DENTISTS and DENTAL SPECIALISTS Yvonne James

DENTISTS AND DENTAL SPECIALISTS Yvonne James

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 1 Dentists and Dental Specialists

and tooth pullers (CDA, 2002). Of the 52 healers listed in Québec City and Montreal, nine were classified as blood letters and tooth pullers. These professionals, although they did little beyond extractions, are considered the forerunners of modern-day dentists in Canada.

By 1816, dentists of a higher calibre and with more specialized training had started to replace these early tooth pullers. However, it is difficult to track exact numbers because dentistry was a sideline business for many: dental services were often provided by gunsmiths, blacksmiths and other tradespeople. By the 1850s, hardly anyone was practising dentistry as a profession in itself. Instead, those who practised were primarily physicians who performed emergency dental treatment, graduates of medical schools who took some apprenticeship training and limited their practices to dentistry, and men who served as apprentices to dentists under an indenture agreement (CDA, 2002).

A CALL FOR REGULATION In the early days of dentistry, there was intense variation in regulation and no real training or expertise. INTRODUCTION This was cause for increasing concern among patients and more specialized practitioners. Some practitioners Dentistry is a unique part of the Canadian health-care began to advocate for establishing dentistry as a system that has been described as an artistic as well as profession, but they were faced with legal, clinical and a scientific profession (Canadian Dental Association social obstacles. Levi S. Parmly, who was in favour of [CDA], 2014a). The scope of a dentist’s work is much regulating and “demystifying” the profession, was open broader today than ever before: the modern dentist about this issue in The Summum Bonum, the first dental must not only have a deep understanding of oral book published in Canada: anatomy and how the health of teeth, gums and mouth relate to general health, but also be able to The veil of mystery which still hangs over navigate through the demands of cosmetic dentistry. Dentistry, renders it not only conjectural, Through oral health education, and diagnosis and but even a suspicious art. This has long treatment of dental disease, dentists provide an ago been removed from the other sciences, essential health service (CDA, 2014a). which induces many to believe that Dentistry is a mere trick….Dentistry, HISTORY OF THE PROFESSIONS however, needs only to be better known The first directory, published in 1791 for the region in order to secure the esteem of mankind. later known as Canada, included listings for those (Bishop, 2014) who practised the healing arts of the day: physicians, surgeons, midwives, apothecaries, and blood letters

2 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists Efforts to establish dentistry as a regulated profession continued and became more organized. In 1860, TABLE 1: Canadian dental schools by year of establishment Charles Brewster of Montreal sent a letter to all School Year of establish-ment known dentists in Canada asking, “What is your opinion University of Toronto 1875 as to incorporating the dentists by Act of Parliament and obliging all those who in future may wish to practice in McGill University 1905 Canada, to pass a proper examination before a Board of Université de Montréal 1905 Dentists?” (Gullett, 1971). He received many replies in 1908 favour of his proposal, but it could not go forward to Dalhousie University Parliament because health care, as it does today, fell University of Alberta 1923 under provincial jurisdiction. University of Manitoba 1958 The first dental meeting in Canada took place in University of British Colum-bia 1964 Toronto on January 3, 1867, and is considered the University of Western Ontario 1966 birth of the Ontario Dental Association (ODA). Working with medical leaders, the ODA produced a University of Saskatchewan 1968 draft Act Respecting Dentistry, which was debated, Université Laval 1971 amended and ultimately passed by the Ontario legislature in 1868. The act established the Board of THE CANADIAN DENTAL ASSOCIATION Directors of the Royal College of Dental Surgeons of On September 16, 1902, 344 dentists gathered in Ontario and gave it the right to establish standards Montreal to found a national association to help them for the now regulated profession (Crawford, 2002). pursue the profession’s ambitions and values (CDA, Dentistry was regulated in Quebec the following year. 2002). As each dentist registered at the conference, he was handed a copy of a proposed constitution, THE ESTABLISHMENT OF DENTAL SCHOOLS complete with by-laws and code of ethics for the new The first formal educational program was established association. These were adopted unanimously on the in 1875 in Toronto, Ontario. The School of Dentistry first day of the meeting. Much of the credit for the was eventually affiliated with the University of Toronto, meeting’s success was due to the tireless efforts of and remains so today. In 1892, the Dental College Dr. Eudore Dubeau of Quebec, who wrote to every of the Province of Quebec became the first school dentist in Canada to rally support for a national of dentistry in French Canada. organization (CDA, 2002). The profession was then largely male dominated Since the 1902 Montreal conference, the CDA (CDA, 2014a). But in 1893, Caroline Louisa has been the national voice for dentistry in Canada. Josephine Wells became the first woman to graduate Today, the CDA’s official mission statement says that from a dental program, graduating from the School the association remains “dedicated to the advance- of Dentistry in Toronto (University of Toronto, 2011). ment and leadership of a unified profession and to In 1905, dental schools opened at McGill University the promotion of optimal oral health, an essential and Université de Montréal. In 1908, Dalhousie component of general health” (CDA, 2014a). University in Halifax, Nova Scotia, became the first school in Eastern Canada to offer a dentist education THE ADVENT OF DENTAL JOURNALS program. By 1964, there were dental schools from Academic dental literature followed the advancement coast to coast in Canada. As of 2018, there are still no of the dental profession in Canada. The first national dental schools in the territories. Table 1 lists Canada’s dental journal was the Canada Journal of Dental dental schools and the years they were established. Science, which published in Quebec and Ontario from 1868 to 1879. The Dominion Dental Journal was established in 1889 and published until 1934.

