Article

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

Authors:
  • Southeast Alaska Regional Health Consortium
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Abstract

Objectives: Dental Health Aide Therapists (DHATs) have been part of the dental workforce in Alaska's Yukon-Kuskokwim (YK) Delta since 2006. They are trained to provide preventive and restorative care such as filling and extractions. In this study, we evaluated community-level dental outcomes associated with DHATs. Methods: This was a secondary data analysis of Alaska Medicaid and electronic health record data for individuals in Alaska's YK Delta (2006-2015). The independent variable was the number of DHAT treatment days in each community. Child outcomes were preventive care, extractions, and general anesthesia. Adult outcomes were preventive care and extractions. We estimated Spearman partial correlation coefficients to test our hypotheses that increased DHAT treatment days would be associated with larger proportions utilizing preventive care and smaller proportions receiving extractions at the community-level. Results: DHAT treatment days were positively associated with preventive care utilization and negatively associated with extractions for children and adults (P < 0.0001). DHAT treatment days were not associated with increased dental treatment under general anesthesia for children. Conclusions: Dental therapists are associated with more preventive care and fewer extractions. State-level policies should consider dental therapists as part of a comprehensive solution to meet the dental care needs of individuals in underserved communities and help achieve health equity and social justice.

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... In addition, cultural barriers between dental professionals and community members have decreased resulting in increased trust and access to care for community members. Dental Health Aide Therapists are an upstream approach and have diversified the dental workforce [6,8,13]. This has created opportunities for community members to serve as healers and removed cultural barriers to care [6,8,13]. ...
... Dental Health Aide Therapists are an upstream approach and have diversified the dental workforce [6,8,13]. This has created opportunities for community members to serve as healers and removed cultural barriers to care [6,8,13]. As well, increased DHAT treatment days were positively associated with child and adult preventative care and negatively associated with extractions for children and adults [6]. ...
... This has created opportunities for community members to serve as healers and removed cultural barriers to care [6,8,13]. As well, increased DHAT treatment days were positively associated with child and adult preventative care and negatively associated with extractions for children and adults [6]. After dental therapy implementation, providers from six Yukon Delta communities noticed improvements in oral health in the communities in which dental therapy provided care [7]. ...
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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.
... Additionally, in Alaska, having a DT in the community has been shown to be positively associated with receiving preventive dental care, for both children and adults; over 10 years, communities with a DT saw at least a twofold increase in children's receipt of preventive care. Having a DT has also been shown to be negatively associated with D-E-F-G extractions in children [20]. Ultimately, DTs in Alaska have expanded regular access to dental care to over 40,000 Alaska Native people [21]. ...
... This pattern of structural racism is underscored by longstanding racial inequities in oral health and drives home the positive impact DTs can have on underserved communities. The evidence is robust: DTs improve access to preventive care and health outcomes such as reducing the need for tooth extractions [20]; are highly trusted and respected; and are a regular source of care in communities that have historically lacked dental providers [25]. DTs additionally strengthen the oral health provider market and make clinics more profitable, while increasing their ability to see new patients and expand care for underserved communities. ...
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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.
... While these dynamics are shifting, all empirical evidence shows that DTs provide safe and competent care. 12,[50][51][52] Access to Care: Dental Therapy Impact on Oral Health Equity ...
... In Alaska, where DTs are deeply rooted in ties to Tribal communities, have strong institutional support and cohesion, and a local Tribal college's education capacity, it is not surprising that here we find the strongest body of evidence of access to safe and high-quality care and significant improvement in the health of Alaska Native populations. 44,45,50,[52][53][54][55][56][57] Alaska may also be the most studied program over time, from initial training, deployment through the health system, and impact on communities. The positive outcomes are most notable from an equity perspective because the Alaska Native population has been among the most disadvantaged with extremely high oral health disease burden (Table 1: Q3). ...
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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.
... This increase could be attributed to the expansion of the DHAT program which has been described in a previous study. 13 One concern is the low proportion of children <2 years who are getting comprehensive exams where opportunities exist to provide prevention counseling and care. 13 These missed opportunities may account for the finding that most of the caries in this 0-5 year age group occurred by age 3 years. ...
... 13 One concern is the low proportion of children <2 years who are getting comprehensive exams where opportunities exist to provide prevention counseling and care. 13 These missed opportunities may account for the finding that most of the caries in this 0-5 year age group occurred by age 3 years. ...
