November 3rd 2010

1. MASTERS OF PUBLIC
HEALTH (MPH) PRACTICUM
PROJECT, 2010
Presented by: Genevieve Braganza H.BSc, MPH(c)

2. OUTLINE

Two Projects:


Cost of Treating Early Childhood Caries(ECC) in the
Saskatoon Health Region (SHR) and Province of
Saskatchewan
Oral health and Dental Service Needs for the
Vulnerable Population in Saskatoon (Quality
Improvement Questionnaire)

Key Findings

Recommendations

3. COST OF TREATING EARLY CHILDHOOD
CARIES (ECC) IN THE SASKATOON
HEALTH REGION (SHR) AND PROVINCE OF
SASKATCHEWAN
Reference: http://www.pediatricdentist.com/images/pagePhotos/early.jpg

4. BACKGROUND

What is Early Childhood Caries (ECC)?

the presence of one or more decayed, missing (due to
caries), or filled tooth surfaces in any primary tooth
in a child 71 months or younger.
http://health.state.tn.us/images/oralhealth/caries.gif
Source- Canadian Dental Association (CDA), April 2010

5. TREATMENT


Dental treatment or dental surgery under
General Anaesthetic (GA) is most common.
Advantages:
Safe*
 Efficient
 Less physical and mental stress on the child and
dental professionals

Source: Anderson H K, Drummond B K. Thomson W M 2004

6. TREATMENT

Disadvantages:

Non-life threatening


nausea and vomiting, fever, pharyngitis and swollen lips
Life threatening:

bronchospasms, anaphylaxis, cardiac arrest and respiratory
failure
Source: Anderson H K, Drummond B K. Thomson W M 2004

7. WHY ARE WE INTERESTED?

In Canada the prevalence of ECC is 6% to 8%



Disadvantaged populations: 25%- 72%
In 2007, Prime Minister Stephen Harper
announced a Wait Times Guarantee, to reduce
waiting lists for children awaiting surgery in
pediatric hospitals, identified as one of the
priorities was dental treatment under GA.
ECC is almost 100% preventable disease.
Source: Schroth RJ, Brothwell DJ, 2004

8. OBJECTIVES
1.
2.
3.
To compare children under age 6 receiving
dental surgery under GA versus all other
pediatric surgeries.
To determine the cost associated with treating
preschool children with ECC under GA in
Saskatchewan, specifically focusing on the
Saskatoon Health Region.
Identifying if majority of children treated for
ECC under GA are from northern/remote
communities.

9. DATA SOURCES



CIHI Portal Discharge Abstract Database,
collected April 1, 2008 to March 31, 2009.
The 2008-09 In-Province General Anesthesia
costs obtained from Medical Health Service
Branch (April 2010).
Cost estimation:
The College of Dental Surgeons of Saskatchewan
(Fee Guide)
 NHIB Regional Dental Benefit Grid
 Supplementary Health & Family Health Benefits
Program.


10. RESULTS: PEDIATRIC SURGERIES
In Saskatchewan, of the
4858 provisions, 2105
cases (43%) were dental
related cases & 57%
were non- dental
related cases.
All pediatric surgeries for children under age
6 compared to dental related surgeries by
health region (April 2008- March 2009)
3000
Number of cases

2500
2000
1500
1000
All Services
500
0

Dental (incl Oral
Surgery)
In Saskatoon Health
Region:

Of 2636 provisions,
1104 cases (42%) were
dental related cases &
58% were non-dental
related.
Health Regions

11. RESULTS: COST

Estimated average treatment for ECC under GA:

Exam, 2 bitewing x-rays, 4 two-surface amalgam
fillings, 4 Stainless Steel Crowns, 2 pulpotomies and
4 extractions-deciduous teeth.

Dental Fee Guides to determine average cost.

Cost of General Anaesthetic (GA): $ 324

12. RESULTS: COST

In Saskatchewan:


In 2008- 009, the cost of treating ECC for children
under age 6 was approximately 3.4 million*
In the Saskatoon Health Region:

Saskatoon had the highest number of cases and
therefore highest cost of approximately 1.9 million
(accounting for cases by postal code/ residence)
Reference: www.energeticforum.com/general-discusion/460...

