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Dental Therapists [Emerging New Providers?]

Coming to a State Near You

By D. Kellus Pruitt DDS

The topic of the day in the dental industry concerns the recent WK Kellogg Foundation announcement of their $16 million initiative to help dentalcare stakeholders in five U.S. states, including Kansas and New Mexico, develop dental therapist programs similar to Alaska’s experiment in low cost – high risk dentalcare. The project is moving forward because of reportedly excellent results in a 2 year study following 5 therapists who are a couple of years out of high school with 400 hours of training and 300 Alaskan patients in hard to reach places. That’s risky even in the best of conditions in better climates. It doesn’t take many tragedies to eat up the savings from cheap.

A Balanced Article

DrBicuspid.com contributing writer Mary Otto posted a balanced article on the topic titled “More states moving forward with midlevel providers.”


In My Opinion

I am very pleased to see ADA President Dr. Raymond Gist making his presence known concerning the dental therapist controversy. At last count, his name has come out on the Internet four times since yesterday – even though the ADA had to pay a lot of money for the press releases. If dentists fail to represent the interests of dental patients, nobody else will.


Paid advertisement is not as effective and not as cheap as an ADA Facebook would be, but press releases are certainly better than silence from ADA President Dr. Raymond Gist.


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11 Responses

  1. Is the nation really ready for two-tiered dentistry?

    DrBicuspid posted “Pew report finds economic upside to midlevel providers” this morning (no byline).


    “Most private-practice dentists who hire new types of dental care providers can serve more patients while maintaining or improving their financial bottom line, according to a report released December 6 by the Pew Center on the States — the first to examine the effects of hiring hygienists or dental therapists on the productivity and profits of a private practice, according to Pew.”

    This means, if a dentist accepts Medicare, patients with little or no money can expect to be treated by less trained and cheaper dental therapists, while the real dentist’s time can be profitably spent helping the more fortunate in America.

    Is that not morally bankrupt?

    D. Kellus Pruitt DDS


  2. Corporate-sponsored, state-provided, cheap dentistry in Alaska

    Boy was I ever ripped off for a dental degree!

    I spent 4 years in college and 4 years in dental school, and according to a CNBC article with no byline titled “Alaska’s efforts on rural dental care paying off,” I could qualify for this job after only 2 years of study right out of high school. What’s more, instead of it costing me tens of thousands of dollars in tuition, the state of Alaska insists that corporations will pay for dental therapists’ education as part of the deal… with strings attached of course.


    “Organizations that employ certified dental therapists are Yukon Kuskokwim Corp, Southeast Alaska Regional Health Corp., Maniilaaq Assoc. (Kotzebue), Norton Sound Health Corp. and Bristol Bay Health Corp.”

    In return, dental therapists must serve those corporations for four years to pay them back for their investment in the state certification, as well as produce income to cover the corporations’ liability and adequately compensate CEOs for their cleverness in business. Since DDSs aren’t trained to make shrewd business deals like the Alaska plan, I bet the CEOs are MBAs.

    Aren’t there laws against this kind of business arrangement in the 49 states south of Alaska?

    Other than the indentured servitude problem, did not one of the RTI researchers hired by W.K. Kellogg Foundation to turn out swell research, have anything at all to say about risks of having inadequately trained high school grads performing surgery in the middle of nowhere? Did not one of the 14 therapists experience an unexpected treatment complication that required the skill and training of a real dentist – and quickly? Since the therapists work under “general supervision” of fully-licensed dentists in Alaska, rather than ”direct supervision,” how far away by plane will the DDS be when unanticipated problems predictably arise? Mysteriously, issues involving tedious parts of the Hippocratic Oath were not covered in the CNBC article.

    Are those reaping the profits from this experiment in iatrogenics properly informing Alaskan parents who live in unnamed communities that the dental care their children receive is inferior to that provided by a fully trained dentist? Or perhaps RTI researches have proven that the additional, traditional education makes no actual difference in dental care.

    Since there is no bad news to report, politicians could conclude from the CNBC article that the level of care provided by dental therapists with 2 years training is equivalent, or even superior to dentists’ who have four years of post-graduate training. It looks to me like Alaska is proudly racing New Zealand’s to the bottom to save money on dental care in the short term while incidentally boosting corporate profits the American way. So why not push the envelope of humane treatment, and include a capitation plan run by and for Dental Health Maintenance Organizations?

    As I write this, the Texas HHS is proposing capitation to state lawmakers as a way to save money on Medicaid dentistry for children in Texas who have no choice or voice. Rather than paying per filling, DHMO corporations reward neglect on a per-head basis. I suppose worse things could happen for dental therapists’ patients.

    Since CNBC’s obviously biased article has no byline, it’s a sure bet it was not written by a CNBC reporter. So who purchased this press release? Follow the tuition.

    D. Kellus Pruitt DDS


  3. More on Dental Therapists

    Dental therapists – as primary care providers – are the dental equivalent of a physician’s assistant. They provide more services than dental hygienists, but are not able to do everything a dentist does.




