Two-thirds of Canadians support the national dental care program, but fewer than half maintain that support if delivering the program requires a tax increase. The federal government and citizens are reasonably looking for accountability and cost-effectiveness from health-care investments. Until we radically embrace and tie substantial funds to oral health promotion, cavity prevention and public health delivery of oral health services for young children, we expect that any federally funded dental care program will be impossible to sustain financially while failing to meet the greatest needs of young children.

The current interim dental benefit program will run for two years, allowing the federal government and health-care professionals time to devise a long-term, improved version. We offer three policy recommendations for children aged one to five that we hope will be included in the permanent plan.

Here is the problem as we see it.

Imagine you as a parent receive the interim Canada Dental Benefit ($650 per child per year for families earning less than $90,000 annually). You take your four-year-old to the dentist. You are surprised to hear that your child has three cavities. Everything was fine at her check-up when she was three years old. The dentist recommends surgery under general anesthetic to fix all the cavities at once, explaining that, unlike adults or older children, it’s too difficult for very young children to keep their mouths open and co-operate well enough for a long enough time to do complex work like fillings. The surgery will cost $3,000.

Even with your interim Canada Dental Benefit, you will still have to pay $2,350 out of pocket – which many families earning less than $90,000 per year cannot afford. Your family has high enough income to exclude you from existing provincial programs that are targeted toward families with minimal financial resources, but you still can’t afford the $2,350, so your child goes without treatment.

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As dental hygienists with decades of experience, we’ve seen scenarios like this play out far too many times. Young children have cavities that are either severe or numerous enough to warrant a recommendation for surgery. They are then put on a months-long surgery waitlist or their cavities are left untreated because the cost of surgery is out of reach. Either way, without timely care, the cavities will grow. Untreated cavities can affect children’s chewing, nutrition, learning, sleeping and quality of life.

In Canada, cavities are the No. 1 reason for day surgery under general anesthetic in children one to five years old – more than for ear infections or tonsils. In 2012, these dental surgeries were estimated to cost Canadian taxpayers approximately $21 million yearly for the hospital costs alone. This estimate doesn’t account for dentist and anesthesiology fees or for similar procedures carried out in private dental offices, so $21 million is really just the tip of the iceberg.

When cavities go untreated, children may end up in the emergency department or at the family doctor in severe pain because our publicly funded health-care system covers the cost of those visits. But doctors aren’t trained to do dental work, so children may get pain medication or antibiotics to calm an infected tooth while the cavity itself remains untreated, which means the pain will probably return.

In Alberta, emergency department visits for these types of infections in one- to five-year-olds cost $1.8 million in 2013, while serious dental infections requiring IV antibiotics grew by 700 per cent between 2011 and 2019 at Alberta Children’s Hospital. Half of those infections were in children under five years old.

Most of this cost and suffering is avoidable.

Two effective, safe, quick, affordable and pain-free options already exist to prevent and reverse small cavities, stop bigger cavities from growing and reduce the risk of future cavities. Fluoride varnish is acknowledged in clinical practice guidelines worldwide. It is available for children aged one to five years old in many provinces and territories through public health and can be brushed on their teeth in about three minutes by public-health dental hygienists and dental assistants. Because it is quick and painless, most young children co-operate well.

Silver diamine fluoride or SDF is an essential medicine, according to the World Health Organization and has been used for decades in many countries. Twice-yearly applications are 96 per cent effective at stopping small- and medium-sized cavities. Silver diamine fluoride is specifically recommended as a low-cost option to delay or avoid the need for surgery in young children. Dental hygienists can apply silver diamine fluoride via public-health programs, mobile clinics, schools and private homes to broaden access to this service beyond the traditional dental office. Combined with daily brushing and flossing, fluoride varnish and silver diamine fluoride are central to a sustainable dental care program.

Yet fluoride varnish applications for young children remain under-used as a dental service, even in public health and among pediatric dentists. We also see very little use of silver diamine fluoride considering that research shows it is the preferred alternative among parents when compared to surgery under general anesthetic.

It is important for any new publicly funded program to start well and to be perceived by its intended users as working. Without broader awareness and widespread uptake of fluoride varnish and SDF as the preferred, evidence-based, cost-effective and safe options, parents will continue to face costly, wait-listed, surgical treatment as their only option. As a result, many young children will go without care; and parents and taxpayers will see the program as a failure.

Well-reasoned principles have been suggested for the Canada Dental Benefit program. To avoid the scenario above, we make three additional recommendations specific to the needs of children one to five years old.

1. Paradigm shift. High surgery rates for preventable cavities, high numbers of hospital visits for dental problems, and many children with untreated cavities – despite $13.6 billion spent yearly on dental services – all point to the failure of treat-over-prevent models in Canada and worldwide. The revised Canada Dental Benefit program provides an opportunity to invest in prevention and early treatment to improve oral health outcomes at the population level.

2. The basket of services. Ethical and scientifically defensible services for the majority of young children are those that prevent or stop early cavities in baby teeth and that support children in developing daily brushing skills for life. Timely, age-appropriate, least invasive and effective services that match a child’s capacity to co-operate are best.

3 Public or private delivery. In our experience, regular preventive dental check-ups after age one to catch cavities early have not been widely adopted, beyond taking a “quick peek” or a ride in the chair. Existing public-health fluoride varnish programs targeted to children 1-5 years of age, where dental hygienists and dental assistants are experienced working with young children, are well-utilized but their impact is profoundly limited by funding. Innovative delivery models that bring care to children where they gather in schools and day cares, or via mobile dental clinics, also make sense. Structural investments in public health prevention and early intervention could scale and spread programs such as these across Canada to truly deliver a no-cavity or low-cavity future for young children that won’t cost taxpayers the moon. Appropriate data collection and evaluation of services and health outcomes would then be possible.

Health policy and programming wisely integrates patient needs and values, research evidence and frontline clinical experience. Despite substantial clinical expertise as primary-care providers, hygienists’ frontline experience with patients and communities who seek prevention and early intervention is often overlooked and the care we deliver is often undervalued. We hope that the forthcoming version of the Canada Dental Benefit program changes this pattern.

To deliver a sustainable dental program in Canada, services for young children must be heavily weighted toward prevention of cavities. Appropriate remuneration and investments by the federal government will incentivize non-invasive procedures that stop cavities before or soon after they start.

Genevieve Schallmann, a registered dental hygienist and University of Manitoba graduate with 32 years of teaching, research and care experience, and Nicole Warin, a registered dental hygienist of 26 years and graduate of Ferris State University in Michigan, contributed to this article.

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Cynthia Weijs
Cynthia Weijs, PhD, held a Canadian Institutes of Health Research health system impact fellowship (2017-20). She is interested in evidence-based health system change to improve cavity prevention services for children. Twitter @CynthiaWeijs
Sandra Jean Jensen
Sandra Jean Jensen is a registered dental hygienist with 47 years of oral health primary care experience across the health system, including private practice, school-based public health, continuing care, hospital and clinical settings.
Wendy Ulrich
Wendy Ulrich is a registered dental hygienist who has worked in private dental practice and has 30 years’ experience in public health clinical practice related to cavity prevention in young children.

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