Oral Health Group
Feature

Noteworthy Trends in a Successful Governmental Dental Program in Alberta

January 1, 2013
by Dennis H. Bedard, BSc, DDS, Dip. Paedo, FRCD(C); Maryam S. Amin, DMD, MSc, PhD


The Alberta Child Health Benefit (ACHB) is a program administered by Alberta Human Services, formerly Alberta Human Resources and Employment. It was launched in response to the need for a health benefit program in low-income families identified by Albertans before the National Child Benefit (NCB) program was introduced.1,2 The ACHB is Alberta’s key provincial reinvestment under the NCB, a joint initiative of the federal, provincial and territorial governments to assist low income families with children. Before the NCB program in 1998, there was minimal coordination between the Federal system and the Provinces. The Government of Canada instituted this increased funding in 1998 but the Provinces determined how they would access the money and develop their own program. Approximately 40% of the funds of the NCB related to the Supplementary Health Benefits can be attributed to the ACHB which was the largest program of this type in the country for the year 2006-2007. When instituted in 1998, the health plan was targeted to families with a net income of $20,921/year. This ceiling has been raised to $24,397/year for single parent with one child and up to $44,000/year for a couple with four children. The program offers coverage for children’s dental, optical, drugs prescription and emergency ambulance service. There are no premiums or fees to join the plan, families can be enrolled at no cost. This report is based on the dental benefits provided by the ACHB program from 2007 to 2011.

FINDINGS
In 2007, $17.4 million was spent on dental services for 47,332 patients while in 2010/11 the money spent was $20.5 million for 46,385 patients (Table 1). The number of patients seen each year has relatively remained the same for the four reported years, peaking to 50,253 in 2008/09. There was an increase of 17.9% in funding for a decrease of 2% in the number of patients seen. The delivered treatments were divided into nine categories presented in Table 1. While expenditures of eight categories show a slight increase, spending on orthodontic treatments has dramatically increased over the four years, rising from $44,022 in 2007/08 to $440,624 in 2010/11, an increase of 900%. A significant decrease was found in amalgam use for both primary and permanent teeth (Table 2). For primary teeth, the decrease was 22% with an increase of 24% in the use of acid etch bonded composite filling. For permanent teeth, the decrease of amalgam use was 15% with an increase of 21% composite filling. In total, 3,055 three or more surface composites were reported on posterior primary teeth (Table 3). The number of general anesthetics performed each year increased from 1,299 patients in 2007/08 to 1,847 patients in 2010/2011 although in the last three years, the dollar increase or decrease was minimal (Table 1).

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DISCUSSION
As mentioned above, the increase in expenditures from 2008 to 2011 was 17.9% with a decrease in the total number of patients in this time period. One of the explanations would be the increased use of composite restorative materials which tend to be more expensive than the traditional amalgam restoration. Our figures similarly show an increase of 16.9% in restorative expenses in this time period. The other categories also show smaller increases with the exception of the 900% increase for orthodontics.

Dental amalgam is neither tooth-colored nor adhesive to remaining tooth tissues, its use has been decreasing in recent years and the alternative tooth-colored filling materials have become increasingly more popular.3 Although the American Dental Association Council on Scientific Affairs concluded that both amalgam and resin-based compomer/composite materials are safe and effective for tooth restoration, there is still a continuing controversy regarding which material is more durable.4-6 Soncini, et al, found that resin-based compomer restorations had greater replacement rates than did amalgam restorations, but the difference was statistically significant only among replacements due to recurrent caries. They concluded that compomer/composite restorations in pediatric patients may require more procedures than do amalgam restorations to maintain their integrity.7 Similarly, DeRouen found that starting at five years after initial treatment, the need for additional restorative treatment was approximately 50% higher in the composite group than in the amalgam group.8

Another disappointing figure in our report is the large number of three or more surface composites on posterior primary teeth, which the authors felt would be better served by placing a stainless steel crown restoration as the American Academy of Pediatric Dentistry recommends: “Children with extensive decay, large lesions or multiple surface lesions in primary molars should be treated with stainless steel crowns.”9 Using stainless steel crowns could also realize a cost saving of $74,949 as demonstrated in Table 3. In addition, among the nine rendered treatment categories, utilization of orthodontic treatment had the biggest increase in the program. If we look at the services provided in the ACHB brochure, dental coverage includes dental exams, teeth cleaning, x-rays, fillings, and extractions. This would provide a basic dental coverage for patients. However, the highest increase was found for the orthodontic treatments over the reported four years, which [in our definition] is not classified as basic dental services. This increase should be cause for concern.

