Time to listen to what our mouths are telling us We need to give oral health the attention it deserves

May 24, 2017

There’s no debate, the facts definitely speak for themselves—the connection between good oral health and overall health is well-documented in the scientific evidence (…as you may recall from the March 2014 edition of The Inside Story). With a solid body of evidence about the importance of good oral health, why is it that our approach to health care in Canada seems to favour health issues below the neck? What’s going on? Let’s break it down…

What is oral health? 

Your teeth are just part of oral health. The World Health Organization defines oral health as, “a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss and other diseases and disorders.”1

And the Fédération Dentaire Internationale (FDI) World Dental Federation describes oral health as multi-faceted and that it “includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex.”2

For good overall health, open wide

Oral health care rarely gets the spotlight even though good oral health enables us to breathe—not to mention, eat, drink, speak, and smile. So instead of the underdog, why isn’t oral health care a “top dog” right up there with other medically necessary services?

 The scientific evidence reveals various links between good oral health care and disease prevention and disease management. For example, in addition to an association between good oral health and identifying cavities and gum disease, links have been found between oral health care and oral cancer, as well as a range of other conditions:

  • Cardiovascular disease: People who have gum disease or a history of it, also tend to have coronary heart disease. Research is also investigating the association between oral bacteria and blood clots and the relationship between gum disease and stroke.3
  • Diabetes: The presence of dental issues can lead to investigating whether the patient may have undiagnosed diabetes or pre-diabetes.4
  • Respiratory illnesses: Research has shown a link between some patients with an above-average number of gum problems and a higher pneumonia rate.5
  • Osteoporosis: Bone loss in teeth can sometimes indicate the first stages of osteoporosis.6

…Premature labour, low birth-weight babies, and even Alzheimer’s disease—research continues to find links between oral health and overall health but oral care continues to take a backseat to other health care issues. 

This may in part be due to Canada’s approach to health care that often considers the head as separate from the rest of the body—if the head is considered at all. We also see this head/body disconnect regarding mental health (which fortunately is increasingly getting the attention it deserves). By contrast, oral health is still disembodied—its role continues to be under-emphasized.

The trend in health care toward a holistic approach may help get the head firmly affixed on the body with more attention paid to oral health care. You can think of a holistic approach as focusing on the whole person rather than on just a specific illness or body part. The idea is that an issue with one element of the body, can be far reaching—physically, mentally, emotionally, and spiritually.

Oral health care is becoming more frequently viewed as a medical necessity, and various dental associations and public health organizations internationally have recognized oral health as a basic human right. For example, as one researcher put it, “Dental care was recommended in the 1964 Royal Commission on Health Services that helped shape our current health care system but has yet to become a part of publicly funded health care. This has left almost one third of Canadians without dental insurance, leading to poor health outcomes and stark inequalities. Evidence indicates that dental care should be incorporated into Canada’s existing system as it is medically necessary, will decrease long term costs, and its inclusion will promote accessibility and comprehensiveness in our system.” 7 So what is the state of the nation; do all Canadians have access to good oral health care?

The state of oral health care in Canada

The situation is definitely nothing to smile about as approximately 32% of Canadians8 have no access to dental coverage. Here’s why…

Unlike health issues below the neck—that are mostly publicly covered—by contrast, oral health care issues are mainly privately covered. For example, Canadians access dental benefits through their employers’ dental plan or they have private dental insurance that is not employment related. Others pay directly out-of-pocket for oral health care services as needed.

Publicly funded oral health care services

  • Federal government programs are designed for Canadians who meet eligibility requirements related to indigenous status, military personnel, veterans, federal prisoners, refugees, and the Royal Canadian Mounted Police. 
  • Provincial/territorial government programs are designed for Canadians who are eligible for surgical dental services that require hospitalization or the procedure is associated with a medical need or a medical issue that developed before birth (congenital anomaly). In addition, there are programs that target Canadians who meet eligibility requirements related to social assistance recipients and their dependents, as well as certain child, adult, and senior citizen populations (e.g., low-income families), and some disabled and institutionalized populations (e.g., those in long-term care), certain individuals with developmental disabilities, and provincial prisoners.
  • Municipal government programs are also sometimes available—depending on various issues like cost-sharing arrangements with the provinces—and have programs for social assistance recipients and their dependents, certain child and adult populations (e.g., low-income families), and some disabled and institutionalized populations (e.g., those in long-term care).

And although a small number of publicly funded programs do exist, the inequities are obvious; some governments—not all of them—offer programs for certain vulnerable groups, but not other groups. For example, some offer services for children from low-income families, while others don’t, and in turn, some offer services for certain seniors, while others don’t. Even when programs are available, they typically cover a limited range of basic services. This lack of consensus on standards of oral health care provision among Canada’s federal, provincial, territorial, and municipal governments is often cited as a major issue.

The result is that a significant number of Canadians are not getting oral health care: a breakdown of this private/public approach to providing oral care reveals that approximately 62%9 of Canadians have private dental coverage and just 6%10 of Canadians are covered by publicly funded programs.

