THE LOST CHILDREN
Dental issues plague northern families
After 29 years of peering in little mouths, Penny Griffith doesn’t wince anymore.
The dental therapist with the Lac La Ronge Indian Band has become accustomed to seeing preschoolers’ teeth in a state most of us would find shocking — all four baby molars pocked with deep pits, and front teeth black and stumpy, literally rotting away to nothing.
“It’s an accepted thing — the front smile being black and stubby,” the frankly spoken Griffith said. “It’s so ‘normal’ here that it doesn’t matter.”
Like a rite of passage, many — some still in diapers — will take a trip south down Highway 2 and end up in Dr. Mohan Teekasingh’s Saskatoon operating room, where the dentist will often drill and fill as many as six or eight teeth, and extract four to six more.
“A lot of these kids, unfortunately, live with the pain and take it as part of their normal existence,” Teekasingh said.
Of the more than 1,900 Saskatchewan patients on a waiting list for dental work under general anesthetic, more than half are under age six and more than three-quarters are age 10 or younger.
The most common reason kids are put to sleep is because of dentistry, says Dr. Frank Hohn, department head for dentistry and maxillofacial surgery at the Saskatoon Health Region and president of the College of Dental Surgeons of Saskatchewan.
“I think it probably runs under the radar,” Hohn said, who adds the problem exists across the country.
Although dental disease can affect anyone regardless of wealth, a disproportionate number of kids in the OR are aboriginals from northern Saskatchewan. More than half of the kids having dental surgery self-identify as aboriginal, the Ministry of Health says. Babies, toddlers and preschoolers who live in Saskatchewan’s three northernmost health authorities are put under for teeth woes at more than three times the provincial rate.
Early childhood dental disease is painful. It stops kids from eating healthy foods and getting proper nutrition. It interferes with learning. And unlike many costly health problems, it’s almost entirely preventable.
“It’s a travesty that many children have to be going through a general anesthetic because of the end stage of dental disease — something that’s preventable. It’s a crime,” said Dr. Gerry Uswak, dean of the University of Saskatchewan’s dentistry college.
It’s also costing taxpayers a lot of money.
In 2010-11, the provincial Health Ministry paid for 2,015 patients age five and younger to have dental surgery under general anesthetic. The anesthesiologists’ time alone cost $662,260 and the ministry doesn’t track the cost of the dentist’s time, much of which is covered by private insurance.
For children on reserves, Health Canada’s Non-insured Health Benefits (NIHB) program paid out $516,033 that same year for anesthesia and dental fees for another 873 Saskatchewan kids.
“We’re paying for the cost of early childhood caries (cavities) one way or another,” said Dr. James Irvine, medical health officer for Saskatchewan’s three northern health authorities. “One way is through dental treatments, dental surgeries, dental anesthesia and the cost of getting children down from remote locations, and sometimes not so remote locations, for dental treatments.”
Prevention would be more cost-effective, he says, and dental surgery isn’t a cure.
Some unlucky preteens and teens end up back in the OR to have their permanent teeth filled, too.
A backlog of child dental surgeries also affects overall surgery-wait times in the province.
If regional reports are any indication, the problem is hardly isolated to the north and is getting worse in some places.
According to dental health screening reports on Grade 1 and 7 students prepared every five years by the province’s regional health authorities, children in Prince Albert Parkland and Regina are moving further away from national guidelines laid out in the Canadian Oral Health Strategy (COHS). The data show shrinking numbers of cavity-free children and — according to the COHS — too many kids with untreated dental problems.
Data from the Canadian Health Measures Survey show that across the country, children’s dental health is not meeting all of the COHS targets.
Dr. Ross Anderson, head of pediatric dentistry at Dalhousie University and a member of a Canadian Dental Association committee pushing for better access to dental care, says not only are the COHS targets attainable, but the country should be aiming to do far better.
“Saskatchewan is not special — this is an across-the-nation issue,” Anderson said.
WHY DOES IT
HAPPEN?
Ask anyone who works in the field, and they’ll tell you the issue is more complex than remembering to brush twice daily. Poverty and low socio-economic status comes up again and again.
“It’s everything from not knowing what to eat, how to eat, how to brush,” said Uswak, the dentistry college dean. “If we’re worrying about roaming packs of wild dogs in northern Saskatchewan, where does toothbrushing fit on the continuum of priorities?”
