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Support for the Alaska Dental Health Aide Therapist and Other Innovative Programs for Underserved Populations

Policy Date: 11/8/2006
Policy Number: 20064

The American Public Health Association (APHA) views access to preventive and therapeutic oral health services as vitally important for all Americans;1 and APHA desires to foster effective broad-based policies and programs to help alleviate oral diseases. 2,3,4

Oral health is an integral part of overall health and well-being. 5 According to the 2000 U.S. Surgeon General's report, Oral Health in America, the burden of oral problems is extensive and may be particularly severe in vulnerable populations. There are profound and consequential oral health disparities within the U.S. population; and reducing disparities requires wide-ranging approaches that target populations at highest risk for specific oral diseases and involves improving access to existing care .5

Many populations, such as the 85,000 Alaska Natives living in 200 remote and isolated villages spread out over about 400,000 square miles, have overwhelming unmet oral health needs that have been longstanding and require prompt action to prevent further unnecessary pain and suffering.6,7 In most of these villages, the only health care provider available on a routine basis is the community health aide who provides services out of a small clinic, many of which lack even running water or a piped sewer. In many instances, Alaska Native patients must travel by bush-plane, boat, or snow machine in order to obtain dental services. Alternatively, children, or adults with toothaches, can only access care during itinerant visits from dentists working in the tribal programs, but these visits are very limited and can be sporadic.

Children and adolescents of Alaska Natives have dental caries rates that are 2.5-5.0 times the rate of children in the U.S. general population; 8,9 60 percent of Alaska Native children under age five years suffer from severe early childhood caries;8 dentists serving in rural Alaska remark that it is not uncommon for Alaska Native adults to be completely edentulous by the age of 20 years.10

There is an inadequate supply of dentists to provide regular and continuous oral health care for the Alaska Natives in the remote and isolated villages.11 There is a 25 percent annual vacancy rate and a 30 percent average annual turnover rate for dentists in Alaska's tribal programs. There are more than 20 vacancies for dentists in the Alaska tribal programs.12

Recognizing the plight of the Alaska Native population, applications for Dental Clinical Preventive and Support Centers by the Indian Health Service, USPHS were sent out in FY 2000. Emphasis for awarding funding was placed upon collaborative efforts between tribal programs and IHS-managed programs that were designed to meet the perceived needs of the areas. The Alaska Dental Health Aide Program proposal received a favorable review for technical and scientific merit, by a panel of non-federal experts and tribal health staff, and was one of the successful grants funded that year.11 The Alaska Native Tribal Health Consortium, in compliance with federal law,13 developed the Dental Health Aide Therapist (DHAT) program as part of that comprehensive initiative to respond to these overwhelming dental needs in an established and effective way, which ensures program continuity and year-round services in isolated, under-served communities.14 The DHAT program is an expansion of the successful Community Health Aide Program initiated about 37 years ago that provides overall primary health care to Alaska Natives using community health aides.15 DHATs are trained and educated in a certified program with professional supervision to perform primary prevention services including health education as well as routine fillings and extractions which organized dentistry has referred to as "irreversible procedures."9 Evaluation of the program is an integral component16 and a recent independent evaluation has shown that the DHATs are providing competent and safe dental care to Alaska Natives.17 It is stressed in the evaluation document that dental health aides must meet the same standard of care, for those procedures that they perform, as dentists or any other provider in our system. There are not two standards of care.16

DHATs have been used successfully in 42 other countries, including New Zealand for over 84 years .18,19 In Saskatchewan, Canada, where DHATs have been employed for over 30 years, there have been no incidents of malpractice or any complaints reported to the Regional Disciplinary Board,20 and one study demonstrated that "the quality of restorations placed by dental therapists was equal to, but more often better than ...those...by dentists."21

In spite of the evidence supporting the effectiveness and safety of dental therapists, the American Dental Association (ADA) and Alaska Dental Society (ADS) are opposed to non-dentists performing "irreversible" procedures and have taken extraordinary action to block the Alaska DHAT program, such as full-page advertisements in the Alaska newspapers attacking the program and lobbying and testifying in Congress. 9,22-30 Reasons given by the ADA for their opposition to DHATs include lack of supervision by dentists, that DHATs are acting illegally, that DHATs deliver second-class care, that DHATs are inadequately trained and educated, that only dentists should perform irreversible procedures and that volunteer dentists can fill the need. In January 2006, the ADA filed a lawsuit in Alaska State Court seeking a court order against the Alaska Native Tribal Health Consortium and the individual dental therapists under which their practice would be barred since it is not licensed by the State,31 even though the Alaska State Attorney General had already ruled that dental therapists may perform these procedures under Federal law.32 The ADA has proposed alternative mechanisms for improving access to care for this population that are not viewed as providing a more suitable alternative by the Alaska Native Tribal Health Consortium.11 The ADA has recognized the unavailability of dentists in remote villages of Alaska as far back as 1987. 33,34,35 Attempts to encourage private practicing dentists to provide dental care in these settings has not proved to be successful.

