Under Pressure: Navigating Controversy, Crisis, and Care in Dentistry

A publication advancing ethics, professionalism, leadership, and excellence in dentistry.

The Journal of the American College of Dentists (ISSN 0002-7979) is published by the American College of Dentists, Inc.

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Journal of the American College of Dentists

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While every effort is made by the publishers and the Editorial Board to see that no inaccurate or misleading opinions or statements appear in the Journal, they wish to make it clear that the opinions expressed in the articles, correspondence, etc., herein are the responsibility of the contributor. Accordingly, the publishers and the Editorial Board and their respective employees and officers accept no liability whatsoever for the consequences of any such inaccurate or misleading opinions or statements.

For bibliographic references, the Journal is abbreviated J Am Col Dent and should be followed by the year, volume, number, and page. The reference for this issue is J Am Col Dent 2025; 92 (1): 1-78.

Communication Policy

It is the communication policy of the American College of Dentists to identify and place before the Fellows, the profession, and other parties of interest those issues that affect dentistry and oral health.

The goal is to stimulate this community to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College.

The College is not a political organization and does not intentionally promote specific views at the expense of others. The positions and opinions expressed in College publications do not necessarily represent those of the American College of Dentists or its Fellows.

Objectives of the American College of Dentists

THE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in healthcare, advance the standards and efficiency of dentistry, develop good human relations and understanding, and extend the benefits of dental health to the greatest number, declares and adopts the following principles and ideals as ways and means for the attainment of these goals,

A. To urge the extension and improvement of measures for the control and prevention of oral disorders;

B. To encourage qualified persons to consider a career in dentistry so that dental health services will be available to all and to urge broad preparation for such a career at all educational levels;

C. To encourage graduate studies and continuing educational efforts by dentists and auxiliaries;

D. To encourage, stimulate, and promote research;

E. To improve the public understanding and appreciation of oral health service and its importance to the optimum health of the patient;

F. To encourage the free exchange of ideas and experiences in the interest of better service to the patient;

G. To cooperate with other groups for the advancement of interprofessional relationships in the interest of the public;

H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge the acceptance of them;

I. To encourage individuals to further these objectives and to recognize meritorious achievements and the potential for contributions to dental science, art, education, literature, human relations, or other areas which contribute to human welfare—by conferring Fellowship in the College on those persons properly selected for such honor.

Executive Director

Michael A. Graham

Editor

Toni M. Roucka, RN, DDS, MA, FACD

Program Director

Suzan Pitman

Publication Manager, JACD

Communications Director

Matthew Sheriff, BA, MS

Editorial Board

Albert Abena, DDS, JD, FACD

Odette Aguirre, DDS, MS, MPH, FACD

Joshua Bussard, DDS, FACD

Michael Maihofer, DDS, FACD

Ethan Pansick, DDS, MS, FACD

Vishruti Patel, DDS, FACD

Catherine Frankl Sarkis, JD, MBA

Carlos Smith, DDS, MDiv, FACD

Kristi Soileau, DDS, MEd, MSHCE, FACD

Pamela Zarkowski, JD, MPH, FACD

Officers

Robert A. Faiella, President

Terry L. Norris, President Elect

Peter H. Guevara Vice President

Joseph P. Crowley, Treasurer

Teresa A. Dolan, ACD Foundation President

Regents

Julie A. Connolly, Regency 1

Robert G. Plage, Regency 3

Brenda Thompson, Regency 4

Nancy Y. Larson, Regency 5

Kristi M. Soileau, Regency 6

Ned L. Nix, Regency 7

Robin Henderson, Regency 8

Krista Jones, At Large Regent

Toni Roucka, At Large Regent

Pamela Alston, At Large Regent

William Calnon, At Large Regent

Pamela Zarkowski, ASDE Liaison

Kjeld Nelson, SPEA Liaison

Joshua Bussard, Regent Intern

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Letters from Readers

The Journal of the American College of Dentists (JACD) welcomes letters to the editor. The opinions and views expressed in letters to the editor submitted to the JACD are those of the individual authors and do not necessarily reflect the opinions, positions, or policies of the JACD, its editorial board, or the American College of Dentists. The JACD reserves the right to edit submitted letters for clarity, length, and adherence to our editorial guidelines. The publication of a letter does not imply endorsement by the JACD or its affiliates. Readers are encouraged to critically evaluate the content of each letter and to consider it within the broader context of scientific and professional literature. Submit letters to editor@acd.org.

4 Editorial: A Wake-Up Call

Mike Maihofer, DDS

6 Ethical Dilemmas Surrounding Community Water Fluoridation

Roopwant Kaur, BDS, MS; Herminio L. Perez, DMD, MBA, EdD; Mark E. Moss, DDS, PhD

13 Digital Media, Truth Decay, and the Inversion of Trust in Science

Nicholas G. Mosca, DDS, DrPH

20 The Ethical Imperative of Preserving Federal Oversight in Academic Dentistry

Jennifer D. Talley, EdD; Linda Olszewski, DBA, MBA

29 21st Century Dental Public Health: Revisiting the Role of Community Water Fluoridation

Larry Williams, DDS, MPH; Preetha Kanjirath, BDS, MS

35 Silent Signals: Human Trafficking and the Dental Professional’s Duty to Act

Pamela Zarkowski, JD, MPH, FACD

44 Taking the Temperature: What the ACD 2025 Survey Reveals

Mike Graham, Suzan Pitman

50 Ethical Dilemma in Dentistry: Upholding the Social Contract in a Profit-Driven System

Kamyar Sartipi, BS, DDS (Class of 2025)

58 Ethical Care is Excellent Care

Elizabeth Gershater, BS

68 From the Archives: An Examination of Conflicting Social Philosophies

(1935) Maurice William, DDS, FACD; Bissell B. Palmer, DDS, FACD

A Wake-up Call

Michael Maihofer, DDS

We believe that medical, dental, and scientific journals, like ours, play a crucial role in vetting and disseminating scientific information and the best evidence-based scientific truth.

The recent letters of inquiry from the US Attorney General’s office to multiple scientific publications questioning their editorial practices and standards should be a cause of concern for all evidence-based, peerreviewed publications like the Journal of the American College of Dentists (JACD).

The letters, which were sent last May to several well-respected, peer-reviewed medical publications, including The Journal of the American Medical Association (JAMA) , Obstetrics and Gynecology, and CHEST (published by the American College of Chest Physicians), seem to suggest these publications may be biased in the research they report and partisan in their scientific debate.

Although the letters don’t cite specific examples of supposed bias or specify the government’s potential actions, recipients perceive them as threatening in tone and an attempt at intimidation. Many feel that this may be an attempt by the administration to use the legal process to compel scientific journals, medical professionals, and anybody else they disagree with into silence. Some have speculated that this could be seen as an attack on the First Amendment that protects those publications. Such action also seems consistent with current policies attacking the scientific community, including scientists at universities or institutions like the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC).

Medical, dental, and scientific publishers must stand up for academic freedom, freedom of speech, and editorial independence.

We join with our medical and scientific peer publications in support of the independence of journals and their First Amendment rights to free expression . The JACD is a scholarly publication presenting proactive and informative perspectives on issues affecting the dental profession and society. The JACD uses rigorous peer review and editorial processes to ensure the objectivity and reliability of the papers we publish. Our journal encourages scholarly scientific dialogue and remains steadfast in its commitment to the highest standards of publishing ethics. We evaluate submissions based on merit to ensure a broad range of perspectives that can contribute to the advancement of knowledge.

We believe that medical, dental, and scientific journals, like ours, play a crucial role in vetting and disseminating scientific information and the best evidence-based scientific truth.

The idea of the government trying to encourage similar peer-reviewed scientific publications to publish different types of editorials or change their editorial practices based solely on what a US attorney feels is appropriate smacks of authoritarianism and should act as a wake-up call for all of us.

This issue of the JACD focuses on some critical topics challenging the dental profession today, including scientific skepticism, human trafficking, accreditation, and the most recent fluoride controversy. The historical article chosen for this issue recalls a similarly challenging time in the US nearly a century ago. Enjoy this issue of the journal.

Ethical Dilemmas Surrounding Community Water Fluoridation

Roopwant Kaur, BDS, MS

Assistant Dean for Engagement

Clinical Associate Professor of Operative Dentistry

School of Dental Medicine, East Carolina University

SHerminio L. Perez, DMD, MBA, EdD

Assistant Dean for Campus Life

Rutgers School of Dental Medicine

Mark E. Moss, DDS, PhD

Associate Professor Division of Dental Public Health

School of Dental Medicine, East Carolina University

LISTEN TO THIS ARTICLE

ince the 1950s, community water fluoridation (CWF) has stood as a cornerstone of dental public health. However, a growing amount of public scrutiny necessitates reflection on the ethical basis for coming to a firm position on the topic. Aside from CWF, fluoride in the form of ingestible supplements has recently been identified as a concern by the US Food and Drug Administration. Indeed, it is challenging to wade through the facts, opinions, misinformation, and policy shifts. This article examines the ethical dilemmas that surround CWF through the lens of the American Dental Association (ADA) Principles of Ethics and Code of Professional Conduct (ADA Code)— autonomy, beneficence, nonmaleficence, justice, and veracity—and contemporary science, highlighting tensions between individual rights and the collective good. Additionally, the manuscript considers educational, clinical, and policy implications to equip dental professionals and educators with critical tools to engage ethically and effectively in public health discourse and ethical decision-making.

Keywords: Community water fluoridation, dental ethics, caries risk assessment, public health policy, preventive dentistry, health equity, patient autonomy, dental education, risk-based care, ethical principles.

Introduction

Community water fluoridation (CWF) involves the controlled addition of fluoride to public water supplies to prevent dental caries, a major chronic disease globally.1 A growing amount of public scrutiny on the use of fluoride additives and supplements necessitates reflection on the ethical basis for coming to a firm position on this topic.2,3 This paper explores those issues.

Fluoride acts primarily through topical mechanisms, enhancing enamel remineralization and inhibiting bacterial metabolism.4 Systematic reviews estimate that CWF reduces caries prevalence by approximately 25% in children and adults.5-7 The practice is grounded in research dating back to the early 20th century, when evidence first indicated that dental caries were inversely correlated with naturally occurring fluoride in water. 8 Despite robust evidence supporting the safety and efficacy of CWF, some ethical and policy concerns fuel controversy, and a good deal of effort has gone into developing evidence-informed responses that can address misinformation.9,10 Concerns about fluoride exposure have also spread beyond CWF to ingested fluoride supplements and even toothpaste.

Crest, Colgate Lawsuits Target Fluoride in Kids’ Toothpaste, Mouth Rinse

Reuters.com Accessed August 25, 2025

FDA Begins Action to Remove Ingestible Fluoride Prescription Drug Products for Children from the Market

FDA News Release Accessed August 25, 2025

Within the operatory, a patient may refuse fluoride treatment due to fears about potential neurotoxicity, compelling clinicians to balance the imperative of delivering evidence-based preventive care with honoring individual patient autonomy. The scenario can become more challenging when it involves a high-caries-risk patient who declines fluoride exposure based on deeply held personal or cultural beliefs. Here, the ethical challenge lies in advocating for effective preventive interventions without coercing or dismissing the patient’s values, striking a delicate balance among respect for autonomy, beneficence, and justice.

Such dilemmas are not isolated incidents but reflect the broader integration of caries risk assessment and chemotherapeutic management with fluoride in clinical practice. While genetic predisposition can influence the likelihood of developing dental caries, environmental factors have proven more significant in predicting the condition in children. These include exposure to cariogenic bacteria, frequent consumption of sugary foods, inadequate saliva production or composition, limited or delayed fluoride exposure, and poor oral hygiene practices.11

The Case for Fluoridation

Robust evidence underscores the synergistic effect of combining systemic fluoridation through community water with topical fluoride applications—such as varnishes and gels—for high-risk populations.11 Topical agents serve as important adjuncts to CWF, which can be used to target individuals with elevated susceptibility to caries by enhancing protective benefits. These multimodal preventive strategies require clinicians to tailor care plans based on individual risk profiles, underscoring the importance of comprehensive caries risk assessment protocols in guiding ethical and effective treatment.

Ethical Dilemmas Surrounding Community Water Fluoridation

Roopwant Kaur, BDS, MS; Herminio L. Perez, DMD, MBA, EdD; Mark E. Moss, DDS, PhD

Dental caries risk assessment integrates individual biological, behavioral, and environmental factors to stratify preventive needs and guide management strategies.11 The ethical discourse around CWF and fluoride supplementation intersects with caries risk management, public health equity, and clinical decision-making, requiring a nuanced understanding from dental professionals and policymakers.

Community water fluoridation is defined as the addition of fluoride ions to a municipal water supply at optimal levels (eg, 0.7 mg/L in the US) to reduce the prevalence of dental caries across populations.12 It is endorsed by numerous health organizations, including the CDC and WHO, as a safe, effective, and equitable measure.12,13

Ethical Principles and Fluoridation

From an ethical perspective, discussions about fluoride safety need to be framed differently when the dentist is speaking about an individual patient versus the health of the community. Caries risk assessment guides our knowledge base and informs discussions on the rationale for promoting fluoride in both contexts.11 However, in both contexts, the fundamental questions are:

1. What is best for the individual patient?

2. What is best for the community as a whole?

Each ethical principle applies to the use of fluoride as follows:

Autonomy

Autonomy emphasizes individuals’ right to make informed decisions about their health.14 Opponents argue that CWF violates this right by imposing fluoride without explicit consent. Proponents counter that public health interventions often require balancing individual choice and collective welfare.

Beneficence

The principle of beneficence requires professionals to act in the best interests of others. Dentists must serve patients and the public by sharing evidence-based research that protects or improves health. The principle of nonmaleficence obliges dentists to safeguard against harm, requiring them to stay updated, provide quality care, and educate patients to prevent misconceptions.15 Beneficence supports CWF due to its substantial caries prevention benefits, which are clearly supported by evidence-based data.

Nonmaleficence

Nonmaleficence concerns must not be ignored. These include the potential risk of dental fluorosis and inconclusive data on neurotoxicity.16,17 Ethical practice demands careful risk-benefit analyses, particularly for vulnerable groups, as well as education for patients and the general population.

The purported neurodevelopmental harm and IQ deficits are not found in studies that examine the level of fluoride in places where the level of exposure is similar to that offered by community water fluoridation.18 Fear can influence one’s perception of risk,19 and this makes it important to acknowledge fear and demonstrate empathy to build trust.20 Knowledge of the facts must be demonstrated in a manner that builds trust and conveys the profession’s commitment to the greater good.

Justice

Justice requires professionals to be fair with patients, colleagues, and society, ensuring access to care for all without bias. CWF promotes justice by providing caries prevention to underserved populations lacking regular dental care. However, mandatory implementation without community consensus raises concerns about procedural fairness.

A recent analysis estimated that removing fluoride from US water systems would lead to an increase in dental caries, at a cost of $9.8 billion over 5 years. Much of this burden will be shouldered by the Medicaid system, which is already suffering from a lack of dentists who participate and faces uncertain funding cuts.

Veracity

The principle of veracity emphasizes truthfulness and honesty in all professional interactions. In the context of community water fluoridation and fluoride supplementation, this principle requires dental professionals to provide patients and the public with accurate, evidence-based information about the proven benefits of fluoride for preventing dental caries, while also being transparent about potential risks, so individuals and communities can make informed health decisions.

Public Health and Policy Considerations

CWF represents not only a health strategy but also a cost-saving measure, with estimates suggesting that $32 is saved for every $1 invested.21 A recent analysis estimated that removing fluoride from US water systems would lead to an increase in dental caries, at a cost of $9.8 billion over 5 years.22 Much of this burden will be shouldered by the Medicaid system, which is already suffering from a lack of dentists who participate23 and faces uncertain funding cuts.24

Globally, CWF policies reflect varied public health priorities, cultural attitudes, and ethical considerations. In the United States, about 73% of the population receives fluoridated water.25 Australia surpasses this with 89% coverage,25 and in Ireland, fluoridation is mandated nationally.26 These nations endorse CWF as a cost-effective preventive measure against dental caries, backed by strong institutional support.

However, there are viable alternatives to CWF. Countries such as Sweden, Norway, and the Netherlands have opted to emphasize community-based programs that utilize topical fluoride applications and comprehensive dental care programs. This raises ethical questions: When is it appropriate to mandate a public health measure, and at what cost to individual autonomy?

Within the current political and social landscape, these ethical tensions are palpable. Dentists must advocate for the benefits of fluoridation while respecting patient autonomy, especially amid widespread misinformation.2 Patients may refuse fluoride based on philosophical or health-related beliefs, challenging the informed consent process and threatening provider-patient trust. Ethical prevention must include stakeholder engagement, opt-out alternatives, and outcome monitoring. Sociopolitical forces complicate this further. Current fluoridation debates often mirror larger struggles between individual liberty and collective good, amplified by political perspective, that are often infused with misinformation via social media echo chambers.

Role of Educators

The skills needed for public discourse in this environment are challenging to master. Educational institutions bear a crucial responsibility to prepare the profession not only in clinical proficiency but also in ethical discernment and cultural competence. Beyond technical skills, curricula and continuing education courses must cultivate the ability to critically engage around controversial

Ethical Dilemmas Surrounding Community Water Fluoridation

Roopwant Kaur, BDS, MS; Herminio L. Perez, DMD, MBA, EdD; Mark E. Moss, DDS, PhD

topics, with a particular focus on fluoridation, in a manner that respects diverse perspectives while maintaining scientific integrity and cultural sensitivity. This dual focus may help clinicians navigate the multifaceted ethical and social dimensions surrounding fluoride and fluoridation.

Real-world clinical scenarios vividly illustrate these complexities. In some communities, dental professionals actively advocate for reinstating fluoridation programs in response to rising dental caries rates, confronting resistance from residents who prioritize bodily autonomy and harbor mistrust toward public health authorities.

Dental students frequently gain clinical experience in communities where fluoridation policies have been discontinued or are contentious, forcing them to reconcile their scientific education with prevalent local skepticism or opposition. In these settings, educators play a pivotal role in fostering advocacy that is scientifically sound yet culturally humble and inclusive. Training must emphasize respectful dialogue, listening to community concerns, and building trust while communicating the benefits of fluoride interventions grounded in evidence.

Equity remains a foundational concern within this discourse. Access to fluoridated water varies widely both internationally and within the United States, often leaving marginalized and underserved communities disproportionately vulnerable to dental decay. This inequity amplifies ethical considerations around justice and social responsibility, compelling dental professionals and public health advocates to prioritize efforts that reduce disparities and ensure that preventive measures reach all populations equitably.