It’s only recently dental professionals learned cavities are literally infectious. A baby is born without the bacteria that causes decay, and usually picks it up from family.
Why aboriginal children are so disproportionately affected could be a result of inadequate housing, a lack of affordable and nutritious food, lack of easy access to dentists and social problems well beyond the purview of dental-health workers.
“If you don’t have a roof over your head, or mom or dad are drinking again, or there’s a party at your house, or maybe 85 people live at your house, maybe teeth brushing isn’t just as important as it is to us,” dental therapist Griffith said.
Her program has given out about 5,000 toothbrushes because many people just don’t have them.
Lac La Ronge mom Jennifer Halkett is trying to make changes to improve her family’s oral health. Two of her five children have had dental surgery in Saskatoon under general anesthetic — long trips she describes as stressful and full of worry about how her kids would react to the anesthesia. Her youngest daughter, two-year-old Serena, is now on a waiting list for surgery in Nipawin.
She tries to floss her children’s teeth, but Halkett literally has to chase the kids down first. She’s trying to buy drinks with less sugar in them, too.
When she has the money, she buys more fruit and vegetables.
“I have to try not to take them with me to the store, because they always aim for the candy,” the single mom said, adding it’s not easy to find babysitters on the First Nation.
When you have a lot of children, it’s so tempting to put a child to bed with a bottle of milk or juice, she says. “Parents just want the peace and quiet sometimes,” she said.
She admits she has trouble keeping up with her kids’ teeth brushing as well as she should.
But Uswak feels some responsibility lies far from the front lines of oral hygiene. He laments that despite wellestablished connections between oral health and overall health, dental care remains mostly in the private domain and is often a low government priority.
“We know in this country and in this province that the funding for dental public health and oral health proper is not at the level that it should be,” he said. “There’s finite resources. Government does not fund programs adequately to target all the highrisk populations and improve oral health.”
The population most affected by serious dental disease is also growing. According to Saskatchewan Health, the number of children in the province increased 16 per cent between 2005 and 2010, and the populations growing the most quickly are aboriginal.
FLUORIDE
And then, there is the political lightning rod of water fluoridation. Detractors argue citizens should be able to make their own choices about what chemicals are added to drinking water.
Water fluoridation is the most cost-effective way known to prevent dental disease. The Ministry of Health website says every $1 spent on water fluoridation can save $38 in downstream dental costs.
The Saskatoon Health Region’s surveillance found that while not perfect, school-age kids’ teeth fared better here — a difference the region attributes to the City of Saskatoon’s fluoridated water.
The City of Regina’s water is not fluoridated and neither is Prince Albert’s water system, which is currently undergoing upgrades with the ultimate aim of fluoridation.
Saskatchewan also lags the rest of the country in access to fluoridated water. Fortynine per cent of Canadians have access to fluoridated water, compared to 36 per cent of Saskatchewanians. Only four Saskatchewan reserves have access to fluoridated water from nearby towns — none have their own fluoridation systems.
Although the Canadian Paediatric Society, the Canadian Dental Association, Canadian Medical Association, Health Canada and others all promote community water fluoridation, governments say it’s up to each community to decide whether it’s right for them to invest in putting the system in place.
THE RISKS
Decayed teeth are not a purely esthetic problem. Research has established links between poor oral health and some cardiac, respiratory, and bone problems. Pregnant women with poor oral health are more likely to go into premature labour and deliver babies with low birth weights.
Pain, infection, fevers and other problems interfere with normal childhood development, sleep, eating, self- esteem and learning.
“It’s robbing that child of their right as a full and complete development as a human being,” Uswak said.
Extract rotted baby teeth and more problems await. They are placeholders for permanent teeth and when they’re removed too early, permanent teeth grow in crooked, Uswak said, opening the door to a future of orthodontic problems.
General anesthetic also carries risks, including rare occasions when a patient doesn’t wake up.
“The significance of the actual procedure is not appreciated well enough . . . If it was a child of mine, I would do everything I could do to make sure they never undergo a general anesthetic.”
PREVENTION
Access to preventive programs in Saskatchewan has been a patchwork that varies by region by city or town, and sometimes by neighbourhood or school.
Health regions have different incarnations, such as dental-sealant programs in highrisk schools, public-health nurses dispensing oral-health wisdom, fluoride-mouth rinses, and in some places such as Saskatoon’s West Winds clinic, free dental treatment for kids.
