Policy Options to Complement the New Canadian Dental Program Enabling High Quality Care for People With Disabilities and Older Adults

ABSTRACT

Background

The newly announced Canadian Dental Care Plan (CDCP) particularly aims to reduce financial barriers to dental care for individuals living below a family income threshold. The Canadian government has also launched an “Oral Health Access Fund” to support projects aiming to address financial barriers to dental care for older adults, those with disabilities and other groups. Evidence from programs implemented elsewhere in the world could inform policy decisions and address such non‐financial barriers for older Canadians and those with disabilities.

Aim

To identify dental programs and policies in OECD countries focusing on people with disabilities and older people, and to outline how they might be applied to the Canadian context.

Methods

The strategy for this narrative literature review comprised a combination of Medical Subject Headings (MeSh) or their equivalent, title/abstract keywords, truncations, and Boolean operators. Medline (Ovid), Embase (Ovid), CINAHL and Scopus were used. The searches were limited to English language publications involving programs and policies in all OECD countries. All searches ran from inception to January 25, 2023, with no restrictions on publication time.

Results

The search identified 129 articles eligible for review. Findings were categorized as (1) interventions at the institutional‐level (subdivided into patient‐, professional‐ and community‐focused programs) and (2) interventions at the governmental‐level (subdivided into universal, population‐specific, and community‐based programs). Evidence suggests that targeted, integrated coaching or education programs for oral health care are beneficial, especially when programs are constantly evaluated and improved. Programs with a unified network system that integrates various relevant organizational and health domains have demonstrated to be most effective in the improvement of oral health care and overall health. Dental and medical healthcare workers play a crucial role in improving oral health outcomes and need motivation and fair compensation when caring for older people.

Conclusions

There is limited quality evidence supporting approaches to improving oral health care and oral health for older people and those with disabilities. It is important for policymakers and stakeholders to consider programmes from other countries when expanding the CDCP.

1. Introduction

The Canadian healthcare system operates as a publicly‐funded system with virtually total exclusion of dental care. Since the establishment of the Canada Health Act in 1985, the exceptions are some “surgical dental services” in hospital settings, and an ad hoc collection of public dental services within in the provinces and territories [1, 2]. For example, Quebec's provincial government covers some dental services for children until their 10th birthday [3]. In practice, apart from the federal program for Canada's indigenous peoples, most routine dental care is not covered by public insurance.

In 2018, 6.8 million Canadians avoided going to the dentist because of cost, and many opted to seek treatment in hospital emergency departments (EDs) to meet their oral health care needs. This places additional stress on Canadian hospital systems and is estimated to cost CAN $1.8 billion annually [4, 5, 6]. The high financial cost of dental care has long been highlighted as a major barrier to Canadians accessing dental care [7, 8, 9]. Approximately one‐third of Canadians pay out of pocket, a small proportion (6%) depend on public insurance, and the rest rely on private employment‐based insurance that offers partial coverage [10]. Among groups at particular risk of having no insurance are retirees, who face both income reduction and loss of insurance upon retirement, with the result that many stop their dental visits [11, 12]. To date, governments in some Provinces and Territories have provided individuals who meet specific eligibility criteria with more public dental insurance coverage, for example, Prince Edward Island Provincial Dental Care Program [13, 14]. Collectively, these issues have resulted in a patchwork of coverage across Canada that fails to fill the gaps in the largely privatized dental care system.

The newly announced Canadian Dental Care Program (CDCP) aims to address eligible Canadians' financial barriers to accessing oral health care [15]. The CDCP will provide dental coverage for families with an income under CAN $90,000. It was formally launched in December 2023, initially focusing on older people, then in the summer of 2024, children and adolescents under 18 years old were admitted; by 2025 all eligible people in Canada fulfilling the annual income threshold will be included [16, 17, 18]. Approximately one in four Canadians is thought to be eligible for the complete program [15, 19]. The CDCP also includes the Oral Health Access Fund, which aims to address oral health gaps among vulnerable populations and reduce additional, non‐financial barriers to accessing dental care [15].

