Applying New Ideas and Program Design to Ontario Government

Sponsored Dental programs—— ——

Dr. Ian McConnachieOntario Dental Association

• Ontario Statistics– 55% with employer sponsored plans– 4% with private dental plans– 5% on government plans– Balance self-paying– 14.4% defined as “low income” (Statistics Canada)

– 70% of Ontarians visit a dentist annually• Highest percentage in Canada

• Ontario government perspective on government plan coverage– Gap coverage– High needs, not high risk

• Low socioeconomic levels• Disabled and their families

• 36 Public Health Departments in the province– All provide dental services required by

mandatory provincial programs– Some have dental clinics– Services vary with local mandates and funding

• Over 4000 private dental practices

• Ontario Public Health Programs for At-Risk Children– Healthy Babies, Healthy Children– Best Start– Early Years Centers– 18-month Well Baby Visit– Nipissing District Developmental Screen– Healthy Schools Initiative

Oral Health Care is not currently a part of these programs

• Mandatory government dental programs for public health– Dental Indices Survey (DIS)– Oral health screening– Monitor fluoridation of water supply– Provide Children In Need of Treatment

Program (CINOT)– Provide dental education to high risk schools,…

• Dental Indices Survey (DIS)– Limited value– Non-calibrated– Less than ideal examination– No radiographs– Inconsistent data collection methods

Beynon et al 2004

• Provincial government children’s dental plans– Children in Need of Treatment (CINOT)– Ontario Works (OW)– Ontario Disability Support Program (ODSP)– Assistance for Children with Severe

Disabilities (ACSD)

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1990 1992 1994 1996 1998 2000* 2002 2004

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CINOTProcendure Code Profile Restorative vs Preventive

by Number of Procedures Paid for

Preventive

Restorative

• Decreasing Welfare Rolls does not decrease your risk– Persons covered on social assistance 1995

• 1,344,600– Persons covered 2003

• 673,900– Children under 19 living in poverty

– 594,428 Quinonez et al 2005

– Persons on social assistance accessing care• Between 20% and 40%

• Patient profile Self-identified and other barriers to dental care

• Lack of info re program funding• Language• Inflexible work situation• Mistrust of bureaucracy Harrison et al 2003

• Foreign born• Lower education level of caregiver• Lower income level Kenney et al 2000

• Delivery Models - Problems– Unique high-needs populations

• Dental care is only one of their needs– Low socioeconomic levels– Homeless– Recent immigrants with cultural differences– Out of work with lost benefits– First Nations – Working poor– Language barriers

• Delivery Models – Problems– Lack of a “dental home”

• Delivery Models – Problems– Lack of a “dental home”– Dental care a low priority until pain/infection

• Delivery Models – Problems– Lack of a “dental home”– Dental care a low priority until pain/infection– Many of population lack awareness of oral

health priorities

• Successful Delivery Models - School-based prevention

School-based dental care (Albert et al 2005)

• Screening• Preventive• Office-centered• Collaborative• Preventive/primary restorative• Comprehensive community dentistry

• Successful Delivery Models – School-based prevention

• PEI• ChildSmile Pitts

• Forsythkids Niederman 2005

• Scandinavia Axelsson 2006

• Quebec – CLSC’s Verronneau 2008

• PEI School Program– deft/DMFT = 0 grown 6-12 % 1998-2007– deft/DMFT scores lower 0.30-0.55– Exception 9 year olds – no change– 80% participation– Dental community generally positive

• Successful Delivery Models – Pre-school prevention is important

– U.S. Surgeon General 2000– Vargas et al 1998– Beltran-Aguilar et al 2005

• AAPD and Head Start Schneider et al 2007

– Underlying philosophy of prevention, early intervention and parental involvement

• Role of medical community– “Into the Mouths of Babes” Savage et al 2004– Wawrzyniak et al 2006

• First exam by first birthday

• Successful Delivery Models – Integrate with community resources

Hartsock et al 2006 Burry unpublished

– Sensitivity to unique community needs• Lay ethnic counselor Harrison, Wong 2003

• Community dental facilitator Harrison et al 2003 • Motivational interviewing Harrison

• Ontario Government– Recognition the programs are not meeting

needs– Co-ordination of oral health with public

health initiatives– Increased resources– Willingness to collaborate

• Ontario Government– Promotion of water fluoridation

– CDC 2001, Health Canada 2007

– Development of educational resources for providers and public

– Funding of further epidemiological research– Process of accurate reporting of outcomes

with sharing of data

• Dental Public Health– Evaluate the needs of the community

– Data collection – ICDAS

– Design local programs with the dental community

– Measures to assess performance• E.g. RE-AIM Glasgow et al 1999

– Case management model• ADA, Ottawa

– Increased resources

• Dental Public Health– Development of community-specific

programs– Collaboration

• Individual communities• School boards• CHC’s• Medical and dental community

• Organized Dentistry– Collaborate in program design, setting up

outcomes and measurement– Education of dental team re early

intervention– Work with members to increase

participation

• Program Specifics– Adequate funding– Involvement of the dental community in plan

design and delivery – Strong preventive emphasis including

antimicrobials with appropriate periodicity– Strong data-collection standardized and calibrated– Ongoing review and revision incorporating new

techniques– Education and involvement of parents/caregivers

• Program Specifics– Pre-school

• Select communities• Data collection (ICDAS) and review

– Referral system to dental community– Preventive module within medical offices

paid for by health system– Fluoride varnish twice yearly for high risk

children

• Program Specifics– School-age

• Preventive model within schools in urban areas where numbers warrant

• High risk schools• Office-centered preventive model in less-built up

areas

• My Field of Dreams– “if you build it, they will

come”