Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta

Integration of dental therapists in safety net practice increases access to oral health care in Minnesota

OBJECTIVES

This study evaluates the impact of introducing dental therapists (DTs) into Children's Dental Services (CDS), a large non-profit organization in Minnesota. The aim is to assess the effect of DTs in improving access and reducing dental care costs in Minnesota by analyzing the trends in dental care delivery and procedures performed by CDS dentists and therapists.

METHODS

Using 2009 to 2021 data from CDS, the study compares trends in patient volume, types of procedures, salary data and payments by dentists, DTs, and registered dental hygienists (RDH). Return on investment (ROI) trends are calculated using salary and revenues for each provider type.

RESULTS

After introducing DTs at CDS and implementing mobile clinics, the number of patients served and volume increased steadily, demonstrating increased access. DTs provided an increasing proportion of fluorides, sealants, and extractions through 2020. Interestingly 2021, there was a decrease for DTs, possibly due to Covid related workforce shortages. ROI analysis showed that DTs' ROI dramatically rose, eventually surpassing dentists, while RDHs maintained a constant ROI. Dentists' ROI also initially increased after adopting DTs in the practice.

CONCLUSION

Integrating DTs at CDS improved access by expanding mobile clinics, increasing patient volume, and redistributing procedures, while demonstrating a positive return on investment. Results suggest that adopting the DT model may be a promising practice for other organizations seeking to improve access to dental care, increase operational efficiency, and boost the dental care team's ROI.

Policy interventions to improve the accessibility and affordability of Dutch dental care. A scoping review of effective interventions

Caries and periodontitis remain prevalent in the Netherlands. Given the assumption that increasing the accessibility and affordability of dental care can improve oral health outcomes, policy interventions aimed at improving these aspects may contribute to better oral health. To identify possible solutions, this scoping review firstly identifies policy interventions from around the world that have effectively improved the accessibility or affordability of dental care. Secondly, this review discusses the potential of the policy interventions identified that are applicable to the Dutch healthcare sector specifically. A literature search was performed in four databases. Two reviewers independently screened all potentially relevant titles and abstracts before doing the same for the full texts. Only studies that had quantitatively evaluated the effectiveness of policy interventions aimed at improving the accessibility or affordability of dental care were included. 61 of the 1288 retrieved studies were included. Interventions were grouped into four categories. Capacity interventions (n = 5) mainly focused on task delegation. Coverage interventions (n = 25) involved the expansion of covered dental treatments or the group eligible for coverage. Managed care interventions (n = 20) were frequently implemented in school or community settings. Payment model interventions (n = 11) focused on dental reimbursement rates or capitation. 199 indicators were identified throughout the 61 included studies. Indicators were grouped into three categories: accessibility (n = 137), affordability (n = 21), and oral health status (n = 41). Based on the included studies, increasing managed care interventions for children and adding dental coverage to the basic health insurance plan for adults could improve access to dental care in the Netherlands. Due to possible spillover effects, it is advisable to investigate a combination of these policy interventions. Further research will be necessary for the development of effective policy interventions in practice.

Indigenous data governance approaches applied in research using routinely collected health data: a scoping review

Globally, there is a growing acknowledgment of Indigenous Peoples' rights to control data related to their communities. This is seen in the development of Indigenous Data Governance standards. As health data collection increases, it's crucial to apply these standards in research involving Indigenous communities. Our study, therefore, aims to systematically review research using routinely collected health data of Indigenous Peoples, understanding the Indigenous Data Governance approaches and the associated advantages and challenges. We searched electronic databases for studies from 2013 to 2022, resulting in 85 selected articles. Of these, 65 (77%) involved Indigenous Peoples in the research, and 60 (71%) were authored by Indigenous individuals or organisations. While most studies (93%) provided ethical approval details, only 18 (21%) described Indigenous guiding principles, 35 (41%) reported on data sovereignty, and 28 (33%) addressed consent. This highlights the increasing focus on Indigenous Data Governance in utilising health data. Leveraging existing data sources in line with Indigenous data governance principles is vital for better understanding Indigenous health outcomes.