Article
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.
... However, a recent report from Alaska, summarized in a journal article, presents the first such oral health outcomes associated with dental therapy. 35,36 This villages and larger centers in Alaska. A number of evaluations have demonstrated the quality and effectiveness of their services. ...
Article
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.
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Background: The goal of the study was to identify secular trends in dental service delivery between dental therapists and dentists in the Yukon-Kuskokwim Delta region of Southwest Alaska, the first area of the United States to authorize dental therapy practice. Methods: Electronic health record transactions from the Yukon-Kuskokwim Health Corporation from 2006 through 2015 (n = 27,459) were analyzed. Five types of dental services were identified using Current Dental Terminology procedure codes: diagnostic, preventive, restorative, endodontic, and oral surgery. Main outcomes were percentages of services provided by dental therapists compared with dentists and population-level preventive oral health care. Results: The overall number of diagnostic, preventive, and restorative services in the Yukon-Kuskokwim Delta increased. For diagnostic services, there was a 3.5% annual decrease observed for dentists and a 4.1% annual increase for dental therapists (P < .001). Similar trends were observed for restorative services. For preventive services, there was no change for dentists (P = .89) and a 4.8% annual increase for dental therapists (P < .001). Dental therapists were more likely than dentists to provide preventive care at the population level. Conclusions: Dental therapists have made substantial contributions to the delivery of dental services in Alaska Native communities, particularly for population-based preventive care. Practical implications: The study's findings indicate that there is a role for dental therapy practice in addressing poor access to oral health care in underserved communities.
Article
Importance: Currently, 13 states and tribal nations have expanded their dental workforce by adopting use of dental therapists. To date, there has been no evaluation of the influence of this policy on dental care use. Objective: To assess changes in dental care use in Minnesota after the implementation of the policy to authorize dental therapists in 2009. Design setting and participants: In this cross-sectional study of 2 613 716 adults aged 18 years and older, a synthetic control method was used to compare changes in dental care use after the authorization of the policy in Minnesota relative to a synthetic control of nonadopting states. Data from the Behavioral Risk Factor Surveillance System from 2006 to 2018 were analyzed. Data analysis was conducted from June 1, 2021, to December 18, 2021. Exposure: Authorization of dental therapy. Main outcomes and measures: Self-reported indicator for whether a respondent had visited a dentist or a dental clinic in the past 12 months. Results: Among 2 613 716 adults aged 18 years or older, the mean (SD) age at baseline was 46.0 (17.7) years, 396 501 were women (weighted percentage, 51.3%), 503 197 were White (weighted percentage, 67.9%), 54 568 were Black (weighted percentage, 10.1%), 39 282 were Hispanic (weighted percentage, 14.5%), and 34 739 were other race (weighted percentage, 6.7%). The proportion of adults visiting a dentist before the authorization of dental therapists in Minnesota was 76.2% (95% CI, 75.0%-77.4%) in the full sample, 61.5% (95% CI, 58.4%-64.6%) for low-income adults, and 58.4% (95% CI, 53.0%-63.5%) among Medicaid-eligible adults. Authorizing dental therapists in Minnesota was associated with an increase of 7.3 percentage points (95% CI, 5.0-9.5 percentage points) in dental care use among low-income adults, a relative increase of 12.5% (95% CI, 8.6%-16.4%), and an increase of 6.2 percentage points (95% CI, 2.4-10.0 percentage points) among Medicaid-eligible adults, a relative increase of 10.5% (95% CI, 3.9%-17.0%). In addition, the policy was associated with an increase in dental visits among White adults (low-income sample, 10.8 percentage points [95% CI, 8.5-13.0 percentage points]; Medicaid sample, 13.5 percentage points [95% CI, 9.1-17.9 percentage points]), with no corresponding increases among other racial and ethnic groups in the low-income and Medicaid population. Conclusions and relevance: In this cross-sectional study, expanding the dental workforce through authorization of dental therapists appeared to be associated with an increase in dental visits. In Minnesota, the policy was associated with improved access to dental care among low-income adults overall. However, racial and ethnic disparities in dental use persist.
Article
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.
Article
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.
Article
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.
