Strong partnership transforms oral health of Alaska Native people
Back in 2004, Aurora Johnson was a mother of three young children in the Western Alaska coastal village of Unalakleet when she saw a posting about a new opportunity to study dental health in New Zealand.
Johnson, who grew up farther north in the small village of Noorvik, and her husband, Middy, uprooted their family for two years of study in a foreign land. She returned and became certified to provide dental care in rural Alaska, where it was desperately needed. Some young children showed up in clinics with cavities in every tooth. Every tooth had to be filled, pulled or rebuilt while the child was under general anesthesia. Older people with missing and broken teeth struggled to eat properly.
“It was a scary move but it was the best move we ever did,” Johnson said recently. Her husband was her anchor —essentially becoming a single parent to their three children while she pursued her studies. The children got to experience a different country and “I got to become a DHAT, which I love.”
They say it “D-HAT” – shorthand for Alaska’s dental health aide therapist.
Johnson is a pioneer in this innovative and proven model that reset the boundaries for dental care in the United States. Dental health aide therapists usually have deep ties to the communities where they practice, so there’s not the turnover seen among some professionals in Bush Alaska.
They are supervised from afar by dentists and provide a variety of services including applying sealants, filling cavities and extracting teeth. Work to establish the program began in 2000 under a partnership of tribal health organizations led by the then-new Alaska Native Tribal Health Consortium.
Early on, the tribal health consortium asked Rasmuson Foundation for $1 million to send Alaska students for training in New Zealand, where these primary oral health practitioners were long established.
“We replied, ‘A million dollars? To New Zealand? Are you crazy!?’” Cathy Rasmuson, vice chairwoman of the Foundation Board, recalled in a speech years later.
Dentists push back
In Alaska, the case was compelling. Dentists made it to villages only sporadically. Most patients who lived in these remote areas were Alaska Natives who had to fly, boat or snowmachine to hub communities or cities for care in between, and many couldn’t afford that.
“Because of this, devising effective strategies to meet their oral health needs has posed daunting, nearly insurmountable, challenges for over a century,” researchers in a 2010 DHAT study said.
A state study in 2010-11 found that 40 percent of Alaska Native third-graders had untreated tooth decay. Tribal health research found that in one small Alaska village, 81 percent of 4- to 6-year-olds had gone under general anesthesia for oral surgery to treat severe tooth decay.
“An epidemic of oral disease” is how dentist Dane Lenaker, now with Southeast Alaska Regional Health Consortium, described the situation he found when he arrived on the Yukon-Kuskokwim Delta in 2009.
The Foundation Board in 2002 agreed to contribute $1 million, which helped cover the cost of developing an Alaska program so students wouldn’t have to travel to New Zealand, one of about 50 countries where dental therapy practice is allowed. Dental therapy practitioners there have been providing care since the 1920s. Before in New Zealand, poor oral health there kept young men from military duty.
The Alaska partnership ran into strong opposition from the American Dental Association and the Alaska Dental Society. When the dentist groups sued to stop Alaska dental health aide therapists from practicing, Valerie Davidson, then senior director of legal and intergovernmental affairs for the tribal health consortium, led the defense that ensured the program’s survival.
Davidson’s children were the second and third to be seen by the dental therapists trained in Alaska. The moment was overwhelming. Davidson’s mother cried as she thought about how lives were changing. Her grandchildren wouldn’t end up with dentures like her and so many others.
Davidson now serves as Alaska’s health and social services commissioner. She remembers how terrified village children would be rounded up when the dentist came to town, and how they would scream as their teeth were being pulled.
“We knew that there had to be a better way,” Davidson said.
Significant support has come from Rasmuson Foundation, which now has designated a total of $2.5 million for DHAT. Bethel Community Services Foundation was an early supporter, eventually contributing about $160,000, including help in establishing a dental therapist training clinic in Bethel.
National funders took interest. Help came from M.J. Murdock Charitable Trust and the Robert Wood Johnson Foundation. Ford and Annie E. Casey foundations also invested, along with others.
W.K. Kellogg Foundation contributed $1 million for a comprehensive 2010 study, which found the Alaska dental health aide therapists provide safe and competent care. Kellogg since has contributed more than $6 million for the training program itself.
Yukon-Kuskokwim Health Corp. and its counterparts around the state, eager for more dental care, agreed to sponsor students who would go work for them. The tribal consortium board sets aside almost $500,000 a year.
By 2009, training had moved from New Zealand to Alaska with students in Anchorage their first year and in Bethel for their second year of studies at Yuut Elitnaurviat, or the People’s Learning Center, the regional vocational school. Two years ago, Iḷisaġvik College in Utqiaġvik on Alaska’s North Slope became a partner offering an associate degree in dental therapy.
Research has consistently proven the effectiveness of the DHAT model in improving dental health, Diane Kaplan, Rasmuson Foundation president and chief executive officer, said in nominating Johnson for a statewide honor: Distinguished Rural Provider of the Healthy Alaska Natives Foundation. In March 2018, Johnson accepted the award.
“The data is very clear. The communities that have dental health aide therapists have much better outcomes in terms of dental health and overall health,” Kaplan said.
As dental health aide therapists become more established, their work is shifting from emergency dental care to prevention.
One University of Washington study completed in 2017 — and funded in part by Pew Charitable Trusts, Kellogg Foundation and Rasmuson Foundation — focused on the Yukon-Kuskokwim Delta. It found that in villages served the most by dental health therapists, children and adults had more preventive care — fluoride, cleanings, X-rays and the like — and fewer extracted teeth, one of the worst outcomes in dentistry.
“All these changes are significant changes by scientific standards,” said Dr. Mary Williard, a dentist who serves as the tribal health consortium’s director of oral health promotion. In the Bethel area, one community has seen a 50 percent reduction in cavities among children from kindergarten through seventh grade as a result of a DHAT student-led project applying sealants.
“That stunned us all,” Williard said. One of the students, Samantha Sparks, gave a presentation on the project in April 2018 at the National Oral Health Conference in Louisville, Kentucky.
Around the state, Williard said, the oral health of Alaska Native people is being transformed in a single generation. It’s a health-care revolution rooted in collaboration. And it’s spreading.
Seven states, including Washington and Oregon now allow dental therapists in some form and a dozen other states are considering it, according to Pew Charitable Trusts.
‘This one teacher’
Johnson has worked 12 years now as a dental therapist in the Norton Sound region. Some kids call her their dentist. She travels with medical files, dental instruments and a portable dentist chair on small planes to Shaktoolik, Koyuk, St. Michael and Stebbins, as well as serving Unalakleet, where she lives.
The results she encounters aren’t in scientific papers and reports but rather in the smiles of the children.
“Now we are seeing 30, 40 kids with no cavities,” she said.
When teachers and principals from the 15 villages in the Bering Strait School District gather in Unalakleet at the start of each school year, Johnson and her assistants hound them to work with children on brushing. They started a weekly fluoride rinse program that Shaktoolik and Koyuk embraced to good result.
“Then there’s this one specific teacher,” Johnson said. “She stays on top of tooth brushing.” After breakfast and again after lunch, her kids brush at school.
They never get a cavity.
The partnership that supports the care is continuing. The Alaska Dental Therapy Educational Program, which is attracting increasing numbers of students, has $10 million in hand from the tribal consortium. Williard said it is trying to create an endowment of $50 million for long-term survival.