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

Last month I traveled to Washington, DC for the celebration of a colleague and a dear friend. No, she’s not a dentist. She’s a pharmacist. And our dinner companions were physicians, social workers, public health professionals, nurses, and clinicians of other stripes. Many of us had known each other for many years, and in 2007, a core group of us banded together around a common purpose: educating our health professions students for interprofessional practice.

“We had this vision that people should collaborate in practice,” Polly Bednash, PhD, RN, FAAN, recalled when we recently spoke. “The Joint Commission was very clear in its work on patient safety. Almost uniformly, communication problems were what caused errors, and we agreed that we have to figure out how people can talk to each other and trust each other and respect each other’s work and see their work as having value to the whole enterprise.”

At the time, Polly, who currently serves on the Board of Trustees of Dartmouth Health and several other health entities, was leading the American Association of Colleges of Nursing. She, Carol Aschenbrenner, MD (then chief medical education officer at the Association of American Medical Colleges), our counterparts at the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, and the Association of Schools and Programs of Public Health, and I (then President and CEO of the American Dental Education Association) would meet every few weeks to wrestle with what it would take to bring our learners together. Along the way, we started to share stories about our professional challenges and personal lives. These comfortable exchanges created an environment for engaging in substantive, frank discussion around interprofessional education (IPE) as well.

By 2009, we had formed the Interprofessional Education Collaborative (IPEC), the group that hosted the celebration dinner I mentioned. The guest of honor was its immediate past chair, Lucinda Maine, PhD, RPh. Having worked closely with Lucinda and the other IPEC founders, this was an event I was not about to miss, and they felt the same about the special bond we had formed, one that transcended other professional relationships.

As Polly put it, “I don’t think this could ever have happened if we hadn’t started to develop personal relationships. We began to actually trust that we were not looking to stake out territory for each profession. Instead, we were driving toward a common goal—the greater good of the people we were supposed to serve as health professionals.”

Today, IPEC is alive and well, and it currently boasts 21 national associations representing various health professions as members. The Core Competencies for Interprofessional Collaborative Practice, which IPEC developed in 2011, have been widely embraced, and in recent years, more universities have established offices and created administrative roles to facilitate IPE on their campuses, thanks in part to IPEC’s influence.

Last month, the organization hosted its fifth annual IPEC Interprofessional Leadership Development Program, a three-day professional development experience facilitated by the Academy for Advancing Leadership (AAL). The theme of this year’s IPEC gathering was bridging the gaps between education and practice.

Unfortunately, those gaps still persist, and can be especially challenging at health professions institutions housed outside of academic health centers. As Karl Haden, PhD, who leads AAL, put it, “Much of education is isolated from practice, and health professions are still largely siloed. The physical and geographic distance between the institutions and their partners is another fundamental challenge.”

Karl acknowledged that some institutions are working hard to create more authentic interprofessional clinical experiences for their students. Making these universally available is going to involve more conversations with the practice community, health systems, and possibly the organized professions, in his view. “That means building bridges to the practice community that haven’t been there before,” he told me.

The NYU College of Dentistry is fortunate to be part of an academic health center and to have had leadership supporting IPE since the days when Michael Alfano, DMD, PhD, was dean. Under Mike’s leadership, NYU’s nursing programs, which were housed at the time in the NYU School of Education, found a new home in a college of nursing housed within the College of Dentistry. The novel arrangement made NYU a pioneer in interprofessional collaboration and fostered the development of many nurse leaders with strong commitments to integrating oral health into overall health care.

The best known of these is Judith Haber, APRN-BC, PhD, FAAN, Ursula Springer Leadership Professor in Nursing at NYU Rory Meyers College of Nursing. Judi took the lead in forming the Oral Health Nursing Education and Practice program, a national initiative aimed at integrating oral health into nursing care and education. She was also the lead author on an influential paper, Putting the Mouth Back in the Head: HEENT to HEENOT, which advocated that all health professionals routinely look inside the mouth when assessing a patient’s eyes, ears, nose, and throat. While not universally employed, the HEENOT exam has been widely disseminated.

