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Episode 24: The state of dentistry in Canada

In episode 24, host David Willows and producer Sarah Murphy invite Dr. Carlos Quinonez to the podcast studio to talk about the state of dentistry in Canada in 2020 and how it impacts benefits plans.
And now for something completely indifferent

And now for something completely indifferent

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Episode 24 Transcript

[INTRODUCTION]

[00:00:15] SM: Hello and welcome to another episode the GSC podcast And Now For Something Completely Indifferent where well be discussing the hottest topics and trends in Canadian health benefits. I am the producer and editor, Sarah Murphy.

Before we get started with today's episode, we would like to remind listeners that the views expressed in this podcast are those of the individual speaking and not necessarily the views of GSC. We may talk about possibly controversial subjects, and therefore reserve the right to potentially offend some listeners but were apologizing for it up front. You can download this podcast from our website at greenfield.ca/podcast or subscribe to it from wherever you get your podcasts.

We also encourage you to read our publications, The Inside Story, Follow the Script, and g(sc) TALK, which you can also download from our website. Please be sure to follow the conversation on Twitter and LinkedIn.

[INTRO]

[00:01:07] SM: Now, lets get started. Todays episode is hosted by David Willows, GSCs EVP of Digital, Innovation, and Brand Experience. Hello, David.

[00:01:17] DW: Hi, Sarah. I think this is probably the last time well be in the studio for a little while. We just interviewed Dr. Carlos, and I'll explain who Dr. Carlos is when we get to the content of the podcast. But the coronavirus clouds are gathering over Canada and more and more talk of how we are going to work and gather as people. The NBA has been canceled, and I think starting next week therell be a lot more talk about moving out of where we normally work and getting into other spaces. I'm not sure when this is going to come out, whether its going to be in March or in April. But I hope whenever it does, it gives people some content to listen to and times that I think are going to be quite different than they are right now.

[00:02:06] SM: Certainly.

[00:02:07] DW: If I can guess, I think when people are settled into that different world, they're going to want to have a 40-minute podcast on dentistry in Canada.

[00:02:15] SM: Yes, absolutely. The folks are going to be asking for that.

[00:02:19] DW: We thank Dr. Carlos for coming in. He's probably one of the most esteemed talkers about dentistry in Canada and specific around public health and dentistry. We are lucky to get him, and lets go right into it.

[00:02:30] SM: Thanks.

[INTERVIEW]

[00:02:34] DW: Okay, we are back in the podcast studio for a topic that we have not tackled before, which at its sort of highest level is oral healthcare in Canada, and I think were going to drill down. Oh, my goodness! It was a pun. I dont do puns but I just did it unintentionally. Were going to drill down to talk about dentistry. Oh, my goodness! I'm forever ashamed of that. We have with us today Dr. Carlos Quiñonez from the University of Toronto. Carlos, youre an associate professor at the faculty of dentistry.

[00:03:03] CQ: I am.

[00:03:03] DW: You're the director of the graduate program in dental public health.

[00:03:06] CQ: Thats right.

[00:03:07] DW: What is dental public health?

[00:03:11] CQ: I think the easiest thing is to compare it to medicine. In medicine, they have community medicine, essentially specialists in public health. We in dentistry have the exact same thing, except its just called dental public health or public health dentistry. If were using an older term, it would be called community dentistry. Just like there are oral maxillofacial surgeons or radiologists, orthodontists, and so on, there are also dental public health specialists.

[00:03:34] DW: Got it. Youre a dentist.

[00:03:35] CQ: Yes, sir.

[00:03:36] DW: How did you end up going from just the idea of sort of pure dentistry, poking around in peoples mouths, to all of the things that you're doing now?

[00:03:44] CQ: That is a bit of a longish story, so Ill make it short. I got into dental school when I was 19.

As I told you before the podcast started, I come from a family of physicians, and the joke in my family was, Carlos or anybody else, any other child in the family, you have all the options in the world that you can become any kind of doctor you want.”

[00:04:06] DW: Congrats.

