The Canada Dental Care Plan: Missing pieces – A commentary on the national dental program

Abstract

The Canada Dental Care Plan (CDCP) is now approaching its first anniversary of patient care. This paper is a brief analysis of some current design and operational flaws diminishing the success of the plan. The paper evolves from a more comprehensive document submitted to Health Canada in fall of 2024.¹

The CDCP provides access to oral care for vulnerable populations estimated, when fully implemented, to be up to 9 million Canadians. When combined with the other parts of the national initiative, it is the most significant oral health initiative in the history of Canada. The current wide uptake of care from oral health professionals results from considerable efforts from government and those professions to make it work. However, the significant absence of data at this time to evaluate more deeply what is working and what needs further efforts severely limits lessons learned and actions to be pressed. Specifics on that with a recommended pathway forward will be discussed in a second paper. This paper provides some examples of where the basket of services is not meeting the needs of the targeted population.

The Canada Dental Care Plan (CDCP) is now approaching its first anniversary of patient care. This paper is a brief analysis of some current design and operational flaws diminishing the success of the plan. The paper evolves from a more comprehensive document submitted to Health Canada in fall of 2024.¹

The CDCP provides access to oral care for vulnerable populations estimated, when fully implemented, to be up to 9 million Canadians. When combined with the other parts of the national initiative, it is the most significant oral health initiative in the history of Canada. The current wide uptake of care from oral health professionals results from considerable efforts from government and those professions to make it work. However, the significant absence of data at this time to evaluate more deeply what is working and what needs further efforts severely limits lessons learned and actions to be pressed. Specifics on that with a recommended pathway forward will be discussed in a second paper.

The design of the CDCP is very much like all other Canadian government-funded dental plans at federal, provincial and territorial levels. As such it fails basic requirements for a 21st Century government-funded dental plan. Modern design for such plans must be centrally focused on managing risk and consequences of specific diseases, while current plans focus publicly on “X” services costing “Y” dollars for “Z” people, without focus on current best practices of disease risk management. At no time with current plan design can government or the profesional community state with clinical evidence that their design improves health outcomes nor that the design achieves this in a cost-effective way.

While the core diseases to be managed are caries and periodontal disease, logically additional diseases such as temporomandibular joint-related disorders and orthodontic care for significant malocclusions would be included. There are also other aspects of sound preventive care missing from the plan.

LISTEN: What Needs to Change for the CDCP to Work

The key goal of risk management approaches for both caries and periodontal disease is to manage risk before lesions progress to the point of requiring extensive and expensive care. Detecting, diagnosing, monitoring, and treating oral diseases earlier also has an impact upon overall health, with growing confirmation of links and causation of numerous systemic diseases. This is true at all ages, not just in pediatrics.^2-9

With caries management, the ability to assess risk and implement management is relatively mature with identified tools such as Caries Management by Risk Assessment (CAMBRA)^{10, 11} and the International Caries Classification and Management System (ICCMS),^{12, 13} and best practice management standards as put forward by various organizations. The incomplete inclusion of such base standards in the CDCP core basket of covered services diminishes the level of success with caries.

With periodontal disease, while similar identified risk assessment and management systems appear less well established, recognized periodontal disease diagnostics and sanitive management measures do exist and are not adequately in place as part of core services. Further, the total absence in the covered services of key surgical procedures dooms the CDCP to poor periodontal health outcomes. Resolving this failure is urgently needed and will again require a true collaboration with the oral health professions.

For treatment of disorders of the temporomandibular joint and significant orthodontic malocclusions, the CDCP is currently largely silent and in need of considerable collaboration with the profession and consequent adjustment of the basket of services. With discussions planned or underway on limited orthodontic services, we will defer comment pending further efforts to be carried out.

There exist within the scope of practice of oral health professionals a number of inexpensive additional preventive and risk management procedures of benefit to patients. While some are caries-related, others are not linked specifically to management of either caries or periodontal disease. Their absence from the CDCP is regrettable and warrants reconsideration.

