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Changing the Tide

The adoption of midlevel practitioner models helps American Indian/Alaskan Native communities lead the way in improving oral health.

A number of recent studies have documented that dental caries and periodontal diseases are more prevalent in American Indian/Alaskan Native (AI/AN) populations than in other majority and minority populations in the United States.1–4 Dental diseases are preventable under the right circumstances, especially in situations where behaviors can be modified to help prevent oral diseases and facilitate good oral health. To encourage behavior changes at the patient level, oral health professionals must help patients develop new habits, such as brushing twice a day with fluoride toothpaste, reducing the intake of fermentable carbohydrates, and flossing interproximal spaces. However, at this time, there is not a strong evidence base supporting the reduction of fermentable carbohydrate consumption and flossing as strategies for preventing oral disease.


The Center for Native Oral Health Research (CNOHR) was established in 2008 through funding from the National Institute of Dental and Craniofacial Research to investigate why the rates of dental disease are so high among AI/AN populations, what effect this has on individuals in the community, and to suggest solutions to eliminate these disparities. The CNOHR conducts research aimed at developing culturally acceptable and effective strategies to prevent infectious oral diseases in AI/AN populations.5 In my opinion, research suggests that two primary issues are related to these high levels of oral diseases in AI/AN populations: limited oral health literacy and the lack of access to dental care.6–16 These two factors are interrelated, and I believe strategies do exist that can reduce these disparities.

Before discussing potential ways to address these issues, the effects of limited or no access to quality oral health care must be noted. For purposes of this essay, I will only focus on three negative effects: morbidity, school learning, and systemic health. Two studies demonstrate that the well-known death of Deamonte Driver due to a tooth infection in 2006 was not an isolated incident. One study found that 66 patients died in hospital settings over 9 years due to periodontal abscesses.17 In another study, 101 people who visited a hospital emergency department for a dental problem died there; the vast majority of these patients had no other presenting conditions that may have been complicating factors.18 Both of these studies demonstrate the seriousness of the access-to-oral-health care dilemma in the US.

Over the past few years, a number of studies have shown the significant impact of dental problems and dental pain on learning among young school-aged children .19,20 Education can offer a way out of poverty for disadvantaged populations, but if children are in pain or miss school frequently due to dental problems, their ability to learn is compromised.

A growing body of scientific literature exists on the effects of poor oral health—particularly periodontal diseases—on systemic health, including diabetes, atherosclerotic heart disease, and low-birth weight/premature births.21–28 Clearly, poor oral health can have devastating effects on mortality, school learning, and systemic health.

Access issues can be addressed in part by increasing the number of dental professionals available to provide care. Unfortunately, the dentist-to-population ratio in many AI/AN communities is less than half the US average. Generally, AI/AN populations are located in isolated, rural areas where private dental services are generally not available. Even with loan forgiveness programs, the Indian Health Service (IHS) has difficulty recruiting dental professionals to these communities. The second major factor uncovered in recent research is the population’s lack of oral health literacy. If patients do not recognize the importance of oral health, they will generally be unwilling to change their behaviors to better prevent dental diseases. This issue can also be addressed with a more culturally competent workforce, ideally coming from the populations clinicians are serving.

The access issue for underserved and vulnerable patients was clearly addressed by the Institute of Medicine (IOM) in 2011 in its groundbreaking report “Improving Access to Oral Health Care for Vulnerable and Underserved Populations.”29 While this report did not define access to oral health care, the IOM produced a “Vision for Oral Health Care in the US” in which everyone has access to quality oral health care across the life cycle. To be successful with underserved and vulnerable populations, the report suggested that an evidence-based oral health system needs to eliminate barriers that contribute to oral health disparities; prioritize disease prevention and health promotion; provide oral health services in a variety of settings; rely on a diverse and expanded array of providers competent, compensated, and authorized to provide evidence-based care; include collaborative and multidisciplinary teams working across the health care system; and foster continuous improvement and innovation.29


