The politics of dental care in Canada

INTRODUCTION

The Politics of Dental Care in Canada is a powerful and informative book examining the complexity of Canada's dental care system, its history, challenges, ideological discord, and opportunities for improvement. Author Carlos Quiñonez is a professor and director of public health at the University of Toronto. He holds master's and doctoral degrees in community health, serves on the board of directors for the Canadian Association of Public Health Dentistry, and is a prolific researcher of social equity in dentistry. His breadth of knowledge, experience, and expertise make him an ideal authority to bring this incisive analysis of dental care in Canada together as part of Canadian Scholars Press' Politics of Health Series.

The book provides a brief introduction to the series followed by four chapters that cover the politics and history of dental care in Canada, related politics and policy and the challenges therein, and a robust discussion of potential solutions to move oral health care forward. Each chapter includes a summary of key messages and data organized into tables, boxes, and figures. The book also has bibliographic references and an informative index.

The Politics of Dental Care in Canada is the first book to chart a detailed map of the politics of Canadian dental care that not only indicates where we are and how we got here, but also where we must go and how we can get there. The breadth of this book makes it an excellent foundation of knowledge for aspiring oral health care leaders including dental hygienists, and a key resource for anyone concerned with oral health policy, politics, economics, education or health care in Canada.

Cover

CHAPTER OUTLINES

Chapter 1, “Introduction to the Politics of Dental Care,” describes what is meant by the politics of dental care, discussing who in society gets more in terms of oral disease (oral epidemiology) and access to oral care, and why. The author illustrates the complexities of dental care's organization, financing, and delivery, and links this structure to current resource allocation and the historical policy decisions of stakeholders, noting how oral health is shaped by social factors. Quiñonez explains how the dental political economy offers insight into the distribution of oral disease and the implications of this distribution for individual Canadians, their communities, and society. Furthermore, he highlights the “ideological trade-off” between individual and social responsibility in today's welfare state—a philosophical dichotomy that continues throughout the remaining chapters.

Chapter 2, “The History of Dental Care in Canada,” delves into the history of the dental care system, beginning with how the prevailing ideology and sociohistorical context have shaped professional identity from dentistry's inception. Quiñonez discusses the ideological trade-off between individual and social ideals at the root of tensions between public health dentistry and private practice. He examines dentistry's “golden age” during the 1950s when technological advances, growth of the middle class, and strategies to address human resource shortages were key issues. During this era increased use of dental assistants and the establishment of dental hygiene brought gains in productivity. Quiñonez discusses Medicare, the idea of universal dental coverage, and the evolution of oral care financing. Here again we see the impact of dentistry's deep-seated value of individual responsibility on policy decisions that have shaped today's largely privatized oral care system.

Chapter 3, “A Tale of Two Cities and Loose Ends,” explores the public-private polarity in oral health care, highlighting Canada's over-reliance on private spending at the expense of significant public investments in oral health. The chapter also reviews the inequity in Canada's public programs, the distribution of oral disease, access to dental care, and the appropriate use of resources. Quiñonez covers the size and effect of inequalities in oral disease and access to care among different groups, ranging from those with lower incomes and the working poor, seniors, and those with disabilities to the homeless and Indigenous populations. The intersectionality of such groups is examined. Quiñonez identifies costs to individuals, the health care system, and society that could be reduced through prevention and improved access to care.

A review of the oral-systemic link highlights the need for research that moves beyond associative to causal relationships. Potential opportunities to reduce health care costs through programs and policies that improve the oral and overall health of Canadians are also identified. However, the oral health care landscape lacks the collaborative structure and organization to achieve this goal. The remainder of the chapter explores the challenges of addressing oral health inequalities and lack of access to oral health care. This discussion is lengthy, covering underlying tensions, ideology, preferences, and other factors that have led to the current climate where dentistry is largely viewed as a business and services tend towards societal preferences for aesthetics. The final section of this chapter reveals the dental profession's role in erecting barriers that hinder Canada's ability to resolve oral health inequities. It also discusses how, in neglecting to prioritize the public's needs, dentistry has eroded public trust, ultimately jeopardizing the social contract.

