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

The community water fluoridation (CWF) tide is turning and it’s happening fast.

• In late March, Utah became the first state to ban CWF.
• Last week, Florida became the second state to ban the practice.
• Bills are pending in at least three more states and circulating in many more to reverse CWF mandates.
• At the federal level, the Environmental Protection Agency announcedit would review the evidence on CWF’s potential risks, and the Centers for Disease Control and Prevention and the Community Preventive Services Task Force are expected to reverse their recommendations in favor of CWF.
• In a related move, the Food and Drug Administration announced last week it will take steps to stop the marketing of ingestible fluoride products aimed at children.

Members of our community are speaking out in response. The American Dental Association, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics issued a joint statement affirming the safety and efficacy of CWF, and the American Dental Education Association released a separate statement supporting the practice.

While some have argued that CWF is no longer essential given the widespread availability of fluoride via toothpaste and other consumer products, the evidence from communities that have discontinued CWF underscore its continued relevance. In fact, studies strongly indicate that the practice still has a meaningful role to play in preventing tooth decay, especially among children.

The Evidence

Take Calgary, Alberta. When the city’s fluoride injection system broke in 2011 necessitating millions of dollars in repairs, city councilors saw removing fluoride from the water supply as a way to avoid a major expense and respond to public sentiment opposing fluoridation. From a political standpoint, halting CWF was clearly the smart choice. Ten years later, a marked rise in childhood caries shifted public opinion and the political winds. A 2021 ballot measure to reintroduce CWF passed with 62% of the vote.

In Juneau, Alaska, CWF was stopped in 2007. Researchers studying Medicaid data observed a statistically significant increase in caries-related dental procedures and treatment costs for children from low-income families between 2003 and 2012. The increase was most pronounced in children under 7 who had almost no exposure to fluoridated community water during their lifetimes.

A similar rise in decay occurred in Israel after the minister of health ended mandatory water fluoridation in communities of 5,000 or more in 2014. This policy change occurred despite strong evidence that children 3 to 12 years of age in Israeli communities with no fluoride in the water had almost twice as many dental restorations as their counterparts in communities with CWF. What was the effect of eliminating the mandate? Not surprisingly, a study comparing the dental records of military recruits who entered service between 2012 and 2021 found higher rates of caries-related treatment among those with less exposure to CWF during their childhoods. What might surprise some is that the study also found no association between access to free, universal pediatric dental care (introduced in 2010 and extended to teenagers in 2018) and the recruits’ oral health. It appears access to treatment is no substitute for community-based prevention when it comes to dental caries.

Where We Stand Today

Less than a year after changing its fluoridation policy, Israel’s Ministry of Health decided to reverse it. The Knesset approved the change, but funding has yet to be appropriated to support fluoridation’s reintroduction. Calgary is in a similar holding pattern. Four years after voting to restore fluoridation, the city is still working to upgrade its infrastructure to achieve that goal, and the initial estimated cost has almost tripled. Juneau has no plans to reintroduce CWF, so local dental professionals rely on topical fluoride treatments to protect their patients’ teeth.

I hope dental professionals and other clinicians will continue to advocate for CWF at the state and community levels, but in communities where fluoridation is halted, we will need to take other steps to protect our patients’ health.

What We Can Do Moving Forward

In my December post on this topic, I described a variety of steps dental professionals can take to protect our patients’ oral health. These included:

Oral hygiene education. We should make sure our patients know how to properly brush and floss and understand the role of diet in tooth decay.

Encouraging the use of sealants to protect children’s teeth. We need to inform families of their value, especially in communities that discontinue CWF.

Introducing silver diamine fluoride (SDF) in your practice. This effective tool for caries treatment and prevention has yet to be widely adopted. Its wider use could make a major contribution to mitigating the harm to children’s oral health that we anticipate.

Employing other fluoride treatments. Fluoride-containing toothpastes, varnishes, gels, and rinses can also benefit our patients — at least for now. Some of these are also under attack. At the end of April, the Texas Attorney General filed suit against Colgate and Proctor & Gamble claiming that their practice of marketing flavored toothpastes containing fluoride to children and parents is “misleading, deceptive, and dangerous.” 

Sugar taxes are another public health measure that has substantially reduced childhood caries, but Americans have often balked at efforts to reduce their sugar consumption. When then New York City Mayor Michael Bloomberg attempted to restrict the sale of soda in large containers, the backlash was fierce, and two years later, the regulation was overturned by the courts.

