Exploring the association between dental insurance coverage and dental care utilization and oral health among elderly Ontarians

Abstract

Objectives

There has been an increasing interest in addressing the equity issue of accessing dental care for low‐income elderly. This study aimed to estimate the marginal effects (ME) of dental insurance coverage for seniors on dental care utilization and oral health status outcomes. We also estimated the ME of dental insurance across income subgroups.

Methods

Data was sourced from the 2017/18 Canadian Community Health Survey (CCHS)‐Annual component. The ME analysis included individuals aged ≥65 years residing in Ontario (n = 10,030). ME were derived from multivariate probit regression models for dental care utilization and oral health status outcomes.

Results

Dental insurance increased the likelihood of reporting excellent/very good oral health and never avoiding foods due to oral problems by 6.9% (ME:6.9, 95% CI: 5.4–8.3) and 3.5% (ME: 3.5, 95% CI: 1.9–5.1), respectively. Dental insurance increased the likelihood of dental visits within the past year by 11.3% (ME: 11.3, 95% CI: 9.8–12.8) and decreased the likelihood of dental visits only for emergencies by 11.2% (ME: −11.2, 95% CI: −12.5 to −9.9). Compared to low‐ and high‐income groups, dental insurance had the highest ME for the middle‐income groups for dental visits within the past year (ME middle: 13.1, 95% CI: 10.5–15.7) and dental visits only for emergencies (ME middle: −14.4, 95% CI: −16.0 to −12.8).

Conclusion

Dental insurance can improve the utilization of dental care and can help mitigate the negative effects of poor oral health in elderly populations.

INTRODUCTION

Globally, a demographic transition is evident, shown by a decrease in mortality rates and birth rates [1, 2]. Canada is not an exception, where findings from Statistics Canada show that Canadian men and women are expected to live 79 years and 84 years, respectively [1, 3]. The aging population is increasing and becoming much more predominant representing about 15% of the Canadian population and is expected to reach 25% by 2036 [1, 3]. This raises concerns about providing better welfare to this population and mitigating the inequities in oral health care they face.

There is a significant link between age and poor oral health, which can be explained by several factors including gingival recession, xerostomia and side effects of medication, chronic systemic diseases, difficulties in oral hygiene practices, and dietary changes [4]. Poor oral health is highly prevalent among Canadian seniors, with one in six of those aged 60–79 years suffering from untreated caries. This age group also had the highest mean number of Decayed (D), Missing (M), and Filled (F) Teeth as measured by the DMFT index (DMFT: 15.7), compared to younger age groups (DMFT: 12.3 for the 40–59 age group, DMFT: 6.9 for the 20–39 age group), based on findings from the Canadian Health Measures Survey (CHMS) conducted in 2007/09 [4, 5]. In addition, more than half (58%) of the same age group retained 21 natural teeth or more, potentially increasing their needs to access dental care services [4, 5]. A recent report published by Public Health Ontario showed that older adults (65 years and older) suffered the most from poor access to dental care, among all age groups [6]. Furthermore, about 60% had no private dental insurance to cover dental expenditures, and only 58.6% had a dental visit in the last year [6].

The “inverse care law” describes the dental care system in Canada today, with those having the highest need for dental treatments receiving the least care [7]. Although the use of medical services in Canada increases with age, the situation is quite the opposite for dental and oral health services [4, 8]. Research on the impact of public funding for dental care and insurance coverage on dental visits in Canada reported that those with poor oral health visited dentists less than those with excellent oral health [9, 10]. Inequity in dental care is an issue for the elderly population and is becoming more concerning as the aging population increases and becomes more frail [3]. This is fundamentally influenced by financial barriers to accessing dental care [3]. As people get older, they tend to have more dental needs; however, at the same time, they experience progressively lower incomes and become more likely to be uninsured due to the loss of dental benefits after retirement [3, 11].