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 3 It was succeeded by the Journal of the Canadian EDUCATION Dental Association in 1935, which is the present-day In Canada, dentists must complete at least eight years academic publication of the CDA (University of of education beyond secondary school. In addition Toronto, 2011). A growing body of other academic to a bachelor’s degree, dentists must also complete literature also supported the clinical and professional a four-year Doctor of Dental Surgery or Doctor of advancement of the profession. Dental Medicine degree.

DENTISTRY AND MEDICINE Most schools require certain basic pre-dental education The relationship between dentistry and medicine courses—mainly in the maths and sciences—that must is unique among health-care fields. While most be completed during an undergraduate degree before health-care occupations are treated as subordinate enrollment in a dental school. Advanced biology and to medicine, dentistry has remained independent physics are typically not required. However, since these and largely outside of medical dominance. There requirements vary from school to school, prospective are a number of reasons for this, as set out by students should contact the school(s) they are inter- Adams (1999): ested in to determine specific admission requirements.

First, dentistry and medicine pursued Most Canadian dental schools also require applicants their professional projects at the same to complete a Dental Aptitude Test (DAT), which is time. Second, from the beginning, dentistry conducted by the CDA and designed to help students pursued a separate sphere of competence assess their aptitude for a career in dentistry. The DAT or jurisdiction than did medicine. Third, both is an in-person exam available in French or English, medicine and dentistry claimed professional held in November and February each year. Test centres are available across the country and are usually status and expertise by drawing upon the located on college and university campuses. The DAT precepts of medical science; dentistry did consists of a reading comprehension test, a perceptual not challenge medicine’s claim to expertise. ability test, biology and general chemistry questions, Fourth, similarities in the gender and and a manual dexterity text. In 2011, the manual class background of professional leaders dexterity test portion of the DAT became optional as encouraged positive relations between some dental schools do not require these test results. the two professions. There are 10 schools of dentistry in Canada at universities across the country. These include: DENTISTRY TODAY University of British Columbia, University of Alberta, Today, dentistry continues to evolve as both a science University of Saskatchewan, University of Manitoba, and an art within an increasingly complex regulatory University of Toronto, Western University, McGill environment. Major changes to the field of dentistry University, Université de Montréal, Université Laval have included the increasing number of female and Dalhousie University. In 2018, there were practitioners as well as changes to service coverage. 491 Graduates of Canadian DDS programs, For example, in Saskatchewan, fairly extensive public 68 Graduates of accredited Qualifying/Degree dental health plans have been replaced by private Completion programs, 263 Graduates of accredited insurance or out-of-pocket payments. The future of programs in the US, Ireland, New Zealand, and dentistry in Canada will be predominately shaped by Australia and 320 Individuals who successfully changes in the supply and demand of dental health- completed the Equivalency Process for a total of care services as well as advancements in regulation 1143 newly certified dentists. Figure 1 outlines the and technology. The culmination of all these factors— different pathways to licensure depending on where technological, regulatory and social—will continue to a dental graduate obtained their dental degree. affect how dentists practise in Canada.