Older adults and those living with disabilities experience a high prevalence of dental caries, periodontal disease, tooth loss, and impaired oral function and quality‐of‐life due to oral disease [20, 21, 22, 23]. In addition, these groups experience a high prevalence of comorbidities, such as coronary artery disease, diabetes, arthritis, and polypharmacy [20, 21, 22]. Patients on long‐term medications, such as antihypertensive drugs, frequently report having xerostomia, which significantly increases their risk of dental caries and mucosal infections [20, 24]. People with substantial tooth loss, dentures, or dental pathologies may also limit their intake of nutritious whole foods [24, 25]. This combination of chewing difficulties and dietary limitations can exacerbate nutritional deficiencies, which are often observed among older people and disabled people in residential care [24, 26, 27, 28, 29, 30, 31]. Further, they are also at high risk of having poor oral hygiene and consequently aspiration pneumonia [32]. Notably, the prevalence of stigma between healthcare workers and patients can further hinder the care of patients [33, 34]. Further barriers for older people accessing dental care include physical (i.e., being able to physically access a dental office) and geographical barriers, and a lack of dental professionals willing or able to provide care for people with complex needs and medical histories [11, 33, 35, 36, 37].

As the proportion of older adults increases globally, and in Canada, it is crucial to develop preventive geriatric health services to encourage successful aging with minimal disease and disability [38, 39, 40, 41]. To facilitate the best public dental care policy options for Canadians, evidence gathered from programs tailored to older adults and those living with disabilities and used in other countries needs to be identified. This review aimed to identify and compare oral health‐related policies, interventions, and strategies from OECD (Organisation for Economic Co‐operation and Development) countries to inform and guide Canadian policymakers and stakeholders.

2. Methods

This narrative review followed the methodological frameworks outlined by Arksey and O'Malley [42]. The reporting of our review was guided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and Extension for Scoping Reviews (PRISMA‐ScR) [43, 44]. In collaboration with a medical librarian, our research question was first established, followed by a systematic scoping search of the literature to identify relevant articles. The inclusion criteria were: (1) elderly/seniors/older adults including disabilities, (2) program/intervention OR suggestions/recommendations, (3) relevant to dental care OR oral health care, (4) in the English language, (5) were retrievable. Countries included in this review were: Australia, Brazil, Belgium, Canada, Denmark, France, Germany, Ireland, Israel, Jerusalem, Japan, Korea, Norway, New Zealand, Portugal, Sweden, Turkey, United States, United Kingdom. The methodological steps of the review comprised:

2.1. Step 1: Establishing the Research Question

What programmes, policies, and other interventions exist to provide dental care for people living with disabilities and older adults?

2.2. Step 2: Identifying Relevant Studies

The population of focus are older adults and older adults living with disabilities. Older adults are defined as older than 65 years of age. A disability is defined as one that affects an individual's “Activities of Daily Living” (ADL) and can be of the body or mind such as intellectual disabilities and/or health conditions like diabetes [45, 46, 47].

In collaboration with a medical research librarian, a search strategy was developed which included controlled vocabulary Medical Subject Headings (MeSH), keywords, and Boolean operators to combine the concepts of public health dentistry, health policy, elderly persons, geriatric dentistry, special care dentistry, and people living with a disability. We searched Ovid Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature); searches were run on February 13, 2023. English language articles only were searched, but no restrictions were placed on publication year. The articles were transferred to Endnote and subsequently evaluated manually for eligibility. The grey literature search was conducted using Trip Database (https://www.tripdatabase.com/Home), government websites, and websites of non‐governmental organizations. Two of the authors (LD and PA) screened the titles and abstracts, then the whole paper, if necessary, to select studies for inclusion.

Articles were excluded if (1) they were not about elderly/seniors/older adults, including disabilities, (2) did not discuss a program or intervention, (3) not relevant to the topic, (4) not retrievable, and (5) not in the English language.

2.3. Step 3: Study Selection

Articles saved in Endnote were filtered by title, then by abstract. Articles were then reassessed for eligibility based on the aforementioned criteria and sought for retrieval. All articles filtered post‐title and abstract eligibility were read in full and manually assessed for eligibility based on the specific criteria (Figure 1).

FIGURE 1.

Study selection process. [Colour figure can be viewed at wileyonlinelibrary.com]

2.4. Step 4: Charting the Data

Data were extracted from the selected articles and entered into an Excel spreadsheet according to ‘Interventions/programs at the institutional level,’ ‘Interventions/programs at the government level’ and ‘Established Programs’. The following definitions for each category were developed iteratively among the research team. Figure 2 outlines the method used to initially categorize the articles into institutional intervention, governmental intervention, and established programs.

