Issue 02
Spring 2019
Tribal Oral Health Newsletter
The Latest News on Oral Health from across Indian Country

In Your Inbox Every Quarter!
In This Issue
Tribal Dental Therapy News
NIHB Publishes Dental Therapy Start Up Guide for Tribal Leaders
Swinomish Opens New Dental Clinic and Dental Therapy Training Facility
Poll of Washington State Shows Strong Support for Dental Therapy
The Best Part of Being a Dental Therapist

Updates from Capitol Hill and the Administration
NIHB Calls for Congress to Establish Dental Benefit under Medicare
As Community Health Aide Program Expands Out of Alaska, Tribal Advisory Group Helps Form Policy
Congress Considering Several Bills to Improve Oral Health

The Latest in State Legislatures
Idaho Tribal Dental Therapy Bill Crosses Finish Line
New Mexico Tribes’ Persistence Pays Off with New Dental Therapy Law
Arizona Legislature Considers Oral Health Legislation

Funding Opportunities and Resources
USDA Economic Impact Initiative Grants
Medicaid Resources
DentaQuest Partnership for Oral Health Advancement
IHS Dental Portal
Calling all Tribal Dentists:

If you support having a dental therapist as part of your team, join

Dentists and dental therapists work together as a team, each making the other's work stronger. It is very important that dentists working in Indian Country who support dental therapy make their voices heard!

Click here for more information on how to join the Partnership!
Tribal Dental Therapy News
NIHB Publishes Dental Therapy Start Up Guide for Tribal Leaders
The National Indian Health Board (NIHB) is proud to announce the publication of its Dental Therapy Start Up Guide for Tribal Leaders! This guide is intended to provide information and context for Tribal leaders who have heard of dental therapy's success in Alaska and the Pacific Northwest but don't know where to start in bringing it to their own communities.

The guide provides recommendations for Tribal leaders to consider when utilizing dental therapy's potential for their Tribes, such as working with the state to ensure that the services performed by a dental therapist can be reimbursed by Medicaid, and engaging with the Tribe's existing oral health care delivery team to ensure that dental therapists hired by the Tribe can integrate seamlessly.

NIHB hopes that this guide will be a resource for Tribal leaders across the country. In addition to implementation recommendations, included in the guide are the standards from the Commission on Dental Accreditation on a dental therapist's education and training, a sample dental therapy curriculum for educational institutions, and model legislation for licensing dental therapists.
Swinomish Opens New Dental Clinic and Dental Therapy Training Facility
by Miranda Davis, Northwest Portland Area Indian Health Board
On April 9, the Swinomish Tribe welcomed visitors to the Grand Opening Ceremony of their newly expanded and remodeled dental clinic. The dental clinic will also house the clinical portion of the future Washington Dental Therapy Education Program.

Swinomish Chairman Brian Cladoosby spoke to a jam-packed reception area about the historical trauma associated with dental care for his community. He explained the great significance this new dental clinic holds for the Swinomish people and the sense of hope it brings for the community’s health in years to come.

As is the Swinomish tradition, Chairman Cladoosby called forward four individuals to witness the event and to say a few words. Dr. David Branch, chair of Arcora Foundation, described how impressed he had been to witness dental therapist Daniel Kennedy’s professional expertise at Swinomish. Austin Miles of HKP Architects credited the dental team with contributing to the clinic’s design. Mark Pottle of Pottle and Sons Construction said he felt honored to work on the project. Andrea Johnston, a dental assistant and member of the Swinomish Tribe, spoke of her pride and gratitude to her community.

The new dental clinic boasts spectacular views, 16 state-of-the-art operatories, lab and sterilization rooms, and all digital records. Four of the operatories are reserved for the future Dental Therapy Education Program, as is a classroom, office space, and a locker/shower room.

The Dental Therapy Education Program is a partnership between Skagit Valley College and the Swinomish Tribe, and will be the first CODA accredited Dental Therapy Education Program in the lower 48. The program is working toward welcoming its first class in autumn 2020.