A compelling case study highlights the ethical and public health implications of community water fluoridation policies and their impact on den-

tal health outcomes. In Calgary, Alberta, Canada, the decision to discontinue water fluoridation led to a notable increase in dental caries among children within a few years after cessation.27 This rise in preventable tooth decay imposed a significant burden on children and their families, as well as dental clinicians and healthcare teams who must now manage a higher prevalence of disease that could have been mitigated through continued fluoridation. The situation underscores the responsibility of public health policy to prioritize preventive measures that protect vulnerable populations, particularly children.

Several relevant studies demonstrate the impact CWF has on health equity.28-30 These examples illustrate how fluoridation acts as an effective public health intervention capable of leveling oral health disparities across diverse populations. By providing equitable protection regardless of individual socioeconomic status, fluoridation demonstrates its role not only as a preventive strategy but also as a social justice tool to promote oral health equity on a large scale.

Conclusion

Today, community water fluoridation stands at the intersection of science, ethics, and society. Balancing the rights of individuals with the needs of communities requires transparent dialogue, cultural humility, and a commitment to equity. Dental professionals must engage in ethical reflection, patient-centered education, and policy advocacy to navigate these complexities and advance oral health for all.

REFERENCES

1. Moss ME, Zero DT. Fluoride and caries prevention. In: Mascarenhas AK, Okunseri C, Dye BA, eds. Burt and Eklund’s Dentistry, Dental Practice, and the Community 7th ed. W.B. Saunders; 2021:277-295.

2. Patel B, Patrick A, Dyer TA. The ethics of community water fluoridation: Part 1: An overview of public health ethics. Br Dent J. 2025;238(5):311-315. doi:10.1038/s41415-024-8058-4

3. Spencer AJ, Do LG, Mueller U, Baines J, Foley M, Peres MA. Understanding optimum fluoride intake from population-level evidence. Adv Dent Res. 2018;29(2):144-156. doi:10.1177/0022034517750592

4. Featherstone JDB, Crystal YO, Alston P, et al. Evidence-based caries management for all ages: Practical guidelines. Front Oral Health. 2021;2:657518. doi:10.3389/froh.2021.657518

5. Belotti L, Frazão P. Effectiveness of water fluoridation in an upper-middle-income country: A systematic review and meta-analysis. Int J Paediatr Dent. 2022;32(4):503-513. doi:10.1111/ipd.12928

6. Iheozor-Ejiofor Z, Walsh T, Lewis SR, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2024;10(10):CD010856. doi:10.1002/14651858.CD010856.pub3

7. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2015;2015(6):CD010856. doi:10.1002/14651858.CD010856.pub2

8. NIDCR. The Story of Fluoridation. Updated December 2024. Accessed August 25, 2025. https://www. nidcr.nih.gov/health-info/fluoride/the-story-of-fluoridation

9. ADA. Fluoridation Facts. American Dental Association; 2025. Accessed August 25, 2025. https://ebooks. ada.org/fluoridationfacts

10. Nguyen TM, Sexton C, Do L. Why policy relevant research still matters for community water fluoridation. Aust. Dent. J. 2025;70(2):99-102. doi:10.1111/adj.13063

11. National Institutes of Health, National Institute of Dental and Craniofacial Research. Oral Health in America: Advances and Challenges. US Department of Health and Human Services, National Institutes of Health; 2021. Accessed August 25, 2025. https://www.nidcr.nih.gov/research/oralhealthinamerica

12. CDC. Community Water Fluoridation. Updated 2024. Accessed August 15, 2025. https://www.cdc.gov/ fluoridation/index.html

13. WHO. Inadequate or excess fluoride: A major public health concern: Preventing disease through healthy environments. Published May 1, 2019. Accessed August 15, 2025. https://www.who.int/publications/i/ item/WHO-CED-PHE-EPE-19.4.5

14. Childress JF, Faden RR, Gaare RD, et al. Public health ethics: Mapping the terrain. J Law Med Ethics 2002;30(2):170-178. doi:10.1111/j.1748-720x.2002.tb00384.x

15. ADA. Principles of Ethics & Code of Professional Conduct. American Dental Association; 2024. Accessed August 25, 2025. https://www.ada.org/about/principles/code-of-ethics

16. Levy SM. Caution needed in interpreting the evidence base on fluoride and IQ. JAMA Pediatr 2025;179(3):231-234. doi:10.1001/jamapediatrics.2024.5539

17. Taylor KW, Eftim SE, Sibrizzi CA, et al. Fluoride exposure and children’s IQ scores: A systematic review and meta-analysis. JAMA Pediatr. 2025;179(3):282-292. doi:10.1001/jamapediatrics.2024.5542

18. Kumar JV, Moss ME, Liu H, Fisher-Owens S. Association between low fluoride exposure and children’s intelligence: A meta-analysis relevant to community water fluoridation. Public Health. 2023;219:73-84. doi:10.1016/j.puhe.2023.03.011

19. Wake S, Wormwood J, Satpute AB. The influence of fear on risk taking: A meta-analysis. Cogn Emot 2020;34(6):1143-1159. doi:10.1080/02699931.2020.1731428

Ethical Dilemmas Surrounding Community Water Fluoridation

Roopwant Kaur, BDS, MS; Herminio L. Perez, DMD, MBA, EdD; Mark E. Moss, DDS, PhD

20. Wu Q, Jin Z, Wang P. The relationship between the physician-patient relationship, physician empathy, and patient trust. J Gen Intern Med. 2022;37(6):1388-1393. doi:10.1007/s11606-021-07008-9

21. Ran T, Chattopadhyay SK; Community Preventive Services Task Force. Economic evaluation of community water fluoridation: A community guide systematic review. Am J Prev Med. 2016;50(6):790-796. doi:10.1016/j.amepre.2015.10.014

22. Choi SE, Simon L. Projected outcomes of removing fluoride from US public water systems. JAMA Health Forum. 2025;6(5):e251166. doi:10.1001/jamahealthforum.2025.1166

23. Flynn B, Starkel Weninger R, Zaborowski M, Vujicic M. Barriers to dental care among adult Medicaid beneficiaries: A comprehensive analysis in eight states. ADA Health Policy Institute. Research Brief. Published November 2024. Accessed August 25, 2025. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/barriers_Medicaid_participation_utilization.pdf.

24. Bhaumik D, Hedges I, Zaborowski M, Vujicic M. What happens if the adult Medicaid dental benefit goes away? ADA Health Policy Institute. Research Brief. Published March 2025. Accessed August 25, 2025. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/what_ happens_if_adult_Medicaid_dental_goes_away.pdf

25. Centers for Disease Control and Prevention. Healthy People 2030 Objective OH-11: Increase the proportion of people whose water systems have the recommended amount of fluoride. US Department of Health and Human Services. Published 2022. Accessed August 25, 2025. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/health-policy/increase-proportion-people-whose-water-systems-have-recommended-amount-fluoride-oh-11.

26. The Irish Expert Body on Fluorides and Health. Code of practice on the fluoridation of drinking water. Published 2016. Accessed August 25, 2025. https://www.fluoridesandhealth.ie/assets/files/pdf/cop_fluoridation_of_drinking_water_2016.pdf.

27. McLaren L, Patterson SK, Faris P, et al. Fluoridation cessation and children’s dental caries: A 7-year follow-up evaluation of Grade 2 schoolchildren in Calgary and Edmonton, Canada. Community Dent Oral Epidemiol. 2022;50(5):391-403. doi:10.1111/cdoe.12685

28. Matsuo G, Aida J, Osaka K, Rozier RG. Effects of community water fluoridation on dental caries disparities in adolescents. Int J Environ Res Public Health. 2020;17(6):2020. doi:10.3390/ijerph17062020

29. Matsuyama Y, Ha DH, Kiuchi S, Spencer AJ, Aida J, Do LG. Water fluoridation as a population strategy for reducing oral health inequalities: High-dimensional effect heterogeneity analysis using machine learning. Int J Epidemiol. 2025;54(4):dyaf080. doi:10.1093/ije/dyaf080

30. Sanders AE, Grider WB, Maas WR, Curiel JA, Slade GD. Association between water fluoridation and income-related dental caries of US children and adolescents. JAMA Pediatr. 2019;173(3):288-290. doi:10.1001/jamapediatrics.2018.5086

Digital Media, Truth Decay, and the Inversion of Trust in Science

Nicholas G. Mosca, DDS, DrPH Associate Professor, LSU Health School of Dentistry

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Digital media enables the rapid dissemination of scientific oral health information from subject experts to the public. However, it also poses significant risks by facilitating the dissemination of misinformation and disinformation, thereby blurring the boundaries between truth and fallacy. This paper characterizes the decay of scientific truth in policymaking, characterized by increased public debate about scientific facts and a decline in confidence in science. It describes psychological mechanisms, such as confirmation bias and motivated reasoning, and social dynamics, including algorithm-driven content distribution and echo chambers, that accelerate the circulation of misleading science information. It suggests psychological interventions to counter misinformation, such as content labeling, debunking, and prebunking, along with digital literacy education. The paper emphasizes the ethical responsibility of dental professionals to counter misinformation with evidence-based and culturally sensitive messaging. The dental profession is called upon to uphold its core ethical values of veracity, integrity, and professionalism to combat misleading oral health information and restore public trust.

Keywords: social media, oral health, health communication, science literacy, behavioral health, misinformation, disinformation, public trust.

Digital Media, Truth Decay, and the Inversion of Trust in Science

Nicholas G. Mosca, DDS, DrPH

Introduction

Websites, social media posts, blogs, podcasts, and videos comprise the primary communication tools of the information age. Innovation in digital media communications has progressively revolutionized how the public consumes health and scientific information, enabling the rapid dissemination of complex scientific phenomena by scientists and health experts. Digital media are particularly suited to sharing visual information to increase health awareness.1 For example, millions of people posted ice-water dousing videos online to raise awareness of the neurodegenerative disease amyotrophic lateral sclerosis (ALS);2 millions more posted photos of new mustaches in the Movember campaign to encourage prostate and testicular cancer screening.3 Digital media also demonstrates remarkable potential to improve public awareness of the prevention and treatment of dental diseases and oral cancer.4 While digital media technologies enhance health literacy and promote well-being, they pose risks by enabling the sharing of misleading health information and undermining public trust in science.

The Problem of Truth Decay

Traditional sources of science and health information include government institutions, academic institutions, industry, advocacy groups, nonprofit organizations, practitioners, and professional journalists with experience in science and health, who communicate with the public to enhance literacy. Alternatively, digital media enables information to be filtered and curated in ways that allow individuals to bypass these content experts, journalists, and editors who have traditionally served as information gatekeepers, discerning the credibility of scientific health information. The public plays a role in shaping individuals’ epistemic beliefs, defined as the way people comprehend and apply scientific knowledge, irrespective of veracity, to inform their perspectives and guide their conduct.5

Science-based health information should be communicated to the public clearly and accurately to enhance epistemic beliefs. Epistemic beliefs form the basis for understanding the certainty of scientific knowledge, as well as how we use logic and intuition to assess credibility and reliability and discern trustworthiness in science.5 Objectivity is a core value for scientists, requiring researchers to rely on verifiable facts and evidence to minimize subjective bias. Additionally, critical appraisal of research by peers is necessary to distinguish good scientific methods from poor ones. New claims that are inconsistent with the weight of accepted scientific evidence available at the time should be approached with skepticism, not acceptance. Ideally, epistemic beliefs should align with the best available scientific evidence. In a 1998 study by Andrew Wakefield and colleagues, published in The Lancet, on the prevalence of autism in children who received the measles, mumps, and rubella (MMR) vaccine, the researchers erroneously associated autism with vaccination due to examiner bias and selective sampling (cherry-picked subjects).6 The Lancet publicly retracted the study in 2010, but vaccination opponents continued to disseminate the study’s findings to encourage vaccine skepticism.

Misleading information is categorized based on its truthfulness, accuracy, and intended use. The American Psychological Association defines misinformation as the sharing of false or inaccurate information without conscious intent to mislead, and disinformation as the sharing of false or inaccurate information with the conscious intent to deceive others.7 Truthful information can be used for deception too, for example, taking credible research findings out of context as false information for ulterior motives.

In a large-scale empirical study, a dataset comprising 126,000 stories shared over 4.5 million times by approximately 3 million users on X (Twitter) was examined. The classification of each story as true or false was based on evaluations from six independent fact-checking organizations, which

The

RAND Corporation described

“truth decay” as

polarizing civil

discourse in civic engagement by weakening the distinction between fact-based science and opinion to create uncertainty and erode public trust in credible public health policies and interventions.

demonstrated a 95%-98% agreement rate. False news was found to spread significantly farther, faster, deeper, and more broadly than true news across all content categories, with the effect being most pronounced in political news compared to topics such as terrorism, natural disasters, science, urban legends, and financial information. False stories were generally more novel, making them more likely to be shared. They also tended to evoke emotions such as fear, disgust, and surprise, while true stories more often elicited anticipation, sadness, joy, and trust. Contrary to popular belief, bots were found to spread both true and false news at similar rates, suggesting that human behavior rather than automated accounts primarily drives the greater reach of false news.8

Public communication about science should be accurate, understandable, unbiased, and relevant to the research intent. People make value judgments about science when it is applied to changing behaviors or informing policy decisions.9 The RAND Corporation described “truth decay” as polarizing civil discourse in civic engagement by weakening the distinction between fact-based science and opinion to create uncertainty and erode public trust in credible public health policies and interventions.10 Opinions tend to reflect our values, deeply held beliefs, and cultural experiences, as our brain interprets information based on these values. The fragility of civil discourse during the COVID-19 pandemic revealed the consequences of truth decay, as limited initial scientific knowledge about the novel

virus facilitated the spread of misinformation and eroded public trust. Gaps in knowledge regarding COVID-19 transmission, infectivity, fatality, and treatment hindered the effectiveness of communicated policies, leading to mixed and conflicting messaging about mask-wearing, vaccination, and social isolation from public health and government officials.11 There were disagreements even among scientists, which led to the October 2020 Great Barrington Declaration that advocated for the end of social lockdowns to promote herd immunity. Notably, during the peak of the COVID-19 pandemic, public confidence in science declined sharply. The percentage of people who believed science had a positive impact on society fell from 73% in 2019 to 57% in 2023.12 A 2024 survey found nearly half of Americans think scientists make judgments based solely on facts, while almost as many believe scientists have biased judgment.13

The deliberate rejection or distortion of scientific consensus in public discourse poses serious risks to dental health. A key example is the debate over fluoride, where antifluoride advocates claim it is a toxic substance and argue that fluoridating public water supplies amounts to forced medication, alleging it causes severe health problems such as cancer, cognitive impairment, and thyroid dysfunction.14 Eighty years of rigorous science demonstrates fluoride’s safety and efficacy in preventing dental caries, yet intentionally misleading fluoride content on digital media abounds, accounting for 59% of fluoride mentions on X compared to 15%

Digital Media, Truth Decay, and the Inversion of Trust in Science

Nicholas G. Mosca, DDS, DrPH

Psychological and social factors influence public distrust of scientific information. Identifying health risks while ignoring health benefits illustrates confirmation bias, a cognitive bias in which individuals use information to confirm their existing beliefs or opinions, disregarding well-established facts. Information, accurate or not, reinforces preexisting beliefs.

factual fluoride content on X. 15 In 2025, Utah and Florida became the first states to ban community water fluoridation programs, driven in part by politicians who use misleading information to fuel issue salience, the degree to which an issue has public importance.16 US Health Secretary Robert F. Kennedy Jr. has publicly opposed the ingestion of fluoride and urged the Food and Drug Administration to consider a federal ban on ingestible fluoride supplements. 17

Some dentists also contribute to public distrust in fluoride by promoting antifluoride messaging to market non-fluoride products, often without credible evidence of their effectiveness in preventing dental caries, primarily for financial gain. Similarly, misinformation surrounding dental amalgam fillings, suggesting toxic mercury exposure despite overwhelming evidence supporting their safety, fosters unnecessary public anxiety and enables dentists to replace amalgam fillings for financial gain.18 Some marketing campaigns misleadingly promote unregulated DIY teeth whitening agents, exploiting consumer desire for aesthetic enhancement. These claims are often amplified by social media influencers and celebrities who share these campaigns, widely spreading misinformation.

Psychological and social factors influence public distrust of scientific information. Identifying health risks while ignoring health benefits illustrates confirmation bias, a cognitive bias in which individuals use information to confirm their existing beliefs or opinions, disregarding well-established

facts. Information, accurate or not, reinforces preexisting beliefs.19,20 Additionally, information that aligns with shared values within social groups can strengthen group identity and cohesion through homophily, the tendency to associate with others who are similar. In this context, misinformation serves as a social bond, reinforcing group norms and deepening resistance to contradictory scientific evidence. 21 For instance, communities with historical distrust in governmental institutions might interpret public health initiatives, such as water fluoridation, as intrusive or harmful. Similarly, individuals who rely heavily on anecdotal evidence from personal networks may dismiss scientific consensus in favor of community-shared beliefs. Psychological biases include motivated reasoning, which drives individuals to selectively consume and share information that aligns with their existing beliefs and values.5 Misinformation is often shared not out of ignorance or by mistake, but for deliberate reasons, such as fostering social relations, generating income, gaining political influence, or expressing personal emotions. 22

Sharing novel information that reinforces polarizing group opinions can offer social rewards, strengthening social identity, cohesion, and reach. Digital media platforms contribute to this by using algorithmic filtering to supply users with content similar to what they have previously interacted with. Digital media companies have faced criticism for inadequate content moderation and for allowing misleading information to persist on their platforms. An echo chamber is an isolated “fringe” group within a

larger social network where opinions become highly polarized. An example is health freedom groups, which value the freedom of conscience—the belief that individuals should make health decisions based on their personal values. This concept drives their group identity and selective information curation. Research shows that vaccine-hesitant individuals value freedoms related to choice, speech, and autonomy, making health freedom groups particularly persuasive to this audience.6 These groups use these values to challenge vaccination mandates for school entry to disrupt efforts by public health professionals to improve rates. Similarly, medical freedom groups have opposed community water fluoridation by selectively exposing themselves to counterfactual information that aligns with their values, reinforcing their positions through confirmation bias.22,23 Understanding how these polarized subgroups form is key to developing strategies that promote a more balanced information flow within communities.

Ethical Obligations to the Truth

Health professionals are guided by core ethical values such as beneficence, competence, integrity, compassion, justice, professionalism, tolerance, and veracity. These core values should also guide the pursuit of epistemic knowledge, which necessitates a rational and objective evaluation of scientific claims and evidence. Epistemic freedom, the ability to think independently and critically, is essential to scientific inquiry, but it can also be misused to challenge well-established scientific consensus. When leveraged to advance political persuasion, epistemic freedom may be distorted to influence public behavior and decision-making in ways that undermine the truth.24 This misuse inverts core social values, prioritizing misinformation over evidence, financial gain over patient welfare, and biased interpretations over objective science.