FIGURE 2.

Charting data schematic. [Colour figure can be viewed at wileyonlinelibrary.com]

Interventions at the institutional‐level were defined as those programs that take place in nursing/long‐term care facilities (LTCFs), clinics, hospitals, psychiatric institutions, or other organizations, subdivided into the following categories: patient‐focused (programs that were patient‐centred), professional‐focused (programs and policies that focused on caregivers and dental healthcare workers in LTCFs) and community‐focused (programs that focused on a specific community or group of individuals) (Figure 3).

FIGURE 3.

Overview of interventions at the institutional level. [Colour figure can be viewed at wileyonlinelibrary.com]

Interventions at the governmental‐level were defined as local/municipal, regional, or federal/central government programs and/or policies, subdivided into the following categories: Universal interventions (programs that were aimed at the entire population), Population‐specific interventions (programs that focused on two or more population groups), community‐based interventions (programs that focused on a single group of individuals) (Figure 4).

FIGURE 4.

Overview of interventions at the governmental level. [Colour figure can be viewed at wileyonlinelibrary.com]

Established programs were defined as an initiative or system that had been formally developed and implemented either at an institution or organization or by the government.

2.5. Step 5: Collating, Summarising and Reporting the Results

Collaboratively among the research team, the data were discussed, interpreted and synthesized to provide a summary of the relevant interventions and their application to the Canadian context [48, 49].

3. Results

Results were grouped according to the level of intervention (institutional‐level and governmental‐level) associated (which were subcategorized), and established programs. Institution‐level interventions were subcategorized according to intervention type: patient‐, professional‐ or community‐focused (Figure 3). Governmental‐level interventions were subcategorized according to intervention type: universal, population‐specific, or community‐based (Figure 4). In total, 129 articles from 19 countries were included in the results, and they are summarized below; Tables S1–S4 provide further detail.

3.1. Institution‐Level Interventions

3.1.1. Patient‐Focused Interventions

Seven studies had interventions that focused on patient health education (HE), health coaching (HC), motivational interviewing (MI) or a combination thereof. Health education is defined as the process where health professionals impart information to improve patients' health [50]. Health coaching is a behavioural approach to improve lifestyle through thought‐process transformation and action plan setting to manage health [51, 52, 53, 54].

Three studies compared and evaluated HC versus HE programs to better manage oral health and diabetes for older patients diagnosed with type‐2‐diabetes (T2D) and found that HC was more effective in addressing oral health concerns [52, 53, 54]. Informed by these studies a clinician's guide was developed, “One for All” [55]. In a study with patients living with multimorbidity, individual patients were able to set goals, have group discussions and raise awareness with the facility of their concerns about addressing their dental care needs [56].

In nineteen psychiatric hospitals, Yoshii et al. [57] conducted a study that demonstrated the effectiveness of an education and self‐care program to improve the oral health of persons with disabilities.

An alternative methodology used in two studies to improve oral health among older adults was motivational interviewing, a technique developed to promote behaviour change through cognitive behavioural principles [58]. Two studies implemented this strategy and demonstrated that participants had an overall improvement in oral health‐related knowledge and oral health‐related quality‐of‐life (OHRQoL). Further, it had significantly better long‐term outcomes than HE [59, 60].

3.1.2. Professional‐Focused Interventions

Nine studies described providing educational programmes aimed to enhance oral health care provided by nursing staff, personal care assistants (PCAs) and personal support workers in LTCFs. Two studies examined different programmes such as health coaching and oral health promotion.

US federal regulations, such as the Omnibus Budget Reconciliation Act (1987), ensure quality care and dental services for residents in Medicare/Medicaid funded LTCFs [61]. In a case‐based interactive training program, Kaiser et al. [62] found significant improvements in nurses' total oral health‐related knowledge and ability in detecting residents' oral health‐related conditions.

In three studies, nursing staff participated in an HE program led by dental hygienists that focused on the “healthy oral cavity” [63, 64, 65]. Initially, the intervention implemented by Isaksson et al., indicated improvements in resident participants' oral mucosal status and mucosal index [64]. The improvements extended three‐years post‐intervention in LTCFs [66]. In Sweden, an oral HC program to improve oral health‐related beliefs of caregivers and the oral health of residents living with disabilities in LTCFs resulted in good oral health among residents plus changes in staff behaviours, which could be attributed to the program [67, 68].