Oral Health Workforce and American Indian and Alaska Native Communities: a Systematic Review

OBJECTIVE

Understanding the oral health workforce representing and serving American Indian and Alaska Native (AI/AN) communities is vital to improving community dental health outcomes. No systematic review of recent published literature on the oral health workforce among this population has been completed.

METHODS

We conducted a systematic review of published literature examining the oral health workforce representing and serving AI/AN communities in the USA. We analyzed 12 articles according to the PRISMA Statement.

RESULTS

The studies suggested that AI/AN identity is an important aspect of routine and accessible oral healthcare. There are unique barriers and motivations that personnel in the oral health workforce face, let alone the distinctiveness of serving AI/AN communities.

CONCLUSIONS

This review provides evidence that expanded oral health positions aid in community members receiving more routine and preventative care and is an upstream public health approach that has diversified the dental workforce.

Native American Community Perspectives on Oral Health Access: Understanding the Impact of Rurality

PURPOSE

Oral health disparities related to access persist for American Indian/Alaska Native (AI/AN) communities compared to the general population, especially in rural areas of the United States. The objective of this study was to better understand community perspectives of oral health, how rurality impacts access to care, and attitudes towards the implementation of dental therapists in Oklahoma, particularly among the AI/AN population.

METHODS

A descriptive, observational study design was utilized. An exploratory survey was conducted online and comprised of qualitative and quantitative data. The total frequencies and percentages were evaluated for the quantitative questions. The qualitative data was analyzed using thematic analysis. Utilizing descriptive and qualitative research methods, the focus was to describe the experiences of the respondents and their characteristics related to oral health in Oklahoma.

RESULTS

A total of 201 responses were obtained, where 65% (n = 131) identified as an enrolled member or employee of a tribe represented in Oklahoma. Key qualitative themes included community access to care, community concerns, and community motivated solutions.

CONCLUSIONS

AI/AN communities are an underserved group in healthcare. Although communities in rural areas face major barriers to oral health services, evidence-based solutions can be implemented.

Children's Oral Health Initiative: workers' perspectives on its impact in First Nations communities

INTRODUCTION

Since 2004, the Children's Oral Health Initiative (COHI) has been working in many First Nations and Inuit communities in Canada to address oral health disparities, specifically early childhood caries (ECC). The COHI community-based approach improves early childhood oral health (ECOH) by balancing prevention with minimally invasive dentistry. The goal is to reduce the burden of oral disease, mainly by minimizing the need for surgery. We investigated program success in First Nations communities in the province of Manitoba, from the perspective of COHI staff.

METHODS

First Nations community-based dental therapists and dental worker aides participated in three focus groups and an in-depth semistructured interview. The collected data were thematically analyzed.

RESULTS

Data from 22 participants yielded converging and practitioner-specific themes. Participants reported that dental therapists and dental worker aides provide access to basic oral care in their communities including oral health assessments, teeth cleaning, fluoride varnish applications and sealants. The participants agreed that education, information sharing and culturally appropriate parental engagement are crucial for continuous support and capacity building in the community programs. Low enrolment, difficulty accessing homes and getting consent, limited human resources as well as lack of educational opportunities for dental worker aides were identified challenges.

CONCLUSION

Overall, the participants reported that the COHI program positively contributes to ECOH in First Nations communities. However, increased community-based training for dental workers, community awareness about the program, and engagement of parents to facilitate culturally appropriate programming and consent processes are critical to improving program outcomes.

Exploring factors associated with parent-reported early childhood caries with Alaska's childhood understanding behaviors survey data

OBJECTIVES

Early Childhood Caries (ECC) can negatively impact the lives of young children, despite being preventable. The purpose of this study was to utilize available data in Alaska to describe changes in parent reports of ECC, and identify factors related to ECC.

METHODS

The Childhood Understanding Behaviors Survey (CUBS) is a population-based survey of parents of 3-year-old children and was utilized to describe changes in: parent-reported ECC among children with a dental visit, access to and or utilization of dental care, and consumption of three or more cups of sweetened beverages between 2009-2011 and 2016-2019. Logistic regression modeling was used to explore factors associated with parent-reported ECC among children with a dental visit.