When I last spoke with Judi about the early days of IPE, she described oral health as “the key that turned the lock” when NYU faculty were thinking about innovative strategies for meeting accreditation standards related to IPE. “Oral health was a perfect clinical education focus for operationalizing the IPEC competencies in nursing curricula,” she said.

I agree, and patients will benefit. That said, IPE is a two-way street, and even here at NYU, dental students remain relatively separate from their clinical peers in other health professions, just as dentists often do in practice. One positive development is the recent addition of a federally qualified health center (FQHC), Metro Community Health Centers, to the NYU Dentistry clinics. The common location gives dental and dental hygiene students opportunities to collaborate with medical professionals in primary care and behavioral health and to learn how to advocate for patients’ overall health.

Is that enough? Absolutely not. “In our IPEC panel discussions, the disconnect between the education and the practice communities was clear,” Karl told me. “Many practitioners (and health systems) are unaware of IPE efforts. In addition, many educators do not appreciate the challenges graduates face when they enter the practice setting. I think of IPE as a strategy with a vision for how practice should be; in the practice setting, this strategy is often derailed by organizational culture and the imperative for fiscal responsibility and generation of revenue.”

The good news is that students who do take part in authentic interprofessional experiences love them. “It makes them feel like they’re part of something larger than themselves and who they are as a particular discipline,” Polly told me, “and if you can get students exposed to these kinds of collaborative experiences, they will demand more of them.”

That’s what I’ve seen as well. When NYU Dentistry Dean Charles Bertolami, DDS, DMedSc, and I gave a detailed presentation on interprofessional education and clinical practice to NYU’s third year dental students in April, they were excited by the potential of collaborative care to transform dental practice and patients’ lives.

I hope that enthusiasm carries over into classrooms and clinics. IPEC laid a solid foundation for IPE, but over the years, the work of constructing education and practice environments that foster collaboration has become sporadic. In my view, it’s past time to renew our focus on IPE. Dental educators can start by acquainting themselves with a paper I wrote for the Journal of Dental Education on integrating oral and overall health care in this 2021 paper in Frontiers in Oral Health. The authors mine the wisdom contained in three leading integrated practices to propose recommendations for reshaping dental education. I’m also looking forward to reading the results of IPEC’s recently completed scoping review, which provides strong evidence that IPE impacts patient outcomes. The evidence is on our side. Now we need to recommit to doing the hard work of preparing our students for interprofessional collaborative practice.

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

Let’s be honest — none of us were prepared for the COVID-19 pandemic. Still, it’s undeniable that the Centers for Disease Control and Prevention (CDC) was caught flat-footed. The agency’s decision to stick with testing protocols that were no match for the fast-moving coronavirus was the first of several missteps, and they undermined the public’s trust in the once vaunted institution. The erosion has been profound. At the start of this year, 43% of poll respondents — up from 13% in April 2020 — told NBC News that they did not trust the CDC’s coronavirus information.

In the face of this reality, the agency announced this spring it would conduct a one-month review of its structure, systems, and processes. “Never in its 75-year history has CDC had to make decisions so quickly, based on often limited, real-time, and evolving science,” CDC Director Rochelle Walensky, MD, MPH, said in the April announcement. The agency also had to contend with political pressures and years of disinvestment in the nation’s public health infrastructure. Regardless, Walensky acknowledged the CDC must do better the next time a public health emergency occurs and integrate the lessons learned during the current pandemic into “a strategy for the future.”

So, what have we learned from recent events? The CDC has yet to issue its report, but some lessons are all too clear. First and foremost, we can no longer take the CDC — and the rest of our public health system — for granted. In a fascinating online discussion, hosted by the Harvard T.H. Chan School of Public Health, five former CDC directors talked about what went wrong at the agency during the pandemic and what can be done “to rebuild the CDC’s capacity and restore its credibility.” Here are the lessons I took away and other food for thought.

