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Homelessness & Health in Canada

 | 
Manal Guirguis-Younger
, 
Ryan McNeil
, 
Stephen W. Hwang

Part II-Policy & Programmatic Responses to Homelessness & Health

Chapter 8. Homelessness and Oral Health

Bruce Wallace, Rafael Figueiredo, Michael MacEntee et Carlos Quiñonez

Texte intégral

Introduction

1In Canada, dentistry is generally funded as an employment-based benefit or as an out-of-pocket expense rather than via the public health care system. Consequently, socioeconomic status heavily influences access to dental treatment. In this system, persons experiencing poverty and homelessness face significant barriers to oral health care. The links between poverty and poor oral health are well documented, as is the importance of good oral health to overall health and well-being. However, less is known about how to reduce the barriers to oral health care faced by persons experiencing poverty and homelessness.

2Dentists often seek to meet the needs of homeless persons and other low-income populations through charitable donations of their services. However, there are strong opinions that charity offers little more than a 'band-aid solution' to a complicated set of social problems (Crall 2006; De Palma and Nordenram 2005; Frankish, Hwang and Quantz 2005; Hwang 2001, 2002; Moore, Gerdtz and Manias 2007; Mouradian 2006). The British Dental Association (2003), for example, states that charitable dentistry by unpaid volunteers "is clearly no substitute for a coherent and properly-funded dental access strategy for homeless people", and adds "that homeless people, just as much as any other section of the community, are entitled to adequate and accessible dental care as a right, and should not be forced to rely on charity" (37).

3The issue of access to dental care is gaining more prominence as a health policy issue in Canada. Social and professional pressure has mounted on governments for renewed investments in dental care, and some provincial and municipal governments have responded (Quiñonez et al. 2010). However, policy-makers and service providers lack a definite strategy to respond to the numerous groups and challenges associated with oral health and oral health care inequalities (Quiñonez, Figueiredo and Locker 2009a). Meanwhile, governments and local health authorities continue to reduce health care spending and to encourage shifts of public health care into the private realm (Quiñonez, Figueiredo and Locker 2009a). Therefore, it appears that dental care reform is not a priority at present (Birch and Anderson 2005) and that dentistry is likely to remain outside the Canadian national health care system for the foreseeable future. In this context, the oral health needs of homeless persons are often ignored and excluded in service plans or policies that address access to dental care, and similarly in those that address homelessness and health in general.

4Improvements to oral health policies and practices for homeless populations are most likely to occur through the inclusion of oral health within national, provincial and local strategies to reduce poverty and homelessness. Provincial poverty reduction plans with measurable goals and timelines have been developed as a proactive response to regressive 'welfare reform', which has dismantled the public safety net significantly over the last few decades. In some cases, the strategies have recommended increased public dental benefits. For example, the Ontario Poverty Reduction Strategy contains a Low-Income Dental Program that includes building community capacity to deliver prevention and treatment services for low-income Ontarians (Province of Ontario 2008). New Brunswick's poverty reduction plan includes a plan to provide dental care to children in low-income families and the extension of dental benefits for individuals leaving welfare for work for three years as part of an overall goal of a comprehensive system of supplementary health care for low-income people (Government of New Brunswick 2010).

5Homeless action plans have become a standard response to homelessness. Again, the inclusion of dental care in these strategies is a possible approach to ensure that oral health is not excluded from health care for the homeless. The report of the Mayor's Homelessness Action Task Force from Toronto (Golden et al. 1999) notes that many people who are homeless cannot access dental care and that we must first ensure that all homeless persons get dental benefits and then expand the number of accessible clinics where people can walk in and receive basic dental care along with other health and social services (Golden et al. 1999). Victoria's Mayor's Task Force on Breaking the Cycle of Mental Illness, Addiction and Homelessness (City of Victoria 2007) led to the creation of the Greater Victoria Coalition to End Homelessness. Calgary developed a 10-Year Plan to End Homelessness (Calgary Committee to End Homelessness 2008) and Ottawa also has a Community Action Plan on Homelessness—and there are similar examples of more local poverty responses in other Canadian urban areas.

6Meanwhile, communities are seeing the immediate needs and, on a local basis, are responding in unique ways. There are now numerous examples of treatment alternatives helping homeless persons and persons living in extreme poverty get the dental care they need (Leake 2005, 2006; Main, Leake and Burman 2006). The literature on community dental clinics in Canada and the United States shows that they can play a unique and valuable role as a source of dental care for groups with traditional access barriers (Byck, Cooksey and Russinof 2005; Geller, Taylor and Scott 2004; Gooch, Griffin and Malvitz 2006). Indeed, they have been deemed by some as a 'mandatory' health service due to the shortcomings of the existing dental care delivery system and the overwhelming unmet dental health needs of the underserved (Byck, Cooksey and Russinof 2005).

