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© 2005 American Public Health Association
DOI: 10.2105/AJPH.2004.053546
COMMENTARY |
The authors are with the American Dental Association, Chicago, IL.
Correspondence: Reprint requests should be addressed to Albert H. Guay, American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611–2678 (e-mail: guaya{at}ada.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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There is a high prevalence of oral disease in the Alaska Native population, much of which goes untreated, creating a large discrepancy between the level of their oral health and that of the general population. The causes of this discrepancy are multiple—a major cause being the lack of access to care, especially in remote Alaska Native villages.
Improving the oral health status of Alaska Natives will require treatment of current disease and initiation of an effective program to prevent oral disease. Cooperation between the Alaska Native organizations, dental health aides, the dental profession, and the government will be important.
A strategy that combines addressing the disease currently present and preventing the occurrence of disease in the long run is the only strategy that offers a sustainable solution.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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A NEW PROGRAM INVOLVING dental health aides has recently begun, based on the medical Community Health Aide Program now in operation in Alaska. These dental health aides would extend oral health services to remote Alaska Native villages. Trained to work properly and safely, these dental health aides can be key components of a comprehensive plan to improve the oral health of Alaska Natives.
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THE ORAL HEALTH STATUS OF ALASKA NATIVES |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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Information on the oral health status of Alaska Natives has been gathered in The 1999 Oral Health Survey of American Indian and Alaska Native Dental Patients: Findings, Regional Differences and National Comparisons1 conducted by the US Public Health Service, Indian Health Service (IHS) (Figure 1
). Previous similar surveys were conducted in 1984 and 1991. Although data for American Indian and Alaska Native populations are merged throughout the report, the data for Alaska Natives can easily be segregated because they are reported by areas, with Alaska being 1 distinct area. This survey used a convenience sample of individuals who were patients at IHS clinics, so the data may not be exactly representative of the oral health status of the general Alaska Native population, especially those who live in remote villages. Nonetheless, some observations can be made and trends identified.
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For comparisons with the US oral health national averages, data from the Third National Health and Nutrition Survey (NHANES III),1988–19942 and the National Health and Nutrition Examination Survey (NHANES), 1999–20003 conducted by the National Center for Health Statistics were used.
Oral disease is widespread and of significant severity in the Alaska Native population (Figure 2). Although there has been a significant reduction in the prevalence of dental caries in the general population of the United States, there has been only a small reduction of dental caries in the Alaska Native population. In Alaska, that reduction occurred mostly in the 1980s and did not continue into the late 1990s, resulting in a great disparity in oral health between the Alaska Natives and the general population of the United States.
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Comparing data from IHS surveys and National Health and Nutrition Examination Survey surveys gives some insight into the disparities in oral health status between Alaska Natives and the general population described in the text and figures that follow (Table 1
).
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Alaska Native children and adolescents experience approximately 2.5 times the amount of dental caries than that seen in the general US population. Astonishingly, 60% of Alaska Native children have severe early childhood caries, defined as any child aged 5 years or younger with dental decay in the maxillary anterior teeth or 6 or more teeth with decay. Approximately one third of Alaska Native adults have severe periodontal disease, a rate that is higher than in adults in the general population, in which the prevalence of periodontal disease is 12%.
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GEOGRAPHIC BARRIERS TO CARE |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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Gaining access to routine and emergency dental care is particularly challenging for Alaska Natives. Approximately 87 000 of the 125 000 Alaska Natives live in rural communities. Most of these communities are remote, with no access by road. The extreme temperatures commonly experienced in Alaska Native villages make travel and working difficult for those not accustomed to cold temperatures. Throughout most of the state, transportation is accomplished only by airplane, boat, all-terrain vehicle, or snowmobile. In general, there are significant distances between villages. In addition, mountain ranges and glaciers make travel very difficult.
Disregarding the 3 largest population centers in Alaska, the state has a population density of about 0.5 people per square mile, about 150 times less dense than the US national average.
The most difficult aspect of providing dental care to Alaska Natives is access to care for residents of remote villages. The villages are small and cannot support a full-time general dentist or physician, let alone specialists. Dentists must travel to the villages periodically to provide dental care, or patients must be transported to a dentist for treatment, often at great cost.
