Oral healthcare disparities in Canada: filling in the gaps

Imbalances in the oral health workforce: a Canadian population-based study

BACKGROUND

In Canada, a new federal public dental insurance plan, being phased in over 2022-2025, may help enhance financial access to dental services. However, as in many other countries, evidence is limited on the supply and distribution of human resources for oral health (HROH) to meet increasing population needs. This national observational study aimed to quantify occupational, geographical, institutional, and gender imbalances in the Canadian dental workforce to help inform benchmarking of HROH capacity for improving service coverage.

METHODS

Sourcing microdata from the 2021 Canadian population census, we described workforce imbalances for three groups of postsecondary-qualified dental professionals: dentists, dental hygienists and therapists, and dental assistants. To assess geographic maldistribution relative to population, we linked the person-level census data to the geocoded Index of Remoteness for all inhabited communities. To assess gender-based inequities in the dental labour market, we performed Blinder-Oaxaca decompositions for examining differences in professional earnings of women and men.

RESULTS

The census data tallied 3.4 active dentists aged 25-54 per 10,000 population, supported by an allied workforce of 1.7 dental hygienists/therapists and 1.6 dental assistants for every dentist. All three professional groups were overrepresented in heavily urbanized communities compared with more rural and remote areas. Almost all dental service providers worked in ambulatory care settings, except for male dental assistants. The dentistry workforce was found to have achieved gender parity numerically, but women dentists still earned 21% less on average than men, adjusting for other characteristics. Despite women representing 97% of dental hygienists/therapists, they earned 26% less on average than men, a significant difference that was largely unexplained in the decomposition analysis.

CONCLUSIONS

Accelerating universal coverage of oral healthcare services is increasingly advocated as an integral, but often neglected, component toward achieving the health-related Sustainable Development Goals. In the Canadian context of universal coverage for medical (but not dentistry) services, the oral health workforce was found to be demarcated by considerable geographic and gendered imbalances. More cross-nationally comparable research is needed to inform innovative approaches for equity-oriented HROH planning and financing, often critically overlooked in public policy for health systems strengthening.

Oral Health Status and Dental Services Utilisation Among a Vulnerable Sample of Pregnant Women

INTRODUCTION AND AIMS

Oral health conditions during pregnancy can negatively impact both mother and fetus, highlighting the importance of maintaining dental care. In Canada, significant disparities exist between general and dental healthcare access, with limited evidence on oral health status and dental care utilisation among pregnant women. This study aimed to provide initial insights into self-perceived oral health status and dental utilisation patterns among a vulnerable sample of pregnant women in southwestern Ontario.

METHODS

This cross-sectional study recruited a convenient sample of pregnant women referred to the Family Medicine and Obstetrics Clinic, serving those without a family physician. Data were collected using a self-administered questionnaire adapted from the Canadian Health Measure Survey, the Canadian Community Health Survey, and the Survey of Maternal Health. Andersen and Newman's framework for health service utilisation was used as the theoretical framework. Descriptive and univariable analyses were conducted, followed by a forward stepwise selection of variables with p-values < 0.1 from the univariable analyses.

RESULTS

One-hundred-fifty patients were approached and 130 (86.7%) completed the questionnaire. Of these, 96 (73.9%) reported their oral health as good/excellent while 34 (26.2%) reported having poor/fair oral health. Education level and quality of life were the strongest predictors of oral health status. While 101 (77.7%) visited a dentist within the last 2 years, only 35 (26.9%) had a dental visit during pregnancy. Toothbrushing frequency was the main predictor of time since last dental visit, with no other predictive factors once toothbrushing was considered.

CONCLUSION

The study sample showed relatively positive self-perceived oral health and dental visit patterns. However, the low rate of dental visits during pregnancy highlights the need for better integration of dental care into prenatal care. To ensure maternal and child health, pregnant women should be a high priority in policies aimed at improving access to dental care.

Knowledge, attitude, and practice of patients with oral diseases toward oral examinations: a cross-sectional survey study

Background

Properly adhering to oral hygiene and medical care is an important public health issue. Several studies examined the knowledge, attitudes, and practices (KAP) toward oral care in various populations and generally reported relatively sufficient knowledge but unfavorable attitudes and poor practice. However, no previous studies have examined the KAP toward oral examinations among Chinese patients with oral diseases. This study aimed to examine the KAP toward oral examinations among patients with oral diseases in China.

Methods

This cross-sectional study was conducted in patients with oral diseases who visited The Affiliated Stomatological Hospital of Tongji University between December 2023 and February 2024. Data collection and KAP scores assessment were performed using a self-designed questionnaire.

