January 15, 1999

To:Board of Health

From:Dr. Sheela Basrur, Medical Officer of Health

Subject:Harmonization of Dental & Oral Health Services

Purpose:

This report provides a description of current dental and oral health services, along with data on health needs and gaps in service across Toronto. Harmonization options are presented, with a particular focus on municipally mandated and funded dental treatment services.

Source of Funds:

Funding to be determined through the budget process.

Recommendations:

It is recommended that the Board of Health select one of the following options for harmonizing dental services in the City:

(1)That the Public Health dental treatment programs be harmonized to provide services to individuals who lack dental benefits and cannot afford to pay for dental care, including children of low-income families, ESL and other new immigrant adolescents, high risk mothers enrolled in another Public Health program, independent living seniors, and institutionalized seniors (with low income defined in accordance with the definition used by Statistics Canada.)

If this service level option is adopted, the following recommendations apply:

(a)That services be harmonized in the short term by extending the hours of some or all of the current clinic facilities to 8:00 a.m. - 7:00 p.m., at an additional annualized operating cost of $1.9 million for all sites in the former City of Toronto OR $900,000 for 4 sites as detailed in the report; and

(b)That the Board consider upgrading the current dental clinic facilities in Etobicoke to allow the clinic to operate with extended hours as described in (a), at an additional annualized operating cost of $200,000 plus one-time costs of $100,000 to upgrade the equipment and facility.

If Option (1) is not adopted, the following options should be considered:

(2)That the existing treatment budget of $3.6 million be reallocated across the entire City,

Or

(3)That the 100% municipally funded dental treatment programs be eliminated, for annualized savings of $3.6 million.

It is further recommended that:

(4)An internal work group of staff in Social Services and Public Health divisions be established to report on the implications providing basic dental benefits to adults participants of the Ontario Works Program who currently have access to emergency services only.

(5)The Board of Health advocate to the provincial and federal government that dental and oral health are primary health care issues and should be funded accordingly, especially for those groups who cannot access basic dental care due to the cost.

History:

At the Budget Committee meeting of March 2, 1998, Toronto Public Health was requested to report on options with respect to the delivery of dental services in the new City, including the Children's Dental Program. The Report was to include a cost analysis of each option/service. In November 1998, City Council adopted the CAO's recommendations regarding the development of plans to harmonize certain services including public health dental treatment programs.

This report provides an analysis of the City's current dental programs, the health needs related to these services, options for harmonizing service levels related to municipally mandated and funded dental treatment, and costs associated with these options. The report is organized into the following sections:

(A)Dental Programs Administered and Delivered by Public Health

(B)Dental Programs Administered by the Social Services Division

(C)Mandatory Guidelines for Dental and Oral Health Services

(D)Utilization and Costs for Existing Services

(E)Dental and Oral Health Needs

(F)Gaps in Service

(G)Options and Costs Regarding Harmonized Levels of Dental Treatment Services

Comments:

(A)Dental Programs Administered and Delivered by Public Health

Table 1 provides a detailed analysis of all Dental Program components including treatment programs that are currently administered and delivered by Public Health. Public Health dental services consist of the following components:

(1)Provincially mandated requirements, including:

(a)Regular school-based dental and oral health surveys; and

(b)prevention, education and treatment for children 0 - 14 years of age from low-income families, through the Children In Need of Treatment (CINOT) Program.

Prior to provincial downloading in 1998, these programs were cost-shared 60:40 with the Ministry of Health. The Province also covered 100% of the costs of dental treatment for children in the CINOT program if their families declared financial hardship.

(2)Municipally mandated dental treatment programs, including:

(a)Nine community based clinics in former Toronto which provide basic dental care to children of low-income families from JK to grade 8, ESL (English as a Second Language) and new immigrant high school adolescents (emergency services only are provided to non-ESL high school students), high-risk mothers attending other Public Health programs, low-income independent living seniors, and a mobile dental preventive program for institutionalized seniors.

(b)a school based dental program in North York which provides basic dental care for children from preschool to Grade 6 and emergency care to adolescents of low-income families;

(c)a school based program in York which provides basic dental care to low income children from JK to grade 8;

(d)a community-based clinic in Etobicoke which provides basic dental care to a limited number of low-income adults and seniors; and

(e)No dental treatment programs in Scarborough or East York.

