Dental care not only saves smiles, it saves lives. Yet millions of Americans can’t afford to go to a dentist. They may not have health insurance that covers dental care, or they may live far from a dentist or one who accepts Medicaid patients.

In Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, Mary Otto describes how American dentistry came to the point of producing Hollywood smiles for some while leaving enormous gaps in care for others. In this excerpt, she describes a model of accessible, affordable dental care that is used successfully in other countries and now, in some parts of the United States. Dental health aide therapists, or DHATS, provide much of the same basic care as dentists. Their training and overheads costs are lower, so dental therapists can go where people need them most—in this case, a remote tribal community in Alaska.

In spite of vast changes to their lives over the past three centuries, Alaska Natives have fought to hold on to their ancient traditions, their dances and ceremonies, their hunting and fishing that embody both survival and prayer. Increasing reliance upon Western diets, however, has exacerbated problems with tooth decay. Soda pop arrives by the crate load to villages that are unreachable except by plane or boat or snowmobile. Public water supplies and other community sources of fluoridated water are rare. People drink melted snow. The perennially underfunded Indian Health Service has had chronic difficulty hiring dentists to serve in remote communities. Even if they come, they often leave. Alaska Native children suffer from tooth decay that has been estimated at rates more than twice as high as other American children. In Alaska, complete tooth loss by the age of 20 is not uncommon.

Wrapped in icy mist, the village of Angoon is perched upon a spit of land east of Sitka, surrounded by slate-blue water. Beyond the village, there are mountains, deeply furred by forests. Since ancient times, the people have called the place the “Brown Bear’s Fort,” and the bears still outnumber the humans. Pieces of Angoon’s story are scattered along the narrow roads. There is a tiny wooden Russian Orthodox church and a row of tall wooden poles, crowned with ancestral totems, fish, and bears. There is a small power station and the Alaska Native Brotherhood Hall and wooden homes, one crumbling into the sea. There is a dump on the edge of the village where eagles casually feed.

And there is a modern clinic where, beyond the lighted windows, on this morning DHAT Brian James, clad in dark blue scrubs, was at work. He had the compact build, thick black hair, and dark, twinkling eyes of his Tlingít people. He greeted his next patient, Reggie Nelson, a local elder who came to the clinic a couple of months before to have a hopelessly decayed tooth removed. Nelson was back for some restorative work.

“It looks like we have one more filling to do,” said James. He gave Nelson a shot of anesthetic and they chatted about fishing. When James was ready to begin he said, “You feel anything sore or sharp, you raise your left hand and we’ll stop.”

Then James did the thing that had stirred battles in courtrooms and the halls of Congress. He took out a dental handpiece, with its burred bit. As it whirred, he carefully removed the decay from Nelson’s molar. Then he placed a filling in the elder’s tooth.

When James decided to become a DHAT, there was no place in the United States for him to train. He and the other seven of the first Alaskan DHATs were sent by their tribes to New Zealand to learn their skills. The tribes were within their rights to set up the DHAT program, the Alaska state attorney general decided in 2005. Though state and federal dental groups opposed dental therapists, federal laws relating to the provision of Indian health care trumped the state dental practice act, the attorney general said.

Dental groups sued anyway. They sought support in the court of public opinion as well. One full-page advertisement placed by the Alaska Dental Society featured a snarling bear: “2nd class dental care for Alaska Natives deserves a ferocious reaction,” read the headline over the ad. “No Alaskan should face irreversible dental surgery by an unlicensed dental therapist with no dental degree.”

When James completed his training, he returned to Alaska to begin his work, even as the lawsuit by the American Dental Association and the state dental society naming him and the other DHATs continued to threaten to shut down the program. In 2007, the case was settled. The claims of the dental groups against the Alaska Native Tribal Health Consortium were dismissed by the state Superior Court, allowing the DHATs to continue to work legally in tribal areas. James was licensed through the federal Indian Health and Welfare Act’s Community Health Aide Program, an initiative that got started in the 1950s as an emergency response to a tuberculosis epidemic that was devastating Alaskan tribal villages. With professional medical care out of reach, village residents were singled out for the training they needed to provide lifesaving care and medication to their neighbors.

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