Armed to the Teeth: The Fight Over Rural Dental Care


Photo: Jason Fraser/

Let's talk about teeth, baby. Slate is doing a series on the American Way of Dentistry. It's mostly good, but it gets one thing wrong. In a piece on the problems poor people face getting dental care, author June Thomas writes,

The main problem is a lack of decent low-cost options. Chester Douglass, emeritus professor in the department of Oral Health Policy and Epidemiology at Harvard's School of Dental Medicine, puts it this way: "If you want to buy a good, inexpensive car, Volkswagen proved you could do it, then other people started being able to do it." The Volkswagen of dentistry has yet to be built.

In reality, there is a Volkswagen of dentistry. Or, at least, something close to that. (A Toyota Corolla of dentistry?) Like the Bug, it's an overseas import. But, amazingly, when this program first got going in the United States, the American Dental Association sued to stop it.

Actually, scratch that. What's really amazing about this story is that the little guys won…

A decade ago, Alaskan Aurora Johnson was a stay-at-home mom with a high school education. Today, she's one of this country's first Dental Health Aide Therapists, bringing inexpensive, quality care to a very rural community. Johnson lives in Unalakleet, a coastal town 90 miles south of Nome. It is not exactly a booming real-estate market. Temperatures can dip to -50 F in the winter, freezing rivers into seasonal highways. About 750 people live there, mostly Native Americans, and, until 2005, their only access to dental care was one dentist who came in by plane once a year. Get a cavity a week later, and you were basically up a creek.

Alaska's an extreme case, but in general, it's not easy for rural Americans to see a dentist. Particularly if they're on Medicaid, which often pays far less than the going rate for dental services–as little as half in some states. And a lot of rural Americans rely on Medicaid–more than city dwellers do, in fact. With education loans to pay off and expensive businesses to run, most dentists just can't afford these low-payoff clientele. In the country, it's not uncommon to drive 30, 70, even 100 miles to get to the nearest dentist.

And that's where The Dental Health Aide Therapist program comes in. In a lot of ways, it's similar to using a Nurse Practitioner as your primary care physician. People like Aurora Johnson are recruited to serve the communities they already live in. Their training is much shorter, and less expensive, than a dentist's. But at the end, DHAT's can take care of their neighbors' basic and preventative dental health, and they can afford to charge less for their work. Johnson works with a dentist who still visits once a year and refers bigger problems and complicated procedures to him. It's a system that's worked in 42 countries. In fact, Aurora Johnson and her family had to move to New Zealand for two years while she went through her training. (Today, the Alaska Native Tribal Health Consortium—the organization behind the DHAT program—is training new therapists in Alaska.)

Unfortunately, not everybody thinks this is a good thing. In 2006, the American Dental Association sued the Alaska Native Tribal Health Consortium and the DHATs. They framed it as concern over unlicensed dentistry that could put patients at risk. But Ron Nagel, a dentist who serves as a consultant for the ANTHC, sees another motivation.

"There's a fear in the lower 48, from dentists, that this could somehow tip the rice bowl of their income," he told me. "But there's no evidence of that. If you're in private practice and you can delegate things that don't make as much money to someone who costs less, the economics suggest you could make even more money, yourself."

It's the sort of underdog case where you expect the underdog to lose. But, in Alaska, the narrative got flipped. A court ruled against the ADA in 2007 and the organization chose not to appeal.

But as dental therapist programs spread into the rest of the country, they're facing the same fight all over again. And things are more complicated this time. The Alaska program is by Native peoples, for Native peoples. Other states are looking at broader programs that would need the support of legislatures. And that means an opportunity to scare voters, and politicians, away from the idea. In Minnesota, for instance, the state dental association launched a PR campaign designed to make dental therapists out to be about as skilled and well-trained as the average snake-oil salesman. The slogan: "The last thing you want to hear when you're getting dental care is uh-oh."

In the end, Minnesota did become the second state to adopt dental therapists, but we ended up with a bi-level system. Basic dental therapists have a bachelor's degree (four years, as opposed to the two years of schooling Alaska DHATs get) and can't work if a dentist isn't in the building.

Advanced dental therapists can work alone, but have to have the bachelor's + 2,000 hours experience, complete a master's level program, and pass a board-approved exam.

The legislation only passed this summer, so it's hard to know how, or whether, the changes will affect access to dental care. If dental therapists have to work with a dentist, what does that mean for Minnesota's isolated communities and tribal reservations where there are no dentists? If dental therapists have to have five or six years of education, what does that mean for their ability to take on Medicaid patients and bring dental care to low-income families? I don't know. But I'm hoping for the best.

Image courtesy Flickr user p_x_g, via CC.