Dental insurance coverage and income are known to be strong predictors of dental care utilization [9, 12]. A recent systematic review reported that having no dental insurance coverage results in significantly lower utilization of dental care services [13]. These inequalities in dental care utilization are more evident in countries with predominantly private dental care coverage such as Canada and the United States [10]. The CHMS reported that 16% of seniors aged 60–79 years avoided dentists due to cost and were the most likely age group to have no dental insurance which is how dental care is mainly financed by individuals in Canada [5]. There is a notable increase in unmet dental needs and untreated caries among older adults, particularly to the lack of dental insurance coverage, which affects the affordability of dental services, and the prioritization of other healthcare needs over dental care. This results in an imbalance between dental needs and dental demand in this elderly population. In other words, as the dental needs of these populations increase with age, they experience poorer access to dental care services [3].

Ontario, the largest Canadian province, is the least (1.4%) among all other jurisdictions in providing public financing to dental care services to Ontarians [10]. Most provincially legislated dental care programs for low‐income Ontarians are focused on children's oral health [10]. In Ontario, approximately 43.3% (5.3% public insurance only, 37.1% private insurance) of older adults have dental insurance, which is comparable to the national average in Canada (36.4% [6.3% public insurance only, 32.5% private insurance]) [14]. This percentage is lower than in some European and Scandinavian countries like Germany (98%), Czech Republic (96%), Denmark (92%), the Netherlands (87%), Poland (77%), and Sweden (64%) [15]. In contrast, the United States has a lower percentage of older adults with dental insurance, at around 29.2% [16].

There has been increasing international interest in addressing the equity issue of accessing dental care for low‐income older adults [11]. In 2019, the Government of Ontario announced the inclusion of dental care coverage programs targeted towards low‐income uninsured seniors aged 65 years and older [17]. The Ontario Seniors Dental Care Program has been recently implemented to provide access to oral health care services for low‐income seniors, covering both preventive and restorative services [18]. Furthermore, the federal government recently implemented a universal, publicly‐administered dental care program to include more low‐ and middle‐income Canadian seniors, expanding coverage to those with an annual net income of less than $90,000, rather than the annual net income cut‐off of $37,100 or less for the Ontario Seniors Dental Care Program [18, 19]. Therefore, in light of the Canadian government's investment in these programs, using marginal effects (ME) models is important, as these models provide an informative and useful means for summarizing the association of dental insurance coverage with dental care utilization and oral health outcomes among elderly Ontarians [20, 21].

In this study, data from the 2017/18 Canadian Community Health Survey (CCHS)—Annual component (i.e., the most recently available cycle of the CCHS) was sourced to achieve the following objectives: (1) Measure the marginal effects of dental insurance coverage for seniors on dental care utilization and oral health status outcomes. (2) Measure the marginal effects of dental insurance coverage for seniors on these outcomes across income subgroups to investigate which income subgroup is likely to benefit the most from having dental insurance coverage.

METHODS

Data source

The CCHS—Annual component is a cross‐sectional survey commissioned by Statistics Canada whose aims were to collect data regarding the health and well‐being of Canadians aged 12 years or older residing in the 10 provinces and three territories. Individuals living on reserves and other Aboriginal settlements and those living in institutions or certain remote regions were excluded from the survey [22, 23]. Data was collected between January and December 2018, during which 54,100 valid interviews were performed using a computer‐assisted personal interviewing (CAPI) system with an overall response rate of 58.8% [23]. This analysis was restricted to individuals aged 65 years or older and living in Ontario to provide more insights to ongoing policy changes related specifically to this vulnerable age group. Appendix 1 provides a detailed description of all the variables included in the analysis. A more detailed explanation of the survey is given by Statistics Canada [22, 23]. This research relies completely on secondary use of publicly available data. Therefore, based on Article 2.4 of the Tri‐Council Policy Statement: Ethical Conduct for Research Involving Humans, research ethics board approval is not needed for this study [24]. This study was prepared using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) cross sectional reporting guidelines [25].

Exposure variable

This study assessed the association of dental insurance (public and private) with dental care utilization and oral health status outcomes. Dental insurance was defined and assessed by the following question asked to the participants: “Do you have insurance or a government program that covers all or part of your dental expenses?” For this question, responses were either “Yes” or “No.”