To ethically and effectively counter the health consequences of truth decay, the dental profession should leverage its trusted role to promote

both system- and individual-level interventions against misleading health information. At the system level, this could include advocating for policy, regulatory, and technological interventions such as labeling misleading content and adding factual counter-messaging, a process called debunking.7 Just as the American Dental Association (ADA) awards its Seal of Acceptance to dental products, a similar system could be developed to evaluate and endorse credible digital health content, including that shared by online wellness influencers. A standardized content labeling system, similar to the Motion Picture Association of America (MPAA) movie ratings, could help the public distinguish between reliable and appropriate online health information. Additionally, prebunking strategies, also known as psychological inoculation, can proactively educate the public about how and why information spreads.25

To mitigate the influence of echo chambers, it is crucial to identify and comprehend the factors that contribute to the formation of these polarized groups. The dental profession should advocate for greater data access and transparency from social media platforms, enabling organizations like the ADA Health Policy Institute to study how these groups influence policy discourse on oral health. Echo chambers may also exist within the dental profession itself, driven by political differences. Promoting transparency around these internal divisions can support more informed and respectful policy discourse.23,24 Similarly, openly acknowledging uncertainties and limitations in dental research can foster public trust and encourage a more nuanced understanding of science. An objective scientific culture requires critical appraisal, open debate, and ethical public discourse. Ethical dental professionals have a responsibility not only to provide scientifically accurate oral healthcare but also to correct or retract harmful misinformation and disinformation. The profession should uphold the core value of veracity by imposing penalties for oral health professionals who use disinformation to mislead the public.

Digital Media, Truth Decay, and the Inversion of Trust in Science

Nicholas G. Mosca, DDS, DrPH

On the individual level, dental professionals should engage in active public outreach and education. Regular interaction on social media platforms, providing accurate information, promptly addressing emerging false narratives, and sharing easily understandable infographics or videos can reduce misconceptions. Social groups may require tailored, culturally respectful communication strategies to effectively bridge knowledge gaps and promote understanding. Professional dental associations should collaborate with trusted community leaders and local organizations to amplify evidence-based messages, enhancing credibility and acceptance among diverse audiences. Clarifying complex scientific concepts into accessible, relatable messages is essential to countering misinformation. Educational interventions within dental school curricula should emphasize behavioral science, critical thinking, digital literacy, and effective science communication skills to prepare future dental professionals to proactively communicate ethically and empathetically through digital media. Additionally, interprofession-

REFERENCES

al collaboration between dental professionals, physicians, public health officials, and communication specialists can create cohesive strategies to address misinformation holistically.

Conclusion

Truth decay in digital communication poses a threat to oral health and public trust in science. To counteract this, dental professionals must translate complex scientific concepts into clear and relatable ones that build public confidence in evidence-based care. Understanding how misinformation spreads enables the profession to design ethical, targeted interventions that close knowledge gaps and improve health outcomes. By promoting transparent, respectful, and culturally sensitive communication, dental professionals can fulfill their ethical duty and help foster a healthier, more informed society. Fluoride may not prevent truth decay, but the profession’s commitment to truth just might.

1. Chen J, Wang Y. Social media use for health purposes: Systematic review. J Med Internet Res. 2021;23(5):e17917.

2. ALS Awareness Campaign. Accessed July 14, 2025. https://alsnetwork.org/10th-anniversary-of-the-alsice-bucket-challenge-continues-to-raise-als-awareness/

3. Movember Campaign. Accessed July 14, 2025. https://us.movember.com/

4. Sharma S, Mohanty V, Balappanavar AY, Chahar P, Rijhwani K. Role of digital media in promoting oral health: A systematic review. Cureus. 2022 Sep 7;14(9). doi:10.7759/cureus.28893

5. Scheufele DA, Krause NM. Science audiences, misinformation, and fake news. Proc Natl Acad Sci USA 2019;116(16):7662-7669. doi:10.1073/pnas

6. Hotez PJ. America’s deadly flirtation with antiscience and the medical freedom movement. J Clin Invest 2021;131(7):e149072. doi:10.1172/JCI149072

7. Using psychology to understand and fight health misinformation: An APA consensus statement. Published November 2023. Accessed August 13, 2025. https://www.apa.org/pubs/reports/health-misinformation

8. Vosoughi S, Roy D, Aral S. The spread of true and false news online. Science. 2018;359(6380):1146-1151. doi:10.1126/science.aap9559

9. Freiling I, Krause NM, Scheufele DA. Science and ethics of “curing” misinformation. AMA J Ethics 2023;25(3):E228-E237. Published March 1, 2023. doi:10.1001/amajethics.2023.228

10. Kavanagh J, Rich MD. Truth Decay: An Initial Exploration of the Diminishing Role of Facts and Analysis in American Public Life. RAND Corporation. Published January 16, 2018. Accessed August 13, 2025. https://www.rand.org/pubs/research_briefs/RB10002.html.

11. Intemann, K. Science communication and public trust in science. Interdiscipl Sci Rev. 2023;48(2):350-365. doi:10.1080/03080188.2022.2152244

12. Science and Technology: Public Perceptions, Awareness, and Information Sources. National Science Board. Accessed August 13, 2025. https://ncses.nsf.gov/pubs/nsb20244.

13. Tyson A, Kennedy B. Public Trust in Scientists and Views on Their Role in Policymaking. Published November 14, 2024. Accessed August 13, 2025. https://www.pewresearch.org/science/2024/11/14/publictrust-in-scientists-and-views-on-their-role-in-policymaking/.

14. Lotto M, Sá Menezes T, Zakir Hussain I, et al. Characterization of false or misleading fluoride content on Instagram: Infodemiology study. J Med Internet Res. 2022;24(5):e37519. doi:10.2196/37519

15. Oh HJ, Kim CH, Jeon JG. Public sense of water fluoridation as reflected on Twitter 2009-2017. J Dent Res. 2020;99(1):11-17. doi:10.1177/0022034519885610

16. Wood, T. Florida becomes second state to ban fluoride in public water. May 16, 2025. Accessed August 13, 2025. https://www.npr.org/2025/05/16/nx-s1-5399745/florida-becomes-second-state-to-ban-fluoride-in-public-water.

17. Nguyen, D. Dentists Are Struggling to Counter RFK Jr. on Fluoride. Published July 10, 2025. Accessed August 13, 2025. https://www.politico.com/news/2025/07/10/rfk-jr-is-winning-on-fluoride-dentists-foresee-a-cavity-crisis-00445489.

18. Lotto M, Jorge OS, Machado MAAM, Cruvinel T. Exploring online oral health misinformation: A content analysis. Braz Oral Res. 2023;37:e049. Published May 29, 2023. doi:10.1590/1807-3107bor-2023. vol37.0049

19. Early JO, Robillard AG, Rooks RN, Smith Romocki L. Pedagogy and propaganda in the post-truth era: Examining effective approaches to teaching about mis/disinformation. Pedagogy Health Promot 2024;10(3):152-165. doi:10.1177/23733799231218936

20. Simon D, Read SJ. Toward a general framework of biased reasoning: Coherence-based reasoning. Perspect Psychol Sci. 2025;20(3):421-459. doi:10.1177/17456916231204579

21. Seymour B, Getman R, Saraf A, Zhang LH, Kalenderian E. When advocacy obscures accuracy online: Digital pandemics of public health misinformation through an antifluoride case study. Am J Public Health 2015;105(3):517-523. doi:10.2105/AJPH.2014.302437

22. Wang Y, McKee M, Torbica A, Stuckler D. Systematic literature review on the spread of health-related misinformation on social media. Soc Sci Med. 2019;240:112552. doi:10.1016/j.socscimed.2019.112552

23. Törnberg P. Echo chambers and viral misinformation: Modeling fake news as complex contagion. PLoS One. 2018;13(9):e0203958. Published September 20, 2018. doi:10.1371/journal.pone.0203958

24. Erduran S. The post-truth era and how science education keeps ignoring it. Science 2025;388(6746):eadx5458. doi:10.1126/science.adx5458

25. Bragazzi NL, Garbarino S. Understanding and combating misinformation: An evolutionary perspective. JMIR Infodemiol. 2024;4:e65521. doi:10.2196/65521

The Ethical Imperative of Preserving Federal Oversight in Academic Dentistry

Jennifer D. Talley,

EdD

Director of Educational Development and Assessment, Marquette University School of Dentistry

Linda Olszewski, DBA, MBA

Director, Academic Assessment and Program Review, Marquette University

This article argues that federal oversight of academic dentistry by the US Department of Education (DOE) is essential to maintaining academic quality, professional standards, financial accessibility, and ethical governance. It examines the role of the DOE in the accreditation process, preserving access to financial aid, ensuring licensure eligibility, and upholding civil rights protections. The authors contend that proposals to dismantle the DOE risk undermining quality assurance, public trust, and equitable access to the profession. Without viable alternatives, preserving federal oversight remains an ethical imperative to protect students, patients, and the integrity of the dental profession.

Keywords: Dental education policy, accreditation, federal education regulation, institutional accountability, equitable dental education

Dismantling or weakening the DOE—absent a robust alternative— risks fragmenting accreditation systems and eroding quality assurance mechanisms, disrupting financial aid access, and increasing inconsistencies in upholding ethical practices. Such destabilization may compromise public trust in dental education and jeopardize patient safety.

Introduction

Recent political discourse has revived proposals to dismantle the US Department of Education (DOE), a movement driven by advocates of deregulation and diminished federal oversight. While such arguments may resonate with specific ideological frameworks, they often fail to account for the profound implications for higher education systems, including academic dentistry. The DOE’s role extends far beyond bureaucratic administration; it is instrumental in upholding the ethical, professional, and educational standards that ensure the competent preparation of dental practitioners. By granting federal recognition, the DOE legitimizes accrediting bodies such as the Commission on Dental Accreditation (CODA), thereby authorizing dental programs to participate in Title IV federal student aid, uphold institutional and licensure standards, and preserve equitable access to the profession. Dismantling or weakening the DOE—absent a robust alternative—risks fragmenting accreditation systems and eroding quality assurance mechanisms, disrupting financial aid access, and increasing inconsistencies in upholding ethical practices. Such destabilization may compromise public trust in dental education and jeopardize patient safety.

The Role of Accreditation in Assuring Quality

The Servicemen’s Readjustment Act of 1944 (GI Bill) and the Higher Education Act of 1965 increased federal investment in higher education,

including dental education, by linking financial aid eligibility to academic quality. To safeguard federal funding, these laws required new oversight mechanisms, leading to the eventual creation of the US Department of Education in 1980 as the new authority over the administration and eligibility criteria for federal student financial aid programs.1 While the DOE does not directly accredit institutions or programs, it exercises regulatory oversight of the accreditation process through periodic, evidence-based reviews of accrediting bodies, ensuring that they apply their standards consistently and rigorously.2

In dental education, the DOE’s most consequential role is its recognition of CODA, the sole agency authorized to accredit US dental programs.3 CODA’s accreditation standards—developed through empirical review and substantial input from diverse stakeholders—define the national expectations for dental program quality. These standards require institutions to deliver a comprehensive didactic and clinical curriculum, assess competency across all relevant domains, and engage in systematic, data-driven quality improvement. All CODA-accredited programs undergo a mandatory seven-year self-study cycle, culminating in the submission of a detailed, evidence-based report demonstrating compliance with each accreditation standard and completing a subsequent site visit.4 While standards vary by program type (eg, predoctoral, advanced dental education, etc), the major categories evaluated in self-study typically include the following:

The Ethical Imperative of Preserving Federal Oversight in Academic Dentistry

Jennifer D. Talley, EdD; Linda Olszewski, DBA, MBA

1. Institutional Effectiveness and Program Planning (program alignment, governance, strategic planning, resource allocation, and institutional effectiveness metrics)

2. Curriculum and Program Content (curricular design and integration emphasizing competency-based, evidence-informed, and interprofessional education across didactic, preclinical, and clinical domains)

3. Faculty and Staff (faculty qualifications, coverage, ongoing development, calibration, scholarly activity, and engagement in curriculum and governance)

4. Students (admissions, support services, progression policies, feedback and grievance mechanisms, and efforts to promote inclusion and belonging)

5. Patient Care and Clinical Education (clinical education and patient care systems that ensure high-quality, safety, and HIPAA-compliant care; effective management of patient records and infection control; structured student supervision and assessment; and integration of community-based experiences and public health principles)

6. Assessment and Outcomes (programmatic assessment and continuous quality improvement processes informed by student achievement metrics, outcomes data, and stakeholder feedback from students, faculty, alumni, and employers)

7. Compliance and Documentation (demonstrated compliance with all applicable CODA standards and alignment with federal and state regulations and institutional policies)

In addition to recognizing programmatic accreditors such as CODA, the DOE oversees institutional accrediting agencies responsible for evaluating colleges and universities holistically, including those housing dental schools. The United States is currently organized into six geographic regions, each served by a federally recognized regional accreditor.5 While criteria vary slightly among these agencies, institutional accreditation typically encompasses core domains addressing academic quality, governance, financial stability, student learning outcomes, and institutional effectiveness.

Certain conservative policymakers have increasingly criticized what they perceive as federal overreach in higher education, particularly through the DOE’s role in linking federal funding to accreditation outcomes. Detractors of the current system, such as Richard Vedder, Distinguished Professor Emeritus of Economics at Ohio University, argue that this relationship enables the DOE to exert indirect influence over institutional policies and curricular decisions, thereby encroaching on institutional autonomy and states’ rights.6 Recent legislative initiatives exemplify a movement toward decentralizing oversight and contesting the authority of federally accrediting bodies. For instance, Florida and North Carolina now require public institutions to rotate accrediting agencies at the end of each accreditation cycle.7 Texas, through Senate Bill 37, has expanded political control over academic governance,8 while some Utah representatives have formally advocated for transferring accreditation authority from the federal to the state level.9

While advocates of recent policy changes in Florida, North Carolina, Texas, and Utah argue that decentralization enhances state autonomy and institutional flexibility, these measures raise significant concerns regarding consistency in accreditation. The absence of a nationally recognized accreditation framework risks introducing substantial variability in educational quality and

graduate readiness, particularly if state-led models lack the rigor, peer review infrastructure, and standardization provided by nationally recognized accreditors, such as CODA.10 Without DOE federal oversight to enforce accountability and quality assurance, several risks emerge: Public funds may support substandard programs, institutions may operate without clear performance benchmarks, and graduates may be insufficiently prepared for future practice—threatening both public trust and patient safety in dentistry.11 Furthermore, devolving oversight to states without corresponding investments in regulatory infrastructure may overburden state agencies and under-resourced private accreditors. These inconsistencies may elevate institutional compliance costs, limiting institutions’ capacity to maintain educational quality while ensuring affordability.

Financial Aid and Access to the Profession

According to the American Dental Education Association (ADEA), the average dental school graduate carries $293,900 in educational debt—a $136,400 increase since 1996, reflecting the escalating cost of dental education and students’ growing reliance on financial assistance. Currently, loans represent the top source of funding for recent graduates, 83% of whom will graduate with loan debt.12,13 Critically, eligibility for this aid, including Direct Loans, Graduate PLUS Loans, and Public Service Loan Forgiveness (PSLF), is contingent upon enrollment in a CODA-accredited program at an institution recognized by the DOE. If the DOE were to cease recognition of CODA, the pathway to federal aid would be disrupted, thereby jeopardizing access to dental education and threatening the stability of the profession’s educational pipeline.14

The DOE currently administers approximately $1.5 trillion in student loans on behalf of nearly

43 million borrowers.15 Critics argue that the centralized nature of this system enables the federal government to influence institutional governance by leveraging financial aid eligibility to shape academic policy, noting that since 2021, the DOE has issued $62.7 million in fines and cut off aid to 35 institutions, citing violations, primarily in for-profit colleges.16 Some proposals have advocated for the decoupling of federal aid from the accreditation process. However, no viable models or implementation frameworks have been proposed to replace DOE oversight. Such a disruption could effectively restrict access to the dental profession to only the most financially privileged, undermining efforts to build a dental workforce that reflects and serves the diversity of the broader population, a clear ethical concern in a healthcare field committed to equitable care delivery.

The implications extend beyond individual access to education. With approximately 72 million Americans lacking dental insurance and an estimated 14 million (28% of the country’s adult Medicaid population) at risk of losing coverage due to proposed Medicaid redetermination policies, the need for a stable, incentivized dental workforce in the public sector is urgent.17,18 Compounding these challenges are persistently low Medicaid reimbursement rates, which suppress provider participation in private practice settings. In this tumultuous landscape, loans and loan forgiveness initiatives like PSLF serve as vital tools for workforce development and are essential to mitigate oral health disparities. PSLF offers loan forgiveness after 10 years of qualifying payments for providers employed full-time in nonprofit or public service roles and has been shown to increase provider retention in high-need communities and reduce financial stress on borrowers, thereby expanding access to care increase provider retention in high-need communities and in turn expanding access to care for the most vulnerable population.19

The Ethical Imperative of Preserving Federal Oversight in Academic Dentistry

Jennifer D. Talley, EdD; Linda Olszewski, DBA, MBA

While federal recognition of accreditation bodies determines access to financial aid, licensure eligibility functions as another vital gateway to the dental profession. As of 2024, 100% of US dental schools offering licensure-eligible degrees are accredited by CODA; no state-based accreditor currently maintains comparable capacity to ensure academic quality. If DOE oversight were revoked, graduates could be ineligible to practice—a consequence that raises both ethical and legal concerns regarding professional access.

Upholding Ethical Principles

The DOE is a primary regulator of institutional data, providing stakeholders with metrics on student debt, graduation rates, and post-graduation earnings.20 Moreover, the DOE enforces civil rights protections under Title VI (prohibiting discrimination based on race, color, or national origin) and Title IX (prohibiting sex-based discrimination) for institutions receiving federal funding. These regulatory functions serve to ensure transparency, enforce equity, and identify patterns of discrimination across higher education.21

Data collection and transparency are critical to the continuous improvement of academic programs and institutional effectiveness. In dental education, both the DOE and the American Dental Association (ADA) collect and disseminate data, though for distinct purposes. The ADA focuses on workforce planning, policy development, and academic benchmarking, compiling data on enrollment, graduation rates, faculty composition, financial metrics, clinical capacity, licensure outcomes, curriculum design, and accreditation compliance. The DOE oversees the Integrated Postsecondary Education Data System (IPEDS) through the National Center for Education Statistics (NCES), as well as the College Scorecard. All financial-aid-eligible institutions are required to submit updated data annually for all bachelor’s, master’s, and doctoral

programs. IPEDS reports data at the institutional level, including information on the university that hosts the dental program, when applicable. It provides detailed metrics on cost of attendance, admissions criteria and yield, enrollment, financial aid, degree completions, persistence and graduation rates, human resources, and fiscal resources. In contrast, the College Scorecard is designed for a student and family audience, offering a more consumer-focused dataset. It highlights earnings and debt outcomes for recent graduates as well as program-specific alumni repayment and default rates, all presented through a user-friendly interface that facilitates easy comparisons between institutions.

