Hello. This is Cameron Cortejano with the Becker's
Dental and DSO review podcast.
I'm thrilled to be joined today by doctor
Rick Valakovic,
clinical professor and executive director of the NYU
Dentistry Center for Oral Health Policy and Management.
Doctor Valakovic, thank you so much for being
here today.
Thanks, Cameron, for having me.
To start us off, can you introduce yourself
and tell us a little bit about your
background?
Sure.
I'm a pediatric dentist by training and began
my career on the faculty at the Harvard
School of Dental Medicine in in Boston.
I was then recruited to be president and
CEO of the American Dental Education Association,
where I served for twenty two years.
The American Dental Education Association or ADEA is
the the national organization,
representing all of the academic dental institutions in
The United States and Canada.
And, I stepped down from that position in
2019 and joined the faculty here at NYU
at that time, and I've been,
been here since.
Great. Thank you so much.
And what what are some of the biggest
issues that you're following in the dental industry
this year?
So I think there's a number of them
that that
that we're following.
The first one really is is well, evolving
workforce dynamics.
We have shortages of professionals in in
in dental practice at all levels, including dentists,
dental assistants,
dental hygienists, front desk staff.
If you talk to
most dentists now who are in private practice,
they'll tell you that the major,
obstacle to being more productive,
is that they don't they can't find the
the,
the support staff that they need, to to
to
to really fill their schedules.
So, you know,
as part of this whole dynamics as well,
there's been a very significant change over the
the past decade in particular
in that, more than 50% of dental graduates
are now women.
Many schools like,
NYU,
that number is about 65%.
So,
we have more diversity,
in terms of
men and women and coming out of, our
dental schools, but more diversity
in general.
I think that we have a retirement wave
that's gonna come over the next decade.
The average age of of
of retirement for dentists is now in mid
sixties, and and,
that cohort that came through, you know, finishing
up in the late seventies and early eighties,
we're gonna be seeing a a a wave
of retirements that are gonna really impact,
the the number of dentists that are available
to to care for patients.
This next generation of of dental students who
are now graduating,
have a much more focus on work life
balance that I think is gonna be changing
things as well.
We'll talk in a moment about how
dental practice is changing,
but this expectation of of these,
graduating students to
to find ways to to have a a
better balance in their life is is, is
gonna,
have an impact.
Dental education,
went through a significant transformation in the '8
nineteen eighties and nineteen nineties
with the closure of seven dental schools and
the reduction in class size and many others.
You know, we went from 6,300
graduates
in 1980.
With the closure of dental schools and
reduction in class size and others, we went
down to less than 4,000
just ten years later.
So,
what we've seen a resurgence
in universities interested in dental school, so
20 new dental schools have opened in the
past thirty years,
but here's the rub.
It we were graduating
6,300
dentists in, in 1980 when the population in
United States was about 245,000,000.
We're just back now even with the the
opening of all these new dental schools, we're
only
back up to about
7,000 graduates,
only really a 10% increase in in the
number of,
of graduates, but yet we know that the
population of The United States has gone from
245,000,000
in in 1980,
to nearly 340,000,000,
today.
So the issues around workforce dynamics are something
that we're really focused on.
The second is is the business landscape.
You know, I I think
that many folks will will think of dentistry
as as it
as it was historically,
until very recently, which was
92%
of dentists were in one or two person
private practices.
So that boutique small practice.
But there's been a major change,
over the past, ten years or so. And
and, you know, dentistry has always been about
ten years behind
medicine,
in in significant
changes that were occurring within the industry.
So now we're seeing the the private equity
coming in, the corporatization
of dentistry, the development
of DSOs,
and large group practices,
that are putting pressure on on the smaller
practices.
Third thing is persistent disparities
in access to care. We all know that,
nearly a third of Americans lack, access to
any form of dental insurance.
Medicaid dental coverage for adults vary significantly
state by state.
There's no dental benefits in Medicare.
We know
from an evidentiary
perspective,
in 2019,
there were two million emergency room visits,
with a discharge diagnosis of dental pain.
And each one of those on average
costs about,
a thousand dollars per visit.
Dental education is going through a thoughtful evolution.
How are we going to,
implement all these,
technological changes that are occurring? Digital dentistry, CADCAM,
three d printing,
AI assistant, assisted diagnosis.