The basket of preventive services do not provide adequate care for the patient, particularly if the patient is diagnosed as at high risk. Polishing should be increased since it will allow for the accurate diagnosis of early white spot lesions (ICDAS 1 or 2 ranking) and monitoring of changes over time, both positive and negative.^{6, 12, 14} Polishing / dental prophylaxis will have a positive impact upon overall health.^{6, 15-17} Topical fluoride and remineralization agents have been shown to stabilize and or re-harden early caries lesions.¹⁸ The appropriate timing for identified high risk patients is between 3 – 4 months.^18-27 Scaling removes calcified plaque and needs to be done more than 4 units per year in high-risk patients. This is particularly realistic given the higher disease rates anticipated in much of these populations.^{9, 28-30}

While pit and fissure sealants on permanent bicuspids and molars is of proven benefit, the use of sealants, either resin or glass ionomer, on primary molars and incisors, is recommended but with less strong conclusiveness in randomized controlled trials. That said, again for the young child and for other pre-cooperative children, it can play a role as part of a comprehensive risk management protocol in preventing much more serious disease morbidity and treatment. It further advantages the child by prolonging the interval before introduction of further care, if any.^31-33 It should be further noted that a Rapid Response Report from the Canadian Agency for Drugs and Therapeutics in Health from 2016 does review the benefits for sealants in prevention of decay in permanent teeth. ³⁴ It does not, however, assess sealants of any type for primary dentition.³⁴ Similarly, The American Academy of Pediatric Dentistry guideline panel on the use pit and fissure sealants, while highlighting the need for further research specifically to assess effect of sealants on primary dentition, does suggests the use of sealants is superior in controlling pit and fissure caries compared with fluoride varnishes in primary and permanent molars.³²

Further, this is a good minimally invasive treatment that will help to avoid the ultimate placement of large restorations, pulpotomies and crowns on primary teeth.^{30, 31, 33-36} It also is done as a method of “staged” care to bring the young pre-cooperative child into a trusting relationship. It further can reduce the need for extensive treatment provided at a young age requiring the use of sedation and general anesthesia.^{31, 32} Absence of such procedures will force more care to be done under general anesthesia that is significantly preventable.

All sports carry with them the risk of injuries to the face and mouth. The statistical summary from the AAPD is particularly conclusive and worth quoting at some length:

“A systematic review reported between 10-61 percent of athletes experienced dental trauma. A 10-year study of 3,385 craniomaxillofacial trauma cases presenting to an oral and maxillofacial surgery department found 31.8 percent of injuries in children occurred during sports activities. Children ages 17 years and younger represented 80.6 percent of the total (sport- and non sport-related) dental injuries that presented to United States (U.S.) emergency rooms from 1990-2003, with the majority presented in children younger than seven years of age.”³⁷

This is basic inexpensive protection, is often included in basic government-funded dental plans, and should be added to the schedule. This would include mouthguards used in sports; they are designed to help protect the teeth from cracks or fractures either from injuries or even clenching and grinding while playing various sports.^38-41

There has been a large increase in bruxism, grinding and cracked teeth since the onset of COVID in 2020.^42-46 This continues to be a problem, and a number of clinical practices are still reporting patients clenching and cracking teeth. The American Dental Association Health Policy Institute did two surveys during COVID. There was a large increase in tooth grinding, chipped teeth, cracked teeth and jaw joint related issues.⁴⁷ One of the best methods to prevent tooth fracture and issues with the TM Joint is the placement of a bite splint.^48-53 This set of procedure codes needs to be inserted into the CDCP.

Among the core principles in the growth and development of the dental arch, is the goal of preserving the length of the dental arch into the full eruption of the permanent dentition. Premature loss of arch length measured from the front contact point of the first permanent molar to the same point on the other side of the dental arch in most patients will result in an increase in degree of misaligned dentition with increased crowding. Such crowding, besides causing esthetic concerns and potential dysfunction of the masticatory process, increases risk of additional dental caries. Where this arch length loss is the result of a premature loss of certain of the primary teeth, placement of a space maintainer at a time close to the loss of affected primary tooth will, at minimal cost, prevent otherwise increased crowding with potentially significant health consequences orally or more widely.^54-59 This group of procedures should be included in the general program or in the orthodontic section of the dental benefits grid.

Guidelines in several countries call for need for updated research while supporting such interceptive care in selected clinical situations. The American Academy of Pediatric Dentistry Best Practice Guideline states: “The goal of space maintenance is to prevent loss of arch length, width, and perimeter by maintaining the relative position of the existing dentition. The AAPD recognizes the need for controlled randomized clinical trials to determine efficacy of space maintainers as well as analysis of costs and side effects of treatment.”⁶⁰

It is also worth noting that the CADTH Rapid Response Review on space maintainers in 2016, “Dental Space Maintainers for the Management of Premature Loss of Deciduous Molars: A Review of the Clinical Effectiveness, Cost-effectiveness and Guidelines”⁶¹ while concurring that more and better research is needed, does neglect to examine one significant cited benefit of space maintainers, loss of arch perimeter, in its analysis.

