When doctor Hasan Sheikh gets ready to see a patient in the emergency room, he first consults the chart detailing their health issue. Next, he thinks about what questions he’ll ask to get to the root of the patient’s problem — that is, unless they’re complaining of dental pain: “Automatically, before I even see the patient, my heart kind of sinks, because I know that there’s severe limitations to what I can offer them,” says Sheikh, who has worked at Toronto’s University Health Network for about six years.
In the vast majority of cases involving non-traumatic dental issues — toothaches being overwhelmingly the most common — doctors in ERs and clinics can do little more than provide antibiotics or painkillers and send a patient off. “I think that’s the frustrating part,” Sheikh says. “I’m trained to pretty much try to be able to at least be the initial help for really anything that comes in the door.”
Despite doctors’ inability to treat most dental issues, patients seeking this type of care regularly turn up in ERs across the province. Because of a lack of benefits or money, many have run out of options, health-care professionals say. According to one 2017 estimate, every nine minutes, someone arrives at an ER in Ontario with a dental complaint, costing taxpayers $31 million annually. COVID-19 has exacerbated the issue, as the pandemic strains hospital resources and leaves many Ontarians cash-strapped from job losses and reduced working hours. “The problem of being able to access and afford dental care will be worse because of the pandemic,” says Jacquie Maund, policy and government-relations lead at the Ontario Oral Health Alliance, an advocacy group. That has experts and advocates calling for increased government funding for dental care.
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With few exceptions, such as an oral infection so severe it requires hospital surgery, the Ontario Health Insurance Plan doesn’t cover dental procedures. And the existing patchwork of publicly funded oral-health-care programs isn’t nearly accessible enough, experts suggest. “There are mechanisms that can help, but they’re few and far between, they’re by no means systematic — meaning part of the [health-care] system or baked into the system — and there’s ultimately an issue of funding,” explains Carlos Quinonez, a dentistry professor at the University of Toronto.
Quinonez points to the previous provincial Liberal government’s Healthy Smiles program for children under 18, and the Ontario Seniors Dental Care Program, introduced in the Doug Ford government’s 2019 budget, for low-income Ontarians aged 65 and up. To qualify for the former, a single-child household has to earn less than $24,130 per year; the provincial government announced Tuesday that, for the latter, the maximum single income will be increased to $22,200, up from $19,300 (or, for couples, a combined income of $37,100, compared to the previous limit of $32,300). “This will allow approximately 7,000 more seniors to access the Ontario Seniors Dental Care Program,” a press release states.
Sarah Hobbs, CEO of the Alliance for Healthier Communities, tells TVO.org via email that her organization is encouraged by the changes to the Ontario Seniors Dental Care Program but remains concerned about barriers to access for seniors and other groups. “For people who are precariously employed, not having access to essential oral health care is yet another barrier to health and wellbeing and one that impacts racialized, newcomer and low-income families harder than anyone else. This is an unacceptable gap for any committed public health care system. We must do better.” (Ontario Works and the Ontario Disability Support Program offer some support as well, but these too fall well short of demand, advocates suggest.)
Even before the pandemic, there were signs that it had been getting more challenging for Ontarians to visit the dentist. Between 2001 and 2014, the rate of patient visits to physicians (whether it be a walk-in clinic or family doctor) for non-traumatic dental conditions increased 15 per cent, according to a report Quinonez co-authored. From 2003 to 2015, visits to emergency departments climbed 32.7 per cent. “It’s just getting harder and harder to access dental care,” he says.
Multiple long-term trends are to blame, he explains: “One, the nature of labour markets is changing, meaning there is more precarious employment.” So-called gig-economy jobs, such as driving for Uber, don’t provide benefits. Meanwhile, wages have been stagnating as the cost of living — from housing to groceries — rises. “Essentially, real incomes are flat, in a relative sense, and everything else is getting more expensive around you, including dental care,” Quinonez says.
In his view, federal policy and funding are needed to solve the problem. With Canadian Medicare, the federal government sets criteria for provincial and territorial health-care plans and then provides 22 per cent of the funding through the Canada Health Transfer. This model, he says, should be applied to dental care. Extra funding could also help hospitals treat patients when they do turn up. “There are dental units in hospitals, but those units are generally for people who are really, really sick, and they’re not there to take the overflow of what’s going on in an emergency department,” he explains. “But, with appropriate funding, there’s no reason why those hospital dental units cannot also be resourced to play that role.”
The federal government is “always working with provinces and territories to strengthen health care in Canada,” a spokesperson for the office of Canada’s health minister, Patty Hajdu, says in an email statement. “Last year, we welcomed the Standing Committee on Health’s decision to study the idea of a national dental care program,” the spokesperson adds, noting that the work would help policymakers decide how best to improve dental-care access.
In February 2020, the committee adopted a motion to begin the study. However, because Parliament was subsequently prorogued that summer, the motion must be readopted to move forward — something that has not yet happened, a committee clerk confirms. Last week, during House debate over an NDP motion for a national dental-care program, Liberal MP Francis Drouin said, “We do not have comprehensive data on unmet dental care needs at a national level, nor do we have a full understanding of the need of various subpopulations. This is why our government has committed to support a parliamentary study on the issue.”
Like Quinonez, Maund would support a universal, publicly funded dental program. However, in terms of policy, the Ontario Oral Health Alliance advocates first for the expansion of existing programs to fill coverage gaps for those most in need: the one in five Canadians who, according to Statistics Canada, don’t go to the dentist, because of the cost. “Our call — both to the federal government and the provincial government — is that we need to invest in public dental programs even more now than ever,” she says. (TVO.org reached out to the Ontario Ministry of Health but did not receive comment by publication time.)
The fact that Canadian Medicare doesn’t cover dental work stems from conditions around the time of its inception, in 1968, researchers say. Communities began adding fluoride to tap water in the 1950s, so cavities had dramatically declined, according to the Canadian Association of Emergency Physicians. “At the same time, tax incentives for employers and employees led to an expansion of employment-based dental insurance,” reads a CAEP statement that Sheikh drafted. It notes that about 20 per cent of Canada’s oral-health care was publicly funded in the early ’80s, compared to 5 per cent today (and 10 per cent south of the border). Of all 37 OECD countries, only Spain has a lower share of public dental-care funding.
However, advocating for change can be difficult. The cost of a universal dental program can be a tough sell politically, and those suffering from lack of care can be reluctant to go public, because of the stigma of having bad teeth. “Often people don’t want to go public with these stories — they’re ashamed, and so it’s challenging … to get attention at the political level,” says Maund. One email the OOHA received reads, “Ottawa - hello, I am in my early 40's and in desperate need of serious dental work. Unfortunately, I have no coverage and can't afford much. My teeth are falling apart. it is extremely embarrassing to talk or smile because of how my mouth looks.”
Sheikh’s emergency-room experiences have made one thing clear to him about dental care in the province. “It highlights the failure of upstream public policy that we’re seeing patients in the emergency department for dental pain when the patient knows — and the provider knows — it’s not the right place for them,” he says. “There’s all these ways that, if we provided oral-health care, we would see people’s health outcomes get better.” Cases of pneumonia have been shown to decline when dental care is provided in long-term-care homes, he says, and diabetics see health benefits, too. “I think it’s a big shame that we’ve taken this one part of our body outside of our health-care system and treated it completely differently.”
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