Since 2003, the Alaska Dental Health Aide Therapist Program has trained a new type of mid-level dental provider to perform routine dental services in remote rural areas of the state, with a focus on increasing access to preventive and basic dental care for the Alaska Native population. This past year, Minnesota approved a more limited dental therapist role to help enhance access to basic dental care.
Dental therapists in Alaska work under the general supervision of a dentist and are part of a team of providers, but they can provide care without being in the physical presence of a dentist. "The ability to use general supervision allows dental therapists to get to areas where dentists have not traditionally been, and to bring people into the oral health and dental care system who would not otherwise have access," says Dental Health Aide Program Director Mary Williard, D.D.S, of the Alaska Native Tribal Health Consortium.
The Alaska Native population experiences oral health disparities and a lack of access to dental care compared with the state and nation overall, largely due to geographic isolation and dental workforce shortages. Eighty-five thousand of the 120,000 Alaska Natives in the state live in 200 rural villages, many of which are accessible only by airplane or boat, with the nearest dentist sometimes hundreds of miles away. Alaska Native adults have disproportionately high rates of tooth decay, and the rate of tooth decay among children is more than twice the national average. The Indian Health Service and the tribes have had trouble recruiting adequate numbers of dentists, including clinicians of Alaska Native ethnicity. In Alaska, tribal programs have historically had a vacancy rate of 25 percent for dentists, and annual turnover rates are as high as 30 percent.
The first phase of the program, initiated by the nonprofit Alaska Native Tribal Health Consortium with outside grant funding, built on other countries' extensive experience training similar providers. Forty-two countries use some version of a dental therapist to address workforce shortages or maldistributions and increase access to care. An initial group of six Alaskan students began training as dental therapists in 2003 at the University of Otago in New Zealand, where dental therapists have been providing comprehensive primary dental care since 1921.
In Alaska, dental health aide therapists are part of an integrated team of dental care providers, and are able to provide preventive oral health services, including nutrition and tobacco cessation counseling, as well as basic dental services such as tooth cleanings (above the gums), filling cavities, primary tooth and nerve treatment, primary tooth preformed crowns, and simple extractions.
In 2007, the Alaska Native Tribal Health Consortium and the University of Washington School of Medicine Physician Assistant Training Program, MEDEX Northwest, launched a collaborative Alaska-based training program, the DENTEX Dental Health Aide Therapist Program. In addition to 10 New Zealand-trained dental therapists who are now practicing, nine have graduated from the DENTEX training program and are either working in the field or undergoing a mandatory certification process. The training program is funded mainly with foundation grants, with additional federal funding from the Indian Health Service and the Health Resources and Services Administration. Students are sponsored by tribal health organizations for two years of training, and then owe four years of service to that entity as salaried employees.
The dental therapist model helps address recruitment challenges. "It is very hard to recruit dentists to serve Medicaid populations when reimbursement is low—but dental therapists' salaries are about half that of dentists, so the financing becomes workable," said Williard. Further, Alaska's Medicaid program recently shifted to paying the same amount for a dental visit, regardless of whether a more expensive treatment or a less costly preventive service is provided. Dr. Williard hopes this change "will tip the scales even more toward primary prevention, and motivate people to train and get out into the villages, where this care can make a big difference."
Two independent evaluations have found that Alaskan dental therapists provide high-quality, appropriate care that is within their scope of practice, and another comprehensive evaluation is under way. There is no official estimate of how many people are currently served by dental therapists, but according to Williard the numbers are growing and the integration of these new providers into the communities they serve has been successful. They live in the villages where they work, and in some cases may be the first dental providers to be permanent residents in the area.
In Minnesota, a law enacted in May 2009 created two new dental therapist roles with a more limited scope of practice than in Alaska, requiring the new providers to practice with a dentist present in the same office. There was extensive debate in Minnesota, with the Minnesota and American Dental Associations successfully arguing for narrower scope of practice than the Alaska program allows. Minnesota established its own training requirements for its dental therapists, with the University of Minnesota's dental school offering its first classes in the fall of 2009 for a four-year Bachelor of Science in Dental Therapy degree and a two-year Master of Dental Therapy degree. In Alaska, students can enter the dental therapist training program after completing four years of high school.
Minnesota's experience illustrates the challenges that efforts to implement the Alaska dental therapist model in other states (or outside the tribal health system) would likely face. The Alaskan program reached an agreement with the American Dental Association that its model would not be extended outside the tribal health system, and that it would support proposed language to be included in the Indian Health Care Improvement Act that would limit the model to Alaska, even within the tribal health system. The U.S. House and Senate passed that Act as part of their health reform bills, but its ultimate enactment depends on further action on health reform. If the legislation passes, Alaska and Minnesota's programs would continue unchanged, but any new programs in the rest of the country would require changes in state law similar to the process Minnesota went through.
"The Minnesota model is important not only because it will certainly improve access to care for many people in the state, but because it really changed the playing field for the rest of the country outside Alaska," says Dr. Williard. "For a state to change their practice is a major development."