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Alaska Native Health Board1840 Bragaw Street, Suite 220Anchorage, Alaska 99508Phone: (907) 562-6006Fax: (907) 563-2001Testimony beforeThe Senate Committee on Indian AffairsHearing on Expanding Dental Health Care in Indian Countryby Evangelyn DotomainPresident/Chief Executive Officer,Alaska Native Health BoardDecember 3, 2009Good afternoon and thank you for the opportunity to testify today. I am honored to behere. My name is Evangelyn “Angel” Dotomain and I am the President/Chief Executive Officerof the Alaska Native Health Board (ANHB). ANHB was established in 1968 and representstwenty-five tribal health organizations across the state of Alaska who collectively employ over7,000 individuals and serve approximately 130,000 American Indians/Alaska Natives. Ourpurpose is to promote the spiritual, physical, mental, social, and cultural well-being and pride ofAlaska Native people.I am of Cupik and Inupiaq descent from the villages of Mekoryuk, Shaktoolik, andMary’s Igloo. I have been blessed to have previously worked for the Alaska Native TribalHealth Consortium (ANTHC) for approximately nine years in Education & Development,Recruitment, and in the Alaska Native Medical Center Administration office.My testimony will address expanding dental health care in Indian country and Alaska’sdental health aide therapist program. I appreciate the privilege and opportunity to share theAlaska Tribal Health System experience with the DHAT program. The DHAT program hasprovided high quality care that meets all the standards of care as that of a dentist within theirscope of practice and exists as another example of innovations to ensure access to high qualitycare in Alaska.BackgroundIn response to extensive dental health needs and high dental vacancy rates, the AlaskaDental Health Aide Therapy (DHAT) program began in 2003. The DHAT program is part of theCommunity Health Aide Program (CHA Program), which is authorized under Section 119 of the

Indian Health Care Improvement Act, 25 U.S.C. § 1616l. The CHA Program started in the1960s by the Indian Health Service to provide emergency, clinical, and preventive services undergeneral supervision of physicians. Following the CHA Program model, the DHAT programselects individuals from rural Alaska communities to be trained and certified to practice undergeneral supervision of dentists in the Alaska Tribal Health System.The Alaska DHAT program was created in part due to the high rates of dental caries andoverall lack of access to dental services in rural Alaska villages. Alaska Native children andadolescents suffer dental caries rates at 2.5 times greater than general US children andadolescents.1 This, combined with a vacancy rate of 25% and 30% annual turnover rates indentists has developed into a serious problem in Alaska dental care.2Nationally, with the number of dentists declining from 60 per 100,000 currently to anexpected 54 per 100,000 in 2030 (ADA), there is clearly not an adequate supply and/ordistribution of dentists to meet the basic oral health needs of America’s First People. The greatunmet need for dentists or other oral health providers in Indian Country, where there are, on theaverage, about half the dentist-to-population ratio of the national average, is well-documented.3According to the Indian Health Service: “The fact that dental decay affects more than 75 percentof AI/AN people presents a major challenge requiring a large-scale public health approach.”4Based on our experiences in Alaska, we could not agree more. Dental Therapists can help to fillthe gap to provide desperately needed services where dental services are either limited or do notexist at all.Dental Therapists WorldwideThe Alaska DHAT training program is modeled after New Zealand’s National School ofDentistry in Otago. New Zealand’s Dental Therapists have been highly valued for over 80 yearsand are providing high quality care. In fact, over 14,000 dental therapists operate in over 53countries worldwide. The United States is the only industrialized nation without a midleveldental practice available to its citizens.Dental therapists have been in practice for many years world wide especially in1Smith EB. Dental therapists in Alaska: addressing unmet needs and reviving competition in dentalcare. Alaska Law Review. 2007;24(1):105-43. Nash DA, Nagel RJ. Confronting oral health disparitiesamong American Indian/Alaska Native children: the pediatric oral health therapist. Am J Public Health.2005;95(8):1325-1329. One-third of school-age children in rural Alaska miss school because of dentalpain, and a quarter report avoiding laughing or smiling because of the appearance of their teeth. Ibid. OralHealth disparities plague not only Alaska Natives, but all of Indian Country. According to the Departmentof Health and Human Service’s Agency for Healthcare Research and Quality (AHRQ), AI/AN childrenbetween the ages of 2 and 4 have the highest rate of decay in the U.S.—five times the national px?id 1840. According to the Indian Health Service, 79percent of AI/AN preschool children from 2 to 5 years old have a history of dental decay, 68 percent haveuntreated dental decay, and more than 50 percent have severe childhood dule hs providers oral health.2Nash, DA. Ibid.3Agency for Healthcare Research and Quality, http://www.innovations.ahrq.gov/content.aspx?id 1840.4Indian Health Service, http://www.ihs.gov/headstart/index.cfm?module hs providers oral health.