4 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists Figure 1: Becoming a licensed dentist in Canada

GRADUATE FROM AN GRADUATE FROMA NON ACCREDITED DENTAL PROGRAM ACCREDITED DENTAL PROGRAM General Dentistry Dental Specialty

NDEB Certiﬁcation NDEB Equivalency Process DSCKE – NDEB Dental Specialty Core Process Knowledge Examination

AFK – Assessment of Fundamental knowledge DSATP – Dental Specialty Assessment and Traing Program

ACJ – Assessment of NDEB Written Clinical Judgement NDSE – RCDC Examination Examination and OSCE + ACS – Assessment of Clinical Skills

NDEB Certiﬁcation Qualifying / Degree Completion Program Provincial Licensure

Source: National Dental Examining Board of Canada, https://ndeb-bned.ca/en/requirements

In dental school, students are educated in basic not include additional compulsory fees that vary from and dental sciences, and receive practical training institution to institution, such as fees for athletics, and hands-on clinical experience. They also have the student associations and student health services opportunity to gain experience working in hospitals (Statistics Canada, 2018). In addition to the high and to undertake supervised clinical practice. cost of tuition, dental students are also required to purchase their own dental instruments. Students Pursing a dental specialty requires additional training, at the University of Toronto are expected to spend and many schools also require at least two years of almost $10,000 on required dental instruments formal experience as a general dentist before entering in the 2018–2019 academic year (University of a specialty residency. For example, a specialty in Toronto, 2018. orthodontics requires an additional three-year Master of Science degree and a residency program. And INTERNATIONALLY TRAINED DENTISTS once a dentist has graduated from an orthodontic Internationally trained dentists (ITDs) coming to work residency program, they must successfully complete and live in Canada bring innovation and offer diversity the national dental specialty board certification and culture to the Canadian dental health workforce. examination. A fully certified orthodontist will To become licenced to practise as a dentist in Canada, have spent upwards of 12 years in school. ITDs must:

TUITION COSTS 1. Contact the relevant regulatory body in the Undergraduate students in dentistry pay the highest chosen province/territory for assessment and average university tuition fees. In 2016–2017, recognition of credentials, including language Canadian dentistry students paid, on average, proficiency for registration and other licensing $22,297 in tuition fees per term. This figure does requirements;

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 5 2. Complete an accredited dental program, as a as well as information and advice on developing regular or degree completion student, or com- and maintaining good overall health. plete an accredited qualifying program (to enter a qualifying program, applicants must complete • Detection and management of oral conditions: the Eligibility Examination administered by the Research shows there may be a link between oral Association of Canadian Faculties of Dentistry); disease and other health problems such as diabetes, heart disease and stroke, as well as 3. Pass the National Dental Examining Board of pre-term and low-birth-weight babies. Dentists Canada written examination and the Objective are often the first health-care professionals to Structured Clinical Examination; spot a wide variety of systemic diseases, such as hypertension and cancer. 4. Pass the National Dental Specialty Examination through the Royal College of Dentists of Canada • Aesthetic improvement: Dentists can help (if the prospective dentist wants to practise as improve a patient’s appearance (as well as health) a dental specialist); and through the use of newly developed cosmetic dental techniques. 5. Register with a provincial/territorial regulatory body (CIHI, 2011) • Restoration: Dentists repair damage to the teeth and address gum and oral tissues caused The licencing of ITDs has been the subject of debate by accidents or diseases such as dental caries within the profession, with some arguing ITDs do not (tooth decay) and periodontitis (gum disease). meet Canadian standards of practice. Cholakis, speaking in favour of ITDs, reminds his colleagues that • Correction: Dentists correct oral health problems “concerns should lie in our attitudes toward change caused by crooked, crowded or poorly spaced and realities of a modern world that globally produces teeth or misaligned jaws with orthodontic highly skilled, mobile professionals” (2005). appliances, mouth splints, and other devices and treatments. The CDA has been actively involved in easing the transition of ITDs into the Canadian dental health • Reconstruction: Dentists fabricate substitutes workforce. In 2014, the CDA published an online for lost teeth and oral tissues, including fixed guide to help ITDs navigate the Canadian regulatory replacements and dentures. environment, manage the economic realities of practising in Canada, improve communication skills • Surgery: Dentists perform many kinds of and seek out mentorship opportunities to further oral surgery aside from tooth extractions. assist in the transition into Canadian oral health-care They also perform surgery to correct facial teams (CDA, 2014b). and dental deformities caused by accidents and birth defects.