Similar studies of hands‐on educational dental care programs on LTCF residents' oral hygiene showed improved plaque scores and denture cleanliness with significant improvements lasting six‐years [69, 70]. However, in one study, Simons et al. [71], found that oral health training programs for carers of older adults and those with disabilities had mixed results, with some improvement in carers' knowledge but no improvements in residents' oral health.

A health education program designed for PCAs aimed to improve their oral health awareness and attitudes towards dementia patients in LTCFs showed a link between PCAs' confidence in their own oral health and their ability to assess patients at risk for poor oral health [72]. Though a similar program for personal support workers showed mixed results in improving oral health knowledge [34].

In 2005, Chalmers et al. conducted a study to evaluate an Australian national oral health care promotion video and booklet for older adults in LTCFs in Australia. Findings concluded that the resources were useful for staff in identifying oral disease risks. Feedback from staff highlighted the need for specialized learning packages for behaviourally difficult and dementia residents [73]. In 2015, the Australian Dental Foundation was established to offer oral health care to Australians, helping 41,500 people. Through this not‐for‐profit foundation the Australia's Aged Care Dental Program emerged to provide comprehensive dental care in LTCFs via portable and tele‐dentistry, including an emergency dental hotline [74].

France's Santé Orale et Autonomie project to examine the feasibility of training dentists to provide standardized oral health promotion interventions in facilities for persons living with disabilities through an e‐learning program with a program implementation component. The program improved dentists' self‐efficacy in caring for this population group and led to oral health improvements in residents [75].

3.1.3. Community‐Focused Interventions

Eleven studies described providing a variety of community‐focused interventions to improve oral health within the older adult population.

One study implemented an oral function promotion program led by dental hygienists in senior centres for independent older adults. The program consisted of sessions covering oral anatomy, disease prevention, oral exercises, the role of the oral cavity in overall health, and dietary choices. Findings showed improved oral functioning, including improved salivary flow of independent older adults [76].

An oral health promotion program for older Greek and Italian migrants, based on the Oral Health Information Seminars/Sheets (ORHIS) model and delivered in their native language, improved oral health attitudes, knowledge, hygiene practices, self‐assessed health, and use of oral health services [77]. A culturally tailored version of ORHIS for independent‐living older migrants improved participants' gingival health and self‐efficacy. The findings demonstrated the benefits of culturally curated programs, with ongoing success, an e‐ORHIS program was developed [78]. Where the program was evaluated and improved based on participant feedback (available at: http://www.e‐dentalez.com/sitio/oral‐health‐promotion/). Through program utilization, participants demonstrated significant improvements in oral health‐related attitudes, knowledge, self‐efficacy, and self‐reported oral hygiene practices [79].

In Australia, Aboriginal Community Controlled Health Organisations (ACCHOs) addressed oral health disparities through programs that focused on dental caries prevention, education, and dental service provision and coordination. Programs combined nutrition and overall health education and were delivered in community settings by Aboriginal health workers and dental therapists. With a focus on advocacy, outreach, portable dentistry, and dental training, the programs were audited, and Poirier et al. concluded that ACCHOs play an integral role in oral health promotion and service delivery [80].

The Community Dental Services in Northern Ireland developed an oral disease prevention quality‐improvement project to improve the oral health of older adults living in LTCFs. The program used fluoride varnish to prevent oral disease in dentate older adults. Jabir et al. [36] found a significant decrease in carious teeth and highlighted the benefits of treatment‐based approaches.

A Swedish oral health promotion media campaign aimed to improve periodontal knowledge in older adults was implemented nationwide and evaluated through a questionnaire. Findings demonstrated improved knowledge post‐campaign, and individuals with secondary education showed the most significant improvements [81].

A culturally sensitive oral health education program, Take Charge of Your Oral Health, was developed through community partnerships and MAP‐IT guidelines to reduce oral health‐related disparities among African American older adults. Assessment tools helped identify and target knowledge gaps to readily improve the program. Findings suggest significant improvements in oral health‐related knowledge of the participants [82].