Outcome variables

We reported the association of dental insurance coverage with dental care utilization and oral health status (Appendix 1). Dental care utilization was defined by two distinct variables: the time since last dental visit and dental visits only for emergencies. Last dental visit was assessed using the following question: “When was the last time that you visited a dentist?” Responses were categorized as last dental visit ≤1 year or >1 year. Dental visits only for emergencies was defined as whether the individual reported visiting the dentist only for emergencies or not (“Yes” or “No”).

The oral health status outcomes included two distinct variables: self‐reported oral health and frequency of avoiding foods due to oral problems. Self‐reported oral health was assessed using the following question: “In general, would you say the health of your mouth is: excellent, very good, good, fair, poor?” We categorized the responses as excellent/very good, good, and fair/poor. The second variable, frequency of avoiding foods due to oral problems, was assessed using the following question: “In the past 12 months, how often have you avoided eating particular foods because of problems with your mouth?” For this question, participants were supposed to choose one of the following options: “often,” “sometimes,” “rarely,” and “never.”

Covariates

The following self‐reported variables from the CCHS were included in the multivariate models as covariates of interest: age, sex, marital status, dental insurance, household income quintile, highest education level, self‐perceived general health, and having Diabetes (types 1 or 2) (Appendix 1). Household income measure at the provincial level categorizes respondents into deciles based on the ratio of their household income to the low‐income cut‐off for their household and community size [26]. For analysis by income quintile, these deciles were combined into quintiles.

Statistical analysis

Weighted descriptive statistics for baseline characteristics were reported for the whole sample and separately for individuals with and without dental insurance. The difference in the categorical variables between individuals with and without dental insurance were analyzed using Chi‐squared test.

In order to quantify the changes in the outcomes of interest due to changes in the dental insurance status, we conducted the average ME approach described by Onukwugha [20, 21]. ME are different from relative effects (e.g., odds ratio (OR) and relative risk (RR)) in that they are measured in absolute terms, therefore representing an informative means to convey the magnitude of the difference in the outcomes between groups rather than quantifying the relative differences between the groups [20, 21]. The main advantage of using absolute rather than relative terms is facilitating the interpretation of the results. For example, an OR of 2.4 associated with having dental insurance in a model for the probability of having excellent/very good oral health indicates that the odds of having excellent/very good oral health are 2.4 times higher than the odds in the control group (those without dental insurance). This ratio indicates the direction of the association rather than conveying the size of the impact of dental insurance at the individual level [20, 21]. However, in the ME models, a ME of 0.2 indicates that if a participant has dental insurance, the probability for having excellent/very good oral health rises by 20% points, compared to those without dental insurance. A more detailed explanation of the marginal effects is given by Onukwugha [20, 21].

In this study, we used a multivariate probit regression model to quantify the ME with adjustment for the above‐mentioned covariates. We used the ordered/discrete ME model. Multiple imputation through Statistical Package for Social Sciences software (SPSS, Version 26.0, Armonk, NY) was used to create 10 complete datasets with 10 burn‐in iterations to account for the uncertainty associated with estimating missing data. Each complete dataset was analyzed separately using SAS® Software. Estimates derived for the 10 datasets were pooled according to Rubin's rules [27]. The distribution of missing data is presented in Appendix 2. The minimum percentage of missing data was 0.04% for the household income variable, whereas the maximum percentage of missing data was 7.54% for the last dental visit variable. There were no missing data in the age and sex variables (Appendix 2).

RESULTS

The analytic sample comprised a total of 10,030 subjects (Figure 1). More than half of the participants (56.7%) reported having excellent or very good oral health, while 72.7% reported never avoiding eating foods due to oral problems. In terms of dental visits frequency, 67.9% reported visiting a dentist within the past year, whereas 22.0% reported visiting the dentist only for emergency care. More than half (57.5%) of the participants reported having no dental insurance. The overall sample characteristics are presented in Table 1. Sample characteristics are also presented for individuals with or without dental insurance separately in Table 1.

FIGURE 1.

Flow chart of the analytic sample. [Color figure can be viewed at wileyonlinelibrary.com]

TABLE 1.

Baseline characteristics of elderly Ontarians in the 2017/18 Canadian Community Health Survey (CCHS) Annual component.