RESULTS

Over time, a significantly smaller proportions of parents whose 3-year-old child had seen a dental professional reported ECC. Additionally, a smaller proportion of parents reported three or more cups of sweetened beverage consumption by their child, while larger proportions had seen a dental professional by age 3. Factors associated with parent-reported ECC included consumption of three or more cups of sweetened beverages, and enrollment in Medicaid or Tribal health care insurance, while protective factors included a parent earning a college degree, and military insurance.

CONCLUSIONS

Although at the statewide level, improvements were observed in parent-reported measures over time, regional disparities were apparent. Social and economic factors as well as excessive consumption of sweetened beverages appear to play important roles in ECC. CUBS data can help identify trends in ECC within Alaska.

Feedback on audit and action planning for dental caries control: a qualitative study to investigate the acceptability among interdisciplinary pediatric dental care teams

Introduction

American Indian and Alaska Native children suffer from the poorest oral health of all populational groups in the United States. Evidence-based practices (EBP) for caries control are well established, but systematically implementing such practices have proven difficult. Audit and feedback with goal setting, and action planning to implement these EBPs have not been tested or adapted for Alaska Native healthcare settings. The aim of this study was to investigate acceptability and perceived feasibility of an audit and feedback intervention for pediatric dental caries control among dental providers and patient stakeholders.

Methods

The pilot program was implemented in two dental clinics from a tribal healthcare consortium in Alaska. Key-informant interviews were conducted to investigate the contextual, organizational, and behavioral facilitators and barriers to the implementation and expansion of the program. Interview transcripts were analyzed by two researchers using thematic analysis.

Results

Eight key informants were interviewed twice (during and after the intervention period), and one once, for a total of 17 interviews. Patient stakeholders were not interviewed due to COVID-19 pandemic clinic closures and social isolation mandates. Three principal themes emerged: a positive organizational climate and culture fostered the acceptability of the program, the positive impacts of the program observed in the pediatric dental teams and the organization, and the challenges to implement the program including understanding the data reports, trusting the accuracy of the data, and competing priorities.

Conclusions

The intervention of audit and feedback with goal setting and action planning was well accepted and perceived as feasible by the study participants given the financial and human resources provided by the research project. This qualitative study can inform the design and evaluation of process-oriented implementation strategies geared towards decreasing health inequities and improving health outcomes, such as dental caries in American Indian and Alaska Native children and adolescents.

Undoing structural racism in dentistry: Advocacy for dental therapy

Like other areas of health, structural racism has a deep impact on oral health and is a key driver of racial inequities in access to care and outcomes. Racism also structures the relationship between oral health and access to economic opportunities. As a result, communities of color, American Indian/Alaska Native (AI/AN) communities, and low-income populations experience the highest rates of the health, social, and economic costs of dental disease. This is compounded by issues of community-level dental fear/trauma resulting from receiving itinerate care. Dentistry has long struggled to equitably distribute care and diversify its overwhelmingly white and affluent workforce, resulting in many communities not having access to providers who represent their identity and/or live in their community. While multi-generational lack of access to dental care is not unique to Alaska, Alaska Native communities are the home to a reimagined, community-centered care delivery system that is improving health outcomes. For almost two decades, AI/AN leaders have recruited and trained community members to serve as dental therapists-dental team members who offer routine and preventive care responsive to local geographic and cultural/community norms. As members of the communities they serve, dental therapists are fluent in the language and cultural norms of their patients, improving patient-provider trust, access to care, and oral health outcomes. The communities that dental therapists serve are also now investing money and training in their community members, building educational opportunities, and professional wage jobs and directly countering the economic impact structural racism has on oral health.

Dental Therapists in the United States: Health Equity, Advancing

BACKGROUND

Dental therapists (DTs) are primary care dental providers, used globally, and were introduced in the United States (US) in 2005. DTs have now been adopted in 13 states and several Tribal nations.

