BH.01.SEP0419.R16 - Dental Clinic Update

Recommendations

It is recommended that the Board of Health:
1. Receive this report for information.

Key Points

• Poor oral health status and access to dental care are important issues in Wellington County, Dufferin County and the City of Guelph (WDG). By Grade 2, almost half of WDG children will have experienced tooth decay.1
• In November 2018, Wellington-Dufferin-Guelph Public Health (WDGPH) recruited a dentist to provide basic dental care to children and youth enrolled in the Healthy Smiles Ontario (HSO) program out of the Chancellors Way location one (1) day per week.
• The dentist clinic is currently operating at full capacity, from November 2018 - May 2019, 362 appointments have been booked.
• This service expansion supports equitable access to dental care for children and youth from low-income households in the community.
• The addition of a dentist at WDGPH creates a “dental home” in the community where children and youth enrolled in the HSO program can be seen by a public health dental hygienist as well as an in-house dentist for routine and urgent dental care.

Background

Oral health status and access to dental care

Oral health is an important part of overall health and wellbeing. The World Health Organization defines oral health as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.”2

Oral diseases such as dental caries (cavities or tooth decay) and periodontal (gum) disease are threats to oral health. Tooth decay is caused when sugars in food and bacteria in the mouth produce a mild acid that eats away at the outer surface of teeth.3 Tooth decay is very common. It can weaken teeth and cause health issues such as infection, pain, abscesses, poor nutritional status and gastrointestinal disorders if left untreated. In children, tooth decay can affect the growth of adult teeth, school performance and sense of self-esteem.4 Gum disease, an infection and breakdown of the gum tissue and bone that hold teeth in place, can lead to tooth loss and has been associated with other serious health problems such as respiratory infections, cardiovascular disease and diabetes as well as pre-term and low-birth weight babies.3,4

Prevention, detection and treatment of oral health complications is an important part of maintaining good oral health yet, access to oral health care is a challenge that many Canadians face. With the majority of oral health care being privately funded and delivered, individuals and families must pay for dental care “out of pocket”, through dental insurance, or through a government-subsidized program if certain qualifications are met. Vulnerable groups such as low-income families, refugees and immigrants, Indigenous people and people living in remote and rural areas experience substantial barriers to accessing oral health care through this system.5

Oral health status and access to dental care are important issues in WDG:

• By Grade 2, almost half of children in WDG will have experienced tooth decay.
• Approximately one fifth of WDG residents do not brush their teeth twice per day as recommended.
• Approximately one third of WDG residents experience tooth sensitivity and one tenth experience bleeding gums.
• Only two thirds of WDG residents have dental insurance.
• Only 70% WDG residents have seen a dentist in the last 3 years.1

Healthy Smiles Ontario

WDGPH currently receives dedicated 100% funding from the Ministry of Health to provide dental care to children and youth from low-income households enrolled in the HSO program. However, the province has indicated its intention to shift to a 70-30 cost-shared model in the near future. To date we have not had official notification of this and the exact dollar value/anticipated shortfall is still unknown. Free dental care is available to eligible children and youth 17 and younger through three streams: 6

Community need

Oral Health staff at WDGPH identified a significant need for improved access to dental care for families eligible and enrolled in the HSO program. Local data found that many eligible children do not utilize their HSO benefits and that availability of care under the HSO program was limited in the community:

• Only 54% of eligible children were enrolled in the Core Services Stream as of March 31, 2017;7
• Only 60% of children enrolled in Core Services Stream utilized treatment from April 1, 2016- March 31, 2017;7
• Only 2% of local dentists in WDG took more than 40 clients enrolled in HSO per year in 2015;8
• Over 80% of local dentists were seeing six or fewer clients enrolled in HSO per year in 2015.8

Families may not be aware of the HSO program or may have difficulty finding a dentist that will accept HSO coverage. Some local dental professionals may be hesitant to treat clients enrolled in HSO due to low fee schedules and burdensome administrative processes.9

Many income-challenged families live in a cycle of stress, poverty and crisis which can impact if and how oral health services are accessed. It is not uncommon for families experiencing stressful life events to miss or be late to dental appointments, which can have a financial impact on a private business. The Oral Health program at WDGPH aims to provide patient-centred care, where concerns are managed with empathy, acceptance and an understanding of the social determinants of health.9 Staff are able to raise awareness amongst clients about other programs and services that are offered at WDGPH.