On reserves, Health Canada has run the Children’s Oral Health Initiative (COHI) since 2004, which targets children from newborn to 7, their caregivers and pregnant women. According to the federal agency, COHI has 55 dental therapists working in 61 of Saskatchewan’s 72 First Nations. A Health Canada spokesperson wouldn’t say whether there are plans to expand COHI to all reserves.
Off-reserve in northern Saskatchewan, a scaled-back version of the once-provincial children’s dental program now covers kids who live in the three northern health regions.
Both Griffith and Irvine say the newest push is to start prevention with pregnant and new mothers. Often, the damage is done long before a child sets foot in a school.
For people who receive social assistance, some dental coverage is available though the provincial government’s drug plan and extended benefits, but the government doesn’t know how many of those enrolled use the dental benefits. The CDA says most provinces’ programs are too limited.
WHAT TO
DO
It was in the context of these troubling numbers — growing wait times for dental surgery, kids drifting further from national targets — that prompted the Saskatchewan government to launch the Enhanced Preventive Dental Services program last fall.
The $1.4-million initiative is meant to make prevention more uniform across the province. It’s part of the Saskatchewan Surgical Initiative, which aims to have no patient wait longer than three months for surgery by 2014.
Tami Denomie, a director with the Health Ministry’s population health branch, says she’s optimistic the program will make a difference.
“We have really looked at this one over the last couple of years — taken a really good hard look at it — and that’s why we’ve taken some of the steps that we have,” Denomie said.
The money funds a new coordinator in every health region to make widely available prevention tacts that were previously offered inconsistently between regions. Now in effect across the province, the initiative includes training for other health-care workers, such as family doctors and public-health nurses, to give oral-health counselling and basic dental treatments such as fluoride varnishes.
The ministry plans to routinely evaluate the program, Denomie said, although it doesn’t have specific targets yet for reducing disease. It may not make a noticeable difference in surgery numbers for three to five years.
As for an apparent spike in the number of pediatric dental surgeries in the province in the last five years, that may be a blip due to a concerted effort to cut wait times. Hohn says Royal University Hospital got money in 2009 to dedicate two operating rooms, five days a week, to do pediatricdental surgeries — up from one OR. The boost suggests the number and cost of these surgeries won’t escalate at the same rate they have in the last five years, although Denomie wouldn’t speculate about future trends.
There are more steps oralhealth experts would like to see the province take.
The Canadian Oral Health Strategy recommends each province and territory appoint a chief dental officer or consultant to direct public dental services — a call Uswak and Anderson echo. That job is filled in six other provinces, and Nova Scotia is recruiting one. A Saskatchewan Health spokesperson says this province has no plans for that.
To help with a dearth of dentists and other professionals in the north, Uswak would like to see the government offer incentives to practise and open private clinics in remote communities.
Anderson says a key CDA recommendation is that all babies have their first dentist’s visit by 12 months of age, or six months after their first tooth pokes through — whichever comes first.
There may also be an appetite in Saskatchewan for culturally sensitive prevention programs. Dr. Rosamund Harrison, chair of pediatric dentistry at the University of British Columbia, has studied extensively how to successfully introduce prevention into communities with high rates of dental disease, such as inner-city Vietnamese in Vancouver, East Indian immigrants in Surrey and First Nations.
She found training workers from those communities to do the counselling helped eliminate language and cultural barriers and helped reduce dental disease rates. She also found one-on-one counselling with mothers that used praise and reinforcement worked better than showing videos and handing out pamphlets.
Those approaches have also worked in Lac La Ronge, which began its own dental therapy program in 2003.
At first, parents who’d had terrifying encounters with dentists in the past were leery of Griffith and the other dental therapists. They employ women from the community as dental aides, who visit families at home, give kids fluoride rinses, track people down to get forms signed and can speak to residents in their first language.
“We are part of the community now,” Griffith said. “We are very accepted in the classrooms.”
But despite pockets of success, the stream of stubbytoothed children down the highway to Saskatoon ORS continues.
“It’s not an inevitable thing that’s going to happen,” said Irvine, the medical health officer for northern health authorities.
“In the past, it was so common, there’s kind of an acceptance of it. But why? Why is there an acceptance of it?”