Synthesis of Canadian Oral Health Disparities in Dental Care

Introduction

Oral health as a part of general health

There is a growing recognition that oral health is linked to general health around the world (Vergnes & Mazevet, 2020). Poor oral health and dental ailments that include oral pain, gingivitis, periodontitis, dental caries, and edentulism negatively affect a person's quality of life. Furthermore, there is growing evidence to suggest that poor oral health increases the risk of other systemic diseases such as diabetes, cardiac hypertension, and Alzheimer's disease (Dörfer et al., 2017).

What is health?

In 2021, the World Health Organization (WHO) approved a landmark resolution urging WHO member states, such as Canada, that oral health should be firmly embedded within the non-communicable disease agenda and that oral health care interventions should be included in universal health coverage programmes (WHO, 2022). Following the WHO's definition of health from 1946 - which is that ''a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity" - attaining good oral health should be based on achieving an optimal state of being based on the person's current conditions (WHO, 1946). This definition means that the ability to achieve an optimal state of being should be possible regardless of a person's completeness physically, mentally and socially.

Therefore, the burden of oral diseases and other noncommunicable diseases can be reduced through public health interventions by addressing social determinants of health affecting the most vulnerable populations in Canada.

Social Determinants

Social Determinants that influence oral health in Canada

The Government of Canada recognizes 12 determinants of health as a broad range of personal, social, economic, and environmental factors (Government of Canada, 2022). These determinants are income and social status, employment, education and literacy, physical environments, social supports, healthy behaviours, access to health services, gender, culture, and race. These determinants have a strong influence on not only general health but also dental health, and they play a large role in how public policy can determine the quality of resources and the equitable distribution of those resources. Because these determinants are not equal amongst individuals, they create oral health inequalities in the Canadian health system.

Federal and Provincial Dental Care in Canada

The role of dental care in Canada's health system is primarily within a private system, and it has been viewed in the past as an individual's responsibility with limited government assistance (Grignon et al., 2010). The majority of Canadians afford dental care through private dental insurance or as out-of-pocket expenses. The federal government has oral health programs for veterans, refugees, and eligible Indigenous peoples only. Every province has their own oral health initiatives and programs that attempt to target marginalized groups. The absence of publicly financed dental care is detrimental to certain groups unable to afford dental care.

Marginalized groups

Marginalized groups with the greatest oral health inequalities are highest for those who live in poverty, who do not have dental care insurance, or who do not have readily accessible dental care services or staff. An individual's oral health behaviours are largely shaped by their or their family's socioeconomic situation, so these socioeconomic determinants play a significant factor in an individual's oral health status. These vulnerable populations in Canada that suffer the most from oral health disparities are recognized as poor, less educated, Indigenous, rural dwellers, and recent immigrants to Canada (Fisher-Owens et al., 2007).

Multilevel Model of Health

Understanding the role of SEM

Multilevel models of health like the socio-ecological model (SEM) aim to understand and intervene in individuals, groups/communities, and population health when health disparities in chronic diseases are an issue (Gargano et al., 2019). The SEM takes into account the interconnectedness between influential individual factors and upstream determinants of health. According to the SEM, oral health - similar to general health - is influenced by interactions between individuals, groups/communities, and their physical, social and political surroundings.

Note. The socio-ecological model. (CDC, 2022).

Different SEM Levels

At the first level, the oral health of an individual is influenced by personal factors such as age, education, income, biology, diet, and oral health practices (Dülgergil et al., 2013). For example, because sugars are an etiological factor in the dental caries process, if a person has frequent high sugar consumption and poor oral hygiene, he or she is more at risk for developing dental caries and other dental diseases (WHO, 2013).

The second level, relationships, encompasses a person's social influences such as family and peers, all of whom contribute to positive or negative oral health practices. For example, if the parents have low household incomes, educational backgrounds, and dental skills and knowledge, their children are more likely to have a higher association with developing cariogenic practices that lead to dental decay (Russo et al., 2020).

