“Dental tourism” occurs when people travel out of their home country to access dental care abroad. In the absence of a reliable means to track patient involvement in dental tourism, we cannot know how many people are traveling abroad for particular procedures.1,2 However, academic and media reports suggest that Canadians are traveling abroad for dental care when they face barriers to access, seek care at a lower cost or both.2,3 Financial barriers are particularly pronounced for underinsured, low-income Canadians, including those using limited, publicly funded dental services and the “working poor,” i.e., those who do not qualify for public insurance or employment-based insurance.4 Underinsured and socially marginalized Canadians are reported to seek needed care options abroad 2,5 along with Canadian immigrants.3 However, much of this discussion has focused on describing pull factors and individual motivations, with only limited examination of systemic factors that could play a role in pushing Canadians to participate in the dental tourism industry.2,3
The following analysis responds to this knowledge gap. By documenting the perspectives of targeted institutional stakeholders with extensive knowledge of the dental care system in Canada, we provide an overview of how systemic factors such as dental care financing and delivery, the rising costs of care and consumerism in dental care could push Canadians abroad for dental care. Although we do not discuss here particular contexts under which individual Canadians might decide to travel abroad for dental care (see work by Calvasina and colleagues3), our objective is to highlight broad systemic factors that should be considered when researching and addressing the dental tourism phenomenon in Canada.
Methods
Between September and December 2015, we conducted 11 semi-structured telephone interviews with 14 key informants (2 interviews were conducted with multiple participants). Interviewees worked at Canadian institutions: 7 in national, provincial and territorial dental associations; 2 at dental schools; 3 in provincial dental colleges (regulatory bodies); and 2 in patient advocacy groups. Interviews lasted approximately 45 minutes.
After all authors agreed on an interview guide, KA conducted the interviews. As the participants had different responsibilities in their organizations, the interviewer facilitated conversation by adjusting questions according to participants’ areas of expertise. The questions prompted informants to discuss issues related to access to dental care in the region served by their organization, resources or programs available to Canadians struggling to access dental care and knowledge of and perspectives on Canadians’ participation in dental tourism.
Participants were recruited via email sent to organizations whose work focuses on the development, regulation or promotion of dental care in Canada. All of the Canadian dental associations (provincial, territorial and national) (n = 13), English-language dental schools (n = 8) and dental regulatory authorities operating separately from the dental associations (n = 5) were contacted. We also contacted Canadian patient advocacy groups whose mandate includes promoting members’ access to dental care (n = 10). Representatives of these organizations who were interested in participating were required to read the study details and provide consent before the interview.
Interviews were recorded and transcribed verbatim. Thematic analysis followed.6 The authors first met and discussed the themes that emerged from the transcripts and identified 3 systemic factors mentioned as producing barriers to accessing dental care in Canada. Manual coding was used to identify data relevant to each theme. The extracted data were then contrasted with the existing literature and our study objectives to assess the scope of each theme.
Results
Participants emphasized their limited knowledge of overall trends in Canadians’ participation in dental tourism. However, they did suggest that when facing systemic barriers to care, some Canadians likely seek alternative care options (e.g., services provided in emergency rooms, by unlicensed dentists at home or by dentists abroad), suggesting that systemic factors could play a role in Canadians’ participation in dental tourism.
The 3 main themes or systemic factors emerging from these discussions were financing and delivery, cost of care and consumerism in dentistry. We use quotes to report participants’ views of these systemic factors.
Financing and Delivery
Participants raised concerns about Canadians’ lack of access to adequate dental services as a result of gaps or limitations in the current Canadian dental care system (Table 1). Quote 1 cites over-reliance on employer-based insurance coverage to finance care, particularly for the working poor.7 Participants suggested that precarious employment (e.g., shift splitting, contract work) limits opportunities for employed people to obtain private dental insurance through work. Moreover, with yearly maximums for dental coverage increasing little or not at all, even patients with employer-based health benefits can face care needs not fully covered by these forms of insurance.
