Lessons from the past: How dentistry’s treatment of lab techs mirrors today’s attacks on hygienists

Part 5 of 6

"Those who fail to learn from history are doomed to repeat it.” (Winston Churchill)

In my last article, I challenged the premise on which dentists’ claim to supervise dental hygienists is built, exposing significant gaps in their own education and credentialing. It revealed how those deficiencies undermine the legitimacy of dental oversight and have enabled self-serving regulatory practices. Organized dentistry’s incessant attempts to dismantle our profession—by advocating and supporting legislation that permits on-the-job training for the complex disease prevention and management that defines dental hygiene—necessitated and justified that rebuttal.

Here I examine the record of organized dentistry’s conduct toward another profession, revealing eerily similar tactics and the documented harm inflicted on patients as a consequence. Why revisit this? Because, as we’ve heard, insanity is doing the same thing and expecting a different result.

Some have seen this metaphorical movie before. I lived it. With professional experience in both dental hygiene and dental laboratory technology, I offer a rare vantage point on what happens when oversight is replaced by opportunism, and accountability is cast aside.

NADL and ADHA: Unknown cousins in a fractured family

Despite sharing similar histories, educational frameworks, and missions rooted in patient protection, the National Association of Dental Laboratories (NADL) and the American Dental Hygienists’ Association (ADHA) have rarely been seen as kindred organizations. Yet both groups are, in many ways, estranged cousins—two allied professions with parallel struggles.

Both have advocated for improved regulation, transparency, and recognition within a system dominated by organized dentistry. Both have fought for their legitimacy against a backdrop of systemic indifference or outright resistance. And both have witnessed what happens when those in power decide that safety is optional and accountability is negotiable.

Nowhere is that more evident than in the collapse of dental laboratory education. At its peak, nearly 60 CODA-accredited dental technology programs operated across the US.¹ Today, only 10 remain.² Unlike the mandatory licensure required to practice dental hygiene, board certification in dental laboratory technology was never more than a professional aspiration—valued, but optional. The certified dental technician (CDT) credential once held weight. Dentists expected it. Labs pursued it. Patients benefited from it.

The Great Recession, coupled with the rapid rise of CAD/CAM technology, fundamentally shifted the economic and professional landscape. Dentists prioritized lower-cost options. Offshoring became routine. Restorations were no longer crafted by credentialed technicians in nearby labs but instead in mega facilities, some offshore, often with little oversight or transparency.

In this environment, the NADL’s efforts to mandate training and enforce quality standards unraveled.³ Organized dentistry, despite holding the authority to implement meaningful safeguards, chose convenience and profit over patient protection.

Why credentialing matters

Years of training and work as a dental technician gave me a deep understanding of how vital properly fabricated prostheses are to oral health. The longevity and function of restored dentition and implant prosthetics are not solely dependent on patient hygiene and professional maintenance; they are directly tied to the precision of manufacturing and the integrity of design.

From the emergence profile of a crown to bridge design, margin accuracy, interproximal contours, ridge-lap designs on pontics, implant emergence profiles, occlusion, material type,^4,5 thickness, and contour, each element plays a critical role in the lifespan of the restoration and the supporting dentition. Perhaps my greatest frustration as a hygienist is the widespread ignorance of Melker’s protocol^6,7 in periodontally compromised cases. Any one of these design or preparation errors will lead to iatrogenic failure.⁸

The cost of cutting corners

In 1993, lab fees averaged $100 for a crown, while patients were charged around $500, a 20%–25% cost ratio.⁹ Today, labs are pressured to produce crowns for as little as $50, yet the average patient fee has climbed to nearly $1,500 while materials and overhead have soared. Meanwhile, consultants continue to advise dentists to keep lab costs at or below 5%.

Prosthetics are not made in a vacuum. When the dental laboratory technology profession is devalued and skilled technicians are pushed aside, they are left with limited options: sell to corporate conglomerates, turn to black market materials, or outsource to untrained, low-cost labor. Profit is necessary, but dismantling a vital, skilled profession in the name of profitability is indefensible and the consequences are predictable.

The lead scandal

In 2008, an elderly woman in Ohio developed systemic symptoms—burning oral tissues, fatigue, and mucosal irritation—shortly after receiving a porcelain-fused-to-metal bridge.¹⁰ She insisted it be removed and she contacted the NADL for assistance. Independent testing revealed the prosthesis contained 210 parts per million of lead—nearly three times the legal threshold for children’s toys¹¹—and tested positive for radioactive isotopes. The bridge had been fabricated in an unregulated offshore laboratory.