Critics argue that the centralization of data collection through IPEDS represents yet another instance of federal overreach into higher education. Recently, under Secretary of Education Linda McMahon, the NCES was reduced from a staff of about 100 to just three, dramatically reducing the scope of work the organization is capable of overseeing.22 In addition to concerns about federal authority, members of the Senate’s Education Committee, such as Senator Bill Cassidy (R-LA), have raised issues regarding the quality and reliability of IPEDS data, noting that the self-reporting process often results in delays, inconsistencies, or even manipulation by institutions, and have advocated for a new data collection system. He stated, “The current college reporting system is overly burdensome on institutions yet provides little practical information for students and families due to significant gaps in college data,” a position that has gained bipartisan support.23

While criticisms of IPEDS raise valid points about federal efficiency and data complexity, the system remains an indispensable tool for ensuring transparency, consumer protection, and evidence-based policymaking in higher education. Tools such as customizable Data Feedback Reports, summary tables, and trend generators

The Institute for Higher Education Policy, a nonpartisan research, policy, and advocacy organization, maintains that the Scorecard “is a pivotal tool for transparency: Students deserve to know which colleges and programs of study deliver a good return on investment, enroll a diverse student population and support those students through to completion, and prepare graduates for success in the workforce.”

empower institutions to benchmark their performance against that of peer organizations, drive data-informed strategic planning, and strengthen accreditation submissions by demonstrating institutional effectiveness, student outcomes, and financial sustainability.24 Not limited to institutional use, data transparency also empowers students and families to make informed decisions. The Institute for Higher Education Policy, a nonpartisan research, policy, and advocacy organization, maintains that the Scorecard “is a pivotal tool for transparency: Students deserve to know which colleges and programs of study deliver a good return on investment, enroll a diverse student population and support those students through to completion, and prepare graduates for success in the workforce.”25

While open-access data systems like IPEDS and the College Scorecard are central to promoting transparency and accountability in higher education, debates over the federal government’s role—particularly in enforcing civil rights statutes and embedding DEI principles—have prompted some lawmakers to call for a reevaluation of the Department of Education’s authority. Under current policy, adherence to civil rights statutes, such as Title VI and IX, is a required condition for institutions to receive federal assistance; however, some detractors are calling for the end of this historical pairing. Project 2025 called for the elimination of the Department of Education, shifting all civil rights functions to the Department of

Justice, while Linda McMahon’s statement before the Committee on Appropriations noted a 35% reduction in funds to the Office of Civil Rights.26,27

Some Republican lawmakers, including Representative Virginia Foxx (R-NC), former Chair of the House Education and Workforce Committee, contend that the DOE has overreached by embedding liberal diversity, equity, and inclusion (DEI) agendas into accreditation and compliance frameworks.28 To this end, legislation such as HR 3724, the “End Woke Higher Education Act,” aimed to prevent accreditors from assessing an institution’s or program of study’s “commitment to any ideology, belief, or viewpoint.”29 Further illustrating this point, President Trump’s Executive Order 14173, “Ending Illegal Discrimination and Restoring Merit-Based Opportunity,” ordered the elimination of DEI initiatives at higher education institutions and gained public attention when he halted over $2 billion in federal grant funding to Harvard University for noncompliance.30

Despite fierce opposition, dismantling federal enforcement mechanisms could compromise ethical governance and heighten the risk of unchecked discriminatory practices in higher education. Dental schools, like all health professional programs, have an ethical obligation to ensure that students are educated in safe, inclusive, and academically rigorous environments—standards that benefit from federal enforcement. In 2024 alone, 5,067 Title IX and

The Ethical Imperative of Preserving Federal Oversight in Academic Dentistry

Jennifer D. Talley, EdD; Linda Olszewski, DBA, MBA

The elimination of federal oversight would endanger licensure eligibility, restrict access to financial aid, and erode standards essential for equitable and rigorous dental education. While some policymakers advocate for greater state autonomy, no comprehensive infrastructure currently exists to replace the DOE’s functions.

4,307 Title VI complaints were filed with the Office for Civil Rights (OCR), underscoring the continued need for federal data transparency mechanisms to monitor and address trends in civil rights violations.31 Although CODA does not collect civil rights data, evidence of inequities in dental education is well documented. The 2022 American Dental Education Association (ADEA) Climate Survey revealed persistent racial disparities in campus climate ratings among faculty, staff, and administrators, with Black, Asian, and Hispanic respondents reporting lower perceptions of well-being and inclusivity compared to White peers. Additionally, women consistently rated the climate more negatively than men. They reported higher incidences of harassment and discrimination, reinforcing the necessity of accessible, formal channels to report and resolve civil rights complaints without fear of institutional retaliation 32,33 Federal compliance with civil rights laws such as Title VI and Title IX is not an imposition of a so-called “woke” agenda, but a data-informed approach to protecting student welfare within an industry that continues to face persistent patterns of inequity.

Conclusion

Federal oversight of dental education is not merely administrative—it is essential to maintaining academic quality, ensuring professional com-

petence, expanding financial access, and upholding institutional accountability. The DOE plays a critical role by recognizing accrediting bodies, enforcing civil rights protections, managing student aid programs, and providing data transparency that supports informed decision-making and continuous improvement. Proposals to dismantle or weaken the DOE threaten to destabilize these interconnected systems. The elimination of federal oversight would endanger licensure eligibility, restrict access to financial aid, and erode standards essential for equitable and rigorous dental education. While some policymakers advocate for greater state autonomy, no comprehensive infrastructure currently exists to replace the DOE’s functions. State-based alternatives would likely vary widely in quality, lack consistent oversight, and rely on untested mechanisms for accreditation and civil rights enforcement. Such decentralization would disproportionately affect underrepresented students, reduce institutional accountability, and exacerbate existing disparities in the delivery of oral healthcare. Until viable, evidence-based alternatives are developed and rigorously evaluated, the DOE remains indispensable to the ethical governance and accountability of the dental profession. Its preservation is necessary not only for protecting students and patients but also for sustaining the integrity of dental education in the United States.

REFERENCES

1. Thelin JR. A History of American Higher Education. 3rd ed. Johns Hopkins University Press; 2019.

2. U.S. Department of Education. Summary of the Recognition Process for Accrediting Agencies. Published 2025. Accessed August 18, 2025. https://www.ed.gov/laws-and-policy/higher-education-laws-and-policy/ college-accreditation/summary-of-recognition-process-accrediting-agencies

3. U.S. Department of Education. Programmatic Accrediting Agencies. Published 2025. Accessed August 18, 2025. https://www.ed.gov/laws-and-policy/higher-education-laws-and-policy/college-accreditation/programmatic-accrediting-agencies

4. Commission on Dental Accreditation. About CODA. Published 2025. Accessed August 18, 2025. https:// coda.ada.org/about-coda

5. Council for Higher Education Accreditation. CHEA-Recognized Accrediting Organizations. Published 2025. Accessed August 18, 2025. https://www.chea.org/chea-recognized-accrediting-organizations

6. Vedder R. Let Colleges Fail: The Power of Creative Destruction in Higher Education. Independent Institute; 2025.

7. Moody J. Florida’s Accreditation Shuffle Begins. Inside Higher Ed. August 30, 2023. Accessed August 18, 2025. https://www.insidehighered.com/news/governance/accreditation/2023/08/30/flas-accreditation-shuffle-begins-one-college-gets-us

8. Texas Legislative Reference Library. Senate Bill 37: Bill Analysis (89th Legislature, 2025). Published 2025. Accessed August 18, 2025. https://capitol.texas.gov/tlodocs/89R/analysis/pdf/SB00037F.pdf

9. Utah System of Higher Education. 2024 Legislative Update: Week 5. 2024. Accessed August 18, 2025. https://ushe.edu/2024-legislative-update-week-5

10. Eaton JS. An Overview of U.S. Accreditation. Council for Higher Education Accreditation. Updated November 1, 2015. Accessed August 18, 2025. https://www.chea.org/overview-us-accreditation

11. Kelchen R. Higher Education Accountability. Johns Hopkins University Press; 2018.

12. Istrate EC, Cooper B, West KP. Dentists of tomorrow 2022: An analysis of the results of the ADEA 2022 Survey of U.S. Dental School Seniors. J Dent Educ. 2022;86(10):1405-1417. doi:10.1002/jdd.13116

13. Hanson M. Average Dental School Debt. Education Data Initiative. Updated August 31, 2024. Accessed August 18, 2025. https://educationdata.org/average-dental-school-debt

14. U.S. Department of Education. An Overview of the U.S. Department of Education: How Does ED Serve Students? Published 2025. Accessed August 18, 2025. https://www.ed.gov/about/ed-overview/an-overview-of-the-us-department-of-education--pg-2

15. U.S. Government Accountability Office. Federal Student Loans: Preliminary Observations on Borrower Repayment Practices After the Payment Pause (GAO-24-107150). July 29, 2024. Accessed August 18, 2025. https://www.gao.gov/products/gao-24-107150.

16. Federal Student Aid. Enforcement. U.S. Department of Education. Accessed August 18, 2025. https://studentaid.gov/data-center/enforcement

17. CareQuest Institute for Oral Health. Out of Pocket: A Snapshot of Adults’ Dental and Medical Care Coverage. May 9, 2025. Accessed August 18, 2025. https://www.carequest.org/resource-library/out-pocket-snapshot-adults-dental-and-medical-care-coverage.

18. CareQuest Institute for Oral Health. New CareQuest Institute Analysis: More Than 14 Million People May Lose Dental Coverage Under Medicaid Redetermination. Published 2023. Accessed August 18, 2025. https://www.carequest.org/about/press-release/new-carequest-institute-analysis-more-14-million-peoplemay-lose-dental

The Ethical Imperative of Preserving Federal Oversight in Academic Dentistry

Jennifer D. Talley, EdD; Linda Olszewski, DBA, MBA

19. Cather W, Harris EE, Romney MA. Your tax dollars at work: The effectiveness of the public service loan forgiveness program. J Am Tax Assoc. Forthcoming 2024. 1-16. doi:10.2308/JATA-2023-046

20. U.S. Department of Education. Data. Published 2025. Accessed August 18, 2025. https://www.ed.gov/data

21. U.S. Department of Education. Office for Civil Rights (OCR). Accessed August 18, 2025. https://www.ed.gov/about/ed-offices/ocr#home

22. Knox L, Blake J. Assessing the Damage After the Education Department’s Mass Layoffs. Inside Higher Ed Published March 13, 2025. Accessed August 18, 2025. https://www.nasfaa.org/news-item/35832/Assessing_the_Damage_After_the_Education_Department_s_Mass_Layoffs

23. Cassidy B. Momentum Continues to Build for College Transparency Act. Press Release. July 12, 2019. Accessed August 18, 2025. https://www.cassidy.senate.gov/newsroom/press-releases/momentum-continues-to-build-for-college-transparency-act.

24. National Center for Education Statistics. IPEDS: Use the Data. U.S. Department of Education. Accessed August 18, 2025. https://nces.ed.gov/ipeds/use-the-data.

25. Institute for Higher Education Policy. Updated College Scorecard Data Shed New Light on Student Earnings, Borrower Repayment Outcomes, Campus Diversity, and More. Published May 15, 2023. Accessed August 18, 2025. https://www.ihep.org/updated-college-scorecard-data-earnings-repayment-campus-diversity/.

26. The Heritage Foundation. Mandate for Leadership: The Conservative Promise. Published 2023. Accessed August 18, 2025. https://static.heritage.org/project2025/2025_MandateForLeadership_FULL.pdf.

27. McMahon L. Statement on the President’s FY 2026 Budget Before Senate Committee on Appropriations. U.S. Department of Education. June 3, 2025. Accessed August 18, 2025. https://thehill.com/video-clips/5329934-watch-live-linda-mcmahon-senate-appropriations-education-budget-hearing/

28. U.S. Congress. Accreditation for College Excellence Act of 2023, H.R. 3724, 118th Cong. Updated September 23, 2024. Accessed August 18, 2025. https://www.congress.gov/bill/118th-congress/housebill/3724/text

29. Foxx V. Accreditation for College Excellence Act of 2023. Cong Rec. 2024;170(pt.1):H5463-H5465. Accessed August 18, 2025. https://www.govinfo.gov/content/pkg/CREC-2024-09-19/html/CREC-2024-09-19pt1-PgH5463-5.htm

30. Federal Government. Letter to Harvard University. Published April 11, 2025. Accessed August 18, 2025. https://www.harvard.edu/research-funding/wp-content/uploads/sites/16/2025/04/Letter-Sent-to-Harvard-2025-04-11.pdf

31. U.S. Department of Education, Office for Civil Rights. 2024 Fiscal Year Annual Report. Published 2024. Accessed August 18, 2025. https://www.ed.gov/about/ed-offices/ocr/serial-reports-regarding-ocr-activities

32. Ester TV, Smith CS, Cain L, Ramaswamy V. The impact of role and race on overall climate in dental schools. J Dent Educ. 2025;89(5):722-730. doi:10.1002/jdd.13730

33. Garcia MN, Rocha-Sanchez SM, Joy-Thomas A, Zarkowski P, Kytridou V, Quick KK. Gender-based dynamics in the 2022 ADEA Climate Study: Perspectives of faculty, staff, and administrators. J Dent Educ 2025;89(5):712-721. doi:10.1002/jdd.13726

21st-Century Dental Public Health: Revisiting the Role of Community Water Fluoridation

Larry Williams, DDS, MPH

Professor, Midwestern University College of Dental Medicine, IL

Preetha Kanjirath, BDS, MS

Professor, Midwestern University College of Dental Medicine, IL

Community water fluoridation (CWF) has been celebrated as a major public health achievement, significantly reducing dental caries and narrowing oral health disparities. While historically effective, today’s fluoride exposure landscape has shifted, with multiple sources contributing to cumulative intake. This article reviews the scientific foundation, mechanisms of action, public health benefits, and ethical considerations surrounding CWF, alongside real-world outcomes from policy reversals. It examines contemporary concerns, including potential neurodevelopmental risks and vulnerable populations, and calls for recalibrated policies that maintain caries prevention benefits while monitoring total fluoride exposure to ensure safety in modern contexts.

Keywords: Community water fluoridation, Dental caries prevention, Public health policy, Fluoride exposure, Health disparities, Neurodevelopmental effects, Ethical considerations, Oral health equity, Preventive dentistry

21st-Century Dental Public Health: Revisiting the Role of Community Water Fluoridation

Larry Williams, DDS, MPH; Preetha Kanjirath, BDS, MS

Public health experts recognize water fluoridation as one of the top 10 public health achievements of the 20th century. Its implementation was driven by the need to address the widespread prevalence of dental caries in the US population. At that time, dental disease contributed to 8.5% of military disqualifications, underscoring its broader impact on public health and national readiness. Perhaps the most significant benefit was observed among 12-year-old children, who experienced a 68% decrease in the number of decayed, missing, and filled teeth. 1

Even today, dental caries remains one of the most widespread chronic diseases globally, with a disproportionate impact on underserved communities.2 In this context, community water fluoridation serves not only as a preventive measure but also as a tool for reducing health disparities. Since its introduction in the mid-20th century, community water fluoridation (CWF) has provided a powerful public health tool by delivering low-dose fluoride through public water systems, thereby overcoming barriers related to socioeconomic status and access to preventive care. Today, about 72.3% of the US population served by public water systems receives fluoridated water.3 Globally, over 400 million people across 25 countries receive fluoridated water.4 In regions where centralized water fluoridation is not feasible, fluoridated salt or milk often serves as an alternative. It is important to note, however, that much of the foundational evidence originates from studies conducted before 1975, before fluoride-containing toothpastes and other topical interventions became commonplace.5 Thus, despite extensive scientific validation regarding the safety and efficacy of community water fluoridation, it is a flashpoint of public debate today, as the broader context of fluoride exposure has changed significantly. As contemporary patterns of fluoride exposure from diverse sources have evolved, there is a growing need to reexamine and update the evidence base to reflect current preventive practices and cumulative fluoride intake. This article explores

the scientific foundation, mechanism of action, public health impact, and ethical considerations, along with case studies where policy reversals offer real-world insight.

The body of evidence overwhelmingly supports the notion that the primary mode of caries prevention is through topical fluoride.6 Any form of fluoride present in the mouth, whether from toothpaste, fluoridated water, or professional varnishes, decreases demineralization and enhances enamel remineralization, while inhibiting acid production by bacteria.7 Systemic fluoride, typically consumed in early childhood, is incorporated into the developing dental structures. Although this pre-eruptive effect contributes to caries resistance, current evidence indicates that the predominant protective mechanism is through topical fluoride exposure after tooth eruption. After tooth development, ingested fluoride functions mainly as a salivary reservoir, contributing to topical protection.8 Even though community water fluoridation is a systemic method of delivery, it acts topically each time someone drinks fluoridated water, providing frequent lowdose exposure that mirrors ideal fluoride delivery. This makes community water fluoridation particularly valuable in communities where access to dental care or consistent oral hygiene is limited.

