The rise and fall of dental therapy in Canada: a policy analysis and assessment of equity of access to oral health care for Inuit and First Nations communities

Practice Trends and Job Satisfaction of Dental Therapists in Canada: Results from a National Survey

The objective of this research was to evaluate the practice trends, clinical services and job satisfaction of dental therapists in Canada. Licenced Canadian dental therapists were recruited to participate in this cross-sectional study. A total of 124 dental therapists completed the survey (~68% response rate), with 57.3% of respondents being over the age of 50. Most respondents were actively engaged in full-time clinical practice in private dental offices. Indigenous dental therapists were significantly more likely to work outside of private dental offices providing care for Indigenous communities. Just over half of respondents were compensated by an annual salary, with the highest proportion of full-time practitioners earning between $75,000 and $99,000 per year. Dental therapists who were active in clinical practice performed a wide range of preventive, diagnostic, and treatment services consistent with their scope of practice. This research demonstrates that Canadian dental therapists are highly engaged and satisfied with their profession. Dental therapists can facilitate improved access to oral health care in less accessible areas of Canada; however, compensation packages and incentives to work in these less accessible areas must be addressed, as well as legal and regulatory requirements to ensure that dental therapists are licenced providers throughout Canada.

Anaesthesia and Caries Treatment by Dental Hygienists: A Worldwide Review

OBJECTIVES

This study aimed to summarise the competencies and legal position of the dental hygienist (DH) regarding local anaesthesia and caries treatment through a worldwide review.

METHODS

A structured and peer-reviewed online questionnaire consisting of 27 questions was developed and emailed to all DH associations that are members of the International Federation of Dental Hygienists or European Dental Hygienists Federation. After obtaining the data, all responding associations were contacted to confirm that the data were summarised in the correct order and were asked to provide further clarification of answers if necessary. A descriptive analysis was performed to summarise the data.

RESULTS

Thirty-one countries were approached and 26 responded, resulting in a response rate of 84%. In 62% of the countries, the DH can administer local anaesthesia via infiltration and/or block anaesthesia. In 23% of the countries, the DH can indicate the placement of a caries restoration. In 15% of the countries, the DH can place caries restorations. In 81% of the countries, the DH can apply sealants.

CONCLUSIONS

Considerable variation exists amongst countries regarding the extended scope of DH practice. Overall, independently administering local anaesthesia appears to be more accepted as being within the scope of DH practice than caries removal and the placement of restorations.

Key Challenges for Indigenous Peoples of Canada in terms of Oral Health Provision and Utilization: A Scoping Review

Background

The oral health of Indigenous peoples in Canada is lacking compared with their non-Indigenous counterparts. This scoping assessment aimed to investigate the obstacles of providing and using oral healthcare among Indigenous peoples in Canada.

Methods

The scoping review took place between December 15, 2021 and January 10, 2022. Five key databases were examined: PubMed, Scopus, ISI Web of Science, Embase, and PROQUEST. The data were analyzed using NVIVO software to facilitate understanding of the major themes, subthemes, and codes provided.

Results

Seven major themes and eighteen subthemes were identified as impacting the oral health provision and utilization of Indigenous peoples in Canada. The major themes are individual characteristics, affordability, availability, accessibility, accommodation, acceptability, and public or government policy. Thus, to improve the oral health of the Indigenous peoples in Canada, an integrated approach is required to address these obstacles.

Conclusions

To address the oral health disparities among Indigenous peoples in Canada, policymakers should adopt an integrated approach.

'Toothless'-the absence of political priority for oral health: a case study of Ireland 1994-2021

BACKGROUND

Calls are emerging for oral health system reform under the Universal Healthcare (UHC) domain, while internationally there is an absence of political priority for oral health. In the Republic of Ireland there is very limited coverage of oral healthcare for the whole population. 'Smile agus Sláinte' Ireland's oral health policy published in 2019, represents the first change to national policy in over 25 years.

METHODS

This research examined the key factors influencing oral health policy, development, and implementation in Ireland during the period 1994-2021. A case study approach was adopted with two strands of data collection: documentary analysis and semi-structured interviews with elite participants. Analysis was guided by Howlett's five stream framework.

RESULTS

Ireland shares the international experience of oral health having very low political priority. This has perpetuated unequal access to public dental services for children and special needs populations while austerity measures applied to adult schemes resulted in increased unmet need with no universal coverage for dental care. The only area where there is political interest in oral health is orthodontic care. This low political priority combined with a lack of actor power in national leadership positions in the Department of Health and Health Service Executive has contributed to successive non-implementation of oral health policy recommendations. This is most evident in the failure to publish the Draft National Oral Health Policy in 2009. The research finds a failure to adequately engage with key stakeholders, particularly the dental profession in the development of the 2019 policy. All these weaknesses have been exacerbated by the COVID-19 pandemic.

CONCLUSIONS

Ireland's new oral health policy, 'Smile agus Sláinte', presents an opportunity for the provision of much needed public dental services. However, successful reform will require strong political will and collaboration with dental leadership to provide advocacy at national level. Global calls to incorporate oral health into the UHC agenda and an agreed political consensus for UHC in Ireland may provide an opportunity for change. Genuine engagement of all stakeholders to develop an implementation strategy is necessary to harness this potential window of opportunity for oral health system reform.

