The CDCP has arrived. Most dentists are participating. Now what?
The practice of dentistry is constantly evolving, especially as it relates to new technologies and techniques. The pace of evolution is only speeding up, and this trend requires oral health professionals to adapt their practices to keep up with the changes. In contrast to advancing technologies, the patient base of Canadian dental practices has remained remarkably stable for many years.
Exceptions exist, of course. Perhaps a new condo will be built across the street from an existing clinic. Or maybe a methadone or suboxone clinic moved in next door to deal with a local surge in narcotics addictions. Still, if you practice in the average dental office, patient demographics, the percentage of patients covered by insurance, and the breakdown between compliant and emergency-only patients, etc., seem to endure. Like the frog slowly getting boiled, the temperature changes so gradually it’s more common for the dental team to perceive nothing. That stasis may soon turn flux.
Change on the horizon
With the introduction of the Canadian Dental Care Plan (CDCP), Canadian dentistry could face an unprecedented change in our patient base. The federal government estimates that, within the next few years, up to nine million Canadians may receive coverage through the CDCP. This is nearly a quarter of the Canadian population who “reported avoiding visiting an oral health professional because of the cost.”1 In any system, demand impacts supply. Increasing demand by a significant factor will have both unforeseen and unintended consequences. When the nature of the demand changes as well (i.e., the socioeconomic status, needs, and expectations of the patients) the impact on those tasked with meeting the demand may (read: likely will) be significant.
In the remainder of this article, we consider how a sudden and dramatic change in both the quantity and characteristics of patients seeking dental care might affect dental professionals and their teams. We also consider whether, in light of the novel opportunities, risks, and challenges the CDCP promises, dentists need to adapt the way they manage their practices.
Off the grid: What is happening to dentistry with the CDCP?
Let’s begin what we know: the CDCP targets a subset of the Canadian populus that may not have been attending the dentist regularly. By definition, many of these patients were avoiding the dentist. For how long? We have no idea.2 Many of these patients will present as “new patients” in our practices. But they may not have the same goals or expectations as the new patients we are used to welcoming. For the most part, CDCP members haven’t moved. They probably haven’t found a new job. They didn’t recently get referred to the practice by a significant other. For the new patient who has enrolled in the CDCP, the only relevant change is the federal government’s policy.
Given the reason these new patients are walking into a dental clinic differs from the reasons new patients have historically entered a new practice – one must at least consider that their behavior and oral health needs will also differ. Such patients may not desire or even understand the typical new patient protocol. They may have immediate needs, given potentially years of dental avoidance, but not fit into the typical mold of (nor consider themselves to be) emergency only patients.
To add another wrinkle, your practice will have existing patients who now have coverage under the CDCP. Their new financial reality may require a shift in how their treatment needs are managed. Many dentists report that CDCP patients are excited to be able to afford needed overdue treatment, grateful their dentist accepts CDCP and confused about what the CDCP plan covers. The CDCP has changed the emotional baggage patients carry with them into the operatory. Dentists know that a patient’s emotional state can influence the likelihood of success of a dental appointment.
And the advent of the CDCP will also influence existing dentist-patient relationships. Bring to mind a patient who has rejected treatment recommendations for years. The reason, they cannot afford the cost. The reality is that every dentist has many such patients in their practice. After years of treatment refusals, the dentist may throw in the towel and accept that the patient simply won’t agree to the treatment plans due to financial constraints. If that patient qualifies for the CDCP, it may be time to think again.
Cohorts based on age
The focus of the CDCP is to help make the cost of dental care more affordable for eligible populations, which initially rolled out to include seniors, and has expanded to include children and those with a disability tax credit certificate. These populations face distinct dental challenges that are often intertwined with their broader medical health. Seniors and individuals with disabilities, for instance, are likely to have more medical complexities that may affect their oral health and their dental management. For example, issues like dry mouth due to medications or age-related changes can increase their risk of new and recurrent decay as well as periodontal disease.3 Seniors are more likely to be taking medications known to increase the risk of certain dental procedures such as bisphosphonates and anticoagulants3. Those living with disabilities may also encounter increased barriers to oral hygiene due to physical or cognitive impairments, which can be compounded by additional medical comorbidities such as diabetes or autoimmune conditions, both of which are known to affect oral health.4,5 Tailoring the way our practices manage these unique needs and working effectively with specialists, who may have greater expertise in these areas, is essential to address both dental issues and the broader health implications tied to the individual conditions.
New patients, existing patients, and something else
When taking on new patients, practices generally have a standard protocol on the process of diagnosis and treatment planning for these patients. Having such a protocol ensures patients receive the standard of care established by the clinic. While practices do their best to practice patient centric dentistry, there is not much deviation in the diagnostic records taken or in the sequencing, presentation and management of treatment plan options. But with the introduction of the CDCP, dentists have an opportunity to reconsider whether all new patients should in fact receive the same experience.