The journalist who broke the story had already been investigating offshore dental restorations and had found even higher levels of lead contamination at 490 parts per million in other imported restorations.^12,13

The ADA issued a special report promising further laboratory analysis and a comprehensive scientific publication. What followed instead was a diluted summary, claiming that lead was “unlikely to be released” into the oral cavity.¹⁴ Their testing was limited to static acidic conditions and failed to account for masticatory forces or occlusal adjustments, an omission that is academically indefensible. Although ADA leadership had publicly acknowledged that “there is no appropriate use for lead in dental prosthetics,”¹⁵ it quietly walked back the urgency of its initial response.

According to a senior NADL official, that preliminary statement was the only document ever released. Despite daily collaboration with ADA staff at the time, no peer-reviewed article or comprehensive study followed. The investigation was quietly shelved, and the public health scandal buried.

2008 was not an outlier

The crisis did not end in 2008. In 2013, a dental laboratory in Ohio, operated by a convicted felon, was exposed for producing restorations in conditions so unsanitary they resembled a horror film set.¹⁶ These devices were sold to licensed dentists and placed into the mouths of unsuspecting patients.

In 2015, an investigative report in Arizona uncovered another unregulated lab linked to direct patient harm.¹⁷ By 2023, yet another lab, also run by a felon, was discovered operating jointly with a laundromat and drug den.¹⁸ In 2024, an Indiana facility manufacturing anterior growth guidance appliances (AGGA) without regulatory oversight became the subject of multiple lawsuits and a criminal investigation.¹⁹

Are these isolated issues, or are they a sustained pattern of negligence, denial, and regulatory failure? I encourage every reader to watch the news footage linked in this article. The images are not just revealing—they’re damning.

As of last year, 37 states still do not regulate dental labs. Only 10 require disclosure of material content or country of origin. Just six require dentists to use registered labs, and only four mandate that a CDT be on staff.^3,19

A tale of two associations

In 2007, the NADL introduced a model bill to establish basic public protection requirements: at least a single credentialed technician in each lab, material and point of origin disclosure to dentists, OSHA compliance, and lab registration.²⁰

The ADHA not only endorsed this model legislation, it went a step further. Recognizing both patient safety and technician protection, the ADHA adopted policies supporting the unbundling of dental laboratory fees from CDT procedure codes,²¹ an effort to challenge the stranglehold of third-party payers that has long suppressed transparency and fair compensation. Ironically, this policity also represents a win for dentists, who would be able to choose a lab based on quality, not costs.

The ADA’s policies on dental labs reflect a concerning unwillingness to acknowledge the significant gaps in prosthodontic and technological education among dentists. Rather than endorsing the NADL’s model legislation or addressing the role of third-party payers—the central challenge to reform— the organization relies on noncommittal language or outright opposition to regulations not controlled by dental boards.²² This approach preserves a perceived financial advantage while avoiding meaningful collaboration with credentialed laboratory professionals and protections for the public.

When trust is broken

What was done to laboratory technicians is now being done to hygienists. Licensed, credentialed providers are being displaced by minimally trained personnel. Supervision laws are being manipulated, not to ensure quality, but to suppress wages and centralize control.

The warning signs are no longer theoretical. Dentistry has allowed an antiquated economic model that prioritizes profit over transparency, convenience over competence, and silence over safety. The evidence of harm is growing, and awareness is spreading across clinical, academic, and public sectors. As scrutiny increases, so will accountability.

The profession is at a crossroads. Those in power must choose between leading reform or clinging to the status quo and facing its consequences.

This is not just a call for reflection. It is a demand for responsibility. When organized dentistry insists, “Trust us, we’re dentists,” while defending the use of untrained, unregulated workers to deliver permanent medical devices and services, the answer must be “no!”

Trust has been broken. The public endures it. The professionals affected live it. 

Author’s note: The final article in this series will outline an ethical, evidence-based path forward for states to advance professional autonomy for dental hygienists and help lay the groundwork for achieving it nationwide. 

