Issue 07
Summer 2020
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
- Dental Therapists’ Diverse Skill Set Helps Meet the Challenge of Providing Dental Care during a Pandemic
- Tribes Taking Care to Ensure Safe In-person Oral Health Services

Updates from Capitol Hill and the Administration
- RADM Michael Weahkee Sworn into Four Year Term as IHS Director
- Indian Health Service Implements CHAP Expansion
- BLS Data Show Oral Health Providers Gradually Returning to Work

The Latest in State Legislatures
- Dental Therapy Bill Introduced in New York for First Time

Funding Opportunities and Resources
- NIHB Fact Sheet on Tribal Oral Health during COVID-19 Pandemic
- CDC Resources on Oral Health Services during COVID-19 Pandemic
- 2020 Continuing Dental Education Catalog from the Indian Health Service
- State by State Factsheets on Medicare Oral Health Coverage
As the COVID-19 pandemic continues, normal oral health care services have been disrupted nationwide. Join the National Indian Health Board and the National Partnership for Dental Therapy in advocating for a solution to unmet oral health needs!

Dental therapists are an invaluable resource to our oral health provider teams. Click here to learn how dental therapists can improve oral health in Tribal communities!

Click here for more information on how to join the Partnership!
Tribal Dental Therapy News
Dental Therapists’ Diverse Skill Set Helps Meet the Challenge of Providing Dental Care during a Pandemic
With the onset of the coronavirus pandemic, providing routine and non-urgent oral health services is challenging. Over the past several months, oral health service providers have had to go the extra mile to find creative ways to deliver the care their communities need. In that time, dental therapists have shown that they can uniquely step in and provide care that otherwise might not occur.
Rochelle Ferry, a dental therapist working for a Tribe in Washington State, is currently offering the majority of her clinic’s in-person care. She and her supervising dentist alternate days in the clinic to avoid exposure, and on the days she is in the clinic her dentist keeps in touch for remote consultation. Rochelle discussed her experience providing emergency care during this pandemic, mainly extractions and giving anti-biotics. “Toothaches don’t stop for a pandemic,” she says, “There has to be someone there to provide emergency care. We have maintained the ability to provide dental care throughout the COVID experience.” In the position of working with an older dentist, Rochelle has been able to step in, as a dental therapist, and provide necessary services to her community members. For those cases beyond her scope, she is able to refer them to the oral surgeon. Without Rochelle’s skillset as a dental therapist, these patients would have had to go without care until the clinic resumed normal operations.

Since the role of dental therapists is to provide mainly routine and preventative care, the majority of their services can be done through teledentistry. The Lummi Nation in Washington State, as mentioned in a recent Community Catalyst webinar , has employed two dental therapists to work alongside two dental hygienists as “runners”. These “runners” bring oral health supplies directly to a patient’s home, Wi-Fi boosters included. The patient then has a virtual appointment lead by either a dentist or dental therapist. Simple preventative procedures that a provider typically performs in the clinic, like fluoride treatments, oral health education, and evaluations, can be done by the patient through the video appointment. The dental therapist can walk a patient step by step through the procedure. For many patients, in Tribal communities and in the broader population, getting to an oral health clinic right now can be extremely difficult or impossible. With dental therapists providing care through teledentistry, patients who may have not received care now have the opportunity.

A dental therapist can also diagnose an issue over the video call, and if the patient needs to come into Lummi Nation’s dental clinic for treatment by a dentist, all necessary information will already be available, streamlining the process and minimizing the amount of time each patient spends in the clinic. This is especially helpful during a pandemic, when reducing exposure to the coronavirus is essential, not only for patients, but for practitioners as well.

The pandemic has placed oral health care providers in a uniquely challenging situation. Dental therapists have shown their irreplaceable ability to provide care to patients in a variety of pandemic-influenced settings. Whether it’s delivering care in a limited capacity clinic or walking a patient through a procedure using teledentistry, dental therapists have shown that they strengthen oral health delivery teams immeasurably. 
Tribes Taking Care to Ensure Safe In-person Oral Health Services
As restrictions on providing dental services due to the coronavirus pandemic gradually decrease, clinics are able to reopen and resume providing in-clinic care. However, there is still the risk of coronavirus exposure and transmission, and many providers are designing reopening plans with extra precautions.

In a recent National Indian Health Board (NIHB) webinar, NIHB and SPTHB Tribal Oral Health Services during COVID-19 Webinar Resources , Dr. LaTonya Shelton-Miller, a dental director for the Shawnee Tribe, discussed her clinics plans for reopening. Her clinic will open in phases, beginning with emergency patients only and gradually increasing dental services offered. In order to minimize exposure to the virus, her clinic is creating guidelines for patients such as screening and checking temperature prior to entering the building, and wearing a mask at all times. She recommends ensuring your clinic has sufficient personal protective equipment (PPE) before opening. Also important to consider, is how to control or mitigate aerosol procedures. Aerosol procedures increase the risk of spreading respiratory droplets that may be carrying coronavirus.

