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Access to Oral Health Services - The Stories and Actions in Two Cities

I Introduction

Access to dental care is a major problem in Canada. For people who are socially and economically disadvantaged, regular access to basic primary dental-health services are largely unavailable. In March 2000, a landmark report entitled "Oral Health in America: A Report of the Surgeon General" was published (US Department of Health and Human Services, 2000). The report revealed disparities in oral-health status and barriers to access among society's most vulnerable groups, including racial/ethnic minorities, low-income individuals and special populations, including the homeless, elderly, disabled and medically-compromised individuals.

Dental care stands outside Canada's publicly-funded health services, and people who are unemployed or underemployed often do not have insurance coverage for dental services. Community-based agencies that work with these populations and have set up dental clinics face great difficulties sustaining their programs. Similarly, hospital-based dental services are very limited for special needs people.

Without dental services, many people wait until they have a dental emergency before caring for their teeth. They then must turn to emergency rooms in hospitals for care that is not only extremely costly but often results in prescriptions that lower-income people cannot fill or tooth extractions that compromise the persons overall health. These situations would be unnecessary if they had ongoing, primary oral-health care. These emergency procedures, particularly in the case of tooth extractions, affect self-esteem and limit opportunities for employment or career advancement.

Several Toronto agencies, concerned about the increasing demand for dental services and believing that dental care should not be separated from overall health care, formed the Toronto Oral Health Coalition (TOHC) in 2001. The purpose of the group is to explore delivery of services to populations who have lower incomes and are without insurance benefits. In Hamilton, at about the same time, similar concerns were raised by dental-health professionals in the Academy of Dentistry and by the health planners of the Hamilton District Health Council (HDHC).

This article brings together the perspectives and initiatives of these two separate groups by combining contributions from HDHC's senior health planner Ernest Jodoin, and Lorraine Purdon of the Toronto Oral Health Coalition. Ernest shares the extensive Review of Dental and Oral Health Needs of Special Populations in Hamilton and Lorraine shares stories about lack of access' impact on people lives.

The HDHC review used four approaches to gather information on dental- and oral-health needs in Hamilton:

* A literature review was conducted on the dental and oral health needs of special populations

* Information on the supply of dentists and dental hygienists in Hamilton was collected

* An inventory of community and hospital-based dental and oral health services in Hamilton was prepared

* A survey of 177 community agencies and hospitals was conducted regarding unmet needs and perceived barriers to dental- and oral-health of special populations.

II Key Findings From the Literature--The Access Statistics

Residents' Access to Dentists--According to the Ontario Health Survey, two thirds of Hamilton residents had contact with a dentist in the previous year, 15 percent had not seen a dentist in three years. Approximately one third of Hamilton residents responding to the HDHC survey indicated they did not have coverage for dental expenses. This survey did not include persons living in institutions.

Seniors Population--Seniors are at high risk of developing oral diseases (Ontario Dental Association, 2000). Seniors of today retain more of their natural teeth. However, they use dental services significantly less than the general population. Seniors also experience barriers to accessing dental and oral services, including physical access to services, financial barriers and the lack of mobile or outreach services.

Persons with Disabilities--Persons with disabilities not only present some of the most challenging dental cases, but the prevalence and severity of dental diseases increases in the disabled population (ODA, 2000). Persons living on their own in the community have greater unmet dental needs than their residential counterparts, as these clients tend to have less regular contact with dental services (Tiller, Wilson and Gallagher, 2001). Disabled persons face the traditional barriers to access, as well as a significant lack of professionals available to treat them.

Medically Compromised Patients--Certain types of patients, such as dialysis and cancer patients, are at risk for developing a variety of dental- and oral-health problems as a result of treatment (Klassen and Krasko, 2002; Gagliardi and Abate, 2001).

Low-Income Groups--Overall health and oral/dental health are positively correlated with income. Costs and lack of dental insurance remain the primary barriers for low-income groups (ODA, 2000). Two recent studies conducted in Hamilton found high levels of dental needs among low-income families (Hagens and Hatanaka, 2001; City of Hamilton, 2001). Recent studies of homeless/street youth in Toronto also found high levels of unmet needs in these populations (Lee, Gaetz and Goettler, 1994).

When two Toronto researchers, Dr. David Locker and Dr. David Matear, carried out an extensive review of the literature, their results, reported in 2000, indicated that oral disorders can lead to significant systemic problems. Severe dental decay undermines the quality of life of young children through pain and problems with sleeping, eating and behaviour. It can also be a contributing factor in a failure to thrive as it is a condition whose manifestations include low weight or height for age.