[00:04:06] CQ: Thanks. My older sister actually paved the way. Shes actually a pediatric dentist and also an academic at the University of North Carolina. As I was trying to figure out what to do, my sister suggested, Hey! Why dont you give dentistry a shot?” I was 19. What did I know? So I said, Yeah, I'll try.” Lo and behold, I got into dental school. I was in dental school from 19 to 23. I was 23, still had no clue what I was doing in life. So I decided to buy some time as many young people do and took on an internship, which was a community dentistry internship which allowed me to work in the northern reaches of Canada, on the northern shore of Baffin Island in Central and Northern Manitoba, and also in hospital and long-term care sector and mobile operation in clinics in the Downtown Corner in Winnipeg, Manitoba where I'm originally from. I just fell in love with it and the rest is history.

[00:05:02] DW: Good, good. Thats terrific. This is a podcast thats a companion to an Inside Story that's coming out very shortly, where we talk a fair bit about the state of dentistry in Canada. We sort of veer in a little bit into sort of how it's impacting health benefits but we really try to make the first of two parts actually that were doing an inside story sort of about what it's like to be a dentist in Canada right now. Something that I asked you when we were preparing for that article Im going to ask you again today, sort of some perspective. Is it easier and better to be a dentist in Canada than it was 10 or 20 years ago or is it sort of a harder road to get down being a dentist in Canada in your opinion?

[00:05:48] CQ: There are always two sides to every story. It has two sides to a coin, so it really depends on who you ask, of course. But in preparing for this, lets see about how I might respond to that question, and let me just take a step back. Dentistry, the oral healthcare space and dental care markets, dental insurance markets, everything that surrounds that, including dentistry's institutions, are in a bit of a flux. So there's like a larger context of change in dynamic tension action and in our environment right now. To me, that ultimately boils down to the fact that dentistrys social contract is being renegotiated. What is the social contract? Well, every profession has one. Its unwritten. Thats essentially what can dentists expect from governments, from society, from the public, and what can they expect from us. Just like in medicine and law, all these social contracts are being renegotiated.

[00:06:52] DW: I would assume that there's some discomfort in the profession because of that change.

[00:06:57] CQ: 100%, 100%. I think your question is a timely one. Was does it mean to be a dentist today compared to 10, 20, 30 years ago? Ill say that I think I'm being true to my colleagues if I say that it's harder and more complex, and those two things clearly interrelate from the clinical side. I think the advancement of the science has come so far that that too is creating some change, and we can get into that if you like as well, related to as explosion of information which has implications for the clinical provider, as well as the patient.

[00:07:32] DW: Whats good and bad information?

[00:07:34] CQ: Yes, very much so. I think that there is clear business pressure. Things cost more, regulation and accountabilities on dentists and their practices because they essentially run mini hospitals are more than they've ever been. Then also, an important part of this is who's coming into the market, graduating dentists. I think we really need to pay attention to what are essentially crushing student loans and what that might do to their career choices to how they behave in clinical situations and so on. Were in a significant time of flux I would say.

[00:08:07] DW: Are we graduating too many people into a tougher marketplace, or do we actually have the right amount coming in and we just havent organized the system around them appropriately?

[00:08:19] CQ: I don't think anybody has done the work to figure out how many dentists we, in fact, might need. People often ask me this question in the context of do we have too many dentists. I think we have too many dentists in downtown Toronto. I think if you head out to other rural regions in this country, there might not be any dentists, so I would say that we have a maldistribution of dentists.

[00:08:39] DW: Thats true in many health practices.

[00:08:41] CQ: 100%, yeah. 100%. Yeah. That said though, we've done research to show that there are dentist deserts” even in the GTA, because its a private sector health space, so people have to go essentially to where their services can be paid for. That leaves several communities in the city in want of much needed care.

[00:09:04] DW: In terms of that first question I asked about 10 or 20 years ago compared to now, what are some of the big ticket issues where like clinically this has advanced so far in the last for a while that the job of a dentist is very different than it was before? There are some common examples that we would know from going into the dentist that, holy cow, that wasnt like that 10 years ago.

[00:09:23] CQ: Yes. New diagnostic or imaging techniques, if you've ever heard of cone-beam CT. This is the latest and greatest in terms of imaging your mouth, your head. But my sense is that that is being overused in dentistry. Its not necessary in a lot of cases, but people like technology.