John Stephens, Swinomish programs administrator and senior health policy advisor, pointed out that their new clinic and dental therapy educational space is ready well ahead of the education program’s planned start date, signifying the Tribe’s commitment to and investment in dental therapy.

Stephens explained that a turning point for the Swinomish Tribe’s health programs began in 1996 when the Tribe chose self-governance in accordance with Public Law 93-638. Swinomish later became the first Tribe in the lower 48 states to employ a dental therapist and the first Tribe to create a dental licensing board. They will welcome two newly graduating dental therapists from their own Tribe in June.
Chairman Brian Cladoosby addresses the opening ceremony.
Swinomish's dental team is excited
to work in their new clinic!
Poll of Washington State Shows Strong Support for Dental Therapy
In 2017, Washington State became the first state to enact legislation for dental therapy specific to Tribes. As advocates work to expand dental therapy to communities statewide, a new poll shows Washington state residents are on their side.

62% of poll respondents support dental therapy, with strong support coming from urban, suburban, and rural areas. Support was also consistent across the political spectrum, with more than 60% of Democrats, Independents, and Republicans each supporting the innovative workforce model.

The strong support for statewide dental therapy is in part due to the record of success it has generated in Washington’s Tribal communities. Click here to read more about how Tribes in Washington and the Pacific Northwest are using dental therapists to restore oral health to their communities.
The Best Part of Being a Dental Therapist
Savannah Bonorden has been a Dental Health Aide Therapist—or DHAT—for over six years now. Working for the Southeast Alaska Regional Health Consortium, Savannah serves her fellow Tlingit and Haida Tribal members.

As the frontline oral health provider for Alaska Native communities in her region, Savannah spends a lot of time gaining trust and building relationships with her patients, which helps grow their acceptance and understanding for the importance of oral health and delivering treatment care plans. She has worked with several young patients, and even adults, who have become interested in the oral health care profession because of her example.

But to Savannah, the best part of being a Dental Therapist is seeing the big healthy smiles coming from her patients, especially those times when they realize that their tooth can be saved, and that the extractions they have become so accustomed to are not their only option. “Being able to treat a minor fracture with a filling, building up a decayed molar they thought they would have to lose, or completing a large treatment plan and saving more of their dentition is priceless. To see the sheer happiness and appreciation they show, lets me know I'm on the right side of this battle,” Savannah says.

“My main goal is to educate and give our people, our communities, the knowledge and tools to see that oral pain is not a social norm, and we, together, can make a difference and help the younger generations live a healthy life, beginning with the oral cavity.”

NIHB created a video showing the impact Savannah and DHATs like her have had on Alaska Native children. Click here to watch that video.
Use NIHB's state legislative tracker to learn more about dental therapy legislation in your state and how you can help make access to oral health care a reality for the Tribes!
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Updates from Capitol Hill and the Administration
NIHB Calls for Congress to Establish Dental Benefit under Medicare
At the first quarterly Board of Directors meeting of 2019, the National Indian Health Board passed a resolution calling for public health insurance programs to include dental benefits. While the Children’s Health Insurance Program offers coverage for services "necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions," and Medicaid offers the Early and Periodic Screening, Diagnostic and Treatment benefit, oral health coverage for adults is more piecemeal. Medicare dental coverage varies by state, and Medicare does not cover non-medical dental services at all!

NIHB passed this resolution in support of the oral health care needs of the nearly 200,000 American Indians and Alaska Natives on Medicare who must either secure private dental insurance or go without coverage. Legislation in the Senate would add a dental benefit to Medicare, and NIHB is in support of S. 22, the Medicare Dental Benefit Act of 2019.
As Community Health Aide Program Expands Out of Alaska, Tribal Advisory Group Helps Form Policy
Tribal appointees to the Community Health Aide Program Tribal Advisory Group (CHAP TAG) have worked with the Indian Health Service for over a year to develop the agency’s policy for national expansion of CHAP. The program currently operates only in Alaska. The Indian Health Care Improvement Act authorized IHS to expand the program to Tribes outside of Alaska, and in 2016, IHS announced that it would do so.

