Canada’s dental program only matters if it gets children into dental offices

The Canadian government recently committed to implementing a national public dental program. When fully implemented, the dental plan will provide coverage to those under 18, seniors and people with disabilities although the scope of services is yet to be determined.

As a first step, in December 2022 the government launched an interim Canada Dental Benefit that will be offered for two years, giving the government and health-care professionals time to design the full program. The interim benefit is available to low-income families (below $90,000 per year) with children 12 years old and younger who do not have access to dental insurance. Families can collect a maximum of $650 per child per year if they have incurred dental-care expenses or plan to during the year. This benefit is an important first step, although it may not cover all treatment costs for low-income families, especially those who have avoided the dentist for a long time.

This benefit is timely. An estimated one-third (32.4 per cent) of Canadians have no dental insurance, and those without dental insurance are less likely to visit the dentist. One consequence is greater reliance on hospital services. Recent pressures on Canada’s health-care systems that resulted in closed emergency departments and postponed treatments highlight the urgency of initiatives to reduce demands on hospitals, including surgeries whenever possible. Dental care is usually outside of the basket of publicly insured general health-care services, but this changes when oral health services require use of general anesthetic and an operating room. This can occur when cavities become so severe that affected teeth need to be removed under a general anesthetic. It is also a largely preventable use of hospital resources as severe cavities are almost always preventable through multiple strategies, including visiting a dentist during early stages of the cavity development. (We deduce that in Canada the mouth is considered a part of the body within the walls of an operating room, but not outside it).

Surgery for teeth extractions is very common among children, with teeth extractions being the most common day surgery in Canada for children under 6 (31 per cent of child day surgeries), ahead of myringotomies (tubes in ears, 19 per cent) and tonsillectomies and/or adenoidectomies (11 per cent) in 2010-2012.

In addition to taxing hospital resources, the surgeries put huge stress on children and families. When dental problems are untreated, including when waiting for surgery, children miss school and have lower academic performance. They also often experience debilitating oral pain that interferes with their eating, sleeping and socializing. Ongoing pain can hinder a child’s physical and social development. One dentist described the excessively long wait times for children to receive dental surgery as tantamount to child abuse. In 2021, while waiting for oral surgery, a child in Northwestern Ontario (Sioux Lookout First Nation Health Authority) developed dental infections that led to sepsis and systemic complications, and ultimately to death. This death was preventable via so many avenues. While less important, these long wait times also carry economic consequences as they commonly result in missed school and work for the children and their parents. In Canada in 2015, it was estimated that 2.26 million school-days were missed due to dental issues.

Given the pressure on hospitals, the rates of pediatric oral surgeries and the stress and costs associated with waiting for oral surgeries, the need for improved accessibility to community dental care is hugely important, and targeting children first makes great sense. If the new dental benefit gets children into dental offices, they may receive treatments that prevent cavities altogether or stop their progression. For example, routine application of fluorides and dental sealants (e.g., 2-4 times/year) can effectively inhibit tooth decay. Another example is silver diamine fluoride (SDF) that is specifically recommended as a low-cost option to delay cavity development or avoid the need for surgery in young children.

The planned program will only improve the oral health of children if they actually visit oral health-care provider.

However, the planned program will only improve the oral health of children if they actually visit oral health-care providers and, ideally, see the same oral health-care provider repeatedly and build a rapport.

But how likely is it that children will get into the dental offices? Even when dental care is available and dental services are provided at no cost to the patient, often more than one-half of eligible individuals do not access dental care. For example, in the B.C. Healthy Kids Program, only 41 per cent of the children who were registered for the program accessed it. In Quebec in 2019, the Public Dental services program had an uptake of 52 per cent for children under 10 and 35 per cent for children over 10. In Prince Edward Island in 2018, the Children’s Dental Care Program–Preventative Dental Services provided services to only 44 per cent of the 25,535 eligible children.

Many factors beyond cost affect access to care. Regarding oral health, the cost of dental services is certainly a barrier. However, even when no-cost dental services are available, other barriers persist. Among these are:

• Availability. Some communities lack permanent dental clinics. This includes but is not limited to many First Nations reserves in Northern Ontario, requiring travelling off reserve for care or waiting for fly-in providers to receive episodic care.
• Accessibility. Eligible participants must have time and funds to cover travel to the clinic, be able to get time off work if the clinic only has daytime hours, and secure childcare for children at home.
• Awareness. Eligible participants may lack oral health literacy, program awareness or feel unequipped to tackle the enrolment process.
• Acceptability. Eligible participants may have a mistrust of, or fear disrespect from, oral health-care providers.

Strategies are available to address these barriers such as: employing a dental care coordinator navigator to help families address structural barriers; providing services in accessible settings such as schools or daycare or long-term care; and integrating dental with medical services such as in community health centres. Without opportunities to identify and address barriers, it is unlikely that the program will be used as intended. Helping individuals access care and establish a relationship with a dental team is critical to building trust and reaching good oral health.

Offering direct payments to low-income families without accompanying outreach, education or strategies to increase attendance is unlikely to dramatically improve oral health in young Canadians. This involves working with communities to educate them about oral health and build trust in those who could benefit from the program. We also need to monitor utilization and gather feedback from participants and nonparticipants so we can learn what is needed to make it better.

Let’s do this right and realize that our mouths are key parts of our bodies, even outside of the operating room. Because ultimately, oral health is critical to overall health.