New workforce models are helping to address access and oral health literacy in vulnerable populations. They can also meet some of the suggested characteristics of an evidence-based health care delivery system noted in the IOM report. The community dental health coordinator (CDHC) was developed by the American Dental Association and is essentially a patient navigator or case manager who can “coordinate care (eg, arrange transportation); reduce dental anxiety/support access; encourage patients to complete treatment; enhance cultural competency; educate the population about prevention; navigate Medicaid or other dental systems of care; and improve productivity and integration of the oral health team.”30,31 Potential employment opportunities for CDHCs include: federally qualified health centers (FQHCs); IHS; local health departments; schools; women, infant, and children nutritional programs (WIC); Head Start centers; institutional settings; social service agencies; and community-based dentists. A series of case studies is available touting the success of CDHCs but little data are available at this time. CDHCs have approximately 18 months of education, usually through a community college. CDHCs should be helpful in assisting patients with accessing dental services and with oral health literacy related to the prevention of dental diseases, but they are not trained to provide actual dental services. As such, they are of limited value in actually increasing access to dental care. If they are recruited from the populations they serve, they are more likely to be culturally competent. More important, while they may be able to improve patient oral health literacy, they can do little about the primary barrier to access to oral health services—cost. Thus, it is unlikely that they will be utilized much in private practice, fee-for-service settings, unless those dentists participate in Medicaid. However, they should be of great value in safety-net clinics such as FQHCs. Finally, utilizing individuals who are already trained as dental hygienists may shorten the length of education required, but in the long run, this is a lot of education for an individual who cannot provide actual treatment. More time and published studies will be important in evaluating the long-term effectiveness of CDHCs.

The dental therapist model is used to provide care to AI/AN populations.32 Dental therapy has a 100-year track record of safety and effectiveness in 54 countries in providing quality dental care to a variety of populations.33 Dental therapy is relatively new in the US. The Alaskan dental health aide therapist (DHAT) program, based on the New Zealand model, has about a 10-year track record. Education takes approximately 2 years post-high school and 1,000 hours of monitored preceptorship clinical activity. An Alaskan DHAT can provide a limited number of preventive, restorative, and surgical services under general supervision. DHATs in Alaska almost always come from the AN population and return to villages and cities in Alaska. They have had a number of evaluations that demonstrate the quality and effectiveness of their care.34–37

Minnesota has been using two midlevel oral health practitioner models for the past 5 years with solid success (see page 19 for more information). The Minnesota Department of Health has produced two in-depth evaluations of this model and has concluded that dental therapists and advanced dental therapists can practice safely and effectively, and they have been helpful in increasing access to quality oral health care.38 The formal report on the programs will be published in the fall of 2016. Both the Alaskan and Minnesotan models spend a considerable amount of their efforts focused on improving oral health literacy and prevention.

AI/AN populations are clearly interested in utilizing the services of dental therapists. However, one impediment is that recent language inserted into the IHS Act prevents tribes from implementing dental therapy unless their home state allows this workforce model. The good news is that this model is spreading and legislation is being actively pursued in several states. In addition, the Commission on Dental Accreditation has approved accreditation standards for dental therapy educational programs.39 This action gives legitimacy and guidance to emerging dental therapy programs.

The Swinomish Indian Tribal Community in the Pacific Northwest could not wait and has recently implemented a dental therapy program.40 More AI/AN tribes are pursuing dental therapy programs, and this can only positively impact oral health literacy and access to quality oral health care, leading ultimately to better oral health. These actions by AI/AN tribes should lead the way for the rest of the country to develop dental therapy educational programs to improve access to quality oral health care for all underserved populations.