In short, there is considerable variability in the client groups served, eligibility requirements, level of care and delivery systems across the new City.

Municipal dental programs also have strong partnerships with several teaching institutions, e.g. University of Toronto, George Brown College and Ryerson Polytechnical University through the Teaching Health Unit program. These partnerships provide dental students with invaluable field placement experiences which help to increase their awareness of community needs and sensitivity to community service issues, such as the causes and extent of unmet health needs within the socioeconomic, cultural and linguistic diversity of Toronto's population.

(B)Dental Programs Administered by Social Services Division

Social Services Division dental programs are cost-shared between the provincial Ministry of Community and Social Services and local municipalities as outlined below. These programs consist of the following components:

(1)Emergency Dental Program for Adults in Receipt of Ontario Works

The current municipal dental program is a limited emergency program primarily geared to adult social assistance recipients. Emergency is defined as an "immediate circumstance where the patient appears in immediate suffering, requires care and immediate appropriate treatment is instituted to correct the problem". Dental services are a discretionary benefit provided through Special Assistance. Municipalities choose whether to provide such a program and have substantial flexibility regarding its design and delivery. Under the Ontario Works Act, dental programs for adults in receipt of Ontario Works continue to be provided at the discretion of the municipalities. Provincial/municipal cost sharing is currently 80/20. The program is currently administered by a third party, The Great West Life Assurance Company.

(2)Denture Program

The current discretionary municipal denture program provides a basic denture program for recipients of Ontario Works and Ontario Disability Support Program (ODSP). The funding for the denture program is cost shared with the Province on an 80/20 basis. This program is also currently administered by Great West Life.

(3)Mandatory Dental Program

In May 1998, the new Ontario Works Act and Ontario Disability Support Program Act made it mandatory for municipalities to provide dental services to dependant children (0-17) of recipients on Ontario Works, and to children and adults under the Ontario Disability Support Program. The provincial : municipal funding ratio is 80%/20% for services and 50%/50% for administration. The costs of these programs are detailed in Table 5.

In Toronto, Public Health currently administers the Ontario Works dental program on behalf of Social Services. The Ontario Dental Association currently administers the mandatory program for ODSP recipients on behalf of the Ministry of Community and Social Services.

(C)Mandatory Guidelines for Dental and Oral Health Services

Table 2 lists the new requirements for public health dental programs, along with recommendations on how the new City should comply with these requirements. As described in a companion report on this agenda entitled, "Meeting Provincial Standards Across the City for Selected Public Health Programs and Services", not all former municipalities were in compliance with the old Mandatory Program Guidelines. For example in Toronto and East York, there is no classroom education, while in other jurisdictions the school-based screening program was completed on an 18 month cycle rather than annually.

(D)Utilization and Costs for Existing Services

Table 3 summarizes the resources used in providing Public Health services.

Resources are shown by the major program areas for the year 1997 and can be summarized as follows:

(a)56.23 FTE and a total operating budget of $3,337,800 for provincially mandated community prevention programs (surveys of dental indices, education, school-based screening, follow-up of clients with identified needs, clinical prevention);

(b)10.44 FTE and a total operating budget of $4,135,300 for the provincially mandatory CINOT program, most of which was paid out to private practitioners for services provided to eligible children; and

(c)51.3 FTE's and a total operating budget of $3,639,800 for dental treatment.

Across the City, dental program staff resources (including management) total 118.2 FTE and the total operating budget is $11,112,900, including fees paid to private practitioners under the CINOT program. Prior to January 1, 1998 100% of CINOT costs and 40% of other Mandatory Program costs were reimbursed by the Province. With downloading, the full costs have become the City's responsibility.

During 1997, staff provided:

(a)100,000 treatment procedures, (diagnosis, x-rays, fillings, dentures, root canals, extractions)

(b)8,400 services in senior residences

(c)66,500 preventive services (fluorides, scaling, cleaning, sealants)

(d)168,000 oral screenings

(e)27,200 dental health status surveys

(f)4,200 oral health education presentations to 70,750 children and

(g)900 presentations to 12,720 people in other groups

It should be noted that the current cost of providing treatment services in the City-operated clinics is $3.6 million. If the same services were provided on a fee for service basis using the Ontario Dental Association Fee Guide, it would have cost the City $7.8 million.

