Dimensions of Dental Need and the Adequacy of Our Response: Forum Proceedings

Executive Summary

This paper summarizes proceedings of a workshop funded by the Canadian Institutes of Health Research to develop a research agenda that would contribute to a reduction in oral health disparities of British Columbians. “Dimensions of Dental Need and the Adequacy of Our Response” was held at the University of British Columbia in Vancouver, Canada, on June 17 and 18, 2010. Formal presentations and open discussions among Canadian and international educators, researchers, service providers and government representatives provided detailed information on the oral health policies and services that have emerged in BC and elsewhere in response to oral health inequities. Discussions focused on the adequacy of the policies and services, and on the research neededto influence policy and clinical practice. Participants identified gaps in our knowledge and responses, and they recommended a research agenda focused on solutions rather than needs. In particular, they suggested a systematic exploration of the programs currently operating around the province to gather information that would support the development of health and social policies aimed at reducing the inequities that are becoming increasingly more evident in BC and elsewhere.

Current Policies and Programs

Overviews of oral health policies and case studies of specific oral health programs provided examples of innovative practices, as well as their perceived inadequacies, challenges and gaps. The discussions included a review of oral health policies, dental clinical service programs for disadvantaged people and professional education, with a focus on community-service learning for the dental personnel.

Oral Health Policies

Two presentations highlighted government policies to address the oral health needs of low-income residents: one focused on policies in British Columbia, the other on policies in Europe.

Rosamund Harrison, University of British Columbia, Canada

Rosamund Harrison provided an overview of publicly funded dental services and benefits in BC. While most Canadians either have private dental insurance or pay out of pocket, there are public dental benefit programs funded at the provincial or federal level that provide assistance to specific populations. These include the federal Non-Insured Health Benefits (NIHB) program for eligible First Nations and Inuit people; Health Canada’s Children’s Oral Health Initiative (COHI) for First Nations and Inuit children; and Healthy Kids, a provincial dental program for children. Dental benefits are available for people receiving income assistance or disability benefits. Other types of government-sponsored dental public health programs delivered by regional public dental staff include programs focused primarily on children, programs in long-term care facilities and other “special” initiatives.

Björn Söderfeldt, Malmö University, Sweden

Björn Söderfeldt explained that within Europe there are many different systems of oral health care, but most can be understood to fit into one of five models: 1) the Nordic Model in Denmark, Sweden, Norway and Finland is characterized by the state playing a central role, with a large salaried public sector of dental personnel; 2) the Bismarckian Model in Austria, Belgium, France, Germany and The Netherlands has minimal service in the public sector and is financed by employers and employees; 3) the Beveridgian Model in the United Kingdom and partly in Ireland is free for children, financed by taxes, employs a small workforce in the public sector and has contracts with independent dentists; 4) the Southern European Model in Italy, Portugal, Spain and Greece where the public sector has a small role, there is limited insurance from employers and is provided mostly by independent dentists; and 5) the Eastern European Model in the Czech Republic, the Baltic Republics, Poland, Hungry, Slovenia and Slovakia is changing from a public to private service offered by independent dentists increasingly supported by private insurance.

Dental Clinical Service Programs in BC

Several participants presented case studies of unique initiatives around the province that were created in response to local inequities.

Bruce Wallace, University of British Columbia, Vancouver

Bruce Wallace reported on a provincial scan of local initiatives that help low-income residents access dental care. He described four types of initiatives: 1) dental access funds; 2) charitable volunteer clinics; 3) community dental clinics operating as social enterprises or with government subsidies; and 4) teaching clinics supported by colleges or universities. Over the preceding decade at least one new community dental clinic was established annually and other local responses have occurred in rural, urban and Northern areas. Many of the responses are limited to emergency care by volunteers, much like food banks. In addition, Mr. Wallace conducted a case study of five community-based dental clinics offering basic treatments by paid dental staff who work in settings integrated with other health and social services. The current patchwork of community clinics around the province provide basic care at reduced costs to vulnerable communities. However, these clinics are financially vulnerable and they lack evidence of effectiveness. Further investigations are needed to clarify the process, capacity, outcomes and effectiveness of the clinics and the potential for securing governmental assistance to ensure their sustainability.

Kyle Pearce, Strathcona Community Dental Clinic, Vancouver

The Strathcona Community Dental Clinic is an inner-city Vancouver public school established in November 2001. Although it primarily serves children and families in a low-income, ethnically diverse neighbourhood, the clinic also accepts seniors. As a social enterprise, it is financed by donations, grants and professional fee-for-services. The clinic generates surplus revenues, which allows staff to provide treatments at reduced fees or pro bono at their discretion.

