A reason to smile: National dental care is a smart health care investment

Canada is an unequal country and nowhere is this clearer than one’s smile. The wealthy have the perfectly straight pearly whites, while the rest make do the best that they can.

This is a consequence of dental care being excluded from Canada’s universal health care system. The good news is that the federal government has committed to create Canada’s first-ever national dental care program for kids 12 and under. It’s a wise investment.

Right now, Canada’s spending on public dental programs is second last among OECD countries, at only 5% of overall dental spending. This is well behind the United Kingdom, at 46%, and Japan, at 76%.

Existing public dental spending goes toward programs for specific populations. While the program for Indigenous Peoples and children’s programs in a few provinces (Nova Scotia, Newfoundland and Labrador, and Quebec) guarantee coverage to the uninsured, the rest of the programs in the country are only for people with low income and those on social assistance. Across the country, public dental programs vary widely in the populations and services that they cover.

This structure leaves many gaps, and those relying on the public programs often struggle to find a dentist who will accept them. This is due to low fees that the programs pay out and the increased administrative burden for service providers. One in three dentists openly acknowledge that they made a business decision to see fewer patients who rely on public insurance.

Paltry public dental spending results in gaps between those who are eligible for public programs and those who can access care privately through work-related insurance and/or out-of-pocket payments.

As a result, one in three Canadians lack dental insurance and more than one in five avoid the dentist each year due to financial constraints. These numbers are increasing as fewer employers provide dental insurance and many elderly people are retiring and losing coverage. The financial hardship caused by the COVID-19 pandemic has only made things worse.

When people experience dental pain and are unable to access care, many look to physicians for relief. Visits to the emergency department for dental pain costs $150 million per year, while still leaving the patients in need of treatment from a dentist.

Leaving dental infections to linger can lead to complications. CBC News has reported on how dental infections can lead to near-death experiences. For example, the Sioux Lookout First Nations Health Authority stated in 2021 that an individual passed away due to complications from a dental infection.

It should be clear that lack of access to dental care is not just cruel, it is wasteful. It leads to inefficient downstream spending on health care.

It should be clear that lack of access to dental care is not just cruel, it is wasteful. It leads to inefficient downstream spending on health care.

The increased pressure on health care spending is exacerbated by the fact that poor oral health has been associated with cardiovascular disease, diabetes, having a low-birth-weight infant, aspiration pneumonia, erectile dysfunction, osteoporosis, metabolic syndrome, and stroke.

This is why I am happy to see the supply and confidence agreement between the Liberals and NDP, which, if fully implemented, would bring dental insurance to uninsured families that are making less than $90,000 per year, with no co-payments for those making less than $70,000.

This month’s federal budget set aside $300 million to bring dental coverage to those 12 years old and under in 2022. If the agreement continues, the plan will be expanded to everyone aged 18 and under, seniors and people with disabilities in 2023, followed by the remainder of Canadians who are below the income threshold in 2025.

If fully implemented, this would insure approximately 6.5 million Canadians with dental coverage and more than double public dental spending in Canada. The program would cost $1.7 billion per year and would leave the existing public dental programs in place.

The NDP dental plan would fill many gaps in coverage and is expected to insure a wider array of procedures than most existing public programs. The question remains, will newly insured people be able to find a dental provider willing to do the work?

While many private practices will see patients under the new program, I am skeptical that it will be enough to meet the demand. This is particularly true for poor and rural communities that have an inadequate supply of dental workers to begin with.

Fortunately, there are solutions to these problems. The dental workforce can be expanded in a cost-efficient manner by bringing dental therapy into the mainstream. Dental therapists are providers that can perform procedures like cleanings, fillings and simple extractions all at a fraction of the cost of a dentist. The relationship of a dental therapist to a dentist is much like that of a nurse practitioner to a physician. Having dental therapists work in easily accessible and publicly owned clinics would allow the dental workforce to be expanded and distributed based on public health needs.

In the 1970s to 1980s in Saskatchewan and Manitoba, dental therapists were used in school-based dental programs very successfully.

As described by the economist Stephanie Rezansoff: “… a relatively small proportion of the population is receiving dental care, and that much of this care is received by those in higher socio-economic groups … the results of this study [on the Saskatchewan Dental Plan] tend to support the contention that changes in the nature of the dental care delivery system are such that inequalities in the receipt of care are eliminated.”

The program was successful because the dental workforce was expanded and distributed in easily accessible, school-based clinics which did not allow children to fall through the cracks. This is why the Saskatchewan Dental Plan had a utilization rate of 90%, whereas comparable private practice-based children’s programs only had 45% utilization rates.

The program was privatized, but could be brought back. The CCPA estimated in 2011 that a similar school-based program for 5- to-14-year-olds would cost $540 million per year. That’s a pretty low amount, considering Canadians spend over $15 billion per year on dental care.

This model could help fill the gap for communities whose dental needs are not being met, particularly for those who are insured by the new federal dental plan. These clinics could be set up in community health centres, schools, prisons, long-term care facilities, and more. For those living in a long-term care facility, it is much easier to bring dental care to them than to get each resident to a private clinic.

Former NDP Leader Ed Broadbent has warned that the Liberals may not follow through with their promises and that we need to keep up the pressure to make it more difficult to back down. We will certainly keep up our advocacy at the Coalition for Dentalcare. Public delivery needs to be the next step to make sure those with coverage can access comprehensive care. Ultimately, Canadians need a universal dental care system.