Fluoride Action Network

Is ADA impeding access to dental care?

Source: The Denenberg Report | July 25th, 2005 | By Herb Denenberg

There go the dentists again, not the public health dentists who support dental therapists and broader access to dental care, but the dentists in private practice represented by the American Dental Association (ADA), attempting to deny children with toothaches and rotting and infected teeth the care they need. This is the same old garbage they have been shoveling to protect their turf, when their turf won’t even be affected. The ADA has been dishing out the same baloney since 1950, and it doesn’t even come up with new objections.

The ADA, with a Pavlovian-reflex-like reaction, always opposes attempts to train professional technicians to take care of underserved populations who need fillings and extractions, who suffer from abscesses and tooth aches, and who need other routine care. These are often children, in remote areas, where there aren’t any dentists and where dentists don’t want to go.

The location is immaterial. The dental reaction is always the same, regardless of the facts, regardless of the location, regardless of the evidence, regardless of the needs. Don’t worry about the location of the latest dental outrage. It is likely to eventually come to a neighborhood or area in your community.

What’s worse, the approach of the dental profession to this issue betrays a decision process that is likely to produce bad results on other issues.

Here’s the latest dental profession outrage, inflicted on the state of Alaska. In that state, there are historically dentally underserved children and adults living in remote, low-income areas where there are only a handful of public health dentists who can’t possibly meet these dental needs. So the Alaska Native Tribal Health Council has come up with a perfect solution – use what are called dental therapists (or dental health aide therapists). They are technicians who are professionally trained to do routine fillings, extractions and preventive care for the dentally neglected populations. It is also important to note that the dentist therapists are supervised by the regional pubic health dentists. The public health dentists also provide treatment that is beyond the scope of the dental therapists, but, as noted, there are too few of them to treat the entire population.

The Alaska dental therapists are trained in a school in New Zealand that, since 1921 (!), has specialized in training dental therapists. Ninety-eight percent of New Zealand children – rich and poor alike – are treated in its school based dental clinics, to the complete satisfaction of parents.

Even if this were a new idea, it should get serious consideration. But what makes its logic even more compelling is that it is nearly a century-old idea used around the world, with the training facilities and capabilities to back it up in every way.

Dental therapists are now deployed in 42 countries including Australia, Canada, England, and New Zealand. Over 30 years ago, Dr. Jay Friedman, the leading authority on dental quality, went to New Zealand to study its implementation of a dental therapist program. He documented his findings in an article published in the Journal of the American Dental Association, “The New Zealand Dental Service: A Lesson in Radical Conservatism” (JADA 1972, 85:609-16). He proved then what has been demonstrated many times since – that the dental therapists can deliver quality work and meet the needs of those who will not otherwise get dental care. In my next column, I’ll explore what stands in the way of using dental therapists to provide dental care to those now not getting it.


There’s a proven way to deliver high quality dental care to those not getting it now. They are those who live in rural areas, in our inner cities, and elsewhere. It’s the use of dental therapists, professionally trained dental technicians, to provide fillings, extractions, preventive care and other routine services. Dental therapists are now delivering high-quality care, economically and efficiently, in 42 nations across the world. But not in the U.S. Why is that?

What stands in the way of the implementation of this urgently needed program? The American Dental Association, state dental associations and local dental societies. And what arguments do they make against the program? Their approach is almost too embarrassing to even repeat. As Abe Lincoln would say, “These arguments are weaker than the shadow of a pigeon that starved to death.”

One of the first and most ridiculous arguments is that there is an adequate supply of dentists to serve this population. The ADA argues (and apparently with a straight face) that volunteers will come from the Lower 48 to treat the 60,000 Alaska natives half of whom are residing in remote areas. Who are they kidding? I’ve been to Alaska and just getting to Anchorage or Juneau is a major adventure. But can anyone imagine these volunteers not only going to Alaska, but then going to these remote areas by boat or snowmobile to take care of the Alaska natives. I can imagine some child suffering from a tooth ache, waiting for the ADA volunteer to fly in from Omaha, Nebraska – after the snow storm has subsided. This whacky approach has been tried before, and failed before. There is no reason to think there will be a different result another time around. You need paid Native American dental therapists recruited from the local communities, located in these communities, not volunteers from the lower 48 who come in for a 10-day vacation.

Even if you could get these ADA dental sojourners, who could only be found in a Jules Verne novel, this would not be an efficient, much less an effective approach. If the ADA can produce these volunteers, let them work on the complicated cases the dental therapists can’t handle.

The ADA also argues that the dental therapists will produce inferior work. This is simply not the case and there is ample evidence including Friedman’s landmark study and studies since that demonstrate therapists can do quality work as good as that of dentists. Even the ADA-sponsored report on this Alaska proposal did not find that therapists produce inferior work.

Finally it is argued the therapists would be practicing dentistry illegally. This is the easiest argument to dispose of on three counts. First, this type of professional assistance has been allowed under all kinds of codes of professional conduct. Just think physicians assistants and nurse practitioners, and a whole array of other medical technicians without whom physicians would be as delinquent as dentists. Second, if the law says therapists are illegal, it can quickly and easily be changed. Third, even an ADA-sponsored report failed to show that dental therapists are practicing dentistry illegally.

The real objection of the ADA is the dental therapists “seem” to be invading turf long owned by private practicing dentists. That is ridiculous. There is no way these dentists are going to serve these low-income natives living in remote regions, much less those neglected children in the inner cities and rural areas of the Lower 48. Where have they been up to now?

It’s time that the ADA for once shows that George Bernard Shaw was wrong when he said, in effect, that every profession is a conspiracy against the public interest. Shaw was right for law, medicine, dentistry, and for every other profession that I know of. Isn’t it time the dental profession as well as other professions prove Shaw wrong? Wouldn’t it be nice if for once the professions stand up and “do the right thing” for the public and for themselves.


Herb Denenberg is a former Pennsylvania Insurance Commissioner, professor at the Wharton School, and Pennsylvania Public Utility Commissioner. He is a member of the Institute of Medicine of the National Academy of Sciences and is a board member of the Center for Safe Medication Use. He is an adjunct professor of insurance and information science and technology at Cabrini College. You can write Herb at POB 7301,St. Davids, PA e-mail him at hdenenberg@aol.com or reach him at his two Web sites: thedenenbergreport.org or denenbergsdump.org