Dental health therapists bringing oral health care to US tribal communities: Opening up access
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* Lindsey Wahowiak

The problem of oral health disparities is one that faces every American Indian and Alaska Native community. The ways tribal communities are addressing dental health needs are as different as the communities themselves. But many of them have something in common: They are looking to dental health aide therapists to provide care and improve oral health.

Dental health aide therapists, sometimes called dental health therapists or just dental therapists, are licensed, mid-level oral health providers. They can perform about 50 of the most common procedures typically performed by dentists, and at the fraction of the cost, according to the American Dental Hygienists’ Association. Dental therapists are licensed middle providers in the oral health care team — similar to a physician’s assistant or nurse practitioner in primary care.

“It’s not business as usual: We’re changing the way dentists practice in their offices and clinics,” Jane Koppelman, MPA, director of research in Children’s Dental Policy with the Pew Charitable Trusts, told *The Nation’s Health.* “We know that the beginning of decay is the beginning of a cascade of problems. Dental therapists are able to treat decay…and treat it in a cost-effective way.”

For many years, the United States did not train or license dental therapists, so communities that wanted to benefit from a therapist’s services had nowhere local to turn. So when the Alaska Native Tribal Health Consortium in 2004 introduced the country’s first dental therapist program, the first six therapists in the program were trained in New Zealand — the only country with substantial training programs for therapists, though dental therapists practice in many countries, said Robert Onders, MD, medical director of community and health systems improvement with the consortium. Because the consortium assumed responsibility for the operations of the majority of the Indian Health Service Alaska Area office’s programs in the late 1990s, it was able to make decisions about how to best care for the community’s health among members of the community themselves.

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Dental health aide therapist Daniel Kennedy, right, sees his first patient, Anthony Cladoosby, at the Swinomish Dental Clinic on Jan. 4. American Indian and Alaska Native tribes and communities are using therapists to meet oral health needs.

Photo courtesy Swinomish Indian Tribal Community

What was tried before the dental health therapists had not worked, and the numbers tribal communities face reflect that. As of 2014, 43 percent of preschool-age American Indian children had tooth decay, compared to 11 percent of white children.

In 1999, the last year the Indian Health Service surveyed American Indian adults on oral health, nearly 70 percent of the population ages 35 to 44 had untreated tooth decay, and 43 percent also had periodontal disease, according to the Pew Charitable Trusts.

Disparities continue to persist. On the Pine Ridge Reservation in South Dakota in 2011, 97 percent of adults had untreated tooth decay and 68 percent had gum disease, according to Pew. Among the general U.S. adult population that year, only 27 percent had untreated decay.

“The reasons why AI/AN children have more tooth decay are not known,” according to an April 2015 IHS report, but it may be due in part to differences in bacterial, behavioral, sociodemographic and environmental risk factors. Alaska Natives are particularly in need: The Alaska consortium serves 180 village-based clinics, many in towns as small as 250 people, accessible only by plane.

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Aurora Johnson, left, a dental therapist, fills cavities for Paul Towarak, 10, in the village of Unalakleet, Alaska, in March 2008. The Alaska Native Tribal Health Consortium introduced the country’s first dental therapist program in 2004. Other American Indian tribes around the nation are following suit.

Photo by Alex Berenson, courtesy The New York Times/Redux Pictures

“There was a need for services, that was a crisis from access, (with) lots of factors that caused disproportional burden,” Onders told *The Nation’s Health.* “To have some sort of health care, behavioral care…there has to be someone in that community to provide that care.”

While many tribal communities are too small to support a full-time dentist, they could support a dental therapist — particularly if that therapist was a person from the community. Indian Health Service dental positions are historically vacant, Koppelman said, and those who did serve typically did so for only two years before moving on to a different post.

The results seen in Alaska were encouraging: In a study published in 2013 in the *International Journal of Circumpolar Health,* therapists in the Alaska Dental Health Aide Program were found to be competent in their services, and people were happy with the care they received. The results encouraged other tribal communities around the U.S. to push forward for their own dental therapy programs.