Expanding dental services at WDGPH

In 2016, WDGPH began planning for the addition of a dentist at the Chancellors Way location in Guelph. The Oral Health program consulted and received the support of an advisory group comprised of local dental professionals in planning this service expansion.

A dentist at WDGPH:

• Improves access to oral health care in the Guelph and rural Wellington communities for children and youth from low-income families;
• Creates a “dental home” in the community where children and youth who are seen by a public health dental hygienist can also be seen by an in-house dentist for routine and urgent dental care;
• Relieves local pressures on local dentists working in the current HSO system;
• Supports new community partnerships and opportunities for better integration and alignment across the health care system.

It is anticipated that over time, having a dentist at WDGPH will reduce the number of children and youth presenting at the hospital emergency department with dental issues and result in cost-savings for the healthcare system.

On November 21, 2018, the new dental clinic model was launched and the dentist began providing routine and urgent dental care to children and youth enrolled in the HSO program. The Oral Health program has informed community partners such as the Guelph-Wellington Poverty Task Force and their Oral Health Action Committee, local dental professionals, the school sector and community organizations of the preventive and restorative dental care that is offered at WDGPH. Staff continue to promote the importance of oral health and equitable access to dental care through clinics and community outreach opportunities. Establishing and maintaining strong community partnerships remains a priority for the Oral Health program.

Model Description

• The dentist clinic was created using existing infrastructure, space and funding through the HSO program. WDGPH received a $20,000 one-time grant in 2018 and $50,000 increase to the HSO base budget to support the new dental clinic model beginning in 2019.
• The dentist clinic functions as a turn-key operation with all of the space, equipment, supplies, reception, sterilization and equipment maintenance provided by WDGPH.
• The clinic operates on a ‘billings’ model where the dentist is hired on contract, supplies their own chairside dental assistant, and is reimbursed directly from the third-party administrator according to the HSO fee guide.
• The dentist is available for appointments one day per week from 9:00 A.M. – 6:00 P.M.

Dentist clinic utilization

• Total number of dentist appointments (November 2018 – May 2019): 362
• Number of unique dentist clients (November - December 2018): 47
• Number of unique dentist clients (January - May 2019): 116

Figure 1. Dentist appointments by type from November 2018 – May 2019.
Note: Tooth extractions are captured under Oral and Maxillofacial Surgery

The dentist clinic is currently operating at full capacity. From Nov 2018- May 2019, only one 30-minute appointment slot was left open, not including late cancellations, clients who did not show up for their appointment, or time reserved for emergency exams.

Within the first six months of operation, the dentist clinic saw an initial influx of new clients to be examined, many with extensive treatment plans. In April 2019, there were 89 outstanding appointments to be booked and there has since been a steady decline as the dentist completes treatment and books the next required appointment. At the height of the initial demand, clients were waiting 7-8 weeks for an open appointment with the dentist. As of June 2019, this waiting period dropped to 4-5 weeks. The initial demand for service was anticipated and this data suggests that waiting periods for service are becoming more manageable over time.

Referrals

Referrals are tracked when clients attend the dentist clinic for the first time. The majority (91.6%) of referrals to the dentist from November 2018– May 2019 were from WDGPH dental hygienists. Once the clinic is broadly advertised, it is expected that referrals from community partners, private dental offices, doctor’s offices and hospital emergency departments will increase.

Impact on preventive services

The Oral Health team in Guelph has seen an increase in the number of children enrolled in HSO seeking preventive services at WDGPH over the last year. This is likely a result of the dentist clinic becoming available and the creation of a “dental home” for children who do not have a family dentist. The number of applications for the Emergency and Essential Services stream of the HSO program has also seen some monthly increase over the last year. If a child does not have a family dentist, they are able to receive urgent dental treatment at WDGPH.

Figure 2. The number of children receiving preventive services in Guelph with active HSO cards from June 2018 – May 2019.

Conclusion

The service expansion at WDGPH to include both preventive and restorative oral health care has been successful. Since opening its doors on November 21, 2018, the dentist clinic at Chancellors Way has been utilized to its full capacity, with wait times for service becoming more manageable in recent months. The dentist clinic supports equitable

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access to oral health care for children and youth from low-income households in the community. WDGPH has created a “dental home” for clients without a family dentist and is in a better position to meet their oral health care needs. The Oral Health team is committed to increasing awareness amongst families and service providers about the free dental services available at WDGPH.