SCOPE OF PRACTICE SPECIALIZATIONS Dentists perform a number of duties, some of which Dental specialties were not governed in Canada until are regulated acts. These acts may differ slightly across 1944, when Ontario adopted bylaws to recognize provinces. Provinces and territories define dentists’ specialties and certify specialists (Royal College of scope of practice in legislation, most commonly Dentists of Canada [RCDC], 2015). In 1945, the titled “Dentists Act”. The CDA (2015) speaks to the CDA established a Committee on Specialists and variety and depth of a dentist’s scope of practice. Specialization as a stepping stone to creating training For example, dentists may take part in some or all programs in the various branches of dentistry while of the following activities on any given workday: also clearly delineating each specialty. In 1960, a CDA report shed light on the lack of regulatory uniformity • Prevention/public education: Dentists educate for dental specialties across the nation. That report their patients and the general public on how to included a proposal to institute a national specialty prevent oral health problems. As primary health- regulations body. care providers, they provide nutritional guidance

6 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists In 1965, the Act of Incorporation for the Royal College • Oral and maxillofacial radiology is the branch of Dentists of Canada was passed in Parliament, and specialty of dentistry concerned with the which gave the RCDC the parliamentary authority prescription, production and interpretation to examine dental specialties at the national level of diagnostic images for the diagnosis and (RCDC, 2015). management of diseases and disorders of the craniofacial complex. Dental specialties in Canada are regulated by both the RCDC and the Commission on Dental Accreditation • Orthodontics and dentofacial orthopedics is of Canada (CDAC), which reviews and accredits the branch and specialty of dentistry concerned dental and allied oral health-care education programs. with the supervision, guidance and correction of To date, the CDAC has accredited nine nationally growing or mature dentofacial structures, and recognized dental specialties in Canada. The National the diagnosis, prevention and treatment of any Dental Specialty Examination is offered for all nine abnormalities associated with these structures. specialties in Canada. • Pediatric dentistry is the branch and specialty of The RCDC (2015) describes the nine recognized dentistry concerned with providing primary and dental specialities in Canada as follows: comprehensive preventive and therapeutic oral health diagnosis, care and consultative expertise • Dental public health is the branch and specialty for infants and children through adolescence, of dentistry concerned with the diagnosis, including those of all ages with special care needs. prevention and control of dental diseases and the promotion of oral health through organized • Periodontics is the branch and specialty of community efforts. dentistry concerned with the diagnosis, prevention, and treatment of diseases and conditions • Endodontics is the branch and specialty of of the supporting and surrounding tissues of the dentistry concerned with the morphology, teeth or their substitutes, and the maintenance physiology and pathology of the dental pulp. Its of the health, function and aesthetics of these study and practice encompass the basic clinical structures and tissues. sciences, including biology of the normal pulp, and etiology, diagnosis, prevention and treatment • Prosthodontics is the branch and specialty of of diseases and injuries of the pulp and associated dentistry concerned with the diagnosis, resto- periradicular tissues. ration and maintenance of oral function, comfort, appearance and health by the restoration of the • Oral and maxillofacial surgery is the branch natural teeth, and/or the replacement of missing and specialty of dentistry concerned with the teeth and contiguous oral and maxillofacial tissues diagnosis and surgical and adjunctive treatment with artificial substitutes. of disorders, diseases, injuries and defects. It also involves the functional and aesthetic aspects In 2010, approximately 11% of dentists in Canada of the hard and soft tissues of the oral and were dental specialists. The speciality with the highest maxillofacial regions and related structures. number of specialists was orthodontics, with approximately 735 orthodontists. The speciality with the • Oral medicine pathology is the branch and fewest number of specialists was oral radiology, with specialty of dentistry concerned with the diagnosis, only 12 specialists nationwide (CDA, 2010). Table 2 nature and primarily non-surgical management of outlines the specialty training programs at Canadian oral, maxillofacial and temporomandibular diseases dental schools. Figure 2 details the number of certified and disorders, including dental management of dental specialists by province/territory in 2009. patients with medical complications.

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 7 Figure 2: Number of certiﬁed dental specialists by province/territory, Canada, 2009

British 326 Columbia Alberta 214

Saskatchewan 41

Manitoba 96

Ontario 1,059

Quebec 358

New Brunswick 36

Nova Scotia 79

Prince Edward 6 Island

Newfoundland 16 and Labrador Yukon 0

Northwest Territories 2 0 200 400 600 800 1,000 1,200

Source: CIHI, 2011. Notes: This table represents a summary of dental specialists certiﬁed in endodontic, oral and maxillofacial surgery, orthodontics, pediatric dentistry, periodontics, prosthodontics, dental public health, oral pathology and oral radiology.