(E)Dental and Oral Health Needs

The newly amalgamated City of Toronto has the highest health needs among urban areas in Ontario. Amalgamation has resulted in the creation of the most populous Public Health jurisdiction in Canada.

While the new City has only 51% of the population of Greater Toronto Area, it has:

(a)70% of its single parent families;

(b)two thirds of its households with incomes under $20,000 in 1990, and 75% of GTA households on social assistance in 1997;

(c)child poverty rates as much as eight times greater than neighboring municipalities;

(d)two thirds of the GTA immigrants in 1995, of which about 14% were refugees; and

(e)57% of the low birth weight babies in the GTA.

Furthermore, the population age 75 and over is projected to increase 35% in the new City between 1995 and 2003. It is these segments of the population that are affected most by the lack of universal, publicly administered dental health insurance program comparable to the Ontario Health Insurance Plan (OHIP).

Dental diseases are not just cosmetic problems. When not treated, dental disease can cause pain, disfigurement, malnutrition and even death. Furthermore, a child or youth with a toothache cannot eat, sleep or learn, and adults with oral conditions causing pain or embarrassment about their appearance are unlikely to seek and secure employment.

Comprehensive information regarding the oral health status of Toronto residents is available only for children, through Ministry of Health mandated surveys. A summary of dental and oral health indices by age group is outlined below, along with a summary of perceived needs from community representatives.

Oral Health Status of Children:

Surveys of the dental health status of children indicate that, while the dental health status of the majority of children has generally improved in the last two decades, more than 50 percent of children experience dental decay by age 13. This makes dental decay the most frequent condition suffered by children other than the common cold. These surveys show that approximately 20 percent of children have 80 percent of the decay, and that approximately 7% of children suffer from dental neglect and require immediate treatment. Early childhood tooth decay is an extreme form of dental caries that results in complete decay of the crowns on baby teeth. It affects children as early as 12-18 months old, who, by the time they are 36 months have multiple abscesses and require hospitalization to be treated. In a study done by Abbey (1998), the disease was found to affect 8.6% of four year-old children. Children born outside of Canada, children born to recent immigrants, and children in low income families experience the bulk of dental disease.

Oral Health Status of Adolescents:

Surveys in the former City of Toronto indicate that 21% of ESL high-school adolescents have dental decay and 6% have conditions requiring immediate treatment. In a study done on the oral health of street youth in the former City of Toronto, Gaetz and Lee (1996) found that 41.4% had dental decay. In addition, 49.4% of those surveyed reported that they had experienced dental and oral pain in the past month. This is higher than would be expected for teenagers and young adults in the general population. Fifty-seven percent of street youth indicated that the primary reason for not going to see a dentist is a lack of money. A minority of street youth are on welfare and so have access at least to emergency treatment; that is, if the patient is in pain, welfare will pay for the treatment. The remainder lack even this level of access to service.

Oral Health Status of Adults and Seniors:

There has never been a comprehensive adult dental health survey in Toronto, although the 1990 Ontario Health Survey gives some insight into the dental health of adults. It is known that older adults experience tooth loss and problems with chewing, which can lead to other problems such as malnutrition and a reduced ability to socialize, which in itself can lead to even further health problems. For older adults, the Ontario Health Survey ( Locker and Payne, 1993 Report 1) showed that 15.3% of adults aged 50 - 64 and 35.1% of those age 65 and older had no natural teeth. However, older people are keeping their natural teeth longer. As a result, the need and demand for dental care among this growing segment of the population will continue to increase.

Surveys in the former City of Toronto reveal that 48% of institutionalized seniors do not have teeth and of those without teeth, 45% do not have one or both dentures. Of those with dentures, 88% of the dentures were dirty, 50% did not fit well and 20% needed to be repaired. Of those institutionalized seniors who had teeth, 55% had decayed teeth and 39% needed to have one or more teeth extracted. It is likely that the oral health of institutionalized seniors across the new city follows a similar pattern.

Oral Health Service Needs Identified by Community Agencies:

Two community consultation sessions were held to identify perceived needs for dental care. During these sessions, community agencies identified the following broad issues:

(a)dental and oral health must be seen as an integral part of health as a whole;

(b)there must be equity of service across Toronto;

(c)low-income seniors around the City are not being given dental services;

(d)the price of dentures is so high that seniors are not able to get them, while hearing aids and assistive devices are covered;

(e)families who have very low incomes do not seek dental services on a regular basis, but only in emergency situations;

(f)community health centers have no resources to provide services;

(g)homeless and cognitively impaired people have no access and need care providers who are sensitive to their issues; and

(h)some new immigrants, especially some refugees, who do not speak English and do not have third-party insurance, have no knowledge of how to access dental care and sometimes have very little or no knowledge of the importance of dental care.

