Alaska Native

Denotes a person having origins in any indigenous people of Alaska and their descendants and who maintains tribal affiliation, or community or cultural attachment. T he concept refers to population subgroups such as Eskimos, Aleuts, Inupiat, Yupik, Alutiiq, Egegik,and Pribilovian, Alaskan Athabascan, T lingit, and Haida. T he concept refers also to individuals who classify themselves as such. Qeios · Definition, February 2, 2020


Background
In response to extensive dental health needs and high dental vacancy rates, the Alaska Dental Health  The Alaska DHAT program was created in part due to the high rates of dental caries and overall lack of access to dental services in rural Alaska villages.Alaska Native children and adolescents suffer dental caries rates at 2.5 times greater than general US children and adolescents. 1This, combined with a vacancy rate of 25% and 30% annual turnover rates in dentists has developed into a serious problem in Alaska dental care. 2 Nationally, with the number of dentists declining from 60 per 100,000 currently to an expected 54 per 100,000 in 2030 (ADA), there is clearly not an adequate supply and/or distribution of dentists to meet the basic oral health needs of America's First People.The great unmet need for dentists or other oral health providers in Indian Country, where there are, on the average, about half the dentist-to-population ratio of the national average, is well-documented. 3ccording to the Indian Health Service: "The fact that dental decay affects more than 75 percent of AI/AN people presents a major challenge requiring a large-scale public health approach." 4ased on our experiences in Alaska, we could not agree more.Dental Therapists can help to fill the gap to provide desperately needed services where dental services are either limited or do not exist at all.

Dental Therapists Worldwide
The Alaska DHAT training program is modeled after New Zealand's National School of Dentistry in Otago.New Zealand's Dental Therapists have been highly valued for over 80 years and are providing high quality care.In fact, over 14,000 dental therapists operate in over 53 countries worldwide.The United States is the only industrialized nation without a midlevel dental practice available to its citizens.
Dental therapists have been in practice for many years world wide especially in children's oral health services and have shown they provide high quality care.For example, since 1963, Canadian dental therapists have been providing excellent care equal to or exceeding the quality of care of dentists and they have been more cost-effective. 5In the Netherlands, there is greater investment in a dental therapist/dental hygienist combination and a 20% reduction in dental school numbers to improve access to care and decrease care cost. 6With no litigation or malpractice suits in over 50 years, Malaysian dental therapists have proven their worth in the treatment of children's dental needs. 7Dental therapists have proven their ability through high quality care worldwide.DHATs are trained to provide oral health education, preventive services, fillings, and uncomplicated extractions to preserve function and address pain and infection.DHATs are able to provide atraumatic restorative technique, placement of temporary restorations, simple restorations, simple extractions, lab processed crowns, pulpotomy, and pulp capping just to name a few.In addition, DHATs provide community education, many times in schools for young children and to families who visit the clinics.

DHAT Program Information
An additional requirement of participating in the program is for each student to have a sponsor agreement with a tribal health organization for which they will work after graduation and certification.The sponsoring tribal health organization covers the costs of the student's training for the two year program in return for four years of service.In addition, the sponsoring organization provides a supervising dentist for the DHAT.
In addition to the agreement and extensive training, the student must complete a preceptorship of at least 400 hours with their supervising dentist.Since the DHAT will be practicing under the general supervision of the supervising dentist, it is during this preceptorship time that the supervising dentist and DHAT agree on the DHAT's scope of practice.The preceptorship time also allows the dentist and DHAT to develop a rapport as they will be in constant communication once the DHAT is at their permanent station many times talking telephonically three to six times per day, communicating via e-mail and/or telemedicine consultations regarding patient needs.
Only after the DHAT completes this clinical preceptorship are they eligible for certification.Each DHAT must apply for and receive certification to the Indian Health Service's Community Health Aide Program Certification Board.This independent federal board serves to credential providers and respond to issues and patient complaints.In addition, this board ensures standards for discipline, suspension or revocation of a certificate are met.
Once DHATs are trained, complete their preceptorship, and are certified, they begin work at their respective tribal health organization.However, their review and education does not stop there.DHATs must be recertified every two years and complete continuing education hours.A DHAT review consists of direct observation of each service performed eight times every 2 years.They are also required to complete 24 hours of continuing education per two year cycle.

