LA CONNER, Wash. — Going to the dentist evokes a special anxiety for Verne McLeod. He grew up on the Swinomish Indian reservation here in northwest Washington state in the 1950s and vividly remembers the dentist who visited periodically. The doctor worked from a trailer, and did not bother with painkillers.
"They just strapped us down and drilled," said McLeod, 70.
Poor oral health is a scourge on tribal lands across the nation. Indian preschool-age children had four times the rate of untreated tooth decay as white children in a recent study. Poverty, diet and a decades-long dearth of access to good care on remote reservations compound the problem.
But Indians and health experts now see hope: If formally trained dentists are scarce, they ask, can people who master many of a dentist's skills but lack the professional degree get the job done just as well?
Daniel B. Kennedy is out to prove that they can.
Kennedy, 56, a soft-spoken Tlingit, is a dental therapist, the rough equivalent of a physician assistant. He is trained to perform the most common procedures that dentists do, from fillings to extractions. Since January, when he started at the Swinomish Dental Clinic, over 50 miles north of Seattle, he has been the only dental therapist on tribal land anywhere in the lower 48 states. He studied in Alaska, which has the nation's only program — patterned after one in New Zealand — aimed at training therapists specifically to work in underserved tribal areas.
Laws here in Washington and most other states bar dental therapists, who have long been opposed by the American Dental Association, so the tribe created its own licensing system. The federal Indian Health Service, which pays for medical care on Indian lands, cannot compensate therapists unless authorized by the state, so the Swinomish (pronounced SWIN-o-mish) needed private foundation support and meticulous accounting so that no law was violated.
"We had to take matters into our own hands," said Brian Cladoosby, the chairman of the Swinomish Senate and president of the National Congress of American Indians.
The breaking point came in 2015, after Washington's Legislature — pressured by the dental lobby, Cladoosby said — declined for the fifth year in a row to pass a bill allowing a therapist program. Asserting tribal sovereignty, the tribe forged ahead anyway.
"The American Dental Association is no friend to American Indian tribes," Cladoosby said in an interview.
A spokeswoman for the American Dental Association, Dr. Jane S. Grover, said her group supports tribal self-determination, but that therapists — whatever the intentions behind their training or hiring — remain a bad idea.
"Drilling on a tooth is a surgical procedure," said Grover, who is the director of the association's Council on Access, Prevention and Interprofessional Relations. And surgical procedures, she added, "should be performed by a dentist."
She said that poor oral health, wherever it occurs, is a societal problem that can include elements of poverty, diet and lifestyle choice, not just access to care. But the ADA, Grover added, also has no plans to challenge the legality of the Swinomish project.
Cladoosby said he thinks that gives a green light to tribes everywhere.
"There are 567 federally recognized tribes, and I'm encouraging all of them to follow our lead," he said.
Midlevel dental care is already common in many other countries, including Canada, where it started in the 1970s in the Yukon to serve remote villages not unlike Alaska's. Three states have also begun inching toward allowing dental therapists. Minnesota has had a therapist program since 2009, though none of the 56 graduates so far are working with tribes. Maine authorized a therapist program several years ago, but has yet to put it in place. The Vermont Legislature passed a bill last month allowing dental therapists.
Kennedy, who was in the first graduating class in Alaska's program in 2008, said he got interested in it partly because his son was terrified of dentists. After two years of training, including a year of clinical work in a tribal area where he filled cavities for as long as 10 hours a day, he returned home not just as someone his son trusted for treatment, but as a veteran of what he called "dental boot camp."
"I had filled hundreds of cavities by the time I got back," he said.
William Bailey, 40, who was in the clinic on a recent morning for a drop-in visit after a rear molar flared up, said he likes looking up from the dentist's chair and seeing another person from Indian country.
"He knows what we've gone through," Bailey said as he waited for his mouth to go numb.
Kennedy said he hears that from many patients. "They're happy to see a native doing this," he said.
Dr. Rachael R. Hogan, a dentist who works at the Swinomish Clinic, supervises Kennedy's work. At first she did not think the arrangement would work. The ADA's safety concerns made sense, she said.
"I was leery," she said.
But after watching Kennedy for the past four months and visiting the training school in Alaska, she has changed her mind. By practicing procedures over and over — more than most dental school graduates, who must also study a broad range of diagnostic and disease issues — therapists can hone procedures, she said, to an art.
"Their fillings are better," she said. "Are we providing substandard care by providing a therapist? Actually, I would say it's the opposite."
And now what started here is getting a second wave. The state of Oregon authorized a pilot project in February allowing two tribes — the Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians and the Coquille — to hire dental therapists. By summer, four students from those tribes will be in Alaska for training.
A nonprofit tribal group called the Northwest Portland Area Indian Health Board helped the Swinomish Tribe get its therapist program started with grants from the W.K. Kellogg Foundation and the Pew Charitable Trusts, and it is also working with the Oregon tribes.
"This is huge for my family and my tribe," said one of the new students, Alexandria Jones, 24, a Coquille Indian who will begin training in July in Anchorage. It will be her first time in Alaska, and first time on an airplane.
"The Coquilles don't have our own clinic yet, so that's a long-term goal," she said. "That's my dream."