“The important common denominator with dental therapy is that communities clearly recognize their need for a dental provider in their community, who knows their community — and are raising their voices to improve their oral health,” Alice Warner, PhD, MA, director of policy for the W.K. Kellogg Foundation, told *The Nation’s Health.* “The oral health crisis is not unique to Alaska, and we should learn from the tribes’ success, where more than 45,000 people now receive regular dental care and they are beginning to see cavity-free kids.”

In the lower 48 states, the Swinomish Indian Tribal Community, in Washington, is the first to launch its own dental therapy program, announced in 2015 and offering services at the start of this year. The Swinomish community tried for years to work with the state Legislature to license and fund mid-level dental care professionals — a requirement of the Indian Health Care Improvement Act, enacted as part of the Affordable Care Act — but each bill died before making it to a vote, said John Stephens, programs administrator for the Swinomish Indian Tribal Community.

“To us, that was a direct assault on tribal sovereignty,” Stephens told *The Nation’s Health.* “The state Legislature didn’t help the tribes in Washington meet their public health responsibilities…So Swinomish had to exert its sovereignty, and other tribes may need to do the same.”

The Swinomish community developed its own licensing program for dental therapists. The first in the program, Daniel Kennedy, was trained in Alaska. Stephens said the move made financial sense, as therapists can perform about 50 percent of the tasks a dentist would, for 50 percent of the cost — freeing up the time a dentist might spend on routine cleanings and fillings for more complicated and expensive procedures. But it also made sense for the community. Because people from the tribal community are being trained in the program, there is economic and employment opportunity, but there is also a guarantee of culturally competent care that remains steady over the years, important especially for generations who only saw a dentist to get teeth pulled, Stephens said.

He estimated that the first year of the Swinomish program would increase oral health care access by 40 percent.

The improvements do not surprise Pam Johnson, oral health project specialist with the Northwest Portland Area Indian Health Board.

“Tribes are sovereign, and they can actually do what they need to do to take care of their own,” Johnson told *The Nation’s Health.* “Finally, something’s happening. People are excited that the tribes are leading the way on this. My organization feels like we should be using every known, proven, common-sense solution and this is one of them.”

Johnson said the board is working with other tribal communities to launch their own dental therapy programs. Several federally recognized tribes in Oregon, for example, have launched a pilot program to train dental therapists within the Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians, as well as the Coquille Tribe of Southern Oregon. But unlike in Washington, the tribes in Oregon have gotten cooperation from the state Legislature. Senate Bill 738, which permits the Oregon Health Authority to approve one or more pilot projects relating to dental health, was signed into law in 2011.

Other states are still working for access. In New Mexico, tribal communities have been a big part of the push to get the state to consider licensing dental therapists. A bill before the state Legislature died before a vote in 2015, and was reintroduced, but tabled indefinitely, in January this year.

Tribal communities are facing resistance from a perhaps surprising source: dentists themselves. The American Dental Association sued the Alaska consortium when the state’s program first launched — and lost.

APHA supports dental health therapists, particularly among at-risk populations. In a 2014 policy statement, the Association noted that “DHATs have been used successfully in 42 other countries, including New Zealand for over 84 years.” It also pointed out that one study showed that “the quality of restorations placed by dental therapists was equal to, but more often better than” those done by dentists.

Scott Tomar, DMD, DrPH, professor and interim department chair at the University of Florida College of Dentistry and chair of APHA’s Oral Health Section, noted that while some dentists have had a monopoly on the market, they are not reaching most people needing care: Just 1 in 15 dentists in the state of Washington accepts Medicaid patients, for example, pointing to a problem looming beyond tribal communities. In states such as Minnesota, where dental health therapist legislation was approved in 2009, people receiving public assistance gained improved access to care, particularly those in rural areas.

Tomar said the precedent set in other health disciplines shows that dental health therapy is the obvious choice for public health.

“Medicine has learned this long ago: Why use the most expensive member of your health care team if you can delegate,” Tomar told *The Nation’s Health.* “You can expand services. I don’t know of any modern practice that doesn’t employ mid-level providers.”

To learn more about the Alaska program, visit [www.anthc.org](http://www.anthc.org).

*   Copyright The Nation’s Health, American Public Health Association