(F)Gaps in Treatment Services

Varying Standards Among Existing Services:

As seen in Table 1, compared to the former City of Toronto, all of the other areas of the City have significant gaps in the provision of dental care.

Basic primary dental care (i.e. diagnosis, x-rays, cleaning, scaling, fillings, extractions, dentures, root canal) programs for low-income children, adolescents, high risk mothers and low-income independent living and institutionalized seniors were not available in three or more of the former municipalities.

It should be emphasized that, even in Toronto, a significant segment of the population who needed access to dental services were continually denied access due to lack of resources. These groups include non ESL adolescents of working poor families, working poor adults, unemployed and homeless people.

In addition, adults on Ontario Works have access to Emergency Dental Services (i.e. relief of pain) only, even though their dependent children 0-17 yrs and all Ontario Disability Support Program participants have access to basic dental care. Basic dental care includes diagnosis, x-rays, fillings, extractions, root canal, cleaning, scaling and dentures.

Financial Accessibility of Services:

Dental services are not part of the publicly administered universal health care system, resulting in restricted access to care for the poor, the elderly and those in poor general health.

In the past, the rationale for not including dental care was the acute shortage of providers relative to the high levels of disease. More recently the reason appears to be the concern over financing a program with the potential for rapidly escalating costs.

The growth in commercial indemnity plans is evidence of the value that the public places on dental health services. However, this growth has resulted in unequal access, whereby unionized and other large groups of employees, as well as people on social assistance, have access to tax free dental care, while the self-employed, unemployed and working poor who lack dental benefits have to pay for their care in after-tax dollars.

The contrast in access to dental care compared to access to physicians is dramatic. As shown in Table 4, factors that predict the use of physicians - such as unemployment, low income, poor health, older age - are the very barriers to dental health care.

(G)Options and Costs Regarding Harmonized Levels of Service

The current dental programs administered and delivered by the City represent a multi-tiered system of benefits. Children and adults across the City with the same health needs have access to different levels of dental benefits depending on place of residence, eligibility for social assistance or severity of dental disease.

The introduction of the provincial Mandatory Dental Program for beneficiaries of Ontario Works and ODSP has established a minimum level of care that should be available to all residents who do not have access to dental care due to financial hardship.

To be equitable to all residents of the new City who are experiencing dental neglect due to financial hardship, it would be necessary to standardize dental benefits and eligibility requirements. Standardizing dental benefits for all vulnerable groups would reduce the incentive for people to remain on social assistance and enhance their future employability. Moreover, all residents who require subsidized dental care would have access to the same level of care and hence derive the same health and social benefits. This would include children and youth of low-income families, working poor adults, high risk mothers, low income seniors (both independent living and institutionalized), homeless people and unemployed adults. This would include the provision of basic dental care to the adult participants in the Ontario Works program who are currently eligible for emergency services only. The standard of service to be provided would be that which is currently available to dependent children in the Ontario Works Dental Program.

A preliminary cost estimate to provide this basic level of care ranges from $20 million - $40 million, depending on utilization levels and the service delivery model that is chosen. Due to the City's financial constraints, this approach is not put forward as an option for consideration at the present time. Lower cost alternatives that standardize levels of service to a lesser extent are outlined in the following options:

Option (1)Public Health dental treatment programs could be harmonized to provide some additional services to individuals across the City who lack dental benefits and cannot afford to pay for dental care, including children of low-income families, ESL and other new immigrant adolescents, high risk mothers and seniors. Under this option, low income would be defined in accordance with the definition used by Statistics Canada.

This option requires an increase in program capacity to respond to the need and increased demand for dental care. The annualized additional operating costs would range from $900,000 to $2,100,000 plus an optional one-time capital cost of $100,000. This cost range reflects sub-options to increase the capacity of the clinic system to absorb additional clients, as described below.

The current capacity of the community based clinics in the former City of Toronto and Etobicoke could not absorb the anticipated increase in demand for these services. The school based clinics in North York and York are not appropriately located to treat age groups beyond 14 years.