The CHAP TAG has worked tirelessly with the IHS to create a policy document outlining the certification process for community health aides, behavioral health aides, and dental health providers working under the national CHAP and the responsibilities of Area Certification Boards and Academic Review Committees. The TAG was formed to ensure Tribes are adequately engaged in crafting a program that will provide crucially needed health services to Tribes in rural and remote locations. Tribal involvement has been crucial, as the TAG ensure that Areas and Tribes have the flexibility and authority they need to make the program a success.

On May 8, IHS announced that the policy was beginning Tribal consultation and that the agency would accept comments until June 7, 2019. For more information, visit the CHAP TAG website.
Congress Considering Several Bills to Improve Oral Health
The Medicare Dental Benefit Act (see above) is not the only piece of legislation in Congress that addresses oral health. Members of both parties have drafted legislation aimed at improving oral health in underserved populations, strengthening oral health workforce development, and integrating oral health care with medical care.

  • H.R. 96 would require the Department of Veterans Affairs to provide dental care in the same manner as any other medical service, integrating oral health with other health services offered by the Department.

  • H.R. 996 would exclude payments under the federal student loan repayment program from counting as taxable income for “full-time faculty members of dental schools with programs in general, pediatric, or public health dentistry.”

  • H.R. 1554, the Resident Education Deferred Interest (REDI) Act, would allow interest-free deferment on student loans for borrowers serving in a medical or dental internship or residency program

None of these bills have yet received a congressional hearing.
Oral Health Champion's Corner
This issue's Oral Health Champion is Lynda Gregorini, Public Health Registered Dental Hygienist at the Sault Ste. Marie Tribe of Chippewa Indians!

Lynda has worked in oral health for over 18 years, and she sees the level of need for improved oral health outcomes in her rural Michigan community.

Lynda testified to the Michigan State Legislature on how dental therapy would help Sault Ste. Marie and other communities throughout the state. Her advocacy helped the state pass its dental therapy bill in 2018!

Thanks for all you do to keep Indian Country smiling, Lynda!
The Latest from State Legislatures
Idaho Tribal Dental Therapy Bill Crosses Finish Line
On March 25, 2019 Governor Brad Little signed a bill allowing dental therapists to work in Tribal health facilities. The governor's signature was the culmination of months of work from the Idaho Tribes. Following a site visit to see the Alaska dental therapists in action, Tribal leaders and health directors from Coeur d'Alene, Shoshone Bannock, and Nez Perce decided to advocate to lawmakers in Boise for their right to employ dental therapists in their own clinics and dental programs.

The legislation enacted into law applies only to Tribes as part of a compromise. But the legislation follows CODA standards, so Tribes will be able to use the same flexible model that Alaska Tribes have used since 2004. Idaho Tribes will soon be able to hire dental therapists under the new state law. One Tribe even has a student currently studying in Alaska to become a dental therapist!

Idaho's bill makes it the first state to pass a dental therapy bill in the 2019 legislative session and the 9th state with Tribal dental therapy authorization.
New Mexico Tribes’ Persistence Pays Off with New Dental Therapy Law
After nine years of sustained effort, Tribes succeeded in securing passage of dental therapy legislation in New Mexico! Governor Lujan Grisham signed H.B. 308 into law on March 28, 2019. The new law allows dental therapists to practice in certain practice settings statewide, including health facilities run by the Indian Health Service or by a Tribe. Dental therapists can also now practice in Federally Qualified Health Centers and look-alikes, long-term care facilities, or a nonprofit dental organization. The law also provides for an annual report to the New Mexico Legislature on various oral health issues and a biennial report on dental therapy education programs in the state.

