After 29 years of peering in little mouths, Penny Griffith doesn’t wince anymore.

The dental therapist with the Lac La Ronge Indian Band has become accustomed to seeing preschoolers’ teeth in a state most of us would find shocking — all four baby molars pocked with deep pits, and front teeth black and stumpy, literally rotting away to nothing.

“It’s an accepted thing — the front smile being black and stubby,” the frankly-spoken Griffith says. “It’s so ‘normal’ here that it doesn’t matter.”

Like a rite of passage, many — some still in diapers — will take a trip south down Highway 2 and end up in Dr. Mohan Teekasingh’s Saskatoon operating room, where the dentist will often drill and fill as many as six or eight teeth, and extract four-to-six more.

“A lot of these kids, unfortunately, live with the pain and take it as part of their normal existence,” Teekasingh says.

Of the more than 1,900 Saskatchewan patients on a waiting list for dental work under general anesthetic, more than half are under age six, and more than three quarters are age 10 or younger.

The most common reason kids are put to sleep is because of dentistry, says Dr. Frank Hohn, department head for dentistry and maxillofacial surgery at the Saskatoon Health Region, and president of the College of Dental Surgeons of Saskatchewan.

“I think it probably runs under the radar,” Hohn says. “I think people are shocked to hear the largest number of pediatric anesthetics are for dentistry — and that’s around the country.”

Although dental disease can affect anyone regardless of wealth, a disproportionate number of kids in the OR are aboriginals from northern Saskatchewan. More than half of the kids having dental surgery self-identify as aboriginal, the Ministry of Health says. Babies, toddlers and preschoolers who live in Saskatchewan’s three northernmost health authorities are put under for teeth woes at more than three times the provincial rate.

Early childhood dental disease is painful. It stops kids from eating healthy foods and getting proper nutrition. It interferes with learning. And unlike many costly health problems, it’s almost entirely preventable.

“It’s a travesty that many children have to be going through a general anesthetic because of the end stage of dental disease — something that’s preventable. It’s a crime,” says Dr. Gerry Uswak, dean of the University of Saskatchewan’s dentistry college.

The cost

It’s also costing governments — and taxpayers — a lot of money.

In 2010-11, the provincial health ministry paid for 2,015 patients age 5 and younger to have dental surgery under general anesthetic. The anesthesiologists’ time alone cost $662,260, and the ministry doesn’t track the cost of the dentist’s time, much of which is covered by private insurance.

For First Nations children who live on reserves, Health Canada’s Non-Insured Health Benefits (NIHB) program paid out $516,033 that same year for anesthesia and dental fees for another 873 Saskatchewan kids.

“We’re paying for the cost of early childhood caries (cavities) one way or another,” says Dr. James Irvine, medical health officer for Saskatchewan’s three northern health authorities. “One way is through dental treatments, dental surgeries, dental anesthesia, and the cost of getting children down from remote locations, and sometimes not so remote locations, for dental treatments.”

Prevention would be more cost-effective, he says, and dental surgery isn’t a cure. Some unlucky preteens and teens end up back in the OR to have their permanent teeth filled, too.

A backlog of child dental surgeries also affects overall surgery wait times in the province.

If regional reports are any indication, the problem is hardly isolated to the north, and is getting worse in some places. According to dental health screening reports on Grade 1 and 7 students prepared every five years by the province’s regional health authorities, children in Prince Albert Parkland and Regina are moving further away from national guidelines laid out in the Canadian Oral Health Strategy (COHS). The data show shrinking numbers of cavity-free children and — according to the COHS — too many kids with untreated dental problems.

Data from the Canadian Health Measures Survey show that across the country, children’s dental health is not meeting all of the COHS targets.

Dr. Ross Anderson, head of pediatric dentistry at Dalhousie University and a member of a Canadian Dental Association committee pushing for better access to dental care, says not only are the COHS targets attainable, but the country should be aiming to do far better.

“Saskatchewan is not special — this is an across-the-nation issue,” Anderson said.

Why does it happen?

Ask anyone who works in the field, and they’ll tell you the issue is more complex than remembering to brush twice daily. Poverty and low socioeconomic status comes up again and again.

“It’s everything from not knowing what to eat, how to eat, how to brush,” Uswak says. “If we’re worrying about roaming packs of wild dogs in northern Saskatchewan, where does toothbrushing fit on the continuum of priorities?”

It’s only recently dental professionals learned cavities are literally infectious. A baby is born without the bacteria that causes decay. If her family’s teeth are in rough shape, her risk of dental problems increases.

Why aboriginal children are so disproportionately affected could be a result of inadequate housing, a lack of affordable, nutritious food, lack of easy access to dentists, and social problems well beyond the purview of dental health workers.

