Oregon Looks North for Lessons about Expanding Dental Access to Reservation Communities
Native Americans have the highest rates of oral diseases in the United States. A report published in April by the Indian Health Service said that more than half of American Indians and Alaska Natives between the ages of one and five have experienced tooth decay; a rate that is more than four times higher than white non-Hispanic children.
“This disparity exists in spite of the implementation of dental decay prevention programs by IHS and Tribes, including fluoridation of community water systems, the use of topical fluorides and dental sealants, and oral health educational programs for children and parents,” according to the IHS Data Service brief by Kathy R. Phipps, Dr. P.H. and Timothy L. Ricks, D.M.D., M.P.H.
One of their key findings is that American Indian and Alaska Native preschool children do not receive enough dental care.
One out of three children were found to have untreated tooth decay and about 6 percent of the children surveyed had “a need for urgent dental care which means that they have pain or a serious oral infection.” That percentage, the report said, means that almost 8,500 Native American preschool children nationwide “have a serious dental problem resulting in pain or infection.” Even worse: Because of their age, many of the children with decay “must be treated in a hospital setting under general anesthesia at a cost exceeding $6,000 per child.” Indeed, across the country there is a severe shortage of dentists — a problem exacerbated in the Indian health system. (There are more than 50 openings for dentists in the Indian health system as of October 1, including four in the IHS’ Portland Area Office.)
In Oregon alone one estimate is that at least 160 dentists would be required just to meet current dental needs. An Oregon Health Authority survey found that over half of 6-9 year olds have experienced tooth decay and one in five have untreated decay. And, children in southeast Oregon were found to have substantially higher rates of tooth decay than their peers in the rest of Oregon, as did lower income children compared to their higher income peers. On any given day, the survey reported, as many as 3,800 children in 1st to 3rd grades in Oregon may be in school suffering from dental pain or infection.
So Oregon’s tribes and tribal health care providers are experimenting with a new approach to dental care. More about that shortly. First, we need to look north at Alaska’s Dental Health Aide Therapist Initiative. The Alaska Native Tribal Health Consortium decided in 1999 to support the creation of mid-level oral healthcare providers, whose practices would be similar to nurse practitioners or physicians assistants. The idea was that there would never be enough dentists to serve Alaska’s remote villages so a better alternative would be to train people locally to work as providers with a limited scope of practice. In 2003 six Alaska Native students were sent to a university in New Zealand for a two-year training program. Four of those students graduated and went on to work for the Yukon-Kuskokwim dental health organization in Bethel and the Maniilaq Association in Kotzebue.
The Alaska dental health initiative was controversial in some quarters. In 2004 the American Dental Association unsuccessfully lobbied to amend the Indian Health Care Improvement Act so that “no dental health aide is certified under the program to perform treatment of dental caries, pulpotomies, or extractions of teeth.” Then in 2006, the Alaska Dental Society and the ADA filed a lawsuit against the Alaska tribes and the therapists to prevent them from practicing. Alaska’s Superior Court ruled against the dental associations and a subsequent settlement ended the dispute. At least in Alaska.
In September 2006, the W.K. Kellogg Foundation funded the Alaska Native Tribal Health Consortium and the University of Washington to launch an Alaska-based training program. New students began with a year of didactic training in Anchorage, followed by a second year in Bethel for clinical training. Some 25 Dental Health Aide Therapists have graduated and now provide service across Alaska providing basic oral health education, prevention, fillings, and uncomplicated extractions while working under the general supervision of supervising dentists.
Several investigations have shown Alaska’s DHAT program to be a remarkably successful model of care. One such study, by RTI International, reported in 2010 that one reason is the DHATs conscientiously stick to their scope of practice. This is exactly my experience. I visited the Bethel program in 2011 with a group of dentists. During one of the sessions, the dentists quizzed several DHATs about their practice. When it was a procedure outside of their scope of practice, the DHAT said so. But when the questions were about what they did, the dentists told me the answers were spot on. Every time.
And that brings us back to Oregon. Some time over the next few days, the Northwest Portland Area Indian Health Board, working with the Confederated Tribes of Coos, Lower Umpqua, and Siuslaw Indians and the Coquille Tribe, will submit a proposal to the Oregon Health Authority to create a pilot for a midlevel oral health program next year.
The pilot will tap existing, trained DHATs to open in Coos Bay in 2016 and Coquille in 2017. A student from Coos Bay is already in Alaska where she is beginning her training. The plan is for her to return to
Oregon for her second-year preceptorship with a supervising dentist. The health board is projecting five to seven DHAT trainees in as many as four sites. “After three years, we will evaluate the program with our pilot sites and make decisions at that point about whether or not we will add additional sites and trainees,” the health board said. The program will be evaluated based on criteria ranging from expanded access to patient satisfaction.
Oregon’s pilot program will be different from Alaska (or even other states) because there is less contention. Christina Swartz Bodamer, managing director for Government Affairs and Communications at the Oregon Dental Association, said in an email that “ODA was supportive of the 2011 Pilot Project bill and eagerly anticipates the data that will be coming from all pilots.”
Lots of folks will be eager for this data. Especially if it shows, like Alaska, that expanding dental practices mean more access for patients. A recent piece in the American Journal of Public Health says as many as two-thirds of all dental procedures can be performed by midlevel dental practitioners, such as DHATs. And 80 percent of the total dental visits to community health clinics. The end result could be improved access to dental care, especially among populations with the greatest disparity in oral health.
Mark Trahant is the Charles R. Johnson Professor of Journalism at the University of North Dakota. He can be found @TrahantReports on Twitter.