13. RESULTS: COST COMPARISON

In British Columbia:


In 2001- 02, the cost of treating ECC for 5000
children under age 4 was approximately 10 million.
In Toronto, Ontario:

In 1996, the cost of treating ECC for children
between 1 and 4 years was approximately 3 million.
Reference: www.energeticforum.com/general-discusion/460...

14. RESULTS: PLACE OF RESIDENCE
Saskatoon
Health
Region
resident
Northern
Health
Region
resident
Other Health
Region
resident
Saskatoon
Health
Region
(Total)
Dental
treatment
$1,236.40
$1,236.40
$1,236.40
$1,236.40
General
Anaesthetic
$323.48
$323.48
$323.48
$323.48
Additional
Cost ($)
--
$568.03
--
--
Total cost per
child
$1,559.88
$2,127.91
$1,559.88
$1,559.88
Number of
children that
received
treatment
(under age 6)
398
345
361
1104
Total Cost
(2008-09)
$620,832.24
$734,128.95
$563,116.68
$1,918,077.87

15. SUMMARY

In Saskatchewan (2008-09), 43% of pediatric
surgeries were dental related and 57% were nondental related.


Saskatoon Health Region: 42% dental related
surgeries & 58% non-dental related.
In 2008-09, the cost associated with treatment of
ECC under GA in Saskatchewan & SHR was
approximately 3.4 million & 1.9 million
respectively.

16. SUMMARY (CONT’D)

In 2008-09, 398 children were Saskatoon
residents versus 345 were from Northern Health
regions.

17. LIMITATIONS



Limitation of data i.e. dental related surgeries
may not all be ECC related
Limitations with data for disability code i.e.
unaware if disability code is a mandatory field in
the database or an optional code.
Identification of provincial versus federal funds.

18. KEY RECOMMENDATIONS


Establishment of a “dental home” or dental
check-up for children at age 1, as recommended
by the Canadian Dental Association (CDA).
Parents and guardians with poor oral health to
have access to dental insurance and dental
providers to be willing to provide care, in order to
prevent poor oral health in families.
Source- Canadian Dental Association, 2005

19. KEY RECOMMENDATIONS


To encompass oral health messaging and
screening as part of primary health care,
whereby non-dental health providers ensure good
oral health practices.
Develop new multidisciplinary follow-up
strategies between clinical team and
parent/guardian and child, as current follow-up
processes following treatment for ECC do not
exist.
Reference: http://archive.student.bmj.com/issues/08/07/education/images/view_1.jpg

20. ACKNOWLEDGEMENTS

Leslie Topola- Supervisor, Public Health Services- Oral Health Program

Dr. Gerry Uswak- Dean, University of Saskatchewan, College of Dentistry





Lisa Dietrich- Program Manager, Data and Statistical Services, Medical
Health Services Branch
Janet Gray- Technical Dental Consultant/Dental Health Educator (DHE),
Population Health Unit
Shirley Schweighardt- Health Information Analyst, Strategic Health
Information and Planning Systems (SHIPS)
Lynne Warren- Library Technician, Public Health Services- Public Health
Observatory
Cynthia Ostafie- Dental Health Educator, Public Health Services- Oral
Health Program

21. DENTAL HEALTH HUMOUR..
Reference: onedentalcenter.com

22. ORAL HEALTH AND DENTAL SERVICE
NEEDS FOR THE VULNERABLE
POPULATION IN SASKATOON
(QUALITY IMPROVEMENT QUESTIONNAIRE)
Reference: http://3.bp.blogspot.com/_kO5SLwNlPr8/SiWzBOHn-gI/AAAAAAAAAAc/VpoJp3IJNb8/s400/cartoon_dentist_things.gif

23. BACKGROUND


In the last 3 decades in Canada, there have been
vast improvements in oral health, however
vulnerable populations still suffer from poor oral
health.
There is a strong positive correlation between
poor oral health and chronic disease i.e. coronary
heart disease.
Source- Canadian Health Measures Survey, 2010

24. BACKGROUND

Barriers to accessing oral health care:
Financial
 Geographic
 Social/ Cultural
 Legislative.