[00:09:41] DW: Is this both practitioners and patients or is it just sort of the new toy for the dentist, and were going to use this?

[00:09:46] CQ: I would say both. But you probably have to be a pretty sophisticated consumer to know something about that. But all this is driven by social trends, the public's demand for certain services. Another is implants. In the past, implants were considered a really stable solution because it was mostly specialists doing it that had significant training. Success rates of implants were like 95% and up. We don't have a good sense of what the success for implants are today, but I would argue that they are less so, because now we have far more generalists doing it. Its not that theyre doing a poor job. I think its still acceptable but it's not people with advanced training doing that, and that always matters.

For example, the public demand for white plastic fillings. Thats a real issue that people don't want to talk about, but the reality is that based on the latest or the best available evidence that the amalgam silver fillings that you have in your mouth are still a better long-term healthcare solution. But who would want that in their mouth now? I mean, unless, of course, we go to gold, which is the best of all materials, but thats probably challenging for a whole host of other reasons.

[00:10:55] DW: Yeah. Its a mystery that scares me. Lets drive more gold in the medical plans. You talk a bit about the business of dentistry. What are some of the newer pressures that maybe dentists have now but didnt have 10 years ago, and what's coming down the pike at them? What do you think is going to even get more pronounced over the next decade or so if you're running dental practice?

[00:11:19] CQ: Ill start off with the first part of that which is what's going to potentially happen on the business side of dentistry in the next decade. Ill say that theres going to be much greater competition in saturated markets like Toronto, like Montréal, like Vancouver, like Winnipeg, like Saskatoon. Literally, thats where we are. In competition, it has some potentially very negative effects on patient care.

[00:11:42] DW: How does that hit the patient? What are some of the ways?

[00:11:44] CQ: Well, let me back up. I dont think – I think competition can be good, but dentistry is not a perfect market. No healthcare market is a perfect market. In fact, technically it's a monopoly, right? So were not selling widgets. Were not selling anything actually. Were supposed to be providing – were supposed to meet people's needs. But in a competitive market, that changes the service delivery dynamics. We've done research that demonstrates that dentist clinical decision-making changes in different situations, whether they have significant practice on significant student loan, whether there is more dentists around them, and so on and so forth. That's not a criticism of my fellow colleagues. Thats just human nature. In fact, this plays out significantly in the physician or hospital space in the US where it has mostly been studied.

[00:12:30] DW: Okay, fair enough.

[00:12:32] CQ: In line with that, there's going to be a lot more competition between GPs and GPs but also general practitioners and specialists. Were seeing that already, meaning general practitioners are wanting to keep things in house” because they need to keep that in order to keep the business going. That to me is a negative thing for patients, because specialist care is just that specialist care. That also undermines collegiality and what holds a profession together, which I think is important.

I think the other thing that is happening is decreases in insurance payments. What people don't realize is that insurance coverage in Canada is at an all-time high.  There are more insureds than there have ever been. I think now were close to like 74% of the population. No, that might be too much but 60, 70% of the population is covered by some type of insurance. But the quality of insurance has significantly changed over the last two decades, whether it be limiting annual maximums, whether it be not covering as many services, whether it be greater coinsurance, copayments, greater deductibles. Thats how insurance markets have changed.

I also want to make sure people understand that that is also not a criticism of insurance. Its not a criticism of anything. That's just the reality of changes in labor and employments markets. As insurers, you guys respond to the needs of employers, so that whole dynamic is at play. Point is the other thing thats happening is that insurers are paying less and less of the dental bill. I mean, we know this through our studies, so that means people are having to reach deeper into their pockets, which creates a whole set of other issues.

But back to the business side of dentistry, I spoke to you about cost and regulation, infection prevention and control, which incredibly important, especially right now with respect to the coronavirus and things like this. I mean, this is foundational to safe care but this costs money to be able to do this at the requirements that are needed now, which are nonnegotiable. Of course, the cost of equipment and supplies. I mean, everybody is being squeezed wheat. We know this, and ultimately that either gets passed on to patients or employers or insurers or it doesn't, but somebody's eating those costs.