Pediatric oral health: community-based participatory research

Background

The most common chronic disease affecting children in Canada is dental caries. The objective of this study was to explore, identify, and address the strengths and barriers related to oral health services with an independent Indigenous community in Saskatchewan.

Methods

Community-based participatory research used interviews with Elders, health care providers, teachers, and parents/guardians of elementary school-aged children. The research focused on the development of genuine partnerships with the community. During data collection, the findings/results were returned to the community to establish direction, build success, and establish next steps. Thematic analysis was undertaken with the community. Descriptive statistics were analyzed using SPSS.

Results

The most commonly identified themes included: community resilience; the need for resource development and process to improve oral health literacy and skills; and how access to care barriers dually affected and related to personal and community cost, time, and human resources.

Conclusions

The research process involved the co-creation of tools to identify strengths within the community and drive opportunities for change; subsequently generating solutions to the practical problems and potentially transform the health system accessed by the community.

Dental therapy in the United States: Are developments at the state level a reason for optimism or a cause for concern?

Access to dental care continues to be a challenge for millions of vulnerable Americans. In more than 50 nations worldwide, dental therapists (DTs), mid-level providers who deliver a limited scope of dental care under the supervision of a dentist, have helped increase access to needed care. Since 2003, when the Alaska Native Tribal Health System introduced DTs as part of the Federally authorized Alaska Community Health Aide Program, a total of 13 states have adopted the role. However, as of April 2020, there are fewer than 150 DTs in practice throughout the country, and educational and licensing requirements as well as scope of practice vary between each state. Such heterogeneity makes the training and recruitment of future DTs a challenge. This article summarizes the current state of the DT workforce in the United States and discusses the possible future of the profession as other states contemplate adopting the model in the face of ongoing oral health disparities.

Community led: celebrating wellness with a smile

Dental caries is the most common chronic childhood disease in Canada and creates a significant burden on both human and financial costs. In Canada, the annual cost of dental day surgery for children is $21.2 million. The objective of this study was to explore and address the strengths and barriers related to the provision of oral health services in an Indigenous community in northern Saskatchewan. This community-based participatory research project focused on developing authentic relationships with the community. This research is novel because it is community-led and from the perspective of Indigenous people. Descriptive statistics were undertaken to describe the 38 participants. Semi-structured interviews were conducted with elders, healthcare providers, teachers and parents/guardians of elementary school-aged children; and inductive, thematic analysis was undertaken with the qualitative data. The most commonly identified themes included: community resilience, the need to improve oral health literacy and skills and the mitigation of barriers to access care. The research process included co-creating tools with the community that built upon strengths, creating opportunities for change, generated solutions and transforming the health system the community accessed.

Early Childhood Caries in Indigenous Communities

The oral health of Indigenous children of Canada (First Nations, Inuit, and Métis) and the United States (American Indian and Alaska native) is a major child health disparity when compared with the general population of both countries. Early childhood caries (ECC) occurs in Indigenous children at an earlier age, with a higher prevalence, and at much greater severity than in the general population. ECC results in adverse oral health, affecting childhood health and well-being, and may result in high rates of costly surgical treatment under general anesthesia. ECC is an infectious disease that is influenced by multiple factors, but the social determinants of health are particularly important. This policy statement includes recommendations for preventive and clinical oral health care for infants, toddlers, preschool-aged children, and pregnant women by primary health care providers. It also addresses community-based health-promotion initiatives and access to dental care for Indigenous children. This policy statement encourages oral health interventions at early ages in Indigenous children, including referral to dental care for the use of sealants, interim therapeutic restorations, and silver diamine fluoride. Further community-based research on the microbiology, epidemiology, prevention, and management of ECC in Indigenous communities is also needed to reduce the dismally high rate of caries in this population.

Prevalence and Factors Associated with Visiting the Dentist Only for Emergency Care Among Indigenous People in Ontario

Ontario has the largest Indigenous population in Canada. This study aims to examine the prevalence and factors associated with poor dental care use amongst the Indigenous in Ontario. Data from the 2014 cycle of the Canadian Community Health Survey was used. The main outcome was defined as visiting the dentist only for emergency care. Stepwise multivariable logistic regression was performed to assess the association between socio-demographic, socio-economic, and the health related factors and emergency dental care use. 28% of the participants reported visiting the dentist only for emergencies. First Nations people were at increased odds of having poor dental care (OR 2.01, CI 1.12-3.95). Additionally, being male, a smoker, having fair/poor health and lacking dental insurance puts the Indigenous Ontarians at increased odds of having the outcome. Improvements to the current social benefit programs could help better cater to the needs of this population.

Application of Policy Analysis Models in Oral Health Issues: A Review

INTRODUCTION

Oral health is a complex interaction that contains factors such as disease status and physiological and psychosocial properties. Because of complexity of the health system, policymakers should find some ways to simplify the relations to increase the chance of understanding the conditions, values, and ideas behind it. Policy learning could be built on the appropriate policy models application corn stone. The aim of this study was to answer this question that what policy models were applied in oral health policy studies and what oral health policy issues were analyzed by policy models.