To address access disparities, many US dental schools have integrated community‐based dental education into their curricula, assigning students to clinics for marginalized communities. Specifically, the University of Minnesota integrated community program developed a three‐year profile of patients cared for to assess the community benefit and use of their provided services. This program served 43,128 patients, many of whom were paediatric patients, and findings suggested that older adults received the least care, despite services being offered in various community settings such as health centres, community and public health clinics, and mobile vans/buses [83].

In San Diego, California, a digital Comprehensive Geriatric Assessment tool was used in a patient‐centred quality‐improvement project led by a multidisciplinary team that aimed to improve oral health in low‐income seniors. The assessment tool captured client information, including psychological and oral health assessments. Initial screening identified acute cases for hospital referral, while non‐acute patients received need‐based services. Non‐acute dental referrals took part in an education course and screening, categorized as urgent or non‐urgent. Common services included preventative, periodontics, and prosthetics, with almost four in five patients completing treatments. Analyses showed dental urgency was linked to general health, symptoms, pain, or chewing difficulty, with symptoms tied to recent Emergency Department visits. Community‐based inter‐professional care with the assessment tool proved feasible and efficiently addressed the needs of a vulnerable population [84].

In the United States, Apple Tree Dental is an established program that provides services to eliminate access barriers and address the dental needs of the population, including affordable dental care plans based on income, preventative care, mobile dentistry, and more urban and rural clinics [85, 86]. The Pacific Center for Equity in Oral Health Care at Arthur Dugoni School of Dentistry, in San Francisco, California, improves oral health for individuals with special needs, including older adults, by offering on‐site dental services, tele‐dentistry, caregiver education, and a dental clinic, while continuously enhancing its curriculum and raising awareness of barriers to and solutions for ensuring good oral health [86, 87].

Globally, indigenous people typically have poorer oral health in all age groups than their non‐Indigenous peers [88, 89]. In New Zealand, to improve Māori oral health, the University of Otago's Faculty of Dentistry developed a community‐based intervention and strategic framework informed by Māori beliefs and values, exposing dental students to the Māori world and way of knowing. Such a university‐level intervention attempts to train dentists to provide culturally appropriate and culturally safe care and (in turn) contribute to reductions in oral health disparities [90].

In France, an oral health promotion programme in twenty‐seven special care establishments enabled caregivers and dentists to create individualized care plans for residents. Findings indicated reduced plaque among older adult participants with disabilities [91].

Since 2010, Belgium has implemented the Gerodent program, a preventive and curative geriatric OH care program implemented in forty nursing homes. The program includes Oral Health Care Guidelines for Older People in Long‐Term Care Institutions, provides preventive and curative oral care, training, and mobile clinic support [92]. From 2010 to 2014, an assessment of the program in twenty‐one LTCFs found a 31%–66% reduction in oral treatment needs, significantly reduced dental caries, residual roots, and extractions in residents with natural teeth. In addition, among residents with partial/full dentures at baseline, 38% needed a repair, rebasing, or renewal of their existing dentures and 9% at follow‐up [93].

3.2. Interventions at the Governmental Level

3.2.1. Universal Interventions

The Brazilian health system is comprised of both private and public systems, with private services complementing those provided publicly. The public health system covers the entire population for medical and dental services [94, 95]. Primary healthcare is organized through the Family Health Strategy, a large community‐based program that operates through multidisciplinary healthcare teams linked to the National Oral Health Policy [96, 97]. This policy focuses on providing oral health care across the country by increasing the number of dental care teams and expanding centres of specialized dentistry [96]. The treatments offered and covered are preventive, restorative/prosthetic, surgical, endodontic, and cancer monitoring [98].

The private‐public mixed system permits the use of private services through either out‐of‐pocket or private health plans [94, 95]. A recent Brazilian National Household Survey found that women were more likely to use public services than men, and as age increased, there was a decline in the use of all health services. In addition, individuals with private health plans were 49% more likely to use dental services through the plan than individuals without private health plans [94] and older adults utilized that private service more than those provided in the public system, with pain being the primary motivator [99].

The Japanese Universal Health Coverage system covers almost all medical and dental treatments [100]. It operates through a combination of government subsidies, affordable co‐payments, and employer insurance, where the burden of high costs is placed on the government and insurers. Treatment costs are very low and the same across the nation [101]. For all persons who are able to afford co‐payments, only 30% of the treatment cost will come from out‐of‐pocket, and the remainder will be paid through public or employer insurance [102].