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Purpose of Review To review recent literature evaluating how current models of dental education are contributing to reducing oral health disparities in the USA. Recent innovations in dental schools’ curricula and admissions processes will be examined, as well as how oral health disparities have driven the education and subsequent expansion of the allied dental workforce. Recent Findings Dental school curricula and admissions changes have had minimal impact on reducing oral health disparities. Subsequently, educational innovations have resulted in the traditional duties of dentists being performed by dental therapists, advanced dental hygiene practitioners, and independent dental hygienists. Summary Public perception is that extended employment of allied dental professionals has resulted in improved access and delivery of dental care to underserved members of the population. Development of a diversified oral health workforce that provides team-based, inter-professional care will help decrease the oral health inequities that exist in the USA.
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This article seeks to chronicle how dental therapists are being used to bolster the supply of providers for the underserved and explore their potential to diversify the field of dentistry and improve public health. Of the factors that contribute to persistent oral health disparities in the United States, an insufficient oral health workforce figures prominently. A growing number of states are authorizing a midlevel dental provider (often called a dental therapist) to address this problem. Dental therapists work under the supervision of dentists to deliver routine preventive and restorative care, including preparing and filling cavities and performing extractions. They can serve all populations in 3 states, are caring for Native Americans in an additional 3 states under federal or state authority, and are being considered in about a dozen state houses.
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Objective: We conducted a cost-effectiveness analysis of five specific dental interventions to help guide resource allocation. Methods: We developed a spreadsheet-based tool, from the healthcare payer perspective, to evaluate the cost effectiveness of specific dental interventions that are currently used among Alaska Native children (6-60 months). Interventions included: water fluoridation, dental sealants, fluoride varnish, tooth brushing with fluoride toothpaste, and conducting initial dental exams on children <18 months of age. We calculated the cost-effectiveness ratio of implementing the proposed interventions to reduce the number of carious teeth and full mouth dental reconstructions (FMDRs) over 10 years. Results: A total of 322 children received caries treatments completed by a dental provider in the dental chair, while 161 children received FMDRs completed by a dental surgeon in an operating room. The average cost of treating dental caries in the dental chair was $1,467 (∼258,000 per year); while the cost of treating FMDRs was $9,349 (∼1.5 million per year). All interventions were shown to prevent caries and FMDRs; however tooth brushing prevented the greatest number of caries at minimum and maximum effectiveness with 1,433 and 1,910, respectively. Tooth brushing also prevented the greatest number of FMDRs (159 and 211) at minimum and maximum effectiveness. Conclusions: All of the dental interventions evaluated were shown to produce cost savings. However, the level of that cost saving is dependent on the intervention chosen.
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Background: Dental caries (tooth decay) is a significant public health problem in Alaska Native children. Dietary added sugars are considered one of the main risk factors. In this cross-sectional pilot study, we used a validated hair-based biomarker to measure added sugar intake in Alaska Native Yup'ik children ages 6-17 years (N = 51). We hypothesized that added sugar intake would be positively associated with tooth decay. Methods: A 66-item parent survey was administered, a hair sample was collected from each child, and a dental exam was conducted. Added sugar intake (grams/day) was measured from hair samples using a linear combination of carbon and nitrogen ratios. We used linear and log-linear regression models with robust standard errors to test our hypothesis that children with higher added sugar intake would have a higher proportion of carious tooth surfaces. Results: The mean proportion of carious tooth surfaces was 30.8 % (standard deviation: 23.2 %). Hair biomarker-based added sugar intake was associated with absolute (6.4 %; 95 % CI: 1.2 %, 11.6 %; P = .02) and relative increases in the proportion of carious tooth surfaces (24.2 %; 95 % CI: 10.6 %, 39.4 %; P < .01). There were no associations between self-reported measures of sugar-sweetened food and beverage intake and tooth decay. Conclusions: Added sugar intake as assessed by hair biomarker was significantly and positively associated with tooth decay in our sample of Yup'ik children. Self-reported dietary measures were not associated tooth decay. Most added sugars were from sugar-sweetened fruit drinks consumed at home. Future dietary interventions aimed at improving the oral health of Alaska Native children should consider use of objective biomarkers to assess and measure changes in home-based added sugar intake, particularly sugar-sweetened fruit drinks.
