The Unfinished Agenda

The Journal of Dental Education turns 90 this year. That is a remarkable run for an academic publication in a specialized health profession. Nine decades of documenting the arguments, aspirations, and occasional reckonings of a profession trying to understand itself and serve its students and patients better. This guest editorial offers a reckoning. Thirty years ago, the Institute of Medicine published Dental Education at the Crossroads: Challenges and Change 1, one of the most searching assessments of American dental education ever undertaken. It provided the first systematic examination of the profession since William J. Gies's landmark Carnegie Foundation report 2, which had transformed dentistry from a collection of proprietary trade schools into a university-based learned profession. Crossroads found a profession under stress, with enrollment declining, schools closing, the public poorly served, and the educational enterprise poorly integrated with the broader health system. It also found a profession capable of honest self-examination, and it called on that capacity directly. Table 1 At the American Association of Dental Schools (ADEA's name until 2000), the Crossroads report landed with considerable force. Six dental schools had closed in the preceding decade, enrollment was declining sharply, and the profession faced existential questions about its future. Between 1995 and 1997, the Association launched a formal response: Priorities for Change: Creating a National Agenda for Action, an initiative funded by Oral Health America to translate the IOM's diagnosis into a concrete reform program 3. I served as Project Director for that initiative and subsequently as President and CEO of ADEA from 1997 to 2019, spending more than two decades working to advance the agenda it produced. Thirty years on, this anniversary demands a reckoning. How much of that agenda has been completed? What was delivered, what was deferred? And what new urgencies have emerged alongside the work left unfinished? The answers are mixed. The profession deserves to hear them plainly. Honest accounting requires acknowledging genuine progress before naming what remains undone. The community that inherited the Crossroads agenda in the mid-1990s was not passive and the changes it made were not trivial. The enrollment crisis that had defined the late 1980s and early 1990s was reversed. Applicant-to-seat ratios that had approached 1: 1, a figure that threatened the long-term viability of dental education, recovered substantially over the following decade 4. New dental schools have opened. The existential anxiety that had shadowed academic dentistry for a generation largely lifted. The scientific and policy case for oral health as essential health was built with increasing rigor and is now broadly accepted. The relationship between oral disease and systemic conditions, including cardiovascular disease, diabetes, and adverse pregnancy outcomes, moved from hypothesis to established evidence base, and the argument that dental care belongs within the larger framework of healthcare, not apart from it, is no longer seriously contested. Diversity in dental student enrollment improved meaningfully. Women now comprise over 58% of predoctoral students, and the racial and ethnic composition of entering classes increasingly reflects the national population, representing sustained progress in pipeline development, recruitment, and financial support 4. Technology transformed the educational and clinical environment in ways that were barely imaginable in 1995. Digital workflows, cone beam computed tomography, CAD/CAM fabrication, simulation-based training, and, most recently, artificial intelligence and teledentistry have reshaped both how dentists are educated and how they practice. And the Journal of Dental Education itself made a decision worth noting in this context. We moved from a paid print model to a hybrid open digital access, democratizing the scholarship of dental education, and extending its reach far beyond what subscription economics had permitted. These are real achievements. They reflect the work of thousands of faculty members, administrators, researchers, and students across decades. They should be celebrated. But progress is not completion. And professions, this one included, can mistake meaningful improvement for fundamental transformation. The Crossroads report and the Priorities for Change initiative that followed it made commitments, some explicit and some implicit, to the people dental education exists to serve including students, faculty, patients, and communities. Thirty years later, five of those commitments remain meaningfully unfulfilled. The argument has been won scientifically and rhetorically. It has not been won structurally. Tens of millions of Americans, disproportionately low-income, rural, and from communities of color, still lack meaningful access to dental care 5. Medicare's dental benefit, long advocated for and briefly within reach, remains inadequate. Medicaid reimbursement rates in most states continue to discourage participation by private practitioners. Community health centers have expanded their dental capacity, but nowhere near the scale the need demands. The educational system has not yet produced the workforce mix, the practice models, or the policy frameworks