This 32% with no access to dental coverage represents some of the most vulnerable Canadians. Although many in this group may be working, they don’t have an employer-sponsored benefits plan—and are often just making enough to survive—so private insurance is not an option; meanwhile their income level may be above the threshold to qualify for a publicly funded dental program. Others may be contract workers or self-employed and facing similar challenges. In fact, experts explain that “in some cases, the working poor now have worse access to oral health care than their lowest income counterparts, as the latter have access to public insurance while the former do not.”11 And some unemployed people—who could qualify for assistance—do not access it, for a range of complex reasons.

Overall, experts describe the situation as a “patchwork of basic dental programs” that doesn’t appear to be getting the job done. The Canadian Dental Association (CDA) explains that “in particular, Canadian families and individuals with lower incomes and of lower socio‑economic status, those without dental insurance, older Canadians and Indigenous Canadians experience worse overall oral health outcomes than the general population.”12

Canada’s reliance on private dental insurance—with just a limited part played by publicly funded programs—means that that it’s not just those that we traditionally consider as vulnerable who are increasingly at risk. “Research shows that access to dental care may be getting more difficult for the middle-income segment of the Canadian population as well. Middle-income workers have experienced significant changes in their work environments, which includes decreases to both the amount and availability of employment-based dental insurance.”13 In addition, “As jobs become less secure and more part-time in nature, benefits are eroded and more and more people in Canada have significantly reduced dental coverage, or none at all.”14

Even for those with a health benefits plan, dental coverage varies by employer and may be quite basic—plus many plans require a co-pay or other cost sharing. For example, the CDA explains that “Some plans are also taking other approaches to limit plan spending: setting annual deductibles, capping the dollar amount, or limiting the number of visits covered within a year.”15  

Dental care is anything but cheap…

Scanning the provincial dental fee guides—that most dentists base their fees on—reveals that the costs can really add up, especially for families. Some examples:

  • Recall exam: $55
  • Scaling (removal of tartar up to 15 minutes): $45
  • Two X-rays (bitewing): $25
  • Two surface composite (white) filling: permanent bicuspid: $195
  • Two surface amalgam (silver) filling: permanent molar: $125
  • Root canal therapy (one root): $500
  • Complete upper denture: $1,180 including lab fees
  • Metal (gold) crown: $990 including lab fees

…And if you need major services like bridge procedures or root canals followed by crowns, the pricing can be in the thousands of dollars.16

Beyond just availability and affordability…

Even when publicly funded programs are available, not all those who could meet eligibility requirements take advantage of the programs. And even when affordability is not an issue—as is the case with employer-sponsored dental plans some plan members don’t access their plan for regular checkups. Why aren’t people getting the oral health care they need?

  • Low awareness of the importance of good oral health: As we’ve established, good oral health needs a major public relations boost; people may simply not be aware of the mouth/body connection and the importance of good oral health.
  • Unaware of availability of oral health programs: With oral health care taking a backseat in our health care system, many people may not even know that publicly funded programs exist.
  • Complicated processes: There is often a complicated and time consuming process for both patients and dentists to access public dental programs that may be a deterrent for both groups.
  • More immediate priorities: Vulnerable people are typically coping with tackling immediate issues like food, shelter, and mental and physical health, as well as challenges regarding language and cultural barriers or isolation. And regarding people with private dental insurance, being time poor may be the biggest culprit, or dare we suggest, are we often just lazy?
  • Fear of going to the dentist: Some people suffer from anxiety triggered by even the thought of going to the dentist. This can stem from many issues like fear of pain or having had a bad experience. Dental dread can also be due to a distaste for the dental office—like the sound of drills.

…Overall in terms of barriers, the same way social determinants—like income and working conditions, social status, education and literacy, and physical environments—negatively impact overall health, these factors also negatively affect oral health care even when there is some degree of coverage available. For example, research reveals that the elderly, people living and working in poverty, young children, people living in rural areas, recent immigrants, refugees, aboriginal people, and disabled people have both the highest level of oral health problems and the greatest difficulty accessing oral care. To learn more, watch this short video:

Inequalities in Oral Health Care and Access to Dental Services among Canadians

https://www.youtube.com/watch?v=y_mxYIY08WY

Fortunately, improving the state of oral health care in Canada is possible. Although tackling the issues is anything but simple—and it can’t happen overnight—the bottom line is that everyone deserves a healthy mouth and smile plus the overall health and quality of life benefits that go along with it.