Would a similar federal effort by the current administration be more warmly received by some previous objectors? Perhaps. As the number of communities with fluoridated water decline, we may see increased recognition that public health measures to protect American’s oral health are urgently needed.

University of Alaska Anchorage Associate Professor of Public Health Jennifer Meyer, PhD, MPH, CPH, RN, who studied the impact of Juneau’s decision to halt CWF, has eloquently made the case for adding fluoride to the water supply. “We add and supplement beneficial elements in food for many reasons,” Meyer said during a 2019 interview. “It’s an effective and equitable public health strategy. For example, we fortify wheat products with folic acid to prevent spina bifida and other neural tube defects. We add calcium and vitamin D to milk to prevent rickets, and adding iodine to salt has been a primary way of preventing iodine deficiency and goiters. Similarly, fluoride is an important mineral for the development and protection of teeth. Adjusting the availability of fluoride in the community water to an optimal level (0.7ppm) supports a population oral health benefit and mitigates risk.”

I saw the power of CWF firsthand when I was a pediatric dental resident at Children’s Hospital in Boston. When I started, we routinely saw high levels of caries in our patients. After the city introduced CWF, their oral health improved dramatically. I hope the panic surrounding fluoride will subside and efforts to remove this beneficial mineral from water supplies will be successfully countered. In the meantime, history tells us to expect a surge in tooth decay if public fear of CWF continues to dictate public policy.

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

If you’re concerned about sustainability in dental clinics and offices, chances are you care about waste: the endless stream of plastic wrap, gowns, gloves, and all the other single use items that we throw away each day. I have to admit, until recently I hadn’t given sufficient thought to dentistry’s broader environmental footprint.

That changed in 2023, when I attended the annual meeting of the Association for Dental Education in Europe (ADEE). I was struck by how seriously the Europeans take sustainability. They aren’t just focused on disposables. They are looking at how teledentistry can reduce the profession’s carbon footprint and at prevention as the ultimate sustainability strategy. What’s more, they are implanting these ideas into the future dental workforce by adding “sustainable practice” to the list of competencies for The Graduating European Dentist, with the expectation that dental graduates will understand the environmental impact of their clinical practice, demonstrate respect for the environment, critically evaluate current practices, and seek practical solutions within an ethical framework.

Here at Home

Europeans are far ahead of the U.S. dental community, but that’s not to say that nothing is happening on this side of the pond. 

• The American Dental Education Association (ADEA) has formed a special interest group (SIG) focused on sustainability.
• And at several U.S. dental schools, concerned students and faculty have lobbied for innovative clinical practices and curricula related to sustainable dentistry.
• The American Association of Dental Office Managers offers tips on greening dental practices and has initiated a Green Leader Initiative sponsored by the Henry Schein Cares Foundation.

Jennifer Luca, DMD, MS, a Michigan-based pediatric dentist, is chair of the ADEA Sustainability SIG and was a student leader in sustainability at the Harvard School of Dental Medicine (HSDM). She cofounded and led HSDM’s “Green Team” and conducted a survey of student and faculty attitudes towards sustainability at more than a dozen dental schools. The respondents were overwhelming interested, she told me, but “no one had any idea what to do.”

At HSDM, the “Green Team” lowered the school’s carbon footprint by setting the hoods in the bench lab to close automatically when research was not taking place and transitioning from plastic to paper for patient goody bags. At Nationwide Children’s Hospital in Columbus, Ohio, where Dr. Luca did a residency in pediatric dentistry, she formed an employee resource group that attracted 120 members. “We planted trees. We picked up trash. We had green physicians and anesthesiologists and facility workers present to the group.” Dr. Luca also estimated the environmental impact of treating early childhood caries and discovered patients’ travel-related emissions and the use of nitrous oxide, a potent greenhouse gas, had the greatest impact. Now she is focusing her research and advocacy on reducing the environmental impacts of anesthesia use in pediatric dentistry.

Dentistry’s Carbon Footprint

A widely cited 2016 estimate attributes 10% of U.S. greenhouse gas emissions to the nation’s health care sector. Of that, 3% is often attributed to dental care, and a report quantifying the environmental impact of dental care in England supports that figure. That may not sound like a lot, but in the aggregate, the impact is much harder to dismiss.  An estimated one billion plastic toothbrushes are discarded each year in the United States alone, and because most are made from composites, they can’t be recycled.