The third level, community, looks at the social ties people have with schools, neighbourhoods, and the dental care system. Access to fluoridated water systems is one such community-level oral health advantage (AHS, 2016).

The fourth level considers society, which is the broad socioeconomic variable that influences health. Cultural and social standards, as well as health; economic; education; and social policies, all contribute to the existence or reduction of socioeconomic disparities across groups (CDA, 2017).

Applying the SEM

In regards to oral health, oral health professionals, researchers, and community leaders can make programs and initiatives that specifically target variables that can reduce oral health inequalities for vulnerable populations. Rather than simply improving individual oral health behaviours, these types of oral health strategies focus on combining ways to transform the physical and social settings of populations to reduce oral chronic diseases.

Examples of oral health promotion using the SEM can include:

• School-based oral disease prevention and health promotion programs – can target multiple levels by providing nutrition, education, and access to care programs (WHO, 2013).

​Nutrition Programs	​Provision of health food options in cafeterias and vending machines Banning or reducing soft drinks and sweets sold at schools Promotion of healthier food alternatives in school media
Educational Programs	​Incorporating oral health into classroom lessons Daily tooth brushing and flossing exercises Seminars for parents and children on positive oral health behaviours
Access to Dental Care Programs	​Administration of fluoride and sealants Seminars for parents and children on positive oral health behaviours Provision of toothbrushes and fluoridated toothpastes Oral health examinations and screenings

• Legislation movement in social policies, campaigns, and dental benefits – targets societal changes from a government standpoint (WHO, 2013).

Water Fluoridation Programs	​Increase water fluoridation access to rural communities Promotion of water fluoridation and its benefits nation- and province-wide
Access to Dental Benefits	Increase federally funded benefits to more vulnerable populations Increase provincially funded benefits to more vulnerable populations
Access to Dental Care	Increase sites in rural areas for dental facilities and staff Create federally funded jobs for dental providers to go into rural locations Create provincially funded jobs for dental providers to go into rural locations
Oral Health Campaigns	Legislative creation of a nation-wide oral health week Government sponsored oral health promotion through social media advertising
Oral Health Surveillance	Increase oral health surveillance nation- and province-wide on rates of dental caries, periodontitis, and oral cancers Create national targets for oral health promotion for Canadians Increase oral health researchers

Chronic Disease Prevention and Management

Three chronic diseases in oral health

The three types of chronic diseases related to dental care that are most dominant in Canada are dental caries, periodontitis, and oral cancer. The prevalence of dental caries in children is 57%; and among adults who have or had dental caries, it is 96% (Government of Canada, 2010). The procurement of dental caries is the most common health condition in the world according to WHO. Although less prevalent, 21% of adult Canadians have or have had periodontitis; and in 2019, an estimated 5300 Canadians were diagnosed with oral cancer (Badri et al., 2021). As Canada ranks second-last in the public financing of dental health among developed countries, major reformation for the federal allocation of resources towards oral health promotion, disease prevention, and policy-making is severely needed and is lacking with Canada's current government.

Future Directions

Federal plans

Paying for necessary oral health care is among the leading reasons for the inaccessibility of dental care in Canada. However, the state of public dental care shows signs of increasing, albeit slowly. The current Liberal government has proposed a dental care program eligible to families with an income of less than $90,000 annually, with no copayments for anyone under $70,000 (Lexchin, 2022). The dental plan is supposed to start coverage for those under 12-years-of-age in 2022, which will then expand to those under 18-years-of-age, seniors, and persons living with disabilities in 2023. The remainder of people below the income threshold will become eligible in 2025 (Lexchin, 2022). Although this public dental care plan will not encompass all vulnerable populations across Canada with different oral health inequalities, it is a step in the right direction for the federal government to take more responsibility for the oral health of Canadians.

Conclusion

Over the length of this course, I have a deeper understanding of Canada's health care system and the role our government plays in dental care, as well as how their policies and programs affect vulnerable populations. It has increased my awareness and has given me a better perspective regarding for what I can advocate in my profession and for Canadian dental care.

References

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