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CURRENT DENTAL CARE IN ALASKA |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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Dental care is provided for Alaska Natives in a unique organizational manner. Each Native tribe is directly responsible for the dental care of its members and arranges for that care through a collaborative—the Alaska Tribal Health System. This structure has evolved through a series of legislative actions that are worth understanding.
The Snyder Act of 1921 and the Indian Health Care Improvement Act of 1976 authorized Congress to provide federal funds to be used for providing health care for the Alaska Native population. The IHS in the Department of Health and Human Services has been given the primary responsibility for the health care needs of the Native tribes. Until about 1975, the IHS provided dental care directly to Alaska Natives. In 1975, the Indian Self-Determination and Education Assistance Act4 allowed Alaska Natives to assume responsibility for their own health care and to receive funding for that care directly from the federal government, provided they meet certain standards imposed by the Act. The tribes are governed under the Alaska Native Claims Settlement Act of 1971 by private, state-chartered, and state-regulated Native for-profit corporations. The Act also recognizes nonprofit health corporations authorized by individual tribes. Most tribes have entered into an agreement with the IHS, the Alaska Native Tribe Compact, under which health programs are carried out and financing agreed on.
Dental care can be provided to Alaska Natives by dentists who are US Public Health Service Commissioned Corps Officers assigned to a tribe, dentists hired directly by tribes, and dentists who have entered into personal service contracts with the IHS and are assigned by the IHS to work with tribal organizations.
In 2002, there were 463 professionally active dentists in Alaska serving the 642 000 people in that state. The dentist-to-population ratio for Alaska during that time was 1 to 1386, compared with the overall US dentist-to-population ratio of 1 to 1695.5 Currently, there are 72 dentists serving the Alaska Native population of 120 000, a dentist-to-population ratio of 1 to 1667. There are, however, 18 unfilled dental positions allocated to treating Alaska Natives ( J. Tucker, oral communication). Given a full complement of dentists serving the Native Alaska population, the dentist-to-population ratio would be 1 to 1333. According to the Centers for Disease Control and Prevention, there were 392 dental hygienists in Alaska during that time period. It is not known how many of those hygienists were professionally active.6
The Dental Health Aide Program began in 2001 as an expansion of the Community Health Aide Program,7 a program begun as a tuberculosis-control effort in rural Alaska in the 1950s and formally authorized under federal law since 1992. Alaska Natives are trained and used as community health aides in an expanded role to provide overall health care, health promotion, and disease prevention in Alaska Native villages. The role of the Alaska Native medical health aide varies, depending on the availability of other medical professionals in the village, the judgment concerning their capabilities by the supervising physician, and the policies of the specific regional native health corporation. Supervising physicians are located in "hub" rural communities and are in regular telephone contact with the health aides to give guidance on patient management.
The Community Health Aide Program has been successful and enjoys a good reputation. Some level of health care is available to most remote villages at all times and is especially valuable for emergency care. This success has led to the concept being applied to dental care.
The organizational and supervisory structure of the proposed Dental Health Aide program mirrors those of the medical health aides. All categories of aides will work under varying degrees of supervision by a dentist who will be generally located in hub clinics with direct communication capabilities.
The Dental Health Aide Program continues to develop.8 New categories of dental aides are being considered beyond those already deployed, as follows.
Primary Dental Health Aide I
Primary dental health aides (PHDAs) will reside in the local village and provide oral health education, "toothbrush" prophylaxes, topical fluoride applications, and oral cancer screenings. Approximately 20 individuals have been trained, in Alaska, with a curriculum developed at the University of Kentucky.
Primary Dental Health Aide II
PHDAs II will reside in the local village and provide oral health education, topical fluoride applications, prophylaxes, and dental sealants; obtain intraoral radiographs; manage dental emergencies; provide atraumatic restorative treatment for caries; and assist the dentist during visits to the village when dental treatment is provided. A curriculum to be developed by the University of Kentucky will be used to provide PDHA II training.
Expanded Functions Dental Health Aide I
Expanded functions dental health aides (EFDHAs) I will be assigned to regional hub clinics, where they will assist the dentist and provide expanded functions, to include providing prophylaxes, placing restorative materials in prepared simple cavities, and placing stainless steel crowns. The IHS has developed a curriculum and approximately 35 individuals have been trained.