The amount of waste generated by dental offices is also substantial, and dental school clinics, because they are teaching environments, generate even more. In recent months, students and faculty at NYU Dentistry have conducted waste audits in the oral surgery and some general dentistry clinics. Leena Manzoor, a third-year student, led the audit with her classmate Mona Jahangirvand and with Mahsa Salmasi, a second-year student who serves as greening representative to the college’s student government. All three are in the group practice led by Bapanaiah Penugonda, BDS, MS, an associate professor and one of the college’s most vocal advocates for sustainable practice.

The students shared the results of one audit during the college’s recent Research Day, and the results were eye-opening. Their six-day audit of discarded unused materials in the oral surgery clinic found 268 burs, 244 restorative materials, 203 anesthesia components such as carpules and needles, and an assortment of other items. The estimated cost based on this brief audit? $828.

If that sounds like a lot, the audit team discovered even more waste in Dr. Penugonda’s general dentistry clinics that took part. Paul R. Baker, DDS, clinical assistant professor of oral and maxillofacial surgery and one of the professors who encouraged the waste audit, attributes his clinic’s better performance to the unit’s supply clerks, who “constantly ask students, ‘Do you need this? If you’re taking a handful, are you going to use this?’”

Even before the audit, Dr. Baker had made a point of exposing students finishing their oral surgery rotations to the unused items typically discarded in his clinic each day and their costs. While some of the students who are just starting their clinical rotations roll their eyes, he says those on the cusp of graduating are stunned by the financial implications for their future practices.

Strategies for Change

So, what can be done about all this waste?  The students who conducted the audit have made three policy recommendations, which they hope the college will adopt later this year.

1. Reduce waste by standardizing how many supplies students can access for each type of procedure.
2. Reuse discarded burs in the sim lab. These come individually wrapped, so only the packaging would need cleaning.
3. Incorporate sustainability in the curriculum throughout the four years, not just in the final practice management course.

Given our crowded curriculum and the universal sense that students feel stressed for time, this last request is particularly notable.

How can U.S. dental practices reduce waste? While plastic materials are convenient and cheap, there are alternatives. In our clinics, perhaps we can replace disposable plastic nozzles with metal ones that can be sterilized, and we can encourage our patients to use more sustainable oral hygiene products in their homes. Bamboo toothbrushes, biodegradable floss, and toothpaste tablets that obviate the need for plastic tubes are all currently being marketed, and industry heavy weights are striving to make their packaging and manufacturing processes more environmentally friendly.

In most practices, electronic health records have reduced paper waste.  Meanwhile 90% of dental practices have adopted digital radiography, eliminating the waste associated with film stock and development chemicals. A 2021 survey suggested half of dentists were also using intraoral scanners, with two-thirds of those remaining planning to acquire one.

Beyond Waste Reduction

To reduce its carbon footprint, dentistry must also examine a range of other activities that produce emissions. Chief among these is travel. The report on dental care in England I mentioned above attributed more than 60% of the country’s dental carbon footprint to patient and staff travel. The energy used in dental facilities and procurement (production and transport of materials) ranked second and third at almost 20% each.

The establishment of the LEED rating system for design and construction has helped to make many newer buildings more energy efficient, but the facilities we work in are typically beyond the control of most oral health professionals. We could, however, take steps to reduce the amount of travel associated with our provision of care. We could reduce the number of patient trips by offering telehealth consultations, scheduling family members on the same day, and completing adjacent restorations in a single visit. Larger practices can also open satellite clinics in more remote areas to take care to patients, rather than the other way around.

Most importantly, we can double down on prevention — the most sustainable form of oral health care. In some cases that will mean bucking administrative and payment systems that don’t always reimburse for patient education or give dentists flexibility in scheduling procedures for irregular blocks of time. We should take on these challenges, not just because it’s good for the environment, but because avoiding the need for restorative dental care is what’s best for our patients.

Are We Ready to Commit?

It’s hard to say how ready U.S. dentists are to embrace sustainable practices, but I was pleased to see Toni M. Roucka, DDS, MA, FACD, current editor of the Journal of the American College of Dentists, assert this spring that dentists have an ethical responsibility to practice sustainably.

As healthcare providers, dentists must consider the broader impact of their practices on their patients’ overall health and well-being, including the health of the environment and the mitigation of climate change, often described as the greatest public health challenge of the 21^st century.