During the pandemic, many clinics have utilized teledentistry to continue providing care to patients. Even after reopening clinics, teledentistry can still benefit dental clinics. Dental staff can screen patients for COVID-19 before scheduling an in-person appointment, and it also allows dental staff to treat patients who otherwise could not reach the clinic. Teledentistry may also reduce the amount of time each patient spends inside. By speaking with the patient over a video call prior to their in-clinic appointment, a diagnosis can be made and the issue assessed. Once the patient enters the clinic, the procedure can immediately begin with all necessary information previously collected.

Even as clinics face pressure to reopen their doors and return to normal as quickly as possible, providers know many new challenges lie ahead in the new normal.
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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Tribal Dental
Third Thursday of Every Month

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NIHB COVID-19 Tribal Resource Center
The National Indian Health Board has developed a Resource Center for Tribes during the COVID-19 pandemic.

Publications include funding opportunities, community health tools, webinars, and other resources to assist Tribal leaders and public health professionals.
Updates from Capitol Hill and the Administration
RADM Michael Weahkee Sworn into Four Year Term as IHS Director
Rear Admiral Michael Weahkee, Zuni, was confirmed by the United States Senate on April 21, 2020, to serve a four-year term as Director of the Indian Health Service (IHS). The federal agency had been without a confirmed head for over five years before Weahkee’s confirmation. RADM Weahkee had served as the highest official at IHS since June 2017. His nomination was supported by a number of Tribes and the confirmation vote in the Senate was unanimous.

One of the biggest issues RADM Weahkee faces as the new IHS Director is chronic understaffing in the agency, which has a 20% provider vacancy rate according to the Government Accountability Office. As IHS leaders work to reduce this shortage and ensure that Tribes have the quality health care services promised to them, one successful program has shown its potential impact on the Tribal health workforce.

The Community Health Aide Program (CHAP) has operated in Alaska since 2004, providing frontline medical, behavioral, and dental health services to Alaska Native communities. In 2016, IHS began the process of expanding CHAP to Tribes outside of Alaska.

Director Weahkee is a supporter of CHAP and will oversee its expansion during his term. In a 2019 hearing before the Senate Appropriations Committee, he said of CHAP, “This program of certified health, behavioral health, and dental aides will enable us to fill critical care gaps. This program has been used for decades in Alaska to great success and I believe its expansion into the rest of the country will be beneficial and an important tool in meeting the health needs of AI/ANs, as part of a mix of services determined at the local level.”
Indian Health Service Implements CHAP Expansion
On July 2, 2020, the Indian Health Service (IHS) announced that the Community Health Aide Program (CHAP) has expanded to Tribes outside Alaska. This announcement has been eagerly awaited by Tribes across the country looking to bring CHAP providers to their own communities.

As mentioned above (see “Michael Weahkee Sworn into Four Year Term as IHS Director”) the Community Health Aide Program has served Alaska Native communities by providing frontline medical, behavioral health, and dental services for decades.

CHAP expansion follows the publication of the interim policy, which IHS had developed with input from the CHAP Tribal Advisory Group over the course of two years. The published policy is available here.

According to the agency’s press release, “The IHS is taking a phased implementation approach, starting with tribal consultation on $5 million in funding from Fiscal Year 2020 to support key components. These include establishing certification boards at the IHS Area and national levels to begin certifying providers in the lower 48, increasing community education on the role of CHAP across Indian Country, investing into training within tribal communities, and providing additional support to tribally-operated programs.”

The certification boards mentioned will be vital: CHAP providers are able to practice in their field with the credentials issued from the certification boards at either the national or Area levels. Tribes and Area Indian Health Boards will either have to work with their IHS Area offices to determine the certification pathway for CHAP providers in their Area.

This long awaited expansion came after multiple attempts from the Trump Administration to combine CHAP with the successful Community Health Representatives (CHR) model. CHRs are used in reservation communities across the country to connect patients with the care they need and that they face barriers in accessing. While both CHRs and CHAP are successful, they perform fundamentally different roles. The CHAP expansion is a strong signal that the two different models will continue to operate as Tribes desire.
BLS Data Show Oral Health Providers Gradually Returning to Work
The Bureau of Labor Statistics (BLS) has released data showing that dental health care providers are beginning to return to work throughout the country. Due to the COVID-19 pandemic, over 500,000 dental providers (including dentists, dental therapists, dental hygienists, and dental assistants) were no longer working in April. This made up more than one third of the 1.4 million jobs lost in the health care sector in April 2020.

