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

The talk of the dental community this winter is the long-awaited report, Oral Health in America: Advances and Challenges, released by the National Institute of Dental and Craniofacial Research in December 2021. Conceived as a follow up to the groundbreaking Oral Health in America: A Report of the Surgeon General released in 2000, the current report is more than twice as long and covers ground that was far less visible two decades ago: pain management, substance use disorders, team-based workforce models, and major advances in engineering and the biological sciences.

 It’s encouraging to note that we have many more tools at our disposal today for combatting oral diseases:

• new technologies for imaging, manufacturing, and restoring lost or damaged teeth;
• a vaccine against the virus that causes most oral cancers;
• a more diverse dental workforce and greater knowledge of how to work effectively in teams; and
• a better understanding of genomics, the microbiome, and the social determinants of health and disease.

That said, the latest report contains sobering news as well. I was especially struck by how little the nation’s oral health has improved since the 2000 report alerted readers to the silent epidemic of oral disease in the United States. That report made abundantly clear that tooth decay and tooth loss were not natural consequences of aging but preventable diseases, and that their distribution throughout the population was anything but equitable. The 2021 report doubles down on those messages, but they no longer come as a shock.

On a few fronts, there has been progress. Only 13% of older adults (those aged 65-74) lack any or all of their teeth today. That’s a radical improvement over the 1960s, when almost half of this population lived with tooth loss. And tremendous progress has been made in preventing and treating tooth decay in preschool children, thanks in large measure to policymakers’ success in creating and expanding federal insurance programs targeting this population. As a pediatric dentist, I was especially pleased with the report’s emphasis on adolescents as they age into adulthood. Establishing policies to improve their oral health will be the next step in paving the way for a healthier population moving forward. 

The importance of policy change can’t be overstated, and the authors of the new report appreciate the centrality of policy in facilitating improvement in the nation’s oral health. This message resonates strongly here at the NYU Dentistry Center for Oral Health Policy and Management and across NYU Dentistry, where we are already engaged in many of the efforts called for in the report.

• We’re expanding access to care for underserved populations through the Oral Health Center for People with Disabilities and VOCARE (Veterans Oral Care Access Resource), our partnership with the Department of Veterans Affairs (VA). We’re also contributing to addressing the national opioid crisis, called out in the report, through the new NYU Pain Research Center.
• The NYU Dentistry Department of Epidemiology & Health Promotion, the only U.S.-based World Health Organization designated Collaborating Center for Quality Improvement and Evidence-based Dentistry, is working globally to advance prevention of oral disease and integrate dentistry into primary care.
• And we’re preparing a new generation to lead these initiatives through the NYU Dentistry Student Leadership Institute.

My NYU colleagues and I were also involved in creating the report itself. Five of us served as contributing authors, as did four of our colleagues in the NYU medical and nursing schools, and three of us, including yours truly, served as scientific reviewers.

This is not to say that those of us in academic dentistry have it all figured out. I would have liked to see the report discuss dental education in greater detail. While we’ve made a lot of progress over the years, there’s much more to do. I am embarrassed when I think back to my own days as a young white dentist treating patients as a resident at Children’s Hospital in the largely Black community of Roxbury, Massachusetts. I treated some kids over and over again, and never fully appreciated how the lack of access to healthy foods in the neighborhood were contributing to the state of their teeth. Today’s dental students are informed about these challenges, but are we preparing them to meet their patients’ social and economic needs effectively or to advocate on their behalf? I’m not so sure.

The report does mention the high cost of dental education and the burden of student debt, but it does not offer any remedies to these problems. Preparing students for unsupervised practice in four short years at a price that would incentivize students from underserved communities to join the profession is a challenge that merits novel solutions.

Those disappointments aside, I applaud the report’s authors for issuing a clear and concise call to action, one that can fuel oral health advocacy in the years ahead. My hope is that it will galvanize our community’s commitment to advance oral health through policy and research, and rally others to join our efforts.