Many dental students already share this view and are putting their beliefs into action. At NYU, they have petitioned the college, along with Dr. Baker and Dr. Penugonda, to create an official sustainability committee, which they anticipate will begin influencing policy this fall. They hope the integration of sustainable dentistry principles in the clinics and curriculum will not just benefit them but influence practice far beyond the dental college. As Mona Jahangirvand put it, “There are almost 380 NYU Dentistry graduates each year. So, if 400 dentists in America implement these practices, I feel like we will be able to see a change in the field even within the next decade.”

Given the enthusiasm for sustainable dentistry I’ve witnessed at NYU and read about elsewhere, I’d say that’s a strong possibility.

Learn More

The FDI World Dental Federation Sustainability in Dentistry website contains:

• A free, online, three-hour course to help oral health professionals understand the importance of sustainable practice and their own role in tackling sustainability issues
• An interactive sustainability toolkit
• Infographics and journal articles on a range of sustainability topics
• FDI’s Consensus Statement on Environmentally Sustainable Oral Healthcare
• A pledge with signatories from around the globe.

Several of my colleagues also recommend The Sustainable Dentist by Beverly Oviedo-Allison and Marylou Shockley. It provides concrete advice to practice owners on operating their businesses more sustainably.

Those working in large health systems will find additional resources on the Health Care Without Harm website, which seeks to reduce health care’s environmental footprint worldwide.

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

Trust is the foundation of effective health care, yet dentistry faces unprecedented challenges to its professional reputation. When headlines spotlight a child’s death during dental sedation, a practitioner charged with Medicaid fraud, or contentious scope-of-practice disputes that limit access to care, these isolated incidents cast shadows across the entire profession. The damage extends beyond the individuals involved in that it erodes the collective trust that dentists have cultivated through years of dedicated patient care and professional integrity.

Today bad news travels quickly, and Americans’ views of professionals are declining. According to Gallup’s 2024 Honesty and Ethics poll, nurses, who have long topped the poll as the most trusted professionals, earned a positive rating from only 76% of respondents — 9 points lower than in 2019. Positive ratings of physicians fell nine points over the same period to a meager 56%, and at 59%, dentists did not fare much better. Public perceptions of the health professions rose during the COVID-19 pandemic but have since declined to all-time lows, especially among non-college graduates.

To withstand these trends, dentists must possess more than clinical expertise and managerial competencies. We need leadership grounded in the recognition that dentistry must operate as a moral community, where ethical principles, patient advocacy, and social responsibility form the foundation of professional practice.

Defining Our Moral Community

A moral community is a group of individuals bound by a shared commitment to ethical standards and a collective sense of responsibility toward the welfare of others. Through shared values and mutual accountability, this community has the capacity to influence members’ actions. In health care, those fundamental values include a commitment to providing our patients with patient-centered care, but they don’t stop there. The American College of Dentists (ACD) has historically emphasized that dentists have a social responsibility to address access and equity challenges for vulnerable populations as well. Those of us who are dental educators must also ensure that these values inform how we mentor future generations, engage with our communities, and shape the future of the profession.

Persistent and Emerging Challenges

As members of the dental profession, we are obligated to do no harm, to act in the best interests of the patient, and to respect the autonomy and dignity of each individual. Today a host of contemporary challenges undermine our ability to meet those obligations.

• The longstanding tension between the primacy of our ethical obligations to patients and the pressures of self-interest in the marketplace is being exacerbated by the growing influence of private equity in dentistry. According to a study by the American Dental Association Health Policy Institute, the portion of U.S. dentists affiliated with private equity increased from 6.6% in 2015 to 12.8% in 2021, and the number of private equity transactions rose five-fold over the same period. How these acquisitions will affect the quality of patient care has yet to be documented, but dentists will need to keep their ethical obligations in front of mind as the economic pressures on them increase.
• Advances in technology also require that we adopt an ethical lens in evaluating whether the latest procedure or test is appropriate for our patients. The use of high-dose radiographs with children, dental implants when alternative treatments are available, or crowns on healthy teeth to accommodate the quest for a perfect smile all entail a risk of harm and pose moral questions for practicing dentists.
• Persistent disparities in access to dental care and oral health outcomes present another significant moral challenge, calling us to address the larger systemic issues that affect patient care. Public health measures such as community water fluoridation may no longer be an available tool for improving the oral health of those who lack regular access to dental care. Changes in how immigration laws are enforced are also raising troubling patient-advocacy questions for dentists and their colleagues in the other health professions, whose places of works have traditionally been protected from interference by immigration enforcement personnel.
• Concurrently, programs established to dismantle the barriers that prevent underrepresented groups from entering the health professions may see their government funding eliminated. Given what we know about the value of culturally concordant care to the health and well-being of our patients, our community has a moral responsibility to devise alternative strategies for continuing this urgent work.

