A medical revolution that began in Indian country is spreading across the U.S., from Oregon to Vermont, and tens of millions of lives will be better for it.
Most recently, Vermont Gov. Peter Shumlin signed a law that authorizes mid-level dental health aide therapists (DHATs) to practice. Vermont joins two other states—Minnesota and Maine—that have sanctioned dental therapists, while Oregon has authorized pilot projects for the Coquille Tribe and the Confederated Tribes of Coos, Lower Umpqua, and Siuslaw Indians. Almost a dozen other states have filed legislation to approve DHATs just this year. A few months ago, the Swinomish Tribe became the first tribal community in the continental U.S. to hire a dental aide therapist.
Native communities, under the direction of the Alaska Native Tribal Health Consortium, pioneered the concept of DHATs in the U.S. Since 2004, DHATs have provided care to 40,000 people in Alaska’s tribal villages, care that they probably would not have been able to get otherwise. DHATs travel to remote communities and provide care in schools, community centers and clinics.
DHATs are rigorously trained and practice for 400 hours under the direct supervision of a dentist before they are certified to perform oral exams, clean teeth, fill cavities, do simple extractions and provide preventive care on their own under remote supervision. DHATs’ services free up dentists for more complex tasks such as implants and dentures, which before they often had not been able to perform because they did not have time.
Efforts to permit DHATs to practice have met with opposition from the American Dental Association, which has claimed—without evidence—that DHATs provide inferior care. The W.K. Kellogg Foundation, on the other hand, has backed the use of DHATs and provided funds to support training and deployment. In a statement applauding the Vermont law, Foundation President and CEO La June Montgomery Tabron said: “We stand with the people of Vermont and leaders in other states and across Indian country where community-led efforts to improve oral health are beginning to take hold. And we look forward to a future where tooth decay is no longer the number one chronic illness affecting children in the U.S.”
In Indian country, tooth decay rates for children and adolescents are twice the national average, according to the Indian Health Service. The 2015 IHS Oral Health Survey found that American Indian and Alaska Native adults had the highest rate of untreated dental caries (cavities) of any racial/ethnic group in the U.S. They have almost twice the rate of severe periodontal disease as the U.S. population as a whole, and are more likely to have missing teeth and to report having poor oral health and mouth pain. A full 40 percent (compared to 19 percent of the U.S. total population) reported avoiding food because of mouth problems. A 2011 W.K. Kellogg Foundation study found that on the Pine Ridge Reservation, 97 percent of adults and 84 percent of children had untreated tooth decay and 68 percent of adults had gum disease.
The IHS has only 280 dentists to serve 2.2 million people, which averages out to 7,857 patients per dentist, compared to 1,620 patients per dentist for the general population in 2013, according to the American Dental Association.
As Vermont and other states have recognized, people’s inability to get the dental care they need is not limited to tribal communities. Even in a state with as many resources as Massachusetts, where the per capita income was $37,288 in 2014 (compared with $23,683 in New Mexico, or $21,036 In Mississippi, for example), only 53 percent of low-income children and youth and 56 percent of low-income adults saw a dentist that year, according to the Massachusetts Health Policy Commission. Middle-income people have better access, but even they must often postpone dental care, or have teeth pulled instead of repaired, because of cost. DHATs can help—they earn about half of what dentists earn.
In Alaska, the DHAT program is an expansion of the Community Health Aide Program that began nearly half a century ago. CHAP provides primary health care, including education, communicable disease control, mother and child health care, behavioral health, family planning and environmental health, and referrals in more than 170 rural villages.
The Indian Health Service announced June 1 plans to expand the CHAP program to tribal communities throughout the U.S. Writes IHS in its policy statement about the proposal: “The use of paraprofessional health care workers, like community health aides, is a proven strategy for increasing access to much-needed health services and improving the quality of those services in Indian country, as well as other rural and frontier areas.”
Comments on the proposal are due July 29 and may be emailed to firstname.lastname@example.org under the subject line: IHS Expansion of Community Health Aide Program Draft Policy Statement Consultation, or mailed to Alec Thundercloud, M.D., Director, Office of Clinical and Preventive Services, Indian Health Service, 5600 Fishers Lane Mail Stop: 08N34-A, Rockville, MD 20857, ATTN: IHS Expansion of Community Health Aide Program Draft Policy Statement Consultation.