MATERIALS AND METHODS

A systematic review was conducted across international electronic databases (PubMed, ISI Web of Knowledge, and Scopus) with no time limitation and using prearranged keywords. All publications such as articles and thesis were included. Searched terms were selected based on frequent health policy model components and an initial search. Search strategy based on each data base instruction was applied.

RESULTS

Eight models or frameworks were applied in total. Most of these models were focused on process stage of oral health policy making. Five main themes such as the role of stakeholders in oral health policy making, assessment of oral health system, oral health policy development, the process of oral health policy making, and oral health policy learning and capacity building were synthesized.

CONCLUSION

Oral health policy issues could be analyzed more comprehensively, and researchers could be guided by applying policy models and frameworks to answer policy-learning questions. Application of models and frameworks should be based on the nature of problem and issue, and the level of problem screening is a critical point in applying appropriate model.

Educational Models for the Re-Establishment of Dental Therapy Education in Canada

With the closure of the Canadian dental therapy program in Saskatchewan in 2011 and the increasing need for oral health providers, there have been growing discussions at the national and provincial levels regarding the re-establishment of a provider with dental therapy abilities. The aims of this study were to define models for dental therapy education in Canada and explore how dental therapy abilities could best be integrated into Canadian post-secondary education. In 2017, purposeful sampling was used to invite key informants to participate in a semi-structured interview. Participants were individuals from government, education, and regulation and those working with underserved populations in Canada and internationally. A 75% response rate (n=53) was achieved. Thematic analysis was employed for coding of data and generation of themes. Respondents highlighted the need to include minimally invasive restorative services in the current scope of dental hygiene practice across all Canadian jurisdictions and to build dental therapy abilities with or upon accredited dental hygiene curricula. The models supported by respondents were a fourth-year option built on three-year diploma education, a one-year postgraduate diploma based on a baccalaureate degree and a current dental hygiene registration, and a three-year dental therapy diploma incorporating core courses in accredited dental hygiene diploma education. While the respondents' views were divergent, the educational model that received the most support involved a two- to three-term addition to current three-year dental hygiene diploma education. In contrast to international trends, the respondents valued learner flexibility to exit with a diploma dental hygiene credential, thus making the dental therapy scope optional. These educational models provide a starting point for further analysis and exploration.

Exploring dental hygiene decision making: A quantitative study of potential organizational explanations

BACKGROUND

To improve public access to oral health care, dental hygienists have been identified for practice expansion, and, therefore, they must demonstrate decision-making capacity. This study aimed to identify and test potentially influential factors in dental hygiene decision making. Organizational and gender factors were hypothesized to be most influential and focused the study.

METHODS

A 2-phase mixed methods approach was used. In Phase I, a qualitative decision-making model was developed and subsequently published in 2012. Phase II tested aspects of the model through an electronic survey instrument and key informant interviews. This article reports on the statistical results of the quantitative survey. A third article will report on the qualitative thematic analyses and merged interpretation.

RESULTS

The Phase I qualitative model guided the development of the survey instrument. The survey had a 38% response rate; moderate to weak correlations between predictor variables (structural and individual) and clinical decision making were shown. The final statistical model demonstrated that individual characteristics and graduating from a 3-year dental hygiene program were together significantly associated with decision-making capacity.

DISCUSSION AND CONCLUSIONS

Individual characteristics and longer education were together shown to be associated with increased decision-making capacity. These findings did not show the organization or gender to be important in influencing decision-making capacity. However, the merging of the quantitative survey and qualitative key informant data will potentially inform how the organization influences the individual dental hygienist.

Reducing Indigenous Oral Health Inequalities: A Review from 5 Nations

Indigenous populations around the world experience a disproportionate burden in terms of oral diseases and conditions. These inequalities are likely due to a complex web of social determinants that includes poverty, historical consequences of colonialism, social exclusion, government policies of assimilation, cultural annihilation, and racism in all its forms (societal, institutional). Despite documented oral health disparities, prevention interventions have been scarce in Indigenous communities. This review describes oral health interventions and their outcomes conducted for Indigenous populations of the United States, Canada, Brazil, Australia, and New Zealand. The review includes research published since 2006 that are available in English in electronic databases, including MEDLINE. A total of 13 studies were included from the United States, Canada, Brazil, and Australia. The studies reviewed provide a wide range of initiatives, including interventions for prevention and treatment of dental disease, as well as interventions that improve oral health knowledge, behaviors, and other psychosocial factors. Overall, 6 studies resulted in improved oral health in the study participants, including improvements in periodontal health, caries reduction, and oral health literacy. Preferred intervention methodologies included community-based research approaches, culturally tailored strategies, and use of community workers to deliver the initiative. Although these studies were conducted with discrete Indigenous populations, investigators reported similar challenges in research implementation. Recommendations for future work in reducing oral health disparities include addressing social determinants of health in various Indigenous populations, training future generations of dental providers in cultural competency, and making Indigenous communities true partners in research.