The updated ACD Ethics Handbook for Dentistry provides essential resources to support ethical decision-making in the face of these and other challenges. While not addressing the issues above directly, the handbook’s guidelines are useful in navigating them. For example, the section on informed consent advises us to go beyond what is legally required to include “[u]nbiased presentation of all reasonable alternatives and consequences, including costs and the probability of outcomes” and to communicate with patients “on a level assuring comprehension.” Such guidance gets to the heart of how we can act in the best interests of our patients.

The Role of Dental Educators

As members of a moral community, all members of our profession should commit to lifelong learning, humility, and service, but those of us in dental education have an additional obligation: to inculcate future dentists with the values that define dentistry as a moral community. In so doing, dental educators fulfill their fundamental role as stewards—ensuring that the profession remains true to its ethical commitments and moral foundation.

Mentoring is a vital part of this stewardship, as it enables educators to impart the ethical values and responsibilities of the profession to the next generation. So are leadership development programs such as the NYU Dentistry Leadership Portfolio, which not only teaches the technical and managerial aspects of leadership but also emphasizes the importance of character, ethics, and moral responsibility. Such efforts can foster a more empathetic and socially responsible workforce dedicated to providing equitable care for all.

Leadership as a Moral Imperative

Addressing the challenges facing our profession and our patients will require leadership — not just from academic dentists but from everyone in our profession who is committed to improving oral health and shaping the next generation of dental professionals. As stewards of the profession, we must ensure that dentistry remains a moral community—one that is grounded in ethical principles and dedicated to serving the needs of our patients and society at large. By upholding the pillars of the ACD—ethics, professionalism, leadership, and excellence—we can bolster, and where needed, rebuild the public’s trust in our profession and ensure that it continues to thrive, not only as a clinical discipline but as a community of care committed to the well-being of all.

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

Muscle atrophy. Trouble breathing. Paralysis. Death.

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

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

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

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

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

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

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

What the Dental Community Can Do

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

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

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

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

It is a suspenseful time for anyone concerned about public health. In a matter of days or weeks, new leaders will arrive in Washington and Atlanta to lead the nation’s three-letter health agencies. Within the FDA, CDC, CMS, and NIH, people are bracing for change, while nongovernmental stakeholders publicly speculate about how the likely new secretary of health and human services — an attorney known for his unorthodox views on public health — might reshape the research and regulatory environment over the next four years.

Those seeking inspiration or guidance on navigating a changing federal landscape might want to read Anthony Fauci’s 2024 memoir “On Call.” In addition to his widely reported observations on the federal government’s handling of the COVID-19 pandemic, the book describes the forces that shaped this exceptionally talented physician and researcher, including his earlier years in medicine, research, and public health.

Fauci began his professional journey at the NIH’s National Institute of Allergy and Infectious Diseases (NIAID), which he was tapped to direct in 1984. Over the course of a multi-decade career, he responded to a series of public health challenges, including HIV/AIDS, bird flu, Ebola, Zika, and the post-9/11 anthrax scare. In the process, he became an adept influencer of U.S. health policy under seven U.S. presidents, starting with Ronald Reagan.

Both praised and vilified during his time in the spotlight, Fauci remained in public service until the age of eighty-two, concluding a professional journey that offers lessons in leadership we can use today. Here are a few from his early career that resonated with me and offer guidance as we prepare for whatever comes next.

Lesson 1: Build connections with individuals who have the influence to drive change.

Fauci made the fateful decision early in his career to focus his research on the care of patients with HIV/AIDS. At the time, the disease was poorly understood, highly stigmatized, and almost universally fatal. As gay men started dying of AIDS in large numbers, an activist movement arose to pressure the NIH to devote more resources to studying the disease.

The movement’s strident criticism of the government’s response drew widespread attention, elevating Fauci’s public profile and immersing him in controversy. He rose to the challenge, cultivating relationships with both vocal gay rights activists and the powerful government officials they criticized. He proved skilled at helping these adversaries appreciate each other’s perspectives and at communicating with political leaders in ways that would eventually spur action. “I addressed public policy only when it related to my scientific expertise, and I left politics to others, a practice I tried hard to adhere to for the rest of my career,” he wrote. “[I]t was crucial to be truthful and consistent in providing information based purely on scientific evidence and best judgment, and nothing else.” This approach won him the respect of George H.W. Bush and each of the presidents who followed.

