Native American Connections and the Arizona Advisory Council on Indian Health Care have launched an inventive outreach campaign called “Strong Teeth, Strong Kid” that is working to inform Native families about the importance of dental health and will work to reduce disparities in oral health that have hidden Native smiles for generations.
The program, forefronted by a muscular molar named Toby the Tooth, extends throughout February, National Children’s Dental Health Month, and features crossword activity sheets and “Smilestones,” which tell families what to expect as babies’ primary teeth emerge and dental visits become needed.
“The response from partners like the San Carlos Apache Tribe has been strong,” said Cory Hemstreet, health program manager on the Arizona advisory council. “One of the things that they felt worked for them was having their own tribal members present within their marketing materials,” she said. “They could really see themselves being a healthcare provider or going into the clinic.”
American Indian and Alaskan Native children have five times as much untreated decay in their permanent teeth from ages six to eight as compared to the general U.S. population, according to a 2017 Indian Health Service data study. One factor that continues to play a dominant role in this inequality is access to care.
“The mainstream American dental system generally requires waiting periods that last a couple of weeks,” says Brett Weber of the National Indian Health Board. But there are tribes, especially in rural areas, whose waiting periods for dental appointments can last six or seven months.
Kim Russell, executive director on the advisory council told Indian Country Today that providers’ efforts to share information about tooth decay and prevention with Native families have been limited to dental clinics. They say they want the messages to be elsewhere and seen by the tribal communities.
“This messaging is slim to none,” said Russell. “Maybe the only time we get those types of messaging is when we’re at the dental clinic. And we know that our people have a fear of going there in the first place, so if they’re not going to the clinic they’re not getting the message.”
“Strong Teeth, Strong Kid” adopts a versatile, grassroots approach that combines both social media like Facebook and Instagram and traditional media like tribal newspapers. Since many Native homes populate settings where Internet access is unreliable, those print resources can make or break outreach efforts.
Community-wide negative experiences present barriers to care
In the case of Alaska, said Weber, traveling dentists used to fly into villages to provide care over just a week’s time, prioritizing teeth that had to be pulled and finding little time to build rapport with patients. Often they would face overwhelming workloads and burnout.
“So from the patient perspective,” he said, “the dentist came in for a week, pulled your teeth, your friends’ teeth, your family’s teeth and then left, and you never saw them again, and so it’s going to be really difficult to develop a healthy disposition toward oral health when that dynamic is present.”
Totem Concepts owner and campaign partner Kevin Russell, who specializes in marketing and branding, says the best outreach for Arizona’s 22 tribes, living in urban and rural areas, was to invite them to join the campaign, modify it if they had to and embrace it as their own. He also says that for this reason, “Strong Teeth, Strong Kid” tailored its messaging to different target audiences based on each tribe’s values.
Kim Russell said these strategies aim to transform a disconnect between providers and communities, and that “while it may take generations to succeed, there’s an urgent need to start somewhere.”
The call for dental therapists
According to Kim Russell, another big part of increasing dental health outreach in Native communities is through the use of dental therapists.
“Our biggest win, of course, has to be dental therapy,” said Kim Russell, “just because we knew it was going to be a huge undertaking.”
Dental health therapists provide a narrower range of services than dentists but are required to undergo fewer years of training, giving them better access to populations where dentists are scarce or harder to retain. Hundreds of studies attest to the success of the dental therapy model for underserved populations and kids in particular, whose needs usually fall within the scope of the procedures dental therapists cover.
A study by the University of Washington, based on the introduction of dental therapy in Alaska, found that children with more dental therapist treatment days saw huge gains in preventative care and far fewer tooth extractions than previously observed.
“Dental therapy education is a lot more accessible than a doctorate degree,” said Dr. Miranda Davis, who directs the Native Dental Therapy Initiative for the Northwest Portland Indian Health Board. “A doctorate degree is not accessible. And receiving education for dental therapy can bring care to communities where the care is really needed.”
