional licensing and how professions are practiced within their borders while also agreeing to a set of rules that allow practice by professionals licensed in other states. These rules reduce administrative burdens for states and streamline license portability, making it possible for health professionals to practice in other compact states without going through the process of obtaining a second license from scratch.  

According to Anthony (Tony) Ziebert, DDS, MS, the ADA’s senior vice-president for education and professional affairs, the ADA has supported facilitating license portability for dentists and dental hygienists for decades. In 2018, the ADA House of Delegates revised a policy statement supporting “freedom of movement across state lines for all dental professionals” to include a recommendation that states consider adopting licensure compacts to accomplish this end. At the time, leading such an effort independently and lobbying state legislatures one by one felt like a “heavy lift” for the organization, he told me.

Then in 2020, the Department of Defense (DOD) announced that it would make grants available to support the development of licensure compacts. Both the ADA and the American Dental Hygienists’ Association (ADHA) applied. Their support of each other’s applications impressed the DOD, which awarded them joint funding in 2021 and the opportunity to partner with the Council of State Governments (CSG) to develop model legislation establishing an interstate licensure compact for both professions. The DOD’s financial support and CSG’s technical expertise and political connections “made all the difference in the world,” Tony told me.

The DDH Compact

With the launch of the Dentist and Dental Hygienist (DDH) Compact earlier this year, dentistry and dental hygiene now have a mechanism in place to facilitate license portability. The DDH Compact creates a streamlined way for dentists and dental hygienists to obtain the privilege to practice in any DDH Compact state where they don’t hold a license.

To qualify, a dentist or dental hygienist must:

• Hold an unencumbered license in a state that has joined the Compact
• Have graduated from a dental or dental hygiene education program accredited by the Commission on Dental Accreditation (CODA)

States may also ask applicants to pass a jurisprudence exam demonstrating their knowledge of the state’s practice act. This law determines the scope of practice for all dentists and dental hygienists practicing in the state, including those licensed out of state and practicing under a Compact privilege.

Since the Compact’s finalization in March, three states — Iowa, Washington, and Tennessee — have enacted it into law. Five more states have legislation pending. Once seven states enact the Compact, it will go into effect.

Tony is hopeful that enough states will enact it so it goes into effect in early 2024. After that, he expects additional states to get on board. The Compact will be administered and governed by a commission comprised of one representative from the state dental board in each Compact state. Early Compact adopters will be influential in setting the commission’s rules, an opportunity Tony hopes will motivate states to enact the Compact in the coming year.

In addition to facilitating mobility, the Compact should make it easier for state dental boards to identify license holders with disciplinary violations. According to Tony, sometimes it can take weeks or months to get a response to a disciplinary inquiry. States that join the Compact will be obligated to upload all disciplinary information to the Compact commission database. This should prevent dental providers with disciplinary violations from simply moving to another Compact state. “The biggest complaint we hear from boards all the time is that they have no idea what’s happened in other states. This would address that issue,” Tony says.

Entering the Mainstream

It’s great to see dentistry and dental hygiene collaborating in this effort. The Compact provides yet another example of our professions entering the mainstream. I don’t think this would have occurred were it not for previous efforts within our community to bring the dental professions into the 21^st century. Increasing license portability was a key goal of the Coalition for Modernizing Dental Licensure, which ADEA, the ADA, and the American Student Dental Association formed in 2018. The coalition now boasts 125 members representing both educational programs and oral health advocates. We have more work to do on the licensure front, but establishing the DDH Compact is a critical step. Kudos to the ADA and ADHA for making this happen.

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.