You know, what what we expect that students
are gonna be,
learning in just four years is has increased
so dramatically,
but yet we still have to put out,
dental graduates who are ready for unsupervised
practice at the end of of their dental
education.
So that certainly is is gonna continue to
to be an issue.
How are we gonna implement all of these
changes within the four year period? And at
the same time,
the cost of dental education,
you know, the students are graduating with with
$300,000
in debt and then trying to set up
a practice as well.
And, of course, the scientific foundation
of of dentistry
is really something that we need to be
concerned about and ensuring
that we
continue to be a learned profession with with
evidence based dentistry as the source of our
practice.
So those are the those are the things
that I'm following now.
Yeah. Definitely. Those are all all interesting trends.
What do you think has maybe caused
the, I guess, lack of growth,
in the number of dental graduates?
You said it's only increased about 10% over
the last couple of decades.
Do you think it's maybe the the rising
cost of education
or or maybe something else? Or what what
do you think is kinda behind that?
I think that that
the
dental schools are the most expensive unit of
a university
because we have to have,
the classrooms for basic sciences. Then we have
to have simulation labs,
for students to to learn how to do
procedures,
in a simulation
way, and then we have to have
a clinic. Right? So
that's very expensive.
If you compare it to even medical schools,
they need
classrooms and maybe some anatomy labs and so
on and so forth, but then they send
their students out to the hospitals and and
other practices,
for their the clinical tied to their education.
So we're we're having to to,
use our clinical operations,
to to educate students,
and and at reduced prices. So
for the patients,
basically,
most dental schools charge about half.
So the it's just the cost of dental
education is so high.
Universities are are are skeptical
about either starting at one,
or,
expanding the class size of what those that
do exist.
Got it. That makes a lot of sense.
Something that I'm curious to get your thoughts
on are what are some things that you're
most excited about when it comes to dentistry
right now, and what are some things that
are making a little bit nervous about the
industry?
I'm most excited about the technology revolution.
It's transforming our profession
as I as I just spoke about.
And and so, I mean, if we just
think about what happened in the last couple
years around AI and the the introduction of
AI,
into into into dentistry, you know, we
recent you know, we've the we've undergone
a transformation to over the past,
five to ten years in terms of introducing
digital dentistry. So
all
all forms of
of, diagnosis and and, treatment planning,
have become digitized. And,
so, you know, just impression scanning,
three d printing,
CADCAM,
the the way
robotics,
for implant placement and so on.
Just if you think about the changes that
have occurred, that's re
how is that going to be,
implemented? That that excites me a lot because
I think that there's an opportunity,
to really use
this technology,
revolution,
to to
to provide more access,
hair for those who have been having trouble
getting it.
Second thing that excites me is this growing
recognition of oral health and its relate its
relationship to overall health.
You know, people
always you know, often think about dentistry. They
might think about pain or they might think
about some aesthetics.
But, you know, the mouth is the beginning
of the digestive tract.
Not only do do the teeth,
prepare food for digestion by through
mastication and chewing,
but also enzymes
that are in saliva that start to help
to to break it down.
You need a smile for social interaction.
You you you just it doesn't have to
be extreme makeover,
but you do need a smile. You need
a smile to get a job.
You know, and when we think about the
relationship
physically,
between,
the oral cavity and and the rest of
the body,
inflammation
is inflammation.
And so inflammation in the mouth, be it
periodontal,
be it, endodontic, whatever,
they're clear although maybe not a
a cause and effect,
but,
relationship, but certainly,
a a relationship between inflammation in the mouth
part and cardiovascular disease, diabetes,
low birth weight infants.
We and we just it's not just being
free from dental pain. Although
concerns I have
are, you know, expanding on what I've already
said in terms of growing disparities in oral
health care.
Do we have enough dentists
graduating?
Yes. We have enough dentists graduating to treat
those who can afford dental care,
who have the oral health literacy,
to be able to understand the role that
that, dental care,
plays in their lives.
But I think in this regard,
my biggest concern is this,
changes in the way that that the public
is looking at fluoride
and the skepticism.
You know, for seventy five years,
we have had community water fluoridation without very
much of a of a put back, and
75%
of Americans,
enjoy the benefits,
of community water fluoridation.
The the levels that are are,
implemented
in community water supplies
at point seven PPM,
have not been shown at all to to
have any
impact on cognitive
abilities or or,
neurotoxicity.