TABLE 2: Specialty programs at Canadian dental schools School Specialties Endodontics, Orthodontics, Pediatric dentistry, Periodontics, Prosthodontics, University of British Columbia 6 Oral medicine and oral pathology University of Alberta 2 Orthodontics, Oral medicine and oral pathology University of Saskatchewan 0 University of Manitoba 4 Oral and maxillofacial surgery, Orthodontics, Pediatric dentistry, Periodontics Dental public health, Endodontics, Oral pathology and oral medicine, Oral and University of Toronto 9 maxillofacial radiology, Oral and maxillofacial surgery, Orthodontics, Pediatric dentistry, Periodontics, Prosthodontics University of Western Ontario 2 Orthodontics, Oral and maxillofacial surgery McGill University 1 Oral and maxillofacial surgery Université de Montréal 2 Orthodontics, Pediatric dentistry Université Laval 2 Oral and maxillofacial surgery, Periodontics Dalhousie University 2 Oral and maxillofacial surgery, Periodontics Source: Usama Nassar,Connor Fairbanks; Carlos Flores-Mir, Alan Kilistoff, Rick Easton, J Can Dent Assoc 2016;82:g19 https://jcda.ca/g19

8 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists TABLE 3: National associations for dentistry specializations Specialization National association Website Dental public health Canadian Association of Public Health Dentistry www.caphd.ca Endodontics Canadian Academy of Endodontics www.caendo.ca Oral and maxillofacial surgery Canadian Association of Oral and Maxillofacial Sur-geons www.caoms.com Oral medicine and pathology Canadian Academy of Oral and Maxillofacial Pathology and Oral Medicine No website available Oral and maxillofacial Canadian Academy of Oral and Maxillofacial Radiology No website available radiology Orthodontics and Canadian Association of Orthodontics www.cao-aco.org dentofacial orthopedics Pediatric dentistry Canadian Academy of Pediatric Dentistry www.capd-acdp.org Periodontics Canadian Academy of Periodontology www.cap-acp.ca Prosthodontics Association of Prosthodontists of Canada www.prosthodontics.ca Source: CIHI, 2011.

REGULATION OF THE PROFESSION • Protecting the public’s right to quality dental services; and The National Dental Examining Board of Canada (NDEB) is responsible for establishing and maintain- • Providing leadership to the profession in ing a national standard of competence for dentists self-regulation. (Canadian Dental Regulatory in Canada. Graduates of accredited dental programs Authorities Federation, 2014) or accredited qualifying/degree completion programs and individuals who have completed the NDEB In addition to a dental regulatory college, each Equivalency Process must pass the NDEB’s written jurisdiction also has a dental association. In most examination and Objective Structured Clinical provinces, the college is separate from the profes- Examination to be eligible for licensure as a general sional association (this is mandated, for example, in dentist in Canada. Ontario), but sometimes they are joined (as in Alberta). Membership in the provincial/territorial and Dentistry is a provincially regulated health profession. national dental associations is mandatory for licensure The regulatory body is typically called a college and in all provinces except Ontario and Quebec. None of is generally responsible for: the territories require membership in the professional associations for registration and licensing. • Setting the education and other qualifications necessary to enter the profession; Upon successful completion of the NDEB exam, prospective dentists must register with the professional • Setting standards of professional practice; college of dentists in their jurisdiction of practice to • Setting ethical standards; become fully licenced. Moreover, regulatory authorities in some provinces (such as Ontario and Alberta) require • Investigating complaints from people who applicants to complete an examination that tests feel the standards have not been met; knowledge of local law, ethics and regulation of the profession in that jurisdiction. Table 4 presents each • Taking appropriate disciplinary action jurisdiction’s college and association. as necessary;

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 9 TABLE 4: Dental regulatory colleges and associations by province/territory Year of Province/territory mandatory Dental regulatory college Dental association registration College of Dental Surgeons of British British Columbia 1886 British Columbia Dental Association Columbia Alberta 1906 Alberta Dental Association and College Saskatchewan 1906 College of Dental Surgeons of Saskatchewan Manitoba 1883 Manitoba Dental Association Ontario 1868 Royal College of Dental Surgeons of Ontario Ontario Dental Association Association des chirurgiens dentistes du Quebec 1869 Ordre des dentistes du Québec Québec New Brunswick 1890 New Brunswick Dental Society Nova Scotia 1891 Provincial Dental Board of Nova Scotia Nova Scotia Dental Association Prince Edward Island 1891 Dental Council of Prince Edward Island Dental Association of Prince Edward Island Newfoundland and Newfoundland & Labrador Dental 1893 Newfoundland and Labrador Dental Board Labrador Association Yukon 1958 Registrar’s Office Yukon Dental Association Northwest Territories & Nunavut Dental Northwest Territories 1988 Government of Northwest Territories Association Northwest Territories & Nunavut Dental Nunavut 1999 Nunavut Registrar’s Office Association

DEMOGRAPHICS Currently, there is widespread debate regarding the “over-saturation” of dentists in Canada (Blackwell, 2013). The CDA has released data on the age, sex and Some reports suggest that there is a growing per-capita provincial distribution of dentists in Canada. The data pool of dentists in some jurisdictions, particularly in large revealed that the majority of dentists are concen- urban centres like Toronto, Montreal and Vancouver, while trated in Ontario and Quebec (see Table 5). Data rural and remote communities remain underserved. One from 2018 revealed that there were approximately result of the “over-concentration” of dentists in urban 24,731 dentists practising in Canada (CIHI, 2020). centres has been a trend toward bidding wars; many Roughly 20% of dentists are over the age of 60. young dental professionals would rather buy an office that already has a full patient load (Blackwell, 2013).