Lesson 1:
Radically increase our investment in public health.

“We have to approach our nation’s health defense with the same urgency we approach our military defense in peacetime,” said Tom Frieden, MD, MPH, CDC director from 2009 to 2017. “We don’t cut military and intelligence-gathering capabilities so that we’re at risk. Why, then, are we starving our health defenses?”

Walensky’s predecessor at the CDC, Robert Redfield, MD, who retired from the U.S. Army as a Colonel, echoed those remarks. “I personally believe that our national security is much more impacted by the capacity of our public health system in this nation than it is by North Korea, Iran, China, or Russia, and yet we don’t invest proportionately to that,” he said.

“We’re basically operating a CDC and a public health system right now that’s funded, on a per-capita basis, less than it was in the 1950s in real dollars,” said Julie Gerberding, who served as CDC Director from 2002 to 2009. Making matters worse, many of those dollars are earmarked in response to specific needs, leaving the agency without “any capacity to continually improve both our bio-preparedness” and to make sustained investments in health equity and chronic disease prevention. “That just doesn’t make any sense in this day and age,” Gerberding observed.

The Biden administration has requested almost $10.7 billion in discretionary budget authority for the CDC in fiscal year 2023, an increase of $2.3 billion over this year’s budget, but as we all know, Congress will ultimately decide whether the CDC receives that funding and how much of it comes “with strings attached.”

Lesson 2:
Modernize how we collect and share data.

It’s hard to believe, but the CDC is highly dependent on other entities for its access to data. Fifty states and more than 3,000 local jurisdictions submit data to the CDC, but they decide what to submit, what format to use, and how their data may be shared. According to Bill Roper, CDC director from 1990 to 1993, we need to create a standardized, nationwide, public health data system the CDC can rely on, and until we do, “Every governor can basically say, ‘No, I don’t think we’re gonna do that,’ and that just blows the whole thing apart.”

The agency only began receiving COVID-19 hospitalization and laboratory data when the Trump administration declared a public health emergency at the start of the pandemic. When that declaration lapses, the agency could lose its access to key metrics needed to track the spread of the virus.

Fortunately, Congress has allocated more than $1 billion since 2020 to support the CDC’s data modernization initiative. In the last year, the agency also created a national Center for Forecasting and Outbreak Analytics to “enable timely, effective decision-making to improve outbreak response using data, modeling, and analytics.” Congressional support for both these initiatives is a great start, but lawmakers will need to sustain that support over many years to create the reliable data and forecasting systems the agency envisions.

Lesson 3:
Take the long view—in time and space.

This lesson is essential to improving public health, and there’s good evidence to back it up. Bill Foege, MD, MPH, who directed the CDC under Presidents Carter and Reagan, reflected on the work done during his tenure to eradicate smallpox. “Our investment … has been recouped every three months, which means that, since smallpox disappeared, our investment has come back 160 times,” he said. “It’s the same with immunization. For every dollar we put into immunization, we get at least 10 dollars back.” He also stressed the importance of looking beyond our borders. “We are involved in global health, and we can’t walk away from that. This is part of protecting us,” he asserted, noting how coronavirus variants developed in less vaccinated parts of the world.

If enough policymakers adopted Foege’s longer view, they might also support expanding CDC investment — a mere $19.5 million in 2021 — in the nation’s oral health. Historically, the agency’s oral health initiatives have been part of an orphan program, disconnected from most other agency initiatives. At present, the CDC funds health departments in 20 states and Puerto Rico to implement school-based sealant programs, community water fluoridation, and/or chronic-disease surveillance programs that encourage the integration of medical and dental care. That’s commendable, but I’d love to see this happening in all U.S. states and territories.

Lesson 4:
Restoring trust will be a heavy lift.

“Worldwide, people have lost faith in institutions,” and the CDC is no exception, observed William Roper, MD, MPH, CDC director from 1990 to 1993. “People are so anxious for a pronouncement from on high that is permanent and forevermore, and that’s just not the scientific process,” he said.