Variables	Total		With dental insurance		Without dental insurance
	N = 10,030 a		N = 4, 266 (42.5%)		N = 5764 (57.5%)
	Frequency b (N)	Percentage (%)	Frequency b (N)	Percentage (%)	Frequency b (N)	Percentage (%)
Age
65–69	3462	34.5	1683	39.5	1779	30.9
Years 70–74	2609	26.0	1058	24.8	1551	27.0
Years 75–79	1721	17.2	693	16.2	1028	17.8
Years 80 and older	2238	22.3	832	19.5	1406	24.3
Sex
Male	4587	45.7	2049	48.0	2538	44.0
Female	5443	54.3	2217	52.0	3226	56.0
Marital status
Married	6170	61.5	2783	65.2	3387	58.7
Common law	377	3.7	193	4.5	184	3.2
Widowed/divorced/separated	2968	29.6	1082	25.3	1886	32.7
Single	516	5.1	208	5.0	308	5.4
Household income quintile
<$20,000	520	5.2	87	2.0	433	7.5
$20,000–39,000	1998	19.9	432	10.1	1566	27.2
$40,000–59,000	1982	19.7	782	18.3	1200	20.8
$60,000–79,000	1485	14.8	723	17.0	763	13.2
$80,000 or more	4045	40.3	2243	52.6	1802	31.3
Highest education level
<Secondary	2341	23.3	739	17.3	1602	27.8
Secondary graduate	2382	23.7	1045	24.5	1337	23.2
Post‐secondary graduate	5307	53.0	2482	58.2	2825	49.0
Self‐reported general health
Excellent/very good	4698	46.8	2164	50.7	2533	43.9
Good	3349	33.4	1398	32.8	1952	33.9
Fair/poor	1983	19.8	705	16.5	1279	22.2
Diabetes
Yes	1888	18.8	709	16.6	1179	20.5
No	8142	81.2	3557	83.4	4585	79.5
Self‐reported oral health
Excellent/very good	5691	56.7	2703	63.3	2989	51.8
Good	3132	31.2	1176	27.6	1955	34.0
Fair/poor	1207	12.1	387	9.1	820	14.2
Frequency avoid eating
Often	384	3.8	107	2.5	276	4.8
Sometimes	926	9.2	306	7.2	619	10.7
Rarely	1434	14.3	643	15.1	791	13.7
Never	7287	72.7	3211	75.2	4077	70.7
Last dental visit
≤1 year	6810	67.9	3322	77.9	3488	60.5
>1 year	3221	32.1	945	22.1	2276	39.5
Dental visits only for emergencies
Yes	2210	22.0	537	12.6	1673	29.0
No	7820	78.0	3730	87.4	4090	71.0

^a The frequencies in some variables do not add up to the total number of participants. The reason is that sampling weight was used and then divided by 10 (i.e., 10 iterations to get the average estimates). This led to fractions that were rounded to the nearest integer, which led to ±1 individual in some variables.

^b Represent the weighted column frequencies.

Dental insurance was positively associated with regular dental visits within the past year and negatively associated with dental visits only for emergencies

Appendix 3 provides detailed results from the multivariate ordered probit regression models across the entire study sample, including 95% confidence intervals and p‐values. Participants with dental insurance were 11.3% points (ME: 11.3, 95% CI: 9.8–12.8; Figure 2) more likely to report visiting the dentist within the past year, compared to those without dental insurance. Moreover, presence of dental insurance significantly decreased the likelihood of dental visits only for emergencies, where participants with dental insurance were 11.2% points (ME: 11.2, 95% CI: −12.5 to −9.9; Figure 2) less likely to report visiting the dentist only for emergencies, compared to those without dental insurance.

FIGURE 2.