Chapter 4, “Potential Solutions,” proposes comprehensive and, at times, radical solutions to the challenges faced by dentistry in Canada. These multilevel solutions are evidence based and developed with three conceptual frameworks in mind. These frameworks focus on levels of prevention, high-risk and population-based approaches to care, and the social determinants of health. Their usefulness extends to a range of stakeholders within dentistry, health care, government, and the public. This chapter discusses expanding dentistry's focus beyond interventions at clinical and community levels to upstream approaches, such as income supports and universal access to quality education; tobacco cessation and medical-dental integration; the potential of universal coverage; and quality and value in oral health care including incentivizing improved oral health outcomes. Modernizing the culture of dentistry to serve the public good is paramount. Quiñonez argues that strong leadership applying ethical decision making and working with all stakeholders to reconcile oral health inequities will advance the oral health professions and repair the social contract.

ANALYSIS

This book is a vital and timely contribution to Canadian oral health literature. It comes at a time when the World Health Organization is calling for action to improve equity and access, integrate oral health care with primary health care services, incorporate oral health into universal health care coverage, and address determinants that contribute to oral disease. ¹ Quiñonez paints a detailed and well-organized picture of the complexities of dentistry's political climate in Canada and ways the oral health care system can reorient to meet the needs of Canadians. For dental hygienists, this fascinating book stimulates critical thinking and provides opportunities to consider their place within the health care system.

This book will prompt many questions in the minds of readers. For instance, what is the significance of the underlying ideological tension between individual and social responsibility within the dental profession? What should we make of the tendency to see dentistry as a business venture rather than a health care profession? How might the industry change if the focus shifted from fee-for-service to fee-for-outcome? Would burnout decrease? How do scope of practice limitations affect the political economy of dentistry? How can dental hygienists shape their working environment to incorporate Quiñonez's solutions? What educational opportunities will promote the necessary skills to ensure that oral health care is evidence based, including those related to program evaluation and outcome effectiveness? Are there new opportunities for lobbying and advocacy? Could more be said to fully represent the context of dental hygiene care?

Despite dental hygienists' important role in oral health care in Canada and their efforts to reduce barriers and improve equity, they are largely left out of the discussion in this text. Quiñonez mentions the number of dental hygienists in Canada, briefly reviews their governing legislation and options for independent practice from the perspective of dentists, and touches on the professionalization of dental hygiene care. He references the work of sociologist Dr. Tracey Adams, who provides a more fulsome representation of dental hygiene's history and sociopolitics. ^{2, 3} Unfortunately, Quiñonez misses the opportunity to acknowledge the efforts and potential of the dental hygiene profession to address the very issues discussed in the book. This oversight only perpetuates the problem that Quiñonez seeks to address. Although the author explores the impact of the ideology, values, and bias underpinning oral health care policy in Canada, there is no discussion of the longstanding patriarchal ideology faced by the “caring professions.” ⁴ This power dynamic continues to influence dental hygiene and dental care in Canada. To truly move oral health care forward we must understand our present in the context of our past. Nonetheless, dental hygienists can use this robust analysis to identify opportunities for professional advancement and become catalysts for change at this important time in Canadian oral health history.

CONCLUSION

The Politics of Dental Care in Canada is an invaluable resource for oral health care professionals with an interest in understanding and advancing the politics of dental care in this country. This text encourages dental hygienists to question the narrative and dig deeper. It stimulates thought and provides exciting opportunities for dental hygiene to lead Canadian oral health care into the future. Understanding the sociopolitical context of our profession and dental care overall allows us to see a clear path forward to meet the future oral health needs of every Canadian.

Reviewed by Kyla Oshanek, BDSc(DH), DHP(C). Oshanek is a registered dental hygienist in Victoria, British Columbia, Canada. She is completing a Master of Clinical Science (Applied Health Sciences) at Western University, London, Ontario, Canada.