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The oral health of Indigenous children of Canada (First Nations, Inuit, and Metis) and the United States (American Indian, Alaska Native) is a major child health issue: there is a high prevalence of early childhood caries (ECC) and resulting adverse health effects in this community, as well as high rates and costs of restorative and surgical treatments under general anesthesia. ECC is an infectious disease that is influenced by multiple factors, including socioeconomic determinants, and requires a combination of approaches for improvement. This statement includes recommendations for preventive oral health and clinical care for young infants and pregnant women by primary health care providers, community-based health-promotion initiatives, oral health workforce and access issues, and advocacy for community water fluoridation and fluoride-varnish program access. Further community-based research on the epidemiology, prevention, management, and microbiology of ECC in Indigenous communities would be beneficial. Pediatrics 2011;127:1190-1198
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Alaska Native populations are experiencing a nutrition transition and a resulting decrease in diet quality. The present study aimed to develop a quantitative food frequency questionnaire to assess the diet of the Yup'ik people of Western Alaska. A cross-sectional survey was conducted using 24-hour recalls and the information collected served as a basis for developing a quantitative food frequency questionnaire. A total of 177 males and females, aged 13-88, in six western Alaska communities, completed up to three 24-hour recalls as part of the Alaska Native Dietary and Subsistence Food Assessment Project. The frequency of the foods reported in the 24-hour recalls was tabulated and used to create a draft quantitative food frequency questionnaire, which was pilot tested and finalized with input from community members. Store-bought foods high in fat and sugar were reported more frequently than traditional foods. Seven of the top 26 foods most frequently reported were traditional foods. A 150-item quantitative food frequency questionnaire was developed that included 14 breads and crackers; 3 cereals; 11 dairy products; 69 meats, poultry and fish; 13 fruit; 22 vegetables; 9 desserts and snacks; and 9 beverages. The quantitative food frequency questionnaire contains 39 traditional food items. This quantitative food frequency questionnaire can be used to assess the unique diet of the Alaska Native people of Western Alaska. This tool will allow for monitoring of dietary changes over time as well as the identification of foods and nutrients that could be promoted in a nutrition intervention program intended to reduce chronic disease.
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Tooth decay is the most common paediatric disease and there is a serious paediatric tooth decay epidemic in Alaska Native communities. When untreated, tooth decay can lead to pain, infection, systemic health problems, hospitalisations and in rare cases death, as well as school absenteeism, poor grades and low quality-of-life. The extent to which population-based oral health interventions have been conducted in Alaska Native paediatric populations is unknown. To conduct a systematic review of oral health interventions aimed at Alaska Native children below age 18 and to present a case study and conceptual model on multilevel intervention strategies aimed at reducing sugar-sweetened beverage (SSB) intake among Alaska Native children. Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, the terms "Alaska Native", "children" and "oral health" were used to search Medline, Embase, Web of Science, GoogleScholar and health foundation websites (1970-2012) for relevant clinical trials and evaluation studies. Eighty-five studies were found in Medline, Embase and Web of Science databases and there were 663 hits in GoogleScholar. A total of 9 publications were included in the qualitative review. These publications describe 3 interventions that focused on: reducing paediatric tooth decay by educating families and communities; providing dental chemotherapeutics to pregnant women; and training mid-level dental care providers. While these approaches have the potential to improve the oral health of Alaska Native children, there are unique challenges regarding intervention acceptability, reach and sustainability. A case study and conceptual model are presented on multilevel strategies to reduce SSB intake among Alaska Native children. Few oral health interventions have been tested within Alaska Native communities. Community-centred multilevel interventions are promising approaches to improve the oral and systemic health of Alaska Native children. Future investigators should evaluate the feasibility of implementing multilevel interventions and policies within Alaska Native communities as a way to reduce children's health disparities.
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We examined school days missed for routine dental care versus dental pain or infection to determine the relationship between children's oral health status and school attendance and performance. We used 2008 data from the North Carolina Child Health Assessment and Monitoring Program. The study sample, weighted to reflect the state's population, included 2183 schoolchildren. Variables assessed included school absences and performance, oral health status, parental education, health insurance coverage, race, and gender. Children with poor oral health status were nearly 3 times more likely (odds ratio = 3.89; 95% confidence interval = 1.96, 7.75) than were their counterparts to miss school as a result of dental pain. Absences caused by pain were associated with poorer school performance (P < .05), but absences for routine care were not. Mediation analyses revealed that oral health status was associated with performance independent of absence for pain. Children with poorer oral health status were more likely to experience dental pain, miss school, and perform poorly in school. These findings suggest that improving children's oral health status may be a vehicle to enhancing their educational experience.
