Content warning: This article contains images that may discomfort or alarm some readers.
April is Oral Health Month, and tooth decay has become a crisis in the Kingston, Frontenac, Lennox and Addington (KFL&A) Public Health region, the local Board of Health learned at their meeting on Wednesday, Apr. 26, 2023.
Alison Bradshaw, Public Health Promoter on the Dental and Vision team at KFL&A Public Health, made a presentation to the Board about child and adult dental health in the KFL&A region. The presentation focused on the problem of increasing instances of tooth decay, urgent dental needs in children, the severe impact of poor oral health on overall health, and the toll it takes on the health care system.
Community water fluoridation had a key role in the presentation as one community-wide measure that could — and in the KFL&A Public Health team’s opinion, should — be implemented to curb the crisis.
“Poor oral health affects our overall health. Dental diseases such as tooth decay or dental caries and gum disease are largely preventable chronic diseases. Most of us in this room… are fortunate enough that if we do happen to have pain in our mouth… we can phone our dentist and get a same-day or… next-day appointment, and we can get the problem fixed. So it’s probably a relatively minor inconvenience to us,” said Bradshaw.
“But there are thousands of people in our community who are not this lucky, and unfortunately tooth decay and dental diseases do remain issues of public health concern among children and adults and our region.”
Decay has doubled in children aged five since the pandemic
The local data Bradshaw presented to the Board was sobering. Prior to the COVID-19 pandemic, school screenings of five-year-olds showed one in five had active dental decay, easily visible decay, or had been treated either by extraction or fillings. “But since Covid, we’ve seen a 50 per cent increase in the rate of tooth decay,” said Bradshaw.
Of the 67 elementary schools in the KFL&A region, four are considered historically at high risk for dental decay, 18 are medium risk, and 45 are deemed to be low risk. In the most recent school screening, 60 percent of five-year-olds in high-risk schools (about three out of five children) had tooth decay. And even at the so-called low-risk schools, one in three children had tooth decay at five years old. “So we’ve got increasing decay across all schools,” noted Bradshaw, “with decay visibly affecting four to six teeth, on average.”
Bradshaw presented images to the Board to exemplify the kind of decay hygienists are seeing in schools: it is very visible, and an x-ray would detect more underlying decay. “Our school screening has shown that urgent tooth decay, like shown here, has more than doubled since before the pandemic,” Bradshaw pointed out.
And contrary to the popular idea that tooth decay in baby teeth isn’t a big deal because they will fall out, “it gets worse unless treated,” she emphasized. “Many children in our community are suffering due to pain.”
Molars are often the worst affected, and they do not fall out until 10 or 12 years of age.
“This level of decay,” Bradshaw expounded, “is going to impact the foods a child can eat, their behaviour, their ability to concentrate at school. [It] leads to school absences, feeling unwell. It’s going to impact their sleep.”
Looking at some of the burdens to families and the costs of treatment, she said, urgent needs have doubled since prior to the pandemic. “The cost [to fix this type of decay] would be at least $250 per tooth. We’re looking at $1,000 to $ 1,200 if you had four teeth affected, but many families don’t have 100 per cent [insurance] coverage. If they have any coverage, they might have a maximum of $350 per year per child. There’s a huge discrepancy there.”
She also noted the lack of pediatric dentists in the area: “[A patient’s] wait time would be at least six months, and then the decay’s going to be getting worse.”
Treatment has all sorts of other implications that affect family life. According to Bradshaw, “it’s traumatic if sedation is required… and day surgery requires time off work and school for parents.”
Adults too are experiencing increased oral health emergencies
This doesn’t affect just kids. Bradshaw acknowledged that “one in four Canadian adults have untreated dental caries,” a prevalent chronic infectious disease resulting from tooth-adherent cariogenic bacteria that metabolize sugars to produce acid, which demineralizes tooth structure over time.
“One in four adults in KFL&A avoids the dentist due to the cost,” Bradshaw stated. “Just looking at the population of the city of Kingston specifically, that’s equivalent to about 22,000 adults avoiding the dentist because of the cost.”
Access to dental care for people on an Ontario Disability Support Program (ODSP) is also extremely difficult, according to Bradshaw’s presentation.
“In theory, [people receiving ODSP have] their dental care covered, but in reality, ODSP only provides $19 for an extraction, where the real cost is about $200,” she explained.
As a result, people with poor oral health often end up at a hosptial emergency department in extreme pain. And the number of oral health problems that present at KFL&A hospitals (about five a day) is significantly higher than the Ontario average, according to Bradshaw. Further, these hospital visits are often an inadequate solution, since only a dentist can treat a tooth infection.
“The physician can prescribe antibiotics or pain relief, but they can’t treat the problem… So these visits are costing the health care system, and they are not effective for the patient,” Bradshaw said.
Prevention of tooth decay
Preventing tooth decay in our community involves many factors, explained Bradshaw. Individual behaviour, including improved dental hygiene and nutrition, is one step.
Access to dental care is extremely important as well: annual checkups, fluoride varnish treatment for both children and adults, and sealants that prevent tooth decay on children’s molars.
Finally, Bradshaw said, one of the best ways to fight tooth decay at a community level is water fluoridation.
KFL&A Public Health is committed to increasing oral health education and access to dental care, Bradshaw stated, and “supports community water fluoridation.”
What is community water fluoridation?
Municipal governments are responsible for making the decision of whether to introduce community water fluoridation, and the federal and provincial governments set the guidelines and safety parameters on fluoridation, said Bradshaw. “The optimal level of fluoride in water is set by Health Canada, and it’s 0.7 parts per million or milligrams per litre.”
To put this in context, she explained that “toothpaste has about 1,000 parts per million. So, toothpaste is obviously in a much higher concentration of fluoride than what we are talking about in water, which is a very small concentration… In [Kingston’s water supply], it’s around about 0.1 parts per million. In rural parts of KFLA, those levels vary… from 0.1 parts per million up to about 0.8 parts per million. And these readings are from a period of time from 2014 through to 2019.”
“Health Canada sets what they call a maximum acceptable concentration, and that is 1.5 parts per million,” according to Bradshaw. “Over 10 million Ontarians already have access to fluoridated water. That’s almost three-quarters of Ontarians, [including] Metropolitan Toronto, our neighbouring cities of Belleville and Brockville, Oshawa, Hamilton, Peel, York, and many others.”
“There have been a number of previous Board of Health motions on community water fluoridation… leading up to the city of Kingston adding the study of this possibility into their strategic plan for 2019 to 2022,” Bradshaw observed.
Experts agree that water fluoridation is safe, she said, pointing out that “equity and ethics obviously are important when we’re talking about community water fluoridation. It is well documented in the literature that there are inequities in oral health in Canada, as I’ve mentioned. Dental care money is distributed to those who can pay for it rather than according to people’s needs.”
Analysis after analysis shows that community water fluoridation reduces the costs of dental care in a municipality, she stated.
“We have lots of other examples of fortification in Canada, too, a strong history of fortifying foods for health. Vitamin D is added to milk to support healthy bones. We had iodine added to salt to prevent thyroid disease. And then, of course, folic acid to prevent in utero defects within the first trimester of pregnancy,” Bradshaw detailed.
“You might hear common concern that fluoride is toxic. But it’s a naturally occurring mineral considered essential for good health, approved by Health Canada, and it is safe and effective… There are many reasons to support community water fluoridation… It’s a population-level prevention strategy. It doesn’t require any change in behaviour, and it’s available to everyone — even those who don’t have any access to dental care.”
The Board thanked Bradshaw for her informative presentation.