Dental Caries Prevention and Cost Savings

The effectiveness of community water fluoridation in reducing dental caries is supported by decades of research. Early comparisons between fluoridated and non-fluoridated communities showed a significant reduction in tooth decay.9-11

The impact of water fluoridation is particularly significant in populations at higher risk for caries, often those facing socioeconomic barriers. While rising background exposure to fluoride from various sources has made differences more complicated to detect in some populations, fluoridation remains

Unlike in the past, fluoride exposure today is no longer limited to drinking water. Many individuals are exposed to fluoride from a combination of sources, including fluoridated tap water, toothpaste, processed foods, beverages, tea, certain pharmaceuticals, pesticide residues, and natural environmental sources.

both effective and economically sound. The economic benefits of fluoridation are significant. By preventing cavities, it reduces the need for dental treatments. Studies in the US estimate an average of $32 per person, with an average return on investment (ROI) of $20 for every dollar spent.12

The Problem of Cumulative Exposure: A 21st-Century Concern

Unlike in the past, fluoride exposure today is no longer limited to drinking water. Many individuals are exposed to fluoride from a combination of sources, including fluoridated tap water, toothpaste, processed foods, beverages, tea, certain pharmaceuticals, pesticide residues, and natural environmental sources. The Cochrane review, “Water Fluoridation Reduces Dental Caries in Children,”13 had evidence that was largely based on older studies predating modern fluoride use. They also reported that 12% of individuals exposed to 0.7 ppm fluoride experienced dental fluorosis of esthetic concern. The potential impact of fluoride on children’s cognitive development has gained attention, especially from studies conducted in areas with naturally high fluoride levels. Many of these studies are often conducted in China, India, and Iran, where endemic fluoride concentrations far exceed those used in community water fluoridation. A 2012 meta-analysis reported a modest reduction in IQ scores in areas with high fluoride levels,14 but

the studies reviewed had significant limitations stemming from incomplete reporting. Some studies failed to consider confounding factors, such as lack of control for nutrition, socioeconomic factors, and other environmental exposures. In response to growing concerns, the US National Toxicology Program conducted a comprehensive review, concluding in 2024 with moderate confidence that fluoride levels above 1.5 mg/L are associated with a lower IQ in children.15 Importantly, the National Toxicology Program found no significant evidence to conclude that optimally fluoridated water poses any risk to cognitive development. Recent studies in North America, such as those by Green et al16 and Bashash et al,17 reported slight IQ differences associated with prenatal fluoride exposure. These well-conducted cohort studies generated media attention; however, the observed differences were small and inconsistently significant. Moreover, confounding factors and challenges in exposure measurement temper the findings. In contrast, a longitudinal study from New Zealand18 found no difference in IQ between individuals raised in fluoridated and non-fluoridated communities. Meta-analyses that focus exclusively on community water fluoridation level exposure have not consistently demonstrated a statistically significant impact on IQ.19 In short, while high-dose fluoride exposure may warrant caution, the current body of evidence does not support the claim that optimal community water fluoridation poses neurodevelopmental risk.20

21st-Century Dental Public Health: Revisiting the Role of Community Water Fluoridation

Larry Williams, DDS, MPH; Preetha Kanjirath, BDS, MS

Emerging Concerns for Pregnant Women and Infants

The cumulative intake of fluoride has raised concerns about potential overexposure, especially among vulnerable populations like infants and pregnant women. Powdered infant formula mixed with fluoridated water can deliver levels far exceeding what is considered safe. Children who swallow toothpaste or frequently consume processed products may also be absorbing more fluoride than intended. This changing landscape of fluoride exposure makes it increasingly important to monitor and regulate total fluoride exposure. Recent studies have reignited debate about the safety of systemic fluoride exposure during pregnancy and early childhood. Fluoride can cross the placenta and accumulate in fetal tissues, including brain regions critical to neurodevelopment.21 Breastfeeding, which naturally limits fluoride intake, may offer a protective effect. Although the strongest associations with reduced IQ have been observed at high fluoride concentrations (>1.5 mg/L),16 newer research from North America has reported subtle cognitive effects even at typical exposure levels (<1.5 mg/L).15 These effects, though modest and inconclusive, raise legitimate public health questions. Research has shown that certain factors may heighten vulnerability to fluoride-related neurotoxic effects. These include iodine cardiovascular deficiency during pregnancy, 22 biological sex differences,16 and specific genetic polymorphisms.23 The precautionary principle suggests we should minimize unnecessary fluoride exposure during sensitive developmental windows.

Ethical Considerations and Individual Autonomy

Water fluoridation remains a population-level intervention similar to adding iodine to salt or vitamin D to milk. Yet with mounting data on variable exposure, individualized risk ethical questions are gain-

ing traction. Respect for autonomy, transparency, public health messaging, and access to non-fluoridated options are becoming increasingly relevant. Fluoridation policies must be ethically justified not only by historic success but also by contemporary risk assessments.

The Impact of Ending Water Fluoridation: Insights From Real-World Experience

Several communities that have discontinued fluoridation provide natural experiments in public health outcomes, and the consequences are telling. When Calgary, Canada, ended fluoridation in 2011, cavity rates in children rose significantly within just a few years, outpacing those in neighboring Edmonton.24 Based on these outcomes, Calgary voted to reinstate fluoridation in 2024. In Juneau, Alaska, community water fluoridation ceased in 2007. A subsequent study reported a 67% increase in pediatric dental procedures.25 Yet despite these clear health costs, Juneau has not resumed fluoridation, illustrating how difficult policy reversals can be even in the face of strong evidence. Israel, which halted national fluoridation in 2014, has also seen a sharp increase in treatment needs among children.26 These cases reinforce a critical point: The value of community water fluoridation often becomes most apparent only after it is withdrawn, and reinstation becomes a difficult task. Transparent public education and community engagement are essential to prevent such costly missteps.

Recalibrating Fluoride—Balancing Benefits in a New Context

Fluoride should remain a cornerstone of caries prevention, offering well-documented benefits with broad accessibility. However, as fluoride is now encountered through multiple sources such as water, toothpaste, rinses, supplements, and certain

In populations with widespread access to topical fluoride, the cumulative exposure, particularly among children and other vulnerable groups, warrants careful monitoring. Moving forward, a refined strategy is needed that retains the protective benefits of fluoride while optimizing exposure levels to reflect modern usage patterns.

foods and beverages, it is time to reexamine our approach to systemic exposure and determine the optimal concentration and need for community water fluoridation. While community water fluoridation continues to be one of the most effective and equitable public health strategies, its implementation must be informed by current patterns of total fluoride intake. In populations with widespread access to topical fluoride, the cumulative exposure, particularly among children and other vulnerable groups, warrants careful monitoring. Moving forward, a refined strategy is needed that retains the

REFERENCES

protective benefits of fluoride while optimizing exposure levels to reflect modern usage patterns. This includes ongoing surveillance, evidence-based adjustments to recommended levels, and transparent communication with the public. By refining fluoride delivery in the context of contemporary lifestyles, policies can balance the protective benefits against the risk of cumulative exposure and possible neurodevelopmental effects. Fluoride policy must remain flexible, evidence-based, and responsive to emerging science, protecting the most vulnerable, while sustaining long-standing gains in oral health for all.

1. Williams LN. Spreading the word about community water fluoridation. Gen Dent. 2022;70(6):10-12.

2. The Challenge of Oral Disease—A Call for Global Action: The Oral Health Atlas. 2nd ed. FDI World Dent Fed; 2015:8-11. Accessed August 14, 2025. https://www.fdiworlddental.org/oral-health-atlas

3. Centers for Disease Control and Prevention. Fluoridation Statistics, 2022. Published June 6, 2024. Accessed August 14, 2025. https://www.cdc.gov/fluoridation/php/statistics/2022-water-fluoridation-statistics.html.

4. Do, LG, Cury, J A, James, P, Mossey, PA, Zohoori, FV, Fox, CH, Charles-Ayinde, MKS. Position statement on community water fluoridation. IADR June 16 2022. Accessed August 14, 2025. https://www.iadr.org/ science-policy/position-statement-community-water-fluoridation.

5. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2015;2015(6):CD010856. doi:10.1002/14651858.CD010856.pub2.

6. Hellwig E, Lennon AM. Systemic versus topical fluoride. Caries Res. 2004;38(3):258-262. doi:10.1159/000077764.

7. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131(7):887-899. doi:10.14219/jada.archive.2000.0307.

8. Aoun A, Darwiche F, Al Hayek S, Doumit J. The fluoride debate: The pros and cons of fluoridation. Prev Nutr Food Sci. 2018;23(3):171-180. doi:10.3746/pnf.2018.23.3.171

9. Boehmer TJ, Lesaja S, Espinoza L, Ladva CN. Community water fluoridation levels to promote effectiveness and safety in oral health—United States, 2016-2021. Morb Mortal Wkly Rep. 2023;72(22):593-596. doi:10.15585/mmwr.mm7222a1

21st-Century Dental Public Health: Revisiting the Role of Community Water Fluoridation

Larry Williams, DDS, MPH; Preetha Kanjirath, BDS, MS

10. Easley MW. The status of community water fluoridation in the United States. Public Health Rep 1990;105(4):348-353.

11. Centers for Disease Control (CDC). Knowledge of the purpose of community water fluoridation—United States, 1990. Morb Mortal Wkly Rep. 1992;41(49):919-927.

12. O’Connell J, Rockell J, Ouellet J, Tomar SL, Maas W. Costs and savings associated with community water fluoridation in the United States. Health Aff (Millwood). 2016;35(12):2224-2232. doi:10.1377/ hlthaff.2016.0881

13. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2015;2015(6):CD010856. doi:10.1002/14651858.CD010856.pub2

14. Choi AL, Sun G, Zhang Y, Grandjean P. Developmental fluoride neurotoxicity: A systematic review and meta-analysis. Environ Health Perspect. 2012;120(10):1362-1368. doi:10.1289/ehp.1104912

15. National Toxicology Program. NTP monograph on the state of the science concerning fluoride exposure and neurodevelopment and cognition: A systematic review. NTP Monogr. 2024;(8):NTP-MGRAPH-8. doi:10.22427/NTP-MGRAPH-8

16. Green R, Lanphear B, Hornung R, et al. Association between maternal fluoride exposure during pregnancy and IQ scores in offspring in Canada. JAMA Pediatr. 2019;173(10):940-948. doi:10.1001/jamapediatrics.2019.1729

17. Bashash M, Thomas D, Hu H, et al. Prenatal fluoride exposure and cognitive outcomes in children at 4 and 6-12 years of age in Mexico. Environ Health Perspect. 2017;125(9):097017. doi:10.1289/EHP655

18. Broadbent JM, Thomson WM, Ramrakha S, et al. Community water fluoridation and intelligence: Prospective study in New Zealand. Am J Public Health. 2015;105(1):72-76. doi:10.2105/AJPH.2013.301857

19. Taylor KW, Eftim SE, Sibrizzi CA, et al. Fluoride exposure and children’s IQ Scores: A systematic review and meta-analysis. JAMA Pediatr. 2025;179(3):282-292. doi:10.1001/jamapediatrics.2024.5542

20. Kumar JV, Moss ME, Liu H, Fisher-Owens S. Association between low fluoride exposure and children’s intelligence: A meta-analysis relevant to community water fluoridation. Public Health. 2023;219:73-84. doi:10.1016/j.puhe.2023.03.011n

21. Till C, Grandjean P, Martinez-Mier EA, Hu H, Lanphear B. Health risks and benefits of fluoride exposure during pregnancy and infancy. Annu Rev Public Health. 2025;46(1):253-274. doi:10.1146/annurev-publhealth-060722-023526

22. Goodman CV, Hall M, Green R, Chevrier J, Ayotte P, Martinez-Mier EA, McGuckin T, Krzeczkowski J, Flora D, Hornung R, Lanphear B, Till C. Iodine status modifies the association between fluoride exposure in pregnancy and preschool boys’ intelligence. Nutrients. 2022;14(14):2920. doi:10.3390/nu14142920. PMID: 35889877; PMCID: PMC9319869

23. Zhang S, Zhang X, Liu H, et al. Modifying effect of COMT gene polymorphism and a predictive role for proteomics analysis in children’s intelligence in endemic fluorosis area in Tianjin, China. Toxicol Sci 2015;144(2):238-245. doi:10.1093/toxsci/kfu311

24. Yazdanbakhsh E, Bohlouli B, Patterson S, Amin M. Community water fluoride cessation and rate of caries-related pediatric dental treatments under general anesthesia in Alberta, Canada. Can J Public Health 2024;115(2):305-314. doi:10.17269/s41997-024-00858-w

25. Meyer J, Margaritis V, Mendelsohn A. Consequences of community water fluoridation cessation for Medicaid-eligible children and adolescents in Juneau, Alaska. BMC Oral Health. 2018;18(1):215. doi:10.1186/ s12903-018-0684-2

26. Tobias G, Mordechai F, Tali C, et al. The effect of community water fluoridation cessation on children’s dental health: A national experience. Isr J Health Policy Res. 2022;11(1):4. doi:10.1186/s13584-02200514-z

Silent Signals: Human Trafficking and the Dental Professional’s Duty to Act

Pamela Zarkowski, JD, MPH, FACD Professor, Provost, and Vice President for Academic Affairs University of Detroit Mercy, Detroit

Human trafficking is a global public health and human rights crisis that includes forced labor and commercial sexual exploitation. Dental professionals are uniquely positioned to recognize signs of trafficking, as many victims encounter healthcare settings, including dental offices, during their exploitation. This article introduces the types and prevalence of trafficking, outlines legal and ethical responsibilities, and provides clinical red flags, case scenarios, and actionable strategies for screening and reporting. Myths that hinder detection are also addressed. By recognizing their ethical duty to protect vulnerable patients, dental professionals can become vital allies in the identification and support of trafficking survivors.

Keywords: human trafficking, dental Professionals, mandatory reporting, trauma-informed care, patient advocacy, child abuse

Silent Signals: Human Trafficking and the Dental Professional’s Duty to Act

Pamela Zarkowski, JD, MPH, FACD

Introduction

Human trafficking affects millions of individuals globally and is increasingly recognized as a critical public health and human rights concern. According to the International Labour Organization, an estimated 27.6 million people are in situations of forced labor or sexual exploitation at any given time worldwide, including 3.3 million children.1 While women and girls are disproportionately represented in sex trafficking, men and boys are also victimized, but often overlooked in public awareness and reporting.

Trafficking victims in the United States represent all racial and socioeconomic groups. US citizens and legal residents are common victims of sex trafficking, while labor trafficking often affects undocumented immigrants. Racial disparities are evident: White and Black individuals are frequently targeted for sex trafficking, whereas Asian and Hispanic populations are more often victims of labor exploitation. Children in foster care, people with disabilities, and survivors of prior abuse are at particular risk.2

Dental professionals may unknowingly encounter trafficking victims during clinical care. A landmark study found that 88% of survivors reported accessing healthcare during their exploitation, and 13% specifically saw a dentist.3 This underscores a critical opportunity for dental teams to recognize and respond to the signs of trafficking.

Understanding Human Trafficking

Human trafficking involves the use of force, fraud, or coercion to exploit people for labor or commercial sex. Common types include:

• Sex trafficking: Involves coercion or deception to exploit individuals for sexual purposes. In minors, any commercial sex act qualifies, regardless of force or coercion.

Common Myths About Human Trafficking

Myth #1: Trafficking always involves kidnapping or physical restraint.

Reality: Most trafficking involves psychological coercion, manipulation, or fraud, not abduction. Victims may appear to be moving freely but are controlled through fear, debt, threats, or emotional dependency.

Myth #2: Victims will ask for help if they need it.

Reality: Many victims do not self-identify or may be too fearful, ashamed, or traumatized to ask for help. Some may distrust authority figures or not realize they are being exploited.

Myth #3: Trafficking only happens in illegal or underground industries.

Reality: Victims may work in restaurants, construction, domestic care, agriculture, or even legal sex work industries. Trafficking can occur in both visible and hidden settings.

Myth #4: Human trafficking only affects foreign nationals or undocumented immigrants.

Reality: A large percentage of sex trafficking victims in the US are American citizens, including many involved in the foster care system or experiencing homelessness.

Myth #5: If someone chooses to stay, it must not be trafficking.

Reality: Victims may remain due to threats to their safety or their families, lack of resources, addiction, or fear of law enforcement. “Choice” is often a product of coercion.

Myth #6: All trafficking involves sex.

Reality: Labor trafficking is more prevalent globally than sex trafficking, affecting individuals in forced labor, domestic servitude, and agricultural work.

Myth #7: You need proof to report trafficking.

Reality: Suspicion or reasonable concern—especially involving minors—is enough to report. Health professionals are not investigators; they are mandated reporters and ethical advocates.

• Labor trafficking: Includes forced or unpaid work under threat, often in agriculture, construction, or domestic labor.

• Child trafficking: Exploitation of minors in any context—labor, sex, or illegal activity.

• Debt bondage: Involuntary labor used to repay manipulated or insurmountable debts.

• Involuntary servitude: Work performed under threat or coercion.

• Organ trafficking: Illegal harvesting or sale of human organs, often without consent.

While all healthcare professionals can play a role in identifying trafficking, dental professionals have a unique opportunity due to the frequency with which they may see patients for routine care.4,5

Mandated Reporting and Continuing Education Requirements

As of 2024, 17 US states require healthcare professionals to report suspected human trafficking.6 Nine states—Connecticut, Florida, Louisiana, Michigan, New Jersey, New York, Ohio, Texas, and Washington6—mandate continuing education on human trafficking for licensed health professionals. Federal law under the Child Abuse Prevention and Treatment Act (CAPTA) defines sex trafficking of minors as child abuse, making it a mandatory reportable offense in all 50 states when minors are involved.7

Dental professionals must be familiar with their state’s reporting requirements and licensure mandates. Beyond legal compliance, these mandates reflect growing recognition of the profession’s ethical responsibilities.

In Canada, dentists are not universally mandated to report suspected human trafficking unless the individual is a minor or deemed to be in immediate danger. Obligations include:

• Mandatory reporting of child abuse or neglect (varies slightly by province).

• Use of trauma-informed, culturally sensitive care to build trust with patients.

• Respect for patient autonomy and privacy, especially for adult patients.

• Documentation of concerns in a clinical, non-labeling manner.

• Referral or resource offering should only be done if it is safe for the patient.

Dental professionals are encouraged to stay informed through provincial regulatory bodies and continuing education on human trafficking and vulnerable populations.

Who Is at Risk?

While anyone can become a trafficking victim, certain groups are at greater risk:2

• Minors, especially those in foster care or with histories of trauma.

• Women and girls, particularly in marginalized communities.

• Immigrants, especially undocumented individuals.

• People with disabilities or untreated mental illness.

• People experiencing homelessness or poverty.

• LGBTQ+ youth, who may be disproportionately targeted.

• Victims of prior abuse, including sexual assault.

• Individuals living in high-crime or resource-poor areas.

Silent Signals: Human Trafficking and the Dental Professional’s Duty to Act

Pamela Zarkowski, JD, MPH, FACD

Children in foster care are especially vulnerable, with many traffickers targeting group homes or shelters. Studies estimate that over half of trafficking survivors had prior involvement in the child welfare system.2 See Table I for an overview of the demographics of trafficking in the US and Canada.

Recognizing Red Flags in the Dental Setting

Dental professionals may observe physical, behavioral, or contextual clues suggesting trafficking. Common red flags include:8

• A controlling adult answers all questions and refuses to leave the operatory.

• The patient lacks identification, insurance, or personal documentation.

• Signs of untreated decay, trauma, malnutrition, or poor hygiene.

• Tattoos that resemble barcodes, names, or branding symbols, especially in minors.

• Inconsistent or rehearsed personal histories.

• Fearful, withdrawn, or overly submissive behavior.

• Patients express uncertainty about where they are or whom they are with.

• Discrepancies between reported age and appearance.

These signs may be subtle. Trust your clinical instincts—if something feels “off,” it warrants attention.

