There are few dentists in Alaska’s vast tribal lands, where 120,000 Native Americans—members of over 200 different tribes—live in far-flung villages. Some of those villages are only reachable by boat, plane or snowmobile, and until recently, a dentist might pass through once a year, if at all. Visiting dentists would typically have time to address only dental crises, not to provide comprehensive preventive care. As a result, many Alaskan Natives suffered serious and painful dental problems, and it wasn’t uncommon to see children and teens with dentures.
Almost two decades ago, this dental health crisis led Alaska Native tribal leaders to land on an innovative solution: the deployment of dental therapists throughout the region to provide basic care. Dental therapists are mid-level professionals, with more training than a dental hygienist but less than a dentist, who can fill cavities, do basic extractions and provide preventive care. Dental therapists are often compared to physician assistants in the medical field.
With support from the W.K. Kellogg Foundation, tribal leaders pushed for establishment of a dental therapy training program in Alaska, the first in the country. Other philanthropies also played a role: Alaska’s Rasmuson Foundation was an early supporter, the Robert Wood Johnson and Paul G. Allen Family foundations provided key support, and Pew Charitable Trusts provided ongoing evidence of the value of this approach, particularly for low-income and rural communities.
In addition to improving access to care in the region, the initiative also helped launch the dental therapy movement in the U.S.; today, dental therapists are authorized to practice in 12 states and several tribal communities, and the practice is under consideration in close to 20 other states, as well. Chronicled in an ebook recently released by Kellogg, it’s a story that offers an instructive example of the way charitable giving can bankroll an experiment that may one day, with a little patience on the part of the funder, be adopted at a much larger scale.
“Nearly two decades ago, what started out as a tribal-led effort to expand dental care to Alaska Native people has grown into a community- and tribal-led movement to ensure people can get dental care when and where they need it, in their home communities,” Kellogg President and CEO La June Montgomery Tabron wrote in the ebook’s foreward.
For want of a dentist
Dentistry isn’t normally considered a riveting topic, but “For Want of a Dentist: The Rise of the Dental Therapy Movement in Tribal Nations and the U.S.” tells a compelling story. The ebook, published by Kellogg, chronicles the history of dental therapy and the struggle to introduce this approach in Alaska’s tribal lands. There’s even some dramatic tension: The book describes how the powerful American Dental Association tried to scuttle the program. “For Want of a Dentist” also provides a case study for how philanthropy, working closely with local communities, can boost access to healthcare and promote health equity.
Wendell Potter, the author of “For Want of a Dentist,” explains that dental therapists are common in at least 28 countries around the world, but were virtually unknown in the U.S. until recently. In New Zealand, where the practice was first established 100 years ago, the government funds dental therapy treatment for children up to age 18. The results are impressive, as Potter points out: “One recent study found that 72% of low-income New Zealand school-aged children had received a dental visit over the course of one year, while the comparable number for the United States was only 39%. And the gap was even larger for preschool children.”
Access and equity
In 2003, Alaska’s tribal leaders, through the Alaskan Native Tribal Health Consortium (ANTHC), sent a cohort of students to New Zealand’s University of Otago to be trained as dental therapists (at that time, it was the only university in the world that offered the training). The Rasmuson Foundation underwrote expenses for the initial cohorts of students, but sending them so far away for the two-year training was not only expensive but disruptive to families and communities. ANTHC representatives wanted to start a dental therapy program closer to home, so they decided to approach the Kellogg Foundation for support.
“It was one of those rare instances when a proposal comes in over the transom, requesting funding for a project that foundation officials weren’t aware of,” Potter said in a recent interview. “The program officer brought the proposal to the attention of Kellogg’s president, and the foundation decided to back the project.” In 2006, Kellogg provided an initial grant of $2.8 million to the ANTHC.
The proposal may have been unsolicited, but it was in clear alignment with the foundation’s history and mission. W.K. Kellogg started his foundation to benefit children and support children’s health, and oral health has been a focus since its inception. As Potter recounts in his book, the Kellogg Foundation supported the expansion of the fledgling dental hygienist profession after World War II. Over the years, it has underwritten dental training, and more recently, funded programs to increase the number of dentists from diverse backgrounds.
Access to dental care is also an equity issue. Many Americans don’t have and cannot afford dental insurance, and many dentists don’t accept Medicaid, or offer low-cost treatment for those without coverage. Children of color are less likely to see a dentist and receive preventive treatment than white children, and more likely to have untreated tooth decay.
According to Kellogg’s website: “Among children ages three to five, 43.2% of American Indian/Alaska Natives have untreated tooth decay compared to 11.3% of white children. Tooth decay strikes 19.8% of Hispanic children in that age group, and 19.3% of African American children.” And inequities tend to reinforce inequities: Research has found that children with poor oral health miss more school and receive lower grades than those with good oral health.
“Access to dental care is all about equity, and many people don’t realize how inequitable our system of dental health is,” Potter said. “There are 6,000 ‘dental deserts’ around the country, and it’s a crisis particularly in communities of color.” Lack of access to regular dental care not only leads to pain and problems that are more expensive to treat down the line, but can cause cardiovascular and other serious health issues.
Community dental care
In “For Want of a Dentist,” Potter describes his experience accompanying Aurora Johnson, a dental therapist at work in a small town in Alaska. Johnson was among the first Alaskan students to receive training as a dental therapist. Since she has started practicing, she has seen the dental health of her clients measurably improve. “I know all my patients, pretty much. It’s like a family reunion when I go to a community and see everybody, watching all the kids grow. I feel that I am part of it all,” she told Potter.
The most comprehensive study on the effectiveness of dental therapy to date found that “Alaska Native children and adults served by a therapist had fewer tooth extractions and received more preventive care,” as Potter recounts in his book. Another study found that dental therapists benefit both patients and providers, according to Pew. There’s still resistance from organized dentistry, but a number of dentists are backing this approach, including members of the National Association of Dentists for Health Equity.
Meanwhile, Kellogg continues to support the expansion of dental therapy, and is funding state advocacy efforts across the country. “It’s important that the Kellogg Foundation has been willing to stay in this fight,” said Potter. “It’s important for philanthropies to realize that this kind of change can take years, in many cases, to educate lawmakers, to educate the public about how important these kinds of programs are.”
Potter thinks the dental therapy movement will continue to gain momentum and spread as more states adopt the practice. He ticks off the many advantages: Dental therapy is cheaper than regular dental care, it provides good-paying jobs, it allows people to work in their own communities, it promotes overall health, and it even tends to have bipartisan support.
“Dental therapy saves money, as well as pain and agony,” he concluded.
Hard to argue with that.