Expanded Functions Dental Health Aide II
EFDHAs II function as an EFDHA I, except that filling materials may be placed in both simple and complex cavities. The IHS has developed a curriculum to train EFDHA II.
Dental Health Aide Hygienist
Dental health aide hygienists are traditional dental hygienists and provide the services customarily provided by registered dental hygienists, including the administration of local anesthetics. No one has applied for this designation as yet.
Dental Health Aide Therapist
Dental health aide therapists (DHATs) can be located in villages or in hub clinics, where they will provide oral health education, preventive services, diagnosis and treatment of dental caries, uncomplicated tooth removal, and pulpotomies. They may also supervise all categories of dental health aides. Formal training has begun for 6 individuals, in New Zealand. After their formal training, a preceptorship will begin in Alaska early in 2005. An additional 6 individuals have begun the formal training program.
The DHAT is a new element of this proposed structure. After 2 years of training beyond high school, a DHAT may provide diagnostic and treatment services for dental caries, uncomplicated tooth removal, and pulpotomies without direct supervision by a dentist.
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IMPROVING THE ORAL HEALTH STATUS OF ALASKA NATIVES |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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Considering the prevalence and severity of dental disease among Alaska Natives, the effort to bring that population up to an acceptable level of oral health and reduce the disparities in oral health status between Alaska Natives and the general population under the conditions in which dental care must be provided will require considerable effort by highly skilled and experienced dentists working with an effective team of dental auxiliary personnel. In addition, educational efforts to change the lifestyle factors that play a major role in promoting oral disease among Alaska Natives as well as effective preventive therapies must begin in earnest.
Disease therapy will be the most difficult and costly aspect of any program developed to enhance the oral health of Alaska Natives. Education and effective disease prevention will be the easiest to implement and the least costly components of any program and, fortunately, offer the best long-term solution to the oral health problems currently faced by Alaska Natives.
Skilled dentists must treat existing disease as efficaciously as possible. Therapy must begin soon because untreated dental disease is progressive and becomes more difficult to treat. At the same time, an intensive educational campaign must be implemented to change those aspects of Alaska Native life that promote oral disease, especially the excessive daily consumption of sweetened beverages that are conducive to the development of dental caries. Communal water quality must be improved and fluoridated where possible. In circumstances where water fluoridation is not feasible, other modalities for administering fluoride should be considered. A program for the appropriate topical application of fluorides should be initiated immediately.
Only education and the active prevention of oral disease offer any hope for improving the oral health status of Alaska Natives over time. There will always be physical challenges to providing dental care; therefore, the only practical plan is to prevent oral diseases. The beauty of a well-run educational and preventive program is that it can be effective, is far less costly than providing therapeutic treatment, and can be implemented by lower level providers with minimal supervision by dentists.
The effective use of appropriate dental health aides will be a key to any success in improving the oral health of Alaska Natives. PDHAs I and II, with the appropriate training, can be the front-line implementers of the essential educational and preventive activities. They will be living among the target population. EFDHAs I and II can also enhance the disease treatment aspect of this campaign by increasing the efficiency of the dentist when active treatment is being provided.
The use of DHATs to provide diagnostic and treatment services for caries, tooth removal, and pulpotomies is not a prudent way to meet the dental therapeutic needs of the Alaska Native population. Their educational background, dental training, and experience are very limited. The data indicate that there is a high prevalence of severe oral disease in the Alaska Native population, particularly among those living in remote villages. This situation demands that the high level of skill and experience of a dentist is required to effectively address these challenging diagnostic and therapeutic needs. Most important, patient safety will also be best served if only dentists provide nonreversible treatment, because they can draw on a more extensive set of knowledge, skills, and abilities to solve problems and safely respond to unexpected events.
Used appropriately, DHATs can play an important role in enhancing the oral health of Alaska Natives. They cannot, however, be effective substitutes for dentists.
The collective goal of all of the parties involved in the oral health of Alaska Natives should be to bring their oral health status to the same level as that of all other Americans. This can best be achieved by insisting on and working toward the same level of care for all communities, notwithstanding existing barriers to accessing dental care. Several steps should be taken immediately toward improving the oral health status of Alaska Natives: Cooperation on the part of all of the parties involved in Alaska Native health affairs is essential if success is to be achieved. Empowerment of the Alaska Native tribal organizations to oversee the health of the Alaska Natives should be preserved. The Alaska Dental Society (ADS) represents the overwhelming majority of dentists in Alaska. A workgroup consisting of tribal leaders and leaders of the ADS should be convened to seek long-term solutions to problems with access to dental care that are experienced by Alaska Natives.
