Dental care not only saves smiles but also saves lives. Yet millions of Americans can’t afford to go to a dentist. They may not have health insurance covering dental care or 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 used successfully in other countries and some parts of the United States. Dental health aide therapists, or DHATS, provide much of the same basic care as dentists. Their training and overhead costs are lower, so dental therapists can go where people need them most—in this case, a remote tribal community in Alaska.
Despite profound changes to their lives over the past three centuries, Alaska Natives have fought to hold on to their ancient traditions, dances and ceremonies, hunting, and fishing that embody survival and prayer. However, increasing reliance upon Western diets has exacerbated tooth decay problems. Soda pop arrives by crate load to unreachable villages except by plane, 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, 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 town, there are mountains deeply furred by forests. Since ancient times, 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, 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, DHAT Brian James, clad in dark blue scrubs, was at work this morning. He had the compact build, thick black hair, and dark, sparkling eyes of his Tlingít people. He greeted his next patient, Reggie Nelson, a local elder who had come to the clinic a couple of months before to have a hopelessly decayed tooth removed. Nelson was back for some therapeutic 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, 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. Their tribes sent him and the other seven of the first Alaskan DHATs 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 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.”
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. This initiative wasstarted in the 1950s as an emergency response to a tuberculosis epidemic that devastated 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. 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.