Marginal effects of dental insurance on dental care utilization. Data is shown for the income subgroups (i.e., low, middle, and high income) and for the study population. Across all income subgroups, participants with dental insurance were more likely to report visiting the dentist in the past year, compared to those without dental insurance (ME: 11.3, 95% CI: 9.8, 12.8). The highest ME was observed for participants in the middle income quintile (ME: 13.1, 95% CI: 10.5, 15.7), compared to the low and high income quintiles (ME low: 5.3, 95% CI: 2.5, 8.1; ME high: 10.9, 95% CI: 8.8, 13.0). Across all income subgroups, participants with dental insurance were less likely to report visiting the dentist only for emergencies, compared to those without dental insurance (ME: −11.2, 95% CI: −12.5, −9.9). Similarly, the highest ME was observed for participants in the middle income quintile (ME: −14.4, 95% CI: −16.0, −12.8), followed by the low income quintile (ME low: −11.9, 95% CI: −16.0, −7.8). The lowest ME was observed for participants in the high income quintile (ME high: −5.8, 95% CI: −7.6, −4.0). Marginal effect estimates for ordered probit model are adjusted for age, sex, marital status, dental insurance, household income, education, self‐perceived general health, and having diabetes (Type 1 or 2). [Color figure can be viewed at wileyonlinelibrary.com]

Dental insurance was positively associated with reporting excellent or very good oral health status and positively associated with never avoiding foods due to oral problems

Participants with dental insurance were 6.9% points (ME: 6.9, 95% CI: 5.4–8.3; Figure 3) more likely to report excellent or very good oral health status, compared to those without dental insurance. Moreover, participants with dental insurance were 3.5% points (ME: 3.5, 95% CI: 1.9–5.1; Appendix 3) more likely to report never avoiding foods due to oral problems, compared to those without dental insurance.

FIGURE 3.

Marginal effects of dental insurance on self‐reported oral health. Data is shown for the income subgroups (i.e., low, middle, and high income) and for the study population. Across all income subgroups, participants with dental insurance were more likely to report very good or excellent self‐reported oral health, compared to those without dental insurance (ME: 6.9, 95% CI: 5.4, 8.3). However, there was no notable differences across income subgroups. Similarly, there was no significant variation across income subgroups with respect to avoiding eating foods due to oral problems. Marginal effect estimates for ordered probit model are adjusted for age, sex, marital status, dental insurance, household income, education, self‐perceived general health, and having diabetes (Type 1 or 2). [Color figure can be viewed at wileyonlinelibrary.com]

Participants in the middle‐income quintile had the highest ME of dental insurance on dental visits within the past year and dental visits only for emergencies

Across all income subgroups, participants with dental insurance were more likely to report visiting the dentist in the past year, compared to those without dental insurance (ME low: 5.3, 95% CI: 2.5, 8.1; ME middle: 13.1, 95% CI: 10.5, 15.7; ME high: 10.9, 95% CI: 8.8, 13.0; Figure 2). The highest ME was observed for participants in the middle‐income quintile (ME: 13.1, 95% CI: 10.5, 15.7; Figure 2), compared to the low‐ and high‐income quintiles (ME low: 5.3, 95% CI: 2.5, 8.1; ME high: 10.9, 95% CI: 8.8, 13.0; Figure 2). Across all income subgroups, participants with dental insurance were less likely to report visiting the dentist only for emergencies, compared to those without dental insurance (ME low: −11.9, 95% CI: −16.0, −7.8; ME middle: −14.4, 95% CI: −16.0, −12.8; ME high: −5.8, 95% CI: −7.6, −4.0; Figure 2). Similarly, the highest ME was observed for participants in the middle‐income quintile (ME: −14.4, 95% CI: −16.0, −12.8; Figure 2), followed by the low‐income quintile. (ME low: −11.9, 95% CI: −16.0, −7.8; Figure 2). The lowest ME was observed for participants in the high‐income quintile (ME high: −5.8, 95% CI: −7.6, −4.0; Figure 2).

In terms of oral health status outcomes, across all income subgroups, participants with dental insurance were more likely to report very good or excellent self‐reported oral health, compared to those without dental insurance (ME low: 8.4, 95% CI: 5.9, 11.0; ME middle: 4.3, 95% CI: 2.0, 6.5; ME high: 8.7, 95% CI: 7.0, 10.5; Figure 3). However, there was no notable difference across income subgroups. Similarly, there was no significant variation across income subgroups with respect to avoiding eating foods due to oral problems (Appendix 4). Appendix 4 provides detailed results of the adjusted marginal effects of dental insurance on dental care utilization and oral health status outcomes across income subgroups, including 95% confidence intervals and p‐values.

