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Program Brings Dental Care to Remote Alaskans, but Some Dentists Are Skeptical

November 16, 2011 at 12:00 AM EDT
A program to train dental therapists to perform basic care in rural Alaska has been met with both praise and skepticism. Health correspondent Betty Ann Bowser continues her series of reports on dental costs, coverage and access for Americans.

RAY SUAREZ: Now, the second of two stories on increasing access to dental care.

Last night, NewsHour health correspondent Betty Ann Bowser looked at problems of costs, coverage and access. Tonight, she examines one program in Alaska which has been met with both praise and skepticism.

Her story includes picture of dental surgery.

BETTY ANN BOWSER: From the air, you can see the isolation, Toksook Bay, a tiny village of about 500 people on the edge of the Bering Sea in southwest Alaska.

Right now, the native Alaskan Yup’ik people who populate the area are busy braiding fresh tomcod fish with dried grasses and hanging them up along with skinned red salmon to dry. This will be the primary source of protein when winter comes. The Yup’it live today they way they have for generations. There are no paved roads and few stores. The only way in or out is by air or barge.

Yet, on the edge of this tiny town, there is a sparkling modern medical clinic providing dental care to people who have some of the worst teeth anywhere.

DR. WARD HURLBURT, Alaska Department of Health and Social Services: The oceans were lower, and they came by land.

Dr. Ward Hurlburt is Alaska’s top public health official.

DR. WARD HURLBURT: The people in the village, the children in the village drink a lot of soda pop. There is often not good water. A can a pop may cost less than a bottle of water.

They will — babies will be fed things like Jell-O water. And so the kids get a lot of cavities in their teeth. They lose a lot of the teeth, the baby teeth. It goes on into the permanent teeth or the adult teeth. So there are huge problems.

BETTY ANN BOWSER: Dr. Mary Williard has been working with native Alaskan patients in rural areas for over 10 years.

DR. MARY WILLIARD, Alaska Dental Health Aide Therapist Program: We have patients that have more decay than the average patient in the Lower 48 would have generally. We have two-and-a-half times the rate of decay of — in our kids zero to 5 as you would have in the rest of the United States.

WOMAN: Brush your teeth all over.

BETTY ANN BOWSER: But in the past six years, young people like 21-year-old Phylicia Wilde have come to more than a dozen of these areas. They’re called dental therapists or mid-level providers. They aren’t dentists, but they do a lot of things licensed dentists do: drill decayed teeth; fill them; and, when necessary, pull them out.

WOMAN: So, what I would like you guys to do is go ahead and get out a rubber dam.

BETTY ANN BOWSER: The program is run by a consortium of native tribes under a nonprofit organization funded mostly with federal money. It’s the only place in the United States where providers are allowed to do procedures without direct supervision of a dentist.

The idea is gaining some traction because the federal government has identified more than 4,500 areas in all 50 states where it says there are critical shortages of dentists.

WOMAN: Does it hurt when you bite down on it?

MAN: Yes.

BETTY ANN BOWSER: Sixty-one-year-old Moses Channar (ph) came into the clinic on a Wednesday morning with a toothache. Wilde took a look and, after doing X-rays, determined the tooth needed to come out.

PHYLICIA WILDE, Dental Health Aide therapist: Good afternoon, Dr. Wilson. This is Phylicia.

BETTY ANN BOWSER: But, first, Wilde consulted with a supervising dentist 115 miles away in Bethel. After getting the go-ahead from the dentist in Bethel, Wilde spent about 20 minutes tugging away, until the tooth came out.

PHYLICIA WILDE: I felt pretty confident in removing it.

BETTY ANN BOWSER: So, if you hadn’t taken it out, what would’ve happened to him?

PHYLICIA WILDE: He would expect more pain, possible swelling, a lot more swelling, and a cyst could have possibly formed and caused other teeth loss.

BETTY ANN BOWSER: Dr. Williard says the two-year training program for high school graduates prepares therapists for the kinds of dental problems that are most often seen in native tribal areas.

DR. MARY WILLIARD: In the first year, they get a lot book training and get their basic sciences. And they start working on mannequins.

