ORAL HEALTH AND OVERALL HEALTH

Oral health is a critical component of an individual's overall health. There are a number of associations between poor oral health and poor general health, including cardiovascular disease, diabetes, having a low birth weight infant, erectile dysfunction, osteoporosis, metabolic syndrome, and stroke.^{Reference Blaizot, Vergnes, Nuwwareh, Amar and Sixou8–Reference Sfyroeras, Roussas, Saleptsis, Argyriou and Giannoukas15} There is increasing evidence, however, that poor oral health can actually cause or worsen other general medical conditions due to chronic inflammation.^{Reference Moutsopoulos and Madianos16} Treating periodontal disease in persons with diabetes has been shown to improve blood sugar control to a similar degree as adding another oral diabetes medication.^{Reference Simpson, Weldon and Worthington17} Providing oral care in long-term care settings has been shown to reduce the risk of developing aspiration pneumonia.^{Reference Yoneyama, Yoshida and Ohrui18} Periodontal therapy has been shown to reduce patients’ cardiovascular risk category.^{Reference D'Aiuto, Ready and Tonetti19} Integrated comprehensive oral healthcare has been shown to increase completion of substance use disorder treatment, increase employment, increase drug abstinence, and reduce homelessness.^{Reference Hanson, McMillan and Mower20} Poor oral health also has a negative impact on a person's self-esteem, social interactions, and employability.^{Reference Bedos, Levine and Brodeur21}

Given the important relationship between oral health and overall health, our current dental care system is inconsistent with the principles of the Canada Health Act: “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

THE HISTORY OF DENTAL CARE IN CANADA

Canada began adopting community water fluoridation in the 1950s, around the same time as the genesis of Medicare, Canada's single payer public healthcare system. This led to a sharp decline in dental caries, and a false reassurance that the solutions to oral health concerns would be non-provider based.¹ The 1964 Commission on Health Services did not include dental care in its recommendation of publicly financed services, believing oral healthcare to be a personal responsibility. At the same time, tax incentives for employers and employees led to an expansion of employment-based dental insurance, which further reduced public investments in times of economic hardship.¹ In fact, in the early 1980s, approximately 20 percent of all spending on oral healthcare was public, compared with approximately 5 percent currently.^{Reference Quiñonez, Sherret and Grootendorst22} This ranks Canada amongst the lowest in public spending for dental care of all Organization for Economic Cooperation and Development (OECD) countries, second only to Spain. In fact, public spending on dental care in Canada is less than that in the United States, where 10 percent of all dental care is publicly financed.^{Reference Devaux23} Furthermore, Canada has been reducing its proportion of public dental expenditures, whereas the United States and most other OECD countries have been increasing their public share of dental spending.^{Reference Birch and Anderson2}

Currently, dental care in Canada is almost entirely funded through the private sector. Approximately 51 percent of dental spending is paid for by employment-based insurance, and 44 percent through direct out-of-pocket payments.^{Reference Quiñonez, Sherret and Grootendorst22} The remaining 5 percent that is funded publicly is delivered through a patchwork of policies targeting marginalized groups.¹ Public per capita spending on dental care is approximately $24, compared with $337 on drugs, and $999 on physician services.^24,25

CONSEQUENCES FOR THE INDIVIDUAL

The lack of a robust, publicly funded dental care system in Canada has led to significant barriers for many Canadians to access care. Approximately six million Canadians avoid visiting a dentist each year due to the cost.¹ The people who experience the most difficulty accessing oral health care are also the ones who experience the highest burden of dental disease, including children, low-income adults, seniors, indigenous communities, refugees, people with disabilities, and people living in rural areas.^{1–Reference Quiñonez, Ieraci and Guttmann5} Overall, approximately 20 percent of people cite cost as a barrier for seeing a dentist.⁴ Studies show that 42 percent of low-income Canadians avoid seeing a dentist when they need to due to cost, compared with only 15 percent of high-income Canadians.^{Reference Birch and Anderson2} This is in stark contrast to physician services, where the only 9 percent of low-income Canadians and 5 percent of high-income Canadians avoid seeing a physician due to cost.^{Reference Birch and Anderson2} Despite having higher needs, seniors are 40 percent less likely to have private dental insurance compared with the general population.²⁶ In Canada's largest province, Ontario, 3.5 percent of the population avoids social interactions, including conversation, laughing, and smiling, due to a dental condition; this proportion increases to 8.5 percent amongst those in lower income groups.⁴

CONSEQUENCES FOR THE EMERGENCY DEPARTMENT

People who are suffering with an oral ailment and cannot access affordable, timely dental care often turn to the emergency department (ED) in desperation. In fact, approximately 1 percent of all visits to the ED are for dental complaints.^{Reference Quiñonez, Gibson, Jokovic and Locker6,Reference Brondani and Ahmad27} The majority of patients presenting to the ED for dental complaints are low-income adults, and these visits in Ontario alone are estimated to cost the healthcare system in the range of 16 to 31 million dollars annually.^{Reference Quiñonez, Ieraci and Guttmann5,28}

Both patients and providers often know that the patient needs to see a dentist, but patients turn to the ED when they have nowhere else to go. Most of these patients receive either no intervention or pharmacotherapy for temporary symptom relief.^{Reference Quiñonez, Gibson, Jokovic and Locker6} This is expected, because emergency physicians do not possess the training or equipment to deal with most dental complaints in a definitive way.^{Reference Sheikh29} Emergency physicians often end up prescribing antibiotics, anti-inflammatories, or opioids to try and provide some relief – medications that would otherwise be unnecessary if patients could access dental care. Opioids are prescribed in more than 50 percent of non-traumatic dental condition visits to the ED, and emergency physicians are five times more likely to provide an opiate prescription for a dental complaint compared to a dentist.^{Reference Okunseri, Okunseri, Xiang, Thorpe and Szabo30–Reference Janakiram, Chalmers and Fontelo32} In the midst of an opioid epidemic, it is important that we take steps to reduce our reliance on these potentially harmful medications. This is particularly true in cases like these, where opioids are not the optimal therapy for the presenting problem.

ORGANIZATIONS SUPPORTING PUBLIC DENTAL CARE IN CANADA

According to the Canadian Association of Public Health Dentistry: “All Canadians should have equitable access to oral health care, regardless of their employment, health, gender, race, marital status, place of residence, age or socio-economic status.”³³

According to the Canadian Dental Hygienist Association: “It is the position of the CDHA that oral health care – a significant component of overall health – is the right of all Canadians … CDHA promotes access to affordable oral health care through alternative practice settings and by working in cooperation with governments, health agencies, public interest groups, and other health professions.”³⁴

According to the Canadian Dental Association: “The CDA … recommends the development of a national action plan to reduce the barriers to access to dental care.” “Alternative models of care or funding should be explored to alleviate access to care inequities.”³⁵