Because dental providers work in patients’ mouths—where transmittal of coronavirus can easily spread to nearby people--and due to the shortage of personal protective equipment, dentistry as a profession was hit especially hard. Within the Indian health system, Tribal dental clinics and those operated by the Indian Health Service cancelled elective procedures and opened their doors only for emergency cases. In the meantime, telehealth services helped connect Tribal patients to the care they needed.

However, perhaps due to pressure to reopen and the increase in protective equipment, dental providers are beginning to return to work. June saw 190,000 dental providers return to work following 244,000 returning to work in May. (The May figure represented 78% of job gains in the health care sector and 10% of total job gains nationally.)

As the COVID-19 pandemic continues, dental clinics have proven to be more susceptible to closures than the typical health care profession. Dentists may want to look at workforce models like dental therapy that can meet patient need in or out of the clinic.
Oral Health Champion's Corner
This issue’s Oral Health Champion is Dr. Miranda Davis, a dentist working with the Northwest Portland Area Indian Health Board!

In early March 2020 when Dr. Miranda Davis first realized that COVID-19 was going to have some dramatic effects on oral health care, she was working in a Tribal dental clinic in southern Oregon. Davis had traveled the 400 miles from her home in Seattle to this small-but-growing clinic to serve as an additional supervising dentist for the clinic’s two dental therapists and one dental hygienist. “I was reading reports from other countries and becoming worried, as most clinicians were, that this virus was proving to be dangerous and that we needed to find ways to keep clinicians and staff safe while still providing needed services. At the same time I was concerned about getting home to my family.”

By the following week Dr. Davis was back in the Puyallup clinic where she has served since 2006. She says that the changes in operations that this and other clinics are undergoing are unprecedented, and really highlight the need for clinics to remain flexible and ready to advance as the community's needs and environment change. "I see dental clinics needing to be strategic in their evolution as we keep up with the changing times and the best methods of delivering care. Adding dental therapists to the team is one great example of making changes to improve the dental team and optimize care for the community." 

Dr. Davis has seen many methods of delivering dental care in her 14 years working in a Tribal clinic. This experience, combined with a Masters degree in Public Health from the University of Washington, has culminated in her current position with the Northwest Portland Area Indian Health Board as the Native Dental Therapy Initiative Project Director. In this position she supports Tribes as they research optimizing their dental clinics and as they incorporate dental therapists into the team. She points to this last position as a highlight of her career, and looks forward to continuing to provide this support to Tribes. “All my experience has really helped me to understand that solutions must come from within communities. Watching the dental therapists in our area do their great work gives me optimism that American Indian and Alaska Native people and all people can be the healthiest in the world.” 

Thanks for all you do to keep Indian Country smiling, Miranda!
The Latest from State Legislatures
Dental Therapy Bill Introduced in New York for First Time
As dental therapy continues to improve oral health access for rural and urban communities, more states are evaluating the workforce model. New York, the nation’s fourth largest state, may become the latest dental therapy state. S. 7935 by Senator Alessandra Biaggi, a Bronx Democrat first elected in 2018, would implement dental therapy throughout the state, with a few restrictions.

The bill would establish a dental therapy model, but would require that dental therapists have at least a Bachelor’s degree and that Advanced Dental Therapists have a Master’s degree, limiting the pool of potential practitioners. Additionally, certain parts of a dental therapist’s scope of practice—restorative procedures in particular—would have to be done under the indirect supervision of a dentist, with the dentist being in the building and having authorized the specific procedure. These limitations in other states have been less effective in meeting Indian Country’s oral health care access problem than has the Alaska dental therapy model.

It is unclear when or if the legislature will consider this bill, as the COVID-19 pandemic has disrupted the normal proceedings of many state legislatures, including New York’s. S. 7935 has not yet received a hearing from the Committee on Higher Education to which it was referred upon introduction.

Read NIHB’s summary of the legislation and the impact it would have on New York’s Tribes here.

If this bill were to become law, New York would become the 14th state to have a pathway for Tribes to utilize dental therapy.
Funding Opportunities & Resources
NIHB Fact Sheet on Tribal Oral Health During COVID
The National Indian Health Board (NIHB) has created a fact sheet on dental services during the COVID-19 pandemic. This fact sheet is part of a larger body of work created by NIHB to assist Tribes and American Indian/Alaska Native populations navigate the pandemic.

Click here to visit NIHB’s Tribal COVID-19 Resource Center.
2020 Continuing Dental Education Catalog from the Indian Health Service
The Indian Health Service Division of Oral Health offers several webinars and in person trainings for Continuing Dental Education for dentists, dental hygienists, and dental assistants year round.

While in person opportunities are currently unavailable, several online opportunities exist.

Click here to view the catalog of 2020 courses.
CDC Resources on Oral Health Services During COVID-19 Pandemic
The Centers for Disease Control and Prevention (CDC) has published several fact sheets, guidance documents, and other resources related to providing and accessing safe oral health care services during the COVID-19 pandemic.

These documents are entitles “Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response.”

Click here for more .
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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