OBJECTIVES

The objective of this study is to qualitatively examine the drivers and outcomes of the US dental therapy movement through a health equity lens, including community engagement, implementation and dissemination, and access to oral health care.

METHODS

The study compiled a comprehensive document library on the dental therapy movement including literature, grant documents, media and press, and gray literature. Key stakeholder interviews were conducted across the spectrum of engagement in the movement. Dedoose software was used for qualitative coding. Themes were assessed within a holistic model of oral health equity.

FINDINGS

Health equity is a driving force for dental therapy adoption. Community engagement has been evident in diverse statewide coalitions. National accreditation standards for education programs that can be deployed in 3 years without an advanced degree reduces educational barriers for improving workforce diversity. Safe, high-quality care, improvements in access, and patient acceptability have been well documented for DTs in practice.

CONCLUSION

Having firmly taken root politically, the impact of the dental therapy movement in the US, and the long-term health impacts, will depend on the path of implementation and a sustained commitment to the health equity principle.

Using electronic dental records to establish a surveillance system for dental decay in rural Western Alaska

OBJECTIVES

Previous surveys have demonstrated high rates of early childhood caries (ECC) in the Alaska Native (AN) population of western Alaska. There are many challenges to providing dental care in this road-less Yukon-Kuskokwim Delta region. The regional Tribal Health Organization implemented an electronic dental record (EDR) system in the late 1990s. We explored use of the EDR to establish an oral health surveillance system in children.

METHODS

We contracted with EDR software developers to implement calculation of a summary count of decayed (d), missing (m) or filled (f) primary (dmft) score for each individual. We calculated the yearly average dmft scores for 2011-2019 for children aged 3 and 5 years with a comprehensive exam in a given year. We also assessed the number of children undergoing full mouth dental rehabilitation (FMDR). We used US census data population estimates for these age groups to calculate rates.

RESULTS

Over the 9-year period, 2,427 3-year-old children (47 percent of all 3-year olds over this period), received a comprehensive exam; increasing from 24 percent in 2011 to 62 percent in 2019. Their average dmft score over the 9-years was 6.4 with a significant annual decline over this period. Seventy percent of AN children who turned 6 between 2015 and 2019 had received at least one FMDR.

CONCLUSIONS

An oral health surveillance system has been established in western Alaska using the Electronic Dental Record. High rates of ECC and FMDR were observed. This surveillance system will allow assessments of ECC prevalence and impact of dental interventions.

Effects of Medicaid expansion on self-reported use of dental services in socioeconomically vulnerable subgroups

OBJECTIVE

Research suggests Medicaid expansion led to modest increases in the use of dental services among low-income adults, especially in states with more generous Medicaid dental benefits. We expand upon this research by examining whether the effect of Medicaid expansion differed across important socioeconomic subgroups.

METHODS

Using Behavioral Risk Factor Surveillance System data from 2012 to 2016, we employed a difference-in-differences framework to estimate the effect of Medicaid expansion on annual use of dental services overall and by whether states offered more-than-emergency Medicaid dental benefits. We used generalized linear mixed-effects model trees to estimate effects across socioeconomic subgroups (e.g., age, education, race, income).

RESULTS

The effect of Medicaid expansion varied by state's generosity of Medicaid dental coverage and combinations of socioeconomic subgroups. Overall, there was no significant association between Medicaid expansion and probability of using dental services (-0.1 pp percentage points [pp], p = 0.914). Medicaid expansion was associated with a modest increase in the probability of using dental services in states with more-than-emergency Medicaid dental benefits (2.3 pp, p < 0.001) and with a modest decrease in states with no or emergency-only benefits (-4.3 pp, p < 0.001). Among adults aged 21-35 without a high school diploma, Medicaid expansion was associated with an 8.1 pp (p = 0.003) increase in dental use probability, but there were no associated effects of Medicaid expansion for other subgroups.