To illustrate the point, there are significant differences between new patients arriving from another clinic where they received routine care, and new patients who have avoided dental care for many years. The former may arrive hoping to see the dental hygienist more than the dentist. The latter may have accumulated a number of oral health issues only a dentist can address. From the dental team’s perspective, expecting patients to go from avoiding seeing a dentist altogether to attending three dental hygiene appointments per annum may not be realistic. On the other hand, treating such patients as emergency patients may not square either. Given their newfound access to funds to pay for essential dental treatment, such patients may have a list of treatments they need and desire. Routine scaling and polish may not be on that list.
Furthermore, we can’t only consider the different dental needs of these new patient cohorts; we must also consider the underlying reasons such patients have avoided the dentist for years. Social determinants of health play a large role in the ability of patients to access care and, ipso facto, those with the most significant dental needs often have the most difficulty accessing care.6 Patients who, for years, have not received routine dental treatment may also have different expectations, lower dental IQ, as well as other social barriers and communication needs. In short, the trusty new patient protocol may not be what these patients need or expect.
How might the CDCP change the practice of dentistry?
How will this new subset of patients affect the way we practice dentistry? Of course there may be some increased risks to practice, including missed/cancelled appointments, patient misunderstandings about the CDCP being “free dental care”, and increased time required by the administrative team and the dental providers to appropriately manage the needs of the patients and the exigencies of accepting assignment.
Also, due to the nature of the benefits grid and the manner in which the CDCP was rolled out, dentists may perceive an increased pressure to stick within frequency limits of the CDCP or limit the care they recommend to that which is covered under their plan. The CDCP is designed, after all, to minimize out of cost expenses for patients. Dentists know they must treat the patient not the plan.7 However, is it not unreasonable for a dentist to believe that a patient who has consistently ignored their oral healthcare due to cost will reject treatment options that are expensive and which the CDCP does not cover. So, how often and with what conviction should dentists put forward treatment plans they believe almost certain to be declined? While this ethical dilemma is not new, it may take on renewed prominence as more and more members of the CDCP begin to seek care.
It is undeniable that educating patients about dental treatment options (like implants for example) and their associated costs takes time. No one, including dental regulatory bodies and Health Canada, should act surprised when both dentists and patients find themselves, for different reasons, leaning toward options that are covered by the CDCP – whether they’re the second or third best (from a purely clinical perspective).
Having devised the treatment plan and staging that best meets the patients’ needs, oral healthcare providers may encounter additional challenges. A lack of dental care in the past could result from or even lead to increased anxiety in patients8. Patients who regularly attend their dental hygiene appointments report anxiety. Anywhere from 48 percent9 to nearly 60 per cent10 of the population experiences a form of dental anxiety or extreme dental fear. In Canada, over a third report being somewhere between “a little afraid” to “terrified”.11 This could be significantly greater, on average, for patients who have not seen the inside of a dental office in many years, particularly when they require fillings, extractions, or root canals.
This in turn may require oral health care practitioners to use more medical patient management techniques, including an enhanced importance on sedation skillsets and/or referral options that these patients can access. Dentists may find that the usual specialist they refer to does not accept CDCP or, if they do, they are booking into the distant future. Other skillsets of dentistry may gain renewed prominence, such as a potential increase in the number of patients seeking full or partial dentures due to either their current oral health condition and/or the limitations of the benefits plan regarding removable tooth replacement options. Dentists must consider meeting this increased demand in a variety of ways, including honing their skills in such techniques or partnering with other oral health providers such as denturists to meet demand for such treatment options.
Balance billing or not, change has arrived
Dentists have learned to expect changes in dental technology. It is equally important that dental practices prepare to manage emerging patient needs and expectations. How exactly dentistry changes will only be clear in hindsight. That said, those who adapt to the changes while they happen will thrive, and so will their patients. Dentists and their teams need to pay attention to the shifting landscape, and modify the way they approach patient care, accordingly, including methods of communication, education, follow-up, and insurance navigation. In satisfying the eligibility of patients to receive the services outlined in their treatment plan, pre-authorization to insurance may be required. While this is not entirely new, the CDCP’s benefits grid includes only such dental treatment that is “evidence based” and “medically necessary”. Canada had not seen such an approach to dental benefits at this scale.