Redfield laid part of the blame on the complex structure of federal public health, noting the CDC director reports to the Secretary of Health and Human Services who reports to the President, and there may be a special White House advisor on health who must also be consulted. “It’s the lack of perception of independence that has undercut trust,” he believes.

How can the CDC restore trust in its authority? Roper thinks it will require speaking with humility and contextualizing pronouncements with, “This is our best advice given what we know today. We may know [something different] tomorrow, and if it is different from what we know today, we will change our advice tomorrow…. People should value that humility.”

Lesson 5:
Nothing will happen without the workforce to do it.

Whatever does or doesn’t change at the CDC in the months and years ahead, we’ll need to build back our public health workforce if we’re to withstand the next public health emergency. As Walensky pointed out during a White House briefing in April, “During the decade prior to COVID-19, the public health workforce lost an estimated 60,000 jobs nationwide.” That was before the pandemic drove still more people to leave the field, including dentists and dental hygienists.

One ray of light: The American Rescue Plan sets aside federal dollars to recruit, train, and develop the next generation of public health leaders. So far, 80 grants have been awarded to 32 states through Public Health AmeriCorps, a partnership between AmeriCorps and the CDC. Once again, it’s a good start, but the initial investment will fund fewer than 3,000 positions — a tiny fraction of workforce we need. With now more than one million U.S. COVID-19 deaths officially counted — more than on battlefields in all the country’s wars combined — it is essential that we take these lessons to heart and act on them at scale before the next public health crisis occurs.

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

Summer is nearly here, and while the pandemic is far from over, people have resumed many of the activities they put on hold when COVID-19 arrived. For me, that has meant traveling to conferences, including the American Dental Education Association (ADEA) Annual Session held in Philadelphia in March. I was impressed that almost 2,000 other ADEA members joined me. The pleasure of reconnecting with old friends was comforting and familiar, but the meeting felt and looked different as well. Women and people of color dominated the stage, and the election of Puerto Rico’s Ana López-Fuentes to succeed ADEA Board Chairs Nader Nadershahi, Keith Mays, and Ryan Quok made one thing abundantly clear:

1.
Diversity in leadership will be the expectation, not the exception, as we enter the next normal.

The following week, I logged on to the annual gathering of the American Association for Dental Research, which held a hybrid meeting in Atlanta. From my perspective, hybrid is the way to go. The technology is there and it’s not expensive to do, and it answers a question we often posed when I was at ADEA: How do we get this great content to more people? The take-away?

2.
Organizations will take advantage of virtual meeting technologies, even if COVID-19 case numbers continue to remain low.

As I write, omicron and its subvariants continue to sicken Americans, including those who have been vaccinated and boosted, and while no one is panicking, many in our community continue to mask and take other precautions even without mandates. Much of the public seems to associate the word “endemic” with “benign.” Health professionals know better. Endemic means we’ll be living with the risks of this disease for some time to come, probably decades. Some regions may eradicate it through vaccination and natural immunity (think measles or polio), but in other regions it will continue to make people sick and die, and more potent variants may well emerge and drive new surges. As a result,

3.
Navigating different perceptions of public health risk will continue to challenge us for the foreseeable future.

In the meantime, the current pandemic continues to pose economic challenges and to have especially negative effects on the health care delivery system and its workforce. Dental practices were not immune. According to research by the American Dental Association Health Policy Institute (ADA HPI), patient volume remained 10% lower than pre-pandemic levels in October 2021, and at the start of this year, shortages of dental assistants and hygienists continued to stymie efforts to return practices to full productivity. What does this mean for the next normal? Writing in Dental Economics, ADA HPI staff observed…

4.
“Practices need to think creatively not only about recruitment, but also staff retention.” Cross-training, professional development opportunities, and technological solutions, in addition to pay increases, were among the strategies they proposed.

