CAHS report on access to oral health care: strategic pressure for change. A Presentation for Public Health Ontario August 2015

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2 CAHS report on access to oral health care: strategic pressure for change A Presentation for Public Health Ontario August 2015

3 Presentation outline Background brief overview of CAHS report Focus of presentation barriers and solutions Middle income people and families The elderly Those in precarious and poorly paid work Interactions with groups to promote action and possible action areas

4 CAHS The Canadian Academy of Health Sciences (CAHS) provides timely, informed and unbiased assessments of urgent issues affecting the health of Canadians. These assessments, which are based on evidence reviews and leading expert opinion, provide conclusions and recommendations in the name of CAHS. (

5 Charge to the panel What is the current state of oral health in Canada? What is the current state of Canada s oral health care system(s)? What factors determine the oral health of individuals and communities? What are the impacts of poor oral health on individuals and on Canadian society? Are there any identifiable groups among whom these impacts are more severe? What measures could be taken to improve the oral health of Canadians?

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7 Special thanks to the panelists Dr. Jim Lund, former Dean, Faculty of Dentistry, McGill University, who initiated this process but suddenly died and so was not able to complete it. Dr. T. Bailey, BA, LLB, Health Senior Team Lead, Barrister and Solicitor, Alberta Health Legal and Legislative Services, Justice and Attorney General Dr. L. Beattie, MD, FRCPC, Professor Emeritus, Division of Geriatric Medicine, Department of Medicine, University of British Columbia Dr. S. Birch, D. Phil., Professor of Health Economics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario Dr. L. Dempster, BScD, MSc, PhD, Assistant Professor, Disciplines of Preventive Dentistry and Dental Public Health, Faculty of Dentistry, Kamienski Professorship in Dental Education Research, University of Toronto Dr. N. Edwards, BScN, MSc, PhD, Scientific Director, Institute of Population and Public Health, Canadian Institutes of Health Research Dr. B. Graham, DDS, Dean, University of Illinois at Chicago, College of Dentistry, USA Ms. J. Gray, DT, DH, Dental Program Technical Consultant for The Saskatchewan Ministry of Health, Mamawetan Churchill River Health Region, Keewatin Yatthé Regional Health Authority and Athabasca Health Authority Dr. D. Legault, DMD, MBA, Conseillère principale, Centre d'excellence pour la santé buccodentaire et le vieillissement, Université Laval Dr. N. E. MacDonald, MD, MSc, FRCPC, FCAHS, Professor of Pediatrics, Dalhousie University, Division Pediatric Infectious Diseases, IWK Health Center, Halifax, Nova Scotia Dr. M. McNally, MSc, DDS, MA, Associate Professor, Faculties of Dentistry and Medicine, Dalhousie University, Halifax, Canada Dr. R. Palmer BSc, Cert Ed., PhD, LEAD Consulting Ltd., Edmonton, Alberta Dr. C. Quinonez, DMD, MSc, PhD, FRCD, Assistant Professor and Program Director, Dental Public Health Specialty Training Program, Faculty of Dentistry, University of Toronto Dr. V. Ravaghi, BDS, PhD, Postdoctoral Fellow, Faculty of Dentistry, McGill University Dr. J. Steele, CBE, BDS, PhD, FDS RCPS, FDS Rest dent, Chair of Oral Health Services Research, School of Dental Sciences and Centre for Oral Health Research, Newcastle University, UK Dr. F. Power MSc, DDS, Assistant Professor, Faculty of Dentistry, McGill University Canadian Health Measures Survey data

8 Acknowledgements Sponsors: Association of Canadian Faculties of Dentistry Canadian Association of Dental Research Department of Dentistry and Dental Hygiene, Faculty of Medicine and Dentistry, University of Alberta Dental Program, Schulich School of Medicine and Dentistry, University of Western Ontario Faculté de médecine dentaire, Université de Montréal Faculty of Dentistry, Dalhousie University Faculty of Dentistry, McGill University Faculty of Dentistry, University of British Columbia Faculty of Dentistry, University of Toronto Henry Schein Ltd. Institute of Musculoskeletal Health and Arthritis, Canadian Institutes of Health Research Nova Scotia Health Research Foundation Ordre des dentists du Québec Réseau de recherche en santé buccodentaire et osseuse Sunstar GUM 3M ESPE

9 Overall findings: a quick review

10 Principal findings: significant inequalities in adult oral health status 25% 23% 20% 21% 20% 18% 17% 16% 15% 11% 10% 10% 9% 10% 5% 0% Dental pain Having difficulty eating food Lowest income quintile 2nd quintile 3rd quintile 4th quintile Highest income quintile

11 Principal findings: significant inequalities in adult oral health status Decayed teeth Missing teeth Lowest income quintile 2nd quintile 3rd quintile 4th quintile Highest income quintile

12 Determinants of inequalities in oral health and disease: decomposition analysis Socioeconomic status Access to oral health care Oral health behaviours Total Inequality Decayed teeth Missing teeth Dental pain (30.2%) (58.9%) (10.9%) (48.7%) (7.6%) (7.6%) (49.6%) (45.0%) (5.3%) Having difficulty eating food (30.0%) (62.8%) (7.1%)

