Dental Therapists Help Solve an Alaska Town’s Oral Health Crisis
The city of Bethel, some 6,000 people strong, is the hub for 56 villages in the delta formed by the Yukon and Kuskokwim rivers on the west coast of Alaska. No highways connect it to anywhere else; all of the necessities of modern life come in by plane or boat.
Surrounded by Alaska’s vast spaces and rugged terrain, and bitten by harsh weather, residents here have challenges receiving not only the goods and supplies they need but also health care. Recently, under the auspices of the W.K. Kellogg Foundation, a group of dentists and health care professionals traveled to Bethel to check out a groundbreaking program that has helped alleviate an oral health care shortage by deploying a new class of providers called dental therapists—essentially dentistry’s version of physician assistants.
Dr. Mary Williard, a public health dentist who directs the therapists’ training for the Alaska Native Tribal Health Consortium, told the group that when she first came to the region in 1998, she found “a health crisis. … Tooth decay among children was twice the national average, only 50 percent of kids at age 6 had access to dental care, and 59 percent of adults suffered from periodontal [gum] disease.” To cope, the dentists in Bethel resorted to triage. “I would often end up taking kids to the hospital to do full mouth surgery, removing multiple teeth due to extensive decay,” she said.
“Surgery was our only option when presented with ‘bombed-out mouths.’ I can do that quite well, but that shouldn’t be the default,” said Williard. “If we were going to spare children the experience of that pain and trauma, we needed to get to patients earlier.”
Dental therapists provided the answer. While they are widely used across the globe to offer basic dental services—such as fluoride treatments, fillings, and simple extractions—they were unknown in the United States until the nonprofit Alaska Native Tribal Health Consortium, which provides health care to Alaska Natives, sent four students to New Zealand for training in 2003. When the quartet came back, they began work under Williard’s supervision.
Therapists in training, who have high school diplomas and nominations from their tribes, spend two years mastering a limited scope of work (46 dental procedures, compared with the more than 500 that dentists may provide after eight years in college and dental school). When they finish, they return to their communities to work side by side with supervising dentists for a three- to six-month preceptorship, or residency. Once they have demonstrated their proficiency, they work under “general supervision,” which means a dentist does not have to be on-site and has issued standing orders to authorize most services that the dental therapist provides. Some other procedures require consultation with a dentist, often via telehealth technology.
Bethel may be a fun place for a bike ride, but before dental therapists, the town's remoteness made dental care so rare that tooth decay among children was twice the national average.
“There is such a need, and it makes your heart heavy,” said Ashley Sipary, a second-year student from Toksook Bay, Alaska. “On one of my first days, a child came in with abscesses on his front teeth. He had to be strapped to a papoose board and have every one of those teeth extracted. I don’t want to see any kids go through that experience again. In the villages I serve, I can make sure they don’t.”
Thirty dental therapists now work in communities across Alaska, joined by five or more newly trained colleagues each year. The numbers convey their impact: Forty-thousand children and adults now have regular access to dental care, and all 6-year-olds in these communities have received dental services. On average, the therapists bring in $150,000 to $250,000 more per year than it costs dental clinics to employ them (accounting for salaries, benefits, travel, and supplies).
For patients, it has been a sea change. Before the dental therapist program was created, a dentist would visit a village for a few days once a year. Priority was given to pulling decayed and infected teeth for children, with no time for preventive care. For adults who could not get to a dentist, all that could be offered were pain medicine and antibiotics. Now, dental therapists are a fixture in these communities, providing preventive and restorative services; treating patients in their villages; diagnosing disease early, when it is easier to treat; and not only giving patients better care but also saving an estimated $40,000 in travel costs per year per dental therapist.
While Alaska’s isolation contributes to the challenges of providing treatment, communities throughout the United States have difficulty accessing care. According to the federal government, more than 5,000 communities across the country that are home to more than 48 million people are experiencing dentist shortages. The problem is worse for the more than 70 million children and adults relying on Medicaid: Two-thirds of the nation’s dentists will not accept public insurance. Pew has helped lead efforts in the Lower 48 to expand the number of dental therapists, urging legislatures to establish the new category of providers in law. Minnesota and Maine were the first to do so (see Trust, Fall 2015).
A member of the fifth class of dental therapists in Alaska, Savannah Bonorden is part of a team that provides care in her hometown of Sitka and four villages that hug the state’s southeastern coast. She said her experience demonstrates the immediate benefit and the long-term impact of their work. “In my second year, I met a lovely junior in high school. At that first encounter, she had significant decay in a tooth, and after sending an image to my supervising dentist, we determined it needed to be extracted.
“She was so upset to lose her tooth. I spent time walking her through an exam of her entire mouth and educating her on how to avoid cavities through good oral hygiene,” said Bonorden. “At her next appointment, she returned and had no decay. She was so grateful and told me, ‘I’ve never known the importance of my oral health until you. My smile is great. I’m not in pain, and I’m happy.’”