that would meaningfully change this picture. We have made the case for oral health as essential health eloquently and repeatedly. We have not yet built the infrastructure that would make it true in the lives of the people who need it most. In 1995, student debt was a concern. Today it is a crisis. The average educational debt for indebted dental school graduates in the class of 2024 was 312, 700, and for many graduates at private institutions it approaches 400, 000 or more 6. The real-world debt load has more than doubled beyond the rate of inflation, driven mostly by tuition increases that have outpaced the general cost of living. These are not abstract numbers. They are the financial conditions under which every career decision a new graduate makes, whether to pursue academic dentistry, public health, rural practice, or specialty training, will be made for the next two to three decades. Dental schools recruited these students, shaped their professional values, trained their clinical hands, and collected their tuition. The academic dental community cannot be a passive observer of what happens to them afterward. The long-documented relationship between debt burden and career choices makes this more than a financial concern. It is a structural force shaping where new dentists practice, who they serve, and whether they ever consider academic careers 7. The profession must also reconsider whether the 8-year path to a dental degree, uncommon globally and increasingly questioned domestically, remains the only defensible model or whether accelerated pathways could reduce debt burden without compromising educational quality. Dental student enrollment today is more diverse than at any point in the profession's history. Dental school faculties and academic leadership are not keeping pace 4. Academic salaries that cannot compete with private practice income continue to drain clinical talent from the academy, and the gap falls hardest on candidates from underrepresented communities for whom both debt burden and the financial trade-off make academic careers nearly untenable, creating a pipeline too thin to produce the faculty diversity our student bodies deserve. The result is a structural contradiction. We are educating an increasingly diverse generation of dental professionals inside institutions whose leadership and faculty still reflect an earlier and less representative era. This is simultaneously a workforce problem, an equity problem, and an educational quality problem. Students learn from those who teach them. The composition of our faculties is not a peripheral issue. The case for integrating dental and medical education, for training future dentists and other health professionals together around shared patients and shared competencies, has been made, remade, and made again since Crossroads. It appeared in the IOM report. It appeared in the Priorities for Change agenda. It has appeared in accreditation standards, strategic plans, and conference keynotes across three decades 8, 9. And in most dental schools, it remains largely aspirational in actual curriculum structure and clinical training environments. There are genuine exceptions, and they are instructive. But exception is not transformation. True interprofessional education, where dental and other health professions students learn together routinely rather than ceremonially, requires structural commitments that most institutions have not yet been willing to make. True architectural change, as Crossroads recognized, also requires strengthening the relationship between dental schools and their parent universities, yet many schools remain structurally and culturally isolated within their own institutions. The oral-systemic connection cannot be taught as a concept while being ignored as an organizational principle. The Crossroads report understood that transforming dental education required transforming dental leadership. That understanding has not yet produced the systematic investment the challenge demands. Academic dentistry faces a leadership pipeline problem that is both quantitative and qualitative. Not enough people are moving into leadership roles and too many of those who do arrive without the preparation those roles require. Management and organizational skills, policy fluency, strategic thinking, conflict navigation, and the capacity to build coalitions across institutional and professional boundaries are not elective competencies for dental leaders. They are the core of the job. And yet they are rarely taught, rarely developed, and rarely evaluated in the pathways that lead to academic and organizational leadership in dentistry. We train excellent clinicians. Academic dentistry needs reliable pathways from predoctoral leadership education through early-career mentorship and mid-career fellowships to senior administrative roles, not the current model of recruiting leaders only when positions open. The unfinished agenda would be demanding enough on its own. But it does not sit still. Two forces that were nascent or entirely absent in 1995 have accelerated to the point where dental education can no longer treat them as emerging considerations. They are present realities, and they are reshaping the environment in which the unfinished agenda must now be addressed. AI-assisted diagnostics, treatment planning support, administrative automation, and patient communication tools are already in use in dental practices and beginning to appear in educational settings. The profession is not facing a future disruption. It is trying to manage a present one. Recent systematic reviews and meta-analyses report a pooled sensitivity of 0. 