TABLE 5: Registered dentists by province/territory, Canada 2014-2018 Province 2014 2015 2016 2017 2018 British Columbia 3,196 3,261 3,379 3,371 3,591 Alberta 2,318 2,430 2,461 2,518 2,694 Saskatchewan 434 438 442 489 533 Manitoba 675 697 718 711 730 Ontario 9,216 9,452 9,737 9,939 10,417 Quebec 4,980 5,055 5,173 5,175 5,350 New Brunswick 319 327 337 321 326 Nova Scotia 534 528 539 553 565 PEI 74 77 80 80 84 Newfoundland & Labrador 198 205 206 223 235 Territories 190 195 189 176 206 Canada 24148 24680 25277 25573 26749 Source CIHI 2020

10 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists Figure 3: Population to dentist ratio in Canada in 1997, 2005 and 2014, by province

2,740 Newfoundland 3,150 and Labrador 3,720

2,680 Saskatchewan 2,790 2,870 2,450 New Brunswick 2,610 3,100

1,910 Manitoba 2,060 2,120

1,890 Prince Edward 2,260 Island 2,780

1,850 Alberta 1,820 1,960

1,730 Nova Scotia 1,830 2,170

1,660 Quebec 1,870 1,880

1,510 Ontario 1,590 1,760 1997 1,470 2005 British 1,470 Columbia 1,610 2014

0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000

Population per one dentist

Source: Population to dentist ratio in Canada by province 2014, John Elﬂein, Mar 13, 2017, https://www.statista.com/statistics/686403/population-to-dentist-ratio-in-canada-by-province/

This statistic shows the population to dentist ratio in Canada in 1997, 2005, and 2014, by province. In 2005, there were some 1,590 people per every dentist in Ontario. Nine years later, this ratio decreased to 1,510 persons per every dentist.

Figure 3 shows two trends. First, although the bulk The CDA also highlighted the increase of women of dentists are in Ontario and Quebec, the density entering the profession. In 2019, 38.5% of dentists of dentists is the second and third lowest in those were female. The proportion of women in the provinces. Second, it shows a trend towards a profession ranges from a low of 28.7 in Alberta decreasing population to dentist ratio, which supports to a high of 48.3 in Quebec (CIHI 2020). the ‘over-saturation’ hypothesis.

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 11 The recent influx of women into dentistry has led profession but rather taking part in a previously researchers and health workforce planners to consider male-dominated field as professionals socialized the potential impact of feminization1 on the profes- within a predetermined operational model. sion. In 2005, Dr. Tracey Adams conducted a case study on the Ontario dental profession to analyze PRACTICE SETTING the possible ripple effects of this demographic shift. Dentists practise in a variety of settings. Most dentists (approximately 54%) are in solo private practice. While Adams found little evidence that women are About 19% are in partnerships, and another 19% transforming the dental profession, she did find are associates in a private practice. In partnerships, some key gender differences in practice (2005). dentists share clinic management and revenue Among other things, 55% of male dentists worked in more or less equally. An associate is more akin to a solo practice, compared to 35% of female dentists an employee with a stake in managing, creating and (2005). The most striking demographic characteristic distributing clinic revenues. A very small percentage difference, however, was “the extent to which [female of dentists (just over 2%) work in academic settings. dentists] are foreign born and foreign-trained” Dentists may also work in the public health sector (Adams, 2005). Adams found that more than one or in the military (see Figure 4). third (36%) of Ontario female dentists were trained outside of Canada in 2002, compared to 15% of male dentists (2005).