In the second year, it’s pretty much a clinical clerkship, basically, where they are seeing patients almost the entire day. They don’t get to learn everything a dentist learns. And we really focus on prevention, community prevention programs as well, and the basic services that people need generally, fillings, cleanings and simple extractions.

BETTY ANN BOWSER: Delivering basic dental care to Native Americans in isolated villages in Alaska is one thing. But whether the model can be replicated in the Lower 48 is a subject that’s being debated today, with some very powerful voices saying it just won’t work.

Dr. Bill Calnon is president of the American Dental Association.

DR. WILLIAM CALNON, American Dental Association: I cringe when I hear the terms it’s just a routine filling or it’s a routine extraction. There is no such thing as routine, because they’re on a patient. There’s no such thing as a routine patient. Every patient is different.

BETTY ANN BOWSER: The ADA and one other leading dental group also oppose the concept, because they say current work models don’t give trainees enough education.

DR. CHRISTINE MOLESKI, Alaska Dental Society: So are you getting things squared away with that?

BETTY ANN BOWSER: Dr. Christine Moleski, who practices in Juneau, is president of the Alaska Dental Society.

DR. CHRISTINE MOLESKI: I can’t imagine after having only 18 months of education, after getting my high school diploma, and with a limited amount of training or coaching, even being comfortable extracting teeth on my patients. And I believe that any patient in Alaska really deserves to have someone who has a more thorough education and background, so that you can manage problems as they arise.

BETTY ANN BOWSER: Does the ADA have any evidence or any concrete examples of anything that’s ever gone wrong?

DR. WILLIAM CALNON: To my knowledge, there is no documentation at this point, but we are dealing with so few people. There are not that many people in the program in Alaska.

BETTY ANN BOWSER: Advocates of the Alaska program say the dental therapists are trained to know when they have a case that is beyond their training, like this situation with 12-year old Jason Therchik (ph).

PHYLICIA WILDE: He will need to have one of his premolars removed to make room, although that is out of my scope of practice, because there is no decay on that tooth.

BETTY ANN BOWSER: Wilde tells his mother she will have to take him to Bethel to see a dentist.

WOMAN: Thank you, Doctor.

BETTY ANN BOWSER: But Calnon says, even with those limitations, any procedure, especially pulling a tooth, can be dangerous.

DR. WILLIAM CALNON: I have had patients in my chair have heart attacks. I have had people have strokes. I have had people that have allergic reactions, life-threatening allergic reactions, to medications they took before they came in this office. You do not have a lot of time to think when you react to that.

BETTY ANN BOWSER: But proponents of the dental therapist model say the ADA is worried about more than safety. A recent survey of over 100,000 of the ADA’s members showed the majority of dentists feel some level of uncertainty about their economic stability.

And supporters of the mid-level-provider idea say, if large numbers of providers who aren’t dentists started doing routine procedures, charging lower fees, the traditional dental office model might be threatened.

DR. MARY WILLIARD: I think they are afraid of the unknown. They are afraid of change. They are afraid of losing control. You know, dentistry has been the dentist for purview for years. And now we have a new provider that’s coming in and being able to do some of those things that only dentists could do before. I think they’re afraid of it coming down into their area. That’s the biggest fear.

DR. WILLIAM CALNON: I really would take exception to that, because I think a lot of people feel that a model like that is not going to impact a tremendous number of dentists in their practices.

I think that what ultimately will take place, and I think everyone will probably embrace, is not the model that we’re seeing now. But we already have dental extenders, if you will, in the dental field, OK, working as part of the dental team, working as part of the team of the dentists, the hygienists, the assistants, OK?

We have — in several states, we have expanded function dental assistants, which do more, but they don’t do surgical procedures.

BETTY ANN BOWSER: The new federal health care reform law provides for dental therapist work model pilot programs. Minnesota just graduated a small class of providers like these in Alaska. And at least 10 other states, with the help of foundation money, are looking at ways they too can train people who aren’t dentists to do dental work.

RAY SUAREZ: On Friday, we will have a live chat online with some of the experts Betty Ann interviewed. You can leave your questions right now on the Rundown blog.