The Moral Imperative of Responsible Advocacy: An Educator’s Perspective on Dental Therapy

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I teach an introductory dental public health course for first-year dental students. The course encourages students to use the scientific literature as the basis for developing evidence-based solutions to public health problems.

In the course, we discuss dental therapists: a workforce solution that is increasingly being adopted by communities and states to improve access to dental care for vulnerable populations in need. Dental therapists are part of a dental team and provide a limited preventive and basic restorative care to patients living in underserved communities, under the supervision of a licensed dentist. In communities and clinics where dental therapists practice, this careful division of labor allows dentists to focus on complex procedures that require in-depth biomedical knowledge and clinical training.

I was a dental student in the early 2000s, when dental therapists were first being trained to provide care in the U.S. I recall having the same concerns about dental therapists that students express today. Are dental therapists able to provide high quality care? Given that some of the allowable procedures are irreversible, like fillings and extractions, is patient safety at risk? Is this creating a two-tiered dental care system? Can dental therapists actually do anything to improve access to care?

There were no clear answers to these questions when I was a dental student. Given the lack of data, I believe organized dentistry’s initial opposition to dental therapy legislation was understandable. We now have answers to questions I had as a dental student. No published data support any of the concerns mentioned above. In fact, all the data show dental therapy is safe and effective.

Most peer-reviewed publications on dental therapists in the U.S. are based on data from Alaska, where dental therapists have been providing care in indigenous communities for nearly 20 years. When assessing the limited procedures dental therapists are allowed to perform, studies show the quality of care provided by dental therapists and dentists is equal.[1] The rates of post-treatment complications are also the same.[2] Patient satisfaction with care provided by dental therapists is high.[3]

More recently, I was part of a University of Washington research team that analyzed 10 years of data from Alaska’s Yukon-Kuskokwim Delta. We found in communities where dental therapists provided care, children and adults got more preventive care and kept more of their natural teeth.[4] This is the first study of dental therapists practicing in the U.S. to show that dental therapists can in fact improve access to dental care.

When students are presented with the actual data that underscore the safety, quality and effectiveness of dental therapists, the conversation shifts to more practical reasons for opposing dental therapists, such as debt and job competition. These concerns are understandable.

According to the American Dental Education Association, the average debt for a 2018 dental school graduate was $285,184.[5] When I finished pediatric dentistry residency training in 2009, I graduated with nearly $200,000 in loans.

Students also believe dental therapists are a potential threat to finding jobs, making a living, paying off loans, and living life. What students overlook is the fact that most dentists will not compete for patients treated by dental therapists. Patients seen by dental therapists live in communities that have little hope of attracting a dentist. States in which dental therapists are allowed to practice stipulate that a minimum percentage of patients seen by dental therapists must be from underserved subgroups.

Furthermore, dental therapists are not independent practitioners and must be supervised by a licensed dentist, similar to the model of supervision imposed on physician assistants. Whatever competition newly-minted dentists face is likely to come from community health centers, corporate dental chains, and dentists in private practice that end up employing dental therapists.

As a scientist, what I find most alarming is the disinformation spread by dental therapy opponents and the questionable practice of using dental students and trainees to communicate unsubstantiated concerns to policymakers. Their message is that dental therapists are bad for patients, the public, and the profession. And the slippery slope warning is that dental therapists will eventually put dentists out of business. This is untrue. Dental therapists are trained to provide a very narrow set of dental services under the supervision of a dentist. In addition, a significant proportion of the population will have treatment needs that go beyond basic dental care. Dentists will always be an important part of the dental care delivery system.

The opposition to dental therapy boils down to what I view as protecting turf at the expense of increasing access to dental care and improving oral health equity.

So far, eight states have passed dental therapy legislation and a handful of states have active legislation under consideration. Given the heated political climate that shrouds policy discussions on dental therapy, I remind dental students of the moral imperative to advocate responsibly.

In an era of alternative facts and misinformation, I think an emphasis on evidence is critical. Before lobbying or testifying on health legislation, dental students should know the relevant scientific literature, understand the limitations and conclusions that can be drawn from available studies, know where the knowledge gaps are, be truthful with policymakers, and recommend solutions that get to the root of persisting problems in dentistry.

The public has granted dentistry the privilege of self-regulation, which is one of the defining characteristics of a profession. In my opinion, there is no bigger threat to the legitimacy and future autonomy of dentistry than having well-educated health professionals use misinformation to oppose evidence-based policies aimed at improving the lives of vulnerable individuals.

Guest Blogger: Donald L. Chi, DDS, PhD



[1] Bader JD, Lee JY, Shugars DA, Burrus BB, Wetterhall S. Clinical technical performance of dental therapists in Alaska. J Am Dent Assoc. 2011 Mar;142(3):322-6.

[2] Bolin KA. Assessment of treatment provided by dental health aide therapists in Alaska: a pilot study. J Am Dent Assoc. 2008 Nov;139(11):1530-5.

[3] https://www.wkkf.org/resource-directory/resource/2010/10/alaska-dental-therapist-program-rti-evaluation-report

[4] Chi DL, Lenaker D, Mancl L, Dunbar M, Babb M. Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta. J Public Health Dent. 2018 Mar;78(2):175-182.