Again, such a procedure is relatively inexpensive and effectively manages in some cases the risk of crowding, malocclusion, loss of arch length perimeter, and greater oral disease that is preventable.⁶²

With respect to persons eligible for care under the CDCP, one of the significant gaps in government-funded care nationally has been for persons living with disabilities. Their inclusion in the CDCP is a key success. Among the difficulties in delivering on that commitment is lack of good national data identifying this diverse population. “Persons with disabilities” transcends all groups eligible under the current iteration of the CDCP: children, seniors and persons living with disabilities. The current identifier used by the CDCP, the Disability Tax Credit, fails to identify significant numbers of disabled Canadians for the CDCP. Further, that very diversity requires from an empathetic, caring government both a better manner of identifying the populations and declaration of eligibility period accurately reflecting either chronic or lifelong reality of disability rather than a bureaucratic and totally inaccurate artificial timeline. These populations, some with complex medical needs, may also require exceptional efforts for access to care as well as important elements of time and responsibility in the efforts of care providers that has to be captured in their reimbursement.

The shortcomings cited in this paper not only call for changes to better identify the population, but also much improved data collection both within the CDCP and in the wider population. If we seek to improve what we currently have, we need to accurately measure it. For persons with disabilities, for example, there is no specific identifier on claim forms that the recipient has a defined disability. For seniors and children, their age is the key identifier. The missing information on claims forms or in the data base, precludes analysis of billing data, and seriously limits the mass of data on persons with disabilities, the care that they receive, and health changes over time of care.

The commencement of availability of advanced elements of care and the pre-authorization process for a number of procedures as of November 1, 2024, was a major step forward for the CDCP. The refinement of details around these additions through a working group with the professions brought further improvements. With respect to pre-authorizations, it is crucial that the process is well defined and applied appropriately. In this regard, again it is crucial that detailed data on this process is made available for analysis. With good analysis comes improvements. We have concerns with the current absence of data on the pre-authorizations and considerable anecdotal reports that significant numbers of requests for approval are being denied. This needs verifying, and if true, prompt action from organized dentistry and government.

Creating a national dental program is a critical step in improving the oral health and with it the overall health of Canadians. There is need to examine the existing program’s basket of services, limitations on access to services, pre-authorization process and also on developing robust data analysis of the claims data from this program. The analysis of the claims data^{63, 64} along with a properly designed and implemented national oral health survey which uses robust survey tools will allow Health Canada to monitor the program outcomes and also design and implement public health programs to engage and improve the oral health and overall health of Canadians.⁶⁵ This paper also provides some examples of services that should be added to the program but there are a number of other services that should be added to prevent and treat oral diseases. Further, a well-designed data analysis based on detailed review of the claims data will provide key aid to cost containment of the CDCP based on recommended disease risk management design of the basket of services. 

Oral Health welcomes this original article.

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Key questions and answers

1. What is missing from the Canada Dental Care Plan?
The plan lacks a clear strategy for integrating with existing provincial programs, sustainable funding models, and a collaborative approach with practicing dentists. It also overlooks key infrastructure, like a unified data system, and fails to address systemic barriers that contribute to poor oral health.

2. What are the limitations of the Canada Dental Care Plan?
The plan is limited by its top-down approach, lack of meaningful consultation with oral health professionals, and insufficient infrastructure to support long-term implementation. It focuses heavily on cost coverage without addressing broader issues like access, workforce support, or prevention.

3. Why are some dentists concerned about the national dental program in Canada?
Dentists are concerned that the program was developed without their input and may not align with the realities of clinical practice. They fear it may lead to confusion, inefficiency, and potentially disrupt existing care models without truly improving access or outcomes for patients.

4. Who is eligible for the Canada Dental Care Plan?
As of now, eligibility includes lower-income Canadians without private dental insurance, with phased rollout based on age and income. However, specific eligibility details and timelines continue to evolve as the plan is implemented.

5. What does the Canada Dental Care Plan cover—and what does it leave out?
The plan promises to cover a range of basic dental services, but details on specific procedures and limitations remain vague. It appears to prioritize cost coverage, yet leaves out broader determinants of oral health such as education, outreach, and community-level care infrastructure.

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About the authors

Dr. Abrams is a GP dentist. He also does research on caries. He works with the dental associations on access to care and the CDCP. 

Dr. McConnachie is a retired pediatric dentist with an ongoing career of involvement at the local, provincial and national levels in multiple dental organizations.