85 and specificity of 0. 90 for AI-based caries detection across multiple imaging modalities, with accuracy rates ranging from 73. 3% to 98. 6% across datasets, and some studies documenting performance that meets or exceeds experienced clinicians 10, 11. What dental education has not yet done is reckon seriously with what this means for how we teach, what we assess, and what we believe dental education is ultimately for. The question is not whether to use AI. The question is what clinical judgment means in an AI-assisted environment and how dental education develops that judgment deliberately rather than accidentally. This is not a technology question. It is a question about the irreducible human dimensions of clinical care, and it deserves the same serious curricular attention the profession gave to digital radiography and CAD/CAM a generation ago, but faster and with higher stakes. When Crossroads was published, the dominant model of dental practice was the solo or small-group private office. That model has not disappeared, but it no longer describes the environment most new graduates will enter. The share of US dentists affiliated with a dental service organization has more than doubled since 2015, reaching more than 16% in 2024, and among dentists fewer than 10 years out of school in some states that figure exceeds one in four 12. Private equity has become a structural force in dental practice ownership, and the consolidation of the marketplace is accelerating. These changes have implications that dental education has been slow to address directly. New graduates need to understand the organizational, contractual, and ethical dimensions of employment in large group practices. They need financial literacy that goes beyond running a solo office and they need the professional identity formation that allows them to maintain their values and their patients’ interests inside organizational structures that may not always prioritize either. Accreditation standards, curriculum models, and clinical training environments were designed for a different practice world. Updating them is not optional. None of the challenges described above, the access to care gap, the debt burden, the faculty pipeline, the interprofessional deficit, the leadership shortage, the arrival of AI, and the transformation of practice, will be resolved by any single institution acting alone. They are systemic problems and systemic problems require the kind of leadership that builds coalitions rather than programs, pursues strategic alliances across institutional and professional boundaries rather than defending organizational territory, and measures success by what changes in the world rather than what appears in a strategic plan. That kind of leadership can be developed. It can be taught, modeled, and deliberately cultivated in dental students, in early-career faculty, in mid-career administrators, and in the senior leaders who set the conditions for everyone else. The profession's investment in leadership development has been episodic and insufficient. It needs to become structural and sustained. It is what I have committed myself to in my current role at the NYU College of Dentistry. The generation now entering dental education as students, as new faculty, and as emerging leaders is by every measure available, up to this. They arrive with a sophistication about equity, technology, and systems thinking that their predecessors had to acquire slowly and imperfectly on the job. What they do not need is inspiration. They need institutions that take their development as leaders as seriously as their development as clinicians, and a professional community that builds the alliances necessary to support them. The unfinished agenda is not a failure. It is evidence that the problems were harder than they looked in 1995, and that the profession kept working on them anyway. What this moment requires is the honesty to name what remains undone and the will to finish it. For 90 years, the Journal of Dental Education has been the place where this profession argues with itself, about what dental education is for, who it serves, how it should be structured, and what it owes to the future. That function is more important now than at any point in the journal's history. The manuscripts submitted to these pages over the next decade will tell the story of whether this generation closed the gaps that the last one identified and narrowed. The articles published here will determine whether AI integration, workforce transformation, and the other disruptions now underway are navigated thoughtfully or managed reactively. The editorials and commentaries that appear in this journal will reveal whether the profession maintained the capacity for honest self-examination that made Dental Education at the Crossroads worth reading 30 years later. The unfinished agenda is an inheritance and an invitation. Those of us who gather around the JDE at its centennial should be able to say not that the problems were easy, but that the people were equal to them.