children’s oral health services and have shown they provide high quality care. For example,since 1963, Canadian dental therapists have been providing excellent care equal to or exceedingthe quality of care of dentists and they have been more cost-effective.5 In the Netherlands, thereis greater investment in a dental therapist/dental hygienist combination and a 20% reduction indental school numbers to improve access to care and decrease care cost.6 With no litigation ormalpractice suits in over 50 years, Malaysian dental therapists have proven their worth in thetreatment of children’s dental needs.7 Dental therapists have proven their ability through highquality care worldwide.DHAT Program InformationAlaska’s DHATs receive extensive training, certification, continuing education, andclinical reviews to ensure their skills are of the highest quality. Alaska’s first DHATs receivedtheir training New Zealand’s National School of Dentistry in Otago. The first DHATs graduatedin 2004. In 2007, the Alaska Native Tribal Health Consortium in partnership with the Universityof Washington’s MEDEX Northwest Physician Assistant Training Program opened DENTEX,the first DHAT training center in the United States. The DENTEX goal is to provide culturallysensitive patient-centered care to optimize prevention to ensure that patients feel comfortableenough to return for continued care and treatment.The DENTEX program is extremely rigorous. Students receive two years of training inbiological science, social science, pre-clinic, and clinic training. The students receive 2400hours of training and clinical experience during their first year in Anchorage and during theirsecond year in Bethel, Alaska. Utilizing the same textbooks as dental students, DHATs intraining are trained to provide the same high quality level of care a dentist would within theirlimited scope. The DENTEX faculty, most from dental schools, ensures that the students meetall skill requirements throughout their training. The training also consists of extensive clinictraining. In fact, 20% of the first year of training and 78% of the second year of training consistsof clinical components.DHATs are trained to provide oral health education, preventive services, fillings, anduncomplicated extractions to preserve function and address pain and infection. DHATs are ableto provide atraumatic restorative technique, placement of temporary restorations, simplerestorations, simple extractions, lab processed crowns, pulpotomy, and pulp capping just to namea few. In addition, DHATs provide community education, many times in schools for youngchildren and to families who visit the clinics.An additional requirement of participating in the program is for each student to have asponsor agreement with a tribal health organization for which they will work after graduationand certification. The sponsoring tribal health organization covers the costs of the student’straining for the two year program in return for four years of service. In addition, the sponsoringorganization provides a supervising dentist for the DHAT.5Nash, DA. Dental Therapists: A Global Perspective, Int’l Dental Journal, 58:61-70 (2008).Ibid.7Ibid.6

In addition to the agreement and extensive training, the student must complete apreceptorship of at least 400 hours with their supervising dentist. Since the DHAT will bepracticing under the general supervision of the supervising dentist, it is during this preceptorshiptime that the supervising dentist and DHAT agree on the DHAT’s scope of practice. Thepreceptorship time also allows the dentist and DHAT to develop a rapport as they will be inconstant communication once the DHAT is at their permanent station many times talkingtelephonically three to six times per day, communicating via e-mail and/or telemedicineconsultations regarding patient needs.Only after the DHAT completes this clinical preceptorship are they eligible forcertification. Each DHAT must apply for and receive certification to the Indian Health Service’sCommunity Health Aide Program Certification Board. This independent federal board serves tocredential providers and respond to issues and patient complaints. In addition, this board ensuresstandards for discipline, suspension or revocation of a certificate are met.Once DHATs are trained, complete their preceptorship, and are certified, they begin workat their respective tribal health organization. However, their review and education does not stopthere. DHATs must be recertified every two years and complete continuing education hours. ADHAT review consists of direct observation of each service performed eight times every 2 years.They are also required to complete 24 hours of continuing education per two year cycle.Current DHATsThere are currently ten practicing DHATs who were trained in New Zealand and threewho were trained at DENTEX. These DHATs work for the following tribal healthorganizations: Norton Sound Health Corporation (NSHC), Maniilaq Association (Maniilaq),Yukon Kuskokwim Health Corporation (YKHC), SouthEast Alaska Regional Health Consortium(SEARHC), Bristol Bay Area Health Corporation (BBAHC), Metlakatla Indian Community(MIC), and Mount Sanford Tribal Consortium (MSTC). In addition to these tribal healthorganizations having current DHATs practicing, the following tribal health organizations aresponsoring DHATs in their second clinical year of DENTEX: YKHC, BBAHC, Tanana ChiefsConference (TCC), and Aleutian Pribilof Islands Association (APIA). The following tribalhealth organizations are sponsoring DHATs in their first year of DENTEX: Council ofAthabascan Tribal Governments (CATG), YKHC, Eastern Aleutian Tribes (EAT), Maniilaq, andBBAHC. In total, there are thirteen DHATs currently practicing and fourteen in DENTEXtraining. Please see map of DHAT location information attached.In recent independent studies, DHAT skills were assessed to determine if they are on parwith dentist provided services and quality of care provided by DHATs.8 The results of an earlystudy noted that the “program deserves not only to continue by to expand” and that suggestionsthat dental therapists “cannot be trained to provide competent and safe primary care for AlaskaNatives is overstated.”9 In a recent pilot study, there was found to be no significant differencebetween irreversible dental treatment provided by DHATs or dentists and no significant8Agency for Healthcare Research and Quality, http://www.innovations.ahrq.gov/content.aspx?id 1840.Louis Fiset. A Report on Quality Assessment of Primary Care Provided by Dental Therapists to AlaskaNatives (Seattle, WA: University of Washington School of Dentistry, 2005).9