Interestingly, we also have a shortage – well, people speak of a shortage of dental assistants. I haven't seen empirical evidence to that effect but I believe it, because everybody is talking about it. My dentist colleagues and my organized dentistry colleaguesassociations and so on are very concerned about a shortage of dental assistance.

[00:15:08] DW: Do you have any sense of what the room cause of that would be? Id be surprised that that is not an avenue where people are sort of steering themselves towards.

[00:15:17] CQ: I don't have a clear answer to that question actually. Its something that were starting to sort of try to assess as a research group. But remember, its not just your dentist. Its a dental team. Dentists dont do this alone. They do this through the help of some great people, whether it be denturists, dental assistants, dental hygienists, dental technicians, and so on. To see those areas of the market weaken, that has implications for the business side of dentistry.

Then the one that I think people talk about maybe not the least but the point is we are now thinking about a national dental care plan in Canada. What does this mean to the business of dentistry? Whether that happens, we can have a whole another podcast on that and what the factors are that influence that decision-making around that. But that will ultimately have significant implications for the business of dentistry.” It has some good, some bad. 

[00:16:07] DW: There would be price controls.

[00:16:12] CQ: There are many ways to achieve universal coverage of dental care, meaning everybody has coverage. There are some countries that do it specifically around the employer-employee relationship, meaning their insurance markets are healthy and robust. There are almost no countries that do it as a single pair in terms of homogeneity. It tends to not be a good thing in any social system, including healthcare. Does that partly include price regulation? It might. It might.

[00:16:43] DW: Would that be the fear though in that world?

[00:16:45] CQ: That would be the fear. But if your concern as a professional is your income, youve lost the battle right away. This is not about maximizing income, even though the natural human behavior is to be an income maximize. I am, you are, and so on. But there needs to be some cover around that. Of course, thats natural but that's not the priority here. The priority here is helping people meet their oral healthcare needs.

[00:17:13] DW: Let me ask you a bit about innovation and technology and change. I mean, you gave an example earlier around imaging, sort of changing the face of dentistry. As a whole, do you think dentists are quite progressive about accepting new technology across the board? Or are there still pockets that don't? How do you see sort of the next 10 years coming up? Is there going to be an even greater revolution and do you think dentists are poised to embrace it?

[00:17:43] CQ: Ill answer that question and then I'll take a step back. The first response to that is it depends on the dentist. There are some dentists that are incredibly technologically savvy and love the latest toys and gadgets and approaches. Thats got its weaknesses but that could be positive too. Then there are those that just love the status quo and like to practice the way they practice 10, 15, 20 years ago. Now, thats not necessarily a bad thing because first principles will always be first principles, and safe and competent care is – You can do that by giving people silver amalgams or the latest in cosmetic dentistry.

[00:18:24] DW: It wasnt that bad 15 years ago, right?

[00:18:25] CQ: No, it wasnt.

[00:18:26] DW: I think it was a pretty good care, right?

[00:18:27] CQ: Yeah, of course. 30 years of pretty good care and some of the research in this area has actually come out of Canada. One of my colleagues at Dalhousie has found that it depends on a lot of different things for the dentist, meaning the cost. Is it easy to incorporate into their regular day and their workflow? What do their colleagues have to say? What do the specialists have to say? What are they being sold by private enterprise who likes to sell these things? All of these things are things at play.

Now, to take a step back, I think these are the things that are going to drive innovation and ultimately dentistry's appetite for such things. A chief among them is the connection between oral health and systemic health. Thats very popular right now to think about that. I have thought through what the right balance was between public and private in healthcare. What people don't realize is that if I unfolded your gums, I would have a surface area the size of the volar surface of your arm. For your listeners, just look at your forearm. From your wrist to the inside of your elbow, that whole surface area is the surface area of your gums. If that's infected, which is the issue here around the oral systemic health connection, you got a problem, right?

Now, whats interesting though is that the evidence isnt as strong as everybody talks about. I don't think gum disease is causing heart attacks. I don't actually think its actually causing much of anything. What I think it does do though is that its burdensome on your overall systemic health and its a bit of a slow burn, meaning by the time youre 60 and above, if you have had a lifetime of chronic infection in your gums, thats going to have a biological effect. We are seeing this based on some of the research that our group and others have done around the world.

