By Megan Messerly
The Nevada Independent
Growing up, Dawna Brown watched her grandmother eat everything: Antelope, deer brains, fish eyes, the meat of the cui-ui fish after painstakingly picking out hundreds of bones.
As a kid, she was “grossed out” by her grandmother’s “beginning to end, tail to head” eating habits, she said. But now, Brown, many years later the health director of the Pyramid Lake Tribal Health Clinic, thinks her grandmother, who lived to be 101, was onto something.
“Because we have the lake, we were able to sustain ourselves with the fish and, out at the north end of the lake, we have a lot of deer and some antelope — actually they follow the river through here — and we have the rabbits and we have just the vegetables up here,” Brown said. “People used to eat really healthy and good, like, they’re eating the meat you’ve got running around out there one day, and it’s on the table the next day.”
That shift in eating habits hasn’t just happened at Pyramid Lake, but also in tribal communities generally. Driven in part by federal government policies that cut tribes off from traditional food sources, that change in diet has contributed to poor dental health in tribal communities, with American Indian and Alaska Native children having on average four times more oral diseases than white children.
The Pyramid Lake Paiute Tribe is backing a bill this legislative session it says will significantly expand its ability to provide dental services, not just to members of the tribe but to those who travel from as far away as Fort McDermitt and Yomba for treatment.
It’s not just the tribes that could benefit, either. Proponents say that the bill stands to make inroads in meeting the need for dental treatment in both rural Nevada and low-income portions of the urban communities, too.
The legislation, proposed by Democratic state Sen. Julia Ratti on behalf of the Nevada Dental Hygienists Association, would create a new mid-level provider for dentistry much in the way that the medical field has physician assistants, advanced practice registered nurses and nurse practitioners. The mid-level dental providers, known as dental therapists, would be able to perform a number of routine procedures, including extracting loose teeth, filling cavities and applying sealants.
The bill was presented in the Senate Finance Committee on Friday to address a $37,250 fiscal note from the state Medicaid division needed to create the new provider type. Sarah Adler, a lobbyist for the Pyramid Lake Paiute Tribe, promised that the relatively small cost would be “repaid to Nevada many times over in reduction in uncompensated care and emergency department visits” because of untreated dental conditions.
But dentists, who by and large oppose the bill, argue that the routine procedures dental therapists would be allowed to provide could have harrowing complications, and that dental therapists would be ill-equipped to respond to them even with the additional training they would be required to go through to secure the designation. Dentists also dispute whether there’s a need for additional dental providers and, if there is, they wonder why more isn’t being done to encourage dentists to practice in underserved communities.
It’s a debate that stands in stark contrast to the conversation happening in Nevada’s medical community over expanding access to care, with widespread agreement that there is a provider shortage and the role mid-level practitioners play as a panacea. But dentists say that, unlike mid-level medical providers, dental therapists would be allowed to perform procedures that are invasive and irreversible.
“I really feel that I had just enough training by finishing dental school to get out there — and even then it’s scary — but to not feel dangerous. All through dental school they’re constantly pointing out here’s what can go wrong, here’s what you have to watch out for,” said Dr. Ingrid Lubbers, a retired Reno dentist. “In my mind, the two primary services they’d be offering with the extractions and fillings are the two scariest procedures for a dentist to do.”
Proponents, however, are still optimistic that the dentists will eventually come around to the idea of dental therapists, in much the same way doctors have adjusted to the expanded responsibilities mid-level medical providers have been allowed to undertake in recent years.
“At the very beginning, when these new provider types and levels are introduced, there’s a lot of questions, and there should be, right? We want to make sure that people are getting not just access to care but that the care that they are getting is safe and appropriate,” Ratti said. “I suspect that, over time, you’ll see a greater acceptance of dental therapists as well.”
The need for expanded dental care
The divide in the debate over dental therapists begins with whether there’s a need for them at all.
Talk to dentists, and many of them are confident that the need for dental care in the state is being met. The American Dental Association’s 2018 rankings show that Nevada is 25th in the nation for dentists per capita, a far better showing than the state’s typical bottom-of-the-list performance for medical and mental health providers. The association’s data also shows that 96 percent of publicly insured children live within 15 minutes of a Medicaid dentist and 83 percent of the state’s population live in areas where there is at least one dentist per 5,000 people within a 15-minute travel time.