The Fiset evaluation of the DHAT program provides evidence that the concerns raised by the ADA have not materialized.17 The training of the DHATs appears to be sufficient to safely and effectively provide the services for which they have been trained. DHATs are under the general supervision of a dentist who is responsible for writing the standing orders and being the point of contact for the therapist. The supervising dentist also conducts periodic reviews of the therapist that include both chart review and patient examination.16

The Alaska Federation of Natives,36 the Alaska Public Health Association,37 the American Association of Public Health Dentistry,38 the National Rural Health Association,39 the American Association of Community Dental Programs,40 Alaska Primary Care Association and the APHA Governing Council41 have passed resolutions or support Dental Health Aides and Therapists; and the APHA Governing Council has supported the use of innovative programs to expand access to oral health care through expanded duties/functions/roles for dental hygienists and assistants at least four times since 1966, 42-45 This resolution does not supplant these four resolutions but builds upon them.

There is a need for other innovative programs to expand access to oral health care that can reduce disparities.46 The Association of State and Territorial Dental Directors have developed a Best Practices Approach for State and Community Oral Health Programs that includes expanding the traditional delivery system, developing community-based collaborative innovative and integrated delivery systems, increasing the healthcare workforce, and assuring sustainability through adequate and long term funding." In addition, "...Dental auxiliary duties, responsibilities, and services may need to be expanded& the provision of selected dental services by non-traditional providers, such as physicians and nurses, should be explored..."; and "... changes in federal and state statutes and policies need to be implemented to enable and sustain the elimination of barriers for universal access to oral health care."

Examples of such innovations can be seen in various states ,46 in addition to the Alaska Dental Health Aide program. In Colorado, legislation has been enacted to permit direct billing to Medicaid by dental hygienists, and in Minnesota, legislation was passed for expanded functions dental auxiliaries. Iowa's Department of Public Health and Department of Human Services implemented the EPSDT Exception to Policy allowing regional Title V child health contractors to be reimbursed by Medicaid for oral screenings and fluoride varnish application provided by dental hygienists to Medicaid children in areas with a demonstrated lack of access to dental providers. In Connecticut, OPEN WIDE is an oral health training program for non-dental health and human service providers including physicians, nurses, nutritionists, childcare and community health workers. The program training enables non-dental providers to recognize and understand oral diseases and engage in anticipatory guidance and prevention intervention. In North Carolina, Into the Mouths of Babes, a statewide program in which pediatricians, family physicians, and providers in community health clinics are reimbursed by Medicaid to provide preventive dental services for children (risk assessment, screening, referral, fluoride varnish application) and caregivers (counseling).47 In 35 states, dental hygienists can administer local anesthesia and in 21 states can administer nitrous oxide.48

Other models have been developed for improving access to oral health care for under-served populations, such as FirstHealth of the Carolinas, Community DentCare Network in Harlem and the New Mexico Health Commons model, offering basic oral health services in connection with community-based primary care services to ensure comprehensive health care for the most vulnerable and underserved populations, where few dentists participate in publicly assisted programs.49 Where there is a shortage of dental providers, communities are looking to medical providers to provide screening and preventive care.50

Given the evidence of the safe and effective oral health care delivered by Dental Health Aide Therapists and the need for such services for populations in remote and under-served areas and the support for having those oral health services, therefore, the American Public Health Association:
(1) Actively supports the Dental Health Aide Therapist (DHAT) Program and other innovative programs and practices to help prevent and alleviate the great unmet oral health needs of Alaska Natives;
(2) Encourages the Governor of Alaska and other administrative and legislative leaders in Alaska to recognize and support the Dental Health Aide Therapist Program as a legitimate, practical and responsible program to help meet the needs of Alaska Natives;
(3) Urges key members of the Congress, the administration, federal and Alaska health agencies, and Alaska dental, public health and Native Tribal organizations and other groups to support the Dental Health Aide Therapist program.
(4) For other underserved populations in other parts of the United States, resolves to strongly support DHAT and other innovative and effective programs, aimed at improving access to preventive and therapeutic oral health services for other underserved populations in the United States;
(5) Supports efforts to inform, as needed, national and state health, public health and dental organizations and agencies and legislative and judicial bodies, and the general public, of APHA's support of such programs;
(6) Urges the Congress, the administration, and federal agencies to improve oral health policies, programs and funding so that fluoridation, health education, preventive and therapeutic dental services are provided for all underserved individuals and communities who lack these services in the United States.