Source- Canadian Oral Health Strategy, 2004

25. THE PROJECT


Quality Improvement Project
A Dental Health Questionnaire was conducted in
the core neighbourhoods of Saskatoon.


29 mandatory questions & 11 optional questions
Timeframe: 10 questionnaire days, June 2010.
Reference: http://www.phha.mlanet.org/blog/wp-content/uploads/2010/02/survey.jpg

26. THE PROJECT

Organizations:
AIDS Saskatoon
 Mobile Health Bus- Primary Health Clinic
 Westside Community Clinic
 Riversdale Immunization Clinic


Incentive: dental gift bag & optional dental
health consultation with licensed dental
therapist.

27. THE PROJECT



Dental Health Questionnaire was advertised at
multiple locations throughout core city of
Saskatoon.
Sample size: 263
Descriptive statistics & frequency tables were
used using the software SPSS 17.0.

28. OBJECTIVES
1.
2.
3.
4.
Understand the specific needs of this population
based on self-reported dental health.
Determine the prevalence of good dental health
habits among the vulnerable population
Determine specific barriers that prevent
Saskatoon’s vulnerable population from
accessing oral health care.
Understand specific health risks impacting the
dental health of the vulnerable population.

29. DEMOGRAPHICS:




Income (n= 236): 53% identified an income of
$12,000 or less per year.
Education (n= 246): 70% identified having an education
of high school or elementary school.
Housing (i.e. Fixed address) (n= 248): 86% noted fixed
address.
Ethnicity (n= 252): 82% identified themselves as
Aboriginal/ First Nations/ Métis/ Inuit

30. OBJECTIVE #1: SELF- REPORTED
DENTAL HEALTH & SPECIFIC DENTAL
NEEDS
Self- reported dental health (n= 263):
Approximately 32% of participants identified either
“excellent” or “good” dental health
 68% of participants identified their dental health as
“fair” or “poor”.

Self- reported Dental Health
in the vulnerable population
in Saskatoon (n= 263)
Frequency

120
100
80
60
40
20
0
Excellent
Good
Fair
Self- Reported Dental Health
Poor

31. OBJECTIVE #1: SELF- REPORTED
DENTAL HEALTH & SPECIFIC DENTAL
NEEDS

Approximately 70% of participants (n= 262) were
worried or concerned about their dental
health:
Females: 66%
 Males: 69%


Most reported concern (n = 263) and problem
(n= 99) by participants were dental caries (or
cavities), by 63% and 37% respectively.

32. OBJECTIVE #1: SELF- REPORTED
DENTAL HEALTH & SPECIFIC DENTAL
NEEDS
Dental Health Concerns identified by vulnerable
population in Saskatoon (n= 263)

33. OBJECTIVE #2: GOOD DENTAL
HEALTH HABITS

Brush teeth (n= 262): 70% of participants
identified brushing their teeth
38% identified brushing once per day
 46% identified brushing twice per day


Floss teeth (n= 262): 45% identified flossing their
teeth

Approximately 47% identified flossing once per day
Reference: http://1.bp.blogspot.com/_oYgi6XUmHiE/SHbQOXtvBnI/AAAAAAAAA-Q/hCKlyUTqNho/s320/Toothbrush.jpg

34. OBJECTIVE #2: GOOD DENTAL
HEALTH HABITS

Dental Office Visits (n= 263):

Approximately 65 % identified visiting a dental office

Approximately 65% identified visiting dental office once per
year

35. OBJECTIVE #3: BARRIERS TO
ACCESSING DENTAL CARE

Barriers (n= 92):
Fear of Bad
Experience: 28%
 Transportation:27%
 Cost 26%
Reasons for not visiting a dental office
(n= 92)

Use dental services
if they were free of
charge:
approximately 95%
noted “yes”
Frequency

100
90
80
70
60
50
40
30
20
10
0
Barriers to Accessing Oral Healthcare

36. OBJECTIVE #3: BARRIERS TO
ACCESSING DENTAL CARE

Of 90 participants that did not visit dental office:
60% had dental coverage
 28% noted no dental coverage
 12% did not know

