Role of sovereignty in the development of oral health care approaches for American Indians

What is the responsible role for health professionals and their representative organizations when faced with new approaches to improving oral health care in sovereign American Indian (AI) nations? The prevalence the infectious disease Early Childhood Caries is reported at 68% for AI children experiencing untreated decay, a rate three times the average for the general US population. Contributing factors include low dentist to patient ratios and high average distance to a dentist in many AI communities. A plausible and innovative approach to improving access to care and availability of oral health care in AI/AN communities may be the Dental Health Aid Therapist (DHAT). After two years of education and hands-on training for post high school students, the DHAT, a mid-level dental provider is capable of providing preventive services, routine restorative services and urgent care for children and adults in pain. Such providers represent the only alternative to no treatment at all. Versions of the DHAT program are in place in Alaska, New Zealand and several other countries, with Edelstein (2009) reporting acceptable quality and cost effectiveness. The American Dental Association (ADA) has aggressively fought the expansion of this program outside of Alaska, citing arguments about the quality of care and safety of patients. Are there data to support these arguments? Does the evidence justify an approach that limits the options of sovereign Indian nations, most of whom receive their care through Indian Health Service? Can a social justice framework help in understanding the problem and crafting a solution?