How Alaska tribes solved their dental health crisis

Dental health therapy takes half the time it takes to train a dentist. And it does what good medicine should: improve public health.


A long time ago a few smart folks at the Institute for Healthcare Improvement figured out that the best way to improve medical care in this country is to focus on three things: Make a patient’s experience more positive; improve the general health of the population; and reduce costs.

That three-legged strategy makes so much sense.

The first two are self-evident. The art of healing and easing pain doesn’t make much sense if patients are made unhappy by the experience. We need to be partners with our doctors and other health care professionals. At the same time, at a system level, it’s important to measure what works in public health. And then try to do more of that.

The third idea is uniquely American. The country spends way too much on health care and gets a lousy return for the investment. Our costs are more than double the average of other industrial nations, and all that money buys a shorter life expectancy, as well as higher incidents of chronic disease, than comparable developed countries.

I was thinking about this metric when I read a new study about oral health, titled “Dental Utilization for Communities Served by Dental Therapists in Alaska’s Yukon Kuskokwim Delta: Findings from an Observational Quantitative Study.” Yes, I know. The title shouts drama – you want to know the story and then what happens next, right?

But wait. There’s a good story before that story.

A generation ago, back in the 1990s, Alaska Natives faced a dental health crisis. It was a combination of several dangerous trends: too much sugar in the diet (replacing traditional foods) plus an extreme shortage of dentists. A 1998 study by the Southeast Alaska Regional Health Consortium showed that only 20 dentists were serving more than 200 villages with some 85,000 people. That resulted in tooth decay reaching epidemic levels: About 70 percent of children under 14 had dental caries (a bacteria process that causes decay), and more than 90 percent of adolescents showed the disease.

Recruiting dentists to rural Alaska would be difficult and too expensive, so the Alaska Native community did something radically different: It generated its own oral health professionals.

In 2003, six students traveled to New Zealand for a two-year training program to become “dental health therapists.” That’s half the time it takes to train a dentist – and at a cost significantly less. These highly trained mid-level providers work under the supervision of dentists. They do restorative and preventive services, dental exams, fillings, teeth cleaning, sealants, and simple tooth extractions. Basic stuff.

Dental health therapy gave access to oral health services to villages that had gone without. A success story.

More tribes and states have been moving forward with mid-level oral health care. The Swinomish Indian Tribal Community in Washington trained a dental therapist in 2015, and last month a new, Alaska-trained dental therapist began her practice for the Confederated Tribes of Coos, Lower Umpqua, and Siuslaw. Dental therapists have been authorized in Minnesota, Maine, and Vermont, and they are being considered in Arizona, Kansas, Maryland, Massachusetts, Michigan, New Mexico, North Dakota, and Ohio.

But the American Dental Association is opposed to the concept and lobbies against the idea. A June 2017 newsletter published by the Oregon Dental Association (where a dental health therapist pilot program is underway) says, “Proponents often casually remark that this will allow dentists to provide ‘more complex services.’ There are no services in dentistry that are not complex. Because of the training a dentist receives, the procedure may become uncomplicated for the doctor, but from a patient safety perspective, every procedure is complex. They are exaggerating to say that an extraction is not a complex procedure. At the end of the day, the simple truth is that Native Americans deserve the same level of care that every other member of our society deserves.”

That brings us back to the new study, led by Dr. Donald Chi at the University of Washington. This review looked at a decade of patient and Medicaid records for 25,000 Alaska Native patients at the Yukon-Kuskokwim Health Corporation. In research terms, that’s a massive amount of data. The results showed children had lower rates of tooth extractions and more preventive care in Alaska Native communities served frequently by dental health aide therapists than residents in communities not receiving those services. Adults in communities with the highest DHAT visit days also had fewer extractions and more preventive care visits.

Access works. Period.

The UW study confirmed that dental health therapy hits the very best outcomes when it comes to any health care reform: serves patients, improves public health, and lowers costs.

Six years ago, I went with a group of dentists to Bethel, Alaska, to see the work of dental health therapy (funded by a grant by the W.K. Kellogg Foundation, a major supporter of the dental health therapists project). I was struck by a few things.

First, this is a community-based solution that works. Access to good health care is important, and Alaska Natives found a way to get it.

Second, the dentists tested the dental health therapists with questions about practice and procedure. Answers relied on their limited scope of practice, and when a procedure required more, these mid-level providers would refer patients elsewhere.

Third, I want to see this kind of access for all Americans. I hear from people all the time who can’t find or afford a dental provider. Mid-level providers, much like nurse practitioners and physician assistants, lower costs and expand access – exactly what we need.


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