Reference: http://fullcoveragedentalinsurancereview.com/wp-content/uploads/2010/08/full1.jpg

37. OBJECTIVE #3: BARRIERS TO
ACCESSING DENTAL CARE

Preferred dental services (n= 70):
Cleanings and check-ups :40%
 Good/ flexible dentist: 11%
 Dentures/ denturist: 11%


Location of services (n= 33):

Approximately 88% identified west side of Saskatoon


Suggestions: 20th/ 22nd street, Ave U, Riversdale area,
Westside community clinic etc.
Approximately 12% identified any location (east or
west side)

38. OBJECTIVE #3: BARRIERS TO
ACCESSING DENTAL CARE

Participants identified what they needed to have
good dental health:
Reported needs for Good Dental
Health (n= 108)
2% 2%
Dental Services (i.e. checkups, cavities fixed,
extractions, dentures)
6%
27%
9%
Tools i.e. tooth brush, tooth
paste, floss
Better habits (i.e. brush &
floss more, stop smoking, eat
healthier, more education)
14%
16%
24%
A good, respectful dentist
(and an appointment)
Money

39. OBJECTIVE #4: HEALTH RISKS
(TOBACCO USE)

Tobacco use among
participants (n= 261):
Approximately 75% of
participants identified
using tobacco!
 Saskatoon Health
Regions prevalence:
26%.
Frequency of Tobacco Usage
among Participants (n= 192)


Frequency of tobacco
use (n= 192):

Approximately 52%
noted 1- 10 cigarettes
smoked per day.
Reference: Health Disparity Report, 2006
120
Frequency
100
80
60
40
20
0
1 to 10
11 to 25
More than 25
Number of cigarettes/ cigars/ tobacco used

40. OBJECTIVE #4: HEALTH RISKS
(TOBACCO USE)

Number of years smoked or use of spit tobacco
(n= 174):


Approximately 78% identified using tobacco for more
than 5 years.
Number of participants that (n= 174):
Used spit tobacco: 15%
 Engaged in both smoking and used spit tobacco: 14%

http://www.usabledt.com/wp-content/uploads/quit-smoking.jpg

41. OBJECTIVE #4: HEALTH RISKS
(TOBACCO USE)

Prevalence of smoking among participants by
location:
Riversdale: approximately 53% identified tobacco
use.
 Other locations (AIDS Saskatoon, Mobile Health Bus,
Westside Community Clinic): approximately 82%
identified tobacco use.


Possible explanations:
Demographics of participants
 Identified the “correct” answer
 Public Health Services provide 5A’s of brief tobacco
intervention


42. OBJECTIVE #4: HEALTH RISKS
(STRESS RELATED HABITS)


Stress related habits (n= 257) were noted by 55% of
the sample population.
Type of stress related habits (n= 142):
Clenching
 Grinding
 Cheek biting
 Nail biting

Stress related habits among
participants (n= 142)
34%
21%
Clenching your teeth
Grinding your teeth
Cheek biting
11%
34%
Nail biting

43. SUMMARY
 Objective
Health


#1: Self- Reported Dental
Overall the vulnerable population had a poor
perception of their dental health.
Large percentage of the sample (70%)
identified concerns/ worry with respect to their
dental health.

44. SUMMARY
 Objective


#2: Good Dental Health Habits
High prevalence of brushing , flossing and
dental visits among the sample population.
Erroneous results

45. SUMMARY
 Objective
#3: Barriers to Accessing Oral
healthcare


Fear or bad experience, transportation and
cost
Dental services and tools were recommended
by participants to have good dental health

46. SUMMARY
 Objective


#4: Health Risks
High prevalence of tobacco use among the
sample population (75%), however, Riversdale
participants showed decrease in prevalence of
tobacco use (53%).
High prevalence of stress related habits (i.e.
grinding and nail biting) among vulnerable
population.

47. LIMITATIONS
1.
Bias based on location dental health
questionnaire was conducted.
2.
Healthy Volunteer Effect.
3.
Generalizability of results.