Disclaimer: The views and research presented in this series, while they may align with the policies of the American Dental Hygienists’ Association, do not officially represent it or its tripartite structure

Editor's note: This article appeared in the October 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Closure of Oregon dental laboratory program leaves only 13 U.S.-based training programs. Compendium. August 29, 2018. Accessed August 1, 2025. https://compendiumlive.com/news/?newsID=64104&utm_.com
2. Find a program. Commission on Dental Accreditation. Accessed August 1, 2025. https://coda.ada.org/find-a-program
3. State Regulation. National Association of Dental Laboratories. 2020. Accessed August 1, 2025. https://dentallabs.org/state-regulation/
4. Rees TD. Hypersensitivity to dental cast metals: a clinical study. Open Pathol J. 2011;5(1):13-22.
5. Shah KM, Agrawal MR, Chougule SA, Mistry JD. Oral lichenoid reaction due to nickel alloy contact hypersensitivity. BMJ Case Rep. 2013;(5). doi:10.1136/bcr-2013-00975
6. Tucker LM, Melker DJ, Chasolen HM. Combining perio-restorative protocols to maximize function. Gen Dent. 2012;60(4):280-289.
7. Melker DJ, Richardson CR. Root reshaping: an integral component of periodontal surgery. Int J Periodont Restor Dent. 2001;21(3):296-304.
8. Ferlias N, Nielsen H, Andersen E, Stoustrup P. Lessons learnt on patient safety in dentistry through a 5-year nationwide database study on iatrogenic harm. Sci Reports. 2024;14(1):11436. doi:10.1038/s41598-024-62107-x
9. Henry K. Looking back: what were dental fees in 1993? DentistryIQ. December 8, 2012. Accessed August 1, 2025. https://www.dentistryiq.com/dentistry/prosthodontics-and-laboratory/article/16362028/looking-back-what-were-dental-fees-in-1993
10. Documented cases of lead contamination in offshore dental laboratory restorations. National Association of Dental Laboratories. February 26, 2008. Accessed August 1, 2025. https://dentallabs.org/media/2013/07/NADL-News-Alert-to-Industry-February-2008.pdf
11. Mattel to pay $12M in lead suit. San Bernardino Sun. December 15, 2008. Accessed August 1, 2025. https://www.sbsun.com/2008/12/15/mattel-to-pay-12m-in-lead-suit/amp/
12. Baskin R, Bergo S. Dental work made in China might contain lead. ABC News. May 5, 2008. Accessed August 1, 2025. https://rebrand.ly/8of44ok
13. Howard L. Lead in dental work prompts fears about Chinese-made crowns, bridges. Laws passed after problems are detected in several states. New London Day. April 28, 2008. Cited in University of Connecticut Health Center Today. Accessed August 1, 2025. https://today.uchc.edu/headlines/2008/apr08/dental_work.htmll
14. Addressing concerns  about lead, an ADA study. ADA Professional Product Review. American Dental Association. 2009;4:14-15. Accessed August 1, 2025. http://rb.gy/87r156
15. ‘No appropriate use’: American Dental Association urges scrutiny of lead content. Healthcare News. 2008. Accessed August 1, 2025. https://healthcarenews.com/no-appropriate-use-american-dental-assoc-urges-scrutiny-of-lead-content/
16. Toti P. Dental lab checkup. Local 12 News. 2013. Accessed August 1, 2025. https://youtu.be/s0aZBt8tOcQ?si=ALbveMVP5DsrW2Ei
17. Do you know what’s in your mouth? ABC15 Arizona. 2015. Accessed August 1, 2025. https://youtu.be/V2se-_27ymM?si=hz3InLNvyxCr8m41
18. Convicted felon operating dental lab in northern Arizona. AZFamily.com. 2023. Accessed August 1, 2025. https://www.azfamily.com/video/2023/05/23/convicted-felon-operating-dental-lab-northern-arizona/
19. Werner A. FDA said it “never” inspected dental lab that made controversial AGGA device. CBS News. 2024. Accessed August 1, 2025. https://www.cbsnews.com/news/fda-johns-dental-agga-inspection/
20. NADL guidelines for establishing statutory regulations of dental aboratories. National Association of Dental Laboratories. 2007. Accessed August 1, 2025. https://dentallabs.org/media/2013/07/Guidelines-for-Establishing-Statutory-Regulation-Current-2007.pdf
21. ADHA Policy Manual. American Dental Hygienists’ Association. www.adha.org/wp-content/uploads/2023/01/ADHA_Policy-_Manual_FY22.pdf2025
22. Resolution 52. Dental benefits, practice and related matters. American Dental Association. 2013. Accessed August 1, 2025. https://dentallabs.org/media/2017/06/ADA-House-of-Delegates-Materials-2013-NADL-Issues.pdf