Results

A total of 519 valid questionnaires were included, with 292 females. The mean knowledge, attitude, and practice scores were 6.42 ± 2.47 (possible range: 0-9 points), 35.04 ± 5.68 (possible range: 10-50 points), and 16.22 ± 2.05 (possible range: 4-20 points), respectively, indicating sufficient knowledge, positive attitudes, and proactive practice. Pearson's correlation analysis showed that knowledge was positively correlated to attitude (r = 0.468, p < 0.001) and practice (OR = 0.416, p < 0.001). Attitude was positively correlated to the practice (r = 0.503, p < 0.001). Moreover, the structural equation model showed that knowledge influenced attitude (estimate = 1.010, p < 0.001) and practice (estimate = 0.169, p < 0.001). Attitude influenced practice (estimate = 0.122, p < 0.001). The frequency of oral examination per year influenced knowledge (estimate = -0.761, p < 0.001) and practice (estimate = -0.515, p < 0.001). Expenses for oral disease per year influenced attitude (estimate = 0.537, p < 0.001).

Conclusion

Patients with oral disease might have sufficient knowledge, positive attitude, and proactive practice toward oral examinations. Specific knowledge items were identified to require improvements.

Canadian immigrants' oral health and oral health care providers' cultural competence capacity

Background

Immigrants to Canada count among the socially disadvantaged groups experiencing higher rates of oral disease. Culturally competent oral health care providers (OHCPs) stand to be allies for immigrant oral health. The literature reveals limited knowledge of practising OHCPs' cultural competency, and little synthesis of the topic has been completed. A scoping review is warranted to identify and map current knowledge of OHCPs' understanding of culturally competent care along with barriers and facilitators to developing capacity.

Methods

This study was conducted between December 2022 and April 2023 using Arksey and O'Malley's 5-step framework and PRISMA-ScR checklist. Four databases were searched using keywords related to 4 themes: population, provider, oral health, and cultural competence. Peer-reviewed articles published in English in the last 10 years were included.

Results

Search results yielded 74 articles. Title and abstract review was completed and an author-developed critical appraisal tool was applied. Forty-six (46) articles were subject to full-text review and 14 met eligibility criteria: 7 qualitative and 7 quantitative. Six barriers and six facilitators at individual and systemic levels were identified, affecting oral care for immigrants and providers' ability to work cross-culturally.

Discussion

Lack of cultural or linguistically appropriate resources, guidance, and structural supports were identified as contributing to low utilization of services and to lack of familiarity between providers and immigrants.

Conclusion

OHCPs' cultural competency development is required to improve oral health care access and outcomes for diverse populations. Further research is warranted to identify factors impeding OHCPs' capacity to provide culturally sensitive care. Intentional policy development and knowledge mobilization are needed.

History of dental caries in Inuit populations: genetic implications and 'distance effect'

Dental caries is considered the third most important scourge in the world. In North America, Inuit populations are the population the most severely affected by dental caries. It is often assumed that this situation can be explained by a combination of factors classical for Indigenous populations: remoteness (geographical distance), low economic status and low health literacy (cultural distance). Using a bibliographic approach, we tested this hypothesis of the "distance effect" by exploring the caries prevalence in other Indigenous populations living in high-income countries. Next, we tested whether the high prevalence of caries is due to population-specific characteristics by tracking caries prevalence over the past few centuries. In result, we showed that while other Indigenous populations are more impacted by caries than the general populations, the Inuit populations present the highest prevalence. Paradoxically, we showed also that past Inuit populations were almost immune to caries before 1950. These two elements suggest that the prevalence of caries observed presently is a recent maladaptation and that beyond the effect of cultural and geographical distance, specific biocultural factors have to be investigated.

Access to Specialized Care Across the Lifespan in Tetralogy of Fallot

Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.

Barriers to oral care: a cross-sectional analysis of the Canadian longitudinal study on aging (CLSA)

BACKGROUND

Oral health plays a role in overall health, indicating the need to identify barriers to accessing oral care. The objective of this study was to identify barriers to accessing oral health care and examine the association between socioeconomic, psychosocial, and physical measures with access to oral health care among older Canadians.

METHODS

A cross-sectional study was conducted using data from the Canadian Longitudinal Study on Aging (CLSA) follow-up 1 survey to analyze dental insurance and last oral health care visit. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between socioeconomic, psychosocial, and physical measures with access to oral care, measured by dental insurance and last oral health visit.

RESULTS

Among the 44,011 adults included in the study, 40% reported not having dental insurance while 15% had not visited an oral health professional in the previous 12 months. Several factors were identified as barriers to accessing oral health care including, no dental insurance, low household income, rural residence, and having no natural teeth. People with an annual income of <$50,000 were four times more likely to not have dental insurance (adjusted OR: 4.09; 95% CI: 3.80-4.39) and three times more likely to report not visiting an oral health professional in the previous 12 months (adjusted OR: 3.07; 95% CI: 2.74-3.44) compared to those with annual income greater than $100,000.

CONCLUSIONS

Identifying barriers to oral health care is important when developing public health strategies to improve access, however, further research is needed to identify the mechanisms as to why these barriers exist.