In a study conducted from 2013-15, the Aspen Institute’s Center for Native American Youth found that lack of access to dental care in Indian country is a serious issue, mainly because of a scarcity of dentists.
On the Colville Indian Reservation, for example, one dentist serves a population of 6,000. “You never get preventative care,” Colville Tribes Vice Chairman Mel Tonasket told the Tribal Tribune. “You only get emergency care. They open up at 7:30, and to get in you had to be there at 7 if you had a broken tooth or a bad toothache.”
But access to dental care in Indian country is about to change, thanks to the tenacity of the Swinomish Tribe and state Sen. John McCoy, D-Tulalip. And McCoy believes the program will someday expand to benefit all Washingtonians, Native and non-Native.
Gov. Jay Inslee signed into law on February 22 a bill that authorizes the training and employment of dental health therapists—the dental version of a nurse practitioner—to provide basic dental care at Indian country dental clinics in Washington state. The bill, SB 5079, authored by McCoy, authorizes the use of Medicaid and other federal funding for the services of dental health therapists.
Washington is the sixth state to authorize the use of dental health therapists—dental providers who are trained to provide cleanings, place fillings, fit crowns, perform simple extractions, and provide education on oral health. Alaska established a dental therapy program in 2003, followed by Minnesota, Maine and Vermont. Oregon has authorized pilot projects with several Native Nations.
According to Christina Peters, Native Dental Therapy Initiative project director for the Northwest Portland Area Indian Health Board, four students from Northwest states are in training now at the Alaska Native Tribal Health Consortium and Ilisagvik College, which has an accredited dental health therapist curriculum; four more will begin training soon. Including Swinomish’s current dental health therapist, there will be nine dental health therapists in the Northwest by 2019.
The benefits of dental health therapists are manifold, Peters said. It takes two to three years to train and certify a dental health therapist, compared to eight years for a dentist. The dental health therapist provides basic care and preventive treatment, freeing the dentist to perform more complicated dental care procedures.
The use of dental health therapists speeds access to care. In Minnesota, nearly one-third of all patients surveyed for a 2014 report to that state’s legislature “experienced a reduction in wait times for an appointment since the dental therapist was employed … Over 80 percent of patients stated it took less than one month to get their first appointment with the dental therapist.” Patients reported waiting at least twice as long for a dental appointment before the dental health therapist was employed.
According to the Alaska Native Tribal Health Consortium, which pioneered the introduction of dental therapists in the U.S., dental health therapists provide dental health care to 45,000 Alaska Natives. (Until the introduction of air travel and importation of processed foods, Alaska Natives had the lowest rate of cavities in the world, according to an ANTHC report.)
McCoy began legislative efforts to allow dental health therapists to practice in Washington state more than a decade ago. The state’s dental lobby, with support from the American Dental Association, blocked the legislation until this year. The Swinomish Tribe, tired of waiting for the state to act, hired a dental health therapist for its clinic in early 2016, asserting it had the right to do so because it is a sovereign indigenous nation.
In the year since, wait times for a dental appointment at Swinomish have been reduced from three months to less than four weeks. Swinomish Chairman Brian Cladoosby, who is also president of the National Congress of American Indians, reported in the Swinomish news magazine qyuuqs that the employment of a dental health therapist has “greatly improve[d] services available to our community.”
McCoy said Swinomish’s success helped bolster support for his bill (it was approved by the Senate 49-0, the House 80-18). He said the use of dental health therapists “will make a tremendous difference for Native people—especially children. I’m proud to see Native communities lead the way. This is an affordable model that can improve lives by offering routine access to oral health care in places where providers are scarce. I hope we can all finally agree that these providers can safely fill a gap in care for underserved communities. We are already seeing early success with the Swinomish and it will be exciting to watch it expand to Tribes across the state.”
Intense Training to Improve Dental Care in Indian Country
The American Dental Association and its state associations opposed the adoption of dental therapist training and practice in the United States “mainly by asserting that it represents a second-tier or inferior level of care,” according to a June 2014 report on the National Center for Biotechnology Information website.
“This claim has been refuted by numerous studies … Dental therapists are endorsed by the American Public Health Association, the American Association of Public Health Dentistry, and the American Dental Hygienists’ Association as a successful model for increasing access to care for underserved populations.”
Training is intense. “Studies are 100 percent dental—no English lit,” Peters said: Classes for 40 weeks a year for two years, with an internship between the first and second year, followed by a 400-hour preceptorship with a dentist—a period of personal instruction, training, and supervision.
To graduate with an associate of science degree in dental health therapy from Ilisagvik College and be certified, each student must prove competency in medical evaluation, dental evaluation, periodontic techniques, restorative dentistry, oral surgery and local anesthesia, infection control, clinic management and supervision, equipment maintenance and repair, and community and preventative dentistry.
Dental Health Therapists Around the World
According to a 2009 report for the National Academy of Sciences, more than 14,000 dental therapists practice in more than 54 countries throughout the world, including New Zealand, which originated the concept; Australia; Canada; the United Kingdom; and, most recently, the United States.
“Dental therapist programs have been studied extensively in a number of countries, and the quality of care, which includes preventive and restorative treatment for more than 90 percent of school-aged children through high school, has been consistently documented to equal care provided by dentists,” the report states. “School-based dental therapists are salaried public health workers, and the overall cost of providing care to children in schools is thus significantly lower than the cost of private dental care.”
Dental health therapy opens a new, rewarding career field—and a good-paying one at that—in the states that adopt their training and practice. An experienced dental health therapist can earn about 50 percent of what a dentist earns, Peters said.
There are 29 federally recognized Native Nations in Washington state, 21 of which have dental programs. Chehalis, Colville, Elwha Klallam, Jamestown S’Klallam, Kalispel, Lummi, Muckleshoot, Nisqually, Nooksack, Port Gamble S’Klallam, Puyallup, Quileute, Quinault, Shoalwater Bay, Skokomish, Makah, Squaxin Island, Swinomish, Spokane, Tulalip, and Yakama.
Peters looks forward to the day when there are dental health therapists at all 21 clinics. McCoy, a citizen of the Tulalip Tribes, believes the use of dental health therapists will ultimately expand throughout all of Washington state. He told ICMN, “Once we show how well it works [in Indian country], then it will open to all of Washington.”