The American Dental Association (ADA), the ADS, and tribal leaders should seek expansion of the DHAP so that a dental health aide can be stationed in each Alaska Native village that requests one, to provide educational and preventive services and initial assistance in minor emergencies.
Recruitment activities to increase the number of Alaska Natives who select dentistry as a profession should be intensified and innovative financial assistance programs for Alaska Native dental students should continue to be supported as an incentive for them to return and provide dental care in remote areas.
The ADA and the ADS should continue to actively seek to increase the number of dentists and dental hygienists available to provide dental care to Alaska Natives in rural villages by increasing the number of contract dentists, volunteer dentists and dental hygienists, Commissioned Corps Public Health Dentists, and military dentists when they are available. The ADS should establish a new position of dental placement coordinator to facilitate the match-up of available dentists and the needs of the rural villages.
The ADA, the Denali Commission (a federal-state partnership designed to help provide critical utilities, infrastructure, and economic support throughout Alaska, focusing on Alaska’s remote communities. Some of its projects have exemplified the effectiveness of partnerships between federal and state agencies, and the private sector), the ADS, and the Alaska Native tribes should work together to see that dental clinics are built in appropriate rural villages to reduce the costs and improve the quality of dental care provided in those villages.
The ADA should work with the appropriate Alaskan agencies to see that the quality of drinking water in rural villages is improved and fluoridated where possible, so that rural village residents will not have to substitute cariogenic, sweetened drinks for poor quality water.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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The Alaska Native population—especially the children—suffers from severe and widespread oral disease. The barriers to adequate access to dental care are great. A program to increase the presence of appropriate dental personnel in the remote villages to implement educational and preventive dental programs, to increase the availability of experienced dentists to treat the existing disease, and improvements in the physical infrastructure in the remote villages that hinder good oral health practices offer the best opportunity for improving the oral health of Alaska Natives.
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Footnotes |
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Peer Reviewed
Contributors
E. Sekeguchi, A. H. Guay, L. J. Brown, and T. J. Spangler contributed to the writing of the article. L. J. Brown also provided analytic and graphics assistance.
Human Participant Protection
No human participant protection approval was necessary.
Accepted for publication December 21, 2004.
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References |
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TOPABSTRACTINTRODUCTIONTHE ORAL HEALTH STATUS...GEOGRAPHIC BARRIERS TO CARECURRENT DENTAL CARE IN...IMPROVING THE ORAL HEALTH...CONCLUSIONSReferences |
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1. The 1999 Oral Health Survey of American Indian and Alaska Native Dental Patients: Findings, Regional Differences and National Comparisons. Washington, DC: Dept of Health and Human Services, Indian Health Service; 2002.
2. US Department of Health and Human Services. National Center for Health Statistics. Third National Health and Nutritional Examination Survey, 1988–1994, NHANES III Laboratory Data File [CD-ROM]. Public Use Data File Documentation No. 76200. Hyattsville, MD: Centers for Disease Control and Prevention; 1996.
3. US Department of Health and Human Services. National Center for Health Statistics. National Health and Nutrition Examination Survey, 1999–2000. Public Use Data File Documentation. Available at: http://www.cdc.gov/nchs/about/major/nhanes/nhanes99-00.htm. Accessed August 15, 2004.
4. Indian Self-Determination and Education Assistance Act, 25 USC sect 450, et seq, 1975.
5. Distribution of Dentists in the United States by Region and State: 2002. Chicago, IL: American Dental Association; 2002.
6. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Oral Health Resources. Available at: http://www2.cdc.gov/nccdphp/doh/synopses/StateDataV.asp?StateID=AK&Year+2003. Accessed August 16, 2004.
7. The Alaska Community Health Aide Program: An Integrative Literature Review and Visions for Future Research. Washington, DC: Dept of Health and Human Services, Health Resources and Services Administration; August 2003.
8. Alaska Dental Health Aide Program: A Brief for the American Dental Association. Washington, DC: Dept of Health and Human Services, Indian Health Service; December 16, 2003.
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