Why didn’t that happen two decades ago? The 2000 report did light a fire under oral health advocates, and it might have ignited the attention of policymakers, too, but the events of September 11, 2001, quickly absorbed their energies. Today, policymakers are also focused elsewhere — on the COVID-19 pandemic — and rightly so, but they must start to address a broader range of health priorities. As pandemic concerns recede to the background, let’s make sure the nation’s oral health gets the attention it deserves.

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

November 19, 2021 was disappointing for many oral health advocates. That’s the day Medicare dental benefits were stripped from the Build Back Better Act, which Democrats were striving to advance through the U.S. House of Representatives. It’s likely that even more provisions of the bill will be scaled back if it passes at all, but the fact that it contained dental benefits for as long as it did is something to celebrate. Finally, there appeared to be a consensus that all government programs should cover dental care.

This broad acknowledgement constitutes a major step forward. The disagreement lies in how to pay for dental care and how a dental benefit should be designed. At the heart of the debate lies an undeniable fact: Dental care, as currently provided, is expensive. This explains why so many older adults avoid routine and even urgent care, and why many in Congress are hesitant to add dental benefits to the Medicare program.

One way to reduce the cost of a Medicare dental benefit would be to target it at beneficiaries with the greatest financial need. The American Dental Association (ADA) suggested this last year when it proposed restricting any Medicare dental benefit to seniors earning up to three times the poverty rate (less than $39,000 a year). Such a restriction would reduce the number of people receiving the benefit by roughly half.

The ADA also called for situating dental benefits in a new Medicare program rather than in Medicare’s medical coverage, Part B. The association mobilized its members and other dentists to send 60,000 emails to Congress. This action “helped ensure that the proposed Part B benefit was not included in the Build Back Better package passed by the House,” ADA President Cesar Sabates, DDS, told ADA members.

Far from all dentists, including me, were pleased by this outcome. The Wall Street Journal published a letter to the editor that I wrote about the issue.  William Giannobile, DDS, DMSc, dean at the Harvard School of Dental Medicine, and Lisa Simon, MD, DMD, fellow in oral health and medicine integration, provided a well-argued rebuttal to the ADA position last month in the New England Journal of Medicine.

“Beyond excluding many middle- and higher-income older adults who currently lack dental coverage, we believe a means-tested policy that is distinct from other Medicare benefits would restrict advances in oral health for two reasons,” they wrote. “First, limiting a Medicare dental benefit to low-income beneficiaries would make it financially straightforward for most dentists to refuse to accept Medicare.” They went on to point out that fewer than half of dentists currently accept patients insured through Medicaid or the Children’s Health Insurance Program (CHIP). This places an undue burden on safety-net providers, who are already at capacity and desperately need private practices to pitch in.

Lisa and Will also believe a means-tested, stand-alone benefit “would perpetuate dentistry’s separation from the rest of the healthcare system….” As I wrote last month, this separation lies at the root of many of our oral health challenges. It also hinders some of the advancements in health care delivery that policymakers and health care innovators have been seeking: a healthier population, a better patient experience, and lower health care costs. We can’t reach these goals unless we provide care in a way that acknowledges the link between oral and overall health.

Adding a dental benefit to Medicare is highly popular with older adults and with advocacy organizations, including the American Heart Association, Families USA, and AARP, whose policy director called a means-tested dental benefit “a nonstarter” for the association. The American Dental Education Association, my old stomping grounds, the American Dental Hygienists’ Association, and the National Dental Association (NDA), are also on record supporting a universal dental benefit. Dentists in Congress take a different view.

“Here’s the challenge that we see with the current Medicare legislation,” Rep. Drew Ferguson, (R-GA), said during a September event hosted by The Hill. “We see it as an empty promise to seniors.” As a dentist who spent two decades practicing in a rural, economically depressed community, he said his biggest fear is that providers won’t take part in the program. “Dentists can’t stay in business losing money under…what we anticipate CMS (the Centers for Medicare and Medicaid Services) will do with this,” he said.