References:
1. APHA Governing Council Resolution: 200117 (Support the Framework for Action on Oral Health in America: A Report of the Surgeon General). APHA Washington, D.C.
2. APHA Governing Council Resolutions: 20015 (Position Paper on Health Status of AI/AN). APHA Washington, D.C.
3. APHA Governing Council Resolution: 20005 (Effective Interventions for Reducing& Disparities). APHA Washington, D.C.
4. APHA Governing Council Resolution: 9810 (Health Services for AI/AN). APHA Washington, D.C.
5. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000
6. Alaska Dental Health Aide Program. Accessed at http://www.phs-dental.org/depac/newfile50.html on June 9, 2006
7. Alaska Office of Economic Development. http://www.dced.state.ak.us/oed/student_info/learn/aboutgeography.htm Accessed on June 12, 2006
8. The 1999 Oral Health Survey of American Indian and Alaska Native Dental Patients. Rockville, Md: Indian Health Service, Division of Dental Services; 2002:106.
9. Sekiguchi, E., Guay AH, Brown LJ, Spangler TJ. Improving the oral health of Alaska Natives. Am J Public Health 2005 May; 95(5):769-73
10. Garvin, Jennifer. "Are dental therapists the answer to Alaska Natives- caries crisis?" Academy of General Dentistry. AGD Impact April, 2005. Vol 33, No. 4. http://www.agd.org/library/2005/april/garvin.asp Accessed on June 12, 2006
11. US Public Health Service. Dentists in the USPHS. General Background for the Alaska Dental Health Aide Program. Alaska Dental Health Aide Program Brief. 09/14/05. Accessed at http://www.phs-dental.org/depac/newfile50.html Accessed on June 9, 2006.
12. US Dept. Health & Human Services. Indian Health Service. Job Opportunities. IHS Dental Vacancies. http://www.ihs.gov/MedicalPrograms/Dental/Positions/vacancies.cfm Accessed on June 9, 2006
13. The Snyder Act of 1921 and the Indian Health Care Improvement Act of 1976 "provide specific legislative authority for Congress to appropriate funds specifically for the health care of Indian people." (Public Law 94-437, 25 U.S.C 1601 et seq.)
14. Editorial, Dental Health, Trained Aides Are Key To Improving Care In Alaska Villages. Anchorage Daily News, September 13, 2005
15. The Alaska Community Health Aide Program; An Integrative Literature Review and Visions for Further Research. Washington, DC; Dept of Health and Human Services, Health Resources and Services Administration, August 2003
16. US Public Health Service. Dentists in the USPHS. Alaska Dental Health Aide Therapist Program IHS DHA Evaluation. Accessed at http://www.phs-dental.org/depac/newfile50.html Accessed on June 9, 2006.
17. Fiset, L, A report on quality assessment of primary care provided by dental therapists to Alaska Natives, University of Washington School of Dentistry, Seattle, Washington, September 30th 2005. Home page for the Alaska Native Tribal Health Consortium: http://www.anthc.org/ or http://www.anthc.org/cs/chs/dhs/index.cfm or http://www.anthc.org/sitemap.cfm . Fiset Evaluation as a pdf file. Accessed on June 14, 2006
18. FDI World Dental Federation. Facts and Figures. http://www.fdiworldental.org/resources/3_0facts.html Accessed on June 14, 2006.
19. World Health Organization. World oral health country/area profile programme. Malmo, Sweden: World Health Organization Collaborating Center. At:
http://www.whocollab.od.mah.se Accessed on June 14, 2006
20. Personal communication. Darren Bradford, former chairperson of National Dental Therapy Working Group, Saskatchewan, Canada 1998-2002, July 20, 2005.
21. Trueblood, G. A quality evaluation of specific dental services provided by Canadian dental therapists, Epidemiology and Community Health Specialties, Health and Welfare Canada, Ottawa, Ontario, 1992
22. ADA Position on the Dental Health Aide Program in Alaska. http://www.ada.org/prof/resources/positions/statements/index.asp#misc Accessed on 8/9/05
23. Alaska Dental Society, Inc. (full page ad) Governor Murowski 2nd class care for Alaska Natives deserves a ferocious reaction! Juneau Empire. May 26, 2005, Section C, p.7
24. Brandjord, R.M., "Statement of the American Dental Association to the Committee of Indian Affairs and the Committee on Health, Education, Labor, and Pensions U.S. Senate on S. 1057 The Indian Health Care Improvement Act Amendments of 2005" July 14, 2005. http://www.ada.org/prof/advocacy/test_050714_dhat.pdf Accessed on June 14, 2006