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Clinicians and staff in health care organizations experience stress and burnout due to both job conditions and unique pressures of the medical field. Stress and burnout have consequences not only for the health and wellness of employees but for patients through poor quality care. Health care organizations and systems are affected when it causes decreased productivity and even attrition. In safety net health centers, the loss of clinicians and staff and decreased productivity further strain an already resource-poor system, creating a vicious cycle as more demands are placed on those who remain. Acutely aware of this phenomenon, the Association of Clinicians for the Underserved (ACU) sought to better understand stress and burnout experienced by its members in hopes of developing strategies and interventions to break this cycle. This column describes the initial findings from a survey conducted to assess stress and burnout among ACU members. Health care professionals commonly experience stress at their work site; contributory factors include heavy workload, understaffing, high intensity of work, job insecurity,1 and risk of injury or harm.2 Poor communication skills, especially among superiors, and unpleasant physical environments can also contribute to stress.3 Stress commonly arises in a variety of professions, including social work, occupational therapy, nursing, and medicine.4 Research on nurses has found sleep deprivation, ambiguity in work roles, and time pressures to be linked to stress, while studies of physicians found links to unmet patient expectations, threats of litigation, interpersonal conflicts, and coping with the death of patients.2 Safety net health centers, like other health care delivery settings, can cause stress for their clinicians and staff. Due to limited organizational and systems resources, safety net providers face additional challenges such as severely inadequate patient care space and lack of essential supplies. Outside their own facilities, safety net providers lack systems resources such as specialists willing to see uninsured or underinsured patients. The recent economic downturn has caused a rise in uninsured patients seen by safety net clinics and further stretches their resources.5 Low literacy, poverty, and other socioeconomic challenges faced by patients also increase the workload for providers in such settings. Despite the general lack of resources, safety net health centers and their staffs possess characteristics that make them resilient to some of the stressors. For example, safety net providers share a common mission to serve medically vulnerable communities and come into the setting with a systems perspective and are well-aware of potential challenges. Safety net health centers also self-select individuals with personal characteristics and skills suited to working with poor and underserved populations. For example, many have taken initiative to develop cultural competency skills as well as language skills specific to community needs. Nevertheless, stress may lead to a wide range of effects for both workers and organizations. Negative health outcomes of stress include anxiety, depression, immune deficiencies, and cardiovascular problems.6 Stress has also been associated with occupational burnout, characterized by increased feelings of exhaustion, cynicism and inefficacy.7 Stress may directly and indirectly affect critical organizational measures such as job performance, absenteeism, errors in treatment, patient satisfaction, and turnover.4 Factors such as absenteeism and intentions of workers to quit all have an impact on the overall success of an organization, as the cost of recruiting and training adds additional financial burdens. The negative consequences of stress and burnout place delicate health care systems for the poor and underserved at particular risk. In an effort to take the initial steps in developing a program to combat the problem, this study aimed to assess the degree of stress and burnout experienced by those who work in safety net settings as well as the characteristics of their practice environment. ACU conducted an anonymous online survey of current members. Questions focused on perceptions, degree, and impact of stress, burnout, and workplace wellness. The survey also collected information about characteristics of staff, organizations, and any existing workplace wellness programs. Staff members of ACU constructed the survey in cooperation with a public health student and faculty members at a school of public health. Recruitment consisted of e-mail messages to current ACU members, announcement on the ACU website, and announcement in the member newsletter...
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Early childhood caries (ECC) is the most common disease of childhood and often is accompanied by serious comorbidities affecting children, their families, the community and the health care system. This report describes morbidity and mortality associated with ECC and its treatment. The authors reviewed the literature for descriptions and quantification of morbidity associated with ECC and organized a wide range of studies into a visual model--the morbidity and mortality pyramid--that begins to convey the breadth and depth of ECC's penetration. ECC exacts a toll on children, affecting their development, school performance and behavior, and on families and society as well. In extreme cases, ECC and its treatment can lead to serious disability and even death. In finding access to care and managing chronic pain and its consequences, families experience stress and, thus, a diminished quality of life. Communities devote resources to prevention and management of the condition. The health care system is confronted with management of the extreme consequences of ECC in hospital emergency departments and operating rooms. Traditional epidemiologic measures such as the decayed-missing-filled teeth (dmft) index do not adequately portray the effects of ECC on children, families, society and the health care system. The impact of prevention and management of ECC requires the attention of health care professionals and decision makers and extends well beyond the dental office to regulatory and child advocacy agencies as well as public health officials and legislators.
