One World, Uneven Smiles

As Canada moves toward offering more publicly funded dentistry, a look at how other nations support oral health

By Diane Peters

Nine million Canadians, more than a quarter of the population, will soon be eligible for government-funded dentistry via the Canadian Dental Care Plan (CDCP).

Already, 80 per cent of people in Canada have a dentist, 42 per cent have access to fluoridated water and 84 per cent report their oral health to be good or excellent, according to Statistics Canada. However, 32 per cent do not have dental insurance and 5.5 per cent have untreated caries. The CDCP will put Canada on an exclusive list of places around the globe that attempt to “put the mouth back in the body.”

“Unfortunately, in many countries, while they have universal health care, they don’t have universal dental care,” says Paul Allison, professor in the Faculty of Dental Medicine and Oral Health Sciences at McGill University. “There’s no reason why health care for your teeth should be any different from health care for the rest of your body.”

“It’s a worldwide problem,” he says of the lack of publicly funded dental care.

Caries, periodontal disease, edentulism, oral cancer, and untreated noma and cleft lip and palate reduce quality of life, or even cause death, for billions.

“It’s good to have experiences in different parts of the world,” says U of T Dentistry assistant professor Sonica Singhal, who has seen dentistry up close in Australia and India. “Otherwise, we get a bit insular.” A global perspective can help us know how to work smarter to improve overall health, support dental professionals and create an efficient system.

NOT ALWAYS HEALTHY MOUTHS
Oral diseases impact 3.5 billion people worldwide, according to the World Health Organization (WHO). Caries is the most common health condition in the world: about two billion people have caries in their permanent teeth while 514 million children have decay in their primary teeth. About seven per cent of people worldwide have lost their teeth, and that climbs to 23 per cent among people over age 60.

“Tooth decay is expensive for countries to treat, rich and poor, and dental decay is so preventable,” says Allison.

In 2024, the WHO finalized a global strategy on oral health that encourages all nations to include dentistry and oral care in universal health coverage by 2030. “The WHO is not expecting all countries to have achieved those goals in such a short time, but it would like to see some level of progress,” says Allison, who serves on the Lancet Commission on Global Oral Health. “The CDCP is a step in the right direction to achieving that.”

PUBLIC CARE
A handful of wealthier nations are close to satisfying the WHO’s asks on oral health, offering universal or near-universal coverage. Greenland and Japan integrate dentistry into public health care, while Germany, Sweden and Denmark have robust systems that support basic care with minimal co-pays.

The U.K. and France, meanwhile, also offer strong public care systems, as does South Korea.

PUBLIC OUTCOMES
Nations with well-funded dentistry often have better health outcomes. The citizens of Denmark, Germany, Finland and the U.K. have the healthiest teeth and mouths in the world.

However, an over-arching public health dentistry system doesn’t automatically mean care is stellar. In Brazil, dentistry is covered by the government, but the program is poorly funded, and not everyone has a dentist or avoids paying out of pocket.

In public-dominated systems, dentists can struggle, which is what Kyle Kim 2T3 MSc Endo has noticed in South Korea. The government fully covers basic treatments and a percentage of elective or major treatments for some groups, such as 60 per cent of the cost of implants for seniors. However, the payment to the dentist is very low. “Where I’d see about 10 patients a day in Canada, in Korea, dentists are seeing maybe 30 to 50,” he says. “Does that mean patients overall are getting better health care? I don’t think so.” Similarly, in Ontario and other provinces, when dentists offer care through public health programs, their fees may barely cover costs.

Poorly designed public programs can bankrupt themselves. John Dale 7T0, who is based in Sydney, Australia, recalls the Chronic Dental Disease Scheme, which lasted eight years starting in 2004. “Medical practitioners were referring people to the dentist and they would be doing $4,200 worth of treatment, some of which was not necessary.” He heard of people getting bridgework before simple restorative treatments. The plan blew through AUS$1.9 billion, with some dentists getting charged for abusing the system, and studies showing much of the money didn’t go, as intended, to treating chronic dental health conditions. (Australia still covers some dentistry for children, and that program has endured.)

