AJPH PERSPECTIVES Dental Therapy: Communities Lead the Way for Improved Oral Health Growing up in a Yup’ik Native village in southwest Alaska 40 years ago, Valarie Davidson was terrified of the annual visit from the dentist. Children lined up and one by one were called in to have their teeth pulled; extraction was usually the only service available. Cavities weren’t filled; no root canals or cleanings were performed for children who did not have regular dental care available in these communities. In her own words, Davidson described her horrific experience in the 2012 Annual Report of the W.K. Kellogg Foundation (WKKF), a document that discussed the plight of vulnerable children and what communities could do to help them. As a child, I remember when the dentist came to our village once a year. As we waited in line to be seen, we could hear the screams behind the door as teeth were pulled from children ahead of us. The door would open and we’d see our crying brother, sister, cousin or friend holding a bloody gauze bandage to their mouth. We always asked how many teeth were pulled. Every year, one of the little ones would stand in line, terrified, and either wet themselves from fear or run out the clinic door. Our community health aide would wait five minutes to give the child time to calm down and then bring the child back. The ‘runner’ would move to the front of the line. For our children, going to see the dentist was truly traumatic. I have a cousin who still cannot be seen by a dentist unless she is
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under full anesthesia. Imagine how frightening it is for her to seek oral health care for her children.1(p12)
Today, with the support of the Kellogg Foundation and a growing movement led predominantly by communities, I’m pleased to report that there has been progress in expanding dental care and making it more accessible in some locations for more children to receive the care they need, when they need it. In Alaska Native communities, a Dental Health Aide Therapy (DHAT) Program provides education and a college degree for dental therapists who are from the community, and are familiar with the residents and culture. The dental therapists provide education, prevention and treatment of patients and expand access to oral care. For more than 80 years, this model has been in place in more than 50 countries.
RACIAL/ETHNIC DISPARITIES Yet, across the United States, data clearly show that lowincome families and people of color continue to face barriers when it comes to improving oral health and their access to dental care. I find the racial/ethnic disparities so prominent that conscious and unconscious bias has to be considered a factor in
the oral health patterns. Among children aged three to five years, 43.2% of American Indian/ Alaska Natives have untreated tooth decay compared with 11.3% of White children. Tooth decay strikes 19.8% of Hispanic children in that age group, and 19.3% of African American children.2 In fact, nationwide, 49 million Americans live in areas federally designated as shortage of dental providers (as of September 30, 2009, those 49 million Americans lived in one of 4230 dental health professional shortage areas).3 Parents of children suffering from tooth decay, tribal residents and community leaders frequently overlook the signs that untreated dental problems are severely impacting overall health, lead to missed school or work days, and can cause lifethreatening infections. And far too often, parents can’t overcome the obstacle presented by the lack of access to dentists. As per the California Society of Pediatric Dentistry, “Untreated dental disease compromises the child’s ability to eat well, sleep well, and function well at home and at school. The unaesthetic nature of
untreated dental decay compromises the child’s self-esteem and social development.”4 According to the Mayo Clinic, “Research suggests that heart disease, clogged arteries, and stroke may be linked to the inflammation and infections that oral bacteria can cause.”5 To be sure, WKKF has been a leader in expanding access to dental care since 1930. The terrain has been difficult as entrenched laws, policies and practices obstruct change, but we have seen progress. Moving forward it will take coalitions of civic, nonprofit, philanthropic, and public- and private-sector leaders to continue engaging with communities to address the practices, policies, and regulations that prevent dental therapists from caring for patients. Because dental therapists are members of the dental team, they allow dentists to care for more patients, focus on patients’ most serious dental problems, and increase access to oral care.
EXPANSION ON THE DHAT PROGRAM I believe the success of the community-driven DHAT program in Alaska can serve as a model that can be replicated in Native and non-Native
ABOUT THE AUTHOR La June Montgomery Tabron is President and CEO of the W.K. Kellogg Foundation. Correspondence should be sent to Dana Linnane, Communications Officer, W.K. Kellogg Foundation One Michigan Avenue East Battle Creek, MI 49017 (e-mail: dana.linnane@wkkf. org). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted June 12, 2017. doi: 10.2105/AJPH.2017.303960
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communities in other states. The effectiveness of the DHAT has been thoroughly documented in studies. This model creates a pathway for community residents to become dental therapists, allowing people known in their communities to care for their children, a sharp contrast from the harrowing environment Davidson described. “Our children look up to our DHATs,” Davidson wrote in the Annual Report. “They are people that we know and trust. Because of these close relationships, we are already changing the smiles of Alaska Native children.”1(p13) Davidson is now Alaska’s Commissioner of Health and Social Services, and her childhood experiences led her to be a strategist for the DHAT program. A 2010 study found that dental therapists provide safe, competent, appropriate care; are technically competent to perform the procedures within their scope of work; and are operating safely and appropriately.6 Furthermore, a study by researchers at the University of Washington School of Dentistry will be publicly released in the summer of 2017. WKKF, a study cofunder, has received the results. The study focused on oral health outcomes of patients served by the Yukon-Kuskokwim Health Corporation (YKHC) between 2006 and 2015. YKHC cares for 25 000 Alaska Natives. Researchers found that for children, high exposure to dental therapists was associated with fewer extractions, less use of general anesthesia, and more preventive visits. Adults in communities with the highest DHAT visit days had fewer extractions and more preventive care visits. The dental therapist model is gaining momentum, especially in Indian Country. The
Supplement 1, 2017, Vol 107, No. S1
Swinomish Indian Tribal Community in Washington State has hired a dental therapist who is providing dental care in their clinic. And through the Northwest Portland Area Indian Health Board, several tribes throughout the Northwest have launched a demonstration program to send students to Alaska for DHAT training, and they return to their tribe to serve their communities. In addition, dental therapists now practice in Minnesota, and will soon in Maine and Vermont. Other states, such as Kansas, Arizona, Massachusetts, Michigan, New Mexico, North Dakota, and Ohio, are exploring the use of dental therapists to improve and expand oral health care.