| No. | Participant affiliation | Quote |
|---|---|---|
| 1 | Provincial dental association | So I looked at the 1978 fee guide and compared it to the 2014 fee guide and... fees had gone up somewhere between 200 and 300 percent. During that time, the yearly maximums for typical dental plans went up from $1000 to $1200.... If a patient walks into an office now needing more than a check-up and a cleaning and a couple of fillings, the first time they need a root canal or a crown... they are going to hit their yearly maximum. |
| 2 | Provincial dental association | The provision of dental care to seniors is and has been a problem for a long time. And it’s not getting any better. Both the seniors in the general population have retired and possibly lost their dental plans or for seniors in long-term facilities they, they can’t access care either, it’s a problem with funding for them as well as access to people who can go give them treatment and facilities in homes that they can actually go and get it done. |
| 3 | Dental school | Well yeah, I mean you could come to the dental school [for more affordable care], but the problem then is you know, say you live [rurally], I mean, how often could you travel to... the dental school because dental students work more slowly than a dentist in private practice. |
| 4 | Dental school | So the problem really is, those, that group which is the lower socioeconomic group they’re falling through the cracks. So in fact the Faculty of Dentistry has lots of free volunteer clinics on the weekends that are students and faculty staff that help address the need, but still we can’t, it’s too many people for us to take care of.... I mean, we just don’t have the capacity to reach out to everyone and we do go around the province, we go to first nations reserves and do things, but the problem is we’re not big enough to cover the needs, when you think of the population... and think of a third of them as people are falling through the cracks. |
| 5 | Patient advocacy group | There’s also some issues with people on social assistance... you know they might need an alternative sort of model of care that isn’t accommodated in private practice... private providers don’t always accept the patients for those reasons, they limit how many people on these programs they see. |
Quote 2 raises the issue of the oral health of seniors without employer-based dental insurance who are also ineligible to receive care funded by public insurance. These concerns regarding insurance coverage suggest that under- and unemployed Canadians might choose to access care abroad to save money on out-of-pocket dental expenses.
Participants also emphasized that programs providing care to low-income, underinsured Canadians are geographically concentrated in urban centres, further limiting access for rural Canadians facing financial barriers to accessing care. For example, quotes 3 and 4 highlight financial inaccessibility that is amplified as a result of geographic barriers. Furthermore, even in regions served by not-for-profit clinics and dental schools, participants suggested that their capacity to treat is limited as they rely on the availability of volunteer dentists and program funding.
Quote 5 describes concerns about financial barriers limiting access to dental care compounded by other issues not related to geography. For example, participants suggested that reduced rates for low-income patients are not always welcome if patients feel stigmatized or providers are unprepared to use this system.
Overall, participant discussions highlighted how systemic factors related to financing and delivery could produce a variety of barriers to access, causing people to seek out more easily accessible and affordable options abroad.
Cost of Care
Participants expressed concern about the rising costs of providing dental care, potentially limiting the amount of care actually covered by insurance and exacerbating barriers to access for under- or uninsured Canadians (Table 2). According to participants, regulation and safety protocols have increased costs considerably over the past few decades. However, participants emphasized that these costs are justifiable for care to be safe and effective.
One participant (quote 1) compared a dental clinic to a mini-hospital in terms of all the necessary protocols dentists must follow to meet standards set by associations and colleges. This participant agreed with many others that the costs of providing dental care are necessarily high to ensure patient safety; however, these necessary costs are not always reflected in insurance coverage, leaving Canadians underinsured and potentially motivated to find more affordable care options abroad.
Some participants also mentioned other costs, not associated with regulatory requirements, that have been introduced into Canadian dental care, creating a “perfect storm” of factors raising the cost of care. For example, in quote 2, increased dental care costs are attributed to rising fees for dental education, suggesting that dentists must charge high fees to pay back increasingly large student loans. Quote 3 indicates that for many new dental graduates burdened with large student loans, the pressure to establish a profitable business can be compounded by increasing competition for patients in urban centres, driving them to increase fees to cover their operating costs and/or promote increasingly novel treatment that might not be covered by insurance. Once again, informants suggested that rising costs related to both regulation and costs of operation could push some patients to purchase lower cost care abroad.