Clinical Scenarios

Recognizing potential trafficking requires more than a checklist. It calls for context, observation, and professional judgment. The following clinical scenarios illustrate how red flags may present in real dental settings. Each case includes a brief

discussion highlighting behavioral, physical, and

What to Do if You Suspect Trafficking

DO:

• Observe and document signs

• Attempt a private conversation

• Call the National Hotline: 1-888-373-7888

• Report suspected child trafficking immediately

• Post hotline resources in patient areas

DO NOT:

• Confront suspected traffickers directly

• Promise confidentiality you cannot guarantee

• Wait for proof before reporting

contextual indicators that may suggest trafficking, as well as reinforcing appropriate responses.

Scenario 1: The Silent Teen

A 15-year-old boy presents with dental trauma. A woman claiming to be his aunt dominates the conversation, stating, “He needs to be done quickly—he has to work tonight.” The boy avoids eye contact and seems disoriented.

Discussion: A minor accompanied by a non-guardian, fearful behavior, and comments about “working” raise immediate red flags for labor or sex trafficking. This situation must be reported under mandatory child abuse laws.

Scenario 2: No ID, No Questions

A young adult woman arrives with an older man who fills out all the paperwork. She avoids eye contact, has multiple untreated carious lesions, and bruises on her arms. The man refuses to let her be alone.

Discussion: Physical signs of neglect and injury, behavioral control, and lack of documentation suggest trafficking. If the patient is an adult, the team should call the National Human Trafficking Hotline for guidance on next steps.

Table 1: Overview of Demographics of Human Trafficking in the US and Canada

Demographic

Group

Women and Girls

Men and Boys

Children (<18)

LGBTQ+ Youth

Racialized Groups

TABLE 1 REFERENCES

77% of all trafficking victims are women and girls; within sex trafficking, 78% are women and girls.1,2

23% of all victims are men and boys; in forced labor, 67% are men/boys.2

8% of sex trafficking victims are children; within forced labor, 27% are children.2

No national quantitative data: LGBTQ youth are at higher risk for trafficking and exploitation.6

Black girls face disproportionately higher risk for sex trafficking due to systemic inequalities.7

96% of detected victims are women and girls (2010-2020); ~90% under 35.3,4

4%-6% of detected victims are men and boys; 5.6% overall (2012-2022).5

25% of victims were under 18 (2010-2020); 24% under age 18 in 2021.3,5

No national data; recognized as elevated risk for trafficking, including LGBTQ2 persons.4

Indigenous women and girls are overrepresented among victims and identified as an at-risk group.4

1. Government of Canada. Who Does Human Trafficking affect? Public Safety Canada. Accessed August 10, 2025. https://www.canada.ca/en/public-safety-canada/campaigns/human-trafficking/whta.html

2. U.S. Department of Homeland Security. Human Trafficking: Quick Facts Accessed August 10, 2025. https://www.dhs.gov/human-trafficking-quick-facts

3. Conroy, S, Sutton, D. Statistics Canada. Canadian Centre for Justice and Community Safety Statistics. Trafficking in Persons in Canada, 2020. Juristat, Catalogue no. 85-002-X. Accessed August 10, 2025. https://www150.statcan.gc.ca/n1/pub/85-002-x/2022001/article/00010-eng.htm

4. Public Safety Canada. Briefing Binder—Parliamentary Committee Notes: Human Trafficking and Indigenous Populations. Accessed August 10, 2025 https://www.publicsafety.gc.ca/cnt/trnsprnc/brfng-mtrls/prlmntry-bndrs/20241001/11-en.aspx.

5. Heidinger, L. Statistics Canada. Trafficking in persons in Canada, 2022. Juristat Bulletin—Quick Fact, Catalogue no. 85-005-X. Accessed August 10, 2025. https://www150.statcan.gc.ca/n1/pub/85005-x/2023001/article/00002-eng.htm.

6. Polaris Project. Myths, Facts, and Statistics. Accessed August 10, 2025. https://polarisproject.org/ myths-facts-and-statistics.

7. Davey, S. Congressional Black Caucus Foundation. Black Women and Girls, Sex Trafficking in the U.S. Accessed August 10, 2025. https://www.cbcfinc.org/wp-content/uploads/2020/05/SexTraffickingReport3.pdf

Silent Signals: Human Trafficking and the Dental Professional’s Duty to Act

Pamela Zarkowski, JD, MPH, FACD

Questions to Ask if You Suspect Human Trafficking in a Dental Setting

If a patient shows red flags for trafficking and you can speak to them privately and safely, consider asking open-ended, nonjudgmental questions to build trust and assess risk. Use a calm tone, ensure confidentiality, and avoid pressuring them to disclose.

General Questions

• “Are you safe where you’re staying?”

• “Do you feel free to come and go as you please?”

• “Is anyone controlling your decisions or keeping your ID or documents?”

Work/Personal Life

• “Are you working? Can you tell me about it?”

• “Do you owe anyone money for helping you get here or for where you live?”

• “Has anyone ever forced you to do something you didn’t want to do for work or money?”

Travel/Control

• “Can you leave your home or job if you want to?”

• “Has anyone hurt or threatened you or someone you care about?”

• “Has anyone ever made you feel you couldn’t say no?”

Health/Dental Concerns

• “Has anyone prevented you from getting medical or dental care?”

• “Have you ever been injured and not allowed to seek treatment?”

Note: These questions should only be asked if the patient is alone. Never screen in the presence of someone who may be controlling them. Document concerns professionally and follow your state’s reporting laws for suspected trafficking.

Scenario 3: The “Niece”

A woman brings a teenager in for a cleaning. The girl hesitates when stating her name and avoids speaking. The adult refers to her alternately as her niece and “just someone I’m helping.”

Discussion: Inconsistent relationships, conflicting identity information, and visible discomfort suggest a trafficking situation. Attempt to speak with the patient privately and consult the hotline or social services.

Scenario 4: Tattoo Clues

A withdrawn young woman presents with dental pain. While taking X-rays, the hygienist notices a tattoo resembling a barcode on the patient’s neck and a man’s name on her wrist. She says little but winces when her companion speaks sharply to her.

Discussion: Tattoos may be identifiers of trafficking. Combined with behavioral indicators and a controlling companion, this situation warrants concern.

Responding Safely: What Dental Professionals Can Do

If trafficking is suspected:

1. Do not confront the suspected trafficker in the moment—this may endanger the victim.

2. Separate the patient from companions, if safely possible, and offer a private conversation.

3. Call the National Human Trafficking Hotline (1-888-373-7888) for confidential advice.9

4. Contact local law enforcement or child protection services if the patient is a minor or in immediate danger.

5. Document findings carefully, noting observations rather than assumptions.

6. Post hotline information discreetly, including in restrooms or exam areas.

7. Report to the appropriate authorities, following your state’s laws.

Ethical Responsibilities of the Dental Professional

Legal compliance is only part of the dental professional’s responsibility. The American Dental Association’s Principles of Ethics and Code of Professional Conduct10 call upon dentists to:

• Do no harm (Nonmaleficence): Protect patients from further injury or exploitation.

• Act for the benefit of others (Beneficence): Support vulnerable individuals and promote their well-being.

Resources for Responding to Human Trafficking

Human Trafficking Resources for Healthcare Providers

• National Human Trafficking Hotline 1-888-373-7888 (24/7, confidential, multilingual)

Text: 233733 (“BEFREE”) Website: https://humantraffickinghotline.org

• SOAR for Healthcare Providers (US HHS) Free training for healthcare professionals on trauma-informed response https://nhttac.acf.hhs.gov/soar

• Polaris Project

Leading anti-trafficking organization with training materials, data, and victim services https://polarisproject.org

• University of Michigan Human Trafficking Collaborative Comprehensive resource for state-specific laws, continuing education mandates, and best practices for healthcare providers https://humantrafficking.umich.edu

• State Reporting Requirements

National Conference of State Legislatures— Human Trafficking Reporting Laws https://www.ncsl.org

• Continuing Education

Check with your state dental board for required CE on human trafficking awareness and reporting obligations.

Resources for Canadian Dental Professionals

• Canadian Human Trafficking Hotline: 1-833-900-1010 www.canadianhumantraffickinghotline.ca

• Canadian Centre to End Human Trafficking: www.canadiancentretoendhumantrafficking.ca

• National Collaborating Centre for Indigenous Health (Trauma-informed care resources): https://www.nccih.ca

Silent

Pamela Zarkowski, JD, MPH, FACD

Checklist: Next Steps for Dental Offices

Suspecting Human Trafficking

When indicators of trafficking are observed, dental professionals should respond in a traumainformed, ethical, and legally compliant manner. Use the checklist below to guide next steps:

1. Ensure Immediate Safety (if applicable)

Determine if there is an urgent medical or safety emergency.

If immediate danger is present, call 911.

Do not confront the suspected trafficker or alert them to your concerns.

2. Attempt Private Interaction with the Patient

If safe, discreetly request to speak with the patient alone (eg, for X-rays or medical history).

Use nonjudgmental, open-ended questions:

• “Are you safe?”

• “Do you feel free to come and go as you wish?”

• “Is someone hurting or controlling you?”

3. Use a Trauma-Informed Approach

Speak calmly and respectfully; avoid pressuring for disclosures.

Do not ask for detailed accounts of abuse or trafficking.

Respect the patient’s pace and personal boundaries.

4. Document Observations Carefully

Record clinical and behavioral indicators (eg, injuries, demeanor, statements).

Avoid labeling the patient as a “victim” or “trafficked” in records.

Keep notes factual and objective.

5. Know and Follow Mandatory Reporting Laws

If the patient is a minor, report suspected abuse or neglect immediately to child protective services (US and Canada).

In the US, follow your state’s specific reporting requirements.

In Canada, reporting is mandatory for minors; adult reporting requirements vary by province/territory.

6. Offer Resources Privately (if safe)

Provide hotline numbers or discreet printed materials.

Use small cards or pamphlets with contact information for local services.

Do not attempt to “rescue” the patient yourself.

7. Consult Within the Office

Alert designated staff (eg, dentist, compliance officer).

Limit sharing of details to protect= confidentiality.

8. Consider External Consultation

Call for advice or to make a report—anonymously if needed:

• US National Human Trafficking Hotline: 1-888-373-7888 or text “HELP” to 233733

• Canadian Human Trafficking Hotline: 1-833-900-1010

Contact your dental board or licensing authority for guidance.

• Promote justice and fairness (Justice): Treat all patients equitably, regardless of background.

• Respect autonomy: When safe, empower patients to share their story or accept help.

The American College of Dentists11 similarly emphasizes advocacy, compassion, and public responsibility as core values and professional obligations. Failing to act when trafficking is suspected may violate both the ethical and humanitarian obligations of the profession.

REFERENCES

Conclusion

Human trafficking is a hidden crisis, often occurring in plain sight. Dental professionals may be among the few trusted individuals with the opportunity to intervene. With heightened awareness, training, and ethical commitment, dentists can play a critical role in identifying and responding to trafficking, offering hope and safety to those most in need.

1. International Labour Organization. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. Published 2022. Accessed August 12, 2025. https://www.ilo.org/publications/major-publications/ global-estimates-modern-slavery-forced-labour-and-forced-marriage.

2. US Department of Health and Human Services, Administration for Children and Families. Child Welfare and Human Trafficking Report. ACF; 2023. Accessed August 13, 2025. https://acf.gov/.

3. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in health care facilities. Ann Health Law. 2014;23(1):61-91.

4. Greenbaum VJ, Dodd M, McCracken C. A short screening tool to identify victims of child sex trafficking in the health care setting. Pediatr Emerg Care. 2018;34(1):33-37. doi:10.1097/PEC.0000000000000602

5. Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49.

6. National Conference of State Legislatures. NCLS Human Trafficking State Laws. Accessed August 13, 2025. https://www.ncsl.org/civil-and-criminal-justice/human-trafficking-state-laws.

7. Administration for Children and Families. The Child Abuse Prevention and Treatment Act (CAPTA). U.S. Department of Health & Human Services. Accessed August 13, 2025. https://acf.gov/cb/law-regulation/ child-abuse-prevention-and-treatment-act-capta.

8. Michigan Department of Attorney General. Human Trafficking: Red Flags for Healthcare Professionals. Published 2025. Accessed August 14, 2025. https://www.michigan.gov/ag/initiatives/human-trafficking.

9. Polaris Project. National Human Trafficking Hotline Statistics. Published 2024. Accessed August 12, 2025. https://polarisproject.org/2019-us-national-human-trafficking-hotline-statistics/.

10. American Dental Association. Principles of Ethics and Code of Professional Conduct. American Dental Association; 2018. Accessed August 12, 2025. https://www.ada.org/about/principles/code-of-ethics.

11. American College of Dentists. Ethics Handbook for Dentistry: An Introduction to Ethics, Professionalism, and Ethical Decision-Making. 4th ed. American College of Dentists; 2024. Accessed August 12, 2025. https://www.acd.org/communications/ethics-handbook/.

Taking the Temperature: What the ACD 2025 Survey Reveals

Mike Graham, Executive Director

Suzan Pitman, Program Director

The American College of Dentists surveyed its Fellows to help leadership better understand how our Fellows perceive and interact with the College. The results will be used to determine organizational priorities and help guide the continued implementation of the strategic plan. The key takeaways of the survey were that (1) the 2023 Strategic Plan implementation is on the right track, (2) Fellows value their connection to the ACD, (3) communication between the organization and Fellows has improved, and (4) leadership and staff must continue to develop a better-defined knowledge base to support local leaders.

Keywords: leadership, survey, strategic plan, communication, fellowship

Background

In 2023, the Board of Regents, section leaders, and friends of the College worked together to create the ACD’s first strategic plan in more than two decades. In the spring of 2024, a work plan was developed for implementing the strategic plan, which included a survey of the Fellowship.

The survey, which was conducted electronically in April 2025, was intended to help leadership better understand how our Fellows perceive and interact with the ACD. The results will be used to determine organizational priorities and help guide the continued implementation of the strategic plan.

About the Survey and the Respondents

The survey contained 51 questions, with some questions depending on how the prior question was answered. Open-ended questions served

Respondents

as a gauge for how the Fellows viewed the College and its direction. The survey was completely anonymous, and although the results were captured in the College’s database, no personal information, such as usernames or member ID numbers, was recorded. The Fellows had complete anonymity to answer as they wished.

Though most Fellows are Life Fellows (over 70), Active Fellows (under 70) made up the majority of the respondents. Although logging in to take the survey was eliminated to keep it truly anonymous, comfort with technology could be one reason for the lack of participation among Life Fellows. Anecdotally, the office staff hears from Life Fellows who often feel disengaged from the dental profession the further they are from their active careers. Proactively engaging Life Fellows who may wish to share their experiences would benefit all aspects of the College’s work, especially as that segment of membership continues to grow.

Taking the Temperature: What the ACD 2025 Survey Reveals

Mike Graham; Suzan Pitman

About the Survey

Questions were grouped into four major subtopics: (1) leadership, (2) publications and communications, (3) the value of Fellowship, and (4) perception of the strategic plan goals.

1. Leadership: Fellows were asked about leadership positions they have held or would like to hold in the College: if they aspired to those roles, if they were encouraged to take on a leadership role, or if they were thrust into leadership because no one else in their Section or Regency would do so.

• 29 of 567 respondents said they aspired to Section Leadership and had the opportunity to respond to an open-ended follow-up question.

• 102 of 567 respondents said they were currently serving or had served as a Section leader.

• 25 of those who said they were current or former Section leaders reported they viewed Section leadership as an aspiration and actively sought a position.

Both sets of respondents were asked, “What might ACD leadership do to encourage Section involvement and local leadership?” Responses, regardless of position(s) held, fell into three distinct categories:

Knowledge

Notable and repeated sentiment: Better-defined responsibilities and a succinct explanation of what ACD leadership involves are prioritie

Belonging

Notable and repeated sentiment: Better outreach is needed to create leaders. There

is an opportunity to extend a more direct invitation to lead.

Several comments indicated frustration with cliquishness in some Sections. This suggests an opportunity to pitch a bigger tent, welcoming more Fellows to participate actively in Section activities.

Time

Notable and repeated sentiment: More time of all kinds must be allocated to ACD leadership. Processes must be simplified to claw back time from administrative tasks, and more meaningful time together must be established.

To encourage leadership development, current ACD leaders at all levels must actively invite and develop promising leaders within the College. The ACD has established several leadership development programs to support this need.

Sharing knowledge is one way to build a sense of belonging and combat cliquishness. The College has expanded and improved its information sharing and communications, but sharing information is not the same as building a body of shared knowledge. Implementing programs that give Fellows common touchpoints, such as the SHIFT Leadership Program and the Section Focus Initiative, will help move from information sharing to knowledge building.

Notable Comments:

“Provide short explanations of what is involved in serving in ACD leadership may be helpful. Sometimes, it takes those in leadership to just reach out and ‘ask someone.’ Many, I believe, have the desire to serve, but may need to be asked or encouraged.”

“We meet only once a year at a breakfast meeting at our annual session. More frequent meetings may help with engagement.”

“For an older member, it [social media] is of no value. For the future of the College, it is invaluable. Dental organizations ignore social media at their peril. Want to spin up your social media? Do not hire a middle-aged vendor-expert. Enlist young members, then get out of their way.”

2. Publications and Communications: Fellows were asked about their readership of the Journal of the American College of Dentists and the ACD News , as well as their habits regarding visiting the ACD websites and social media accounts.

Both the Journal of the American College of Dentists and the ACD News mainly received favorable responses and comments. The JACD is considered an outward-facing publication, and the ACD News is regarded as an inward-facing publication.

Additionally, the Journal will soon be indexed on ADA Commons, making it more accessible to those outside the ACD. The entire JACD catalog, dating back to its inception in 1934, is currently available at no charge to anyone wishing to read it, but it is only housed on the ACD website and not indexed more broadly.

Email blasts and social media: The ACD has a presence on Facebook, Instagram, LinkedIn, and YouTube. Eighty percent of respondents reported either not following the ACD on social media or not engaging with social media at all. Analytics indicate that the College’s social media followership is growing steadily, although no single platform has more than 2,000 “followers.”

The open rate of the ACD’s email blasts to the Fellowship is usually higher than 50%, and comments about the emails were favorable. It is acknowledged that because the survey was only sent through email, the respondents likely had a higher rate of engagement with ACD emails than the average.

Notable Comments:

Most respondents noted that they either did not follow the ACD on social media or did not engage with social media at all. Several respondents also indicated that it was important whether they participated or not.

“For an older member, it [social media] is of no value. For the future of the College, it is invaluable. Dental organizations ignore social media at their peril. Want to spin up your social media? Do not hire a middle-aged vendor-expert. Enlist young members, then get out of their way.”

Comments about the ACD News and JACD tended to be favorable, with a notable number of respondents wanting the publications in print format.

“I realize that we are in a totally digital age, but I liked the ‘old’ hard copy ACD News (same for the Journal). I’m not suggesting we go back to that, but that is my preference.”

