Elise Takahama The Seattle Times (TNS)
SWINOMISH RESERVATION — The red-and-brown building looking out onto the Swinomish Channel is unlike a typical dental clinic.
Comforting smells from the kitchen at the downstairs senior center waft into the space, as staffers prepare lunch for community elders. Local Native art decorates the waiting room while flutes and percussion instruments play in the background.
"The idea is to feel like you're walking into someone's home," said Dr. Rachael Hogan, dental director of the Swinomish Dental Clinic.
In recent years, the small but quickly growing office in southwest Skagit County, across the water from downtown La Conner, has emerged as a state leader in access to dental hygiene, gaining attention a few years ago for becoming the first in Washington to add a new role to their team: a dental therapist.
Dental therapists are licensed midlevel providers who often play a support role for dentists. They perform about 50 of the 500 procedures dentists do. In Washington and some other parts of the country that have developed programs, dental therapists have worked to expand access to oral hygiene, particularly in rural, underserved communities.
Interest in the position has grown here since 2017, when the state voted to allow dental therapists to practice on federally designated tribal lands. On Monday, Gov. Jay Inslee signed House Bill 1678 into law, officially expanding on past legislation by authorizing dental therapists to practice in hundreds more community health clinics across Washington.
Advocates hope the move will help close the state's gaps in dental hygiene — though critics worry development of the new job class will strip resources away from training programs for other types of dental staffers in an already short-handed field.
"We're not here to steal jobs," said Sarah Chagnon, one of two dental therapists at the Swinomish Dental Clinic. "We're here to treat dental disease."
Dental therapists first emerged in New Zealand in the 1920s after public health officials noted high levels of untreated tooth decay among children, according to a report from Pew Charitable Trusts. The model didn't land in the United States until the early 2000s, when tribal students in Alaska brought New Zealand's training into the state's rural communities.
Since then, at least 14 states, including Washington, have passed legislation approving dental therapy programs in certain spaces, hoping to address disproportionately high rates of untreated tooth decay among Native communities.
When the law takes effect in January, dental therapists will be allowed to work at Washington's 27 federally qualified health centers and their 350-plus clinics. In Washington, these federally funded, nonprofit health care organizations accept Medicare and Medicaid, and generally provide care regardless of pay or insurance status.
King County's federally qualified health centers include HealthPoint, Neighborcare Health and Sea Mar, which also has locations throughout Western Washington.
Like hygienists, dental therapists can handle routine cleanings, but are also trained to provide some simple procedures, like fillings. But they aren't licensed to perform as many procedures as a dentist is, including more complicated root canals, crowns or implants — so the role often clears dentists' schedules to focus on complex care.
"When I was by myself here, I couldn't do everything," said Dr. Ray Dailey, a dentist who has worked at the Swinomish clinic since 1997. Before the clinic got its first dental therapist from Alaska in 2016, the flow of patients was sometimes "overwhelming," Dailey said.
"We could have five or six emergencies in our front area every morning," he said. "And some of them could be simple — a chipped or broken tooth, for example. But others are more complicated. Insert dental therapists, and they can take care of that [simpler problem] immediately before it becomes a major issue."
Since dental therapists became part of the everyday care team in Swinomish, wait times have gone down significantly. The clinic is now able to schedule same-week, if not same-day, appointments — compared with four- to five-month waits in the past, Dailey said.
Costs to patients don't change since they're associated with dental procedures, not providers.
The dental therapists also build community outreach into their schedule. On the Swinomish Reservation, past dental treatment— sometimes without painkillers — have scarred the community, and a lot of work is required to form more trusting relationships, said Asiah Gonzalez, the clinic's other dental therapist.
Gonzalez grew up on the Swinomish Reservation and has her own painful memories of traveling dentists and a lack of understanding care.
"I stopped going at one point because I was so put off by anxiety," she said. "I've been held down, screamed at, yelled at, all while in the chair."
The Swinomish clinic is now 75% Native-run, and staffers have felt a difference in how community members, especially children and tribal elders, interact with them, Chagnon said.
Every Wednesday, the dental therapy team visits the local preschool and day care to teach about dental hygiene and toothbrushing. Now, the kids light up when they see Gonzalez and Chagnon at their dentist appointments.
"It makes sense to have dental providers who look like us," Gonzalez said. "And now they grow up knowing this isn't a scary place."
Marcy Bowers, executive director of the Statewide Poverty Action Network, which helped lead advocacy efforts for the legislation, said she was pleased to see it pass.
"It's really clear that rural areas, who have fewer dentists, would be impacted by this," Bowers said. "But even in somewhere like King County — where there are dentists all over the place, but many don't have sliding scales or treat Medicaid patients — people aren't always able to access care."
In Washington, just 19.8% of adults 21 and over on Medicaid saw a dentist in 2021, according to a report from the Arcora Foundation, a Seattle-based oral health equity group. Any efforts to address the lack of care, particularly in more rural counties, are worth exploring, said Dr. Sarah Vander Beek, a dentist with Neighborcare Health, a federally qualified health center in Seattle.
"Our state has so many rural pockets and corners," many of which have few or no local dentists, Vander Beek said. "I think there's a lot to be learned from our tribal leaders about applying this in our state."
Opponents of the new law, however, argue resources that could have gone toward expanding training in dental hygiene — where staffing holes are prominent — are now going to be redirected to dental therapy.
"We fundamentally don't believe we have a shortage of providers that need to do surgical, irreversible procedures," said Bracken Killpack, executive director of the Washington State Dental Association, which testified against the legislation. "But what we do direly need is a workforce to provide preventive care."
He continued, "While preventive care is within the scope of dental therapy ... there's a lot of additional training and a lot of additional expense that would be needed to use a dental therapy credential to provide preventive care — when you could simply get a dental hygiene credential."
Plus, he said, dental therapy school can be expensive, though Swinomish's therapists agreed it was more accessible than most four-year dentistry programs.
At the University of Washington, tuition costs about $55,000 to $65,000 per year for dentistry students who are state residents, not including books and additional fees. In comparison, the state's sole dental therapy training program at Skagit Valley College is about $38,000 per year for three years.
Dental hygiene programs can range depending on the degree, but Shoreline Community College's two-year program, housed within the UW's School of Dentistry, costs about $12,000 to $13,000 per year.
While the dental association doesn't agree with the expansion of dental therapy in the state, Killpack noted that they "respect [tribal communities'] sovereign right to determine how to deliver health care to their tribal members."
As the state prepares new licensing requirements in the next few months, Skagit Valley College is welcoming applications for the fall cohort.
"I'm just really excited for other communities to have the opportunity to have the chance to have a dental therapist and see the impact they're going to make in their communities because it works and it makes sense," Chagnon said.