There were also differences in practice hours per week, with women working slightly fewer hours per week than men, as well as practice type, both of which

Figure 4: Practice setting for Canadian dentists, 2010

SOLO PRIVATE PRACTICE

PARTNERSHIP PRIVATE PRACTICE

ASSOCIATES IN PRIVATE PRACTICE

ACADEMIC SETTING

MILITARY

OTHER AND RETIRED

Source: CDA, 2010.

appeared to be influenced by family roles and career goals (Adams, 2005). It seems, then, in the case of dentistry, women are not significantly altering the 1 According to Adams (2005): “In the sociological literature, two definitions of feminization can be found. One definition describes feminization as simply involving the movement of women into an occupation or field [Abercrombie, Hill, & Turner, 2000]. The other depicts a more fundamental transformation whereby women not only become more numerically dominant in an occupation, but the occupation itself undergoes a fundamental shift in sex-typing, and comes to be seen as ‘women’s work’ [Jary & Jary, 1995]. While male-dominated professions like dentistry, medicine and law, are clearly experiencing the first dimension of feminization—an increased participation of women—there is less evidence that the second kind of feminization is occurring.”

12 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists COVERAGE OF SERVICES • Individuals with developmental disabilities;

In 2014, the Canadian Academy of Health Sciences • Veterans; (CAHS) released a report concluding a three-year • Federal prisoners; and evaluation into the issue of access to oral health care among vulnerable groups in Canada. The report found • Refugees. that there are significant income-related inequalities in oral health and inequity in access to oral health care. It Most public oral health programs that provide services also found that income-related inequalities in oral health to underprivileged groups fall under provincial or are greater in women than in men (CAHS, 2014). territorial jurisdiction. These include regional and municipal programs as well as university-provided According to a Canadian Association of Public Health programs. It is important to note that while some Dentistry (CAPHD) study, 17% of Canadians had services are provided by public insurance, the majority avoided going to a dental professional in the last year of these oral health-care services are typically because of the cost, and 16% of Canadians had avoided delivered by allied oral health-care professionals such having the full range of recommended treatment due to as dental hygienists and dental therapists. Provincial/ cost. In addition, 32% of Canadians have no dental territorial public oral health programs tend to include: insurance (CAPHD, 2014). This is significant because the CAHS report emphasized that oral health is part • Surgical-dental services requiring hospitalization of general health, with the same social, economic and or associated with a congenital anomaly or behavioural determinants, and with direct links between medical need; poor oral health and poor general health (2014). • Services for social assistance recipients and their Despite these findings, most dental services are not dependants; covered by the Canadian public health-care insurance system. Approximately 55% of all private expenditures • Services for targeted child and adult populations on dental care are covered by private insurance (e.g., low-income families); sources and 45% by out-of-pocket payments • Services for targeted populations with disabilities (CAPHD, 2014). or living in institutions (e.g., those in long-term The public funding envelope does cover some dental care); and services provided in hospitals. However, these and • Services for inmates of provincial prisons. other public dental services represent a very small (CDA, 2010) proportion of the overall dental services in Canada. According to CDA (2010) data, approximately 5% of dental expenditures in 2009 were covered by public funding and provided treatment to individuals in the following groups:

• Military personnel;

• Indigenous people;

• Social assistance recipients and their dependants;

• Seniors;

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 13 DENTAL TECHNICIANS/ may also be based on non-academic achievements, TECHNOLOGISTS such as community involvement.There are dental technician/technologist programs in almost INTRODUCTION every province across Canada. Table 6 provides Dental technologists and technicians design, prepare information on educational institutions in Canada and fabricate dental devices as prescribed by dentists that provide training in dental technology. and other specialists (Human Resources and Skills Development Canada [HRSDC], 2013. After graduating, dental technicians and technologists in all provinces (except in HISTORY Manitoba and the territories) must register Beginning in the mid-19th century, dental schools with the relevant regulatory body. in the United States required students to learn prosthetic fabrication techniques. At that time, TABLE 6: Dental technician/technologist educational virtually all dental laboratories were attached to programs in Canada dentists’ offices (College of Dental Technicians of Province Institution

British Columbia [CDTBC], 2008). By the 1950s, British Columbia Vancouver Community College however, increasing demand for prosthetics required dentists to devote more skill and time to meet Alberta Northern Alberta Institute of Technology these needs. Ontario George Brown College

In response, some dentists shifted their practices Quebec College Edouard-Montpetit to focus solely on designing and fabricating dental prosthetics for other dentists. 2. On-the-job training In some provinces, dental technician educational The foundational partnerships between dentistry and requirements can be met outside the classroom. dental technicians have persisted and, today, there is Dental technicians can qualify to register with still significant collaboration between the two profes- their provincial regulatory college by providing sions. Dentists rely on dental technicians’ skills to dental technician services for at least five years. provide well-constructed dental appliances to meet The on-the-job training must be completed patient needs, while dental technicians rely on referrals under the supervision of a registered dental from dental practitioners (e.g., dentists, dental technician or technologist (HRSDC, 2013). surgeons, orthodontists) to drive their businesses. REGULATION EDUCATION AND TRAINING The profession of dental technology is regulated In some provinces, there are two pathways to fulfill in all provinces except Manitoba and is not regulated educational requirements in dental technology. To in the territories. Requirements for initial and continu- register as a dental technician, students can either (1) ing registration or licensure vary from province to graduate from an approved educational program or (2) province. Each provincial regulatory body sets its complete four to five years (depending on provincial own education, competency and qualification regulations) of on-the-job training (HRSDC, 2013). requirements.