I think digital dentistry and dentist workflow is going to radically change. You can now take pictures essentially to be very simple about it, whereas in the past you had to take an impression. So if anybodys ever gotten a crown, if you recall somebody had to take a mold of that. Those days are quickly disappearing. On top of that, theyre going to be able to print your crown down the hall in the machine, by the way, that costs hundreds of thousands of dollars. That wraps up into some of our other discussions. But nonetheless this is going to radically change dentistry.

I spoke about regulatory requirements and accountabilities. I think regulators at one point will have to step in and think about can dentistry continue in private market so heavily, where I think stuff that comes to market is safe. It has to be. Health Canada wouldnt allow it otherwise. But whether there's any therapeutic benefit is another story. Direct to consumer dentistry, the most recent of which is direct to consumer orthodontics is fundamentally changing our landscape for good or bad. It depends on which side of the charities or the table you sit there. If you really are suffering in terms of access, this could be a real solution for you. If you're worried about protecting your income, well, then maybe not so much. But these things do need to be considered earnestly and thoughtfully, because this isn't the panacea that some people talk about, the new consumer.

I have a colleague who told me about a book. Its like – Im assuming its a now famous book because Ive heard it in other places. But essentially, the tagline of the book is, Doctor, the patient will see you now.” I mean, people are much more in power and rightly so with respect to their healthcare, and the industry is right in that mix. The point is consumers are changing, and one of the things that research out of the American Dental Association has shown is that these different generational cohorts have very different relationships with her dentists. Young people today will say, Thanks for that. Ill move on somewhere else.” People say that these young patients arent as loyal. I don't know. I just think they have more choice and theyre more willing to exercise that choice.

[00:22:25] DW: They can find the choice, right?

[00:22:26 CQ: Exactly. Exactly. Again, I think ultimately this all boils down to the changing nature of dentistry. Specifically again, this is – I study a lot about this, so its my bias. Its this bad thing about the social contract, and that society is expecting different things of dentists and potentially vice versa.

[00:22:46] DW: Not a conversation happening?

[00:22:47] CQ: Very much so. If I can say something that gives me a lot of warm and fuzzies, its that my profession is deeply invested in thinking this through. There are those, of course, that agree with my position on it, those that disagree. But the fact that were having that discussion and that debate I think is incredibly healthy, and Im glad were having it.

[00:23:08] DW: You talked a bit about young people and inevitable change in the profession. You spent a lot of time with young people I think.

[00:23:15] CQ: I do, yeah.

[00:23:17] DW: In academia, are schools sort of maybe looking differently at who should be a dentist and who is coming into the school and what youre teaching them? Is that under examination?

[00:23:31] CQ: That is the conversation but I will tell you this, and this is where I get to lament about dental education. Dental education is also in a time of flux and a lot of that has to do with the fact that we are chronically underfunded. Universities, governments, they do not understand our operations, meaning we run a hospital. We run a dental hospital.

Compared to medicine, for example, medical students get to leave the building of a medical faculty and go to hospitals, go to community clinics. The faculty itself isn't burdened by those service delivery costs. We are and we also spend a lot of time delivering care to socially and economically marginalized individuals that come to us, partly because of some saving for them. Were providing the same level of care in terms of safety and so on that is done in a regular dentists office. Its students doing it obviously but theyre heavily supervised and so on to make sure standards are met, and were receiving less of the dental care dollar than a private practice. You do the math. Were suffering that way.

Id like to tell people I have students who are brilliant. The best part about them is that they're smarter than you. I have some ridiculously impressive students that are 100% interested in public health but cannot do the specialty because of their student loans, which is tragic. These are minds that could fundamentally shape the future of dentistry, but it doesn't happen because of things like student loans. Who gets in? What do we teach them? All on the table, all actively discussed.

I think the other thing thought is that both the public and private sector do not make substantive investments in dental education or in that space, and they should. If I was the public, I would want competent providers and, again, the private sector. How are we going to test these technologies if these things are not donated to dental faculties and medical experiments and studies conducted on whether the things work or don't work and so on and so forth? Unfortunately, that limits a lot of research and dentistry. Our national research associations don't invest tons in public research funds in dentistry. That said though, were trying our best, and I think overall were doing a good job.