The Japanese long‐term care insurance system by municipalities provides comprehensive medical and dental care for those 65 and older. The system covers 90% of costs, with full coverage for those unable to pay, care plans are managed by patients' care managers, and services are delegated to healthcare providers on‐site or community‐based [101, 103]. A study with community‐dwelling older adults that included physical exercise, nutrition and oral health instruction and incorporated a dental hygienist who taught oral exercises, education and toothbrushing techniques resulted in slight improvements in oral function and significant improvements in swallowing for adults aged 65–75 [104].

3.2.2. Population‐Specific Interventions

Portugal's National Health Service excludes dental care, and citizens pay out‐of‐pocket or through private insurance for their dental care. In response to growing health disparities, the National Programme for Oral Health Promotion introduced a dental voucher program for individuals more susceptible to oral diseases. The program targeted pregnant women, older adults on social assistance, children and adolescents (inclusive of special needs), patients with early‐stage oral cancer, and patients with HIV/AIDS. In this program, dentists are reimbursed at a much lower rate than in the private sector, presenting a barrier to providing care to vulnerable populations that require more assistance. Eligible older adults have low rates of voucher use [105].

In Scandinavian countries, all youth are offered free dental care by the Public Dental Services through a tax‐financed system run by local county councils and guided and supervised by government organizations [106, 107]. In Norway, the 1984 Dental Care Law expanded the Public Dental Service to include adults with mental disabilities, institutionalized elderly, and individuals requiring home care, providing them with free dental services. The National Board of Health in Oslo oversees the Public Dental Service and disseminates informational booklets on chairside and community‐based oral health promotion, disease prevention, dietary habits, oral hygiene, fluoride use and regular dental check‐ups [107].

Similarly, in 1994, the Danish Government enacted a law (Act on Dental Health Care) that expanded dental care to adults with physical or mental disabilities who were under the responsibility of local municipalities. Health authorities developed specific guidelines for people with disabilities to provide preventative care, oral examinations and essential treatments [108]. A 2010 study of oral health in older adults enrolled in the program found that 68% had natural teeth, 57% of them had decay, two‐thirds wore dentures, and that smoking impacted tooth count [109].

3.2.3. Community‐Based Interventions

An Australian program, Reach‐Oral Health Therapists [Reach‐OHT], comprised six elements, including geriatric health care and training through a collaborative health network for persons in long‐term care. Evaluation over a three‐year period found three‐quarters of residents receiving oral health assessments, almost half receiving on‐site dental care, and over half being referred to an external clinic. Long‐term analysis demonstrated sustained improvements in oral health care [110]. Further, the Australian Government provided the programs in long‐term care centres and caregivers with the Better Oral Health in Residential Care education and training program [110, 111]. In rural centres, a Reach‐OHT program was implemented with tele‐dentistry, and improvements in oral health were observable though on‐site care was essential because referral pathways rarely existed [112].

In Wales, the Gwên am Byth program was initiated to address poor oral health in older adults. The program used an electronic assessment tool and a quality‐improvement strategy of ‘plan, do, study, act’ cycles where staff identified risk factors/problems and relay information to dental teams in the facility.to create individualized care plans. By 2019, 5000 staff were trained and 5600 residents received care [113].

The National Health Services of Scotland, in collaboration with the National Older People's Oral Health Improvement Group, developed a new educational resource for oral health care training for staff in care homes called Caring for Smiles. The guide is designed to support and equip care staff with the knowledge to perform regular oral health assessments and develop individualized care plans for older adults to ensure that oral health and dental care needs are addressed [114, 115].

Israel's Ministry of Health created a dental program for psychiatric hospitals, offering regular exams and treatment. From 1997 to 2006, the program showed improvements in participant oral health, with on‐site services proving more effective [116]. In addition, Jerusalem's public dental program for underprivileged individuals offers restorative treatments and dentures. After 2 years, 80% of patients were satisfied, 92% used their full dentures, and 84% reported improved chewing [117].

In Norway, a nursing home study found that half of older adult residents had poor oral health and hygiene status despite the ongoing public plan, which led to an investigation of community‐based preventative oral health interventions [107, 118]. The study found that no assessment tools were routinely used, most interventions were framed through international and National Board of Health in Oslo guidelines, and in scenarios where no guidelines had been created, dental professionals would use “inherited knowledge” This signifies the need for assessment tools in the provision of oral health programs, to ensure proper allocation of resources and that optimal care is provided [107].

