Erik Linduska, who lives in Bethel, Alaska, a town of 6,000 on the Kuskokwim River, travels among the state's tiny coastal villages, drilling, filling and cleaning the teeth of the children who live there.
Linduska is not a dentist. He's certified by the state of Alaska as a dental health therapist and ventures to villages so rural no dentist has ever set up shop.
Many of Linduska's patients are Native children and most have never been to the dentist. They open their mouths to show him proof: abscesses, cavities and discoloration.
If a children's advocacy group has its way, dental therapists like Linduska could be treating children in Washington state.
In January, State Rep. Eileen Cody (D-Seattle) will introduce legislation that would create a two-year professional certification for a mid-level dental worker, which would provide more training than a hygienist, but less than a dentist.
The Children's Alliance, which is sponsoring the effort, compares the role to that of a physician's assistant, nurse practitioner or midwife.
The role would fill a need. In Washington state, there are about 600,000 children on Medicare. About half of these children don't have access to dental care, either because there's no dentist in their area or there's no dentist who accepts Medicare.
But not everybody's willing to bite. The Washington State Dental Association opposes the measure, mostly on the grounds that two years of training is not enough to teach someone how to handle procedures like fillings and extractions, which they consider surgical.
"With permanently altering the structure of the mouth, we don't think two years is enough training," said Bracken Killpack the Washington State Dental Association's (WSDA) director of government affairs.
D.D.S. is best?
Despite opposition from dentists' groups, the idea has caught on in the Lower 48. Minnesota adopted a dental therapy program in 2009. Therapists there must receive two years of training after getting their four-year degree. But it's too early to evaluate Minnesota's program. The state's first advanced dental hygiene practitioners will receive their certification next month.
The proposed Washington legislation creates a two-year, post-high school program that culminates in an advanced dental therapist certification.
Is that enough? Killpack, of the state dental association, doesn't think so.
"I don't think you can train someone to diagnose dental disease and all of the symptoms and also fit in surgical competency in two years," he said.
Bolstering the 31 community clinics providing cheap dental care in King County would do more for the children, he said.
Besides, Killpack said, affordability is not the only -- or even primary -- reason most people fail to seek dental care for their children. Only 58 percent of those who have private insurance for dental care actually seek treatment, while 52 percent of those who are on Medicare seek dental treatment.
Education, not a new professional role, will get more kids to the dentist, Killpack said.
"We think there is enough chair capacity and dental capacity in this state if we can make our dental offices and community clinics more efficient," he said.
Mary Williard, director of the dental training program in Alaska, said research shows dental therapists can treat patients safely.
More training drives up the cost of care and pushes dentists into cities, where they can make more money, she said.
Alaska's program is a good place for Washington to start, said Gould, of the Children's Alliance.
"There's really nothing about the model that doesn't make it mainstream and make it applicable to a variety of health care settings," he said.
By preparing for a future shortage in dentists, the whole state could benefit, he said. In Washington, new dentists are not taking up the drill as fast as older ones are retiring.
The state dental care system could lose as much as 37 percent of its current dentists to retirement by 2017.
"We need a work force that can respond to that," Gould said. "The dental work force as it is now constructed is really missing a key player."