CONCLUSIONS

While Medicaid expansion alone is not sufficient to ensure adults receive recommended dental care, some vulnerable subgroups appear to have benefited. Efforts to mitigate barriers to dental care may be needed to increase uptake of dental services by low-income adults.

Early Childhood Caries in Indigenous Communities

The oral health of Indigenous children of Canada (First Nations, Inuit, and Métis) and the United States (American Indian and Alaska native) is a major child health disparity when compared with the general population of both countries. Early childhood caries (ECC) occurs in Indigenous children at an earlier age, with a higher prevalence, and at much greater severity than in the general population. ECC results in adverse oral health, affecting childhood health and well-being, and may result in high rates of costly surgical treatment under general anesthesia. ECC is an infectious disease that is influenced by multiple factors, but the social determinants of health are particularly important. This policy statement includes recommendations for preventive and clinical oral health care for infants, toddlers, preschool-aged children, and pregnant women by primary health care providers. It also addresses community-based health-promotion initiatives and access to dental care for Indigenous children. This policy statement encourages oral health interventions at early ages in Indigenous children, including referral to dental care for the use of sealants, interim therapeutic restorations, and silver diamine fluoride. Further community-based research on the microbiology, epidemiology, prevention, and management of ECC in Indigenous communities is also needed to reduce the dismally high rate of caries in this population.

Provider and community perspectives of dental therapists in Alaska's Yukon-Kuskokwim Delta: A qualitative programme evaluation

OBJECTIVES

Dental therapists deliver preventive and basic restorative care and have been practicing since 2006 in Alaska's Yukon-Kuskokwim (YK) Delta. In this qualitative programme evaluation, we documented health providers' and community members' experiences with dental therapy. The goal of the evaluation was to develop a conceptual model of dental care delivery in Alaska Native Communities centred on dental therapists.

METHODS

We developed semi-structured interview scripts and used snowball sampling to recruit 16 health providers with experience providing care in the YK Delta and 125 community members from six YK Delta Communities in 2017 and 2018. The six communities were a stratified convenience sample based on community-level exposure to dental therapists (high, medium and no exposure). Interview data were digitally recorded, transcribed, verified for accuracy and coded inductively into conceptual domains using content analytic methods.

RESULTS

Providers believed individuals living in the YK Delta have benefited from clinic-based restorative care and community-based education provided by dental therapists. The restricted scope of dental therapy practice limits the complexity of care that may be offered to patients. However, community members expressed high satisfaction with the quality of care provided by dental therapists. Community members noted more widespread knowledge and evolving norms about oral health and believed dental therapists are helping to prevent disease and improve quality of life. Participants believed access to dental care for children has improved over the years, but felt that many adults in the YK Delta continue to have unmet needs. A potential barrier to sustained programme effectiveness is low retention of dental therapists in the region, driven primarily by reports that dental therapists feel overworked, stressed and geographically isolated.

CONCLUSIONS

Dental therapists have contributed to the dental care delivery system in Alaska's YK Delta. Future opportunities remain within the system to address the needs of adults, develop strategies to retain dental therapists in the region and incorporate evidence-based, prevention-oriented strategies to improve oral health behaviours and reduce oral diseases.

In Defense of Dental Therapy: An Evidence-Based Workforce Approach to Improving Access to Care

This article addresses new systems and practice models in community-based dentistry. Its purpose is twofold: to identify strategies and policies that support health equity and access to care; and to identify promising efforts that serve as new models for change in the dental workforce. Dental therapy meets both of these purposes and is the major focus of this article. The fundamental premises explored are threefold. First, the dental care system in the U.S. is broken for many people who then suffer the consequences of poor oral health; this is especially true for racial and ethnic minorities and lower income populations. Second, dental therapy is a proven, safe, high-quality, cost-effective, and ethical way to improve access to oral health care and oral health in general. Third, opposition to dental therapy comes only from the leadership of organized dentistry and is without an evidence base to support objections and criticism. This article reviews each of these three premises in detail. Based on this review, the article concludes that dental therapy is a safe, high-quality, effective, and ethical approach to improve the oral health workforce, increase access to dental care, and achieve oral health equity.