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'Confronting Dental Decay In Indian Country' Part III

Mark Arehart
Denture molds at the Swinomish Dental Clinic. Many older members of the tribe have been fitted for artificial teeth because of years of poor dental care.

The rate of tooth decay among Native Americans is higher than any other population. While the dental community agrees it’s a major health crisis, they can’t reach consensus on how to solve the problem.

To address the issue locally, Swinomish tribal leaders in the Skagit Valley hired a dental health aide therapist. Now more members have access to care and the tribe’s youngest are learning good dental habits.

But some dentists’ organizations on the state and national level are calling it the wrong move. In the final part of our series, “Confronting Dental Decay in Indian Country,” we take a deeper look at the controversy.

One of the biggest concerns that comes up when you talk to dentists, like Dr. KalKlass, about dental therapists is safety. Klass says his more than 30 years experience in both the public health and private sectors means he can diagnose problems quickly and handle emergencies confidently. And to illustrate his point, he described a very common issue many dentists have experienced during a so-called “simple extraction.”

“We’ll go to remove a tooth — It’s a fairly loose tooth; on the x-rays it looks very simple,” Klass said. “It may only take five minutes to do the procedure.”

But he says there are many unexpected things that can happen during a seemingly routine procedure.

“We hear a little break, or a crack, and that is because the tooth is broken, or the bone is broken around it. And within about a minute, that turns into the some complex oral surgery,” he said.

Klass says that type of surgery exposes the bone and requires more anesthetic.

“Now we’re going to need to deal with prescriptions, too; prescriptions of antibiotics and pain medication,” he said.

Klass says his eight years of medical training coupled with his decades of experience means he can finish that complex extraction, safely, in one sitting. But for a dental therapist, who trains for just two years, Klass says they’d be out of their depth by the time they heard the tooth crack.

Credit Ariel Van Cleave / KPLU
The patients' view from the dentist chair at the Swinomish Dental Clinic

“If I’m a patient, and I know there’s a dentist and I know there’s a dental health aide therapist, and I need an extraction or a filling done, would I rather have the dentist do it or a dental health aide therapist do it? And I think I’d rather have the dentist do it,” Klass said.

A Distraction

And it’s not just about safety. Others in the dental community, like Kevin Earle, say offering more treatment isn’t enough. The focus should be on changing behavior and preventing more extractions or fillings. Earle is the executive director of the Arizona Dental Association and has been working with the Navajo Nation to improve oral health care for its members.

“The decay rates among our tribal community here are the highest in the country,” he said.

Earle says you can’t treat your way out of that problem by using dental therapists. So Earle’s organization partnered with the American Dental Association to train what are called Community Dental Health Coordinators.

“This is someone who is drawn from the community that is culturally competent, that knows the language and knows the culture,” said Earle

He says the coordinators share advice and explain how the Indian Health Service delivery system works. They also help navigate the system because Earle says accessing services, like dental care, isn’t always simple.

“There are some IHS service units where you have to make an appointment to make an appointment,” Earle said. “That’s insane.”

Earle says creating dental therapist positions outside of the Indian Health Service system is a distraction. And it’s in the best interest of tribes to improve how the IHS functions.

“And that’s not to say that we haven’t seen the dental health aide therapists operated effectively,” Earle said. “It’s not the be all and the end all answer to the problem.”

'We Are A Sovereign Nation'

“I’ve heard all the arguments on why this should not be allowed,” Swinomish Tribal Chairman Brian Cladoosby said. He’s been instrumental in bringing a dental therapist to the Skagit Valley Reservation. Cladoosby says the first time he heard about dental therapists was at a gathering with other tribal leaders from around the country.

“Right away, I was a believer in this program. I was hook, line and sinker immediately,” he said. “I knew that this was a program we needed to have at Swinomish. I did not fully understand the hoops that we needed to jump through.”

There was one big hoop in particular: a line in the Indian Health Care Improvement Act that effectively banned dental therapists from practicing in lower 48 tribes.

The Swinomish need the state’s blessing before the community is allowed to use Indian Health Service funds to pay the dental therapist’s salary. The measure that would free up that money has failed in the statehouse the last six years. Cladoosby says it’s because of the American Dental Association.

“After a hearing last year in Olympia, we’re able to finally have a conversation with them basically saying, ‘Why don’t you care about our kids?’ And they said, ‘We do.’ And I said, ‘Well, what’s your solution?’” recalled Cladoosby.

The ADA officials told him, “Just hire more dentists.”

“If it was that easy, we would,” he said.

The tribe has tried to bring in more full-time dentists, but he says they won’t stay long-term. Chairman Cladoosby says he had no choice but to hire a dental therapist to help his people. And he’s not convinced there are serious safety or quality of care issues. He points to a recent study by the Kellogg Foundation that shows no real difference in the quality of the 46 procedures a dental therapist delivers when compared to a dentist. Plus, there have been no reported cases of malpractice in Alaska since its program was started a decade ago.

“We are a sovereign nation,” Cladoosby said. “We have a serious issue and we are doing something about it.”

But is it the “right” something? Dr. KalKlass says no.

“I think there’s a place for a dental health aide therapist. But not for doing what they’re doing,” he said.

And that’s the problem right there: the fundamental disagreement about how to move forward in providing care for people in Indian Country.

Should there be more practitioners? Or should the system that’s already in place be fixed and used more effectively? Who should have a say in which solution comes first?

Cladoosby says he can’t wait for the answer. He won’t. And his people shouldn’t have to either. So, in the meantime, the clinic will continue providing care to patients. Only now, the staff will be watched closely by dentists, lawmakers and tribes from all across the country.


Ariel first entered a public radio newsroom in 2004 while in school at Bradley University in Peoria, Illinois. It was love at first sight. After graduating from Bradley, she went on to earn a Master's degree in Public Affairs Reporting from the University of Illinois at Springfield. Ariel has lived in Indiana, Ohio and Alaska reporting on everything from salmon spawning to policy issues concerning education. She's been a host, a manager and now rides shotgun with Kirsten Kendrick as the Morning Edition producer at KNKX.