A political compromise included by the Roundhouse (New Mexico’s name for its State Capitol building) in the final text of the legislation requires that dental therapists first obtain a dental hygienist license. As Tribes have seen in other states with this requirement, dental therapists with a hygiene license are in school for 2-4 years longer than the standards for dental therapy education require, adding a cost and time burden onto the provider. In turn, that provider then has more of an incentive to work in a for-profit setting in an urban area. Tribes are at a competitive disadvantage as employers when a hygiene requirement is added to the mix. So Tribes fought for and won a carve-out: dental therapists working for Tribes or the IHS do not need to have a hygienist license; they only need to follow the standard dental therapy education program.

With the passage of this law, New Mexico became the 10 th state to authorize dental therapy on Tribal lands.
Arizona Legislature Considers Oral Health Legislation
by Kim Russell, Arizona Advisory Council on Indian Health Care
In Arizona, during almost every legislative session, advocates propose various policy priorities that can improve oral health services and decrease oral health disparities. Tribes in Arizona understand that State policies have significant impact on the Indian health care delivery system, especially in the areas of Medicaid, licensure, and workforce development. As a result, Tribes have provided input to various bills and resulted in Tribal provisions successfully being included in state laws.

In 2018, Tribes in Arizona stood in full support of H.B. 2235, which established the practice and regulation of dental therapy. A very important Tribal amendment allowed Tribes, the Indian Health service, and Urban Indian health facilities to hire dental therapists who are not licensed by Arizona to practice in these facilities. The Navajo Nation, the Tohono O’odham Nation, the Inter Tribal Association of Arizona, and the Arizona Advisory Council on Indian Health Care passed resolutions in support of the establishment of dental therapy. Furthermore, Tribal leaders were in attendance at every committee hearing to provide testimony. Governor Doug Ducey signed the bill into law on May 16, 2018. Moving forward, Tribes are in the process of implementing the law and are developing innovative strategies to ensure Medicaid reimbursement, establish dental therapy curricula in Tribal colleges, and to monitor the Rulemaking Process.

This legislative session, Tribes advocated for three additional bills that would have positively impacted oral health.

  1. SB 1088 would provide comprehensive dental care for eligible pregnant women on Medicaid.
  2. SB 1355 would require the Arizona Health Care Cost Containment System (Arizona’s Medicaid Program) to seek federal authorization to reimburse Indian Health Service facilities and tribal facilities for Medicaid-covered dental expenses for adults above the $1,000 cap currently in statute.
  3. SB 1174 would establish a sixth area health education center focusing on Indian health care delivery system to promote the recruitment and retention of health care providers.

The 2019 legislative session ended on May 28, but Tribes in Arizona will continue to advocate for legislation that will help restore their communities' oral health. Tribal involvement in stakeholder groups can make the difference whenever state policy impacts Tribal health care!
Funding Opportunities & Resources
USDA Economic Impact Initiative Grants
Economic Impact Initiative Grants provide funding to assist in the development of essential community facilities in rural communities that have extreme unemployment and severe economic depression.

An essential community facility is one that provides an essential service to the local community, is needed for the orderly development of the community, serves a primarily rural area, and does not include private, commercial, or business undertakings.

Federally recognized Tribes are eligible to apply. Click here for more information.
Medicaid Resources
Medicaid dental benefits vary by state.

The Center for Health Care Strategies, Inc. has a fact sheet providing an overview of Medicaid adult dental coverage by state here.

You can also learn more about Medicaid dental health coverage by visiting the Medicaid website.
DentaQuest Partnership of Oral Health Advancement
These investments will connect, organize, and mobilize oral health leaders at the local, state, regional, and national levels around the achievement of the shared goals for oral health improvement across the lifespan, ultimately reshaping public policy and creating a new social norm in this country about what it means to be healthy.
IHS Dental Portal
The IHS Dental Portal contains resources including reports and data on Tribal oral health.

The IHS gathered data as part of the 2010, 2014, 2015, and 2016-2017 Oral Health Surveys.

To view the draft IHS Division of Oral Health Strategic Plan for 2018-2017, click here.
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