MARY CLARE JALONICK Associated Press writer | Posted: Sunday, November 20, 2005 12:00 am
WASHINGTON - For Wynita Lee, an Inupiaq Eskimo in the small village of Shungnak, Alaska, a trip to the dentist for her children and grandchildren was anything but easy. Getting a cavity filled or a routine cleaning meant a 150-mile trip by airplane, at a cost of more than $200, to the nearest village with a dentist.
That was before Stephanie Woods came to town.
Woods, a 35 year-old from East Texas, married a man from Shungnak and decided to settle in the village of about 300 in northwestern Alaska. She now oversees dental care for Alaska Natives there, with an emphasis on small children who are just learning to brush their teeth. She fills cavities, pulls teeth and does other routine procedures.
There's just one catch: Woods is not a licensed dentist. She's a dental health aide therapist trained in New Zealand, and her job is causing some controversy in Washington, D.C.
Some members of Congress, joined by the American Dental Association, contend Woods and other dental therapists don't have the experience to do the work they are doing and could cause permanent harm to their patients. Other members of Congress from the lower 48 states say they see the benefits of bringing dental therapists to some rural areas, but don't want to see the practice come to their back yards.
As lawmakers struggle to improve Indian health care, which congressional investigators say is lacking all over the country, dental care has emerged as a sticking point in the debate over whether medical training is sacrificed for increased access.
Tom Coburn, a doctor and Republican senator from Oklahoma, argues it should not be. He said the Alaska program is a sign the United States is not taking good enough care of its citizens.
Coburn offered a provision to Indian health care legislation last month that would have banned dental therapists like Woods from doing procedures that could cause "irreversible damage." That would include fillings, extractions and childhood pulpotomies, which are similar to root canals.
Coburn said the dental therapists set a bad precedent. If the country approves unlicensed dental care for American Indians, he asked, what is to stop lawmakers from extending that type of practice to Medicare or Medicaid recipients?
"It starts us down a course to give lesser care to those who are dependent on us," he said.
The American Dental Association agrees. Dr. Robert Brandjord, the association's president and a dentist from Minnesota, said dental therapists are useful but should avoid complicated procedures and focus solely on prevention. Worst-case scenarios, he said, include broken jaws and serious infections.
The ADA contends that many patients have medical conditions, such as diabetes or heart problems, that add to the complexity of dental treatment. Because dental therapists are only trained in the procedures they are allowed to do, they may not be able to handle a simple situation that becomes complicated.
"The ability to diagnose things is the key to it," Brandjord said. "The background to do that comes with greater ability and experience."
Despite aggressive ADA lobbying on the issue, Coburn's amendment was defeated by the Senate Indian Affairs Committee. Many senators appeared conflicted.
"I'm torn," said South Dakota Democrat Tim Johnson. He said he feared Coburn's amendment would have the effect of eliminating dental care for many Alaskans. He said he was concerned, however, about the program's short-term effects.
"There's a danger in having two levels of care, particularly as we seek to improve our rural health network," said Wyoming Republican Craig Thomas, another committee member.
Thomas said there is not a "glaring need" for dental therapists in the rest of the country.
Along with committee Chairman John McCain, R-Ariz., and other senators, Johnson and Thomas supported striking a provision in the bill that would have eventually allowed dental therapists in the lower 48 states.
Alaska Republican Lisa Murkowski strongly defended the practice, describing the state's serious need for more dental care. According to the Alaska Native Tribal Health Consortium, the rate of tooth decay among Alaska Natives - who often live in towns like Shungnak, which are not accessible by road - is 2.5 times the national rate.
This claim was backed by congressional investigators, who said in a report issued earlier this year that many Alaska Natives and American Indians do not have adequate access to specialty dental care. The problem is of particular concern in rural Western states, where reservations often are many miles from the nearest dentist.
It is too soon to draw any conclusions about Alaska's solution to the problem, which is just getting under way. There are only four practicing dental health aides in Alaska, including Woods.
Though Alaska tribal governments have had the legal authority to employ dental health therapists for several decades, tribal leaders first confronted the problem about five years ago and sent several dental aides to New Zealand for two years of training. Alaska's attorney general signed off on the practice earlier this year.
Myra Munson, an attorney for the Alaska Native Tribal Health Consortium, said the ADA has exaggerated the risks associated with the program.
"It is easy for people who have gone through a lot of education to say that only people that have had a similar level of education could do what they do," she said.
Ron Nagel, a dentist and manager of the dental health aide program for the consortium, said the therapists' training - usually done in New Zealand, where dental therapists have worked in remote areas for decades - is actually more rigorous than many American dental schools.
He said he knows of no permanent damage from dental therapists working around the world and calls the ADA campaign a "turf war."
The consortium is advertising a study conducted by Louis Fiset, a professor at the University of Washington School of Dentistry. Fiset visited three rural dental clinics in Alaska and concluded the dental therapists met his set standards of care "in every respect."
At Woods' clinic in Shungnak, he said young patients "appeared eager to receive dental care."
Woods said she has many long-term responsibilities, including working with the small town to get the water fluoridated. She argues that her permanent presence is more useful than volunteer dentists visiting from the lower 48, a solution suggested by the ADA.
She believes lawmakers would see the benefits of the program if they visited the clinic.
"They have no idea what we are up against out here," she said. "It's overwhelming. Every single patient I have is either high risk or very high risk, especially the children."
She said she has had no close calls in her three months working there.
"We are so prudent in what we do," she said. "Of course we know we are under a microscope. We don't take any risks."
Lee says her children know how to take care of their teeth now that they have regular visits with Woods.
"They know what to do and what not to drink, mostly the pop," she says. "Having her here is a big change."