The National Health Service in the U.K. initially offered full dental coverage, but ended up dramatically clawing back services. “Within a few years, the money was exhausted,” says Singhal. She worries the same could happen with the CDCP, as there’s no cap on services, and many people who qualify have complex needs.

PRIVATE CARE
The majority of nations support oral care with limited public health programs or clinics for low-income people — perhaps for seniors and kids, too — and private care for almost everyone else, expecting workplace insurance to fill gaps. Canada, in many ways, still falls in this category.

When a system relies heavily on private insurers, companies can start calling the shots. In Iran, dental insurance is very complicated, with some insurance companies only working with certain dental clinics. “For example, there’s a bank that provides insurance for their employees. And they sign a contract with dentists and they come to an agreement about the fees the dentist can charge,” says Gevik Malkhassian 0T7 MSc Endo, associate professor, teaching stream at the Faculty and director of the International Dentist Advanced Placement Program (IDAPP). He says most people pay out of pocket for dental care in Iran.

In Argentina, private insurance pays, but pays little. “The problem with insurance, is it doesn’t pay dentists well,” says Romina Quiroga, endodontist and instructor at the preclinical lab at the Faculty. “If a crown is more expensive, with a more expensive material, you cannot charge the insurance for that.” Quiroga came to Canada in 2023. Before that she worked at the University of Buenos Aires, her own dental clinic and then would also do root canals in a specialist clinic. Working from 8 a.m. until 9 p.m. is common for most dentists in Argentina.

Dale says that in Australia it’s tough for dentists, with young practitioners having trouble finding a job and the profession dealing with low fees from insurance companies. As well, people in lower-wage jobs often struggle to afford care.

In some countries, public health dentistry operates in nooks and crannies, outside of official systems. Singhal says she worked at a hospital in India treating hundreds of patients a day. “I have never seen a paper from India saying that these are the public health services they offer and how much they cost. How do we know how much is coming from the public?” She suspects many countries similarly support their citizens, but it’s not tracked or widely promoted.

HOW HEALTH FARES
“Private systems end up creating inequalities in access, whereas the public systems reduce the inequalities in access to care,” says Allison. The result, especially for poorer nations, is below-standard oral health overall.

In many corners of the world, dentistry equals extractions, full stop. “I remember going to the dentist for extractions, that’s all I knew. I don’t remember fillings,” says new Faculty grad Ola El-Maki 2T4, who emigrated from Sudan at age 11. There are not a lot of dentists in her home country, which may explain why there’s so little preventive care, but they garner respect and are often turned to for advice.

Relying heavily on private care often leads to more oral disease. The U.S. has a tiny public health system and relies on insurance, but 35 per cent of citizens have none. A quarter of adults in the U.S. have at least one untreated cavity — rates are two- to three-times higher for low-income people — and half of children under age eight have had caries.

About 55 per cent of people over 65 have edentulism in Iran. In Argentina, 41 per cent of children and 37 per cent of adults have untreated caries while severe periodontal disease impacts 18 per cent of people over age 15. Teens in Sudan have a caries rate of 91 per cent.

WORLD SHIFTS
A quick scan of the globe reveals that oral health is a pressing concern for almost every nation. Even those with robust systems struggle with costs and complexities. Many nations find their system does not lead to good oral health.

Canada can be proud of its new federal plan, strong public health messaging and (at least moderately) supported public health programs. “In Canada, people understand that the dentist is important and oral health is important health,” says Quiroga. Singhal agrees that Canadians have it pretty good. “The glass is more than half full.”

All eyes are on Canada as more nations try to better sup- port dentistry and seek an effective model. Private companies are joining together to look at how to better promote oral health for employees. Groups in the U.S. and Europe are calling for improved oral health programs while countries such as Russia and South Korea are bolstering care.

“Dentistry has not been on the radar for decades. Now it is in many countries,” says Allison, who has rising hopes for oral health care getting better across the globe. “It’s moving up the political agenda.”

Top illustration: Ryan Garcia

Interested in more stories? Read the PDF edition of the U of T Dentistry Magazine Summer/Fall 2024 Issue