The Native American Oral Health Care Project reports that dental decay is 300 times more likely in the American Indian population than it is in the general U.S. population. Even more alarming, Representative Paul Goser (R-Arizona), who is also a dentist, stated on the House floor: “In many Native communities, between 25 and 50 percent of preschool children have such extensive tooth decay that they require full mouth restoration under general anesthesia, compared to less than one percent for non-Native children.” According to a 2005 Children’s Dental Health Project report, American Indian and Alaska Native preschoolers are five times more likely to suffer from tooth decay than for U.S. preschoolers generally and have three times more decayed teeth than the general U.S. preschool population. But no one needed to tell Maxine Brings Him Back-Janis or Terry Batliner this.
Both are also of Native descent, both are oral health–care providers and both are passionate about improving the lives of Native people through better dental care. Both worked on an oral-health survey team headed by Batliner for the Center for Native Oral Health Research at the University of Colorado Denver. Janis, Lakota, an assistant professor at Northern Arizona University’s Department of Dental Hygiene, returned to her home, the Pine Ridge Reservation, in July 2010, where she examined the teeth of her neighbors, friends and family on the eighth-largest reservation in Indian country.
“Sadly,” Janis says, “many children develop tooth decay at an early age, before the age of 2 years, when new teeth are particularly vulnerable and eating behaviors and speaking skills are just developing. As a result, children have to be hospitalized for treatment; if left untreated oral infection ensues and death could potentially occur. In addition, self-image and self-confidence are impacted.”
Though some Americans may have trouble comprehending the level of poverty that prevents people from buying toothbrushes, toothpaste and floss, this is the desperate condition of people in diverse, low-income communities throughout the United States. In Indian country, this problem is exacerbated by a lack of access to professional care. Pine Ridge is about the size of the state of Connecticut, but there are only three Indian Health Service dental clinics with two shared hygienists for about 40,000 residents. Many residents also lack money for fuel to risk the long drive to a clinic to try to see a health-care provider during limited drop-in hours. Because of these impediments, Janis says, preventive services are not available to enough people, and procedures for crowns, root canals, dentures and bridges are rare.
This is why Batliner focuses on expanding dental care to the underserved. Batliner, a dentist with an MBA and a private practice in Lafayette, Colorado, grew up in a middle-class household with a Cherokee mother and white father. In addition to his work as a consultant to several foundations, he is associate director of the Center for Native Oral Health Research.
Like Janis, Batliner is particularly passionate about the poor oral health of young people. “Our Native children have devastating dental problems in many locations,” he says. “We need dental therapists to treat the existing disease and to institute preventive programs to reduce future oral disease.”
Both Batliner and Janis point to an innovative program that is serving young people and adults. As Janis explains, “Alaska Natives are providing dental care to fellow villagers in remote communities. High school graduates who are willing to return to their villages are recruited into a training program to become dental health aide therapists. In it, they are trained to provide basic care that will enable community members to preserve their teeth.”
Similar programs are being implemented in Minnesota and throughout the Pacific Northwest.
But not all members of the American Dental Association are pleased with the program. “I think dentistry as a market-based trade organization is all about protecting their profession; which is very much grounded in profit,” Janis says. “Sadly, these professionals have not seen up close the faces of children suffering with dental caries, or adults not able to access a mid-level provider because there are none to be found in many tribal communities in the lower 48 states.”
Batliner would like to see implementation of the Alaska program throughout Indian country: “A training program should be set up at a tribal college,” he explains. “Local people from underserved areas should be recruited and sponsored to attend the program by their tribe or Indian Health Service. The program would last two years with a three- to six-month preceptorship to follow. After graduation, the dental therapists should be contractually required to work in a dental shortage area for at least four years. Most will stay much longer if they are recruited from an underserved area.”
Batliner believes dental therapists “can provide basic dental care very effectively.” Basic care would include fillings, routine extractions, emergency care and preventive services. The health of patients would be protected through a supervising dentist not on-site, but consulting via telephone.
With the use of new technology and portable equipment—an approach to oral care called tele-dentistry—underserved communities can have their oral-health-care needs met without having to travel long distances. With an intraoral camera, hand-held X-ray machine, Spectra (which detects caries) and a laptop, mid-level health-care providers can see the people who most need care in remote, rural areas by traveling to their homes and schools. “Tele-dentistry allows patients to receive dental screenings and interventions onsite and away from the dental clinic,” Janis says.
Another key is to increase the numbers of dentists working in these areas. Batliner offers several reasons why so few dentists work in Indian country. He says “funding for students willing to help the underserved must become more accessible,” pointing out that dental school students often graduate with $200,000 to $300,000 of debt. He also believes dental schools “need to preferentially recruit low-income, minority and rural applicants.” He notes that good grades and high scores on the Dental Admission Test are important factors in considering admission to dental school, “but I also think schools should attempt to attract people interested in working in low-income and rural areas. Experience shows that people from these areas are much more likely to return to rural or low-income areas to practice.”
Finally, Batliner advocates for expansion of the Alaska program through the removal of legal barriers: “The American Dental Association lobbied Congress during the development of the [Patient Protection and Affordable Care Act]. They were successful in getting language in the bill (which is now law) that prohibits the expenditure of federal funds to support dental therapists outside of Alaska in Native communities unless the state in which that Native community resides has laws that make dental therapy legal. This is an insult to Native people and an attack on tribal sovereignty. We, as Native people should not allow this language to stand. It must be changed.”
When asked what major conclusion she drew from her work at Pine Ridge, Janis says, “The voice of the voiceless must be heard.”
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