This somewhat novel constraint will require dentists to rethink how they take clinical notes and records, document plans and diagnoses, and evaluate where they draw the line between necessary and elective treatment options. While clinically it is up to the patient and their dental provider to determine what their best treatment options are, communicating this decision-making process to the insurance company will introduce a new dynamic. The factors that insurance companies use to determine what is medically necessary may differ from the standards of care being taught in the dental schools and could even deviate between provinces across Canada.
While the CDCP presents an immense opportunity to patients and clinicians alike, it also poses new challenges with treatment planning and introduces a third-party into the case acceptance equation. The staging, timing, and scheduling of patients will all have to be adjusted accordingly. Patients with limited financial means, i.e., the focus of the CDCP, may be more prone to elect second or third best treatment options in order to stay within the range of covered services. Dentists will need to document that all treatment plans were presented to the patient – or risk a regulator finding that they failed to receive informed consent.
Conclusion
As oral healthcare providers, it is important that we are able to not only provide technically sophisticated dental treatment to our patients, but that we are also competently managing our patients’ needs and expectations. It is often said that satisfaction is nothing more than experience minus expectations. At the same time as dentists adjust to changing patient expectations, they must also satisfy the shifting requirements of regulators, Health Canada, and insurance companies. Being able to adjust and improve our processes as our patient base changes plays a vital role in running a successful dental practice. Working with patients covered by the CDCP requires dental practices to take the time to find the balance between optimizing the oral health of these patients and managing the responsibilities that go along with it.
References
- The Canadian Dental Care Plan, Health Canada, Dec 11, 2023, at https://www.canada.ca/en/health-canada/news/2023/12/the-canadian-dental-care-plan.html, (last visited Aug 18, 2024).
- StatCan will help shed light on this question—however, the Oral Health Survey question on this topic makes no distinction between someone who has avoided the dentist for four years and someone who has never seen the dentist. See Oral Health Survey Question 40, available here.
- Oral Health in America: Advances and Challenges [Internet]. Bethesda (MD): National Institute of Dental and Craniofacial Research(US); 2021 Dec. Section 3B, Oral Health Across the Lifespan: Older Adults. Available from: https://www.ncbi.nlm.nih.gov/books/NBK578296/
- Alqadi SF. Diabetes Mellitus and Its Influence on Oral Health: Review. Diabetes Metab Syndr Obes. 2024 Jan 8;17:107-120. doi: 10.2147/DMSO.S426671. PMID: 38222034; PMCID: PMC10785684.
- Reilly, Robert JR, William Johnston, and Shauna Culshaw. “Autoimmunity and the oral cavity.” Current Oral Health Reports 6 (2019): 1-8.
- A Snapshot of Oral Health in Canada, at https://www.cda-adc.ca/stateoforalhealth/snap/, (last visited Aug 28, 2024)
- See Dental Benefits Explained, the Ontario Dental Association: “Dentists make their treatment plan based on your dental needs. Sometimes, your dental plan coverage and your treatment plan won’t align. If your dental plan only covers part of the cost of your treatment plan, you’ll need to cover the rest”, available at: https://www.oda.ca/visiting-the-dentist/dental-benefits/.
- Heyman RE, Slep AM, White-Ajmani M, Bulling L, Zickgraf HF, Franklin ME, Wolff MS. Dental fear and avoidance in treatment seekers at a large, urban dental clinic. Oral health & preventive dentistry. 2016 Jul 1;14(4).
- Beaton L, Freeman R, Humphris G. Why are people afraid of the dentist? Observations and explanations. Med Princ Pract. 2014;23(4):295-301. doi: 10.1159/000357223. Epub 2013 Dec 20. PMID: 24356305; PMCID: PMC5586885.
- Saatchi M, Abtahi M, Mohammadi G, Mirdamadi M, Binandeh ES. The prevalence of dental anxiety and fear in patients referred to Isfahan Dental School, Iran. Dent Res J (Isfahan). 2015 May-Jun;12(3):248-53. PMID: 26005465; PMCID: PMC4432608.
- Chanpong B, Haas DA, Locker D. Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesth Prog. 2005 Spring;52(1):3-11. doi: 10.2344/0003-3006(2005)52[3:NADFSO]2.0.CO;2. PMID: 15859442; PMCID: PMC2526218.
About the Authors
Julian Perez is Chief Legal Officer at dentalcorp, where he oversees legal, regulatory compliance, corporate governance and enterprise risk functions to support practices in the delivery of optimal patient care. He earned his bachelor’s degree from Yale University and a JD from Columbia University’s School of Law.
Michelle Budd works with dentalcorp’s Compliance & Risk Management team as a Patient Safety Consultant. She graduated from Western University with a Doctor of Dental Surgery degree and subsequently earned a Master of Public Health degree. Michelle has travelled throughout Canada to help dental practices achieve and maintain professional compliance.