Position Paper on Access to Oral Health Care for Canadians

Approved
CDA Board of Directors
May 2010

Preamble

A daily regimen of brushing and flossing is an important part of good oral health while equitable access to professional dental care for all Canadians is essential for diagnosis, prevention and treatment leading to good oral and general health.

The Health Canada Oral Health Report Card (Canada Health Measures Survey 2010) indicates that most Canadians have access to professional dental care and, as a result, have good oral health. The study and related research findings also provide evidence that poor oral health is experienced by those Canadians who do not have access to regular dental care. Although, this reflects only a minority of Canadians it is important to note that these groups need the dental profession to advocate on their behalf for improved access to care. The groups within this minority for whom access to care is a known problem include: seniors, low-income populations, people with special needs, children and Aboriginal peoples.

Canada has one of the best oral health care delivery systems in the world with care primarily delivered through private dental clinics. Private dental offices are efficient providers of care; however, not all patients can access dental offices suggesting that alternative models of oral care should be explored to alleviate such inequities. Throughout Canada various models exist and are designed to meet the needs of these specific groups of patients. However, access to the clinics may be difficult for reasons outlined in detail below.

The provision of equitable access to care through various models of care for all Canadians is an important goal for professional organizations in dentistry. The collaboration between dentistry, our health professional colleagues, charities and the federal and provincial governments continues to improve access. The CHMS provides an opportunity to renew focus on this important issue by all stakeholders. The CDA believes existing professional, charitable and non-governmental programs should be maintained and new models developed to further strengthen our oral health delivery system. Successful models in one jurisdiction should be considered by other provinces.

Specific groups and their needs

Seniors

Canada's aging population poses significant health care challenges. Older adults and seniors are keeping their teeth longer than ever before. Professional care is therefore required for these adults, who may also have compromised immune systems, to prevent oral infection. While the ability to speak, eat and interact socially is important for all seniors, remaining free from oral infections and pain is critical for those with compromised immune systems.

Frail elders in long term care (LTC) are especially susceptible to aspirated pneumonia, but the younger seniors, including the newly retired, are becoming increasingly vulnerable to dental diseases due to aging dentition, being on medication, disability and illness. As noted in the CHMS, the number of decayed and missing teeth increases with age along with periodontal disease. This highlights the need for regular professional dental care and for appropriate strategies to address the future needs of this growing population of Canadians.

Additionally, there is higher rate of disability among seniors which renders them increasingly reliant on others for daily oral care and access to dental professionals. Moreover, the physical and cognitive disability that frequently accompany older age places substantial strains on the financial resources of our aging population. Given the potential health risks of undiagnosed oral diseases, ranging from dental caries and periodontitis to oral cancers, the potential cost to the health care system of untreated oral diseases could rise very substantially in the next few years. Consequently, there is merit in providing some form of dental assistance for low income seniors such as the seniors' plan provided by the Alberta government.ⁱ

While many provinces have related legislation in place, many Canadian seniors, especially those in LTC, do not have daily oral care, let alone access to professional dental care. Setting national and provincial standards for minimum oral health care in LTC facilities is critical to improving and maintaining the health of seniors. The CDA supports a baseline standard that all LTC facilities provide daily oral care supported by annual access to dentists.

The federal and provincial governments continue to develop strategies to address the health care needs of Canada's aging population. The CDA and the provincial dental associations are working with government and others to develop long- and short-term strategies that include:

• Educating seniors on the importance of maintaining good oral health;
• Educating families and caregivers in all ethno cultural groups on the importance of oral health;
• Developing mandatory oral health standards in LTC facilities for daily oral care and annual access to professional care;
• Supporting collaboration among health care providers to promote oral health as part of overall health;
• Supporting tax-based (income tested) dental benefits for seniors in LTC facilities and seniors with low income;
• Supporting LTC facilities to allocate space with the appropriate dental equipment to provide preventive, surgical and restorative care on site.

Low-income population

A proportionally small number of Canadians cannot access oral health care due to lack of finances. Many of them do not have dental insurance, cannot access dental care or are likely to forgo or delay essential dental treatment. The CDA believes that a strong social safety net can help reduce these health risks.

Poverty is a key social determinant of both oral and general health. For example, the utilization rate for Canadians with dental coverage funded by provincial income assistance programs is low. Furthermore, those who are covered frequently have poor oral health due in part to poor diet, lack of adequate oral hygiene and other key factors in disease prevention.

