Dental care not only saves smiles, it saves lives. Yet millions of Americans can’t afford to go to a dentist. They may not have health insurance that covers dental care, or they may live far from a dentist or one who accepts Medicaid patients.

In Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, Mary Otto describes how American dentistry came to the point of producing Hollywood smiles for some while leaving enormous gaps in care for others. In this excerpt, she describes a model of accessible, affordable dental care that is used successfully in other countries and now, in some parts of the United States. Dental health aide therapists, or DHATS, provide much of the same basic care as dentists. Their training and overheads costs are lower, so dental therapists can go where people need them most—in this case, a remote tribal community in Alaska.

In spite of vast changes to their lives over the past three centuries, Alaska Natives have fought to hold on to their ancient traditions, their dances and ceremonies, their hunting and fishing that embody both survival and prayer. Increasing reliance upon Western diets, however, has exacerbated problems with tooth decay. Soda pop arrives by the crate load to villages that are unreachable except by plane or boat or snowmobile. Public water supplies and other community sources of fluoridated water are rare. People drink melted snow. The perennially underfunded Indian Health Service has had chronic difficulty hiring dentists to serve in remote communities. Even if they come, they often leave. Alaska Native children suffer from tooth decay that has been estimated at rates more than twice as high as other American children. In Alaska, complete tooth loss by the age of 20 is not uncommon.

Wrapped in icy mist, the village of Angoon is perched upon a spit of land east of Sitka, surrounded by slate-blue water. Beyond the village, there are mountains, deeply furred by forests. Since ancient times, the people have called the place the “Brown Bear’s Fort,” and the bears still outnumber the humans. Pieces of Angoon’s story are scattered along the narrow roads. There is a tiny wooden Russian Orthodox church and a row of tall wooden poles, crowned with ancestral totems, fish, and bears. There is a small power station and the Alaska Native Brotherhood Hall and wooden homes, one crumbling into the sea. There is a dump on the edge of the village where eagles casually feed.

And there is a modern clinic where, beyond the lighted windows, on this morning DHAT Brian James, clad in dark blue scrubs, was at work. He had the compact build, thick black hair, and dark, twinkling eyes of his Tlingít people. He greeted his next patient, Reggie Nelson, a local elder who came to the clinic a couple of months before to have a hopelessly decayed tooth removed. Nelson was back for some restorative work. 

“It looks like we have one more filling to do,” said James. He gave Nelson a shot of anesthetic and they chatted about fishing. When James was ready to begin he said, “You feel anything sore or sharp, you raise your left hand and we’ll stop.”

Then James did the thing that had stirred battles in courtrooms and the halls of Congress. He took out a dental handpiece, with its burred bit. As it whirred, he carefully removed the decay from Nelson’s molar. Then he placed a filling in the elder’s tooth.

When James decided to become a DHAT, there was no place in the United States for him to train. He and the other seven of the first Alaskan DHATs were sent by their tribes to New Zealand to learn their skills. The tribes were within their rights to set up the DHAT program, the Alaska state attorney general decided in 2005. Though state and federal dental groups opposed dental therapists, federal laws relating to the provision of Indian health care trumped the state dental practice act, the attorney general said.

Dental groups sued anyway. They sought support in the court of public opinion as well. One full-page advertisement placed by the Alaska Dental Society featured a snarling bear: “2nd class dental care for Alaska Natives deserves a ferocious reaction,” read the headline over the ad. “No Alaskan should face irreversible dental surgery by an unlicensed dental therapist with no dental degree.”

When James completed his training, he returned to Alaska to begin his work, even as the lawsuit by the American Dental Association and the state dental society naming him and the other DHATs continued to threaten to shut down the program. In 2007, the case was settled. The claims of the dental groups against the Alaska Native Tribal Health Consortium were dismissed by the state Superior Court, allowing the DHATs to continue to work legally in tribal areas. James was licensed through the federal Indian Health and Welfare Act’s Community Health Aide Program, an initiative that got started in the 1950s as an emergency response to a tuberculosis epidemic that was devastating Alaskan tribal villages. With professional medical care out of reach, village residents were singled out for the training they needed to provide lifesaving care and medication to their neighbors.

Angoon, Alaska. Photo by Sylvain Cordier/Gamma-Rapho/Getty Images.

Community health aides had managed to dispense other basic health care services in hundreds of villages across Alaska, but they lacked the training to address the epidemic of dental problems. “Although village clinics provide essential medical care, in many instances villagers must travel hundreds of miles by bush plane or boat to obtain dental care,” reported researchers. They estimated that well over half the children had untreated tooth decay and that gum disease was plaguing many elders.

Since James received his training, a focused two-year training program for DHATs has been established in Alaska. The students learn to provide basic restorative procedures as well as preventive care and community education about oral health. They also serve 400-hour preceptorships with the dentists who oversee their work, often remotely, reviewing X-rays and patient records via computer and discussing cases by phone or email.

When the elder’s filling was done, James bathed the patient’s teeth and gums with an iodine solution to fight the decay process. He followed up with a fluoride rinse to help strengthen the enamel. “I’ll try to save the teeth I have left,” said the elder, softly. “I’m 70. I’ve got maybe 10 more years.”

Maybe much longer, James suggested with a smile. “My grandma lived to be 95, or 97.” He shrugged and chuckled. No one knew exactly how old his grandma was. After he finished, the young Tlingít and the elder lingered in the doorway of the clinic, placing one another in the ancient tribal order, using the names of the clans that have helped define the collective identity of their people, that have guided their potlatches and rituals for generations.

Nelson said he was from Eagle’s Nest House. James said he was from the Coho clan.

“Do you participate in the dance festival?” asked Nelson.

“I dance with the Noow Tlein Dancers,” answered James, naming a prestigious group performing in the big Sealaska biannual celebration in Juneau.

As he was leaving the clinic, the elder was smiling. “If you have any trouble, you let us know,” James told him. “We will be here ’til Friday.” On Friday, he and his assistant would take the floatplane back to Sitka. They would return to the clinic in Angoon for another week next month.

This excerpt from Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America by Mary Otto (paperback 2019) appears by permission of the publisher, The New Press.