Research questions

• What is the appropriate structure of public dental fees for low-income patients? Given that the government-sponsored reimbursement for professional services is lower than the profession’s fee guide for dentists, how can dentists be motivated to treat low-income people and patients who are difficult to manage?
• Can operating expenses, such as dental laboratory fees for dentures, be reduced through special financial arrangements with suppliers to community dental clinics?
• How can patients receive support to attend dental specialists?
• How can treatments by multiple dentists be coordinated to provide a continuous and appropriate standard of care for each patient?
• How can provincial and federal jurisdictional issues, such as reimbursement for care provided to Aboriginal peoples, be resolved beneficially?

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Sharon Melanson, Kelowna Gospel Mission Dental Clinic, Kelowna

As a dental hygienist with the Interior Health Authority, Ms. Melanson collaborated with others in her community to develop the Kelowna Gospel Mission Clinic, which opened in 2004 with federal funds for homeless people. The clinic provides dentistry for homeless people two evenings a week, and employs a part-time coordinator. All of the dental professionals are volunteers, and patients are accepted if they have pain or infection, are willing to have a tooth extracted and cannot afford treatment in a private dental practice. The clinic is located in an area close to where low-income and homeless people live. Patients get relief from pain and advice about healthy living, including nutrition, and employment opportunities. The clinic allows dentists to help this segment of the population, to reduce the number of emergency drop-ins to private practices and to enhance the role of dentistry in the community.

In cooperation with the UBC General Practice Residency program, the clinic continues to expand the services it offers, to now include removable dentures and other, more comprehensive, care. The success of the clinic can be attributed in part to local “dental champions” and to other community services that promote the service. Research is needed to determine to impact of the clinic on the number of patients presenting with dental problems at the emergency department of the local hospital.

Chris Zed, Portland Community Dental Clinic, Vancouver

The Portland Community Dental Clinic opened in September 2001 to provide dentistry for adults living in Vancouver’s Downtown Eastside. It is fully staffed and offers comprehensive dental services, including emergency, restorative and preventive treatments provided by dentists, dental hygienists, dental students and general practice residents. The UBC faculty of dentistry provides financial support through an endowed fund. The overall health and social objective in this community is to enable the unemployed to become employed.

Research questions

• What are the appropriate community-based practices for treating dental patients with chronic mental health problems, substance abuse and related chronic diseases, such as HIV and hepatitis C virus?
• How do the mental health disorders and other chronic morbidities in this community influence the signs, symptoms and management of dental pain?
• How do we determine sustainability, and is it ethical to establish an educational partnership with a vulnerable community if the partnership cannot be sustained?
• Do dental clinics serve effectively as long-term contributors to the social safety net, or do they serve more as a safety valve to release pressure temporarily and obscure the need for change in access to more traditional dental services? Are these clinics better than nothing?

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Catherine Poh, UBC Oral Cancer Prevention Program at Portland Community Dental Clinic, Vancouver

The Oral Cancer Prevention Program situated within Vancouver’s Downtown Eastside provides a unique opportunity to reach a population that is medically underserved and that has a very high risk of oral cancer because of heavy tobacco and alcohol abuse, malnutrition, immune-deficiencies and extreme poverty. About 300 patients have been screened as part of this program; the findings to date of oral cancer in two patients and pre-malignant lesions in nine patients confirms the concerns that this community is at very high risk compared to most other communities in BC. This program has expanded to provide mobile screening clinics.

Research questions

• How do you develop a clinical environment that reaches this “hard-to-reach” community?
• How can the screening program become an effective preventive and treatment service?

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Diana Lin, UBC, Healthiest Babies Possible Dental Program, Vancouver

The Healthiest Babies Possible Dental Program offered by the Vancouver Coastal Health Authority is a public health initiative for low-income pregnant women at high risk for delivering pre-term and/or low-birth-weight infants. Ms. Lin used an assessment framework involving detailed descriptions of the program along with evaluations of process and outcomes. She found improvements in the knowledge, behaviour and oral health status of the women, as well as in the oral health status of their children. However, the scope of the program is limited by financial restraints.

The “insider evaluations” used in this research offered useful insights into the program’s process of operations, including economics, relationships and access to treatments. However, these types of insider evaluations have disadvantages, ranging from time constraints to systematic bias.