DISCUSSION

This study showed that dental insurance was associated with better dental care utilization and oral health status outcomes among the elderly population in Ontario and across all income subgroups, after adjusting for covariates. However, the observed MEs were small to moderate in size, with no improvements exceeding 11% points in the entire sample. Middle‐income individuals had the largest ME for dental insurance on dental care utilization compared to low‐ and high‐income quintiles.

Our findings are in accordance with studies conducted in Canada [9, 28], the United States [29, 30, 31], and Australia [32]. A recent study by Zivkovic et al. [28] suggested that dental insurance was associated with improved dental visiting behaviors and oral health status outcomes among Ontarians aged 12 years and older, using data from the CCHS 2013 to 2014. Findings from this study [28] revealed that individuals aged >65 years who reported having dental insurance were 20.4% points (ME: 20.4, 95% CI: 18.8–22.1) more likely to visit the dentist in the past year and 9.5% points more likely to report very good or excellent oral health, compared to those without dental insurance [28]. In the United states, using data from the Health and Retirement Survey, it was estimated that if universal dental coverage is to be implemented, dental care utilization rates will increase from 75% to 80% among individuals aged 50 years and older [30]. In the study by Singhal et al. [31], using data from the 2014, 2016, and 2018 Behavioral Risk Factor Surveillance System, it was shown that Medicaid dental benefits for low‐income older adults were significantly associated with dental care utilization, with low‐income elderly with no Medicaid coverage being the least likely to visit the dentist in the past year (RR = 0.83, 95% CI = 0.74–0.94). Moreover, results from the 2004 to 2006 Australian National Survey of Adult Oral Health showed that uninsured individuals suffered from worse oral health than their insured counterparts and that having dental insurance increased the rate of dental visits by 43% points [32].

The findings of this study have important equity implications for dental care and oral health among elderly Ontarians. While dental insurance was associated with improved dental care utilization and reduced emergency‐only visits across all income subgroups, the variation in the MEs indicates that the impact of insurance is not uniform. Notably, this study showed that middle‐income older adults experienced the greatest benefits from having dental insurance, compared to low‐ and high‐income groups, suggesting that middle‐income individuals may face unique barriers to accessing dental care without dental insurance. This finding sheds light on the issue of access to dental care among middle‐income elderly Canadians and suggests that affordability issues in accessing dental care are no longer restricted to low‐income individuals. A secondary data analysis of six Canadian surveys [33] showed that middle‐income Canadians had the lowest dental insurance coverage at 48.7% compared to other income groups. Additionally, they experienced the greatest increase in cost barriers to dental care (rising from 12.6% in 1996 to 34.1% in 2009) and had the largest increase in out‐of‐pocket dental care expenditures [33]. This can be attributed to the fact that there has been a decrease in both the quality and availability of employment‐based dental insurance [34]. Furthermore, governments have historically overlooked middle‐income individuals as being at risk, hence public dental care programs were limited to low‐income groups. Therefore, our results imply that addressing inequities requires a more comprehensive approach that considers the diverse needs across the income spectrum.

The WHO Global Oral Health Programme highlights that oral health for the elderly population and addressing their dental needs is a priority area that requires immediate action [35]. Given the significant correlation between oral health and systemic health [35], implementing a publicly funded dental care program can help improve the general health and quality of life of the elderly population. Alberta, which offers a dental care program targeted towards seniors, was shown to be the province with the highest dental care utilization rates among seniors with poor oral health [10]. Therefore, with the recent implementation of the new publicly‐funded Ontario Seniors Dental Care Program for low‐income seniors [17] and the recent announcement by the federal government to provide a universal and publicly‐administered dental care program (i.e., Canadian Dental Care Plan) to include more low‐ and middle‐income Canadian seniors (those with annual net income of less than $90,000, rather than the annual net income cut‐off of $37,100 or less for the Ontario Seniors Dental Care Program), these programs can alleviate the financial barriers to dental care for those disadvantaged groups. However, the dentist‐to‐population ratio is approximately 1230 residents per dentist in Ontario, which is lower than the national average of 1530 Canadians per dentist [36]. This ratio indicates a relatively high supply particularly in urban areas. On the other hand, the availability of dentists in rural areas remains a challenge which can hinder access to dental care even if dental services are provided free of charge for eligible individuals under the new program.

