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Crossing the Dental Divide in Indian Country with Dental Therapists

The “dental divide”—the absence of services and access to dental health services in low income communities—is real, especially in Indian country.

Native people represent America’s most rural communities and those communities struggle to find dentists who will practice in their clinics and health systems. In fact, according to the Health Resources and Services Administration (HRSA), there are 45 million people who live in areas where they can’t get dental care. It’s estimated that an additional 6,600 dental providers are needed nationwide to meet the current need. At the Indian Health Service (IHS) 17 percent of all dentist positions are vacant and IHS providers carry a patient load nearly twice as high as dental providers in the general population.

In Indian Country this lack of access to dental health is having a profound impact on those smiles we so often flash when we’re laughing and joking around. For some, the smiles are not as bright or may be covered behind a hand. According to the American Academy of Pediatrics, Native children have three times the rate of untreated cavities compared to other kids; over 50 percent of Native children have untreated decay and 75 percent to 97 percent of adults have untreated decay.

And yet, the “oldest and largest national dental society in the world,” the American Dental Association (ADA), continues to overlook the most promising and proven solution addressing this gap in Native communities – dental therapists. Announced this week at a press conference in Washington, DC, the ADA launched “Action for Dental Health;” a new national campaign to address the “dental health crisis facing America today.”

The plan was bold, calling for great improvements in education and reimbursement and continuing to rely upon the same dental delivery system that has been in place for decades. However, it overlooked a crucial fact: there are not enough dentists willing to live and practice in Indian Country for long periods and what Native people need now is access to treatment. The ADA’s plan should include the use of dental therapists to help expand care, but it does not.

Dental therapists are mid-level providers who are part of a dentist-led team. They educate patients about oral health and prevention, perform dental evaluations, give fluoride treatments, place sealants, clean teeth, place fillings, and perform simple extractions. Like nurse practitioners and physician assistants in the field of medicine, dental therapists expand the reach of dentists and free them to perform advanced treatments.

First introduced to the United States in 2006 by the Alaska Native Tribal Health Consortium, Dental Health Aide Therapists (DHAT) are now providing nearly 40,000 Alaskan Natives with access to regular dental care for the first time. In a study released by Community Catalyst this week, dental therapists –currently practicing in Alaska and Minnesota – are shown to be rapidly expanding access to people in remote areas, those who are publicly insured, and children.

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While the ADA should be commended for its modest initiatives to improve oral health education, increase charity care, and make more efficient use of the current dental care system, we hope the ADA will understand that preventive education alone won’t be enough to increase dental health care in remote tribal communities where dentists don’t go.

Instead, as is being shown in Alaska, closing the gap in some of the most remote areas requires dental therapists to fill cavities and serve as trusted experts preventing disease and providing oral health care to Native people in their homes and communities. It’s a model that Alaska Natives have led with and if deployed throughout Indian Country could quickly close the dental divide.

Alaska’s dental therapists were certified under the Indian Health Care Improvement Act (IHCIA), but Congress changed it upon reauthorization requiring state dental practice acts be amended before the DHAT model is implemented outside of Alaska. Currently, more than a dozen states are seriously exploring mid-levels such as dental therapists as a way to address the oral health needs of their communities, while Indian Country is left out of the conversation. However, state or federal changes can be made which are necessary for dental therapists to be deployed to provide care for more American Indians. And it’s time for the ADA to join the National Congress of American Indians (NCAI) in calling for these changes.

Dental therapists are a viable and proven solution for increasing dental health in Native communities, but the ADA has continued to publicly deny or remain silent on the proven track record of dental therapists. This week there was a glimmer of hope from the ADA’s President Dr. Robert Faiella when he said at the organization’s press conference launching the effort, “we want to help all Americans obtain the best possible health.” Faiella went on to say the ADA is supporting only proven practices.

Dental therapists are proven, not one study shows otherwise.

If the ADA wants to live up to the promises of their campaign, they’ll take action and change their position on dental therapists. It’s time for the ADA to reconsider its position and stand with Indian Country and actually close the dental divide.

That’ll give everyone something to smile about.

Jacqueline Pata is a member of the Raven/Sockeye Clan of the Tlingit Tribe in Alaska and is the Executive Director of the National Congress of American Indians (NCAI). Founded in 1944, NCAI is the oldest, largest, and most representative American Indian and Alaska Native organization serving the broad interests of tribal governments and communities.