Research questions

• How to promote the benefits of prenatal dental public health programs.
• The best way to improve dental services to address the concerns of high-risk pregnant women with low incomes and no dental benefits.
• Strategies to improve collaboration between community-based dental personnel and personnel in other health organizations interested in increasing accessibility and availability of dental services for low-income pregnant women.

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Professional Dental Education Programs in BC

Educational programs for students of dentistry, dental hygiene, denturism and dental assisting have developed curricula in response to the growing awareness of oral health inequities and the perception that community-service learning benefits both students and the community. Formal presentations and open discussions explored the impact of the educational programs and were the basis for developing an agenda focusing research on how students can be prepared to address the oral health needs of disadvantaged communities.

Dianne Stojak, Dental Hygiene Program at the Vancouver Community College, Vancouver

Students and faculty at the Vancouver Community College (VCC) have provided dental hygiene services in community settings using a service-learning model for 34 years. Factors that promote this involvement in community service include strong advocates within VCC, continuous collaboration with public health authorities, and a need to comply with the educational standards required by the Commission on Dental Accreditation of Canada and by regulatory authorities on clinical practice. Scheduling difficulties and time constraints limit involvement of the students in community-service learning. Moreover, there are no useful measures of social responsibility to confirm the influence of this model on clinical practice, other than the endurance of community involvement by the VCC, and the dental hygienists who volunteer at community dental clinics after graduation.

Research question

• How can the influence of community-service learning on the clinical practice of dental hygienists and the satisfaction of the community be measured?

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Rosamund Harrison, Children’s Dental Program at UBC, Vancouver

For more than 30 years, dental students at UBC offer a treatment program of free dentistry to children in and around Vancouver who could not afford the services of a dentist in private practice. As part of the dental curriculum, the program provides basic treatment for about 350 children annually on the Point Grey campus and at the Douglas Community College in New Westminster.

Research questions

• What is the appropriate classification for this educational program—community service, community-service learning, community outreach or community-based dental education?
• How does the program enable and enhance the long-term commitment of dental students after they graduate to meet the needs of disadvantaged children and their families?
• Can the impact of the program on the clinical practice of dentists be measured?
• Can the civic engagement of dentists who participated in the program be measured and improved?
• How do students learn from the experiences and lives of the children and their families?
• Why do families send their children to this program, and what do students learn about how families cope with the stigma of their child being a “guinea pig” for dental students?
• Does this program help students manage the needs of children and their families who have difficult problems?
• What is the optimal way to assess the educational and service influence of this program?
• Can parents and caregivers learn to promote oral health within the “structure” of the program?
• How can the program be extended to treat more children in more communities, and with students from other disciplines?

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Chris Zed, General Practice Residency Program at UBC, Vancouver

The one-year post-graduate clinical program offered by the UBC faculty of dentistry provides salaries for several dentists (usually within a year of graduation) to provide oral health care under supervision to special populations in hospital clinics, community clinics and long-term care facilities. The salaried residents help to sustain some of the non-profit clinics in the province.

Research question

• What is the optimal model for partnerships between the general practice residency program and community clinics for vulnerable populations?

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Jolanta Aleksejuniene, UBC Dental Professionalism and Community Service learning, Vancouver

The four-year Professionalism and Community Service (PACS) learning curriculum at the UBC faculty of dentistry offers workshops, plenary sessions and panel discussions supplemented by practical assignments in various communities of low-income groups, elders in long-term care facilities and other special populations who have difficulty accessing oral health care. PACS provides dental students with knowledge and experience to: 1) learn about the social determinants of oral health; 2) apply the principles of health promotion to improve community oral health; and 3) provide clinical care in hospital clinics, community clinics and long-term care facilities.

Research questions

• What are the best practices for building sustainable social networks and community engagements?
• How should a PACS curriculum be evaluated?

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Professional Dental Education beyond British Columbia

Frank Licari, Midwestern University, Downers Grove, Illinois, USA

Follow-up data on a service-learning program at Midwestern University explain how dental students can be academically, clinically and financially productive in community-clinics.

Research questions

• What are the outcomes measures that will show the long-term behavioural benefits to communities from dentists who participated in community clinics as students?
• How can dental students learn to address disparities of oral health in the community within the constraints of existing curricula?

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Phil Weinstein, University of Washington, Seattle, Washington, USA

Preventive interventions should be a core service in community clinics because it is almost impossible to eradicate oral diseases in disadvantaged groups when diseases are so well established.

Research question

• What programs will prevent oral diseases effectively in communities where access to dental services is difficult?