Dental diseases are mostly progressive and if left untreated they can occasionally result in hospitalization. The CDA believes that programs targeting low income groups to prevent, or diagnose and treat diseases before they escalate is far more effective management of public spending than paying for hospitalization.

For those who qualify for a program of government assistance, many find that their program is inadequate for their needs. The programs for the most part provide very basic coverage for dental expenses with strict limits on services and costs while others are restricted to emergency care only. Often these programs are underfunded and place heavy financial demands on dental professionals.

Fortunately, there are a number of successful oral health care initiatives across Canada. For example, in many provinces there are dental clinics providing free dentistry for the relief of pain and infection in low income areas. Dental schools across the country provide low cost preventive treatment programs to many communities that otherwise might not access professional care. Similarly dental hygiene and assistance programs provide low cost preventive treatment. Dental public health programs have many initiatives to bridge barriers to care for the financially vulnerable. Unfortunately, these initiatives and programs are inconsistent and are struggling for funding.

The CDA believes that public funding is appropriate and necessary where the ability to pay for dental care is a barrier to care. In Canada, dental benefits are provided to the majority of Canadians through private insurance plans funded through employment or public programs funded either at the provincial or federal level. Employment based plans, however, are often limited to full time employees and/or higher paying jobs and some working poor struggle without help. Expansion of public plans is critical for equitable access to dental care for all.

Canadian dentists, CDA and the provincial dental associations, are committed to working with governments and others to provide improved access to dental care for all, with particular emphasis on those most in need.

The CDA supports the following:

• Programs to educate about and encourage oral hygiene, diet and health awareness in schools and public health clinics;
• Oral health be an integral part of public health policy to meet the needs of those in poverty;
• Improvement and expansion of dental public health programs and private plans within the present oral health care delivery system;
• Expanding mandatory standards for dental public health programs and provincial income assistance plans;
• Accurate measures for determining disease level and monitoring program outcomes;
• Developing partnerships with government sponsored employment programs to include clinical dental examinations and basic dental treatments;
• Developing partnerships with housing support programs to provide dental care;
• Increasing awareness of all caregivers on the importance of oral health.

Special needs patients

Patients with physical and developmental disabilities have special dental care needs because the ability to eat and interact socially is critical to their well-being and good health. However, they are particularly prone to dental caries and periodontitis that can have a catastrophic impact on their survival and ability to thrive.

Medical problems limit their ability to be responsible for self-care. For those that are homebound, access is even more difficult. Homebound patients rely on caregivers for many aspects of their health care including daily oral care. Adding to their already compromised oral health is the fact that certain prescribed medications for chronic diseases including neurological and psychological disorders which can contain large proportions of sugar, disturb the saliva, dry the mouth and promote the growth of fungal infections orally and systematically greatly increasing the risk of dental caries and tooth loss. Further to this, although mobile equipment could be used to deliver oral health care to these patients, there are limits to the extent of treatment that can be provided in the home. In those cases all other treatment may require medical transportation to a dental office or hospital.

The majority of special needs patients are covered by provincial dental plans which are separate from the provincial medical plan. Typically, these plans are underfunded with limited services that may not reflect the complex needs of these patients or the usual standard of care accessible to other Canadians.

For many patients, dental treatment is provided through a combination of private dental offices and hospital settings. In many cases, despite the increased risks, competent dental treatment including examinations and radiographs can only be provided under general anesthesia.

The CDA supports the following:

• Developing electronic health records to facilitate the care of special needs patients in multiple care settings;
• Funding or tax relief for clinics with specialized equipment needed to service the health care of special need patients (dental chairs adapted to use wheelchairs, for example);
• Measuring disease rates in this population and providing data to the provider community;
• Ensuring accurate measure for determining disease level and monitoring program outcomes;
• Reducing the use of sugars in medicine;
• Enhanced tax-based (income tested) dental coverage that recognizes the medically complex needs of patients with special needs.

Children

Childrens' oral health has improved significantly over the past few decades reflecting the success of prevention and early intervention programs. Despite these gains, dental decay is more common than asthma and, in extreme cases; dental decay (caries) can lead to hospitalization requiring operating room time to deliver treatment under anaesthesia. However, dental decay is preventable. This begins with educating parents and caregivers about dietary habits and daily hygiene, professional dental care and fluoride.

