Dental Therapists in Alaska: Addressing Unmet Needs and Reviving Competition in Dental Care

• Publication year: 2007

§ 24 Alaska L. Rev. 105. DENTAL THERAPISTS IN ALASKA: ADDRESSING UNMET NEEDS AND REVIVING COMPETITION IN DENTAL CARE

Alaska Law Review
Volume 24
Cited: 24 Alaska L. Rev. 105

DENTAL THERAPISTS IN ALASKA: ADDRESSING UNMET NEEDS AND REVIVING COMPETITION IN DENTAL CARE

ERIK BRUCE SMITH ^[*]

I. INTRODUCTION

II. DENTAL LICENSING

III. STRUCTURE OF ALASKA NATIVE DENTAL CARE AND HEALTHCARE

IV. THE ALASKA NATIVE DENTAL HEALTH CRISIS

A. The Crisis Explained

B. Sources of the Alaska Native Dental Care Problem

V. DENTAL HEALTH AIDES: A SOLUTION TO THE CRISIS

A. Overview of Dental Health Aides and Dental Therapists

B. Opposition to Dental Health Aides and Alternative Solutions

VI. DENTAL THERAPISTS AND LEGAL ISSUES

A. Legal Overview

B. The American Dental Association Lawsuit

VII. REGULATION AND DENTAL THERAPISTS

A. Regulatory Foundations

B. Regulation of Healthcare Professionals

VIII. DENTAL THERAPISTS AS A COMPETITIVE FORCE

IX. CONCLUSION

FOOTNOTES

Dental healthcare is provided to Alaska Natives and all other Native Americans by the United States government as part of its unique legal and political relationship with the tribes. Although Alaska Natives do have some degree of access to dentists, they suffer from the worst dental health of any group in the United States. This crisis exists because of geographic, cultural, and economic constraints, and the dental profession has not acted sufficiently to address these constraints. To deal with this crisis, the federal government granted a special license for Dental Therapists to provide much needed care to Natives. Dental Therapists are a form of dental health professional somewhat analogous to a nurse practitioner and are used in many developed countries. This Note discusses the economic and legal foundations of professional regulation and explores the virtual monopoly that dentists have on the provision of dental care. It shows how Dental Therapists are a needed solution for addressing the Native dental health crisis and how their introduction will force the dental profession to more seriously address the nationwide need for enhanced access and availability of low-cost care for underserved populations.

I. INTRODUCTION

In the United States, healthcare regulation is largely dominated by dentists and doctors via the American Dental Association (ADA) and American Medical Association. In fact, the control of these professionals over their own licensure is unparalleled in any other economic sector in the United States. The fact that dentists and doctors enjoy so much control is no [*pg 106] surprise since the lay public knows little about the technical basis of medical treatment. Therefore, society places a great deal of trust in dentists and doctors in not only the provision of medical care, but also the structure and regulation of the entire healthcare system. Dentists and doctors have effectively been able to stifle competition in the healthcare industry, and this lack of competition has caused segments of the United States population to be neglected. This neglect is a natural result of the absence of meaningful competition, for competition would ensure that every segment of the healthcare market was addressed.

The shockingly poor dental health of Alaska Natives is a reminder that, although the United States as a whole spends more money per capita on healthcare than any country in the world, ^[1] there are still many underserved groups that do not have fundamental access to care. Alaska Natives are one of these underserved groups, and despite some efforts to improve their overall health, their dental health is still the worst of any group in the United States. ^[2] A limited number of dentists do serve the Alaska Native population, but the available dentists are not enough to remedy the Alaska Native oral health crisis. ^[3] The obvious reasons for this deficiency include the villages' geographical isolation and the prohibitive costs involved in supplying a sufficient number of dentists to each village. ^[4]

