November 1, 2010
Low-Cost Dental Care Ignites Wide Debate
By JOYCE COHEN

In remote northwestern Alaska, where dental decay is rampant, some of Stephanie Woods’s patients suffered from toothaches for months on end — “raging toothaches with swelling,” she said in an interview, “something that you or I would go that day and have it taken care of.”

But these patients just lived with the pain. “They thought it was part of everyday life,” she said.

Ms. Woods is not a dentist. She is one of 14 certified dental therapists in Alaska, the only state where nondentists may perform extractions and administer fillings.

The therapists, who receive two years of training, help fill a vacuum: Alaska has long had trouble attracting and retaining licensed dentists. Sixty percent of Alaska Native children ages 2 to 5 have untreated decay, and 20 percent of Native adults over 55 have no teeth at all.

But the American Dental Association, the nation’s leading dental society, opposes the use of nondentists for “irreversible procedures” — including drilling and extraction — citing patient safety.

“If you have a person suffering from pain, that person has advanced disease,” said Dr. Raymond Gist, the association’s president. “I would want that person to see a licensed dentist without delay.”

Now a two-year foundation-supported study has reignited the debate over which practitioners are qualified to provide dental care, especially to underserved populations in high-poverty areas. It found that Alaska’s dental therapists provide “safe, competent, appropriate” care. (The therapists refer cases beyond their scope to supervising dentists.)

The study, financed by the W. K. Kellogg, Rasmuson and Bethel Community Services Foundations, examined the work of dental therapists in five rural Alaskan communities. The positive results are consistent with findings from overseas, where dental therapy programs are well established, said Dr. Mary Williard, a dentist who directs the therapist training program for the nonprofit Alaska Native Tribal Health Consortium.

Ten other states, including Connecticut, are considering midlevel dental provider systems for underserved residents. These practitioners can be trained for relatively little money, said Dr. Allen H. Hindin, who is on the board of the Connecticut State Dental Association.

Partly for that reason, he said, the topic has become a “turf issue” — not just economic, but “intellectual and cultural.”

Unlike Alaska, Connecticut has no shortage of dentists. But Dr. Bruce J. Tandy, the state association’s immediate past president, agreed that dentists were wary of losing patients to midlevel practitioners. “Many dentists don’t understand how these individuals are going to be used,” he said, “so they feel threatened.”

In fact, he said, the midlevel providers “can be trained to do certain simple procedures safely,” and they would most likely work in public health clinics, seeing patients whom “most dentists will never see in their offices.”

Still, the American Dental Association — which went to court five years ago in an unsuccessful attempt to block the Alaska program — is firm in its opposition. Dr. Gist, the group’s president, rejected the accusation that dentists fear a loss of income or status if midlevel practitioners are widely allowed. “We don’t consider that it has merit,” he said.

He noted that the association favored increased Medicaid payments for dental work and said that dentists routinely donated services to needy populations.

The association says a better solution for the underserved population is its own new program of community dental health coordinators, who perform teeth cleaning and other noninvasive procedures, educate people about dental health and connect patients with licensed dentists for further care.

Moreover, the association argues, the Alaska study has little relevance for other states. Remote areas there are typically reached by airplane, boat or snowmobile; rural residents of other states, the association said in a statement, “are accustomed to driving hours to reach a shopping or entertainment destination and can be expected to travel similar distances to reach a dentist.”

But Dr. Williard, in Alaska, called that argument misguided.

“Would I be satisfied to think that I would have to drive five hours with a 3-year-old in the car to get care?” she asked. “No, I would prefer to have care closer to home. I’m not sure that statement is really in touch with the populations in those areas.”