As we picture the future, we should also remember that many people will continue to live with the long-term health consequences of COVID-19, and their long-lasting symptoms will have downstream effects — disrupting housing, employment, and family life. I can’t help thinking about all the members of the armed forces who escape the battlefield but spend years rebuilding their bodies and minds. From our work with veterans here at NYU Dental, we know,

5.
Recovery is possible, but it takes substantial will, support, and resources.

For people who were healthy and economically secure, the pandemic spurred several positive developments that will almost certainly be part of the next normal. Many white-collar workers will continue to work from home, sparing them stressful commutes and reducing vehicle pollution. Organizations will take advantage of the reduced costs and increased productivity this arrangement creates. Educators who previously taught exclusively face-to-face have grown comfortable with engaging adult learners online. And perhaps most consequentially,

6.
Telehealth is here to stay.

In the early days of the pandemic, when people were advised to shelter in their homes, patients’ willingness to communicate with their health care providers via telehealth was unknown. No longer. The technology was widely embraced by patients and providers alike. In dentistry, telehealth allowed practices to triage patients during dental emergencies. Dentists also met with patients remotely to review their medical histories. And the experience encouraged dental providers to think about how the technology might become part of their next normal.

Not everyone in our community is ready to incorporate teledentistry into their practices, and an ADEA report makes clear most schools need to do more to prepare students for this type of practice. Luckily, dentistry has pioneers who can guide our path forward. In the past two decades, colleagues at the University of the Pacific Arthur A. Dugoni School of Dentistry used teledentistry to create their Virtual Dental Home; the University of Minnesota School of Dentistry established a teledentistry network linking university specialists to dentists and patients in remote rural areas; and the University of North Carolina Adams School of Dentistry launched a teledentistry service that is increasing access to care in that state.

We can also look to the experience of the Alaska Native Tribal Health Consortium (ANTHC), which has improved oral health outcomes for residents of the Yukon Kuskokwim Delta by using remote technologies to facilitate the work of dental therapists since 2006. Delivering dental care remotely is not as easy as providing mental health counseling from afar, but these efforts show that with the right training, certification, and team structures, technology can help us improve how we care for underserved populations as we enter the next normal.

One more thought about where we’re headed. The pandemic accelerated the proliferation of misinformation and disinformation, forcing members of the academic, practice, and public health communities to contend with heightened levels of hostility from ill-informed members of the public. In such an environment, it’s essential that students learn how to communicate effectively with patients and analyze the research literature – an area where NYU Dentistry excels.  Since 2000, literature appraisal has been a cornerstone of our effort to prepare students for evidence-based practice. As a result, our students don’t simply conform when faculty say, “Do it this way.” They ask us, “Why?”

WARNING:
With the COVID-19 pandemic accelerating the erosion of trust in government and public institutions, the public will continue to ask for compelling reasons to take our advice regarding their oral health. Preparing ourselves and the rising generation of oral health providers to provide persuasive answers must also be part of our next normal.

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

Today’s leaders in dentistry and dental education have a lot on their minds. The financial health of their practices, organizations, and institutions is ever present, and the lingering challenges of operating alongside a deadly virus are especially salient right now. Leaders also worry about broader social trends: changing demographics; 2020’s racial reckoning; calls for equity and inclusion; the partisan divide that stymies federal policy change; the climate crisis; the digital divide; mounting mental health concerns; the #MeToo movement … I could go on, but you get the picture. Given the breadth and diversity of the issues that keep leaders up at night, how can we prepare a new generation to lead the dental profession?

To get a better handle on this, we invited four panelists who have made significant contributions to leadership education to speak at our recent PROHmotion symposium. They shared their thoughts on preparing leaders for an uncertain future, and I want to share a few of their observations with you.

“Leadership is all about people. … It’s all about people
motivating people to get the job done.”