[00:25:57] DW: My last question. Weve been hanging out with you for a couple years now and were going to talk outside of this podcast and outside of this publication about some of that work coming to fruition probably this year. Lucky you got to hang out some insurance people. You probably had maybe a different view of us and our role or learn more about us and our roles, sort of the benefits administrator and adjudicator. I think you also know that weve had interests sort of in the drug claim management side of really looking at sort of value-based benefits, and then what are our clients paying for thats smart and they should be paying for that, and what are they paying for thats just sort of a historic fact.

In 2020, maybe you can put some question marks around that. I dont want you to sort of walk towards the third rail of dentistry here and your colleagues listening and giving sort of this inside view, but I am going to ask you to do that. What do you think our clients maybe have traditionally paid for that its fair to say maybe you should think about that? What are the things that maybe theyre not paying for that are coming into existence that this is really valuable and will change your cost curve down the line if you consider paying for some things you havent in the past?

[00:27:09] CQ: I seem to be saying this a lot, which I guess that makes me an academic. Lets take a step back. I think there is interest in both the public sector and the private sector to what I term rationalize the goals of primary dental care and rationalize the dental care basket. What do I mean by that? If governments were interested in funding some dental care, I think they need to answer two questions, who and what. Lets forget about the who for now but what, right? What are they going to pay for? What do we know improves health? Where do we know theres good value for money? By the way, this conversation is alive and well in medicine too and in pharmacy and so on. I wouldnt want your listeners to think this is just a dental issue because its not.

Now, why would the private sector care? Well, I pay a premium every month. My employer pays a premium every month. Were very lucky that we have that.

[00:28:07] DW: That we can have that Green Shield benefit.

[00:28:14] CQ: Its great that we have relatively well-functioning system in that space, but those are still in some cases misallocated resources, and Ill get to the specifics in a bit. But the point is, first of all, public and private interest in rationalizing what the goals are here but then also rationalizing what we pay for. Weve done research in this area, a lot of research in this area. If you try to start rationalizing the primary dental care basket, you are in some serious issues. The first one is an issue of evidence.

Surprisingly, there is limited evidence in dentistry as there are in many other areas of healthcare. I experienced this personally, and my daughter was born three months premature. She's perfectly beautiful and healthy, thank the Lord. But when we went from high-risk maternal medicine to prenatal care, its almost like we crossed an evidence divide, right? Maternal – I dont mean to be critical of those high-risk maternal medicine folks, because theyre amazing. They helped us out a lot but they don't know anything. Im not an epidemiologist. Im a public health type person, so I was asking, Whats the absolute risk of this? Whats the relative risk of that?” They were like, Sorry, we dont have that information.” But once you move on to the neonatal side, they have it all. That's an overstatement, obviously, but you get what I mean.

In dentistry, were more like high-risk maternal medicine kind of thing, unfortunately so. Now, I always tell my students, don't take absence of evidence as evidence of absence. I think people really get on this evidence-based anything train now, like if there's no RCTs for it, there's no evidence. That's not true and nonetheless so. If you try to parse out the exact services, you have that problem. Fundamentally, youll end up having to depend on provider and patient preference to choose the services. That itself is a – I wouldnt wish that on anybody, because everybodys going to want orthodontics, veneers, and so on.

What weve done is we've developed a resource allocation framework, meaning if you have a certain amount of money, the first thing you want to pay for are those services that relieve pain and infection. We can all agree on that, right?

[00:30:24] DW: Exactly.

[00:30:24] CQ: After that, you want us to provide services that prevent disease, which seems pretty reasonable. Then you want us to provide services that restore [inaudible 00:30:31] function, then social function, and then the rest is gravy.

[00:30:35] DW: So theres a list [inaudible 00:30:37].

[00:30:38] CQ: Theres rules and principles that you can work by or a framework by which to make decision-making, which is wonderful. But then you have to make the list, so you're still faced with some of that original problem. We have to think that through. We've attempted it a couple of times and it almost killed me, but well get there. I'll give you the examples that I use. When was the last time you went to a dentist? [inaudible 00:31:01] question you.