All Canadians should have access to good oral health care

The Canadian Dental Association “believes the provision of equitable access to care is an important goal for professional dentistry organizations. Collaboration between dentistry, health professional colleagues, charities and the federal and provincial governments continues to improve access. In addition to maintaining existing professional, charitable and non‑governmental programs, new models should also be developed to further strengthen our oral health delivery system.”17

The scientific evidence is telling us to listen to what our mouths are telling us: Dental care is a medical necessity. Of course, with GSC’s mission—to create innovative solutions that improve access to better health—we’ve never been ones to sit back while those in need struggle. “In fact, we’re the exact opposite,” explains Steve Moffatt, GSC’s Chief Strategic Growth Officer. “We’re always looking for ways to take action. In fact, regarding the challenges around good oral health care, we’ve made a commitment to provide the necessary leadership to become a catalyst for change. We recognize that this will be a long-term process, but our goal is to build on the scientific evidence and make a difference in the lives of millions by ensuring all vulnerable Canadians have access to essential oral health care services.”

Steve also explains that to accomplish this goal, GSC’s main strategy is collaboration. “We are engaging with everyone we can to look at the issues from all perspectives and gather this combined wisdom regarding what direction to take and what kinds of initiatives to pursue. We’re aiming for a long, long list of collaborators—from federal, provincial, territorial, and municipal governments to dentists, dental professional regulatory bodies, professional associations, dental educators and other health care professionals and researchers, as well as advocacy groups and vulnerable people themselves.”

We’ll be reporting back on GSC’s overall plan of attack regarding improving the state of oral health care in Canada but until then Steve encourages everyone to…

“As they say these days, join the conversation!”

Sources:

1, 2, 12, 13, 17 “The State of Oral Health in Canada,” Canadian Dental Association, March 2017. Retrieved April 2017: https://www.cda-adc.ca/stateoforalhealth/.

3 “Can periodontal disease ruin your overall health?” Ontario Dental Assistants Association website. Retrieved April 2017: https://odaa.org/can-periodontal-disease-ruin-your-general-health. “The link between periodontal disease and cardiovascular disease: How far we have come in last two decades?” Prasad Dhadse, Deepti Gattani, and Rohit Mishra, 2010, US National Library of Medicine National Institutes of Health website. Retrieved April 2017: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100856/.

4 “Can periodontal disease ruin your overall health?” Ontario Dental Assistants Association website. Retrieved April 2017: https://odaa.org/can-periodontal-disease-ruin-your-general-health. “Diabetes and periodontal disease: a two-way relationship,” L. Casanova, F. J. Hughes, and P. M. Preshaw, 2014, British Dental Journal. Retrieved April 2017: www.nature.com/bdj/journal/v217/n8/full/sj.bdj.2014.907.html.

5 “Can periodontal disease ruin your overall health?” Ontario Dental Assistants Association website. Retrieved April 2017: https://odaa.org/can-periodontal-disease-ruin-your-general-health. “Bad dental health can lead to pneumonia,” Yale study suggests, Richard Alleyne, 2011, The Telegraph. Retrieved April 2017: www.telegraph.co.uk/news/health/news/8979191/Bad-dental-health-can-lead-to-pneumonia-Yale-study-suggests.html.

6 “Oral Health and Bone Disease,” National Institute of Health Osteoporosis and Related Bone Diseases National Resource Centre website. Retrieved April 2017: https://www.niams.nih.gov/health_info/bone/bone_health/oral_health/default.asp. “Dental Care in Canada: the Need for Incorporation into Publicly Funded Health Care,” Elisabeth McClymont, 2015, University of British Columbia Medical Journal. Retrieved April 2017: https://ubcmj.com/ubcmj-volume-7-issue-1/dental-care-in-canada-the-need-for-incorporation-into-publicly-funded-health-care/dental-care-in-canada-the-need-for-incorporation-into-publicly-funded-health-care/

7 “Dental Care in Canada: the Need for Incorporation into Publicly Funded Health Care,” Elisabeth McClymont, 2015, University of British Columbia Medical Journal. Retrieved April 2017: https://ubcmj.com/ubcmj-volume-7-issue-1/dental-care-in-canada-the-need-for-incorporation-into-publicly-funded-health-care/dental-care-in-canada-the-need-for-incorporation-into-publicly-funded-health-care/.

8, 9, 10 Healthy Living: Canadian Health Measures Survey, Health Canada website. Retrieved April 2017: www.hc-sc.gc.ca/hl-vs/pubs/oral-bucco/fact-fiche-oral-bucco-stat-eng.php

11 “Improving Access To Oral Health Care For Vulnerable People Living In Canada,” The Canadian Academy of Health Sciences, 2014. Retrieved April 2017: cahs-acss.ca/wp-content/uploads/2015/07/Access_to_Oral_Care_FINAL_REPORT_EN.pdf

14 “Canada's private dental care system fails the most vulnerable,” Paul Allision, Montreal Gazette, 2016. Retrieved April 2017: montrealgazette.com/opinion/columnists/opinion-canadas-private-dental-care-system-fails-the-most-vulnerable

15 “Understanding Co-payment: What is co-payment?” Canadian Dental Association website. Retrieved April 2017: https://www.cda-adc.ca/en/oral_health/talk/copayment.asp

16 2017 Provincial dental fee guides; approximate costs rounded up.