Many Native American and Alaskan Native communities don’t have enough dental professionals to provide adequate oral healthcare.
For example, the Cheyenne River Sioux Tribe is the fourth largest Indian reservation in the United States. The total reservation area comprises 1.4 million acres in Ziebach and Dewey counties in North Dakota, with Eagle Butte as its headquarters. Just over 1,300 people live in Eagle Butte. The population of the entire reservation is roughly just over 12,000 people.
The Cheyenne River Health Center, which is affiliated with Indian Health Services (IHS), is located in Eagle Butte. Its departments include emergency, medical, behavioral health, physical therapy, and dental. As an agency within the Department of Health and Human Services, IHS is responsible for providing federal health services to American Indians and Alaska Natives.
We also have a tribal program here in the Cheyenne River Dental Clinic, meaning the tribe manages the program, not the IHS federal headquarters. However, we get federal funding to manage it. The Cheyenne River Dental Department was established in 1977.
We provide most aspects of dentistry, including fillings, root canals, extractions,dentures, crowns and bridges. We refer patients to specialists for further care, but the nearest specialist is 90 miles away for endodontics and 165 miles away for oral surgery. Access to care is difficult for everybody because of the shortage of dentists in these clinics. Even though advanced oral care is limited, we maintain the highest standard of care.
Challenges in Recruiting
IHS hires clinicians to work at its facilities. In fact, clinicians have a choice of four different health career paths with IHS: civil service, commissioned corps, military transition, and direct tribal hire. Each comes with different compensation and benefit packages. All of these programs qualify for loan repayment programs.
Since the cost of dental education is increasing year after year, the loan repayment program minimizes the burden of student loans. A four-year dental program can cost anywhere from $250,000 to $400,000. But the current IHS loan repayment is roughly $20,000 a year before taxes, which barely covers the interest of the student loan.
Another major concern is the difficulty in finding dentists who are willing to make a long-term commitment, be open to native culture, and be respectful of their way of life. A key challenge lies with the demographics of the clinic. Most dentists do not feel suited or inclined to want to work in the more rural and isolated areas where most IHS clinics are located.
For instance, our clinic is 165 miles from Rapid City, South Dakota, to the west. Bismarck, North Dakota, is roughly the same distance north. These are the two biggest cities nearby. Moreover, South Dakota doesn’t have a dental school. We have been looking for a dentist for the last three years. We had some dentists who showed interest at one time, but nothing materialized.
One option is finding a contract dentist through recruitment agencies. This is a very costly solution, though, and it isn’t practical in the long term. The lack of continuation of care for the patients is also problematic, raising long-standing trust issues that are difficult to overcome.
Another viable option that we looked at is recruiting a dentist straight from dental school. The new dentist would receive a salary, benefits, and tuition repayment in exchange for a commitment to the dental clinic for a proscribed period of time.
IHS has externship programs for dental students in their final year. They normally come for two weeks to IHS clinics and work under the dentist’s supervision. They visualize a different aspect of the art of dentistry and practice management. This will also give the dental students insight into IHS and open up the door for a new career pathway.
But this always doesn’t work in our favor. We trained more than a dozen dental students when I was at the Lummi Tribal Health Center in Bellingham, Washington, as a dental director. None of the students took up an IHS career to my knowledge.
Another big pitfall is retaining dentists once they are in the program. One way to help is to give them a retention bonus after the yearly evaluation. Also, we give them the tools they need to succeed by improving their skills with various continuing education courses. The downside of this option, though, is that certain clinics work within very limited budgets.
During the COVID-19 pandemic, we have had to modify our practice to meet the community’s needs. We followed the guidelines from the Centers for Disease Control and Prevention and the ADA, and we practiced regular dentistry as well as teledentistry.
The pandemic took a tremendous toll on income, affecting lower-income and rural populations disproportionately. Its impact has already been felt in rural and lower-income communities. The little funds available have been directed toward other projects, and oral care has again sunk to the lowest rung of priorities.
Even in good times, the oral healthcare of Americans on tribal lands and in rural areas suffers. Most dental professionals prefer to practice in highly populated communities where economics are generally stable. The current pandemic has intensified these inequalities.
Several possibilities come to mind, such as scholarships, grants, and collaborations with dental schools for a subsidized student fee structure in return for work in tribal clinics for a certain period of time. But all of these strategies need help, support, and policy implementation from higher officials including elected officials, community leaders, dental school representatives, and other stakeholders.
A very important step in the process of recruiting dental professionals to tribal lands or rural areas is integration, which encompasses understanding, acceptance, empathy, and an openness to learn more deeply another’s culture. Each American Indian and Alaskan Native community has its own culture, beliefs, and attitudes. The same holds true for farmers, fishers, and laborers. It can be seen and felt in poor neighborhoods where services are scarce or non-existent. Changes often occur slowly and trust must be earned. Patience is paramount.
Dr. Sykander is originally from India and now living in the United States. He is the chief dental officer of the Cheyenne River Sioux Tribe Health Department, which is affiliated with the Indian Health Service (IHS). He is the very first foreigner to hold the position of chief dental officer in the organization. Upon graduating from dental school in 1999, he moved to the United Kingdom, where he worked as a senior house officer in oral and maxillofacial surgery in various hospitals run by the National Health Service (NHS). He then moved to the United States in 2008, where he did a two-year postdoctoral residency program in advanced general dentistry at the University of Maryland. From there, he worked in private practices in the Washington State region before becoming the dental director at the Lummi Indian Health Clinic, affiliated with IHS. From there, he went on to corporate dentistry in Virginia with the Heartland Dental Corporation, before working as the chief dental officer for the Cheyenne River Sioux Tribe Health Department in Eagle Butte, South Dakota.
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