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Despite marked improvements over the past century, oral health in America is a significant problem: caries is the most common chronic disease of childhood. Much oral health research examines influences primarily in the oral cavity or focuses on a limited number of individual-level factors. The purpose of this article was to present a more encompassing conceptual model of the influences on children's oral health. The conceptual model presented here was derived from the population health and social epidemiology fields, which have moved toward multilevel, holistic approaches to analyze the complex and interactive causes of children's health problems. It is based on a comprehensive review of major population and oral health literatures. A multilevel conceptual model is described, with the individual, family, and community levels of influence on oral health outcomes. This model incorporates the 5 key domains of determinants of health as identified in the population health literature: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care. The model recognizes the presence of a complex interplay of causal factors. Last, the model incorporates the aspect of time, recognizing the evolution of oral health diseases (eg, caries) and influences on the child-host over time. This conceptual model represents a starting point for thinking about children's oral health. The model incorporates many of the important breakthroughs by social epidemiologists over the past 25 years by including a broad range of genetic, social, and environmental risk factors; multiple pathways by which they operate; a time dimension; the notion of differential susceptibility and resilience; and a multilevel approach. The study of children's oral health from a global perspective remains largely in its infancy and is poised for additional development. This work can help inform how best to approach and improve children's oral health.
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In 1921, New Zealand began training school dental nurses, subsequently deploying them throughout the country in school-based clinics providing basic dental care for children. The concept of training dental nurses, later to be designated dental therapists, was adopted by other countries as a means of improving access to care, particularly for children. This paper profiles six countries that utilise dental therapists, with a description of the training that therapists receive in these countries, and the context in which they practice. Based on available demographic information, it also updates the number of dental therapists practising globally, as well as the countries in which they practice. In several countries, dental therapy is now being integrated with dental hygiene in training and practice to create a new type of professional complementary to a dentist. Increasingly, dental therapists are permitted to treat adults as well as children. The paper also describes the status of a current initiative to introduce dental therapy to the United States. It concludes by suggesting that dental therapists can become valued members of the dental team throughout the world, helping to improve access to care and reducing existing disparities in oral health.
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Unlabelled: American Indians and Alaska Natives (AI/AN) experience significant health disparities relative to the general U.S. Population: In particular, oral diseases affect the majority of the AI/AN population and their prevalence is significantly greater than observed in other demographic sectors of the U.S. Population: The reasons for these disparities are multiple but lack of access to dental care is clearly a contributing factor. The dentist-to-population ratio in many AI/AN communities is less than half the U.S. average. A solution has been developed in Alaska by AI/AN leaders: dental therapists, i.e., local people trained for two years to provide basic dental services. This solution is being fought by organized dentistry that sees the approach as an economic threat, but AI/AN organizations are committed to implementing this Native solution to their access problem. The Alaska experience indicates that access to oral health services can be improved through the addition of dental therapists to the dental team.
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The purpose of this study was to evaluate county-level pediatric dentist density and dental care utilization for Medicaid-enrolled children. This was a cross-sectional analysis of 604,885 zero- to 17-year-olds enrolled in the Washington State Medicaid Program for 11-12 months in 2012. The relationship between county-level pediatric dentist density, defined as the number of pediatric dentists per 10,000 Medicaid-enrolled children, and preventive dental care utilization was evaluated using linear regression models. In 2012, 179 pediatric dentists practiced in 16 of the 39 counties in Washington. County-level pediatric dentist density varied from zero to 5.98 pediatric dentists per 10,000 Medicaid-enrolled children. County-level preventive dental care utilization ranged from 32 percent to 81 percent, with 62 percent of Medicaid-enrolled children utilizing preventive dental services. County-level density was significantly associated with county-level dental care utilization (Slope equals 1.67, 95 percent confidence interval equals 0.02, 3.32, P<.05). There is a significant relationship between pediatric dentist density and the proportion of Medicaid-enrolled children who utilize preventive dental care services. Policies aimed at improving pediatric oral health disparities should include strategies to increase the number of oral health care providers, including pediatric dentists, in geographic areas with large proportions of Medicaid-enrolled children.
