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In Alaska, Better Dental Care

This article was produced and provided by the W.K. Kellogg Foundation.

Alaska Natives have found a way to add more dental providers.

Can Indian Country be far behind?

Historical evidence suggests that dental disease was rare among American Indians and Alaska Natives (AI/ANs) in the early 20th century. Today, AI/ANs have more untreated tooth decay and gum disease than any other population group, due to socioeconomic status, changes in diet, lack of preventive programs, and simply not enough dental professionals to meet the huge backlog of untreated disease. Indian Country will need even more dental providers beginning in 2014 when thousands of American Indian children will become eligible for Medicaid dental benefits under the Affordable Care Act. Who will provide this care?

In 2006 the Alaska Native Tribal Health Consortium forged the way to introduce dental therapists to dental teams in the United States. In Alaska, Minnesota, and around the world, dental therapists perform routine services like basic evaluations and fillings, allowing clinics to accept more patients and freeing their dentist supervisors to treat complex cases. Thanks to Alaska’s thriving Dental Health Aide Therapist (DHAT) Program, about 35,000 people living in remote villages have access to regular dental care, and many of the Alaska DHATs are familiar members of their home communities. The Alaska program can serve as a model for tribal programs in the lower 48 states, but first there are barriers to overcome.

The Alaska Experience

For years, Alaska Native leaders searched for ways to meet the vast need for dental services in rural and remote communities. Then they learned about a successful program in New Zealand, which in the 1920s began training and deploying mid-level dental practitioners known as dental therapists to provide preventive and routine dental care in underserved communities. Dental therapists work as part of a team led by a dentist, in much the same way that nurse practitioners and physician assistants work as part of a medical team to expand access to care.

The Alaska Native Tribal Health Consortium (ANTHC) decided to establish a similar program in Alaska, building on the principles of its successful community health aide program. With funding from the Rasmuson Foundation, the ANTHC sent the first class of dental therapy students to New Zealand for training in 2003. After two years of rigorous training and education, the new dental therapists returned to practice in their villages.

Courtesy Kauffman

DHAT Bernadette Charles at her clinic near the Bering Sea

The American Dental Association (ADA) and the Alaska Dental Society tried to block the dental therapists from practicing, filing a lawsuit that challenged the authority of the Indian Health Service to certify the new providers. That lawsuit failed, and Alaska’s dental therapists—called Dental Health Aide Therapists or DHATs—were certified under the authority of the Indian Health Care Improvement Act (IHCIA). However, when the IHCIA came up for reauthorization, there was a restriction that dental therapists could not practice in the rest of Indian Country. So Congress prohibited dental therapists except where authorized by state law. In response to these provisions, tribal organizations such the National Congress of American Indians and the National Indian Health Board are taking a stand, encouraging tribal governments to support development of the dental therapist provider modeled by the Alaska Dental Health Aide Therapists for the benefit of their member communities. Several tribes in the exercise of self-determination and self-governance recognize that they have the sovereign right to determine who should care for their children’s teeth in their communities and seek to expand their dental workforce now and in the future.

In Alaska, the dental therapist program has blossomed. In 2006, with support from the W.K. Kellogg Foundation, Rasmuson Foundation and Bethel Community Services Foundation, the DENTEX dental therapist-training program was created and cosponsored by the ANTHC and the University of Washington. The intensive two-year education program is based in Anchorage and Bethel.

Today, things are changing. Village by village, Alaska is bringing highquality preventive and routine oral health care to people who previously had little to no access to a dentist. Since 2005, den tal therapists have expanded oral health care access to more than 35,000 people. Twenty-four dental therapists are practicing in Alaska today. They work in schools and Head Start programs, where they teach children how to take care of their teeth, and at clinics in tiny, remote communities, where they provide commonly needed services like cleanings, fillings, and uncomplicated extractions. Already, they are making a dent in the cavity rate among children and are practicing less restorative and acute care than when they started.

Dental therapists are also saving the system money. The average dental therapist salary in Alaska is about half that of a dentist—$60,000 per year versus $120,000—so the savings are very real. Medicaid reimbursements are the same for a dentist as they are for a certified dental therapist in Alaska, so the income is viable.

These efficiencies come at no sacrifice to quality. An independent evaluation conducted by the Research Triangle Institute found that dental therapists in Alaska provide safe, appropriate, and quality care.

What Lies Ahead?

State or federal actions are necessary before dental therapists can be deployed to care for more American Indians. These actions could take the form of changes to state dental practice laws or, at the federal level, amendments to the IHCIA (now part of the Affordable Care Act).

Currently, more than 20 states are exploring mid-levels such as dental therapists as a way to address the oral health needs of their communities.

The experience of the Alaska Native Tribal Health Consortium shows how success can happen when communities commit to solving their most pressing health problems.