A September NDA statement also raised the issue of reimbursement, stressing the organization’s support for a “model and strategy that will attract an adequate provider network.” Ferguson and the NDA have a point. The reimbursement rates for dental services offered through state Medicaid programs attract fewer than half of U.S. dentists to participate. A notable exception are NDA members, 60% of whom take part, the organization’s president told NPR. But as Will and Lisa argue, a standalone dental benefit for low-income Americans would likely make Ferguson’s fear a self-fulfilling prophecy, encouraging dentists who don’t accept Medicaid patients to reject all Medicare-insured patients as well. A universal dental benefit, on the other hand, would give dentists access to an economically mixed and expanded customer base.

From where I sit, these disagreements reflect a growing generational divide. Older dentists accustomed to high incomes and clinical independence may well shy away from accepting Medicare reimbursement rates for their services, but the younger generation of dentists and dental students understand that the dental care economy is shifting. The growth of per-capita dental expenditures has slowed in the past decade, and since 2006, private practice incomes have declined. While there is rampant dental need among un- and underinsured people, the need for restorative care among working-age adults has fallen overall as a consequence of community water fluoridation, widespread use of fluoride toothpaste and varnish, and routine care for those with dental insurance. Many dental schools have picked up on these trends and are preparing their students to practice in areas of growing demand — the Medicaid population and children who received dental benefits through CHIP and as an essential benefit enshrined in Affordable Care Act-compliant insurance plans.

My sense is that younger dentist’s strong sense of social responsibility, well documented among millennials and the rising Gen Z, will translate into their pursuit of the opportunity to serve Medicare beneficiaries. In October, Kaiser Health News quoted one such dentist, Nathan Suter, DDS, a self-described “proud ADA member,” calling on the association to make sure a Medicare dental benefit is “as good a benefit as possible for all of my seniors.” Suter practices in rural Missouri, and roughly half of his patients are older adults.

Like Will and Lisa, I see a universal Medicare dental benefit as “a health and health equity imperative” as well. Our profession needs to serve everyone who would benefit from the care we provide, not just those patients for whom cost is no barrier. It may be a while before Congress approves a Medicare dental benefit, but I’m confident the day will come, and when it does, it will bring us closer to fulfilling that obligation.

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

If you’re wondering what the title of this blog has to do with the NYU Dentistry Center for Oral Health Policy and Management, let me explain. To kick off our work, we held a symposium this past June. In addition to being informative, we wanted it to spur action, so we called it PROHmotion, short for Policy & Research in Oral Health: Moving Forward. The name struck a chord with attendees, and we hope the sense of progress it conveys will also resonate with you and prompt you to become actively involved in our work.

To get a handle on what that might look like, we invited an extraordinary group of thought leaders to speak at the symposium. I’ll introduce you to a few of them today. These folks have been in the trenches—fighting against tobacco use, for mental health parity, for the rights of people with disabilities, to diversify the health-care workforce, and (no surprise here) to promote policies that would enhance the nation’s oral health.

Learning from Tobacco

One keynote speaker, Cheryl Healton, described her experience combatting smoking in the wake of the 1998 nationwide settlement agreement with the tobacco industry. The foundation she led launched an unsparing public education campaign, which accomplished something astounding. It was largely responsible for reducing youth smoking in the United States from 23 percent in 2000 to less than 5 percent today.

Can the tactics the foundation used be applied to other public health problems? Healton, now dean of the NYU School of Global Public Health, believes they can, and I agree, but we will need to think creatively and on the scale of that public health battle to score a similar victory on behalf of oral health.

A Dental Benefit in Medicare?

One powerful piece of ammunition we hoped to have at our disposal was a U.S. Surgeon General’s report on oral health. It was developed under Jerome Adams, MD, MPH, who held the job from 2017 through 2020. The current Surgeon General, Vivek Murthy, MD, MBA, recently announced his decision to send the report to the National Institute of Dental and Craniofacial Research (NIDCR) for finalization and release.

