In December 2008 the first class of Alaska Native Dental Health Aide Therapist (DHAT) students will graduate from a two-year course of study, the DENTEX Program, and begin preceptorships leading to federal certification. They will then move to remote Alaskan villages to provide year-round mid-level dental care to Alaska Native residents while under general supervision of dentists. A second cohort of students is completing its first year of didactic training in Anchorage. The new Alaska-trained DHATs will join 10 New Zealand-trained colleagues who have been practicing in bush Alaska for the past three years.

DHAT graduates will face a daunting task: addressing the vast

First-year student Ooyuan Nagaruck educating preschoolers in Anchorage on oral health.

unmet need for dental care in rural Alaska. Alaska Native children suffer rates of tooth decay 2.5 times the U.S. national average, and more than one-third of rural Alaskan school children have missed school because of dental pain. Historically, dental care in the villages has been provided by itinerant dentists, whose sporadic visits lack a continuity of care. Alternatively, village patients must travel long distances by bush-plane, riverboat, or snow machine, often in inclement weather, to seek basic dental care. The traditional itinerant model has taught communities to view dental treatment as acute care — relief of pain — rather than care that may prevent dental pain and chronic problems altogether.

By living in the villages they serve, DHATs will be able to introduce community-based prevention to everyone, including pregnant mothers, infants and school-aged children, and the elderly. Patients whose dental needs extend beyond the DHAT’s scope of practice will receive palliative care then be referred out to supervising dentists in distant regional clinics.

DENTEX is a partnership between the University of Washington’s MEDEX Northwest Physician Assistant Training Program and the Alaska Native Tribal Health Consortium. The program provides a focused, competency-based primary care curriculum emphasizing culturally sensitive community level dental disease prevention for underserved Alaska Native populations. The curriculum incorporates innovative public health-related preventive and clinical strategies to manage rampant dental caries, as well as other safety net services needed most by native villagers.

The DHAT represents a new dental health professional in the United States, a mid-level provider working in remote settings and using telemedicine communication technology to communicate with the supervising dentist, or working hand in hand with a supervising dentist to expand access to and availability of dental care. DHATs offer a new mix of skills, including the behavioral and public health skills needed to affect change. DHATs take a biological approach to oral disease, focusing on reducing the bacteria in the mouth that produce caries and periodontal disease. DHAT training emphasizes behavior change through patient education, motivational interviewing, risk assessment for dental disease, and triage. Using a primary care team approach, students learn to work with other health professionals — physicians, physician assistants, nurse practitioners, and nurses — and integrate their work into existing community-based medical prevention programs. They receive special training in tobacco cessation, maternal oral health, and diabetes, conditions typically prevalent in rural Alaska.

The World Health Organization cites 42 countries that currently utilize DHATs. The DENTEX curriculum was modeled after other DHAT programs throughout the world including those from New Zealand, the United Kingdom, Canada, and other nations, but modified to emphasize community-based oral health care needs.

During their didactic year of training in Anchorage students focus on basic coursework involving anatomy and physiology, local anesthesia, pathology, and other basic health sciences, and learn to provide preventive care to patients of all ages, including infants and toddlers. Students learn a high level of practical clinical skills based on simulation and direct patient contact.

In their second year, at the clinical training site in Bethel, students are

Second-year class in Bethel.

Instruction in the two-year program is provided by full-time on site dental, dental hygiene and basic health science faculty from the Universities of Washington, Minnesota, Florida, Alaska, and Baylor University, as well as clinical faculty with vast experience providing dental care in rural Alaska.

Following completion of their preceptorship and federal certification by the Alaska Community Health Aide Program Certification Board, each DHAT receives a prescribed scope of practice based upon his/her demonstrated clinical skills and guided by tribal health organization clinical needs. Practicing DHATS must log 24 hours of continuing dental education annually, and need to be recertified every two years.

By living and providing care in remote villages year-round, DHATs will build strong links to their communities, schools, and surrounding villages, enabling them to emphasize oral disease prevention and provide much needed continuity of care.

Anyone interested in learning more about the program may visit the DENTEX  Web site at www.dentexak.washington.edu.

By Louis Fiset, DDS, DENTEX Curriculum Coordinator, University of Washington, fiset@u.washington.edu.