Dental visits should begin during an infant's first year to provide preventive therapies and diagnosis. These visits are critical for the early diagnosis and prevention of dental decay. Inappropriate consumption of milk, juice and sweet snacks can have devastating results including pain and infection, with severe cases requiring hospitalization. Good oral health habits including a healthy diet and oral hygiene can prevent the disease. Obtaining and maintaining good health in childhood is an important investment in a healthy population for the future.

Fluoridating municipal drinking water is another important investment for all age groups and particularly children. Scientific evidence continues to support the health promoting effects of fluoridating drinking water which is a cost effective method of preventing dental caries (tooth decay).

Sadly, there is a strong association between poverty and dental decay and families of children at high risk usually have low incomes among a myriad of other challenges. Unfortunately, dental benefit programs offer very limited help for many of the families in this situation because of other difficulties that hinder their access to dental care. Some public health programs provide care directly through school programs. Other successful strategies identify high risk children through infant inoculation programs to provide the necessary support for their parents and caregivers.

An investment in infants' and childrens' oral health is an investment in lifelong health. Coordinated educational programs need to be incorporated in public educational curriculums, outreach programs and community health centers as part of a larger collaborative approach with dental organizations, child poverty and advocacy agencies, non-dental health care providers and government.

The CDA supports the following:

• Education and support of expectant and new mothers;
• Including oral health as an integral part of early childhood development programs;
• Fluoridating public drinking water;
• Examining targeted preventive programs for the population;
• Ensuring accurate measures for determining disease level and monitoring program outcomes;
• Coordinating public health programs including outreach programs.

Aboriginal Peoplesⁱⁱ

The Aboriginal people of Canada include First Nations, Inuit and Métis. The barriers to care for Aboriginal populations is directly linked to the many determinants of health, including poverty, employment, education, social environments, geographic location and social supports. Aboriginal populations continue to experience poorer oral health than the general population, despite the provision of a federally funded dental care plan. Unfortunately, program utilization rates of Aboriginal people in this dental program are far lower than rates for employer sponsored plans.

However, there are a number of outreach programs operating both on and off reserves that are making a difference such as the federal government's Children's Oral Health Initiative (COHI)iii which identifies and supports parents and caregivers of young children to provide fluoride varnish and daily at home oral care. Expanding these programs is much needed.

Furthermore, the CDA will continue to work with Aboriginal people and government leaders to improve their access dental care. Here too, education programs that are culturally appropriate and raise awareness in the community can help promote good oral health. Support networks need to be established and a collaborative approach used to build community capacity to address the oral health disparities that exist within this population.

The CDA supports the following:

• The development of programs to attract Aboriginal peoples to dental professions;
• Improving the COHI program by increasing the number of dental health workers on reserves;
• Creating and supporting educational programs to promote culturally appropriate prevention of oral disease and tooth loss at all stages of life;
• Accurate measures for determining disease level and monitoring program outcomes;
• Develop models of care that address the issues facing remote communities;
• Support water fluoridation efforts on reserve and other aboriginal communities.

Summary

Finding solutions to the multitude of problems of access to oral health care is not simple and no single organization, government agency or community can solely address the disparities in the oral health of Canadians. The CDA believes that only a collaborative approach among those who have the capacity to contribute to this challenge will lead to equitable access to dental care and ensure good oral and general health for more Canadians.

The CDA, as the body that advocates for the principal providers of oral health care, recommends the development of a national action plan to reduce the barriers to access to dental care. The action plan should incorporate the following goals and principles:

1. Oral health is an integral part of general health;
2. All Canadians have the right to good oral health;
3. Dental caries (decay) is a preventable chronic disease;
4. A collaborative approach is needed among oral health care providers, medical and other health care providers, along with provincial and federal health departments and educators;
5. Dentists, as the oral health experts in Canada, play a primary role in planning and implementing recommendations and initiatives to prevent and manage oral disorders;
6. Creating new minimum mandatory standards for Canadian dental public health programs and providing sufficient resources to meet these standards; and
7. Alternative models of care or funding should be explored to alleviate access to care inequities.

i For more information see: http://www.seniors.gov.ab.ca/financial_assistance/dasp/
ii http://www.hc-sc.gc.ca/fniah-spnia/index-eng.php
iii http://www.hc-sc.gc.ca/ahc-asc/activit/strateg/fnih-spni-eng.php#cohi-isbde