Sunday, December 28, 2008

Alaska's Dental Therapists Help To Fill Urgent Need

In remote areas of Alaska, dental health allied therapists may become an important part of oral health care, especially for young children.

Dental therapists live in these remote areas themselves. They receive two years of training. Then they return to their communities to provide basic care, such as fillings and pulling teeth. They send people to dentists when more complex care is needed.

"Dental therapists are not dentists," said Kenneth A. Bolin, D.D.S., M.P.H. "Their primary aim is to get care for kids at a young age and stress prevention." Dr. Bolin is an associate professor and graduate program director in the Department of Public Health Sciences, Baylor College of Dentistry.

Dr. Bolin studied the quality of dental therapist care. He reviewed the records of 406 patients treated in Alaska. Of these, 171 were treated by dentists and 235 by dental therapists.

The top three procedures done were metal fillings, tooth-colored fillings, and tooth removal (extractions). Nearly half of the procedures were fillings. About 1 in 5 procedures were extractions.

Dr. Bolin found the quality of care was similar between dentists and dental therapists. People treated by dental therapists had no more problems with the procedures or afterward than people treated by dentists.

On average, dental therapists treated younger patients, which is part of their purpose.

Dental health in remote Alaska is very poor. By the age of 5, about 4 out of 5 Alaskan Native children have tooth decay. Most cavities go untreated. In surveys, 1 out of 4 of these children said they avoid laughing or smiling, because they are ashamed of the way their teeth look.

Attempts to recruit dentists to remote Alaskan areas have failed. The Alaskan "bush country" includes villages with few community buildings and no roads. Planes or boats are the only ways in or out. Only a few hundred people live in most communities. Most homes are shacks, many with no running water.

"I have been there, and the living conditions are harsh. There's no way a dentist is going to live there," Dr. Bolin says. "It's hard to understand until you see it. Most of the people against [dental therapists] have not seen it."

The dental therapist concept has led to controversy among dentists. In 2006, the American Dental Association (ADA) sued Alaskan dental therapists. The suit claimed they were practicing dentistry without a license. The therapists won the case. Rather than appealing, the ADA changed course. It pledged funds, volunteers and support to improve dental health in the area.

"I don't think the dental profession should fear the concept of dental therapists," Dr. Bolin says. "They are not going to spread everywhere. There might be a few remote, rural areas where it might be good - areas where there's been a problem recruiting dentists or having a profitable [dental] practice."

The therapists place fillings, extract teeth and place stainless steel crowns on decayed baby molars. They do not deal with dentures, implants, periodontal disease, root canal or any other complex procedures. Community visits are a key part of their work, Dr. Bolin says. Therapists visit schools, Head Start centers and other places to talk to families about dental health.

"They are trained to spot things that need to be bumped up to a higher level of care, or referred to a larger town with a better facility," Dr. Bolin says. "A lot of the younger kids have very bad early childhood decay. They need to get referred to a hospital in Anchorage or elsewhere."

The therapists in Dr. Bolin's study were trained in New Zealand. At the time, no training was available in the United States or Canada.

New Zealand has been using dental therapists since 1921. There, they are known as dental nurses. Every elementary school has one. As a result, close to 100% of children's cavities get treated in New Zealand. Among Alaskan Native children, only 35% of cavities are treated.

A dental therapist school now is open in Anchorage, Alaska. It can train up to eight students per year. Students spend one year in classes. In the second year, they treat patients under the direct supervision of a dentist.

The study appears in the November issue of the Journal of the American Dental Association