“I think with any situation we’re kind of looking at what is the problem, and that has been the difficult part throughout all of this,” said Dr. Erin Anderson, a dentist in Reno. “It hasn’t been for a lack of providers.”
Another dentist, Dr. Mark Funke, believes to the extent to which there is an issue with access to dental care, it’s more an issue of education than it is a shortage of dentists.
“Thirty-seven percent of all adults in the nation seek dental care. Only 37 percent,” said Funke, who is also vice president of the Nevada Dental Association. “So you need to define what the definition of access to care is. Is it because somebody can’t get to a dentist, can’t afford a dentist, or they don’t value and understand the importance? You can have all these programs, but if people don’t choose to go, you can’t force them to go.”
Talk to the proponents, and they’ll tell an entirely different story. For one, Nevada’s 54.71 dentists per 100,000 residents falls short of the national average of 60.97 dentists per 100,000 people, according to the dental association’s statistics.
On top of that, more than 900,000 Nevadans, including roughly 140,000 rural residents and 780,000 urban residents, lived in a dental health professional shortage area in 2017, according to a report from the University of Nevada, Reno School of Medicine. The report found that while dental workforce shortages are “less severe” than primary care and mental health shortages, nearly 32 percent of the state’s population resides in a dental health shortage area, and eight out of 14 of the state’s rural and frontier counties are entire-county dental health shortage areas.
Shaun Griffin, co-founder of the nonprofit, Community Chest, based in Virginia City, described access to dental care in rural Nevada, particularly in central Nevada, as “so scarce that it’s almost not there.” Rural communities have had to lean heavily on charity dental vans rolling through town to provide care to some of their most vulnerable residents, he said.
“My experience at the van events were just devastating. I had adults weeping, praying, pleading for care because they couldn’t get it anywhere else,” Griffin said. “Grown men and women absolutely on their knees, praying that they would get selected for dental care.”
Healthy Communities Coalition, another nonprofit serving Lyon and Storey counties, got involved in oral health care advocacy nearly a decade ago when it came to light that the group’s volunteers were “literally pulling their own teeth in their garage because they couldn’t get to a dentist or afford it,” said Wendy Madson, the coalition’s executive director. But she said the dental vans have only been a “Band-Aid” fix.
“It’s getting help to people, but we still fit in the same scenario,” Madson said. “We have not enough providers.”
It’s an issue the tribal communities feel acutely, too, in part because of the remoteness of many of the reservations.
“The ability to attract and even hire a dentist out in those areas is extremely difficult,” said Alan Mandell, vice chairman of the Pyramid Lake Paiute Tribe. “At Pyramid Lake, we’re 60 miles outside of Reno, and it’s hard to find sometimes a provider to come out here even though we’re relatively close to a larger community.”
Pyramid Lake’s health clinic boasts one of the more robust tribal dental programs with one dentist, one dental hygienist and a couple of dental assistants, and though other tribes offer their own dental services, patients will still come to Pyramid Lake for more complex procedures. Patients from the Fort McDermitt Paiute and Shoshone Tribe, for instance, have come down for dentures and tooth extractions.
“That’s the one thing about the tribes around here is they don’t hesitate — that’s four hours away — they don’t hesitate to drive that far to come to a service,” Brown said. “Coming from McDermitt, they’re going to bypass Winnemucca, Fallon, Lovelock, other places that probably do have a dentist or private practice dentist, but they’re going to come to our place here, and that kind of tells us a lot that they will go that far.”
Griffin has also seen access issues in urban Nevada through serving on the board of directors for Community Health Alliance, a federally qualified health center.
“We see the dental need in the two urban areas as extreme as it is anyplace else. We’re overwhelmed with need at those facilities,” Griffin said.”We’ve had to limit our shop in Northern Nevada to children primarily because that’s where we get the most bang for our buck. That’s the reality we’re living with.”
This article was reprinted with permission by the Nevada Independent. Visit them online at thenevadaindependent.com.
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