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Dental therapists in Alaska Native communities are making a difference

By Donald L. Chi, DDS, PhD

Note from The Sullivan Alliance’s COO Robin H. Carle: This month’s guest blog author Donald L. Chi is a board-certified pediatric dentist and Associate Professor of Oral Health Sciences at the University of Washington School of Dentistry. His new study shows positive long-term outcomes for individuals in communities served by dental therapists in Alaska’s Yukon Kuskokwim Delta and supports the expansion of dental therapy programs into other states to address dentist shortages and improve access to dental care for underserved communities. Before he goes into details about the study, he first shares how he became interested in this important topic.

Aurora Johnson DHATI first learned about dental therapists in 2006, when I was a fourth-year dental student at the University of Washington. Alaska Native communities and indigenous leaders had come to the University of Washington (UW) School of Dentistry in Seattle to ask the university to house the nation’s first dental therapist training program. At first, many of my classmates and I were skeptical. We were just finishing eight years of education beyond high school and some of us were going into residency programs for even more training. It was hard to imagine how someone with just two years of post-secondary schooling could do procedures on patients that had taken us at least four times as long to figure out. For the time being, I set aside my feelings and went to the scientific literature for answers.

Dental therapists, I learned, were active members of the dental workforce in many other countries. They could help solve a major public health crisis in Alaska Native communities caused in part by dentist shortages. Alaska Native children were many times more likely to develop tooth decay and to have untreated tooth decay. Untreated tooth decay could lead to serious problems: pain, facial disfigurement, difficulties eating and sleeping, missed school days, poor grades, hospitalizations, and in rare cases, death. Alaska Native communities were remote, spread out, and sparsely populated, which led to dentist shortages. These shortages required many Alaska Native children and adults to go without treatment until there was a problem, like a toothache or abscess, at which point they would travel long distances by airplane to seek emergency dental care. To me, dental therapists seemed like a sensible solution. But, there was strong opposition from dentists and dental associations, like the way the medical profession was initially against physician assistants. In the end, the UW passed on an opportunity to make a difference.

Back in 2006, the dental literature couldn’t provide all the answers and legitimate concerns were raised. Would the care provided by dental therapists be safe? Would the quality of care be similar to care provided by dentists? Could dental therapists meaningfully improve access to dental care in underserved communities? Since then, several studies from Alaska have shown care provided by dental therapists is safe and as good as care provided by general dentists. Until now, the longer-term effects of dental therapists had not been studied, mainly because Alaska’s dental therapist program was relatively young.

Our team examined 10 years of data from the Yukon Kuskokwim Health Corporation’s dental clinic and the Alaska Medicaid program – beginning in 2006, the year in which Alaska’s dental therapists starting practicing. For each community in the Yukon Kuskokwim Delta, we counted the number of days a dental therapist provided treatment in that community. The outcomes we looked at separately for children and adults were tooth extractions, preventive care, and use of general anesthesia. General anesthesia is reserved for young children with extensive dental treatment needs and takes place in a hospital, where the child is put to sleep and all the necessary dental treatment is provided at once.

We asked two questions. First, what is the relationship between the number of dental therapist treatment days and each outcome? This question would assess the overall impact dental therapists have had in Alaska Native communities. Second, what is the difference in outcomes for communities with the greatest number of dental therapist treatment days and those with the no dental therapist treatment days? This question would give us a sense for how big a difference in outcomes could be expected by introducing dental therapists into communities.

Savannah Bonorden DHAT SEARHCIn terms of the answer to the first question, we found dental therapists are having a positive impact on communities. Children and adults living in Alaska Native communities served more intensively by dental therapists had significantly lower rates of tooth extractions and higher rates of preventive care. In terms of the general anesthesia outcome, there were differences between the two datasets. The health record data showed significantly lower rates of general anesthesia associated with dental therapists, whereas in the Medicaid data the relationship was not statistically significant. A conservative conclusion is that dental therapists did not lead to increased rates of dental treatment under general anesthesia for young children.

For the second question, there were differences in outcomes between communities served most intensively by dental therapists and communities with no dental therapists. Child and adult preventive care utilization rates were 9.3 to 16.4 percentage points and 2.4 to 11.8 percentage points higher in communities with the highest number of dental therapist treatment days, respectively, compared to communities with no dental therapist treatment days. Child extraction rates for children were 5.4 to 15.2 percentage points lower, child general anesthesia rates were 2.4 to 3.1 percentage points lower, and adult extraction rates were 2.5 to 13.5 percentage points lower in communities with the highest number of dental therapist treatment days. These data are further evidence that dental therapists, when given the opportunity to serve communities, can make meaningful differences.

In the next phase of this study, we will travel to Alaska Native communities and talk with individuals treated by dental therapists. These shared stories will give us greater insight on the impact dental therapists have had on individual lives. Equally important, these narratives will give us clues on how we can make an effective program that works even better.

Moving forward, I hope scientists and public health researchers will continue studying dental therapy models to help expand our knowledge base and generate the data needed for evidence-based dental practice guidelines and policies. These data will be essential in guiding policymakers toward evidence-based legislation that improves health outcomes for vulnerable populations. Even with our study findings, I anticipate there will be continued pushback against dental therapists fueled by emotions, protectionist mindsets, and self-interest. However, I remain optimistic that we will continue to make progress toward oral health equity for Alaska Native and other underserved communities. Please contact me if you would like to learn more about our dental therapist study or other ongoing research studies in Alaska.

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