[00:31:03] DW: Six months ago?

[00:31:03] CQ: Six months ago, okay. Did you get a cleaning?

[00:31:07] DW: Yup.

[00:31:07] CQ: Did you get some x-rays?

[00:31:09] DW: I dont think so.

[00:31:10] CQ: Did you get some fluoride?

[00:31:11] DW: I dont know.

[00:31:12] CQ: Okay. The point is if you were a low-risk person, meaning low oral health or oral disease risk, you may have not needed that, and it's seen in the insurance world. Were now to nine months. My insurance plan is great, covered by Green Shield, in fact. I get to go to the dentist every nine months if I want to, right? Ive never had a cavity in my life, so the question becomes do I need to go to the dentist every nine months. I might not need to. Im not trying to argue that people don't need to go. They need to go, and preventive care and so on is good. That's an example Ill give. At your visit, did you have your teeth polished?

[00:31:49] DW: I think so, yes.

[00:31:50] CQ: You think so, yeah. When I go, I get my teeth polished. It feels great.

[00:31:59] CQ: Guess what?

[00:31:59] DW: Yeah.

[00:32:00] CQ: No evidence of therapeutic benefit.

[00:32:02] DW: Now, we can cut you off. This is no good at all. I dont want to hear this.

[00:32:07] SM: Absence of evidence doesnt mean no.

[00:32:08] CQ: Yeah, I know.

[00:32:09] DW: Thats who we are. I forgot, yeah.

[00:32:11] CQ: It might make you feel better and that is a health, in fact. 

[00:32:14] SM: Theres something there though.

[00:32:16] CQ: But if you didn't have a lot of money.

[00:32:18] DW: Yeah, I know. Exactly.

[00:32:19] CQ: As a funder or as an individual. Theres trade-offs to be made, right?

[00:32:23] DW: Yes, absolutely.

[00:32:25] CQ: Whats interesting is my colleagues are going to go crazy when I say that. But nonetheless its true, and this has been a debate in public health.

[00:32:30] DW: We have very few listeners. Dont worry.

[00:32:32] CQ: In public health dentistry and so on for a long time.

[00:32:35] DW: Yes, Im sure.

[00:32:36] CQ: Now, Ill give you the other one that I told you earlier. There are the challenge between silver amalgam fillings and plastic white fillings. I am on the record of saying that there is no health concern with the mercury that is in your fillings. There might be some environmental concerns but that's for another day.

All right, we know that the plastic fillings don't last as long. We know that they need to be redone more often in mouths with a lot of disease. So if you have a lot of cavities, this is not the best choice for you, yet the public demands these hard-core, right? Dentists are left there. Its like, Well, I'd love to give the silver filling but my patients don't want that, and there's also cost of the practice to be able to provide a silver filling because they need something called an amalgam separator, meaning they need to essentially hive off the amalgam waste, because it needs to be disposed of safely and so on and so forth.

Everybody's left and a bit of a pickle, and that's a hard question not only from a policy perspective but also ethically, and the list goes on. These are hard things and I know that we are diving into this deeply and hopefully have some answers for you next time we speak.

[00:33:46] DW: Thats great.

[00:33:46] CQ: Give us about five years or so. 

[00:33:48] DW: I think you may be back in here before five years, because were going to probably end up talking about some of the cool things were not talking about in here today in terms of some public health in dentistry that were taking a look at at GSC. But thank you very much. That was the classic last GSC question about value, and I think you answered it very well, and we really appreciate the time you spent with us today.

[00:34:06] CQ: Thanks for having me.

[END OF INTERVIEW]

[00:34:11] SM: Thank you to our listeners tuning into another episode of And now for something completely indifferent,” a Canadian health benefits industry podcast. To be sure to get future episodes, please subscribe to this podcast wherever you get your podcasts or visit our website at greenshield.ca/podcast to download. As a reminder, we talk about these issues consistently in our publications, which are available on our website, as well as on social media, so be sure to follow the conversation. For todays episode, be sure to check out our latest issue of The Inside Story. Thanks for listening, and well talk again soon.

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