1. Approved educational program SCOPE OF PRACTICE Admission requirements for dental technician/ Depending on province of practice, dental technicians technologist programs may differ by jurisdiction and technologists may perform some or all of the but, in general, educational institutions require following duties: applicants to have Grade 12 English and math credits, as well as credits in science, chemistry, • Design, fabricate or repair dental devices, physics and social studies. A competitive entrance including full or partial dentures, orthodontic grade average in these courses is usually at least appliances, crowns, bridges, inlays, onlays, 70%. Student selection is usually competitive and clasps and bands, and implants;

14 Introduction to the Health Workforce in Canada | Dentists and Dental Specialists • Prepare plaster models and moulds from In recent years, the development of alternatives to dental impressions; removable dental devices and new materials for use in prostheses and ortheses has directly influenced dental • Prepare wax bite-blocks and impression trays; technicians’ and technologists’ evolving scope of practice. In particular, while the demand for complete • Cast gold or metal alloys for bridges and removable devices like dentures has diminished, the denture bases; demand for partially removable devices, fixed prostheses • Pack plastic material into moulds to form (such as crowns and bridges), orthodontic prostheses full or partial dentures; and dental implants has risen (Service Canada, 2015). The rise in demand for complex oral prostheses has • Mould wax over denture set-up to form full contributed to the increasing complexity of dental contours of artificial gums; technicians’ and technologists’ scope of practice. Currently, there is some question as to whether or • Make orthodontic bands from gold, silver, not the educational standards for technicians and stainless steel or other metals; technologists can keep pace with the accelerated • Finish metal framework of dentures and polish rate of technological advancements and the and buff dentures to obtain natural finish; ever-expanding scope of practice.

• Consult with dentists or other specialists on PRACTICE SETTING problematic dental cases; Dental technicians and technologists work in a variety of practice settings. Many experienced • Train and supervise other dental technicians and dental technologists operate their own commercial dental laboratory assistants in fabricating dentures dental laboratories, while others are employed by and other dental devices; and dental laboratories as registered dental technolo- • Perform administrative functions for the dental gists-in-charge. Some professionals may work as laboratory (CDTO, 2012). consultants or hold positions in universities, community colleges and hospitals that offer dental technology services (CDTO, 2012). TABLE 7: Dental technician/technologist regulatory authorities across Canada Province Regulatory body

College of Dental Technicians of British British Columbia Columbia

Alberta College of Dental Technologists of Alberta

Association of Dental Technicians of Saskatchewan Saskatchewan

Ontario College of Dental Technologists of Ontario

Ordre des techniciens et techniciennes Quebec dentaires du Québec

New Brunswick Dental Technicians New Brunswick Association

Nova Scotia Dental Technicians Nova Scotia Association

Newfoundland Newfoundland and Labrador Dental Board and Labrador

Introduction to the Health Workforce in Canada | Dentists and Dental Specialists 15 CONCLUSION ACRONYMS Over the past hundred years, dentistry has evolved CAHS Canadian Academy of Health Sciences to reflect the changing needs of the Canadian population. Over the past decade alone, dentistry CAPHD Canadian Association of Public has undergone a demographic shift in gender makeup. Health Dentistry The rising costs of dental education have led to CDA Canadian Dental Association dentists graduating with some of the highest student debt loads of any professional program in the country. CDTA College of Dental Technologists of Alberta Access to and coverage of services continue to be a significant issue for many people—particularly CDTBC College of Dental Technicians of Indigenous communities, who see the highest rates British Columbia of poor oral health in the country. It will be interesting CDTO College of Dental Technologists of Ontario to see how modern dentists continue to meet the evolving needs of both the dental health workforce CDAC Commission on Dental Accreditation as well as the patients served by that workforce. of Canada

CIHI Canadian Institute for Health Information

DAT Dental Aptitude Test

ITD Internationally trained dentist

ODA Ontario Dental Association

NDEB National Dental Examining Board of Canada

RCDC Royal College of Dentists of Canada

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