A VISION FOR ALL CHILDREN For this vision to become real for all children, communities must acknowledge the role that race and ethnicity has played in oral health disparities, heal those wounds, and move forward to implement strategies that can allow dental therapists to provide much needed care to patients. It will take all segments of the community—people of all color, private and public sectors, nonprofits, and others—to overcome the obstacles and enhance the quality of life for vulnerable children. Mr. Kellogg believed that it takes everyone in a community to address the health and well-being of children.
w-k-kellogg-foundation-annual-report. Accessed June 12, 2017. 2. Phipps KR, Ricks TL. Oral Health of American Indian and Alaska Native Children Aged 1–5 Years: Results of the 2014 IHS Oral Health Survey. Indian Health Service data brief. Rockville, MD: Indian Health Service. Available at: https://www.ihs.gov/doh/documents/ IHS_Data_Brief_1-5_Year-Old.pdf. Accessed June 12, 2017. 3. Shortage Designation. HPSAs, MUAs & MUPs. Health Resources and Services Administration. US Department of Health and Human Services. Available at: http://bhpr.hrsa.gov/shortage. Could not access. 4. The Consequences of Untreated Dental Disease in Children. The California Society of Pediatric Dentistry. Available at: https://www.cda.org/Portals/0/pdfs/ untreated_disease.pdf. Accessed June 12, 2017. 5. Oral Health: A Window to Your Overall Health. Mayo Clinic. Available at: http://www.mayoclinic.org/healthylifestyle/adult-health/in-depth/dental/ art-20047475. Accessed June 12, 2017. 6. Wetterhall S, Bader JD, Burrus BB, Lee JY, Shugars DA. Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska. RTI International. Available at: http://www. rti.org/sites/default/files/resources/ alaskadhatprogramevaluationfinal102510. pdf. Accessed June 12, 2017.
La June Montgomery Tabron REFERENCES 1. Davidson V. At what point did you get involved? Understanding Vulnerable Children: Who Knows What About Community? W.K. Kellogg Foundation. Available at: https://www.wkkf.org/resourcedirectory/resource/annual-reports/2012-
AJPH
Montgomery Tabron
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Montgomery Tabron
under full anesthesia. Imagine how frightening it is for her to seek oral health care for her children.1(p12)
Today, with the support of the Kellogg Foundation and a growing movement led predominantly by communities, I’m pleased to report that there has been progress in expanding dental care and making it more accessible in some locations for more children to receive the care they need, when they need it. In Alaska Native communities, a Dental Health Aide Therapy (DHAT) Program provides education and a college degree for dental therapists who are from the community, and are familiar with the residents and culture. The dental therapists provide education, prevention and treatment of patients and expand access to oral care. For more than 80 years, this model has been in place in more than 50 countries.
RACIAL/ETHNIC DISPARITIES Yet, across the United States, data clearly show that lowincome families and people of color continue to face barriers when it comes to improving oral health and their access to dental care. I find the racial/ethnic disparities so prominent that conscious and unconscious bias has to be considered a factor in
the oral health patterns. Among children aged three to five years, 43.2% of American Indian/ Alaska Natives have untreated tooth decay compared with 11.3% of White children. Tooth decay strikes 19.8% of Hispanic children in that age group, and 19.3% of African American children.2 In fact, nationwide, 49 million Americans live in areas federally designated as shortage of dental providers (as of September 30, 2009, those 49 million Americans lived in one of 4230 dental health professional shortage areas).3 Parents of children suffering from tooth decay, tribal residents and community leaders frequently overlook the signs that untreated dental problems are severely impacting overall health, lead to missed school or work days, and can cause lifethreatening infections. And far too often, parents can’t overcome the obstacle presented by the lack of access to dentists. As per the California Society of Pediatric Dentistry, “Untreated dental disease compromises the child’s ability to eat well, sleep well, and function well at home and at school. The unaesthetic nature of
untreated dental decay compromises the child’s self-esteem and social development.”4 According to the Mayo Clinic, “Research suggests that heart disease, clogged arteries, and stroke may be linked to the inflammation and infections that oral bacteria can cause.”5 To be sure, WKKF has been a leader in expanding access to dental care since 1930. The terrain has been difficult as entrenched laws, policies and practices obstruct change, but we have seen progress. Moving forward it will take coalitions of civic, nonprofit, philanthropic, and public- and private-sector leaders to continue engaging with communities to address the practices, policies, and regulations that prevent dental therapists from caring for patients. Because dental therapists are members of the dental team, they allow dentists to care for more patients, focus on patients’ most serious dental problems, and increase access to oral care.