difference in reportable events.10 Dr. Bolin noted:One of the main objections to the solution of expansion of duties tonondentists was the issue of quality of care. Some who areopposed to treatment provided by DHATs have suggested that it is“second-class care” or, since DHATs do not have dental licenses,that they are practicing dentistry without a license and, therefore,could be “unsafe.”.The opposition has occurred despite study results showing thatDHATs can perform primary care procedures comparably todentists, and that DHAT trainees perform equally well comparedwith dental students.Id. (citations deleted).Next StepsLike the Community Health Aide, the DHATs have become an essential part of thedental health care delivery model in the Alaska Tribal Health System. Their ability to provideculturally appropriate, high quality care has increased Alaska Native access to proper dentalservices and prevention activities. In addition, these individuals have become role models foryoung people sharing and teaching them there are options and careers available to them. DHATscontinue to thrive and prove their worth just as dental nurses and therapists have worldwide.It is exciting to see other parts of the United States are looking at a dental mid-levelmodel. The Alaska Native Health Board believes that dental therapists can be extremely helpfulin combating dental disease and increase the level of oral health throughout Indian country andthe nation. DHATs are an innovative solution to the inadequate numbers of licensed dentistspracticing in underserved areas, not just rural Alaska. Recently, the Minnesota Legislatureapproved the Oral Health Practitioner consisting of the Dental Therapist and the AdvancedPractice Dental Therapist with graduates expected in summer of 2011.11In addition to seeing DHATs provide services, the Alaska Native Health Board is excitedto see the preliminary results of a study commissioned by philanthropic organizations(Rasmuson, W.K. Kellogg, and Bethel Community Services Foundations) who are covering allcosts of the evaluation which will determine the DHAT program’s implementation integrity andconduct a health outcome assessment addressing safety, quality, and patient-oriented outcomes.The study is being conducted under extensive review by two advisory committees; one nationaland one state. The national advisory committee selected RTI International to conduct theevaluation. RTI International is the second largest non-profit research group in the United Statesand has experience in program evaluation and health services research. The study started in theSpring of 2009 and preliminary results are expected in Summer of 2010.10Kenneth A. Bolin. Quality Assessment of Dental Treatment Provided by Dental Health Aide Therapistsin Alaska. Paper presented at the National Oral Health Conference; 2007 May 1.11Minnesota Board of Dentistry Newsletter 24:2 (September 2009).

DHAT Program NeedsMajor issues addressed include program funding shortfalls and evaluation needs. Werespectfully recommend that this Committee urge the Indian Health Service include DHATprogram funding in their funding requests for future years. It has come to our attention that thecurrent philanthropic evaluation meets all but one evaluation request set aside for review by theSecretary of Health and Human Services. Thus, we also respectfully recommend that theCommittee utilize the current study for all other needs of evaluation noted rather thancommission a new study.

Recruitment, and in the Alaska Native Medical Center Administration office. My testimony will address expanding dental health care in Indian country and Alaska’s dental health aide therapist program. I appreciate the privilege and opportunity to share the Alaska Tribal Health Syst