An increase in capacity of the community based clinics could be achieved in the short-term by increasing the operating hours of some or all of the community-based clinics in the former cities of Toronto and Etobicoke from 8:00 a.m. to 7:00 p.m. The clinic in Etobicoke would require upgrading of its equipment, which is outdated. An increase in the number of clinical staff FTE's (i.e. dentists, dental assistants and dental clerks) would also be necessary.

The estimated annualized cost of opening all 9 clinics in the former City of Toronto to extended hours is $1,900,000. Alternately, the following 4 sites could be used to pilot this approach, at a projected annualized cost of $900,000:

Sites:235 Danforth Avenue to serve residents of East York and Scarborough

2398 Yonge Street to serve residents of North York

95 Lavinia Avenue to serve residents of York and Etobicoke

726 Bloor Street West to serve residents of York

In addition, if the clinic in Etobicoke is upgraded and the staffing complement increased to allow the clinic to operate with extended hours, additional operating dollars of $200,000 would be required, plus one-time costs of $100,000 to upgrade the equipment and facility.

The approach of extending the operating hours of existing clinics has the advantage of making maximum use of City-operated facilities without a major increase in capital costs. The disadvantage of using this approach is that the public would be required to absorb the cost and inconvenience of traveling to these sites and, depending on the extent of demand for these services, may be on waiting lists for extended periods.

For the long term, Public Health staff should examine the desirability of closing the school based clinics in York and North York and re-allocating these resources to establish community based clinics. The former Toronto reorganized its dental services from a school-based program to a community-based program, which achieved significant cost savings. As well, community clinics were found to offer more flexibility in hours of operation and suitability of space for the different client groups that need access to dental services. A review of alternatives to the school-based clinics will be necessary even if this service level option is not adopted, due to the Toronto School Boards' requirement to charge market rents to organizations that use school facilities to deliver services. Specifically, the potential closure of these clinics has implications for the current delivery of provincially mandated dental programs as well as treatment services.

Option (2)The existing dental treatment budgets could be reallocated across the entire city, with neither associated savings nor costs.

This would result in an inadequate response to the growing need and demand for dental care among poor seniors, children and adolescents of poor families and high risk mothers. Currently staff from the former City of Toronto are inundated with requests for dental services from residents of the former municipalities. Meeting these needs with current resources would mean unacceptable waiting periods for these residents to access dental care. In addition, current dental benefits would have to be severely reduced and more restrictions introduced to limit access to care, so as to remain within the existing budget. This would result in reduced services for residents of the former municipalities, particularly in North York and Toronto, and to a lesser extent in Etobicoke and York.

Option (3)All municipally mandated dental treatment programs could be eliminated, at a cost saving of approximately $3.6 million.

This is clearly the lowest standard for harmonizing dental services for persons with dental and oral health needs who lack dental benefits and are otherwise unable to afford dental care. This would mean that individuals in North York, Toronto, Etobicoke and York who currently have varying access to some dental care would have to seek and pay for care as their counterparts in the other former municipalities of East York and Scarborough have been doing.

For the most part, dental care for these residents constitutes emergency visits for the relief of pain. One Cleveland Metropolitan Hospital experienced a doubling of dental emergency visits because dental benefits in the general assistance program were eliminated. Emergency room care is more costly than providing basic care in the community (Hill, 1994). As well, some Toronto hospitals have closed their dental facilities as a cost-saving measure, thus reducing the access of vulnerable residents even to emergency care.

Conclusion:

This report has outlined a strategy to harmonize dental services for Toronto residents. By increasing the capacity of current community based clinics, children and youth of low income families, high risk mothers enrolled in public health programs and low income seniors would have better access to dental services. The level of dental care that could be provided is very basic, including diagnosis, x-rays, cleaning of teeth, fillings, dentures, extractions, and root canals on critical teeth, to support the general health and well being of some of the most vulnerable groups in the new City. The Board of Health (and ultimately City Council) has to make policy decisions, determined by health, financial, social and political factors and constraints as to which option is ultimately selected.

Contact Name:

Hazel Stewart,

Regional Director - York/Etobicoke

Tel:392-0442

Fax:392-0713

Dr. Sheela V. Basrur

Medical Officer of Health

Program Budget and Budget Options:

Table 1

Service Impact of Program Options and Budget for Dental Treatment