4. Discussion

With a rise in the aging population worldwide, many oral health and oral‐health‐care‐related challenges and opportunities will arise. This review has revealed that OECD countries have begun to explore improving healthcare delivery systems for their aging and disabled populations. Most countries discussed in this review operate some form of Universal Health Care system, although the involvement of oral health care in that “universal coverage” varies across countries [119, 120, 121]. While the Canadian Federal Government develops and implements the CDCP, it will be essential to consider what has already been done around the world and how those programs can be translated, improved, and adapted to the Canadian context to address the needs of older and disabled Canadians.

A substantial amount of evidence demonstrates that health coaching and health education programs aimed at patients and their professional and non‐professional carers have contributed to the improvement of patients' oral hygiene and oral health indicators, especially for non‐independent individuals such as those in nursing homes. That said, community‐targeted programs, facilities also appear to improve patients' oral hygiene and oral health indicators.

Government programs that offer access to free or affordable dental services, either within a facility or through mobile care, have also demonstrated improved oral health indicators for individuals with poor oral health and should be given due consideration when implementing support. For example, in the United Kingdom, the Dental Community Service provides eligible people free or affordable care, offering services such as restorations and dentures, delivered in a clinic or mobile unit [122, 123, 124, 125].

Programs demonstrating optimal outcomes appear to have a unified network system that integrates all sectors of health (e.g., medical, dental, mental health and social services) and provides comprehensive, coordinated, efficient, and person‐centred care. One example is the holistic California‐based senior centres intervention [84]. Further, community‐based, university‐integrated, and web‐based programs that collaborate with advocacy organizations or those that incorporate quality‐improvement methodologies enable continuous program development through feedback mechanisms. Beneficial outcomes observed from university interventions, such as those in New Zealand, can initiate and drive advancements in Canadian dental school curricula to incorporate geriatric dentistry and culturally/community‐sensitive programs [90].

Although professional and community‐level interventions have been shown to be the most successful, the evaluations of these programs typically focus on short‐term outcomes, overlooking longer‐term impacts. Ideally, an evaluation of disease and health in relevant patient groups should be conducted over a more extended period, such as 2 years.

The main target of programs found in this study was knowledge improvement, behaviour change, or a combination thereof—for example, the Australian e‐ORHIS program. However, considerations need to be placed on receiving patient and client‐based evaluations of programs as well as clinician and researcher‐based evaluations. Fewer studies had focused on clinical oral health outcomes (such as plaque scores or caries rates) and patient‐specific outcomes (such as pain or tooth loss). Community‐based programs like the ACCHO program that incorporate various indicators of health (such as nutrition and oral health) are readily audited, and their evaluation framework can be emulated when expanding the CDCP [80].

Commonly observed concerns found in this review were the lack of oral health‐related knowledge among professional caregivers. Many programs sought to implement intensive educational and practical training programs to alleviate neglected oral health and oral health care in older adults. One factor was that these health professionals are consistently overburdened with excessive workloads. Across Canada, thousands of nurses are facing burn‐out, especially post‐pandemic [126, 127]. An alternative would be to have dental therapists, dental hygienists, and dentists provide oral health care for older adults and those with disabilities in long‐term care and other settings. In Canada, personal support workers are an essential caregiver group that is entrusted to carry out a majority of geriatric care, but unfortunately have received little to no oral health‐related training, and a recent Canadian health education intervention study also yielded ambiguous findings in their oral health knowledge [34, 128]. This further illustrates how involving practitioners trained in the field of oral health and dental care is imperative.

Nonetheless, dental professionals and caregivers need to be incentived and fairly compensated for their efforts to care for this demographic and aid in the maintenance of good long‐term oral health for their clients. For dental professionals specifically, the current fee‐for‐service payment model used needs re‐evaluation, as treatment for patients with complex needs requires more time; thus, fair compensation is imperative [11, 129].

