During a game of Red Rover when she was 16 years old, Rochelle "Roz" Siuvuq Ferry lost a front tooth.
Ferry, who is Inupiaq, remembers having to get on a plane to get from her remote Alaskan village to the city of Nome to start the tooth replacement process.
Traveling to Nome for dental care is what everyone in her community had to do -- even for a toothache or a basic cleaning. There was no such service where they lived.
Ferry knew many members of her community whose teeth decayed so badly, they needed extraction -- simply because they didn't have access to care.
Her tooth mishap 28 years ago and her awareness of neighbors' struggles led Ferry to become a dental therapist.
Dental therapists are licensed to fill cavities, place temporary crowns, extract diseased teeth, and provide other basic preventive dental care, working under a dentist's supervision. They have more training than a hygienist but not the advanced degree of a dentist.
More than a dozen states have authorized the licensing and practice of dental therapists, and the occupation is growing. Critics of dental therapy say state and federal policy should instead focus on supporting dentists. But many experts say dental therapists can help provide better access to oral health care for underserved communities -- including in rural areas and for adults and children who lack insurance coverage or who are on public insurance.
About 58 million Americans live in areas with dentist shortages, according to the U.S. Health Resources and Services Administration. And the ADA estimates just a third of dentists across the nation accept Medicaid. More than half of Medicaid enrollees are Black, Hispanic, American Indian or Alaska Native, and children of color experience significant disparities in oral health.
Poor oral health and gum disease are associated with more serious conditions such as heart disease and diabetes. And research has shown visibly poor oral health can hurt employment opportunities and a person's well-being.
"It was a real kick to my self-esteem. I was knocked down," Ferry said, recalling losing her front tooth as a teen. "I realized that there's a huge correlation between your self-esteem and your socioeconomic status, based on your smile."
Dozens of other countries have had dental therapists since the 1920s. But there weren't any in the U.S. until about two decades ago, when Alaska Native students returned from training in New Zealand, ready to provide care to their remote tribal communities. Ferry was part of that group.
Ferry said she had been the first full-time dental provider in her grandmother's tight-knit Alaska village, St. Michael.
Welcoming dental therapy
Today, dental therapists are authorized in at least some settings in 14 states: Alaska, Arizona, Colorado, Connecticut, Idaho, Maine, Michigan, Minnesota, Nevada, New Mexico, Oregon, Vermont, Washington and, most recently, Wisconsin, according to the National Partnership for Dental Therapy, a group of organizations focused on dental therapy awareness and education that tracks related state policies.
Ferry was the first dental therapist hired in Washington state after Democratic Gov. Jay Inslee signed a law in 2017 authorizing dental therapist licensures and practice. She joined the Port Gamble S'Klallam Tribe Dental Clinic in 2018.
Alaska, Minnesota and Washington have the nation's four dental therapy programs.
Other state efforts to authorize dental therapists to practice have stalled. A bill that would have amended the Illinois Dental Practice Act to create dental therapist licenses died in May.
Lawmakers in Florida -- which has one the nation's worst shortages of dental professionals -- Massachusetts, New Jersey, and New York also have introduced legislation to allow dental therapists to practice, said Laura Hale Brannon, project manager of the Dental Therapy Project at Community Catalyst, which advocates for policies around health equity.
Before Idaho passed its law, some lawmakers cautioned against creating a new midlevel position, as some dentists testified that they'd instead like to see more training for dental hygienists and higher Medicaid reimbursement rates.
Meanwhile, other states are authorizing dental therapists to practice in more places: Last year, Washington state expanded its legislation to allow dental therapists to practice at community health clinics and not just tribal clinics, providing more dental care access to Medicaid patients.
While dentists perform more complex procedures, dental therapists can tend to basic treatment for patients who otherwise would have long waits for an appointment, have to travel far, or may forgo care altogether, worsening their dental health.
Brannon said there is a shortage of dentists who will accept Medicaid because of its low reimbursement rates. Research shows patients on Medicaid disproportionately end up in the emergency room because of oral health issues. Losing teeth also has been associated with a higher risk of death, according to an analysis of 49 studies published in 2018 in the Journal of Prosthodontic Research.
"We really have two dental care systems in the United States: one for people with private insurance and enough money to pay out of pocket for any additional care, and then a safety net for everyone else -- and that safety net is really failing folks," Brannon said.
The ADA did not make officials available for an interview.
'Angel hands'
This month marks 27 years that dentist Raymond Dailey has practiced at the Swinomish Indian Tribal Community's dental clinic in La Conner, WA.
Before the clinic hired dental therapists, staff would have to juggle three to seven emergencies and walk-ins in addition to regular appointments, Dailey said. "I was doing a lot of basic dentistry. So there were a lot of things I wanted to do for our patients or elders, but you can't do those extra things if you're just working on the emergency level of things. So we were definitely overwhelmed."
Now, he said, he can better care for the tribe's elder community, doing implants and dentures.
Dental therapy programs began with workers who came from the communities they were serving, allowing for more culturally sensitive care. The clinic is mostly staffed by Native community members, Dailey said.
Sarah Chagnon, a dental therapist at the Swinomish dental clinic, grew up just outside the reservation. To help quell one child's nerves about going to the dental clinic, Chagnon got to know the girl outside the clinic, visiting the preschool. Step by step, Chagnon was able to introduce brushing, flossing, and other care.
Now, "whenever I'm out in public, she runs up to me and gives me a hug," she said.
Chagnon recalled another patient who fell and broke her front tooth. After Chagnon treated her with a restorative procedure, the patient cried.
"'You have angel hands,'" she remembered the patient telling her. "'I can now smile again.'"
The Alaska Native Tribal Health Consortium estimates that more than 40,000 rural Alaskans now have regular access to dental care from dental therapists, also known as dental health aide therapists. In 2022, a federal advisory committee of dentists and other medical professionals recommended that Congress allocate $6 million annually toward dental therapy programs nationwide.
"They [dental therapists] are part of a team that can be used to expand access to care," said Dr. Karl Self, a dentist and director of the University of Minnesota School of Dentistry's dental therapy program.
"Our statute requires dental therapists to work predominantly in areas that serve low-income, uninsured, underserved patients or in dental health professional shortage areas," he said.
Dental therapist Savannah Bonorden, who practices in Sitka, AK, likened her occupation to physician assistants or nurses.
"If we look over on the medical side of everything, there are so many different tiers and levels of medical professionals," she said.
"I'm not trying to take anyone's job away. I'm trying to add to the team dynamic."
This article was originally published in Stateline and republished by DrBicuspid under the Creative Commons license CC BY-NC-ND 4.0. The Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence.
Nada Hassanein is a healthcare reporter for Stateline with a focus on inequities.
