Applying New Ideas and Program Design to Ontario Government Sponsored Dental programs —— Dr. Ian McConnachie Ontario 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)

Decreasing Welfare Rolls does not decrease your risk –Persons covered on social assistance ,344,600 –Persons covered ,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 - S chool-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 % –deft/DMFT scores lower –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 perform ance 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”