  4. More on Dental Therapists in Alaska

    I posted an open letter to Mr. David Jordan on the Community Catalyst Blog today asking him critical questions surrounding his promotion of dental therapists performing oral surgery in remote parts of Alaska. I don’t think he’ll answer.



    Dear Mr. David Jordan, Dental Access Project Director, Community Catalyst:

    Please don’t try to mislead vulnerable Americans who know very little about dentistry. You can no longer get away with it.

    Since you promote America’s adoption of dental therapists who demand less money to treat the poor than fully-trained dentists, I’m sure you get this question often: If you or someone in your family had to have a tooth extracted, whom would you prefer do the surgery – a dental therapist or a fully-trained dentist? I don’t picture you as being one who would callously profit from endangering poor families’ health any more than your own. So that means you would go for the cheaper dentistry. Am I right?

    Recognizing that neither you nor anyone in your activist organization can be held personally accountable to Alaskans who are harmed by well-meaning but inadequately-trained dental therapists, it’s only fair that you be transparent with Americans about your personal motivation in this effort: What’s in it for you, Mr. Jordan? If you are not a volunteer, we deserve to know who is paying you to promote a second-tier class of providers for the poor. Is it insurers or the reckless and unresponsive W. K. Kellogg Foundation?

    Regardless whether the dentalcare provider’s office is across the street from a hospital or in a remote part of Alaska, even the best dentists occasionally experience complications while performing what were expected to be simple fillings and extractions.

    Quick and proper resolution of such complications always draws heavily on one’s training. You must admit that since cheaper dental therapists receive far less training than dentists, their patients in remote parts of Alaska can expect not only more complications than Americans who are treated by better-trained dentists, but that the damages will be more likely to leave long-lasting and even permanent harm. Are vulnerable Alaskans properly warned about this danger?

    Since it would be absurd to claim that the quality of dental therapists’ care is superior or even equal to fully-trained dentists, it is only fair that you share details about complications experienced by non-dentists in Alaska. If your organization is answerable to the community it serves, you should have such critical information close at hand.

    We also want you to reveal more about dental therapists’ training. But rather than describing what is included in the high school grads’ 2 year dental curriculum, please tell us what parts of dental education they skipped. Again, if Community Catalyst is a responsible organization attentive to weaknesses in the “proven model” it promotes, this information should be very close at hand. I’ll then share why each subject is important to the health of Alaskans who have no choice in providers. Americans everywhere deserve to be warned about the 2nd tier dentistry you promote. It’s no bargain.

    Rather than lowering standard of dentalcare for those who can least afford even inevitable complications, and rather than spending millions more dollars on training dental therapists and purchasing PR services from Community Catalyst, how much more would it have cost for Alaska to simply care for its inconvenient poor in a humane, common sense manner by hiring dentists for a fair market price? Simplicity leaves less room for ambitious stakeholders to siphon off healthcare dollars.

    D. Kellus Pruitt DDS


  5. Lisa Martinez vs The Dentists’ Cartel

    Dentists earn above-average wages because they possess highly specialized skills that most of us lack, and no one should begrudge them that.

    But, according to Matthew Yglesias writing in Slate, “dentists have also gotten quite canny at padding their earnings by enacting regulatory restrictions on the provision of tooth-related services by non-dentists even if the service in question doesn’t actually require a dentist’s specialized skills”.


    Any thoughts?



  6. Moderate this!

    Matthew Yglesias: “Dentists have also gotten quite canny at padding their earnings by enacting regulatory restrictions on the provision of tooth-related services by non-dentists even if the service in question doesn’t actually require a dentist’s specialized skills”

    Thanks, Mary. I concede his point. Nevertheless, boundaries must be established and enforced or vulnerable Americans are certain to be needlessly harmed by well-meaning people who don’t deserve the guilt.

    I would never try to argue that only a licensed dentist should bleach patients’ teeth, and since denturists working out of their garages have illegally yet successfully fabricated and fit patients with teeth for decades, it would be silly to claim that only dentists know how to do that. Indeed, in certain parts of the nation expanded duty hygienists are already legally and safely performing invasive and irreversible procedures for the nation’s 2nd tier dental patients – mostly the poor who have no choice in providers.

    Unlike isolated dental therapists in Alaska, expanded-duty hygienists work under the direct supervision of dentists who can bail them out within minutes when inevitable complications arise. Cavities in asymptomatic teeth that are expected to need “simple” fillings occasionally run deeper than predicted, creating a sudden need for complicated root canals or extractions. How does a high school graduate who has skills in neither keep the patient comfortable until a real dentist can resolve the pain in a tooth that might not have ever bothered the Alaskan – if only the therapist had left it alone in the first place. It’s surprising how often no treatment is better than inadequate dental treatment.

    Alaska’s dentalcare model is transparently cruel to both dental therapists and their patients. Yet insensitive stakeholders like leaders of the Community Catalyst and the W. K. Kellogg Foundation – who cannot be held personally accountable for the effects of their advice – would have naïve people believe that dental therapists cost less to support in remote parts of Alaska than dentists. I think they crunched happy numbers. The basic cost of maintaining a dental practice should be similar for a dentist as a dental therapist, and usually runs around 65% of dentists’ fees. That leaves only a 35% savings even if the dental therapist is paid nothing at all. And let’s not forget that unlike fully-trained dentists, therapists are limited in the procedures they are allowed to bill for. Then of course is the intangible cost to the community by enabling well-meaning but inadequately-trained providers to cause avoidable suffering.

