Long hours, inadequate work spaces and lower pay.
Those are some of the conditions dentists face when they travel to remote N.W.T. communities.
Earlier this year, the territorial government sent out four requests for proposals (RFPs) for service in several communities.
CBC recently reported that two of those RFPs were cancelled in March after neither received bids. One covered the Sahtú, the other Gamètì, Whatì and Fort Resolution.
The RFPs for the Beaufort-Delta and Dehcho each received one bid, but contracts have not yet been awarded, leaving it unclear when dental visits will happen in communities.
Equipment in disrepair
Dr. Pirjo Friedman is a dentist with Adam Dental Clinic in Yellowknife who has spent much of the past 12 years travelling to communities.
She says broken equipment has been one of the biggest challenges, especially post-pandemic.
Last September, she was in Fort Simpson when the tool to rinse patients’ mouths broke and could not be easily turned off.
After every trip, Friedman says she’s required to fill out a form on the condition of equipment. She says she’d reported the tool was malfunctioning for nearly two years before it broke. Despite this, a trip scheduled for January was cancelled because it was still not fixed.
“We would have drowned patients,” she quipped.
In October, Friedman was in Délı̨nę when an air compressor broke. She says a fix wasn’t possible and it was community members who helped fly in a replacement from Tulita. She lost a day and a half out of the five she was in the community.
Todd Sasaki, spokesperson for the territory’s procurement services, said the recent RFPs included a list of available equipment in each community. Dentists would be required to bring compressors and air purifiers to those that didn’t have any. Even portable compressors can weigh 18 to 32 kilograms.
Friedman says that’s “unreasonable,” especially when going to fly-in communities.
Who’s responsible for fixing equipment is not clear. Jeremy Bird, spokesperson for the territorial department of health and social services, said dentists are responsible for “performing minor repairs.” But Friedman says she’s been warned against doing repairs.
Dental services in the territory’s communities are funded through Indigenous Services Canada’s non-insured health benefits program (NIHB). In 2022-2023, the territory received $18.4 million to administer NIHB; $595,000 went for dentist travel to communities.
There is currently no contribution agreement to administer NIHB for 2023-2024.
Indigenous Services Canada (ISC) also provided funding to the territory in 2019 ($207,355) to purchase equipment and in 2020 ($508,000) to assess, purchase and retrofit equipment to follow COVID-19 protocols.
“Discussions are on-going regarding financial support for dental equipment in communities,” said Carolane Gratton, spokesperson for ISC.
Pay cut
Dentists who work in communities where most people are NIHB clients make less money than if they stayed at a standard clinic.
That’s because NIHB rates are lower than those in the guide established by the territorial dental association.
For example, if a resident needed a crown to cover a damaged tooth, dentists receive about 20 per cent less: $943 for NIHB patients versus $1,165 for other patients.
For other common procedures, like cavities and root canals, dentists receive about 25 and 15 per cent less, respectively.
“Definitely that can be something that dentists would consider very much a disadvantage going to the communities,” said Friedman.
NIHB also has stricter limits on cleaning and polishing. Those services are billed in 15-minute “units.” Adult NIHB clients are limited to four units per year — and again at a lower rate. Friedman says many private insurance providers will cover up to 12 units.
As dentists operate private businesses, ISC says, “NIHB cannot dictate the rates that a dental provider chooses to charge.” But, the NIHB fee guide is the maximum dentists can recoup for their services under the program.
“If that was more equal, I’m sure that would be much more helpful to get dentists going to the communities,” said Friedman, the dentist.
Dr. Roger Armstrong, president of the NWT-NU Dental Association, echoes that sentiment.
He said there are several “big picture” issues, like inflation, a labour shortage, and an urban/rural divide, that have led to the rising cost of doing business.
“The expense side of the equation is increasing faster than the revenue side,” he said. “This is especially true in the remote communities with NIHB being the predominant form of dental insurance.”
To balance that equation, he said, NIHB would ideally match the fees set out by dental associations.
Hours to set up, weeks to travel
The N.W.T.’s department of health says there are designated work spaces in each community’s health centre (except Wekweètì) for dentists.
But Friedman says she often arrives to find rooms full of boxes and other supplies that need to be cleaned out before seeing patients.
“Sometimes you’d use cardboard boxes and action packers to have enough surface space for all the equipment that we have,” she said. “It takes me and my assistant several hours to set up and then unpack. All that time the assistant gets paid but the dentist doesn’t.”
And, in the recent RFPs, dentists are charged a daily rental rate.
“The room rental fee was included as a means of offsetting the cost of the space and maintenance of tools and equipment,” said Sasaki.
Dentists would also be limited to 23 kilograms of “consumable supplies” per dental visit that would be eligible for NIHB reimbursement.
But Friedman says she’ll often visit multiple communities back-to-back for five to 10 days each, that weight is used up quickly.
That kind of schedule, she adds, may also be a deterrent for dentists to take on remote services.
“If you have a family, you don’t really want to go for weeks at a time. I find that shorter trips would be preferable for me, and also the assistant as well,” she said.
So who is responsible for the travel schedule?
“ISC is responsible for travel,” said the N.W.T. government’s Bird.
Gratton acknowledged that ISC plans the number of days for communities, but “does not have a role in planning visits to remote communities.”
She later added that ISC planned to contact the health department to clarify the roles of each government.
Dental work in communities ‘badly needed’
Despite submitting the only bid back in March, Adam Dental has still not been awarded the contract for services in the Dehcho.
“I have not been working for two months and I could have been going to do some dental work in communities where they so badly need it,” Friedman said.
The latest delay comes after services were paused for nearly three years during the pandemic in some communities.
Thelma Tobac, a mom of three from Fort Good Hope, previously told CBC she struggled to get dental care for her kids during that time.
Two of her children were recently referred to Edmonton for more dental work.
She says the travel would be covered for both kids through NIHB, as well as the surgery for her five-year-old son, but she has to pay about $2,000 for her 13-year-old daughter’s procedure.
That’s because unless dental clinics are enrolled with NIHB to bill the program directly, clients have to pay out of pocket. They can then request a reimbursement within a year.
Tobac says she doesn’t have the money to pay up front. She’s also tried getting help through Jordan’s Principle, but says she wasn’t eligible because dental services are covered under NIHB.
“Just wait until the money comes, I guess,” she said. “[It’s] kind of stressing.”
Dene National Chief Gerald Antoine said the current situation has “reached crisis levels.”
“I am concerned that lack of dental care will further undermine people’s overall health in our communities,” said Chief Antoine.
Friedman says more regular visits to communities can help prevent a build-up of oral health issues.
She gave the example of Fort Resolution, where she’s been going for 10 years.
“You could definitely see the difference of regular maintenance,” she said. “Patients would come for checkups and cleanings and X-rays, and sometimes you don’t need to do anything.”
At 71, Friedman says she still enjoys going to the communities despite the difficulties, but is nearing the end of her career.
“It feels very meaningful to be able to help those who are in those remote communities,” she said.
With no dentists currently scheduled to travel, residents need to contact their health centre to request an appointment outside of their community.
Bird said NIHB then decides to approve the request or not; if approved, wait times for urgent requests are two to four weeks.
He added that “emergency” cases that are “potentially life-threatening” do not need to be approved by NIHB.
Gratton says ISC is aware of many of the challenges outlined above and that it is working with the territory to address them.
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