Consumerism in Dental Care
Interviews highlighted the role of cultural norms and evolving technology in driving demand for services that are not always covered by insurance companies and must be paid for out-of-pocket (Table 3). Quotes 1 and 2 illustrate participant perceptions that, when paying out-of-pocket for dental care, Canadians might shop around for the best value, just as they would when purchasing other goods and services. Informants expressed concern that Canadian dental patients might emphasize cost of care when deciding to participate in dental tourism or other alternative types of care when their layperson’s knowledge limits their ability to judge the quality or safety of care.
| No. | Participant affiliation | Quote |
|---|---|---|
| 1 | Provincial dental association | There’s a very high overhead situation, it’s like a mini hospital because of all the things that have to be met. |
| 2 | Provincial dental college | One of the reasons that dentistry is so expensive and it is, there are several reasons and one is... the advent of dental insurance... that is a major changer as far as costs go because you know when you have a, when you have a dental insurance that’s covering 100% of your costs... then people are willing to have whatever done they need. And so you know with dental insurance of course the fees have gone up over the last four or five decades.... But what’s happened in conjunction with that is the cost of dental education... now we are at a point where there are way more dentists working for a lot less and education is a lot more and so it’s almost like the perfect storm... and there’s a lot of onerous things put on every dentist... to make sure that everything is as safe as it can be for your patients. |
| 3 | Provincial dental college | We know that from the data we understand that in Canada for any kind of private practice, you need 1200 to 1400 patients... to have a vibrant practice. And we know that the ratio in Toronto is about 700 and in Vancouver it’s 900.... Well you know, where people are coming to for treatment and how much they are paying for treatment, that’s reflected… um… I mean you are at SFU [in Vancouver] and I am sure you turn on the radio and you are bombarded by all types of advertisements from dentists about dentistry and dental practice. It’s just become competitive. Very, very competitive. It’s certainly driving the advertising promotion side, probably to a place we are not very comfortable with. |
| No. | Participant affiliation | Quote |
|---|---|---|
| 1 | Dental school | In Canada if you’re going to a dentist you can ask for options and if, if the person does three crowns maybe it doesn’t have to be three crowns, maybe it can be one or two and I would say that most patients need to push harder on what are the other options, not the most expensive option. |
| 2 | Provincial dental association | So if somebody understands the value of their dental health, they understand they value of the care they need, in light of other costs in society, they’re not going to see dental care all that expensive... any patient that walks into my office in any condition whatsoever, I can get them to the point where they’re pain free and disease free and their mouth is stable and their future treatment needs are predictable for a cost of a package of cigarettes a day for a year. |
| 3 | Patient advocacy group | Maybe like a person goes to the dentist, again they’ve enjoyed dental insurance their entire lives, they retire, they lose their benefits and then they are told how much it’s going to cost to do whatever they want to do to keep up the oral health that they’re used to. And then they, they’re like blown away because they’d rather use that you know $5000 to travel or you know to enjoy their retirement and they never actually thought they’d have to pay that much.... I don’t think people always realize how much it costs to pay for things if they’ve had insurance. |
Interview discussions also detailed how patients could face unanticipated out-of-pocket costs as a result of lost insurance or new diagnoses, particularly when they have not seen a dentist for an extended period. For example, patients who have never previously paid out-of-pocket for services might be unaware of dental costs if their insurance coverage decreases (quote 3). This participant highlighted how surprise costs could also encourage Canadians to shop around for care and alternative options, potentially leading some to consider dental tourism.
Discussion
Our analysis suggests that some Canadians face barriers to access to domestic dental care related to systemic factors: the financing and delivery of care; the rising costs of providing care safely; and increasing consumerism in dental care. Perspectives from 14 people with extensive knowledge of dental care provision in Canada indicate that these systemic factors could play a role in the dental tourism phenomenon, although this research does not specifically suggest how these factors are informing individual decision-making as we did not consult prospective or former dental tourists.