A previous report by Amin demonstrated that 93.1% of respondents to a survey conducted by the Alberta Human Services in 2009 agreed that the programs helped them or their children to obtain dental services that they would not otherwise be able to receive.10 However, only 54.8% of the respondents reported that their youngest child had received at least one dental service in the 12 months before the survey.11 In another study conducted by Fonseca,11 a number of barriers to access to oral health care were reported for low-income patients. It was also found that the emotional costs of dealing with barriers in the dental setting might outweigh the rewards of care resulting in reduced utilization.11 Therefore, identifying, acknowledging, and addressing barriers to available dental services for children of low-income families is imperative to improve an optimal usage of dental benefits for children offered by the governmental programs. Parental awareness of public funding for dental services, while necessary, did not seem to increase their care-seeking behavior or utilization of dental services for young children.10

The Alberta Government along with the Federal Government have developed a very good program to assist the working poor. This has eliminated many people from the Welfare rolls as they are able to keep working or begin working because they are being assisted with costly medical/dental bills. The program has been well-received by the dental profession as most dentists accept families covered by the ACHB plan even though the fee paid by the program is usually below the fee charged by the 5th percentile of Alberta Dentists (the 5th percentile refers to the fee level charged by bottom 5% of Alberta dentists for the various procedures).13 A better understanding of the challenges that low-income families face would warrant a greater usage of the available services for young children.OH

Acknowledgement
The authors would like to acknowledge the Alberta Human Services for sharing their data.


Dr. Maryam Sharifzadeh-Amin received her dental degree in Iran and her masters and PhD at the University of British Columbia. Post-Doctoral Fellowship in Health Education at UBC. Assistant Professor and Division Head of Pediatric Dentistry, Faculty of Medicine and Dentistry, University of Alberta. Involved most of her academic career with oral health needs of young children as an educator, researcher and practitioner. Mission of her program is to improve the oral health of children through
collaborations directed at prevention, education and advocacy. The vision is through collaboration and partnership all high-risk children of marginalized communities will receive the same oral health care as the general population.

Dr. Dennis H. Bedard is Associate Clinical Professor, Pediatric Dentistry, Faculty of Medicine and Dentistry, University of Alberta. Private Pediatric Dental practice in Edmonton from 1984 to 2006. Has taught Pediatric Dentistry since 2007 as a half-time position. Founder of Dentistry for All (www.dentistryforall.org) and has completed 31 dental missions to Nicaragua, Guatemala and the Philippines.

Oral Health welcomes this original article.

REFERENCES
1. Final Report, Survey of Recipients of the Alberta Child Health Benefit, Alberta Human Resources and Employment, Nichols Applied Management, June 2003

2. The National Child Benefit, Progress Report 2007, Report Available: www.nationalchildbenefit.ca

3. Future Use of Dental Materials, Report of Meeting Convened at WHO HQ, Geneva Switzerland, 16th to 17th, November,2009, pg5

4. ADA Council on Scientific Affairs, Direct and Indirect restorative materials. JADA 2003: 134(4), 463-72

5. Coppola MN, Ozcan YA, Bogacki R, Evaluation of performance of dental providers on posterior restorations: does experience matter. A data development analysis (DEA) approach. JMedSyst. 2003:27(5):445-56

6. Rosenstiel SF, Land MF, Rashid RG, Dentists’ molar restoration choices and longevity: a web based survey. JProsthet Dent 2004:91(4) 363-7

7. Soncini JA, Maserejian NN, Trachtenberg F, Tavares M, Hayes C, The longevity of amalgam versus compomer/composite restorations in posterior primary and permanent teeth. JADA 2007 Vol138, 763-772

8. DeRouen TA, Martin MD, Leroux BG, Townes BD, Woods JS, Leitao J, Castro-Caldas A, Luis H, Bernardo M, Rosenbaum G, Martin IP. Neuro behavioural effects of dental amalgam in children: a randomized controlled trial. JAMA 2006: 295(15): 1784-1792

9. Pediatric Restorative Dentistry Consensus Conference April 15-16, 2002. San Antonio Texas, Kevin Donly Conference Coordinator

10. Amin M, Utilization of dental service by children in low income families in Alberta. JCDA, 2011, 77:b57

11. Fonseca MA, The effects of poverty on children’s development and oral health. PedDen, 2012,34(1), 32-38


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