48. RECOMMENDATIONS



Implement a monthly Dental Health Q&A
outside the Mobile Health bus.
Dental office(s) should be located on the Westside
of Saskatoon.
Oral hygiene tools (i.e. toothbrush, toothpaste
and floss) and preventative services should be
available to the vulnerable population in
Saskatoon.

49. RECOMMENDATIONS



Expand 5 A’s of Brief Tobacco Intervention to other
organizations within the Saskatoon Health Region.
Parents and guardians with poor oral health to
have access to dental insurance in order to treat
oral health issues.
Present results of the Dental Health Questionnaire
to private practice dentists in the Saskatoon Health
Region to receive feedback on the results of Quality
Improvement Questionnaire i.e. how to link
patients with specific dentists.

50. ACKNOWLEDGEMENTS
Supervisors and Colleagues:

Leslie Topola- Supervisor, Public Health Services - Oral Health Program

Dr. Gerry Uswak- Dean, University of Saskatchewan, College of Dentistry

Julie Laberge- Lalonde- Dental Health Educator, Public Health Services- Oral Health Program

Joyce Birchfield – Administrative Assistant, Public Health Services- Oral Health Program

Rhonda Richards- Desktop Publisher, Public Health Services

Josh Marko- Epidemiologist, Public Health Services- Public Health Observatory
Contributing Organizations:

AIDS Saskatoon

Mobile Health Bus- Primary Health Clinic

Westside Community Clinic

Riversdale Immunization Clinic
Other:

Special thank you to all participants who took time to complete the Dental Health Questionnaire
and provide Public Health Services, Oral Health Program with valuable information.

51. QUESTIONS?
Reference: http://1.bp.blogspot.com/_a3MDthA0QU/SxQVt2LjViI/AAAAAAAAABU/aDEwkQXtpAg/s1600/GuyThinkingRight.gif

52. REFERENCES











Surgeon General (2000). Oral Health in America. A Report of the Surgeon General. Rockville, MD:
Department of Health and Human Services- U.S. Public Health Service.
Lemstra M, Neudorf C. Health Disparity in Saskatoon: Analysis to Intervention, Executive Summary, June
2010. Retrieved from:
http://www.saskatoonhealthregion.ca/your_health/documents/PHO/HealthDisparityExecSummary.pdf
Canadian Oral Health Strategy, June 2010. Retrieved from:
http://www.fptdwg.ca/assets/PDF/Canadian%20Oral%20Health%20Strategy%20-%20Final.pdf
Health Canada, Canadian Health Measures Survey. Oral Health Statistics: 2007-2009, June 2010:
http://www.hc-sc.gc.ca/hl-vs/pubs/oral-bucco/fact-fiche-oral-bucco-stat-eng.php
Canadian Dental Association. August 2010. Retrieved from: http://www.cdaadc.ca/_files/position_statements/Early_Childhood_Caries_2010-05-18.pdf
Canadian Dental Association. August 2010. Retrieved from: http://www.cdaadc.ca/en/oral_health/faqs_resources/faqs/dental_care_faqs.asp#4
Schroth RJ, Brothwell DJ. Prevalence of Early Childhood Caries in 4 Manitoba Communities. Journal of
Canadian Dental Association 2005; 71 (8): 567a- 567d.
Ismail AI, Sohn W. A Systematic Review of Clinical Diagnostic Criteria of Early Childhood Caries. Journal
of Public Health Dentistry 1999 (59) 3: 171-91.
Anderson H K, Drummond B K. Thomson W M. Changes in aspects of children’s oral- health- related quality
of life following dental treatment under general anesthetic. International Journal of Pediatric Dentistry
2004; 14: 317- 325.
Schroth RJ, Morey B. Providing Timely Dental Treatment for Young Children under General Anesthesia is
a Government Priority. Journal of Canadian Dental Association, 2007: 73 (3): 241- 243.
Association of Dental Surgeons British Columbia. Children’s Dentistry, Task Force Report. Vancouver BC:
Association of Dental Surgeons British Columbia, 2001.