    It looks like Mr. David Jordan from Community Catalyst is going to be slow to respond to my letter if at all. On Saturday, I asked him questions concerning complications already experienced by the dental therapists in Alaska. My comment follows his reckless promotion of dental therapists and is still “awaiting moderation.” It would clearly be unethical for Mr. Jordan to hide information of such importance, and I want him to be aware of my opinion. So I posted this comment on his Blog as well.

    D. Kellus Pruitt DDS


  7. More on Dental Therapists

    Following an article titled “Dentistry without dentists?” by Aaron Burkhalter, I struck up a conversation with Louis Fiset DDS who serves as clinical coordinator to the Alaska dental therapist program.



    Dear Dr. Louis Fiset,

    Thanks for responding. I’m sure dentists in Washington and other states where you also intend to introduce dental therapists are interested in your heads up. I’ll let them know. I’ve also created a Google Alert to keep track of your progress. We’ll meet again.

    You say, “The dental therapist has shown that it is possible to bring routine dental care to underserved areas in Alaska, and this new dental team member offers a great deal of promise here in Washington.”

    Even though none of you stakeholders in academia can be held personally accountable when things go wrong, very few share your level of confidence. You may indeed be the only dentist willing to discuss the calculated lowering of the standard of care in the nation. That’s why our dentist-to-dentist discussion is so important. I have questions for you that I know my friends are interested in as well:

    1. Would you prefer your family members to be treated by a dentist or a dental therapist?

    2. How many complications have your dental therapists experienced and what were their severity? Please don’t continue to hide this information. And if you don’t have that data close at hand, you have no business promoting dentistry performed by dental therapists on Americans who have no choice in dentists.

    3. Considering that the usual overhead of a dental practice runs about 65%, the most that can be saved on using dental therapists is around 35% if they are paid nothing at all. So how much money do stakeholders claim their dental therapists with limited capabilities save? How much more money would it cost to hire fully-licensed dentists who are more likely to properly handle the complications on your list in a timely manner? If any stakeholders actually ran the numbers, I suspect the feel-good, rebellious power of fostering 2nd tier dentistry for the poor became more important for ambitious people than the welfare of vulnerable, trusting Alaskans.

    4. I have no need to be told the number of hours dental therapists have studied dentistry because we already know that dentists have them beat by 100%. It’s what dental therapists don’t know that is critically important for Alaskans’ health, and I bet nobody has actually informed them. In the two years of dental study missing from dental therapists’ training, a large part of traditional dental education was discarded as unnecessary. You’re a dentist. You know that there’s certainly not much fluff in dental education. If you will tell me what subjects were sacrificed to save money on the trapped poor, I will gladly describe what Alaskan lawmakers haven’t been told about their blunder.

    D. Kellus Pruitt DDS


  8. The truth comes out: Dental Therapists expect to be paid after all

    Breaking news from the ADA: The popular but naïve idea of permitting Dental Therapists (DTs) with half the training as dentists to perform second-tier dentistry on poor people in remote locations, has predictably hit a snag. As it turns out, nondentists won’t work for free like generous DT stakeholders apparently assumed they would.

    “The ADA believes that allowing nondentists to perform irreversible surgical procedures is the wrong way to go. And based on these studies, midlevel dental providers would in most settings be unable to generate sufficient revenue to sustain themselves absent a continual source of financial underwriting. Given the current budget constraints at every level of government, and the already insufficient financing for dental care in most states, midlevel providers do not appear to be viable.”

    – ADA President William R. Calnon, DDS

    (See: “New Studies Question the Economic Viability of Midlevel Providers in DentistryADA Calls for Increased Focus on Proven Solutions to Access Disparities”)


    In my opinion, overly-ambitious discount dentistry stakeholders like DentaQuest and the W. K. Kellogg Foundation deceptively inflated dentists’ profit margin on intricate handwork in tender mouths in order to attract support (donations and federal grants). Reality kicked their optimistic butts.

    D. Kellus Pruitt DDS


  9. 2 in 3 Adults Had a Dental Visit in the Past Year

    United Health Foundation recently released a study on prevention measures in all 50 states. Here are some key findings from the report:

    • Almost 77% (188 million) report having a dedicated health care provider.
    • Fewer Hispanic adults (59.2%) have a provider, compared to white (82.1%) and black (76.5%) adults.
    • Childhood immunization rates range from 84.7% in Maine to 63.4% in West Virginia.
    • Adult influenza immunization rates range from 50.2% in South Dakota to 31.7% in Florida.
    • Two-thirds of adults (157 million) had a dental visit in the past year.
    • 87.6% of adults have health insurance, from a high of 95.4% in Massachusetts to a low of 75.1% in Texas.

    Source: United Health Foundation, February 26, 2016


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