  1. WK Kellogg Foundation. An Assessment of Oral Health on the Pine Ridge Indian Reservation. Available at: ridge-indian-reservation. Accessed September 25, 2016.
  2. Batliner T, Wilson AR, Tiwari T, et al. Oral health status in Navajo Nation Head Start children. J Public Health Dent.2014;74:317–325.
  3. Batliner T, Wilson A, Davis E, et al. A comparative analysis of oral health on the Santo Domingo Pueblo Reservation. J Commun Health. 2016;41:535–540.
  4. Phipps KR, Ricks TL. The oral health of American Indian and Alaska Native adult dental patients: results of the 2015 IHS oral health survey. Available at: Accessed September 25, 2016.
  5. Centers for American Indian and Alaska Native Health. Center for Native Oral Health Research. Available at: Accessed September 25, 2016.
  6. Brega AG, Thomas JF, Henderson WG, et al. Association of parental health literacy with oral health of Navajo Nation preschoolers. Health Educ Res. 2016;31:70–81.
  7. Tiwari T, Albino J, Batliner T. Challenges faced in engaging american indian mothers in an early childhood caries preventive trial. Int J Dent. 2015;2015:179189.
  8. Wilson A, Brega AG, Batliner TS, et al. Assessment of parental oral health knowledge and behaviors among American Indians of a Northern Plains tribe. J Public Health Dent. 2014;74:159–167.
  9. Tiwari T, Quissell DO, Henderson WG, et al. Factors associated with oral health status in American Indian children. J Racial Ethn Health Disparities. 2014;1:148–156.
  10. Albino J, Tiwari T, Henderson WG, et al. Learning from caries-free children in a high caries American Indian Population. J Public Health Dent. 2014;74:293–300.
  11. Tiwari T, Sharma T, Harper M, et al. Community-based participatory research to reduce oral health disparities in American Indian children. J Fam Med. 2015;2:1028.
  12. Braun PA, Lind KE, Batliner T, et al. Caregiver reported oral health-related quality of life in young American Indian children. J Immigr Minor Health. 2014;16:951–958.
  13. Batliner T, Wilson A, Tiwari T, et al. Oral health status in Navajo Nation Head Start Children. J Public Health Dent. 2014;74:317–325.
  14. Batliner T, Fehringer KA, Tiwari T, et al. Motivational interviewing with American Indian mothers to prevent early childhood caries: study design and methodology of a randomized control trial. Trials. 2014;15:125.
  15. Braun PA, Lind KE, Henderson WG, et al. Validation of a pediatric oral health-related quality of life scale in Navajo children. Qual Life Res. 2015;24:231–239.
  16. Tiwari T, Casciello A, Gansky SA, et al. Recruitment for health disparities preventive intervention trials: the early childhood caries collaborating centers. Prev Chronic Dis. 2014;11:E133.
  17. Shah AC1, Leong KK, Lee MK, Allareddy V. Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis. J Endod. 2013;39:1104–1110.
  18. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP.Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. J Am Dent Assoc. 2014;145:331–337.
  19. Guarnizo-Herreño CC, Wehby GL. Children’s dental health, school performance, and psychosocial well-being. J Pediatr.2012;161:1153–1159.
  20. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health. 2011;101:1900–1906.
  21. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med. 2014;47:166–174.
  22. Kamyar, N, Vujicic M, Glick M. The relationship between periodontal interventions and healthcare costs and utilization. Evidence from an integrated dental, medical and pharmacy commercial claims database. Health Econ. January 22, 2016. Epub before print.
  23. Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol. 2015;86:611–622.
  24. National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General. Available at: Accessed September 25, 2016.
  25. Oral Health America. A State of Decay: Are Older Americans Coming of Age Without Oral Healthcare? Available at: Accessed September 25, 2016.
  26. National Academy for State Health Policy. Oral Health and the Triple Aim: Evidence and Strategies to Improve Care and Reduce Costs. Available at: improve-care-reduce-costs. Accessed September 25, 2016.
  27. Vedin O, Hagström E, Gallup D, et al. Periodontal disease in patients with chronic coronary heart disease: Prevalence and association with cardiovascular risk factors. Eur J Prevent Cardiol. 2015;22:771–778.
  28. Zhang B, Hazem K, Allan S, Bengtsson T. Gingipains from the periodontal pathogen Porphyromonas gingivalis play a significant role in regulation of Angiopoietin 1 and Angiopoietin 2 in human aortic smooth muscle cells. Infect Immun. 2015;83:4256–4265.
  29. Institute of Medicine and National Research Council. Improving Access to Oral Health Care for Vulnerable and Underserved Populations, Committee on Oral Health Access to Services. Available at: Accessed September 25, 2016.
  30. American Dental Association. Breaking Down Barriers to Oral Health for All Americans: the Community Dental Health Coordinator. Available at: Accessed September 25, 2016.
  31. American Dental Association. Community Dental Health Coordinator: New Dental Team Member. Available at: 28/Jane%20Grover.pdf. Accessed September 25, 2016.
  32. Batliner TS. American Indian and Alaska Native Access to Oral Health Care: A Potential Solution. J Health Care Poor Underserved. 2016;27(1 Suppl):1–10.
  33. Nash DA, Friedman JW, Mathu-Muju KR, et al. A review of the global literature on dental therapists. Community Dent Oral Epidemiol. 2014;42:1–10.
  34. Mathu-Muju KR, Friedman JW, Nash DA. Oral health care for children in countries using dental therapists in public, school-based programs, contrasted with that of the United States, using dentists in a private practice model. Am J Public Health. 2013;103:e7–e13.
  35. Bader, JD, Lee JY, Shugars DA, Burrus BB, Wetterhall S. Clinical technical performance of dental therapists in Alaska, J Am Dent Assoc. 2011;142:322–326.
  36. Friedman JW, Mathu-Muju KR. Dental therapists: improving access to oral health care for underserved children. Am J Public Health. 2014;104:1005–1009.
  37. Mathu-Muju KR. Dental therapists provide technically competent clinical care when performing irreversible restorative procedures. J Evid Based Dent Pract. 2014;14:25–27.
  38. Minnesota Department of Health. Minnesota’s Dental Therapist Workforce, 2015. Available at: Accessed September 25, 2016.
  39. Commission on Dental Accreditation. Accreditation Standards for Dental Therapy Education Programs. Available at: Accessed September 25, 2016.
  40. WK Kellogg Foundation. Swinomish Indian Tribal Community adds first dental therapist to meet dental care needs. Available at: community-adds-first-dental-therapist-to-meet-dental-care-needs. Accessed September 25, 2016

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental HygieneOctober 2016;3(10):16-18.

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