Those kinds of things happen at much higher
levels at four PPM and above.
So
if we
take fluoride
out of the water and we know what's
happening in in Florida,
now the there's a a bill on the
governor's desk in in Utah
to ban community water fluoride fluoridation throughout the
state of Utah.
If we
eliminate
community water fluoridation,
we're gonna go back to a time when,
you know, as I did early in my
career,
working in in Boston as a pediatric dentist
before there was water fluoridation,
I was doing quadrant dentistry all day long,
on those, patients that came in from the
local community.
So I think that that
pulling fluoride out of the water is going
to dramatically impact the
the level
of caries and then the sequelae of of,
either restoration or extraction or or whatever that
may be. Another concern is the economic sustainability
of dental practice and dental education.
You know, we we know that the there's
high debt on, as as students leave,
and the start up costs are are are
high.
Another concern is the pace of change.
You know, just think about it. The students
who graduate
this year in 2025 are gonna be practicing
till 2065,
a forty year professional career.
What how are are we preparing those students
for for what,
is going to happen over the next forty
years given what we've just seen in terms
of particularly this technology,
revolution.
And certainly, one of the most
compelling issues for us to face is the
whole issue of professional burnout.
I think that that,
as as I've gone around to meetings,
I'm hearing as as people at dental meetings
are asking, what do you wanna have on
the on on the agenda for next year
that we had don't have now?
And I'm hearing about we need to have
courses on well-being, on meditation,
on yoga. It's part of the these dental
meetings,
because people are really concerned,
about burnout,
and and,
and well-being. So those are the issues that
I'm excited about and those that I'm that
I'm concerned about.
Yeah. That last,
point that you make about, like, even at
these dental meetings and making it a big
big point to kinda combat,
burnout. I think it just goes back, like
like you were saying before, which is the
lack of staff at at every level Yeah.
Of the industry and and kinda that is
also a big reason why
we're seeing a lot of burnout, which is
just exasperating
the the workforce problems that we currently have.
Great. And just the last question
today.
What will the most effective health care leaders
need, in your opinion, in order to be
successful,
within the next two to three years?
You know, as I,
as I left,
my position at the American Dental
Education
Association in, in 2019,
I left with with an appreciation
that the biggest,
issue facing
the profession,
including
dental education, practice, and so on,
is the future of leadership.
Who's going to be the next leaders? We
just,
there isn't the ladder of people who coming
into leadership positions that there used to be.
And, you know, we need leaders at at
every level, and and that includes
organized dentistry,
dental education,
the military,
in particular,
who's going to provide leadership in in DSOs
and large group practices.
So as I look and we we've created
an a a a whole portfolio
of leadership experiences for our students and faculty
here at NYU.
But I think that what we're seeing is
that adaptability
is going to be paramount.
Data literacy will become increasingly crucial.
We're generating more clinical and operational data than
ever before,
but data alone doesn't create value.
We need to have leaders who understand how
to translate data into actionable insights.
Collaborative leadership,
you know, there's an appreciation of the relationship
between
the oral cavity, oral health,
and, and overall health as we we talked
about.
And so we we need to to have
people in leadership roles
who can collaborate
across the professions and not just within dentistry.
We need
leaders who have financial acumen.
Reimbursement models, we know, are are continuing to
evolve.
They need to leaders will need to understand
how to maintain financial sustainability.
You know, emotional intelligence will always be critical,
for leaders.
And I think that,
technology integration skills like the data literacy,
will
the
the ability of of leaders to understand,
how to integrate technology will separate
those forward thinking leaders, in my opinion, from
those who fall behind.
So those are the kinds of things that
I think that the leaders need to be
concerned about and be successful in the next
two or three years.
Yeah. Absolutely.
I totally agree with with all those those
points. Good. Especially with the data literacy and
and the technology implementation.
Yeah.
It it just seems like tech techs obviously
becoming
more and more important,
in dentistry and in dental practices.
Yep.
Awesome. Well, thank you for joining us today,
doctor Balakovic,
and and sharing your valuable expertise
and insights in the dental industry and in
dental practice and dental education.
It's been a pleasure speaking with you, and
I look forward to connecting with you again
in the future.
Alright. Thanks very much for having me, Cameron.
No problem. Have a good one. You too.