A recent solution to this crisis has been the introduction of Dental Therapists into Alaska. Despite their presence in a number of developed nations, the use of Dental Therapists in Alaska represents the first use of this form of dental professional in the [*pg 107] United States. ^[5] Their introduction into Alaska relies on a new professional license given through the Indian Health and Welfare Act's provision for a Community Health Aide Program. ^[6] Candidates for the program are selected from and by the Alaska Native villages, are trained in New Zealand for eighteen months, and are subsequently licensed to perform various dental health tasks for the Alaska Native population, ^[7] including tooth extraction, cavity filling, and pulpotomies. ^[8]

Although they are not completely opposed to the use of Dental Therapists for the dental education of Alaska Natives, the ADA and the Alaska Dental Society are vehemently opposed to Dental Therapists performing the aforementioned procedures, as they are irreversible. ^[9] In fact, the ADA and Alaska Dental Society have recently filed suit against the Alaska Native Tribal Health Consortium, the State of Alaska, and eight Dental Therapists, claiming that Dental Therapists are practicing dentistry without a license. ^[10] This suit is still pending, though the Alaska Attorney General has written an opinion arguing that the scope of Dental Therapists' practice is legal due to their unique federal license. ^[11] Ultimately, the courts will decide the legality of the use of Dental Therapists in this case.

Regardless of the legality of Dental Therapists, their mere introduction has shaken up the structure of dental licensing and has threatened the exclusive control that dentists previously held over dental procedures. Competition in the dental field will be good for consumers because it sends a strong message to healthcare providers that those who cannot afford high-cost dental care need a low-cost alternative, which is already becoming available. It [*pg 108] further emphasizes the importance of solutions that take into account the unique circumstances of a particular group. By addressing a part of the market that has been chronically underserved, Dental Therapists will force the dental establishment and legislators to more seriously pursue the goal of dental care for all Alaskans. Furthermore, the introduction of Dental Therapists is a great triumph for those who disagree with the ADA's monopolistic attitude regarding the provision of dental services, ^[12] and their introduction shows that consumer choice is an increasingly important concept in the creation of healthcare options.

This Note will give an overview of the dental licensing process, explain the dental healthcare crisis suffered by Alaska Natives, and describe the Dental Therapist program. It will then discuss the legality of the Dental Therapist program, particularly within the scope of a recent lawsuit waged by the ADA. Finally, it will highlight the significance of Dental Therapists as an effective means for providing cost-effective care to Alaska Natives as part of a regulatory regime and as a source of much-needed competition in the national dental industry.

II. DENTAL LICENSING

Dental licensing, as well as licensing for any health professional, is almost always within the purview of the states. ^[13] These licensing laws need to pass rational basis review, which is a fairly easy standard to meet. Some note that the state regulation of health professionals is a remnant from earlier times and argue that federal regulation makes more sense now given our efficient communication and national standards of practice. ^[14] Nonetheless, there is definite standardization imposed via instruction in dental school and by the heavy involvement of groups like the ADA, even with state regulation. ^[15]

Dental licensing is established by state legislation that outlines the requirements for dental practice in that state and establishes a state dental board. ^[16] All states require a dental degree from an [*pg 109] American or Canadian school, a successful written examination, and a sufficient clinical examination. ^[17] With regard to the educational component, all dental schools must meet standards established by the ADA Commission of Dental Accreditation. ^[18] The National Board Dental Examination fulfills the written examination requirement in many states to some degree. ^[19] The Joint Commission on National Dental Examinations is responsible for administering the National Board Dental Examination. ^[20] State dental boards are usually affiliated with the American Association of Dental Examiners. ^[21] Furthermore, state control of the scope of practice of both general practitioners and specialists is defined by the ADA Principles of Ethics and Code of Professional Conduct. ^[22] In addition, almost all states also require continuing education for relicensure. ^[23] The ADA also has a large influence on the licensure of allied dental health professionals, including dental assistants, [*pg 110] hygienists, and laboratory technicians, as suggested by the ADA's Comprehensive Policy Statement on Dental Auxiliaries. ^[24]

III. STRUCTURE OF ALASKA NATIVE DENTAL CARE AND HEALTHCARE

Due to their tribal membership, many Alaska Natives, like American Indians, are entitled to unique health services in addition to the health services granted to all American citizens. ^[25...