Our findings also stressed the importance of policy implementation, in particular holding institutions and governments accountable [1, 34, 40, 62, 86, 91, 130, 131, 132, 133, 134, 135, 136, 137]. Recent discussions of a Canadian Long‐Term Health Act for Long‐Term Care Facilities are in progress to ensure institutions are bound by standard guidelines that ensure proper care. However, many Canadian LTCFs are privately owned for‐profit institutions that are unaccredited and do not undergo inspection. Remarkably, this preliminary Canadian act fails to include oral health care even though oral and general health are closely linked and are increasingly important in older adults [138]. This stresses the need for stakeholders and policymakers in various domains to work together rather than in silos. Consideration of upstream and downstream pathways that influence policy and program trajectories is essential for a strategic and coordinated care system that provides effective and reliable communication among sectors to ensure high‐quality care and health outcomes. For example, having continuous dialogue between governing bodies, community‐based/local NGOs, institutions, healthcare providers, dental professionals and patients.

Other well‐documented barriers to care should also be considered when developing and expanding the program. For example, certain governmental policies can be put in place to diminish the following barriers. Architectural design of dental clinics can be a physical barrier for patients with hearing, visual, and/or mobility impairments [33]. For instance, clinic doors may not be wide enough for wheelchair users to enter [35]. Geographical barriers such as transportation are difficult and costly. Lack of service availability in frequented facilities like community centres and hospitals, and within institutions, for example, nursing homes and rural communities [11, 35]. Operational barriers, like inappropriate or lack of assessment tools to evaluate patient needs, impede care, and staff are often ill‐equipped to treat patients with disabilities [36, 37]. An inadequately trained workforce, including dental professionals trained in mobile and domiciliary dental care, and non‐dental health care professionals working with vulnerable and underserved groups, is another barrier.

Along with the programs and elements to improve access to care, it is important to engage in regular health surveys of the population to provide accurate estimations of population needs for the expansion of the CDCP. Program audits and evaluations are essential to inform knowledge gaps, and to improve and develop more effective programs. In this sense it is interesting to see that the recent Canadian government announcement of the CDCP included mention that they will provide funding to “collect data on oral health and dental care access in Canada and help the government's ability to support those who need it most through the [CDCP]” [15].

4.1. Limitations

Although narrative reviews provide comprehensive coverage of literature, deepen our understanding, and provide interpretation of findings, there can be biases present. Due to their selective nature, narrative reviews are challenging to reproduce and critically appraise, even with thoughtful and transparent methodology [139].

5. Conclusions

Limited evidence suggests that programmes involving coaching or education to improve knowledge and behaviour change, and that a targeted, but integrated, approach to oral health care, including programme evaluations, is beneficial. Some evidence suggests that large‐scale governmental programs that include older adults and/or those in long‐term care centres, either on‐site or in community clinics, can mitigate access to care barriers. Dental and medical healthcare professionals working with older adults have an essential role in shifting and improving the oral health outcomes of these patients and, therefore, need to be motivated and fairly compensated for their efforts. In the case of CDCP and addressing barriers faced by older Canadians and those living with disabilities, this information can be used by policymakers and stakeholders to incorporate into new elements of the CDCP.

Author Contributions

The authors confirm contribution to the paper as follows: study conception and design: Logan D. Davari, Paul J. Allison, Martin Morris; data collection: Martin Morris, Logan D. Davari, Paul J. Allison; analysis and interpretation of results: Logan D. Davari, Paul J. Allison; draft manuscript preparation: Logan D. Davari, Paul J. Allison. All authors reviewed the results and approved the final version of the manuscript.

Ethics Statement

The work reported in this manuscript was a literature review, so no primary data were collected and no human or animal subjects were involved; therefore, no ethics approval was required. Furthermore, Logan D. Davari, Paul J. Allison, and Martin Morris consciously assure that for the manuscript/Policy options to complement the new national dental programme enabling high‐quality care for people with disabilities and older adults/the following is fulfilled: (1) This material is the authors' own original work, which has not been previously published elsewhere. (2) The paper is not currently being considered for publication elsewhere. (3) The paper reflects the authors' own research and analysis in a truthful and complete manner. (4) The paper properly credits the meaningful contributions of co‐authors. (5) All sources used are properly disclosed throughout the manuscript, and a full reference list is available. Any copying of text is indicated by using quotation marks and is cited. (6) All authors have been personally and actively involved in the substantial work leading to the paper and take public responsibility for its content.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.

Table S1.

Table S2.

Table S3.

Table S4.

Data Availability Statement

The authors have nothing to report.