Tuesday, September 1, 2015

Dental Care that Works in Rural Alaska


Mark Trahant Conan Murat, a dental health therapist, and Isaiah Anvil, a dental hygienist, treat a patient at the Yukon-Kuskokwim Health Corp., clinic in Bethel, Alaska. Dental health therapists are mid-level oral health providers who perform about 80% of the work that a dentist would do.

BETHEL, Alaska -- Conan Murat has a tough schedule. About every other week he packs up a portable dental office, checks his groceries, sleeping bags and other supplies, then flies to one of his 13 assigned remote villages in the Yukon-Kushkokwin Delta.

Remote is a relative word.

Murat’s base is Aniak, some 90 air miles north of Bethel, and a village of just more than 500 people. When he reaches his destination, Murat performs the tasks of basic dentistry: fillings, nerve treatments, x-rays, stainless steel crowns, extraction of teeth and preventative care.

Murat’s visit opens up a new world and the prospect of significantly improved dental health. Dental health therapists now serve some 35,000 Alaska Natives in villages across the state. 

Before Murat, people in Aniak had to travel to Bethel (at a fare ranging, today, from $362 to $671) for basic dental services. Or they could wait a year for an annual visit by a dentist. 

In practice all these options meant people in Aniak had no dental care. 

A 1998 study by the SouthEast Alaska Regional Health Consortium showed that only 20 dentists were serving more than two hundred villages and some 85,000 people. Compounding that dentist shortage is rampant tooth decay among Alaska Natives; nearly 70 percent of children under 14 have dental caries (a bacteria process that causes decay) and more than 90 percent of adolescents show the disease.

A decade ago the Alaska Native Tribal Health Consortium began planning for a new dental health initiative, one modeled after the successful Community Health Aide Program. Then in 2003, six students traveled to New Zealand for a two-year training program as dental health therapists. That’s half the time it takes to train a dentist — and at a significantly lower cost. 

Now the training is conducted by the ANTHC in partnership with the University of Washington at classrooms and clinics in Anchorage and Bethel. Moreover, the program trained people from the communities they will serve. As a result, Murat and other Alaska Native dental health therapists are committed to working in villages, places where routine health care is absent. (Of course that’s true of most of Indian Country. We all know about how difficult it is to get an appointment with a dentist on a regular schedule.) 

The Alaska program was unsuccessfully challenged by the American Dental Association — and the ADA continues to block expansion to other reservations through a provision in the Indian Health Care Improvement Act. The ADA doesn’t want non-dentists providing treatment normally given by its membership.

Last week I visited Bethel funded by a grant by the W.K. Kellogg Foundation (a major supporter of the dental health therapists project). I thought (and have written before) that this program was an important innovation. It’s that and more so.

A number of fully credentialed dentists were also a part of this Kellogg visit. Most asked tough questions about the program, but came away seeing its value and potential.

The young people who go through this program start with a high school education or a GED. They quickly become health care leaders in their community. And why not? Dental health therapists are good, long-term jobs that provide immediate better oral health and other health benefits to villages. It makes life better.

Kate Kohl, a second-year student, said the program is challenging. “Sometimes I call it dental boot camp,” she says. It’s improved her communications skills and she says she’s more assertive. “I am growing as an individual, a character and as a professional.”

There are many reasons why this program must be expanded beyond Alaska. We need more health care providers who can deliver basic services, especially in rural areas. Mid-level programs, like this one, create a professional class of young people who use their newly acquired skills to serve their community. And, this is a business model that makes sense both for the patients and for the tribal, regional or IHS facility. It stretches dollars while providing better service. 

And, most important, the dental health therapist program is designed by native communities for native communities. It’s excellent and that’s the essence of self-determination.

Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. Trahant’s recent book, “The Last Great Battle of the Indian Wars,” is the story of Sen. Henry Jackson and Forrest Gerard.


Spelling Error

The region is the Yukon-Kuskokwim, named after the Kuskokwim River that flows through it. Not sure where you got "kushkokwin."

SMART solutions for oral health, mental health, primary care

Alaskan rural populations require SMART solutions -SMART

Specific to rural populations in Alaska,

Measurable in delivering the care needed not only at the start but in the middle and at the ending of health care careers,

Achievable in result established for rural Alaska

Realistic - a sensible, practical design that addresses care the way things really are

Timely - Rural Alaskans need the care now and will need the care for the 20 or more years that it will take to begin to progress toward addressing the care needs for rural Alaskans

Alaska has been a leader in local oral health, local mental health, and local primary care workforce. Alaska has had to design its own as the aberrant US design does not work. Alaska has figured out that it needs permanent solutions, not temp workforce. A state can only pay 1 million more each year for primary care locums, recruitment, and retention so long before it has to develop a real solution that is SMART for Alaska.

The US rural primary care design is failing with 30 years of steadily less rural primary care and primary care delivered per primary care graduate. SMART solutions work by design. The US has not worked on solutions for health access except 1965 - 1980 and 30 years later we are just at the beginning of the consequences. http://basichealthaccess.blogspot.com/2011/08/rural-primary-care-stark-r...

Robert C. Bowman, M.D.

A T Still Dental Students

The public health design of the dental school is matched with students spread out over 25 states including Alaska. An expansion of the school with more graduates has been initiated in Missouri. Sites report that students can facilitate an additional $10,000 in dental care over a 4 to 6 week rotation. Louisiana Primary Care Association presentation at http://www.lpca.net/uploads/File/2009_Conference/Slides/June_23/Hometown...

Dental students are fully approved with simulators, human patients, and preceptors prior to their CHC rotations. Sites take care of the students who also contribute to the oral health care at the sites working with dental preceptors.

Community Friendly designs that are SMART for rural communities contribute more than they require. Mental health and primary care contributions take more time and adaptation than dental. Optimally a 9 to 12 month time period helps to contribute the most to local health care for RN, MD, DO, NP, or PA student team members.

Designs specific for locations in most need of health care delivery must complement delivery and not complicate delivery. For mental, oral, and primary care where needed, designs must be a best fit those in need of care - not an afterthought.

Robert C. Bowman, M.D.