“If you don’t have a roof over your head, or mum or dad are drinking again, or, there’s a party at your house, or maybe 85 people live at your house, maybe teeth brushing isn’t just as important as it is to us,” dental therapist Griffith says.

Her program has given out about 5,000 toothbrushes — some residents don’t have them because “that would be another expense,” she says.

There are some practices that persist despite the tireless counselling of dental therapists, public health nurses, and others, such as babies left in cribs with bottles of milk, pop or juice, which can pool in their mouths.

Lac La Ronge mom Jennifer Halkett is trying to make changes to improve her family’s oral health. Two of her five children have had dental surgery in Saskatoon under general anesthetic — long trips she describes as stressful and full of worry about how her kids would react to the anesthesia. Her youngest daughter, two-year-old Serena, is now on a waiting list for surgery in Nipawin.

She has some small plastic tools to floss her children’s teeth, but Halkett literally has to chase the kids down first. She’s trying to buy drinks with less sugar in them, too.

When she has the money, she buys more fruit and vegetables.

“I have to try not to take them with me to the store, because they always aim for the candy,” the single mom says, adding that it’s not easy to find babysitters on the First Nation.

When you have a lot of children, it’s so tempting to put a child to bed with a bottle of milk or juice, she says. “Parents just want the peace and quiet sometimes,” she says.

She admits she has trouble keeping up with her kids’ teeth-brushing as well as she should.

But Uswak feels some of the responsibility lies far from the front lines of oral hygiene. He laments that, despite well-established connections between dental health and overall health, dental care remains mostly in the private domain and is often a low government priority.

“We know in this country and in this province that the funding for dental public health and oral health proper is not at the level that it should be,” he said. “There’s finite resources. Government does not fund programs adequately to target all the high-risk populations and improve oral health.”

The population most affected by serious dental disease is also growing. According to Saskatchewan Health, the number of children in the province increased 16 per cent between 2005 and 2010, and the populations growing the most quickly are aboriginal.

FLUORIDE

And then, there is the political lightning rod of water fluoridation. It has detractors, who argue citizens should be able to make their own choices about what chemicals are added to drinking water.

Water fluoridation is the most cost-effective way known to prevent dental disease. The Ministry of Health website says every $1 spent on water fluoridation can save $38 in downstream dental costs.

The Saskatoon Health Region’s surveillance found that while not perfect, school-age kids’ teeth fared better here — a difference the region attributes to the City of Saskatoon’s fluoridated water.

The City of Regina’s water is not fluoridated, and neither is Prince Albert’s water system, which is currently undergoing upgrades with the ultimate aim of fluoridation.

Saskatchewan also lags the rest of the country in access to fluoridated water. 49 per cent of Canadians have access to fluoridated water, compared to 36 per cent of Saskatchewanians. Only four Saskatchewan reserves have access to fluoridated water from nearby towns — none have their own fluoridation systems.

Although the Canadian Paediatric Society, the Canadian Dental Association, Canadian Medical Association, Health Canada and others all promote community water fluoridation, governments say it’s up to each community to decide whether it’s right for them to invest in putting the system in place.

The risks

Decayed teeth are not a purely esthetic problem. Research has established links between poor oral health and some cardiac, respiratory, and bone diseases and problems. Pregnant women with poor oral health are more likely to go into premature labour and deliver babies with low birth weights.

Pain, infection, fevers and other problems interfere with normal childhood development, sleep, eating, self-esteem, and learning.

“It’s robbing that child of their right as a full and complete development as a human being,” Uswak says.

Extract rotted baby teeth, and more problems await. They are placeholders for permanent teeth, and when they’re removed too early, permanent teeth grow in crooked, Uswak said, opening the door to a future of orthodontic problems.

General anesthetic also carries risks, including rare occasions when a patient doesn’t wake up.

“The significance of the actual procedure is not appreciated well enough … If it was a child of mine, I would do everything I could do to make sure they never undergo a general anesthetic.”

Prevention

Access to preventive programs in Saskatchewan has been a patchwork that varied by region by city or town, and sometimes by neighbourhood or school. Prince Albert, Regina and Saskatoon all have health-region run programs, including dental health education provided by public health nurses during home visits to mums and newborns, dental sealant programs in some high-risk schools and day cares, fluoride mouth rinses at rural schools without fluoridated drinking water, high school presentations to teen moms, free toothbrushes and toothpaste for interested groups, and oral screenings, referrals and fluoride varnishes offered at public health clinics. All SHR children under 17 who cannot afford a dentist’s visit can have free basic treatment at West Winds Primary Health Centre and the White Buffalo Youth Lodge.

On reserves, Health Canada has run the Children’s Oral Health Initiative (COHI) since 2004, which targets children 0 to 7, their caregivers, and pregnant women. According to the federal agency, COHI currently has 55 dental therapists working in 61 of Saskatchewan’s 72 First Nations. A Health Canada spokesperson wouldn’t say whether there are plans to expand COHI to all reserves.

