Innovating Dental Programs for Ontario: Dr. Ian McConnachie's Vision

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

2. 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

3. Ontario government perspective on government plan coverage Gap coverage High needs, not high risk Low socioeconomic levels Disabled and their families

4. 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

5. 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

6. 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,…

7. Dental Indices Survey (DIS) • Limited value • Non-calibrated • Less than ideal examination • No radiographs • Inconsistent data collection methods Beynon et al 2004

8. 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)

10. Decreasing Welfare Rolls does not decrease your risk Persons covered on social assistance 1995 1,344,600 Persons covered 2003 673,900 Children under 19 living in poverty 594,428Quinonez et al 2005 Persons on social assistance accessing care Between 20% and 40%

11. 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

13. 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

14. Delivery Models – Problems • Lack of a “dental home”

15. Delivery Models – Problems • Lack of a “dental home” • Dental care a low priority until pain/infection

16. 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

17. Successful Delivery Models • - School-based prevention • School-based dental care (Albert et al 2005) • Screening • Preventive • Office-centered • Collaborative • Preventive/primary restorative • Comprehensive community dentistry

18. Successful Delivery Models • School-based prevention • PEI • ChildSmile Pitts • Forsythkids Niederman 2005 • Scandinavia Axelsson 2006 • Quebec – CLSC’s Verronneau 2008

19. PEI School Program deft/DMFT = 0 grown 6-12 % 1998-2007 deft/DMFT scores lower 0.30-0.55 Exception 9 year olds – no change 80% participation Dental community generally positive

20. 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

21. 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

23. Ontario Government • Recognition the programs are not meeting needs • Co-ordination of oral health with public health initiatives • Increased resources • Willingness to collaborate

24. 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

25. Dental Public Health Evaluate the needs of the community Data collection – ICDAS Design local programs with the dental community Measures to assess performance E.g. RE-AIM Glasgow et al 1999 Case management model ADA, Ottawa Increased resources

26. Dental Public Health • Development of community-specific programs • Collaboration • Individual communities • School boards • CHC’s • Medical and dental community

27. Organized Dentistry • Collaborate in program design, setting up outcomes and measurement • Education of dental team re early intervention • Work with members to increase participation

28. 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

29. 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

30. 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

31. My Field of Dreams • “if you build it, they will come”