Periodontal disease (an infectious oral disease known commonly as gum disease) is associated with heart disease and stroke. People with periodontal disease are at 1.5 to 2.7 times greater risk for heart disease and 1.48 to 2.80 times greater risk for stroke.

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III A Story of Oral Health Access

Statistics and facts, though revealing, do not begin to cover the array of emotions and suffering of the individuals whose lives are affected by these conditions.

Eric Rubery is a well-spoken man with the mannerisms of a successful, well-traveled businessman- -which he once was. Now, at age 57, Eric lives on the streets. For the time being, he is making do with social assistance as he starts to rebuild his life.

Eric sees a dentist only when he thinks he has a problem with his teeth. That pattern of dental care is common among homeless adults.

Oral Health is about more than just teeth. Oral health reflects general health and well-being. The oral cavity is a site in which serious systemic conditions such as diabetes; AIDS or cancer can manifest themselves. Dentists, as specialists of the oral cavity, play an important role in the early detection and management of complex oral and systemic conditions. That is why regular checkups are so important.

Eric's last dental visit had been to get an upper denture; he had to wait four months before getting the denture. While waiting, Eric went without a front tooth and had to use a broken denture. "When your teeth look bad you don't feel good about yourself because having wonderful teeth is part of the person that people want to see. It affects your ability to get a job. You just don't feel good about yourself so you lose self esteem about being able to go and get a job. Or to go and get THAT job".

Eric's feelings are not untypical. In 1998, a team of researchers reported that homeless adults with a greater number of missing teeth had very weak perceptions of their current health status and their abilities.

Eric further commented "What I want to do is marketing. Part of marketing is the visual presentation, eye contact. If a person is looking at my missing teeth they're not listening to what I am saying and thereby they probably won't buy what I am trying to sell. Whether I'm right or wrong in my perception, by having that perception, I have less faith in myself. "

The homeless and other members of low-income populations have often been condemned for supposedly not making the effort to seek and /or maintain suitable employment, but the stories of Eric and others like him indicate otherwise. There are many living on assistance or with low incomes that want to change their lives for the better and are struggling to do so. Unfortunately, in addition to the impact on general health, poor oral health adds to the difficulty of obtaining good jobs.

Oral disease also hurt those who have jobs. In 1996, adults in the United States were losing more than 164 million hours each year due to dental disease or dental visits.

Studies have indicated that oral disease, particularly periodontal disease, are associated with respiratory disorders such a chronic obstructive pulmonary disease. It is likely that continued research would discover other systemic effects of poor oral health. But even without extensive research, the link between oral health and general health is clear. Eric Rubery himself expressed the systemic importance of dental health in simple words: "Dental health affects the rest of your health because it can travel and infect you."

This seemingly simple statement holds much truth. Indeed oral diseases and a lack of subsequent dental treatment can lead to death. In Toronto in 1998, for instance, a 24 year old otherwise healthy man died from a tooth infection. He had suffered from a toothache, which led to swelling of his mouth, and with no timely treatment the swelling spread along his throat and obstructed his breathing (The Toronto Star, March 1, 1998). His was just one case--one incident that was reported--in which a clear link existed between death and a dental problem. Dental diseases can and will kill.

[Eric's story is from Dental Care: Who has access?, a report of the Toronto Oral Health Coalition from October 2002.]

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IV Can Supply of Oral Health Professionals and Community Services Meet Demand?

Compared to other municipalities, Hamilton has a good supply of dentists. However, only 4 percent of dentists devote a large portion of their practices to special-needs groups. As dentists retire and practices patterns change, the accessibility issues may continue to worsen. In Hamilton's survey, dentists voiced concerns over access to hospital-based dental services and inadequate reimbursement and coverage levels available from government plans. Between 1999 and 2002, three hospital-based dental clinics closed in Hamilton. This is similar to the provincial trend. Financial issues have been a predominant concern for hospitals. There have been reductions and/or limitations in hospital-based dental services for special-needs groups. Availability of oral health professionals is almost completely urban based. If you live in rural or isolated areas you will likely need to travel to urban areas to receive dental services.