Chapter
Correlated datasets develop when multiple observations are collected from a sampling unit (e.g., repeated measures of a bank over time, or hormone levels in a breast cancer patient over time), or from clustered data where observations are grouped based on a shared characteristic (e.g., observations on different banks grouped by zip code, or on cancer patients from a specific clinic). The generalized linear model framework for independent data is extended to model correlated data via the introduction of second-order variance components directly into the independent data model's estimating equation. This generalization of the estimating equation from the independence model is thus referred to as a Generalized Estimating Equation (GEE). This article discusses the foundation of GEEs as well as how user-specified correlation structures are accommodated in the model-building process. This article also discusses the relationship and similarity to the underlying generalized linear model framework and we point out alternative approaches to GEEs for modeling correlated data such as fixed-effects models and random-effects models. Keywords: working correlation matrix; sandwich estimate of variance; generalized linear models; subject-specific models; population-averaged models
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The Alaska Native people in rural Alaska face serious challenges in obtaining dental care. Itinerant care models have failed to meet their needs for more than 50 years. The dental health aide therapist (DHAT) model, which entails training midlevel care providers to perform limited restorative, surgical, and preventive procedures, was adopted to address some of the limitations of the itinerant model. We used quantitative and qualitative methods to assess residents’ satisfaction with the model and the role of DHATs in the cultural context in which they operate. Our findings suggest that the DHAT model can provide much-needed access to urgent care and is beneficial from a comprehensive cultural perspective.
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The Alaska Dental Health Aide Therapist program has matured to the point that therapists have been in practice for up to four years. A case-study evaluation of the program included assessments of the clinical technical performance of five of these therapists practicing in clinics in small Alaskan villages and towns. The results indicate that therapists are performing at an acceptable level, with short-term restorative outcomes comparable with those of dentists treating the same populations. Therapists' performance when operating within their scope of practice suggested no reason for continued close scrutiny. Further evaluations of therapists should shift their principal focus from clinical technical performance of therapists to effectiveness of the therapist program in improving the targeted population's oral health. Therapists are capable of providing acceptable restorative treatment under indirect supervision.
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This paper examines the effect of oral health on labor market outcomes by exploiting variation in fluoridated water exposure during childhood. The politics surrounding the adoption of water fluoridation by local governments suggests exposure to fluoride is exogenous to other factors affecting earnings. Exposure to fluoridated water increases women’s earnings by approximately 4 percent, but has no detectable effect for men. Furthermore, the effect is largely concentrated amongst women from families of low socioeconomic status. We find little evidence to support occupational sorting, statistical discrimination, and productivity as potential channels, with some evidence supporting consumer and possibly employer discrimination.
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Dental health aide therapists (DHATs) in Alaska are authorized under federal law to provide certain dental services, including irreversible dental procedures. The author conducted this pilot study to determine if treatments provided by DHATs differ significantly from those provided by dentists, to determine if DHATs in Alaska are delivering dental care within their scope of training in an acceptable manner and to assess the quality of care and incidence of reportable events during or after dental treatment. The author audited the dental records of patients treated by dentists and DHATs who perform similar procedures for selected variables. He reviewed the records of 640 dental procedures performed in 406 patients in three health corporations. The author found no significant differences among the provider groups in the consistency of diagnosis and treatment or postoperative complications as a result of primary treatment. The patients treated by DHATs had a mean age 7.1 years younger than that of patients treated by dentists, and the presence or adequacy of radiographs was higher among patients treated by dentists than among those treated by DHATs, with the difference being concentrated in the zero- to 6-year age group. No significant evidence was found to indicate that irreversible dental treatment provided by DHATs differs from similar treatment provided by dentists. Further studies need to be conducted to determine possible long-term effects of irreversible procedures performed by nondentists. A need to improve oral health care for American Indian/Alaska Native populations has led to an approach for providing care to these groups in Alaska. The use of adequately trained DHATs as part of the dental team could be a viable long-term solution.