Taking the Temperature: What the ACD 2025 Survey Reveals

Mike Graham; Suzan Pitman

Of the 415 respondents who reported valuing their Fellowship, 284 (68%) also reported nominating at least one colleague for Fellowship, and most reported feeling that their professional reputation was enhanced by their Fellowship in the College.

3. The Value of Fellowship (in response to the prompt “I value my Fellowship”):

Respondents

I feel the same about my Fellowship in the ACD as I do about my other professional memberships.

capacity, whether sponsoring an ethics course or encouraging others to put up someone for a fellowship.”

4. Perceptions of the Strategic Plan Goals

Of the 415 respondents who reported valuing their Fellowship, 284 (68%) also reported nominating at least one colleague for Fellowship, and most reported feeling that their professional reputation was enhanced by their Fellowship in the College. Comments from individuals who valued ACD Fellowship as much as their memberships in other organizations primarily focused on the organization’s relevance, lack of external visibility, and opaque nomination process. One respondent offered a sentiment expressed by others:

“We are working on being the experts on ethics, and we need to keep promoting that in our national meetings and state meetings. We probably need a presence at these meetings in some

Overall, respondents viewed the ACD’s work on the strategic plan goals as adequate to favorable. Respondents noted that Fellows may be aware of the ACD’s activities, but the ACD remains relatively unknown outside the Fellowship. This indicates that the College’s efforts to reach out beyond the Fellowship to other groups such as the National Dental Association (NDA), the Society of American Indian Dentists (SAID), and Section involvement with dental schools, while positive and worth continuing, are not enough to combat the relative obscurity in which the College operates. (See chart on next page)

Summary

Within its first year, the implementation of the strategic plan appears to be working, as the Fellowship has noticed improvements in many areas. That said, two key areas need to continue to improve: communications regarding ethics and professionalism, both within the College and throughout dentistry, as well as improvements in developing Section leadership and activities that enhance engagement with Section Fellows.

The American College of Dentists currently upholds its leadership position as an expert on ethics and professionalism as oral health is more broadly recognized as a vital part of overall health and wellness.

The ACD recognizes and engages the most talented and diverse emerging leaders in dentistry.

The ACD invests in continuous creation of ACD-branded professional development courses and materials on ethics and, separately, on leadership best practices.

The ACD has successfully expanded and enhanced our communications to advance the ACD Pillars—ethics, professionalism, leadership, and excellence—with members of the oral health delivery team.

The ACD creates, maintains, and fosters interprofessional relationships with other healthcare professional organizations.

The ACD continues to support an organizational leadership and governance structure that is diverse, including, but not limited to, age, gender, race, ethnicity, and socioeconomic status.

Perceptions of the Strategic Plan Goals Chart

OZAR-HASEGAWA STUDENT

ETHICS AWARD WINNER 2025

Ethical Dilemma in Dentistry: A Young Dentist’s Challenge –Upholding the Social Contract in a Profit-Driven System

Kamyar Sartipi, BS, DDS (Class of 2025)

Schulich School of Medicine & Dentistry

with advisor Dr. Drew Smith, and program director Dr. Carlos Quiñonez

The weight of my white coat felt different that day. As I joined my classmates, reciting the oath led by our academic and professional leaders, I knew I was stepping into a profession rooted in trust, service and care. As the White Coat Ceremony’s cornerstone, the recitation of the Oath of Commitment serves as a powerful moment that ties us to the profession’s values of professionalism, ethics, and service. Looking back, I realize that I learned what it truly meant to be a professional during my childhood. My journey in dentistry began far from private practices that populate my adopted home, Canada. In the cliffside villages of Kurdistan, Iran—where houses of soil and cob dotted the landscape—I witnessed dentistry in its purest form. There, watching my father perform intricate procedures on villagers who had never seen a dentist, I learned my first lesson: before any treatment, before any procedure, trust must be established.

Pictured

“I will always uphold the ethical standards of this honourable profession and behave with honour and decency”

(Royal College of Dental Surgeons of Ontario, 2024)

For many, this was their first exposure to dentistry, and with that unfamiliarity came fear. Day after day, I watched as exhaustion set in, yet my father continued, patient after patient. I wondered: what compelled him to work so tirelessly, with no expectation of pay? The answer came not in words, but in the villagers’ parting gesture. As we packed to leave, they brought us freshly made naan—a gift born from a month’s labor. Yet the ultimate reward was in their faces.

Where once there had been uncertainty and fear, there were now grateful smiles. The transformation was profound. In that moment, I understood that dentistry was not just about treating teeth, but about altruism, ethical obligation, and service. More importantly, I learned the true meaning of professionalism—not just in competence, skill or knowledge, but also in dedication to public service, selflessness, and the ability to inspire trust in those who need it most (American College of Dentists, 2022, p. 5). These experiences reinforced for me what it truly means to be a healthcare professional: to use our knowledge, competence, and ethical judgment with the primary goal of serving patients, not pursuing prestige or profit (ACD, 2022, p. 5). This means respecting our patients’ personal health decisions, prioritizing their wellbeing, and maintaining their trust—rather than pushing for treatments just to fund our next Rolex. Our obligation to professionalism and our responsibilities as healthcare professionals are further outlined in what is known as the “social contract” of dentistry. As an exchange of respect, trust and the ability to self-regulate, along with financial rewards provided to the professional, we vow to be competent, ethical, compassionate, knowledgeable, and most importantly, to be of service (Benn, 2003). Although explicitly outlined in legislation, codes of ethics and licensing mandates (Nash, 2015), the social contract remains a predominately implicit agreement between the two parties (Moeller & Quiñonez, 2020).

Throughout dental school, these principles of altruism, trust and professionalism were routinely discussed and tested, painting an idealistic picture of the profession. But now, as my graduation looms, these values are increasingly eclipsed by uncertainty. An uncertainty driven by the struggle to balance my core ethical values as a professional with financial pressures and the growing commodification of dentistry—forces that have eroded our adherence to the social contract and public trust (Moeller & Quiñonez, 2020)

Dualism of Dentistry

In North America, dentistry has evolved in a way that isolated itself from the rest of the healthcare system (12). Many experts agree that the current model of our profession aligns more with a business approach, prioritizing profitability, competition, and the commodification of care, rather than focusing on patient well-being and ethical practice (Dharamsi et al., 2007; Nash, 2015). These principles are incongruent with the profession’s values of cooperation, altruism, and service (Nash, 2007), as implicitly outlined in the social contract.

The pledge that I made during my ceremony –“I will always uphold the ethical standards of this honourable profession and behave with honour and decency” (Royal College of Dental Surgeons of Ontario, 2024) – the core ethical foundation upon which I intended to base my practice on, is increasingly being pushed aside. With rising financial pressures, corporatization, and commodification, I fear that I may struggle to balance my responsibilities as a healthcare professional while navigating the duality of our profession.

What happens when the principles we swore to uphold—non-maleficence, autonomy, beneficence and veracity—collide with the economic forces driving modern dentistry? And most importantly, what can we do to preserve the integrity of our profession?

Ethical Dilemma in Dentistry: A Young Dentist’s Challenge— Upholding the Social Contract in a Profit-Driven System

Kamyar Sartipi, BS, DDS (Class of 2025)

Financial Pressures

As a fourth-year dental student, the only thing that terrifies me more than a perforation during a root-canal, is opening my monthly bank statement. Dental education is expensive, the costliest of all professional programs (Statistics Canada, 2022).

The average 2022 dental graduate starts practice with nearly $300,000 in debt—over 35% more than a decade ago (American Dental Association, n.d.). Adding an undergraduate degree brings the total to $340,000 (Brar, 2024).

As a soon-to-be dentist, finding a way to tackle these financial pressures has become a daily concern, and I often find myself prioritizing associateships that offer the highest pay, regardless of other factors. I’m not alone—my peers and I spend more time comparing our potential paychecks than discussing associateships that offer mentorship, match our personalities, spark our passion for dentistry, or, you know… put patient care first! Meaning, there now exists this shift towards a “profit-first” mindset for the young dentist as they are pressured to pursue more commodified and commercialized landscapes to escape of their debt (Brar, 2024).

Corporate Dentistry

The economic realities of dentistry and the challenges of maintaining ethical practice are not only felt by students like me. The current economic landscape of dentistry is challenging for all, with seasoned dentists also facing similar ethical dilemmas, such as balancing patient autonomy, with the need to sustain an economically viable practice (Strom, 2023). An emerging solution has been the corporate dental practice model, which has been on the rise since the beginning of the 21st century (O’Selmo, Collin, & Whitehead, 2018), with corporate dental chains now owning nearly 25% of practices in the United States (ADA, 2023). From attending glitzy corporate-hosted conferences and networking events, to my dental school’s lounge being corporate-sponsored, the dominance of corporate dentistry was undeniable, painting it as

the promised land. And honestly, with my student debt looming over me like a perio probe reading of 9mm, the temptation was real. However, through various discussions with my mentors and a review of the literature, I became aware that while the corporate model offers a potential solution to our economic pressures, it also presents a significant implication: the primary responsibility of a corporate practice model is to maximize returns to shareholders (i.e., profits), whereas the core duty of a dentist, in any practice model, is to prioritize the best interests of their patients (Holden et al., 2021). As a result, corporate practices often place less value on the patientdentist relationship, possibly reducing both clinician and patient autonomy in the treatment planning process, promote overtreatment and reframe patients as paying customers rather than individuals experiencing dental disease (Holden, 2018; Holden et al., 2021). It’s important to recognize that, just as every dentist is unique, corporate models vary as well, each with its own pros and cons and perhaps not all prioritize profit over care. (Strom, 2023). For instance, some corporate models were found to address the issue of access to care by offering lower service costs and providing a more supportive environment for new graduates (Holden et al., 2021). The corporate model has also found a way of delivering oral care in a more efficient, predictable, calculable and controlled way (Holden et al., 2021), which has lifted many of the economic pressures of the private practice model (Strom, 2023). Furthermore, many independent, dentistowned practices can also prioritize profits, bringing out the same concerns as the corporate model (Holden et al., 2021).

Adding to the challenge, the ever increasing trend of cosmetic demands and the commodification of care that came with the increasing trends of competition may make upholding our ethical values and social contract more difficult (Khalid & Quiñonez, 2015). It is important to highlight that cosmetic dentistry, when truly beneficial, can significantly improve a patient’s self-esteem and quality of life and is an essential part of patient service. I wit-

nessed the profound impact of this in my third year, when I closed the diastema of a patient who had long been afraid to smile, replenishing a sense of confidence they had locked away. However, these lines begin to blur as rising competition and financial pressures have driven deceptive marketing practices, both within the private and corporate model, that focus solely on aesthetics and profit, persuading patients to undergo unnecessary cosmetic procedures without a thorough discussion of the associated risks and benefits, all in the pursuit of maximizing profit (Abbasi et al., 2022; Atiyeh et al., 2020; Kovács, 2024). Furthermore, these practices, which are primarily financially motivated, may foster a hypercompetitive environment where collaboration among clinicians to deliver care is undermined (Yu et al., 2020). This directly contradicts the ethical premise of collaboration in delivering oral care, a principle firmly advocated by the ADA (Horne, 1866).

As my fellow classmates and I are faced with these challenges, there is an undeniable temptation to favor the commercialized landscape of dentistry. This shift towards the profit-driven ethos carries several implications for us soon-to-be dentists, including a greater tendency to perform more aggressive—and sometimes unnecessary—treatments as debt levels rise , as well as decreased participation in research, public and academic dentistry (McAllister et al., 2015). As fewer of us pursue faculty and research opportunities, intergenerational knowledge transfer—whether months, years, or decades later—wanes (ACD, 2022, p. 2). This is particularly concerning, as research and the continuous exchange of knowledge are essential for advancing dentistry and enhancing patient care (Brar, 2024; ACD, 2022, p. 2). Another unfortunate consequence of this paradigmatic shift is that the commodification of dentistry disproportionately benefits those with better access to care (Dharamsi et al., 2007), and the financial means to afford it (Moeller & Quiñonez, 2020), while oral health problems continue to disproportionately impact the less privileged (Muirhead et al., 2009).

Ultimately, the interplay between rising financial pressures, corporatization, commodification and adoption of the “profit-first” mindset may compromise our social contract, as the best interest of the patient is no longer prioritized (Holden et al., 2021; Kovács, 2024). Through overtreatment and deceit, we not only undermine the principles of autonomy and nonmaleficence, but also risk eroding the trust that forms the foundation of our profession (Rostamzadeh & Rahimi, 2025). Furthermore, if we continue to disregard the needs of the most vulnerable by providing them with inequitable care, we risk losing our trust and designation as professionals (Moeller & Quiñonez, 2020). Thus, as these trends continue, it may become increasingly more difficult to uphold our side of the social contract, which may ultimately lead to dentistry losing its designation as a profession (Beemsterboer, 2006) and instead as an economic good and a business (Holden, 2016; Moeller & Quiñonez, 2020). Indeed, these trends have had lasting effects on the profession, with dentistry being increasingly viewed as a hybrid commercial/health service with decreasing levels of public trust and value in the profession (Canadian Dental Association, 2010). Moreover, our professions’ monopoly has been under erosion as procedures historically reserved for dentists are now performed by others. For instance, to address the often-overlooked issue of underserved communities, the practice of dental therapy has emerged and is publicly recognized as a positive, cost-effective solution (Yang et al., 2017).

These realities make me feel as though I am stepping into quicksand as I start my career, and I truly fear that I may be enticed in becoming a complicit in the problem. Yet, while these challenges are deeply entrenched, they are not insurmountable. Restoring ethical integrity and reinforcing our designation as a healthcare profession requires a multifaceted approach that addresses education, regulation, practice accountability and systemic support. By implementing targeted reforms, we can maintain our foundational commitment to stewardship, collaboration and patient-service.

Ethical Dilemma

in Dentistry: A

Young Dentist’s Challenge— Upholding the Social Contract in a Profit-Driven System

Kamyar Sartipi, BS, DDS (Class of 2025)

Reinforcing Ethical Training in Dental Education

The American College of Dentists underscores the importance of lifelong ethical training to continuously refine ethical reasoning skills to navigate the evolving landscape of practice (ACD 2022, p. 13). Throughout dental school, however, such learning opportunities in the curriculum were few, purely theoretical and increasingly waned as I approached my final year. This finding is also evident in the curriculum of other North American dental schools (Lantz et al., 2011), which may explain why dental students become increasingly more cynical about dentistry’s ethical practice as they approach their final year (Brands et al., 2011). Furthermore, student moral skills can be inversely related to attending a formal ethics course, which may indicate their lack of effectiveness in dental education, showcasing that current approaches to ethical education are too theoretical and lack practicality for clinical practice (Mosavi et al., 2025)

I argue, as ethical competency is an integral part of dental training (Lantz et al., 2011; Maart et al., 2021) and one of the biggest issues in dental education (Connolly, 2020), for the implementation of longitudinal, case-based opportunities for ethical learning, as they have been shown to enhance moral reasoning and ethical competence (Ogles et al., 2024). We can also create a framework where the different attributes of professionalism—such as integrity, patientcentered care, and respect—are used to analyze these cases, developing a decision-making model that helps students navigate complex ethical dilemmas in a real-world context. At the beginning of the year, my colleagues and I were exposed to a PBS Frontline series program called “Dollars and Dentists,” which showcased how a corporate chain repeatedly pushed for unnecessary treatments for pediatric patients to take advantage of more attractive Medicaid reimbursements (Rosenbaum, 2012). We could identify the theoretical ethical principles violated, such as non-maleficence, but we were unable to come up with a practical solution to prevent or rectify such

situations if they occurred in our professional careers. Now, by using a professionalism framework, the principle of being primarily concerned with “service, not prestige or profit” (ADA Handbook, pg. 5) is clearly violated. By exposing students to these real-world scenarios consistently in the curriculum, having them identify the problems with a “what would a professional do” mindset and develop solutions, we can reinforce key principles at each stage of their education, ultimately creating a stronger foundation for when they enter practice.

Re-evaluation of the Admissions Process

Gaining admission into dental school is highly competitive and expensive, with strong grades and aptitude tests scores being desirable, almost necessary features for success. Coming from a single-parent household, balancing the costs of the application process, academics and a parttime job was seemingly indomitable. This is unfortunate, as prioritizing grades and performance in aptitude tests introduce significant socio-economic bias (Cleland et al., n.d.), and may hinder applicant diversity (O’Neill et al., 2013). Moreover, privileging “elite” students from highincome or healthcare families (legacy families), who face fewer financial barriers, may have its drawbacks. These applicants, and future clinicians, may be more prone to unethical behavior, resistant to professional values, and are more likely to adopt the troubling, profit-driven ethos we discussed earlier (Morris & Sherlock, 1971). Being raised in more privileged settings may make individuals less likely to seek guidance from dental educators and mentors, and more resistant to adopting the professional values of dentistry. (Morris & Sherlock, 1971). On the other hand, considering an applicant’s socioeconomic status could be beneficial, as those from lower-income families are more likely to adopt and retain professional values throughout dental school (Morris & Sherlock, 1971), work in underserved areas, and provide more culturally competent care (Mitchell & Lassiter, 2006; Terrell & Beaudreau, 2003). Finally, by plac-

ing a greater emphasis on diversity, rather than a candidate’s academics, future dental graduates will become more heterogenous, bringing more unique perspectives and experiences, leading to decision making models that are more ethical and lead to better positive outcomes (DeGrassi et al., n.d.).

Reduction of Educational Costs

As previously discussed, financial pressures on new dentists may be a key driver of the ethical implications that erode the social contract. Making dental education more affordable could be a crucial step in reaffirming dentistry as a trusted healthcare profession. A study by McAllister et al. (2015) surveyed deans of various American dental schools and identified two potential solutions. First, integrating financial literacy, aid services, and counseling into the curriculum could help, as many health profession graduates lack essential financial skills (McAllister et al., 2015). A more transformative approach involves adopting new education models to reduce student debt. Brar (2024) suggests joint or accelerated dental programs that merge undergraduate and dental education, shortening training duration and associated costs. Another proposal is sharing portions of the curriculum with medical schools, which could help reintegrate oral health with systemic care, strengthening dentistry’s standing as a healthcare profession. I believe another solution would be to shift traditional in-person lectures to online learning. Not having to spend my hardearned money (or the bank’s rather) on buses, car fuel, and that ridiculously overpriced cup of coffee just to stay awake in lectures would do wonders for my debt… and caffeine addiction. Especially since online learning offers the same benefits as in-person lectures whilst cutting costs and minimizing resource consumption (Deming et al., 2015).

