SGEM Xtra: See A Dentist – Because I’m an Emergency Physician

Date: October 9th, 2019 Guest Skeptic: Dr. Hasan Sheikh is an emergency and addictions physician in downtown Toronto and a graduate student studying public policy at the Harvard Kennedy School of Government. This is an SGEM Xtra and the result of Dr. Sheikh's recent Canadian Association of Emergency Physicians (CAEP) Position Statement on Dental Care in Canada. It calls for the expansion of publicly funded and publicly delivered dental care in Canada. The Canadian Association of Emergency Physicians believes that every Canadian should have affordable, timely, and equitable access to dental care. You can down load a PDF of the CAEP Position Statement on Dental Care in Canada. For other positions statements from CAEP click on this LINK. You can also listen to the SGEM Xtra podcast on iTunes to hear us discuss the following: Dr. Sheikh's elevator pitch summarizing the position statement The Association between oral health and overall health How the current dental care system in Canada is inconsistent with the principles of the Canada Health Act A brief description on the history of dental care in Canada and the current situation How the current dental system impacts the individual How the current dental system impacts the emergency department What are the organizations that support public dental care in Canada What are the barriers to adopting a public dental care system How CAEP thinks the goal of affordable, timely and equitable access to dental care will be achieved CAEP Position Statement on Dental Care in Canada Executive Summary: Oral health is an important part of an individual’s overall health; however, dental care is not included in the Canadian public health care system. Many Canadians struggle to access dental care, and six million Canadians avoid visiting the dentist each year due to cost (1). The most vulnerable groups include children from low income families, low income adults, seniors, indigenous communities, and those with disabilities (1–5). The lack of affordable, equitable, and accessible dental care puts undue strain on Emergency Departments across the country, as patients desperately seek the care of a physician when they actually need the care of a dental professional(6). Emergency physicians do not have the same expertise or equipment as dentists, and in most cases are only able to provide temporary symptom relief. This results in an increased reliance on prescription opioids that would otherwise be unnecessary if patients could access the dental care they required. The Canadian Association of Emergency Physicians supports the expansion of publicly funded dental care in Canada, starting with the most vulnerable groups including children, low-income adults, and seniors. The Canadian Association of Emergency Physicians also supports the expansion of publicly delivered dental care in Canada via Community Health Centres, Aboriginal Health Access Centres, and Public Health Units, given the failures of the private sector model and the preferences of those who currently have the most difficulty accessing care (1,7). Oral Health and Overall Health Oral health is a critical component of an individual’s overall health. There are a number of associations between poor oral health and poor general health, including cardiovascular disease, diabetes, having a low birth weight infant, erectile dysfunction, osteoporosis, metabolic syndrome, and stroke (8–15). There is increasing evidence, however, that poor oral health can actually cause or worsen other general medical conditions due to chronic inflammation (16). Treating periodontal disease in diabetics has been shown to improve blood sugar control to a similar degree as adding another oral diabetes medication (17). Providing oral care in long-term care settings has been shown to reduce the risk of developing aspiration pneumonia (18). Periodontal therapy has been shown to reduce patients’ cardiovascular risk category (19). Integrated comprehensive oral health care has been shown to increase completion of substance use disorder treatment, increase employment, increase drug abstinence, and reduce homelessness (20). Poor oral health also has a negative impact on a person’s self-esteem, social interactions, and employability (21). Given the important relationship between oral health and overall health, our current dental care system is inconsistent with the principles of the Canada Health Act: “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” The History of Dental Care in Canada Canada began adopting community water fluoridation in the 1950s, around the same time as the genesis of Medicare, Canada’s single payer public health care system. This led to a sharp decline in dental caries, and a false reassurance that the solutions to oral health concerns would be non-provider based (1). The 1964 Commission on Health Services did not include dental care in its recommendation of publicly financed services, believing oral health care to be a personal responsibility. At the same time, tax incentives for employers and employees led to an expansion of employment-based dental insurance, which further reduced public investments in times of economic hardship (1). In fact, in the early 1980s, approximately 20 percent of all spending on oral health care was public, compared to approximately 5 percent currently (22). This ranks Canada amongst the lowest in public spending for dental care of all OECD countries, second only to Spain. In fact, public spending on dental care in Canada is less than the United States, where 10 percent of all dental care is publicly financed (23). Furthermore, Canada has been reducing its proportion of public dental expenditures, while the United States and most other OECD countries have been increasing their public share of dental spending (2). Currently, dental care in Canada is almost entirely funded through the private sector. Approximately 51 percent of dental spending is paid for by employment-based insurance, and 44 percent through direct out-of- pocket payments( 22). The remaining 5 percent that is funded publicly is delivered through a patchwork of policies targeting marginalized groups (1). Public per capita spending on dental care is approximately $24, compared to $337 on drugs, and $999 on physician services (24,25). Consequences for the Individual The lack of a robust, publicly funded dental care system in Canada has led to significant barriers for many Canadians to access care. Approximately six million Canadians avoid visiting a dentist each year due to the cost (1). The people who experience the most difficulty accessing oral health care are also the ones who experience the highest burden of dental disease, including children, low income adults, seniors, indigenous communities, refugees, people with disabilities, and people living in rural areas (1–5). Overall, approximately 20 percent of people cite cost as a barrier for seeing a dentist (4). Studies show that 42 percent of low income. Canadians avoid seeing a dentist when they need to due to cost, compared to only 15 percent of high income Canadians (2). This is in stark contrast to physician services, where the only 9 percent of low income Canadians and 5 percent of high income Canadians avoid seeing a physician due to cost (2). Despite having higher needs, seniors are 40 percent less likely to have private dental insurance compared to the general population (26). In Canada’s largest province, Ontario, 3.5 percent of the population avoids social interactions, including conversation, laughing, and smiling, due to a dental condition; this proportion increases to 8.5 percent amongst those in lower income groups (4). Consequences for the Emergency Department People who are suffering with an oral ailment and cannot access affordable, timely dental care often turn to the Emergency Department (ED) in desperation. In fact, approximately 1 percent of all visits to the ED are for dental complaints (6,27). The majority of patients presenting to the ED for dental complaints are low-income adults, and these visits in Ontario alone are estimated to cost the health care system in the range of 16 to 31 million dollars annually (5,28). Both patients and providers often know that the patient needs to see a dentist, but patients turn to the ED when they have nowhere else to go. Most of these patients receive either no intervention, or pharmacotherapy for temporary symptom relief (6). This is expected, as emergency physicians do not possess the training or equipment to deal with most dental complaints in a definitive way (29). Emergency physicians often end up prescribing antibiotics, anti-inflammatories, or opioids to try and provide some relief – medications that would otherwise be unnecessary if patients could access dental care. Opioids are prescribed in more than 50 percent of non-traumatic dental condition visits to the ED, and emergency physicians are five times more likely to provide an opiate prescription for a dental complaint compared to a dentist (30–32). In the midst of an opioid epidemic, it is important that we take steps to reduce our reliance on these potentially harmful medications. This is particularly true in cases like these, where opioids are not the optimal therapy for the presenting problem. Organizations Supporting Public Dental Care in Canada Canadian Association of Public Health Dentistry: "All Canadians should have equitable access to oral health care, regardless of their employment, health, gender, race, marital status, place of residence, age or socio- economic status." (33)