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We sought to determine the prevalence of caries and associated risk factors in young Native children and their caregivers in two communities in rural Alaska. A random sample of Alaska Native children between 12-36 months and a subset of their caregivers from two Southwestern Alaska communities were examined for dental decay. Caregivers completed a 43-item questionnaire about oral hygiene, dietary and other practices. Of the 65 children examined, 59% had evidence of decay. Among the 41 primary caregivers examined, 98% had experienced dental decay with an average of 11.4 decayed, missing, and filled teeth. On linear regression analyses, factors significantly associated with more decay in the children included a child taking a juice-containing bottle to bed, eating candy 1 or more times per day, and higher caregiver oral S. mutans counts. Our results suggest that preventive efforts for children at high risk for dental decay should begin early in life, should emphasize decreasing candy and bedtime juice bottle use, and should consider the caregivers' oral health status in addition to the child's.
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The purpose of this investigation was a retrospective analysis of a select group of graduates from the University of Kentucky College of Dentistry (UKCD) over a thirty-year history to determine how many of these individuals came from the Appalachian Region of Eastern Kentucky, which historically has been economically depressed and underserved by health care practitioners including dentists. This same group of dental school graduates was then tracked to see if they established dental practices in the Appalachian region of the state. Recruiting trends were investigated by reviewing student records regarding county of origin from targeted classes at UKCD in 1969, 1979, and 1989 to gain ten-year incremental, historical perspectives. To identify more recent trends, classes graduating in 1994 through 1999 were reviewed. Once identified, the databank of the Kentucky Board of Dentistry was used to determine if these individuals reported practicing in counties of Kentucky designated by the Appalachian Regional Commission (ARC). The findings of this study indicate an alarming decline both in numbers of students being recruited from this underserved area and a concomitant decline in those recruits returning to ARC-designated counties in the state. This study establishes the need for persistent diligence in recruitment of students from underserved areas and challenges dental schools to create strategies that will encourage their graduates to establish practices in these regions.
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Recruitment and retention of dentists in the public sector and rural areas in Victoria has become increasingly difficult in recent years. There are little available data on the factors that influence the sector and location of practice of new dental graduates. The objective of this study was to investigate the factors considered by new graduates in determining the location and sector of employment after graduation, and influencing any early changes in career path. Questionnaires were sent to dentists who Mgraduated from The Univrersity of Melbourne from graduated from The University of Melbourne from 2000-2003 who were currently practising in Victoria. There were 154 subjects to whom questionnaires were sent and 109 useable questionnaires were returned, a response rate of 74 per cent. Upon graduation, 53 per cent of the new graduates chose to work in the private sector only, compared to 15 per cent in public sector only and 33 per cent in both. At present, 71 per cent work in the private sector only, 17 per cent in the public sector only and 12 per cent in both. The most important factors for choosing to work in the private sector were receiving broad range of clinical experience, opportunities to familiarize with practice management and providing a continuity of care. The principal factors for practising in the public sector were clinical mentoring and advice, consolidating clinical skills and work environment. Initially, 48 per cent of the sample chose to work in metropolitan areas only, 39 per cent in rural areas only and 13 per cent in both. Factors that influenced the decision to work in rural areas were the broad range of clinical experience and remuneration, while the main factors for choosing to work in metropolitan areas were lifestyle and proximity to family and friends. This study found that a large proportion of new dental graduates initially chose to work in the public sector and rural areas on graduation primarily as a means of consolidating their clinical skills. However, retention of dentists in both these areas appears to be a problem, with less than 10 per cent of 2000-2001 graduates still than 10 per cent of 2000-2001 graduates still working in the public sector and only 20 per cent of 2000-2001 graduates still working in rural areas.
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Former Surgeon General David Satcher's report, Oral Health in America, documents the higher burden of oral diseases and conditions borne by those with relatively low social standing at each stage of life. When an entire community suffers from a health concern, that concern becomes a social justice issue. Racial and ethnic minorities, prisoners, and seniors suffer disproportionately from oral diseases and conditions due to societal prejudices that place them at risk over and above any risk associated with their economic means. Community-based delivery models that involve the community in planning and implementation, build upon the existing health safety net to link oral health services with primary care, and change public or institutional policy to support the financing and delivery of oral health care have proven successful. Here we champion the need for a national health plan that includes oral health care to promote social justice and oral health for all.
Early childhood caries in indigenous communities
  • American Academy of Pediatrics, Committee on Native American Child Health, Canadian Paediatric Society, First Nations, Inuit and Métis Committee
Impact of poor oral health on children's school attendance and performance
  • Jackson SL
  • Vann WF Jr
  • Kotch JB
  • Pahel BT
  • Lee JY