13 Conclusions: In Canada There are significant inequalities in oral health There are significant inequalities in access to dental care Those with the greatest burden of disease (the most vulnerable groups living in Canada) have the greatest barriers to obtaining care The predominantly private dental care model does not work for these groups

14 Vision The Panel envisages equity * in access to oral health care for all people living in Canada. * By equity in access, the Panel means reasonable access, based on need for care, to agreed-upon standards of preventive and restorative oral health care (a concept from the Health Canada Act) Or put another way let s put the mouth back into the body

15 Recommendations: Communicate with relevant stakeholders concerning the core problems raised in the report. Establish appropriate standards of preventive and restorative oral health care to which all people living in Canada should have reasonable access. Identify the health care delivery systems and the personnel necessary to provide these standards of oral health care. Identify how provision of these standards of preventive and restorative oral health care will be financed. Identify the research and evaluation systems that monitor the effects of putting these recommendations into place.

16 Middle income people and families

17 60 Principal findings: inequality in access to dental care highest income upper middle income middle income lower middle/lowest income 0 percentage avoiding dentist because of cost percentage with emergency pattern of dental visit percentage not visiting dentist in past year percentage with no insurance

18 Middle income families: Barriers [Cost] [Lack of dental insurance] [Perceived need] [Fear] Time/conflicting needs and demands

19 The elderly

20 Inequality in people with/without dental insurance Those without dental insurance by age group and family income level yrs 12-19yrs 20-39yrs 40-59yrs 60-79yrs higher income middle income lower income

21 Dental status and visits to the dentist among elderly people living in Canada Dental visit in last year No visit in last year Decayed teeth Missing teeth Filled teeth

22 Dental status and avoidance of dental visits due to cost among elderly people living in Canada 12 Number of decayed, missing & filled teeth Avoided dental visit due to cost No avoiding dental visit due to cost Decayed teeth Missing teeth Filled teeth

23 Indicators of access to dental care and household income in elderly people living in Canada % Percentage avoiding dentist because of cost Percentage with emergency pattern of dental visit Percentage not visiting dentist in past year Percentage with no insurance Highest income Upper middle income Middle income Lower middle/lowest income

24 The elderly: Barriers [Cost] [Lack of dental insurance] [Perceived need] [Fear] Transport Physical and cognitive disabilities and medical problems Expertise of providers Miscommunication/misunderstandings with providers

25 Those in precarious, poorly-paid work

26 60 Principal findings: inequality in access to dental care highest income upper middle income middle income lower middle/lowest income 0 percentage avoiding dentist because of cost percentage with emergency pattern of dental visit percentage not visiting dentist in past year percentage with no insurance

27 Inequality in people with/without dental insurance Those without dental insurance by age group and family income level yrs 12-19yrs 20-39yrs 40-59yrs 60-79yrs higher income middle income lower income

28 Indicators of access to dental care among adults with and without insurance 50% 40% 45% 46% 30% 31% 20% 10% 21% 10% 10% Insurance No insurance 0% No dental visit in past year Avoiding dental professional because of cost Emergency pattern of dental visit

29 People and families in poorly paid and precarious work: Barriers [Cost] [Lack of dental insurance] [Perceived need] [Fear] Time/conflicting needs and demands Transport Other health and social problems Miscommunication/misunderstandings with providers

30 Middle and low income families and elderly people: common and specific barriers Common barriers Cost Lack of dental insurance Perceived need Fear Transport Health & social problems Competing needs Miscommunication with providers Competing needs Specific barriers Middle income Low income Precarity Elderly Physical and cognitive limitations Expertise of providers

31 Some solutions?

32 Trying to address cost barriers Alternative providers Dental therapists Dental hygienists Physicians E.g. geriatricians, pediatricians Nurses Alternative payment systems Salaried providers Paid through Medicare

33 Dental insurance legislation Medicare Private insurance more accessible for those who currently have it, private insurance is a pre-tax benefit at federal government level Ease burden on small businesses Managed care options used in the USA

34 Systems Integrate dental care into general health care systems Dental professionals working with other health care professionals Dental care provided by non-dental professionals Build dental operatories in hospitals and community health and social service settings, as part of pharmacies Engage dental professionals as salaried staff similar to other health professional groups Need for legislation on scopes of practice

35 Setting & delivery of dental care Mobile dental care Mobile equipment going into houses, institutions etc. Dental operatories in trucks Dental care in unusual settings go to the clientele in need rather than waiting for them to come to us Community centres Pharmacies Hospitals and institutions? Churches Orientation/navigation help

36 Education of dental professionals Communication Understanding the needs of others Address perceived need and fear barriers Skills to work with groups with special needs The elderly Those with handicaps and medical problems Those in poverty Skills to work in varied settings Hospitals Mobile care Skills to work with other health care professionals and in teams

37 Action on prevention Focus on population strategies: Fluoridation of water supplies Access to healthy foods Cost Distribution Awareness Food labeling Disincentives for unhealthy foods Hygiene centres (spas for the disadvantaged) Creating a medical/dental home

38 Solutions summary Need to understand overall needs of clientele: Many often conflicting social, employment and health care needs Dentistry often [understandably] not high on list of priorities Need to go to them Where they live Where they work Where they obtain other services Need a variety of strategies for various clientele with various needs and demands

39 Thank you.