EXPANSION ON THE DHAT PROGRAM I believe the success of the community-driven DHAT program in Alaska can serve as a model that can be replicated in Native and non-Native
ABOUT THE AUTHOR La June Montgomery Tabron is President and CEO of the W.K. Kellogg Foundation. Correspondence should be sent to Dana Linnane, Communications Officer, W.K. Kellogg Foundation One Michigan Avenue East Battle Creek, MI 49017 (e-mail: dana.linnane@wkkf. org). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted June 12, 2017. doi: 10.2105/AJPH.2017.303960
AJPH
Supplement 1, 2017, Vol 107, No. S1
AJPH PERSPECTIVES
communities in other states. The effectiveness of the DHAT has been thoroughly documented in studies. This model creates a pathway for community residents to become dental therapists, allowing people known in their communities to care for their children, a sharp contrast from the harrowing environment Davidson described. “Our children look up to our DHATs,” Davidson wrote in the Annual Report. “They are people that we know and trust. Because of these close relationships, we are already changing the smiles of Alaska Native children.”1(p13) Davidson is now Alaska’s Commissioner of Health and Social Services, and her childhood experiences led her to be a strategist for the DHAT program. A 2010 study found that dental therapists provide safe, competent, appropriate care; are technically competent to perform the procedures within their scope of work; and are operating safely and appropriately.6 Furthermore, a study by researchers at the University of Washington School of Dentistry will be publicly released in the summer of 2017. WKKF, a study cofunder, has received the results. The study focused on oral health outcomes of patients served by the Yukon-Kuskokwim Health Corporation (YKHC) between 2006 and 2015. YKHC cares for 25 000 Alaska Natives. Researchers found that for children, high exposure to dental therapists was associated with fewer extractions, less use of general anesthesia, and more preventive visits. Adults in communities with the highest DHAT visit days had fewer extractions and more preventive care visits. The dental therapist model is gaining momentum, especially in Indian Country. The
Supplement 1, 2017, Vol 107, No. S1
Swinomish Indian Tribal Community in Washington State has hired a dental therapist who is providing dental care in their clinic. And through the Northwest Portland Area Indian Health Board, several tribes throughout the Northwest have launched a demonstration program to send students to Alaska for DHAT training, and they return to their tribe to serve their communities. In addition, dental therapists now practice in Minnesota, and will soon in Maine and Vermont. Other states, such as Kansas, Arizona, Massachusetts, Michigan, New Mexico, North Dakota, and Ohio, are exploring the use of dental therapists to improve and expand oral health care.
A VISION FOR ALL CHILDREN For this vision to become real for all children, communities must acknowledge the role that race and ethnicity has played in oral health disparities, heal those wounds, and move forward to implement strategies that can allow dental therapists to provide much needed care to patients. It will take all segments of the community—people of all color, private and public sectors, nonprofits, and others—to overcome the obstacles and enhance the quality of life for vulnerable children. Mr. Kellogg believed that it takes everyone in a community to address the health and well-being of children.
w-k-kellogg-foundation-annual-report. Accessed June 12, 2017. 2. Phipps KR, Ricks TL. Oral Health of American Indian and Alaska Native Children Aged 1–5 Years: Results of the 2014 IHS Oral Health Survey. Indian Health Service data brief. Rockville, MD: Indian Health Service. Available at: https://www.ihs.gov/doh/documents/ IHS_Data_Brief_1-5_Year-Old.pdf. Accessed June 12, 2017. 3. Shortage Designation. HPSAs, MUAs & MUPs. Health Resources and Services Administration. US Department of Health and Human Services. Available at: http://bhpr.hrsa.gov/shortage. Could not access. 4. The Consequences of Untreated Dental Disease in Children. The California Society of Pediatric Dentistry. Available at: https://www.cda.org/Portals/0/pdfs/ untreated_disease.pdf. Accessed June 12, 2017. 5. Oral Health: A Window to Your Overall Health. Mayo Clinic. Available at: http://www.mayoclinic.org/healthylifestyle/adult-health/in-depth/dental/ art-20047475. Accessed June 12, 2017. 6. Wetterhall S, Bader JD, Burrus BB, Lee JY, Shugars DA. Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska. RTI International. Available at: http://www. rti.org/sites/default/files/resources/ alaskadhatprogramevaluationfinal102510. pdf. Accessed June 12, 2017.
La June Montgomery Tabron REFERENCES 1. Davidson V. At what point did you get involved? Understanding Vulnerable Children: Who Knows What About Community? W.K. Kellogg Foundation. Available at: https://www.wkkf.org/resourcedirectory/resource/annual-reports/2012-
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