To address the significant disparity in oral health services for Native people, on Monday, January 4, the Swinomish Indian Tribal Community in Washington State became the first tribe in the lower 48 to hire a dental health aide therapist (DHAT) to perform basic dental services for its members.
Supported by a grant from the W.K. Kellogg Foundation in partnership with the Northwest Portland Area Indian Health Board, dental therapist Daniel Kennedy joined the Swinomish Dental Clinic team in an effort to provide access to high quality, culturally-competent dental care for the tribe’s 3,000 dental patients.
But the move that has drawn fire from the powerful Washington State Dental Association (WSDA) and the American Dental Association (ADA), both of which have aggressively opposed the use of DHATs, claiming they are “unneeded” and provide “substandard” care for Indian people—in spite of numerous scientific studies which reveal American Indians and Alaska Natives are disproportionately affected by lack of oral health care and have the highest rates of cavities and gum disease in the entire world. Neither organization responded to ICTMN’s requests for comment by press time.
“We have one dentist and 3,000 patients at Swinomish. We cannot stand by any longer and allow Native people to continue to suffer tooth decay at a rate three times the national average,” said Swinomish Chairman Brian Cladoosby. “We have developed a tribal approach to solve a tribal issue. This solution will help our people immediately address their oral health needs in ways that have not been possible until today.”
According to the National Center for Biotechnology Information at the National Institutes of Health (NIH), the American Indian/Alaska Native pediatric population has the highest tooth decay rate of any group in the United States?five times the national average for children ages 2–4. Further, the rates for tooth decay among tribal children across the country are staggering: 60 percent among infants; 79 percent of 2 to 5 year olds; 87 percent of 6 to 14 year olds; and 91 percent of 15 to 19 year olds have cavities. Overall, 68 percent of all Native children have untreated cavities.
Therefore, say tribal officials, there is a growing sense of urgency to confront this health crisis with the addition of DHATs, or dental therapists, which are similar to nurse practitioners or physician assistants and are trained to perform a number of routine and preventive dental services, including fillings and simple extractions?at a much lower cost to the tribe.
The Swinomish said that because their repeated attempts to solve the issue through the state legislature went nowhere, they were forced to take action.
“Because of bad federal legislative language on DHAT’s, the Swinomish Tribal Community advocated for the Statewide Dental Health Aide Therapist authorization bill for five years in a row, with testimony from Chairman Cladoosby, Chief Dental Officer Ray Dailey and myself,” the tribe’s program administrator, John Stephens, told ICTMN. “We couldn’t even get it out of committee in either the State House or State Senate, so we decided that we had no choice but to take care of our people.”
Until now, the WSDA has successfully fought to keep dental therapists out of Washington State. The organization’s executive director, Brian Killpack, told the Seattle Times on Monday that instead of creating new providers, the state should instead raise its Medicaid reimbursement rates for dentists, who are reimbursed 29 cents on the dollar for Medicaid patients.
But the tribe says that raising state Medicaid rates would not apply to the Swinomish, nor would it address the enormous patient load for the tribe’s sole dentist.
Additionally, it would not speed delivery of desperately needed services to tribal members, said Cladoosby, many of whom are typically forced to wait weeks or months to receive basic dental treatment like cleanings, x-rays and fillings. Others, frustrated by long wait lists at overburdened tribal dental clinics, simply go without, which can lead to more complex—and even life-threatening—complications.
The lack of access to timely and efficient dental treatment has led to an ongoing health crisis among American Indians and Alaska Natives, many of whom also suffer from the “domino effect” of poor dental health, which has been connected with heart disease, diabetes, stroke, respiratory issues and problem pregnancies. According to the NIH, the two most significant factors that have contributed to a lack of access to dental care include the geographic isolation of many tribes and the difficulty in attracting dentists to work for the Indian Health Service or for tribally-owned health facilities.
To address this crisis, Alaska has allowed DHATs to train and work in tribal communities in that state, which has over 85,000 Alaska Natives who live in rural areas not accessible by road. The Swinomish program, said the tribe, is based on the Alaska model, which has been operating a successful tribal oral health program for over a decade. The DHAT programs are also legal in Minnesota and Maine.
The profound disparity in oral health care services is one of the biggest health crises facing tribes today, said Cladoosby, who is also president of the National Congress of American Indians. It is a model that he hopes will eventually be available to all of the 260 Indian tribes in the lower 48 states.
“Our objective with the dental therapist is to improve access, maintain a high quality of care and be economically efficient with our resources,” said Cladoosby, “all of which are accomplished by integrating a mid-level provider in our dental clinic.”