Ontario Public Health Standard

Chronic Disease Prevention and Well-being: To reduce the burden of diseases of public health importance and improve well-being.

The eligibility criteria for the HSO program identifies children from low-income households that may have difficulty accessing dental care. Access to professional dental care is an important part of maintaining oral health and preventing oral and other chronic diseases.3,4 The oral hygiene education provided in the dental clinic increases client knowledge and capacity to practice healthy behaviours that support oral health and prevention of disease.

Healthy Growth and Development: To achieve optimal preconception, pregnancy, newborn, child, youth, prenatal, and family health.

The dental clinic aims to reduce inequities in access to oral health care and oral health status for children and youth in the community. Poor oral health can lead to oral diseases and other conditions that can impact a child’s growth and development.3,4

School Health: To achieve optimal health of school-aged children and youth through partnership and collaboration with school boards and schools.

The Oral Health program provides services through the HSO program in accordance with the Oral Health Protocol, 2018 (or as current).10 The dental clinic aims to improve the oral health of children and youth by providing quality preventive, restorative and emergency dental care.

WDGPH Strategic Direction(s)

✓ Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.

✓ Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.

✓ Service Centred Approach: We are committed to providing excellent service to anyone interacting with WDG Public Health.

✓ Building Healthy Communities: We will work with communities to support the health and well-being of everyone.

Health Equity

Oral health is linked to the same social, economic and behavioural determinants as general health. Canada’s largely privatized oral health care system creates substantial barriers to care for vulnerable groups such as low-income families, refugees and immigrants, older adults and rural and remote populations. Those with the greatest oral health problems, are also those who face the most challenges in accessing care.5

WDGPH aims to reduce oral health inequities across WDG by providing free services to children and youth from families experiencing financial challenges. With the addition of a dentist at Chancellors Way, WDGPH has improved access to free routine and urgent dental care for eligible clients. In addition, WDGPH dental hygienists provide free preventive services in all locations, including portable settings for eligible clients. The Oral Health program aims to create an environment where all clients feel welcomed, accepted and accommodated while getting their dental needs met.

References

1. Wellington-Dufferin-Guelph Public Health. Oral health status report. [internet]. 2015. [cited 2019 June 18]. Available from: https://www.wdgpublichealth.ca/reports/2015-oral-health-status-report
2. World Health Organization. Oral health. [internet]. 2018 September 24. [cited 2019 June 18]. Available from: https://www.who.int/news-room/fact-sheets/detail/oral-health
3. Canadian Dental Association. Oral diseases. [internet]. 2019. [cited 2019 June 20]. Available from: https://www.cda-adc.ca/en/oral_health/talk/complications/diseases/index.asp
4. Ontario Ministry of Health and Long-Term Care. Oral health – More than just cavities. A report by Ontario’s Chief Medical Officer of Health. [Internet]. 2012. [cited 2019 June 20]. Available from: https://www.fluoridesandhealth.ie/download/documents/oral_health_CMO_Ont…
5. Canadian Academy of Health Sciences. Improving access to oral health care for vulnerable people living in Canada. [Internet]. 2014. [cited 2019 June 21]. Available at: http://cahs-acss.ca/wp-content/uploads/2015/07/Access_to_Oral_Care_FINAL…
6. Ontario Ministry of Health and Long-Term Care. Healthy smiles Ontario operational guide for dental providers. [Internet]. 2018. [cited 2019 June 21]. Available from http://www.health.gov.on.ca/en/pro/programs/dental/docs/HSO_Operational_…
7. Ministry of Health and Long-Term Care. Healthy smiles Ontario program statistics. 2016. [cited 2019 June 21].
8. Wellington-Dufferin-Guelph Public Health. Healthy smiles Ontario billing data. 2015. [cited 2019 June 21].
9. College of Dental Hygienists of Ontario. Review of oral health services in Ontario. [Internet]. 2014 October 7. [cited 2019 July 4]. Available from https://www.cdho.org/docs/default-source/pdfs/oral-health-rpt/review-of-…(full-report).pdf?sfvrsn=eb8b85a0_6
10. Ontario Ministry of Health and Long-Term Care. Oral Health Protocol, 2018. [Internet]. 2018 [cited 2019 June 21]. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/d…

Appendices

None.