Little in politics has surprised Richard Malaby as much as the power of dentists.
For years, local dentists held four Christmas parties at Malaby's 19th-century country inn in the picturesque town of Hancock. But in 2014, Malaby, a Republican lawmaker in the Maine state legislature, voted to create a new type of dental provider to perform basic services in poor and rural areas.
The Maine Dental Association, which opposed the bill, was furious. And the dentists took their Christmas parties elsewhere, costing Malaby $6,000 that December and every Yuletide since.
Among the general public, dentists tend to have a Norman Rockwell appeal - solo practitioners who clean your teeth, tell your kids to cut down on the candy, and put their seal of approval on a range of minty toothpastes and mouthwashes. But lawmakers from Maine to Alaska see a different side of dentists and their lobby, the American Dental Association, describing a political force so unified, so relentless and so thoroughly woven into American communities that its clout rivals that of the gun lobby.
"I put their power right up there with the NRA," Malaby said. "Dentists do everything they can to protect their interests - and they have money."
As the cost of dental care rises beyond the reach of millions of Americans, the dental lobby is coming under increasing scrutiny. Critics say the ADA has worked to scuttle competition that could improve access to dental care in underserved areas and make routine checkups and fillings more affordable.
The Federal Trade Commission has battled dentists in state after state over anti-competitive conduct. In 2007, the FTC successfully settled a complaint over a South Carolina dental board requirement that dentists examine children in school clinics before hygienists can clean their teeth, adding greatly to the cost. In 2015, the FTC won a Supreme Court ruling against the North Carolina dental board, which tried to block teeth-whitening businesses from operating in malls.
This year, the FTC publicly commented on a growing campaign to improve access to dental care by creating a category of mid-level practitioners, or "dental therapists," to provide some routine services. In a letter to the Ohio lawmakers considering such a measure, FTC officials said therapists "could benefit consumers by increasing choice, competition, and access to care, especially for the underserved."
More than a dozen states are considering similar proposals, despite fierce resistance from the ADA and its state affiliates. During the Maine debate, so many dentists flooded the statehouse in Augusta that besieged lawmakers taped up signs declaring their offices a "Dental Free Zone."
The dentists had a unique way to get around the blockade: the regular checkup. While the bill was pending, some lawmakers found themselves getting an earful when they stretched out and opened wide for an oral exam.
"I'm certainly a captive audience when I am in the dental chair," said Brian Langley (R), a Maine state senator who also got calls from four other dentists in his district and ended up siding with them.
The bill establishing a new provider type ultimately passed, but "it was brutal, very brutal," recalled David Burns, a Republican state senator who retired after supporting the measure. Afterward, Burns said, he got a call from his dentist, who vowed never to treat him again, saying, "This relationship is over."
Most of the 200,000 dentists in America work solo, in offices that are essentially small businesses. They are known for projecting a remarkably unified voice on issues relating to their livelihood. The ADA says 64 percent of dentists belong to the association. By comparison, only 25 percent of physicians belong to the American Medical Association.
The ADA agrees that too many Americans are getting inadequate dental care. They argue that the answer is not the creation of "lesser trained" therapists, but more government funding and "community dental health care coordinators" to educate people and get them to a dentist.
"Dentistry has a fundamental belief that dentists should be the only ones to do surgical, irreversible procedures," said Michael Graham, senior vice president of the ADA's Division of Government and Public Affairs. "A lot of things can happen when you cut into a tooth."
Others argue that the American model of dentistry is badly in need of innovation and competition. The Pew Charitable Trusts and other foundations advocate therapists as a way to improve access and affordability.
Therapists cost less to train than dentists do, and states set the rules governing their training and scope of practice. Supporters say the idea is for the therapists to work in concert with a licensed dentist but be more mobile, visiting people in nursing homes and underserved rural areas to perform basic oral exams and fill and pull some teeth.
They would also treat people on Medicaid, the government health-care program for the poor. Two-thirds of licensed dentists do not accept Medicaid, and hospital emergency rooms are swamped with people with neglected teeth.