Count on Leo Rouse, DDS, president of the American College of Dentists, to speak eloquently on the topic of leadership. He joined us at the symposium, where he did just that, but he borrowed these particular words from the late General Colin Powell. Leo worked with General Powell while both served in the U. S. Army, where Leo commanded the Army’s worldwide Dental Corps. Motivating people to join us in leadership roles in oral health, now and for decades to come, is part of the responsibility that the Center for Oral Health Policy and Management’s co-director Michael O’Connor and I have assumed. Cultivating that leadership will be one of our core activities. To do this successfully, Leo stressed the need for communication and collaboration. “Make people feel valued and included,” he said. “People follow you because you have invested in them and helped them become leaders themselves.”

Despite the obstacles, leaders do what is right, and they seek policy change to make it easier to do in the future.

My NYU Dentistry colleague Richard Niederman, DMD, MA, professor and chair of our department of epidemiology and health promotion, talked about a fundamental challenge we face in advancing oral health: Dentists are trained primarily as surgeons and compensated for treating dental disease in well-insured patients. This “architecture of dentist and dental schools and insurance systems” makes it hard for dental professionals to focus on the preventive services that would help keep their patients — especially those on Medicaid — healthy, he told us. Rick argued for an approach that integrates treatment and prevention, “a policy challenge the Center could address at multiple levels,” he said. It’s a policy challenge we are eager to take on.

A leader’s chief function is to orchestrate the efforts of others.

Michael Baer, PhD, a partner at the executive search firm Isaacson, Miller, used the orchestra metaphor to describe how leaders engage others to make things happen. In a dental school context, he said those things would include having a vision and planning strategically; ensuring excellent leadership in classrooms and clinics; supporting research to improve oral health practices; securing a steady stream of students, staff, and faculty; providing the infrastructure that will be needed a decade or two in the future; and promoting public health through the translation of basic research into clinical practice. Mike’s presentation conveyed the magnitude of the job of leading a dental school and the diverse attributes a successful leader needs in this context. These thoughts are very much on our minds as we in the Center develop academic offerings to nurture a broad range of leadership skills.

Leaders must acknowledge the full range of stakeholders they serve and be prepared to face whatever comes their way.

Pamela Zarkowski, JD, MPH, provost and vice president for academic affairs at the University of Detroit Mercy, began her presentation by listing the many qualities sought by university leaders when they search for deans at all kinds of schools. She acknowledged the importance of traditional criteria but added, “Covid was a real eye-opener,” elevating the importance of crisis management skills in today’s leaders. In the case of dental deans, she underscored the need for them to understand the landscape beyond dental education. Pam noted that many candidates for dean positions have excellent track records in the narrow worlds they come from, but often lack the broader perspective they will need to function at senior leadership levels. They must keep their eyes on higher education and the professional landscape, both nationally and globally, she said. Emphasizing that deans should not be expected “to walk on water,” she stressed they nevertheless must be self-aware and able to balance their weaknesses by including individuals with complementary strengths in their leadership teams.

If all this sounds daunting, don’t forget that leaders don’t spring forth fully formed at birth; they grow into their roles over the course of years and decades and typically find support along the way from mentors, peers, and professional development initiatives such as the one we are developing. We can also take heart by remembering that as one generation exits the stage, another is usually waiting in the wings. To quote Leo Rouse, despite leadership challenges in education and organized dentistry, the future looks bright. “The leadership potential is there in our talented students,” he said.

I agree wholeheartedly. Now the task before us is to cultivate that talent so today’s students can carry the work we’ve begun into the future. That effort is already underway. We’re actively cultivating tomorrow’s leaders through a series of NYU Dentistry Student Leadership Track workshops.  We’ve hosted a policy-focused virtual leadership retreat where students debated various approaches to dental licensure, and we’ll host another in April where participants will take on the challenge of shaping a Medicare dental benefit. In February, we opened the application process for the new NYU Dentistry Student Leadership Institute, which will provide mentoring and focused coursework to a cohort of current first year dental students through their graduation. I’m just getting to know this first cohort of student leaders, but I am confident they will soon be ready to lead us into the future.

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.