By Michelle Tirado
January 14, 2010

A shortage of conventional dentists in Indian Country has forced lawmakers to seriously consider an unconventional — and highly controversial — solution: dental therapists, people who can perform many procedures that dentist do but with a fraction of the education and at a fraction of the cost.

Days before Christmas, the U.S. Senate approved an amendment to its healthcare reform bill, which now has rolled into it the reauthorization of the Indian Health Care Improvement Act. It includes a provision that opens the door for the expansion of dental therapy programs by allowing alternative dental health care provider demonstration projects.

There are presently only two states where dental therapists practice: Alaska, where they serve Alaska Natives, and Minnesota, the only state that has sanctioned them.

With proponents and opponents within the Senate, the provision approved reflects a compromise. It allows for dental therapy projects only if they are authorized by state law. But it also allows pilot programs requested by tribes or tribal health organizations that would not have to comply with state laws.

The shortage of dentists in Indian Country has been an escalating problem. The Indian Health Service employs approximately 300 dentists. They serve 1.9 million Native Americans spread across 35 states. The most recent IHS numbers show a 24 percent agency-wide vacancy rate for the position.

There are several reasons for the shortage, but the biggest contributors may be that many IHS dentists have retired or are up for retirement (about 65 percent were eligible for retirement in 2009) and the out-dated civil service pay scale.

The argument for the expansion of dental therapy in the United States was bolstered by a report released last month by the W.K. Kellogg Foundation. The report, titled Training New Dental Health Providers in the U.S., provides a detailed examination of the new types of dental professionals that are needed and have been (or are being) tested to reduce the inequities in access to dental care.

The report clearly documents the training requirements and scope of services of the dental therapist (considered a mid-level practitioner) and compares them to conventional dental professions. It reviews the programs established in Alaska and in Minnesota as well as successful dental therapy programs in other developed countries, like New Zealand, where they have provided basic dental care since the 1920s.

To be a dental therapist in the Alaska program, as highlighted in the report, one is required to complete a two-year certification training program, followed by a three-month (or 400-hour) preceptorship with a supervising dentist. It does not require a college education, just a high school diploma or equivalent. Becoming a dentist, on the other hand, calls for eight years of post-high school education. To be a dental hygienist, one must complete two to four years of post-high school education.

In terms of the types of care that a dental therapist provides, it ranges from routine oral health assessments, x-rays and cleanings to fillings and extractions of primary teeth. And services are performed in coordination with a supervising dentist, who can be located off-site.

Burton L. Edelstein, DDS, MPH, president of the Children’s Dental Health Project, a non-profit pediatric oral health policy organization in Washington, D.C., and author of the report, hopes the report gives policy makers the sound and objective information they need to decide on the issue.

“The fact that there is an option — and that the option is well-documented — should be of value to those who wish to see more equitable care,” he said.

One of the most stalwart opponents of dental therapists has been the American Dental Association. It was ADA that legally challenged the Alaska program in 2006, unsuccessfully, and is even now drumming up support to oppose the demonstration project provision.

ADA President Dr. Ronald L. Tankersley, D.D.S., testified against the expansion of dental therapy at a Committee on Indian Affairs’ hearing on Dec. 3. He said in his testimony, “ADA does not support delegating surgical dental procedures to those without the comprehensive education of dentists.”

The Dental Health Aide Therapist (DHAT) program in Alaska was established by the Alaska Native Tribal Health Consortium in 2003. There are currently 14 students enrolled in the training program, and 12 have already received their certification and are providing services.

DHAT trainees do not have to be Native, though most are, yet they need to be sponsored by a Native health organization. The sponsoring organization contracts with the therapist for four years of service and at a salary that could be half that of a dentist.

Dr. Mary Williard, clinical site director at the DENTEX training center, where trainees spend their first year, does not know exactly how many patients Alaska dental therapists have provided services to date, but she said it is in the thousands.

Without the therapists, many of them would have had to wait months, perhaps even more than year, to get the care needed from a dentist.

Williard spent nine years working in some of the state’s most remote villages, places that only get visited once a year for a one-week period by a dentist. “When the dentist gets out there, we would be completely booked up and busy for the whole time we were there — and there were often many patients that there wasn’t time to see,” she said.