Strengthening Regulatory Oversight

The forces of cosmetic dentistry, corporatization, and the overall commodification of dentistry make it essential to take deliberate steps to uphold ethical principles such as patient autonomy, veracity

and non-maleficence. To ensure that both individual clinicians and larger dental chains act in the best interest of patients, stronger regulatory oversight should be implemented. First, clearer frameworks outlining informed consent, ethical marketing practices, and the implications of overtreatment could enhance adherence to ethical standards (Rostamzadeh & Rahimi, 2025). In cosmetic dentistry, this means moving beyond simply listing risks and benefits to engaging in comprehensive discussions about expected outcomes, alternative treatments, and realistic patient expectations (Maroon et al., 2024). Additionally, regulatory bodies can reinforce the ethical training received in dental school curricula by requiring ongoing ethics-focused continuing education courses for licensure renewal, with a particular emphasis on preventing overtreatment and prioritizing patient care over profit (Rostamzadeh & Rahimi, 2025). For corporate dental practices and larger dental chains, independent ethics review boards should be mandated to ensure compliance with ethical guidelines (Rostamzadeh & Rahimi, 2025). These boards could periodically review treatment policies, address patient complaints, and intervene in cases of unethical practice.

As a final-year student, I recognize that dentistry stands at a crossroads. Financial pressures, corporatization, and commodification threaten the core values of our profession. Yet, I believe trust can be reclaimed. My journey—from a village in Kurdistan to a student in Canada—has shown me that dentistry holds the power to uplift communities. This belief drives me to advocate for ethical reform, to restore the profession to what it was meant to be: a service, not a commodity. The solutions that I proposed, such as strengthening the regulatory oversight and enhancing ethical education and professionalism in dental schools, may serve as key steps in restoring dentistry to its rightful place as a respected profession. The white coat is more than a symbol; it represents the trust society has placed in us. Upholding that trust is not always easy, but it is the only way forward.

Ethical Dilemma in Dentistry: A Young Dentist’s Challenge— Upholding the Social Contract in a Profit-Driven System

Kamyar Sartipi, BS, DDS (Class of 2025)

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Ogles, B. M., Hansen, K. L., & Erekson, D. M. (2024). Competence-based assessment

OZAR-HASEGAWA STUDENT

ETHICS AWARD WINNER 2025

Exploring How Dentists Can Approach Treating VisuallyImpaired Patients Through Different Ethical Frameworks

Elizabeth Gershater, BS

Columbia University College of Dental Medicine, Class of 2027

Special thanks to faculty advisor Dana Wolf, DMD, MS

Why is this an important ethical issue in dentistry?

• Visual impairment and blindness are major sources of disability that affect 23.4 million Americans

• People with visual impairment can face multiple challenges, from maintaining oral hygiene to providing informed consent for dental procedures

• Conditions that can lead to visual impairment can also predispose patients for caries and periodontal disease

• The bottom line: it is imperative that dental care providers know how to treat patients with visual impairments in a respectful, caring, and ethical way 1 2 3 4

Meet Dr. T and Andie

• Dr. T is a recent dental graduate who has just a few years of experience under her belt. She is dedicated to providing compassionate and ethical care for all her patients, but she has never treated a patient with a visual impairment before.

• Andie is 21-year-old who recently aged out of his pediatric clinic and is looking for a new dentist close to where he lives. Andie is visually impaired and sometimes uses a guide dog. He fractured his tooth yesterday and would like to get it repaired.

Ethical Care is Excellent Care: Exploring How Dentists Can Approach Treating

Visually-Impaired Patients Through Different Ethical Frameworks

Elizabeth Gershater

Andie’s Special Care Needs

In his phone call to the clinic, Andie says that he is anxious during dental visits because he cannot see the tools or what the dentist is doing, so appointments can take longer. Andie says bringing his guide dog to future appointments would be helpful. He doesn’t always feel comfortable signing consent forms due to his visual impairment. He also expresses anxiety about not being able to see the aesthetic result of his repaired tooth fracture. Andie wants to be treated by Dr. T, whom he finds friendly and caring, and would like to avoid traveling to other dentists.

The Initial Visit

Dr. T agrees to a consultation with Andie. Andie’s chief complaint is a “chipped right front tooth that hurts when I eat cold foods.” Examination reveals a fracture of the mesial edge of tooth #8. Dr. T diagnoses the fracture as Ellis Class II, with exposed dentin that is causing Andie the sensitivity. Dr. T also observes that Andie has poor oral hygiene that may lead to future caries and periodontal concerns that Dr. T will need to manage, which Andie attributes to being unable to visually inspect his teeth at home. Dr. T has had ample experience restoring this class of fracture and enjoys working with her patients to help them take care of their oral health, but she is still hesitant to treat Andie.

Dr. T’s thoughts

Dr. T has never treated a visually-impaired patient before and she hasn’t established a plan of action for how she can accommodate Andie, so she isn’t sure if she can provide Andie with this specific level of care. She is also concerned about how Andie’s special treatment needs, such as a longer appointment time and accommodations for signing paper consent forms, might change her usual routine at the office. She’s worried about the following ethical dilemmas…

ETHICAL DILEMMAS

Dr. T’s FIRST Ethical Dilemma

Is it ethical for Dr. T to refuse to treat Andie and refer him to another colleague just because she lacks experience and knows the colleague can treat him?

Ethical Dilemma #1

Dr. T considers if it is ethical for her to refuse to treat Andie and refer him to another colleague just because she does not have a care plan already in place and would need to adjust her way of practicing to treat him, while her colleague is more prepared

• On one hand, referring Andie to a colleague is tempting because it seems easier for everyone: Dr. T doesn’t have to make any adjustments, while Andie can see a more experienced professional. Andie will eventually get his tooth restored anyways, so Dr. T doesn’t necessarily feel there is anything ethically wrong with this decision…right?

• One the other hand, Dr. T doesn’t quite feel right about sending Andie off to someone else instead of providing him with prompt care. She knows that under the Americans with Disabilities Act, she cannot refuse Andie treatment just because he is blind, something that Dr. T fully supports. She strongly believes that Andie deserves care from anyone who is capable of treating him and that making adjustments is part of the excellent, individualized care he deserves. While Dr. T is now leaning towards treating Andie, she’s struck with another ethical question…

Dr. T’s SECOND Ethical Dilemma

Is it ethical for Dr. T, someone who has never treated a visually-impaired person before, to accept Andie as a patient and treat him?

Ethical Care is Excellent Care: Exploring How Dentists Can Approach Treating Visually-Impaired Patients Through Different Ethical Frameworks

Elizabeth Gershater

Ethical Dilemma #2

Dr. T also worries about the ethics of treating Andie because he will be the first patient she treats who has a visual impairment

• Dr. T has excellent technical skills and is great at restoring fractured teeth, so she doesn’t think there should be any ethical problems with treating Andie. After all, she’s a licensed dentist who is good at her job

• However, Dr. T still feels hesitant because she thinks that it might not be ethical for her to treat Andie just because he came to her first, especially when she knows a colleague a few towns away who has treated special care needs patients before. She wouldn’t feel right treating Andie if it’s possible that a more experienced colleague might potentially provide better care. What if she overlooks an important aspect of treatment, such as making sure Andie likes the aesthetic result of his treatment despite not being able to clearly see it, or fails to provide Andie with post-procedure care instructions that are in line with his abilities?

Dr. T decides to consult the notes that she took on ethical approaches to care while attending a CE course at an annual dental conference…

ETHICAL FRAMEWORKS OF CARE

Framework #1

The American Dental Association’s Principles of Ethics

First, Dr. T takes a look at the ADA’s five Principles of Ethics to figure out what qualities she and the treatment decision she makes should embody. She considers each value and how they apply to her practice management and care of Andie...

• Beneficence : “do good” for both the patient and general public by providing proper care

• Non-maleficence : “do no harm” by not providing improper care, practicing outside of one’s scope, or not referring the patient to the right providers/resources

• Veracity : “truthfulness” in what the dentist communicates to the patient and how they communicate

• Autonomy : “self-governance” of the patient over their care, facilitated by the dentist, as well as protection of the patient’s confidential information

• Justice : “fairness” and a lack of discriminatory conduct in how the dentist treats everyone they may encounter over the course of treatment

The American Dental Association’s Principles of Ethics

Now that Dr. T knows all the principles, she starts considering how they can help her understand her responsibilities to Andie as a healthcare professional

• Veracity : First, Dr. T will make sure that she will always tell Andie the truth, whether she is admitting the limitations of her abilities or training or discussing the aesthetic qualities of a restoration. It is of critical importance to Dr. T that she maintain a position of trust with Andie and that Andie knows that Dr. T will always tell the full truth

• Justice : Dr. T believes she can embody fairness only by treating Andie the same as her patients without impaired vision. She wouldn’t turn away any other patient with a straightforward fracture that she is capable of treating, so she will not be unfair and refuse Andie care just because of a disability that may not significantly affect Dr. T’s treatment approach

• Beneficence : Dr. T believes that she will embody beneficence by ensuring that Andie gets comprehensive and compassionate treatment in a timely manner, but she isn’t how she can do that best. Would it be more beneficent to treat Andie promptly instead of passing him off? Or would it be more ethical to refer him to a more experienced colleague?

• Non-maleficence : Just as much as Dr. T wants to help Andie, she does not want to harm him, either by providing substandard care such as not managing his anxiety during appointments or by committing a microaggression by making thoughtless comments, which could be avoided by referring him to a specialist. However, Dr. T thinks should this course of action could cause harm by worsening his injury or prolonging his pain and communicating to Andie that he is being discriminated against due to his disability

• Autonomy : Dr. T knows that Andie’s health and treatment plan are ultimately up to Andie, and she must respect that core aspect of patient care. Dr. T reasons that Andie, with guidance, can make his own decision on whether he trusts Dr. T with his health or would prefer to be treated by a different dentist, a decision that Dr. T will do her best to help Andie fulfill

Dr. T is excited that she is starting to reason out the ethics of treating Andie versus referring him, but wants to consult another framework so she can consider those ethics from a different perspective…

Ethical Care is Excellent Care: Exploring How Dentists Can Approach Treating Visually-Impaired Patients Through Different Ethical Frameworks

Elizabeth Gershater

Framework #2

Ozar and

Sokol’s

Central Practice Values

As she consults more of her notes, Dr. T learns of the Central Practice Values model, created by Ozar and Sokol, which organizes six values into a hierarchy of descending importance.

The values are as follows:

1. The Patient’s Life and General Health

2. The Patient’s Oral Health

3. The Patient’s Autonomy

4. The Dentist’s Preferred Patterns of Practice

5. Aesthetic Values

6. Efficiency in the Use of Professional Resources

Ozar and Sokol’s Central

Practice Values

• Dr. T observes that general health and oral health are ranked at the top of the hierarchy and recognizes the importance of this. At no time during her management of Andie’s treatment would it be ethical to compromise any aspect of his health. At this point, Dr. T is certain that she will not simply pass off Andie to another dentist just because she doesn’t want to put in the effort to accommodate him and change her usual treatment approach. Instead, she is committed to Andie’s physical and emotional well-being, however that may be achieved

• Dr. T also acknowledges how patient autonomy is ranked only below health, drawing parallels between this arrangement of values and the ADA’s principles. Instead of making decisions for Andie, it would be most respectful and ethical to put Andie in control of his care plan: now that Dr. T is certain she can put an excellent effort into caring for Andie and looks forward to working with him, she decides it is most ethical to leave the decision of sticking with Dr. T or going to another dentist up to Andie

• Dr. T ruminates over the other values and finds that they better clarify how she will treat ethically treat Andie. Andie’s ability to make decisions is more important to her treatment than is Dr. T’s usual way of doing things. If Andie feels more informed and comfortable after listening to an audio version of a consent form that Dr. T does not usually provide, then it would be most moral to make this slight but significant adjustment in practice management. While checking the aesthetics of a restoration is usually done by Dr. T and her patients, allowing another person that Andie trusts to enter the operatory and confirm shade selection (instead of leaving it up to Dr. T) would ethically take precedence over Dr. T’s typical approach

• Dr. T observes that autonomy and aesthetics are ranked above efficiency, and she finds herself agreeing with this: it is more moral to take some extra time to make Andie feel more in control, let him talk with another trusted person, and ultimately ensure he receives proper care than to try to stick to a standard time limit that does not accommodate Andie. In order to be fair to Andie and make sure he feels as good about his care as do her other patients, Dr. T is ethically obligated to put in additional effort to meet his needs

Dr. T is almost ready. But first, she’d like to consider a model that proposes a step-by-step approach for creating an ethical treatment plan…

Framework #3

Atchison and Beemsterboer’s Six-Step Model

Dr. T reviews Atchison and Beemsterboer’s Six-Step Model so she can have some guidance on what actions she can take before and during her meeting with Andie

Step 1 / Identify the Ethical Dilemma or Problem : Dr. T has already identified two dilemmas: first, whether it is ethical to pass Andie off to another, more experienced dentist so she does not have to make the same adjustments to her routine and second, whether it is ethical to treat Andie despite her lack of experience

Step 2 / Collect Information : During her initial discussion with Andie, Dr. T collected information on Andie’s special care needs and how those needs can be accommodated by Dr. T. She also learned that Andie prefers to be treated by Dr. T instead of having to go to yet another dentist who might refuse him treatment

Step 3 / State the Options : Dr. T has two options: offer her services to Andie or refer him to a colleague

Step 4 / Apply Ethical Principles to the Options : Using the two previous frameworks of care, Dr. T recognizes that, above all, she wants to protect Andie’s health, be truthful with him, and respect his autonomy. In order for a decision to be acceptable to her, it requires Andie to have his fractured repaired, be treated respect, and feel in control of his oral health. She knows that she is ethically obligated to treat Andie fairly, and she thinks she can do that by treating Andie clinically—instead of referring him. Having acknowledged this, she is confident that she can work with Andie to provide him with care that is both beneficent and nonmaleficent, making his restoration procedure an entirely positive experience

Step 5 / Make the Decision : Dr. T decides to agree with Andie’s request to treat him

Step 6 / Implement the Decision : Dr. T is ready to meet with Andie again!

Ethical Care is Excellent Care: Exploring How Dentists Can Approach Treating Visually-Impaired Patients Through Different Ethical Frameworks

Elizabeth Gershater

CASE RESOLUTION

Dr. T and Andie, Revisited

• Dr. T chats with Andie, reassuring him of her commitment to providing Andie with proper care and treating him respectfully while also acknowledging that she has room to learn and develop her skills

• Andie appreciates how Dr. T thoroughly considered both his needs and how she could most ethically ensure they are fulfilled

• Dr. T and Andie discuss his specific care needs and how the two can work together to ensure Andie’s autonomy is respected and, in light of Dr. T’s consideration of ethics, given priority over usual practice management and efficiency

What do Dr. T and Andie Decide?

Prioritization of efficiency/routine:

• Refer Andie to a different dentist

• Perform the restoration without acknowledging Andie’s anxiety or impaired ability to visually observe about what is being done

• Leave the shade match selection up to Dr. T alone

• Provide paper forms only and allow Andie to chose someone to read the forms to him

An ethics-informed approach:

• Work with Andie to develop a caring and collaborative patient-dentist relationship

• Tell Andie what the dentist or dental assistant is about to do throughout the visit, let him touch tools and equipment, and make a special effort to specifically describe the fracture and restoration

• Have Andie choose a trusted person to confirm the shade match selection with Dr. T

• Provide Andie with audio and/or Braille versions of consent forms that he can read himself

WORKS CITED

The appointment goes excellently. Andie is pleased with the restoration outcome and the respectful care from Dr. T, and Dr. T proud of her work in crafting an ethical approach to treating her new patient. A follow-up appointment is scheduled so that they can discuss how to best manage Andie’s oral hygiene given his visual impairment. The two also consider how Andie can be better accommodated in the future, including how his guide dog Benson can be a part of appointments!

Thank you.

ADA National Network.”Health Care and the Americans With Disabilities Act”. February 2025. https://adata.org/factsheet/health-care-and-ada.

Ahmed TA, Bradley N, Fenesan S. Dental management of patients with sensory impairments. Br Dent J. 2022 Oct;233(8):627-633. doi: 10.1038/s41415-022-5085-x. Epub 2022 Oct 28. Erratum in: Br Dent J. 2022 Nov;233(10):893. https://doi.org/10.1038/s41415-022-5085-x.

American Dental Association, “ADA Code of Ethics (2025)” (October 2024). Code of Ethics. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/about/2025_code_of_ethics_ full.pdf.

Beemsterboer, Phyllis L. Ethical Decision Making. Dimensions of Dental Hygiene. June 2010; 8(6): 78-81. https://dimensionsofdentalhygiene.com/article/ethical-decision-making/.

Centers for Disease Control and Prevention, “Fast Facts: Vision Loss”. 15 May 2024. https://www.cdc.gov/vision-health/data-research/vision-loss-facts/index.html.

Ozar, David T., and Sokol, David J.. Dental Ethics at Chairside: Professional Principles and Practical Applications, Second Edition. United States, Georgetown University Press, 2002.

Rein DB, Lamuda PA, Wittenborn JS, Okeke N, Davidson CE, Swenor BK, Saaddine J, Lundeen EA. Vision Impairment and Blindness Prevalence in the United States: Variability of Vision Health Responses across Multiple National Surveys. Ophthalmology. 2021 Jan;128(1):15-27. doi: 10.1016/j.ophtha.2020.06.064. Epub 2020 Jul 11. https://doi.org/10.1016/j.ophtha.2020.06.064.

Saleh GM. Consent of the blind and visually impaired: a time to change practice. Br J Ophthalmol. 2004 Feb;88(2):310-1. https://pmc.ncbi.nlm.nih.gov/articles/PMC1771972/.

FROM THE ARCHIVES

Submitting Manuscripts for Potential Publication in JACD

The communication policy of the College is to “identify and place before the Fellows, the profession, and other parties of interest those issues that affect the dental profession and oral health. The goal is to stimulate this community to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College.

Manuscripts for potential publication in the Journal of the American College of Dentists should be sent as attachments via e-mail to editor@acd.org. In the submission cover letter, please confirm that the manuscript or substantial portions of it or prior analyses of the data upon which it is based have not been previously published and that the manuscript is not currently under review by any other journal.

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Unless a solicited article, review by the editor (or, in some instances, a “guest editor”) will occur within 21 days of receiving a manuscript to determine whether it suits the general content and quality criteria for publication in the JACD. All manuscripts that are suitable for publication will undergo single-blinded peer review. Usually there are two anonymous reviewers comprised of subject matter experts and board members of the College and/or the JACD editorial board. Because all peer reviewers are volunteers, review may take between 4 and 6 weeks. Once reviewer comments are received by the editor, a decision will be made to accept, accept with minor revisions, accept with major revisions, or reject. JACD reserves the right to edit manuscripts to ensure conciseness, clarity, and stylistic consistency.