The academic literature on international medical travel suggests that Canadian medical tourists are motivated to travel for care to take advantage of lower procedure costs abroad, to avoid wait lists and to access domestically unavailable procedures.8 Although our research suggests that cost could be an important factor in the decisions of Canadian dental tourists, given the systemic factors we highlight above, there could be varied motivations for Canadians to travel abroad.2
Participants’ discussions of access to care barriers suggested that multiple systemic factors related to financing and delivery differentially inform individuals’ access to dental care. They identified barriers that are commonly discussed in the dental literature, such as insufficient insurance coverage for the “working poor”7 and fragmented, geographically concentrated, and financially unsustainable programs for vulnerable populations.9,10
However, participants also highlighted how particular systemic factors can amplify existing access challenges. For example, concerns about the limitations of programs intended to meet the needs of vulnerable populations demonstrate that diverse health determinants, including insurance status, socioeconomic status, geographic location, aboriginal status, age, mobility and familiarity with dental care, can produce overlapping vulnerabilities that exacerbate or introduce new levels of inaccessibility.11 Research already shows that Canadian immigrants’ decisions to participate in dental tourism are informed by multiple push factors, such as labour precariousness and language barriers, that limit adequate care options.3 Our findings correspond with this research by suggesting that interrelated systemic factors can exacerbate barriers to accessing dental care, barriers which could ultimately push Canadians to participate in dental tourism.
Interviews also highlighted that increasing dental costs attributed to improved safety and regulatory oversight can result in greater financial burdens on Canadian patients seeking to protect or restore desired levels of oral health,12 particularly for the third of Canadians without any form of dental insurance.13 Furthermore, insurance companies, public insurance and individual patients must navigate what qualifies as “good” oral health and determine which procedures are necessary to achieve this outcome within a context of evolving dental technology and shifting cultural norms. Factors such as cultural expectations of care and technological advancement shift demands for dental care in ways that can increase costs for the patient.12 Participants suggested that increasing costs of care combined with reduced insurance coverage as well as shifting social norms could push Canadians to shop around for care options, including alternative options abroad. As consumers of dental care, patients might seek the best value, unaware that higher cost care may be attributed to enhanced regulatory activities, which may not be reflected in the costs of care charged by dental providers abroad. As a result, participants generally expressed concern about the perceived growth of the dental tourism phenomenon in terms of patient safety, while acknowledging the systemic pressures that could be contributing to this growth.
Overall, this research examines how systemic barriers to accessing needed dental care might push Canadians to seek alternative care options abroad. As the means for overcoming these barriers, such as income and dental health awareness, rest very much at the individual level, Canadians might feel they have no choice but to shop around for what is perceived as lower cost, better value, or more easily accessible dental care to meet their oral health needs. Canadians’ search for these care options might push them towards participation in the dental tourism industry.3,14,15 The research presented in this paper demonstrates a need for further examination of potential health safety and equity concerns surrounding this phenomenon, particularly if pressure to address systemic barriers to accessing dental care lessens if individuals who are able and willing to travel abroad opt for dental tourism.10,16
Given that we spoke with only 14 informants from a targeted population, this research is limited in its ability to suggest the impact of dental tourism on the Canadian dental care system and Canadians’ oral health. Although interviewees were highly interested in discussing the topic of dental tourism, they had limited knowledge of patients’ decisions and experiences regarding this subject. Further research examining the lived experiences of Canadians seeking needed dental care, both in Canada and abroad, could provide a better understanding of the contexts in which these decisions are occurring and, as a result, how this phenomenon could affect dentistry and oral health equity in Canada.
THE AUTHORS
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Ms. Adams is a PhD candidate, faculty of health sciences, Simon Fraser University, Burnaby, British Columbia. |
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Dr. Snyder is associate professor, faculty of health sciences, Simon Fraser University, Burnaby, British Columbia. |
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Dr. Crooks is professor, department of geography, Simon Fraser University, Burnaby, British Columbia. |
Correspondence to: Ms. Krystyna Adams, Faculty of Health Sciences, Simon Fraser University, 8888 University Dr., Burnaby BC V5A 1S6. Email: kaa4@sfu.ca
Acknowledgements: Ms. Adams received funding through a PhD fellowship awarded by the Canadian Institutes of Health Research. Dr. Crooks is funded by a Scholar Award from the Michael Smith Foundation for Health Research and holds the Canada Research Chair in Health Service Geographies.
The authors have no declared financial interests.
This article has been peer reviewed.
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