In my own work, I have also found that successful advocacy requires what I call “RiP SAw” — shorthand for “the relentless pursuit of strategic alliances.” While I was at the American Dental Education Association (ADEA), we forged strong ties both inter- and intra-professionally; across education, practice, and research; with dental professionals on other continents; and with lawmakers in the executive branch and on Capitol Hill. These relationships were integral to our ability to achieve changes in dental licensure, the formation of the Interprofessional Education Collaborative, the sharing of evidence-based curricula throughout the globe, and policy advancements such as the inclusion of a children’s dental benefit in Medicaid and the Children’s Health Insurance Program.

One of our earliest successes dates to the period when Fauci was focused on increasing federal funding for HIV/AIDS research. ADEA partnered with others to secure the inclusion of dental and dental hygiene services in the Ryan White CARE Act, which reimburses providers for uncompensated care of people living with HIV and AIDS.

Lesson 2: Always be looking around the corner.

In the mid-1980s, people with HIV were dying at an alarming rate and trying all sorts of untested remedies on their own in hopes of suppressing the virus. Fauci responded by accelerating NIAID’s work to discover drugs that could be effective in treating HIV/AIDS. He established the Division of AIDS within NIAID and facilitated partnerships between academic institutions and pharmaceutical companies to spur drug development.

“Not everyone at the NIH or in research institutions throughout the country was excited about spending the money to create such a network, especially when we did not have any drugs yet to test in these units. Some scientists were even saying that we were ‘throwing money away,'” Fauci writes. Despite the criticism, he stayed the course, and the network soon proved its value.

This commitment to “looking around the corner,” as I like to say, is an essential leadership skill. The political and institutional pressures to prioritize immediate needs can be overwhelming. Leaders who can also cast their gaze outward, gauge future needs, and invest their resources for the long term are essential to achieving the kind of progress that yields significant impact down the line.

Lesson 3:  Health care is an art as well as a science.

Despite his strong interest in research, Fauci learned this lesson early on. “I was dealing with a human being who needed care, compassion, and comfort in addition to the correct description of her heart murmurs,” he writes of a woman he treated while a medical student. “Right from the get-go I felt the importance of this combination of the art and the science of medicine.”

This realization served Fauci well while caring for patients with HIV/AIDS at NIAID. A particularly poignant event occurred one evening as he made rounds. A favorite patient, with whom he chatted daily, was unable to recognize him. In the intervening hours, an opportunistic infection had rendered him blind. “It was as if someone had stuck a spike in my chest,” Fauci recalls.

I also retain vivid memories of some of my early experiences treating people with HIV/AIDS. They regularly came through our doors when I was dean for clinical affairs at the Harvard School of Dental Medicine in the late 1980s. At the time, few private practice dentists were willing to treat these patients, and dental schools stepped up to provide access to care. In Boston, we became known as a place that welcomed these patients.

One day I was called on to consult on the oral complications of a patient with AIDS at the Brigham and Women’s Hospital. The 25-year-old man was unable to eat or drink because of fungal infections in his mouth. He was in an isolation room, and when I entered — fully gloved and gowned with a mask and a face shield — he began to weep. My attire telegraphed the gravity of his health situation, which he had not disclosed to his parents. He told me they did not even know he was gay.

The encounter taught me a lesson in empathy and was instrumental in shaping my future interactions with patients with HIV/AIDS. I found ways to interject humor in patient encounters and, most importantly, looked for ways to give them hope.

Final Reflection: The enduring power of hope.

Providing hope is woven throughout “On Call.” It is easy to look around at everything that is wrong in the world and get discouraged, but the book reminds us that behind the scenes, people of goodwill are making progress every day. The pace of change may be incremental, but the small gains of clinicians, researchers, and others can accrue in ways that change the lives of millions, especially when changes occur at the policy level. Health scientists willing to serve as honest brokers and do the hard work of informing politicians and the public are urgently needed today. Dr. Fauci led through six decades of often dark and frightening times—we can and will step in as he steps back. Let us hope the qualities that Fauci exemplifies continue to have currency in the years ahead.

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

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

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

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

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

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

Evolving Evidence

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

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

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

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

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

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

Looking Ahead

So, where does the evidence leave us?

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

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

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

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

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

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

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

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

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

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