"Therapists are not a silver bullet but a significant way to begin addressing the problem," said John Grant, director of the Pew Charitable Trusts' dental campaign.
Louis Sullivan, a physician who served as secretary of health and human services under President George H.W. Bush, said dentists' opposition to therapists is largely about money.
"They think dental therapists will be competing against them and therefore will compromise their income," he said.
Sullivan noted that doctors strongly opposed the creation of nurse practitioners in the 1970s. Now doctors - and the health-care system - can't live without them, he said.
As in the nurse-doctor battle, there is a gender factor: More than 95 percent of dental hygienists are female. As a group, they support the idea of therapists and, with additional training, could join their ranks. Currently, hygienists work in small offices with licensed dentists, 70 percent of whom are male.
Dentistry has "been an old boys' club," said Ruth Ballweg, a professor and physician assistant at the University of Washington School of Medicine who has been involved in the fight for dental therapists. "But the model is changing."
More than 50 countries, from Canada to New Zealand, have dental therapists. Alaska Native tribal areas first introduced dental therapists to the United States in 2004. Since then, Minnesota, Maine and Vermont have approved them. Ohio, Kansas, Massachusetts, North Dakota and several other states are now contemplating their authorization.
The ADA has spent millions of dollars trying to block the bills. It also filed multiple lawsuits trying without success to stop the Alaska program.
"They went after these Alaskan therapists like they were ISIS. It was embarrassing," said Jack Dillenberg, a dentist who has taught at the Harvard School of Dental Medicine.
Dillenberg visited the Alaska program, where therapists working in consultation with a licensed dentist - sometimes by telemedicine - visit islands, remote villages and other underserved areas.
"I thought they were awesome," said Dillenberg, one of few dentists to publicly support the therapist idea.
Of two dozen dentists interviewed, a handful said they liked the idea, with some arguing that the existence of therapists would let them concentrate on more complicated procedures. Another proponent, Maine dentist Aatif Ansari, posted pro-therapist comments on Facebook during the 2014 debate. He got hammered by his colleagues.
"It was very aggressive. Folks were upset," Ansari said. "They said things like, 'How could you? I spend this many years in school and how could you let someone with inferior training do this work?' "
The ADA and its state associations often argue that therapists provide second-class care. Jonathan Shenkin, a Maine dentist who is active in the lobby, said the push for therapists is misplaced. He argues for more emphasis on prevention, including better nutrition and regular brushing.
The issue is "intensely debated and can be very emotional," said Mary Otto, author of a new book, "Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America." "It has to do with dentists' identity and the professional autonomy they have fought to keep for generations."
In Maine, the therapist bill turned out to be the most contentious issue of the 2014 legislative session. It passed only after opponents added multiple restrictions, including a requirement that therapists work only in the presence of a dentist. Supporters failed even to persuade lawmakers to let therapists travel to nursing homes alone.
Three years later, resistance remains high. Dentists control the dental schools and the state licensing board, and not one therapist has yet been trained. Supporters of the legislation say restrictions and bureaucracy have made becoming a therapist less desirable.
Meanwhile, people who can't pay continue to put off care. On a recent Friday, Michael Hanson, 54, a lobsterman who went 15 years without seeing a dentist, was sitting in the community health clinic near Maine's Acadia National Park. Over time, lack of care and poor health ruined Hanson's teeth. In February, they were all pulled. He sat toothless, talking about eating soft food for months while he awaits his dentures.
Hanson said his daughter, too, skips annual exams because it is hard to come up with the money.
The dental system is broken, he said. "You go to the hospital and they give you time to pay your bill. But you go to the dentist and they want you to pay right there, and people just don't have the money."
Heather Sirocki, a Maine lawmaker who backed the therapist bill, is a hygienist by training. She has seen the swollen jaws and blackened teeth of people who can't afford dental care. She's even heard of people driving to Canada to seek treatment.
People like Hanson "are not asking for a free handout," Sirocki said. "They are asking for a dental appointment."