Kim Russell said the 2018 law approving dental therapists in Arizona was a dramatic victory, especially since it passed during the first year her coalition dropped the bill. Implementation of this law presents new challenges too, and tribes within the state are still working to train and deploy dental therapists.
Currently, a total of 12 dental therapists serve with tribes in the states of Washington, Oregon, and Idaho, and over 100 provide care in Alaska, where the U.S. dental therapy model was first pioneered in 2006.
“We’re hoping that kids will see dental therapists that look like them,” said Kim Russell, “and then hopefully will aspire to be dental therapists themselves and aspire to be dentists themselves.”
Dental therapists and the American Dental Association
The American Dental Association has officially opposed dental therapists, spending millions of dollars to block state legislation authorizing them and filing lawsuits to challenge the Alaska Dental Therapy program.
The American Dental Association frequently asserts that dentists — trained to address more complex procedures — should always be the key providers of dental care. But while dental therapists cover only 50 of the 500 procedures dentists do, “those procedures treat over 80 percent of the conditions needed in Native communities,” said Davis.
Dr. Jane Grover, who directs the Council on Advocacy of Access and Prevention for the ADA, said solutions to problems in dental care require the services of more than one discipline.
“I think we have to really double down on prevention,” she said. “It’s got to be a multifaceted strategy that consists of sealants, community water fluoridation and all of the aspects that have been shown to be effective in preventing disease.”
Weber says the American Dental Association’s primary goal is to protect the dentistry profession and the monopoly over care it has come to command. This has led to past setbacks in delivering its message to Indian Country from which it’s working to recover still.
“Native communities have a unique experience with the oral health system,” he said. “So the ADA, saying, ‘You don’t know what’s best for your own communities. We do.’ That rubs people the wrong way.”
He also said the American Dental Association often advocates for better funding of the Indian Health Service. The board appreciates this, he said, because the chronic underfunding of IHS by Congress is the greatest constraint weakening oral health in Native communities.
He is hopeful the American Dental Association will eventually reconsider its position on dental therapists and come to see them, not as a threat, but as allies for dentists, just another addition to the healthcare team.
Meanwhile, the search for common ground by tribal leaders and the ADA looks brighter. This year the IHS will be joining the American Dental Association for its annual Give Kids a Smile program. On February 5 providers with the San Carlos Apache Tribe will offer wide-scale screenings and fluoride varnishes for Native kids, and the Mississippi Band of Choctaw Indians will offer services for community members as part of the event too.
Strong Teeth, Strong Futures
Not all dentists oppose recent measures to build dental care directly into Native communities with dental therapists. Organizations like the National Coalition of Dentists for Health Equity, a nationwide alliance of prominent dentists, endorse them, as do the American Public Health Association, the American Dental Hygienists’ Association and the American Association of Public Health Dentistry.
Davis, a dentist, said there tends to be high turnover for dentists at tribal clinics, with a quarter of IHS positions remaining vacant as of 2018. Loan repayment programs help, but dentists rarely stay beyond the few years they’re contracted to. By contrast, the retention rate for dental therapists in Alaska exceeds 80 percent.
“That kind of consistency is essential for building trust and helping people to feel comfortable with receiving oral healthcare,” she said. “We all prefer to receive care from someone we know and trust.”
Weber said tribes’ ownership of their oral health is rooted in the rights of Native sovereignty and the treaty obligations that still promise healthcare in exchange for land and peace.
“Tribes really know what’s best for their own communities,” said Weber, “and we need to empower them to solve the oral health crisis in Indian Country. But our kids are our most precious resource for our tribes, and we want to make sure that their smiles are as bright as their dreams.”
Chris Kopacz, Pascua Yaqui, is a correspondent based in Phoenix, Arizona. Follow him on Instagram @YoemeNativeNews. Email him at firstname.lastname@example.org.