Monthly Archives: December 2022

Addressing barriers and gaps in oral health care – moving from access limitations to health equity for people living with disabilities

By: Dr. Sharat Pani



The CIHR recently awarded a 5-year grant to the Network for Canadian Oral Health Research (NCOHR).  The NCOHR was originally established in 2012 to serve as a platform where researchers and research teams from the 10 dental schools in Canada could come together to advance oral health research.

The lack of access to oral health care among socioeconomically disadvantaged individuals, individuals with disabilities and First Nation populations in Canada have been well-documented. As there is little research on the specific challenges to access of oral health care that each group faces, NCOHR has launched 7 Working Groups (Aging and Well-being, Pediatrics and Growing Healthy, Indigenous Peoples Health, Oral Cancer, Orofacial Pain, Disability and Oral Health, and the CADR-NCOHR Trainee Development). We have opened a grant competition to fund research into the barriers and gaps in oral health care, from access limitations to health equity.  Here we examine the lack of access to oral health care for people living with disabilities and how solutions may be found through collaborative research.


Researching Access to Oral Health Care for Individuals with Disability

The 2017 Canadian Survey on Disability reported that 22.7% of individuals over the age of 15 experienced disability in some form. Previous disability surveys have not looked at access to oral healthcare, levels of oral disease, or oromotor function (ability to speak, chew or swallow) among people living with disability. The current disability survey (2022) is in progress and the report is expected by the end of 2023 and will for the first time include data on accessibility barriers faced by Canadians with disability. However, there is still much work to be done to collect and analyze data on access to oral healthcare for these individuals.

The Disability and Oral Health working group of NCOHR was established in 2022 to promote research on the oral healthcare needs of individuals with special healthcare needs. The group has established collaborations with the Canadian Society of Disability and Oral Health and the International Association for Disability and Oral Health.

There are two components to accessible oral health care the willingness of dental care providers to provide care for persons with disabilities and their ability to do so. Access to oral health care for individuals with disabilities requires oral health professionals who are willing to treat them. However, it also requires individuals who have the required training to provide care within dental offices, and more importantly, effectively triage those cases that need to be seen in the hospital. With this in mind, the group has begun work on research projects that look at how Special Care Dentistry is taught among the dentistry and dental hygiene programs in Canada.

The Canadian Dental Association and the Canadian Society for Disability and Oral Health in 2019 developed a case complexity tool that aimed to provide oral healthcare providers an effective tool to triage patients with disabilities (Fig 1.). It has been estimated that in countries that have established special care dentistry referral pathways, fewer than 10% of patients living with disabilities need to be seen in a hospital setting. A validated tool for the triage of patients with disabilities could help oral health care professionals in Canada see more patients living with disabilities in their offices and effectively triage those individuals that need to be seen in hospitals. Validation of this tool is a priority for the working group, and it is hoped that the use of an effective tool can facilitate access to dental care for individuals with disability.

(Source: Canadian Dental Association: accessible online at:


The path forward

The 2022 WHO, Global Oral Health Report recognizes persons living with disabilities as a significant cause of oral health care inequality. The renewal of the NCOHR grant and the recognition of “Addressing barriers and gaps in oral health care” as an area of priority for collaborative research provides a much-needed launch pad for research into the oral healthcare needs of persons living with disability in Canada. It is hoped that collaborative research into the oral healthcare needs of persons living with disabilities can help address the causes, and provide potential solutions to the oral health care inequalities experiences faced by these individuals.


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Fantastic Teeth and Where to Find Them

By: Noha Gomaa, Schulich School of Medicine and Dentistry, Western University



Show me your teeth, and I will tell you who you are.” This almost 300-year-old quote by the French naturalist and father of paleontology George Cuvier was initially intended to describe how the structure of teeth varied by the type of diet that was consumed by different populations. Cuvier’s remark, although unintentionally, has proven to extend beyond its comparative anatomy connotation to portray the stark differences in oral health between socially advantaged and disadvantaged groups of the population. Oral health today continues to be determined by and reflect one’s social and economic conditions.


Observing such oral health inequalities gives rise to important questions around why social plight makes individuals more prone to oral diseases, and on the other hand, what makes fantastic teeth a trait of social advantage. The answer is a multi-factorial one in which several forces are at play. Good oral health has occasionally been attributed to one’s “good genes” that can be protective against acquiring some of the most common yet preventable oral diseases, such as dental cavities/caries and gum inflammation. However, genetic studies do not, on their own, fully justify the variation in oral disease risk, and are certainly unable to explain any oral (or non-oral) health inequalities. Along with the other determinants of health, an individual’s social and economic conditions can impact their access to resources such as quality dental care, adequate nutrition, and fresh produce, while deterring their consumption of sticky and starchy foods that are known to cause oral diseases. Variations in health-compromising behaviours such as oral hygiene practices and smoking have also long been considered as some of the main drivers of oral disease risk that are largely determined by one’s social stance. Earlier studies have however suggested that aiming to enhance oral health behaviours by educating patients about brushing and flossing, while definitely important, may arguably fail to yield the anticipated sustainable results—at least not for those with less resources.


Here, the role of psychosocial stress emerges. Chronic stress can result from the low-grade yet persistent exposures to adverse social and living conditions on a daily basis. Studies in psychoneuroimmunology have demonstrated the pivotal role of chronic stress in several health conditions. Stress acts on various biological responses, putting the hypothalamic-pituitary-adrenal axis in a constant activation mode. This in turn triggers a cascade of multi-system stress responses that contribute to the increased vulnerability to a multitude of diseases, including those of the mouth. Our team at Western University has been diving deeper into how the psychosocial environment and related chronic stress can “get under the skin and in between teeth” to become biologically embedded. In our previous clinical studies, we found that a higher accumulation of the stress biomarker cortisol in hair and saliva was linked to an increased risk of periodontal disease (inflammation of the tooth-supporting structures) in individuals of lower income. These patients also exhibited oral innate immune cells (neutrophils) that were primed to be more conducive of oral inflammation. In a large study of American children and adolescents, we found the risk of untreated dental cavities to increase with the multi-system cumulative biological toll of chronic stress, known as allostatic load. We noted this as being more evident in children from minority racial/ethnic backgrounds. More recently, we started investigating how social disadvantage and related chronic stress may increase oral disease risk by getting down to the level of the genes involved in oral disease initiation and progression. We anticipate providing insight into how oral health inequalities occur over the life-course, and why socially disadvantaged individuals become more susceptible to oral diseases than their more advantaged counterparts.


To this end, we can conclude that fantastic teeth may not just be found with good genes or oral hygiene. For many, they are a prerogative of affluence and access to enabling resources that can determine whether one becomes susceptible or resilient to oral diseases. Consequently, concerted multi-level solutions that target social and living conditions, curb psychosocial stressors (and their biological toll), and enable equitable access to quality oral health care, will continue to be key.

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