It might surprise many that one in three Canadians lacks dental insurance while nearly one-fifth of Canadians avoid the dentist each year due to financial constraints.
Mainstream though is, if we want to provide universal dental care, we must be willing to spend a lot of money to get it. However, the historical narrative from Saskatchewan offers a different story and shows how we can provide universal dental care for less money than we currently spend.
In 1968, the Canadian Minister of National Health and Welfare created a committee that focused on addressing the oral health needs of the population. This committee was developed due to compounding data which identified significant unmet oral health needs across the country, particularly in remote Inuit and First Nations communities. The committee concluded that the most efficient way to reverse this was to increase the use of dental auxiliaries, including dental assistants, hygienists, denturists and therapists.
Among the dental auxiliaries were dental therapists, mid-level providers who perform many of the same services performed by dentists. Dental therapists are trained in basic dental services such as cleanings, fillings, simple extractions, and silver caps. The relation between a dentist and a dental therapist is very similar to the one between a physician and a nurse practitioner. Dental therapists are an integral part of oral health teams around the world, with the practice adopted in many countries.
The Minister of National Health and Welfare released a report in 1972 based on the committee’s findings. Based on this information, the NDP government of Saskatchewan created the Saskatchewan Dental Plan (SDP). The program was set up to address the dental needs of children between the ages of three to twelve (in 1978 it was expanded to age 14). The plan outlined that dental care be provided to children by dental therapists in school settings. As very few dentists practiced in the rural and northern parts of the province, and families were required to travel long distances to seek care in private practice settings, having dental therapists in schools removed a significant barrier to accessing care.
In 1972, two dental therapy training programs were created in Canada. One was run out of the Regina General Hospital in Saskatchewan, and the second operated out of the National School of Dental Therapy (NSDT) in Fort Smith, Northwest Territories. Free tuition was offered at NSDT to attract those from northern communities, in the hopes they would return to their original communities afterwards to practice.
Dental therapists were considered more attractive for a school-based dental program for multiple reasons. For one, training was only 28 months in duration which was significantly shorter when compared to the 7-8 years required to train a dentist. As a result, dental therapists could reasonably be paid a fraction of what a dentist would earn per year, while serving more people and their needs. This made it more financially feasible to employ dental therapists in all schools across the province. Since the majority of the cost of a dental program goes towards staffing, maximizing the use of dental therapists was a sensible approach.
After the first class of dental therapists graduated in 1974, the NDP government of Saskatchewan started hiring them and setting up dental clinics in schools across the province. The program grew rapidly and was widely popular among parents as they no longer had to arrange appointments at private clinics. This additional pressure meant lost time at work and, for many rural people in Saskatchewan, long drives to the nearest dental office. What’s more, children were more accepting of school-based dental clinics as they were in a familiar atmosphere.
The first year of the program treated 13,070 children and 37,032 the year after. The program grew as new dental therapists graduated to a peak of around 90 percent of school aged children being enrolled. Saskatchewan had a much better acceptance rate from parents than Newfoundland, which had a children’s program focused on dentists in private practice, which only had a 45 percent acceptance rate.
In 1975 a clinical service evaluation of the SDP was completed by professors at faculties of dentistry across the country. The dentists reviewed the work done for 410 children: 300 treated by dental therapists and 110 by dentists. The dentists reviewing the work did not know who did the work at the time of evaluation. They concluded that dental therapists placed fillings that were on average better than those placed by dentists, and the stainless-steel crowns were of equal quality. The program was a huge success. After six years of the SHDP children required, on average, half the number of fillings they did at the beginning.
There were massive cost savings for the SDP to use dental therapists who were paid by salary, rather than dentists who were paid by fee-for-service. To put this in perspective, the SDHP cost an average of $341.89 per child in private dental offices in 1974 but plummeted 271 percent to $91.98 in 1986 in the school clinics with mainly dental therapists. This is easily understood because dental therapist made on average one-third the salary of dentists.
In other words, the SHDP was a significant success story. As the economist Stephanie Rezansoff points out in a paper analyzing the history of the SHDP, traditional private practice, fee-for-service dentistry left many out:
A relatively small proportion of the population is receiving dental care, and that much of this care is received by those in higher socio-economic groups…the results of this study tend to support the contention that changes in the nature of the dental care delivery system are such that inequalities in the receipt of care are eliminated.
Rather than seeing this as a benefit to the children of Saskatchewan who were now receiving adequate dental care, the College of Dental Surgeons of Saskatchewan saw this as a threat to their monopoly on providing dental services. In 1978 the College lobbied for changes to the Dental Professions Act. These changes allowed dental therapists to be hired by dentists in private practice. This severely undermined the federal and provincial governments ability to recruit dental therapists to work in remote communities as they could now stay in urban centers, thereby allowing dentists to make a lot of money off of hiring them.
The College, now with the backing of the Canadian Dental Association, were not done their assault. In 1982, continued lobbying of the now Progressive Conservatives for outright privatization of the Children’s Oral Health Plan eventually succeeded. The program was reshaped to have dentists centered in the program. This resulted in the firing of 400 staff, and 578 school and community dental clinics were closed. Nothing was set up to ensure dentists would locate to the communities where school-based clinics were shut down, leaving many without adeuqate access to dental care.
In 2011, after many years of neglect the last dental therapy training program in the country was closed. The profession is set to dwindle away despite its historic reputriong for cost-effective care.
Today, it is estimated that Canadians are spending upwards of $13.8 billion on dental care. There is undoubtedly massive room for savings in routine dental work such as fillings.
At this critical juncture we must decide whether we will take on dentists’ monopoly on care in order to lower dental spending while providing universal care. If we are to achieve this, we have to ban dentists from being able to hire dental therapists. Second, governments should reopen dental therapy training schools. Third, we must rapidly expand dental therapist-based school and community dental clinics and pass the savings onto Canadians. This will also help to close the growing gap in access to oral health care services between most Canadians and those from Inuit and First Nations communities.
In addition, school and community clinics would have environmental benefits, as they would elimiate millions of commutes (particularly in rural areas) to and from dental offices.
A 2011 Canadian Center for Policy Alternatives report found that a Canada wide school-based universal dental program for children modeled after the dental therapist Saskatchewan based program would cost $560 million. So, for 4.5 percent of what Canada spent on dental care in 2015, we could treat all the children in the country.
The commodification of dental care has left many Canadians discontent with the price they pay for care, if they can afford it at all. Dental therapists are integral to providing high quality, low cost dental care and should be rapidly expanded with the goal of eventually integrating dental care into Medicare.
Brandon Doucet is a practicing dentist currently based in Newfoundland.