In large urban centres, such as Hamilton and Toronto, there are a number of community-based dental/oral health programs. However, as Hamilton's survey shows, approximately 30 percent of agencies indicated that their clients continue to have unmet dental- and oral-health needs, and for almost 40 percent, financial issues are always or usually a barrier to access. People using shelters, supportive housing and other community-based agencies tend to have higher unmet dental- and oral-health needs compared to people in residential facilities. For example, the Hamilton Urban Core Community Health Centre has indicated a high level of need, and waiting times at two public health clinics are three and six months respectively.

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V The Key Issues

Financial barriers are the most significant issue, for the people like Eric who cannot access services that might be available and for the services and professionals who are stretched in what they can offer. Community agencies and dental professionals have identified the need to improve funding, enhance the coverage of government plans and improve claims processing.

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VI What Happens Now? Next Steps in Hamilton and Toronto

The Hamilton DHC is circulating its review of dental and oral health services in the community to verify key findings with its planning stakeholders. This process will also help to identify future planning required. Provided there is community support, the DHC may co-sponsor a community forum to address dental- and oral-health issues in Hamilton.

The Toronto Oral Health Coalition (TOHC) is committed to finding a model(s) and recommendations toward a service delivery system that can include people with low or no income. Activities of the coalition include

* In October 2002, a report describing the issues related to dental services was published and widely circulated.

* Last year, the coalition worked with Regent Park Community Health Centre when the funding for the dental clinic was under threat. The clinic is one of the few that serve people who have lower incomes and who do not have insurance. The coalition was able to find funds save these vital dental services.

* The coalition hosts regular information meetings to support dental services for this population, through sharing information regarding programs, and encourages dialogue and debate on what the appropriate service delivery models that could resolve this crisis.

* Through regular meetings, information sessions and forums, the coalition has begun to develop a clearinghouse role, supporting other groups in the province who are challenged by this issue.

* The coalition has launched a provincial campaign to advocate the three levels of government to include dental services as part of our provincial health plan. To participate in this campaign (e.g., to get copies of the petition for your organization to collect signatures) or to sign the petition please contact Lorraine Purdon at or at (416) 338-7866.

* Currently, the coalition is establishing partnerships and sponsors for a conference to be held in May of 2004. TOHC's vision is that the conference will help take the next steps towards service delivery models and begin to respond to this crisis in oral-health care.

For both the HDHC and the TOHC, their reports are intended to be springboards into their communities, to stimulate dialogue and action. All comments and engagement in the coalition's activities and in addressing oral health care issues are welcomed.

Review of Dental and Oral Health Needs of Special Populations in Hamilton is available from

Who has Access? A report of the Toronto Dental Coalition (Toronto Oral Health Coalition) in available at

VII References

City of Hamilton. (2001) Social and Public Health Issues Report 2001.

Gagliardi, A., Abate, R. (2001) The Oral Complications of Cancer Therapy--The Clinical Information Needs of Ontario Dental Practitioners. Ontario Dentist Nov. 18-24

Hagen, S., Hatanaka, D. (2001) North Hamilton Community Health Centre Dental Needs Assessment. Unpublished.

Halton Oral Health Outreach Task Force. (1999) The Need for Early Intervention and Coordinated Oral Health Services for Adults with Special Needs and the Frail Elderly. Unpublished.

Klassen, J., Krasko, B. (2002) The Dental Health Status of Dialysis Patients. Journal of the Canadian Dental Association, Vol. 68, No. 1, 34-38

Lee, J., Gaetz, S., Goettler, F. (1994) The Oral Health of Toronto's Street Youth. Scientific Journal, 60(6) 545-548

Locker, D., Matear, D., (2000) Oral Disorders, Systemic Health, Well-Being and the Quality of Life. Community Dental Health Services Research Unit. Faculty of Dentistry, University of Toronto.

Mendel, J. (1997) Dental Human Resource Distribution in Ontario: A Report for 1997. Ontario Dentist, June 1997 (Profile).

Ministry of Health and Long-Term Care. (1998) 1996-97 Ontario Health Survey.

Ontario Dental Association. (2000) Final Report of the Access to Care Working Group. Unpublished paper.

Ontario Dental Association. (1999) Hospital Restructuring, Downsizing and Cutbacks--The Impact on Hospital-Based Dentistry. Unpublished paper.

Tiller, S. Wilson, K,. Gallagher, J. (2001) Oral Health Status and Dental Service Use of Adults With Learning Disabilities Living in Residential Institutions and in the Community. Community Dental Health 18 (3) 167-71

U.S. Department of Health and Human Services (2000) Oral Health in America: A Report of the Surgeon General. NIH Publication 00-4713