Current DHATs
There are currently ten practicing DHATs who were trained in New Zealand and three who were trained at DENTEX.These DHATs work for the following tribal health organizations: Norton Sound Health Corporation (NSHC), Maniilaq Association (Maniilaq), Yukon Kuskokwim Health Corporation (YKHC), SouthEast Alaska Regional Health Consortium (SEARHC), Bristol Bay Area Health Corporation (BBAHC), Metlakatla Indian Community (MIC), and Mount Sanford Tribal Consortium (MSTC).In addition to these tribal health organizations having current DHATs practicing, the following tribal health organizations are sponsoring DHATs in their second clinical year of DENTEX: YKHC, BBAHC, Tanana Chiefs Conference (TCC), and Aleutian Pribilof Islands Association (APIA).The following tribal health organizations are sponsoring DHATs in their first year of DENTEX: Council of Athabascan Tribal Governments (CATG), YKHC, Eastern Aleutian Tribes (EAT), Maniilaq, and BBAHC.In total, there are thirteen DHATs currently practicing and fourteen in DENTEX training.Please see map of DHAT location information attached.
In recent independent studies, DHAT skills were assessed to determine if they are on par with dentist provided services and quality of care provided by DHATs. 8The results of an early study noted that the "program deserves not only to continue by to expand" and that suggestions that dental therapists "cannot be trained to provide competent and safe primary care for Alaska Natives is overstated." 9In a recent pilot study, there was found to be no significant difference between irreversible dental treatment provided by DHATs or dentists and no significant difference in reportable events.10Dr. Bolin noted: One of the main objections to the solution of expansion of duties to nondentists was the issue of quality of care.Some who are opposed to treatment provided by DHATs have suggested that it is "second-class care" or, since DHATs do not have dental licenses, that they are practicing dentistry without a license and, therefore, could be "unsafe." . . .The opposition has occurred despite study results showing that DHATs can perform primary care procedures comparably to dentists, and that DHAT trainees perform equally well compared with dental students.

Next Steps
Like the Community Health Aide, the DHATs have become an essential part of the dental health care delivery model in the Alaska Tribal Health System.Their ability to provide culturally appropriate, high quality care has increased Alaska Native access to proper dental services and prevention activities.In addition, these individuals have become role models for young people sharing and teaching them there are options and careers available to them.DHATs continue to thrive and prove their worth just as dental nurses and therapists have worldwide.
It is exciting to see other parts of the United States are looking at a dental mid-level model.The Alaska Native Health Board believes that dental therapists can be extremely helpful in combating dental disease and increase the level of oral health throughout Indian country and the nation.DHATs are an innovative solution to the inadequate numbers of licensed dentists practicing in underserved areas, not just rural Alaska.Recently, the Minnesota Legislature approved the Oral Health Practitioner consisting of the Dental Therapist and the Advanced Practice Dental Therapist with graduates expected in summer of 2011. 11 In addition to seeing DHATs provide services, the Alaska Native Health Board is excited to see the preliminary results of a study commissioned by philanthropic organizations (Rasmuson, W.K. Kellogg, and Bethel Community Services Foundations) who are covering all costs of the evaluation which will determine the DHAT program's implementation integrity and conduct a health outcome assessment addressing safety, quality, and patient-oriented outcomes.The study is being conducted under extensive review by two advisory committees; one national and one state.The national advisory committee selected RTI International to conduct the evaluation.RTI International is the second largest non-profit research group in the United States and has experience in program evaluation and health services research.The study started in the Spring of 2009 and preliminary results are expected in Summer of 2010.

DHAT Program Needs
Major issues addressed include program funding shortfalls and evaluation needs.We respectfully recommend that this Committee urge the Indian Health Service include DHAT program funding in their funding requests for future years.It has come to our attention that the current philanthropic evaluation meets all but one evaluation request set aside for review by the Secretary of Health and Human Services.Thus, we also respectfully recommend that the Committee utilize the current study for all other needs of evaluation noted rather than commission a new study.
Aide Therapy (DHAT) program began in 2003.The DHAT program is part of the Community Health Aide Program (CHA Program), which is authorized under Section 119 of the Indian Health Care Improvement Act, 25 U.S.C. § 1616l.The CHA Program started in the 1960s by the Indian Health Service to provide emergency, clinical, and preventive services under general supervision of physicians.Following the CHA Program model, the DHAT program selects individuals from rural Alaska communities to be trained and certified to practice under general supervision of dentists in the Alaska Tribal Health System.

Alaska' s
DHATs receive extensive training, certification, continuing education, and clinical reviews to ensure their skills are of the highest quality.Alaska's first DHATs received their training New Zealand's National School of Dentistry in Otago.The first DHATs graduated in 2004.In 2007, the Alaska Native Tribal Health Consortium in partnership with the University of Washington's MEDEX Northwest Physician Assistant Training Program opened DENTEX, the first DHAT training center in the United States.The DENTEX goal is to provide culturally sensitive patient-centered care to optimize prevention to ensure that patients feel comfortable enough to return for continued care and treatment.The DENTEX program is extremely rigorous.Students receive two years of training in biological science, social science, pre-clinic, and clinic training.The students receive 2400 hours of training and clinical experience during their first year in Anchorage and during their second year in Bethel, Alaska.Utilizing the same textbooks as dental students, DHATs in training are trained to provide the same high quality level of care a dentist would within their limited scope.The DENTEX faculty, most from dental schools, ensures that the students meet all skill requirements throughout their training.The training also consists of extensive clinic training.In fact, 20% of the first year of training and 78% of the second year of training consists of clinical components.