This study has some limitations that are noteworthy. First, given the cross‐sectional nature of this survey, the causal association between dental insurance coverage and the outcomes of interest cannot be inferred. Moreover, the main issue is that we do not know the time with dental insurance coverage and time without coverage. Therefore, it is unknown if the estimated marginal effects represent short‐term, mid‐term, or long‐term impact, which makes these average marginal effects estimates not specifically relevant to a specific timeframe. Therefore, future studies need to focus on measuring the associations between the length of insurance coverage and oral health, particularly the short‐term outcomes (such as dental visits only for emergencies) which often is the primary interest of public health policies. Second, the data collected in the CCHS‐Annual component is self‐reported which increases the risk of recall bias due to the subjectivity of the participants' responses. Further, given that the CCHS includes only subjective measures that are self‐reported by participants, there are no objectives measures of dental status (e.g., DMFT scores) which may limit the reliability and accuracy of the findings. Another source of bias that should be highlighted, given the cross‐sectional nature of the data and lack of randomization, is selection bias. As indicated in Table 1, there are differences in sociodemographic factors between those with and without dental insurance. To address this source of bias, the sociodemographic factors such as income and education were controlled for in our adjusted analysis. Lastly, due to the exclusion of residents of certain remote regions and institutions, the results of the study cannot be generalized to these subgroups. However, having acknowledged those limitations, the study also has some strengths. To our knowledge, this is the first provincially representative study to investigate the association of dental insurance coverage with both dental care utilization and oral health‐related outcomes among elderly Ontarians using the most recent cycle of the CCHS. A major strength of this study is the utilization of the 2017/18 CCHS cycle. This timing is particularly advantageous as it falls just before the implementation of the Ontario Seniors Dental Care Program, a significant initiative by the provincial government aimed at improving dental care for low‐income seniors. By using this data, the study lays a solid foundation for future evaluations of the program's effectiveness. Subsequent CCHS cycles that reflect the implementation of the program can be analyzed and compared with the variables presented in the study. This comparative analysis will be instrumental in assessing whether the program is achieving its desired outcomes and can contribute to evidence‐based policymaking and program improvement. Although this study is restricted to Ontarians, findings from this study can act as a ground plan for other Canadian jurisdictions when implementing and evaluating dental care programs to address the unmet oral health needs of this underserved population.

CONCLUSION

Dental insurance can improve the utilization of dental care and can help mitigate the negative effects of poor oral health in elderly populations.

POLICY IMPLICATIONS

The findings of this study hold key policy implications for both public and private insurance sectors. Given the impact of poor oral health on general health outcomes among older adults, health policies aimed at enhancing dental care for this demographic can alleviate the overall disease burden. These insights can guide health policymakers and stakeholders in Ontario in implementing and evaluating public health initiatives targeted towards the elderly, thereby addressing their oral health needs, and enhancing their quality of life. Furthermore, advocating for the inclusion of middle‐income groups in eligibility criteria for public dental care programs, such as extending coverage to those with an annual net income of less than $90,000 in the Canadian Dental Care Plan, and/or implementing workplace policies to provide employment‐based dental insurance plans for middle‐income earners, can mitigate affordability issues in accessing dental care among these vulnerable groups.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Supplementary Appendix S1. Description of all variables included in the analysis.

Appendix 2. The distribution of missing data in the study variables.

Appendix 3. Ordered probit model marginal effects of dental insurance.

Appendix 4. Marginal effects of dental insurance on dental care utilization and oral health status outcomes across income subgroups.

Badewy R, Aldossri M. Exploring the association between dental insurance coverage and dental care utilization and oral health among elderly Ontarians. J Public Health Dent. 2025;85(1):92–101. 10.1111/jphd.12657