I’m confident that NIDCR Director Rena D’Souza, DDS, PhD, who also spoke at the symposium, will do everything in her power to promote the report’s findings, but I’m troubled by Murthy‘s decision. As another presenter at the symposium said, the surgeon general’s decision may reflect either the nation’s limited awareness that oral health matters or our community’s lack of political clout.

Those observations came from Michael Alfano, DMD, PhD, former dean of the dental school and executive vice president emeritus at NYU. Mike is also a member and the former head of the Santa Fe Group, a dental think tank dedicated to improving lives through oral health. He offered some possible benign explanations for the demotion of the oral health report, but I share his concerns. In recent years we’ve seen two major advocacy organizations, Oral Health America and the Children’s Dental Health Project, close their doors. Can our new Center fill the gap in oral health advocacy they leave behind? That’s certainly part of our plan, and we have our work cut out for us.

Case in point: There’s currently an effort in Congress to add a dental benefit to Medicare—a move I wholeheartedly support. The Santa Fe Group has done an amazing job of advocating for the benefit on Capitol Hill, and according to Mike, congressional staffers are always impressed by its potential to lower Medicare costs in the long run. “The problem has been in follow-up,” he says.

With the inclusion of Medicare dental benefits in early versions of the Build Back Better Act, it appeared that follow-up had finally arrived, but the version of the bill passed by the House last month dropped dental coverage. Some members of the Senate are still looking for ways to fund a dental Medicare benefit within the legislation, but it’s unclear whether the bill will pass—with or without a dental coverage provision.

Mental Health Parity

Another of our symposium speakers, economist Sherry Glied, PhD, dean of the NYU Wagner Graduate School of Public Service, described the experience of the folks (Sherry included) who advocated for behavioral health benefits. They defined the source of the problem, evaluated policy alternatives, and made the case for why behavioral health benefits mattered. Their efforts succeeded. In 2008, Congress passed a law to ensure mental health services were covered at parity with traditional health services, and in 2010, the Affordable Care Act effectively required all public and most private insurance plans to cover mental health services.

Could the effort to include a dental benefit in Medicare follow the same trajectory? “A very common quip in health policy circles is that policy ends at the neck,” Sherry noted. The best way to secure a dental benefit, she argued, is to make it narrow and not too expensive, then to build on that precedent down the line.

The Role of Data

It wasn’t all that long ago that people with intellectual and developmental disabilities (IDDs) were hidden away at home or shipped off to state institutions, where often they were treated as less than full human beings. Then in 1973, Congress passed the Rehabilitation Act, which protected some rights of individuals with disabilities and laid the groundwork for the Americans with Disabilities Act, which aimed to bring people with IDDs into the mainstream of American life.

These policy victories produced tremendous progress in my lifetime alone, but as another symposium speaker, Marco Damiani, MS, told us, continued advocacy remains essential to the well-being of this population. As CEO of AHRC New York City, a family-run advocacy group for individuals with developmental disabilities, Marco stressed the need for better data collection to inform policy and practice. Too often, he said, people with IDDs are excluded from datasets, and “when people are not included in the data, they’re left behind.”

Our final speaker applied that principle in a different context. Edward Salsberg, MPA, senior research scientist at the Fitzhugh Mullan Institute for Health Workforce Equity at the Milken Institute School of Public Health at George Washington University in Washington, D.C., is focused on diversifying the health-care workforce. This effort has emerged as an effective strategy for addressing racial and ethnic disparities, but progress has been slow. Dental schools achieved notable success in attracting a more diverse group of applicants between 2010-12 and 2017-19, but since then, progress has stalled. The institute is following trends in dentistry and nine other health professions through its Health Workforce Diversity Tracker. By quantifying the scale of the problem, the tracker will provide critical information to inform policy.

One of our Center’s key activities will also involve data. We’re developing a health services research database that Center scholars and others can use to investigate a wide range of questions related to oral health.

As the battles described above illustrate, it takes solid science coupled with creative advocacy to advance public health. It also takes perseverance. Those of us in the fight to promote oral health have a strong legacy to build on, and we’re lucky to have so many veterans of past struggles among our allies.