Off-reserve in northern Saskatchewan, a scaled-back version of the once-provincial children’s dental program now covers kids who live in the three northern health regions.

Both Griffith and Irvine say the newest push is to start prevention with pregnant and new mothers. Often, the damage is done long before a child sets foot in a school.

For people who receive social assistance, some dental coverage is available though the provincial government’s drug plan and extended benefits.

At last count, 36,7000 Saskatchewan people were eligible for these benefits, and in 2010-11, the government paid $12.9 million for the dental expenses of people in the program, along with their kids and other dependents. But how many people in that program are actually seeing oral health workers, the government doesn’t know.

And, in its position paper on access to oral care, the Canadian Dental Association says these supplementary programs are often too limited.

“The programs for the most part provide very basic coverage for dental expenses with strict limits on services and costs while others are restricted to emergency care only,” the CDA says.

What to do

It was in the context of some of these troubling numbers — a growing list and wait times for dental surgery, kids drifting further from national targets — that prompted the Saskatchewan government to launch the Enhanced Preventive Dental Services program last fall.

The $1.4-million initiative is meant to make prevention more uniform across the province. It’s part of the Saskatchewan Surgical Initiative, which aims to have no patient wait longer than three months for surgery by 2014.

Tami Denomie, director of health promotion with the health ministry’s population health branch, says she optimistic the program will make a difference.

“We have really looked at this one over the last couple of years — taken a really good hard look at it — and that’s why we’ve taken some of the steps that we have,” Denomie said.

The money funds a new co-ordinator in every health region to make widely available oral health assessments for all preschool children, fluoride varnish applications for all kids six months to age 5, dental sealants in high-risk schools, followup visits and dentist referrals. The initiative started mainly in northern Saskatchewan and is now in effect in all health regions. It also includes training for other health-care workers, like family doctors and public health nurses, to give oral health counselling and basic dental treatments like fluoride varnishes.

Some of these things have already been happening in places like Saskatoon (which Denomie calls a “shining model” in the province).

The ministry plans to routinely evaluate the program’s effects, Denomie said, although it doesn’t have any specific targets yet for reducing disease. It may not make a noticeable difference in surgery numbers for three to five years, she said.

As for an apparent spike in the number of pediatric dental surgeries in the province in the last five years, that may be a blip due to targeted government funding aimed at reducing wait times. Hohn says Royal University Hospital got money in 2009 to dedicate two operating rooms, five days a week, to do pediatric dental surgeries — up from one OR. The boost suggests the number and cost of these surgeries won’t escalate at the same rate they have in the last five years, although Denomie wouldn’t speculate about future trends.

There are more steps oral health experts would like to see the province take.

The Canadian Oral Health Strategy recommends each province and territory appoint a chief dental officer or consultant to direct public dental services — a call Uswak and Anderson echo. That job is filled in B.C., Manitoba, Alberta, Ontario, Quebec and PEI, and Nova Scotia is recruiting one. A Saskatchewan Health spokesperson says this province has no plans for one.

To help with a dearth of dentists and other professionals in the north, Uswak would like to see the government offer incentives to practice and open private clinics in remote communities.

Anderson says a key CDA recommendation is that all babies have their first dentist’s visit by 12 months of age, or six months after their first tooth pokes through — whichever comes first. Not all dentists feel comfortable looking in wiggly little mouths, and may need more education and training, he says.

There may also be an appetite in Saskatchewan for culturally-sensitive prevention programs Dr. Rosamund Harrison, chair of pediatric dentistry at the University of British Columbia, has studied extensively how to successfully introduce prevention into communities with high rates of dental disease, such as inner-city Vietnamese in Vancouver, east Indian immigrants in Surrey, and First Nations. She found training workers from those communities to do the counselling helped eliminate language and cultural barriers, and helped reduce dental disease rates. She also found one-on-one counselling with mothers that used praise and reinforcement worked better than showing videos and handing out pamphlets.

Those approaches have also worked in Lac La Ronge, which began its own dental therapy program in 2003.

At first, parents who’d had terrifying encounters with dentists in the past were leery of Griffith and the other dental therapists. They employ women from the community as dental aides, who visit families at home, give kids fluoride rinses, track people down to get forms signed, and can speak to residents in their first language.

“We are part of the community now,” Griffith says. “We are very accepted in the classrooms.”

But despite pockets of success, the stream of stubby-toothed children down the highway to Saskatoon ORs continues.

“It’s not an inevitable thing that’s going to happen,” says Irvine. “In the past, it was so common, there’s kind of an acceptance of it. But why? Why is there an acceptance of it?”

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