25. Patkotak, E. Dental Association offers no solution. Anchorage Daily News. August 3rd, 2005. http://www.adn.com/opinion/voice/story/6776181p-6665323c.html Accessed on June 14, 2006
26. American Dental Association, Alaska Dental Society Inc (full page ad), Alaska Attorney General Makes Historic Decision To Lower Health Standards, Anchorage Daily News, September 18, 2005.
27. Nash, DA, and Nagel, RJ, Confronting Oral Health Disparities Among American Indian/Alaskan Native Children; The Pediatric Oral Health Therapist, Am J Public Health 2005 Aug;95(8):1325-9
28. Allukian, M, Bird, MT and Evans, CA, APHA Presidents Support Dental Therapists, Letter to the Editor, Am J Public Health 2005 Nov;95(11):1880-1
29. Campbell, D, Pollick HF et al, Leadership of the Oral Health Section Responds to Sekiguchi et al. Improving the Oral Health of Alaskan Natives, Letter to the Editor, Am J Public Health 2005 Nov;95(11):1880
30. Krisberg, K. Alaska program brings essential oral health to the underserved, The Nation's Health, APHA, Washington D.C, October 2005, p 17
31. Jakush, J. Alaska lawsuit filed, ADA news, 37(3), Chicago, IL, American Dental Association. Posted January 31, 2006 http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1771 Accessed on June 14, 2006
32. Porco, P, State approves rural dental aides, dentists disagree; unlicensed providers may drill and extract teeth, Anchorage Daily News, Sept 10, 2005
33. Current Policies of the American Dental Association. Dental Program for Remote Alaskan Residents (2004:323). Available at http://www.ada.org/prof/resources/positions/policies.asp Accessed on June 12, 2006
34. Current Policies of the American Dental Association. The Alaska Native Oral Health Access Task Force  Strategies to Assure Access to Quality Health Care for Native Alaskans (2004:291). Available at http://www.ada.org/prof/resources/positions/policies.asp Accessed on June 12, 2006
35. Current Policies of the American Dental Association. Utilization of Private Practitioners by Indian Health Service (1987:519). Available at http://www.ada.org/prof/resources/positions/policies.asp Accessed on June 12, 2006
36. The Alaska Native Health Board submitted resolution 2005-06, approved October 22, 2005 by the Alaska Federation of Natives Annual Convention in Fairbanks, Alaska.
37. Alaska Public Health Association Resolution 1-2005, December 5, 2005, Anchorage AK.
38. American Association of Public Health Dentistry. Weyant R. Letter to Senator McCain. February 15, 2006. Available at http://www.aaphd.org/default.asp?Page=mccain.htm Accessed on June 12, 2006.
39. National Rural Health Association. Rural Health Policy Board Meeting: May 2006. Policy Statement.
40. American Association of Community Dental Programs. Resolution. May 1, 2006. (Personal communication. Larry Hill, President)
41. APHA Governing Council Resolution: 2005-LB1. Support for the Alaska Dental Health Aide and Therapist and Other Innovative Programs. APHA, Washington, D.C.
42. APHA Governing Council Resolution: 6604: A National Dental Health Program for Children. APHA, Washington, D.C.
43. APHA Governing Council Resolution: 7214: Increased Utilization of Dental Auxiliaries. APHA, Washington, D.C.
44. APHA Governing Council Resolution; 8121: Employment of Expanded Function Dental Auxiliaries in Public Dental Care Programs. APHA, Washington, DC
45. APHA Governing Council Resolution: 8515 State Practice Acts Relating To Dental Hygiene, APHA, Washington, D.C.
46. American State and Territorial Dental Directors. Best Practices Approach for State and Community Oral Health Programs. Access to Oral Health Care Services: Workforce Development. Accessed on June 5, 2006 at http://www.astdd.org/dynamic_web_templates/bpworkforce.php#three
47. Rozier RG, Sutton BK, Bawden JW, Haupt K, Slade GD, King RS. Prevention of early childhood caries in North Carolina medical practices: implications for research and practice. J Dent Educ 2003 Aug;67(8):876-85.
48. American Dental Hygienists Association. Governmental Affairs. Legislative Information. http://www.adha.org/governmental_affairs/legislative/ Accessed on June 16, 2006.
49. Formicola AJ, Ro M, Marshall S, Derksen D, Powell W, Hartsock L, Treadwell HM. Strengthening the oral health safety net: delivery models that improve access to oral health care for uninsured and underserved populations. Am J Public Health 2004 May;94(5):702-4.
50. Treadwell H, Ro M. Community-based oral health prevention. Issues and opportunities. Am J Prev Med 2002 Jul;23(1 Suppl):8-12