Interview: Dental therapists as answer to racial inequities in oral healthcare

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Interview: Dental therapists as answer to racial inequities in oral healthcare

The 2019 graduating class of dental therapists from the Alaska Dental Therapy Educational Program at Ilisagvik College, which is Alaska’s only tribal college. (Image: Community Catalyst)

A recent study by Community Catalyst, a US non-profit health organisation that advocates for health equity and justice, emphasises how dental therapy can significantly improve access to oral health in underserved communities. Dental Tribune International spoke with co-author Kasey Wilson, a senior policy analyst with the organisation’s Dental Access Project, to find out how dental therapists have improved the relationship of underserved communities with dental services by providing trustworthy and culturally respectful care.

Kasey Wilson, a senior policy analyst at Community Catalyst. (Image: Kasey Wilson)

Ms Wilson, could you tell us a bit more about the organisation Community Catalyst and your position within the organisation? What is the Dental Access Project?
We partner with local, state and national advocates to leverage and build power so that all people can influence decisions that affect their health. Health systems are not likely to be accountable to people without a fully engaged and organised community voice. That is why we work every day to ensure people’s interests are represented wherever important decisions about health and healthcare are made: in communities, state houses and on Capitol Hill.

As a senior policy analyst, I provide research and policy support to community groups and health advocates working on improving access to dental care and oral health. The Dental Access Project is focused on supporting the identification and implementation of effective local solutions that improve oral health access and community health outcomes.

How does structural racism have an impact on the oral health of people from various racial and ethnic communities?
Structural racism has an impact on oral health directly as well as via access to care and broader social determinants of health. It is widely documented that experiencing racism presents a unique form of chronic stress that can cause a variety of health problems. Many of these, including heart disease, diabetes and inflammatory responses, are also associated with oral health problems. Once dental disease develops, treating it requires access to timely, accessible care, which can be expensive. When it goes untreated, dental disease can have an impact on the ability to work or go to school, compounding existing economic inequalities that are, themselves, driven by structural racism.

Structural racism also affects things like who has access to care, where dental providers are located and who has access to dental professional education. Some racial and ethnic communities face greater barriers to accessing dental care and have poorer oral health outcomes as a result. The dental profession is also disproportionately white, meaning that patients from these communities, and black and indigenous patients in particular, are less likely to be able to see a provider who represents their race, ethnicity and/or culture, which is also shown to have an impact on health outcomes.

Asiah Gonzalez, a dental therapist and member of the Swinomish Tribe, at her workplace at the Swinomish Dental Clinic in La Conner in Washington. (Image: Community Catalyst)

As described in your study, Alaskan Natives are an example of communities who, for a long time, did not have proper access to dental care. Then leaders decided to take action and found a solution: dental therapists. Could you please explain what exactly dental therapists are and what they do to serve their community?
Dental therapists are highly trained oral health practitioners who work with dental teams in a similar way to that in which physician assistants work with medical teams. They provide education and preventive services and undertake common dental procedures such as filling cavities and, in limited cases, removing teeth. Through the remote supervision of a dentist, dental therapists can also deliver care in settings that better meet the needs of underserved communities, such as mobile clinics, schools and senior centres. Where employed, dental therapists are enabling dentists and community clinics to see more publicly insured patients, reduce patient wait times and divert emergency room usage. Dental therapists work as part of the existing dental team and may also be dually educated as dental hygienists.

What has changed for the Alaskan Native community regarding dental care since the leaders started to work with dental therapists?
Alaska Native leaders were the first in the nation to bring dental therapists to the US. When the first dental therapy education programme opened in Alaska, they based their training on community-centred models abroad. The dental therapy programme operates on a model of training local people to provide the care their community needs and offering that training in a local context. This increases the likelihood that providers will stay in their local communities to practise.

Members of communities who, for generations, had received only intermittent care from itinerant providers—and who often experienced pain and trauma associated with that care as a result—or who had no access to care at all, now can see a dental provider regularly in their own communities.

In places where dental therapists work, both children and adults have better access to preventive care and more people are keeping their natural teeth. Communities are highly satisfied with the care they receive, saying that they now know more about oral health and regard dental therapists as having improved their quality of life.

Daniel Kennedy, the first dental therapist to work in a tribal community in the lower 48 (the 48 contiguous US states, excluding Alaska and Hawaii) and the first dental therapist to work in Washington, at the Swinomish Dental Clinic in La Conner. (Image: Community Catalyst)

Dental therapists often work within their own home community and are thus responsive to cultural and community norms. Does this increase the patient’s trust in the dental therapist and thus in dental care?
That is exactly right. They represent the language, culture and experiences of their patients, and this has transformed communities’ relationships with dental care. More trust comes from having a provider who understands and respects their patients’ culture and also from regularly accessible care in general. When communities can expect that a provider will be there, month after month, year after year, that consistency builds trust as well.

The model of employing dental therapists is a cycle of consistency, representativeness and trust that was borne of tribal leadership and can be adapted by and for diverse communities across the country.

Are dental therapists employed in other regions too?
Dental therapists have been practising around the world for over a century, and a large body of evidence shows that they provide effective, quality care. As a result of their positive impact on Alaska Native communities, dental therapists have been authorised to practise in at least some settings in 11 other US states. Minnesota was the first state to allow dental therapists to practise statewide, and they have been doing so for a decade with positive results similar to Alaska. Dental therapists have improved access to care for underserved populations and have helped dental clinics see more publicly insured patients.

Aurora Johnson—one of the first dental therapists to begin practising in the US—gives oral health education to a class of children in a tribal community school in Alaska. (Image: Community Catalyst)

Are there any other future aspirations for improving oral healthcare access to underserved communities that you would like to share with us?
Expanding the oral health workforce—and especially increasing the diversity and geographic distribution of providers, which dental therapy helps to do—is only strengthened by related efforts to improve access to care and achieve oral health equity. Improving access to coverage by making dental benefits mandatory for adults in all US state Medicaid programmes and adding a comprehensive dental benefit to Medicare is critical. So also is giving people a choice in the type of care they receive and where they receive it. This includes better integration of oral healthcare into medical settings—like fluoride being provided in paediatricians’ offices—and prioritisation of less invasive approaches to treating dental caries that are more likely to allow people to keep their teeth and avoid the dental drill.

Is there anything else you would like our readers to know?
Continuing to evaluate how and where structural racism shows up in access to care and health outcomes is critical in achieving oral health equity and health justice more broadly. In addition to the policy solutions we have already talked about, ensuring that communities have a say in decisions that affect their oral and overall health is also integral. This means that people who are most affected by a problem must lead the charge in coming up with the solutions.

Editorial note:

The study, titled “Undoing structural racism in dentistry: Advocacy for dental therapy”, was published online on 11 January 2022 in the Journal of Public Health Dentistry, ahead of inclusion in an issue.

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