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Judith Albino, University of Colorado, Aurora, Colorado, USA

Community-based participatory research (CBPR) is suitable for investigating oral health care inequities and publicly funded dental programs for vulnerable populations. The method is used widely in public health programs, such as research protocols involving Aboriginal communities.

Research question

• Can the principles of CBPR help to develop, implement and evaluate services and educational programs for communities where there is evidence of oral health disparity?

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How Research on Disparities Can Influence Policy and Practice

Various speakers explained how research elsewhere on health inequities might influence oral health disparities in this province.

Bruce Wallace, University of British Columbia, Canada

Local advocacy for change in health care has helped to integrate oral health indicators within research on poverty reduction and homelessness. Advocacy can take many forms and can influence political decisions, as has happened in BC and Ontario. A journalist in Toronto, for example, used information about dental inequities to stir public sympathies, attract political attention and ultimately produce change in health care policy.

Björn Söderfeldt, Malmö University, Sweden

The relationship between research and policy can be viewed as a “garbage can model” where the public system is a garbage can of research ideas, interests and lobbies, while decisions about policies occur accidentally, with problems and solutions associated randomly.

Research question

• If politics plays a role in health policy, what influence does public opinion have on political decisions?

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John Millar, Provincial Health Service Authority of BC, Canada

Politics is a strong social determinant of health and there are many ways in which policies are developed. It is therefore helpful to recognize that the process is generally non-linear. Policy develops in the political moment and is rarely driven by evidence, which gets in the way of policy-making most of the time. Consequently, a focus on oral health inequities rather than disparities is likely to have a greater influence on policy, because disparities are limited to reporting observed differences whereas inequities are associated with values and judgments that declare injustice. Health inequities raise a highly complex set of issues that require more than a governmental response. They can be identified with policy and research as part of a dynamic network of parallel agents that are constantly acting and reacting to each other. It is useful, therefore, to provide a vision or framework that identifies and engages the administrators and politicians who activate the policy process.

Other provinces have addressed poverty through provincial poverty plans with multidimensional goals, targets and investments. In BC there is an opportunity to present inequities within the context of a “Prosperity and Health Action Plan” that can frame a complex adaptive system, such as health inequities, for action. There are four elements to this action plan: 1) labour market catchment; 2) job creation; 3) productivity; and 4) social fabric. Action on each element will require participation not only from government, but also from labour, business and nongovernmental organizations (NGOs), academics and researchers in an iterative process of building on successes and momentum.

Peter Cooney, Chief Dental Officer, Health Canada, Ottawa

The recent Canadian Health Measures Survey (2007-2009) provides useful data from which it should be possible to estimate oral health care needs in different communities across Canada. Consequently, the survey offers a solid foundation for studying disparities in oral health and influencing policies and health care interventions in BC and other regions across the country. Results from the survey indicate that Canadians generally have good oral health; however, one out of three Canadians has a dental need and one out of six reports that this need cannot be addressed because of financial reasons.

Research questions

• What are the relationships between oral health, chronic diseases and the social determinants of health?
• How can the relationships be used to develop practical interventions that will reduce and ultimately eliminate inequities in oral health?

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Recommendations for a Research Agenda

Overall, participants emphasized a solutions-focused research agenda for oral health inequities in BC. Rather than engaging in research to better measure and define unmet needs and inequities, there are opportunities to learn from the policies, practices and educational programs already addressing oral health inequities. A solutions-focused agenda would emphasize community engagement and practice-based evidence (on administration, services and economic costs) that effectively provides outcome measures and cost-benefits in ways relevant to inform policy and practice.

In summary, the research agenda should aim to:

• better integrate oral health with general health, notably in research and policies focused on social determinants of health, health inequities and public health policy and practice
• explain how dental needs are defined and addressed by different populations
• provide evidence for providers about the adequacy of “alternative” responses to enhance and sustain community treatment alternatives and ensure they are affordable, accessible, acceptable and sustainable
• calculate the costs and benefits of different policies and programs to address oral health inequities
• explore the benefits and limitations of different treatment objectives, particularly emergency care and treatments under different fiscal arrangements
• track visits to hospital emergency departments for unmet dental needs
• explore relationships between oral health, homelessness, social marginalization, psychiatric disorders, substance abuse and other co-morbidities
• distinguish between “safety nets” and “safety valves” in the absence of changes in health and social policies relevant to oral health inequities
• evaluate the impact of service-learning programs on the professional careers of dental personnel.

THE AUTHORS