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

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

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

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

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

The HPV Vaccine: Effective but Underutilized

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

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

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

What Dental Professionals Can Do

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

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

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

Can these barriers be overcome? Lauren believes they can.

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

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

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

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

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

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

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

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

Seizing the Moment

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

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

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

From the Lab to the Clinic

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

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

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

Promising Investments

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

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

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

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

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

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

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

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

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

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

Universal Health Coverage

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

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

Challenges at Home

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

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

Where NYU Dentistry Fits In

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Having a healthy mouth means everything.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I couldn’t agree more.

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

Barbie Vartanian, NYU Dentistry’s director of advocacy and policy initiatives, remembers the day she first answered the question posed above. She was in a dental clinic helping answer the phones when a woman on the line requested an appointment. “I have twins and they’re autistic. Will you treat them?” she asked. “Well, sure. Why wouldn’t we?” Barbie replied. Then the caller told her numerous other dental practices had refused to book the appointment. “I hadn’t had Sam yet, but I just thought, ‘Of course! We’re health care providers. That’s our job.’”

Barbie’s teenage son, Sam, is profoundly autistic, so in the years since that call, she’s had her own share of challenges obtaining care for him, and she is not alone. According to the Centers for Disease Control and Prevention (CDC), one in six U.S. children has an intellectual or developmental disability (IDD), and one in four U.S. adults lives with a disability of some sort. According to one study, dental care topped the list of unmet care needs among children with special health care needs, “affecting substantially more children than any other health care need category.”

The Oral Health Center for People with Disabilities

NYU Dentistry is helping to fill this gap. In 2019, the College opened the Oral Health Center for People with Disabilities within our current clinical facilities. The Center’s staff is trained to ensure quality treatment and holistic care for people with disabilities and complex medical conditions, and the environment is designed to put them at ease. The dental operatories are larger than usual, providing 360-degree access to patients and space for their caregivers. There’s a bariatric bench to accommodate heavier individuals, and a reclining platform that allows patients in wheelchairs to receive care without leaving their familiar seating. A multisensory room with weighted blankets, special lighting, and videos on the wall provides a space where patients can become acclimated to the clinic environment.

“From there, we transition them into the dental care setting,” explains Robert Glickman, DMD, associate dean for clinical affairs and hospital relations at NYU Dentistry. “We are able to tailor the appropriate therapy, and the appropriate management of therapy, to the individual’s needs; we’re not limited by the facility’s structural configuration.”

In just three years of often pandemic-constrained operation, the Center has given almost 2,000 underserved patients a much-needed dental home, while also serving another critical function. “We want to ignite in our students a sense of wanting to help, and more importantly, to show them that this should be the routine approach to patient care, not something out of the ordinary,” asserts Robert, who is responsible for overseeing the Disability Center’s academic and clinical missions.

Barbie agrees. She has made it her mission to ensure that individuals with disabilities have access to oral health care. “What is needed to treat our population is a shift in mindset,” she told me.

Changing Attitudes Through Advocacy and Education

Last year, Barbie joined our team in the Center for Oral Health Policy and Management. In her current role, she works with Project Accessible Oral Health, an advocacy group she previously led, and other partners in the effort to improve oral health care for people with disabilities. “We’re seeing momentum like we’ve never had before,” she says.

NYU Dentistry is a leader in serving the IDD population, but we are not alone. Our dental school colleagues at the University of Pennsylvania, Touro University, the University of Michigan, and UTHealth in Houston are also committed to serving this community. The University of the Pacific Arthur A. Dugoni School of Dentistry is another pioneer in this area. Early in September, the school cohosted a two-day event with the Santa Fe Group on achieving oral health equity for people with IDD. My partner at the Center for Oral Health Policy and Management, Dr. Michael O’Connor, was among the presenters.

There’s also an effort being spearheaded by the American Academy of Developmental Medicine and Dentistry to draft a national curriculum on treating the oral health needs of people with disabilities. The idea is that any dental school will be able to take it off the shelf and implement it, providing consistency in what’s being taught across the country.

A 2018 change to the Commission on Dental Accreditation (CODA) standards for dental education programs, which asserts, “Graduates must be competent in assessing and managing the treatment of patients with special needs,” should incentivize programs to make use of the curriculum if they aren’t already addressing this topic. Dental educators in New York State can also take part in Unit Zero, a free, eight-credit, NYU Dentistry continuing education program on caring for people with disabilities. We’re offering the two-day program twice this fall, with support from the Mother Cabrini Health Foundation.

Persistent Barriers

Despite these advances, barriers persist. Sadly, one of these is the stigma and bias associated with treating people with IDD. Steve Perlman, DDS, a clinical professor of pediatric dentistry at the Boston University Goldman School of Dental Medicine and a pioneer in this field, once told Barbie people would say to him, “You must not be a great dentist if you’re treating these people.” As Barbie and others can testify, the people who have dedicated their careers to treating populations with special needs are not only great dentists; they’re also great human beings.

One I’ve come to know and admire is Rita Bilello, DDS, an NYU Dentistry alum and chief executive officer of Metro Community Health Centers, Inc. (MCHC), which runs a federally qualified health center here at NYU Dentistry. Rita and MCHC specialize in serving people with IDD. Rita gained exposure to the medical complexities faced by this population during her general practice residency. When she entered private practice, she became the go-to dentist whenever a person with IDD walked through the door.

“I used to get really, really annoyed at my fellow dentists because they would come to me and ask me for the number at the hospital so the patient could be put to sleep prior to the dental procedure,” she told me. “I’m like, ‘There’s no reason why you need to send this person to a hospital. Just do it.’”

In addition to some dentists’ reluctance to provide care, there’s also the issue of payment. Many people with disabilities are insured through Medicaid. Too few providers accept this insurance (see my last post), and those who do are not compensated for the extra time it takes to provide respectful and compassionate care to these patients.

A Better Model of Care

Thanks to MCHC’s presence on the NYU Dentistry campus, the Center is preparing the next generation of dentists and dental hygienists to treat people with IDD in an integrated care environment. Rita views this delivery model as especially beneficial to the patients she treats. “You can’t separate out one component of a human being and think that you’re going to have overall success in taking care of them,” she says. “By the time a patient gets to me for a dental issue, they’ve usually been to the ENT and the psychiatrist because they’re hitting their head and they’re refusing to eat, and you know what? Sometimes the problem is something as simple as a toothache.”

Having the Center and MCHC in the same building makes it easy for students to collaborate with medical staff on behalf of the Center’s patients. In the process, we hope they will come to share Rita’s enthusiasm (and mine) for integrated care delivery.

 The practice of providing integrated, compassionate care in facilities that can accommodate a wide range of patient needs is still in its infancy, but I’m confident others will adopt this approach. As Robert said to me, “If we were the only institution in the country providing this care, it would be a pretty good thing for people who live in our region, but our effort would be a failure. Our goal in establishing the Center is that other dental schools will try to replicate it.”

An oral and maxillofacial surgeon, Robert remembers vividly the times he was asked to perform extractions on people with IDD who arrived at the hospital in pain in the middle of the night. “To take somebody who doesn’t understand what’s going on, put them to sleep, and then wake them up with less teeth — and everybody’s saying, ‘Well, at least we got the infection out,’ — that’s a failure of the system,” he told me. “When we do a root canal at the Center on a patient who previously would have had that tooth extracted, that’s rather amazing to me.” With on-going advocacy efforts and the commitment of more dental schools to preparing their students to treat people with IDD, we may soon see the shift in mindset that could make it a matter of course.