7Community dental clinics in many parts of Canada are expanding dental care for underserved populations, including homeless populations. Inner-city community health centres (chcs), in particular, provide an avenue to address the health care needs of vulnerable and marginalized populations, yet most of them do not have dental clinics. To advance discussion in this area, we will describe the oral health care needs of homeless populations, the barriers they face to accessing these services and the growing role that community dental clinics play in improving access to care.

Oral Health and Homelessness

8Studies of homelessness and oral health (Table 8-1) are few and usually limited to small sample sizes (Blackmore et al. 1995; Chi and Milgrom 2008; Collins and Freeman 2007; Conte et al. 2006; Daly, Newton and Batchelor 2009; De Palma and Nordenram 2005; De Palma et al. 2005; De Palma 2007; Gibson et al. 2008; Jago, Sterberg and Westerman 1984; Kahabuka and Mbawalla 2006; Kaste and Bolden 1995; Lee, Gaetz and Goettler 1994; Luo and McGrath 2006; Pizem et al. 1994; Waplington, Morris and Bradnock 2000). Overall, they show that homelessness has a direct association with poor oral health (Bolden and Kaste 1995; Clarke et al. 1996; Conte et al. 2006; De Palma and Nordenram 2005; De Palma et al. 2005; De Palma 2007; Dogan et al. 2006; Gaetz and Lee 1995; Gelberg, Lin and Rosenberg 1988; Gibson et al. 2003; Han, Wells and Taylor 2003; Jago, Sterberg and Westerman 1984; Kaste and Bolden 1995; Lee, Gaetz and Goettler 1994; Luo and McGrath 2006; Pizem et al. 1994). Homeless persons have poor oral health, such as missing and decayed teeth, oral pain, gum disease and related conditions in need of urgent attention (Allukian 1995; City of Toronto 2000; Clarke et al. 1996; Collins and Freeman 2007; Hwang 2001, 2002; King and Gibson 2003). For example, 91 percent of clients of a dental program associated with homeless shelters in Boston had a very high need for preventive and restorative dentistry due to caries (Kaste and Bolden 1995). They reported difficulty accessing dental care and caring for their teeth due to a lack of oral hygiene products and adequate restroom facilities. Similar observations were made in Brisbane, Australia, where homeless individuals had thick calculus deposits on their teeth and seemed to accept tooth loss without complaint or obvious concern, although they did state that dentists were reluctant to treat them (Jago, Sterberg and Westerman 1984).

9Research published as early as the 1990s shows that Canada's homeless populations have fared no better. In Montreal, in 1994, Pizem and colleagues (1994) reported that 61 percent of the homeless population needed dental treatment. In Toronto, 50.6 percent of the homeless youth (14 to 25 years old) reported toothache and 74.1 percent expressed willingness to visit a dentist, but among those one-third did not know where to go (Lee et al. 1994). Also in North York, Ontario, and 72.7 percent of the homeless youth needed dental restorative treatment and 72.7 percent had moderate to severe gingivitis (Clarke et al. 1996).

Table 8-1. Select published studies of the oral health status of homeless people

Table 8-1. Select published studies of the oral health status of homeless people

Table 8-1. (Continued)

Table 8-1. (Continued)

10A recent report from Toronto found similarly high distributions of oral pain and poor self-rated oral health (Khandor and Mason 2007). The report also notes that many of those interviewed were without teeth or dentures because social assistance in Ontario would only pay to have their teeth extracted (Khandor and Mason 2007). Moreover, nearly half (43%) of respondents stated that they could not afford dental care and had not been to a dentist in the past three years due to poverty (Khandor and Mason 2007). Homeless persons in Vancouver and Victoria also made little use of dental services compared to other health services, especially emergency departments of local hospitals (sparc-bc 2008; Victoria Cool Aid Society 2007). Homeless persons in Victoria identified dental problems as a barrier to finding work (Victoria Cool Aid Society 2007), and they feel that public dental benefits from welfare programs do not cover extensive treatment needs (Klein et al. 2008).

11Many factors contribute to poor oral health of homeless people:

  • a chaotic lifestyle and more pressing 'survival needs' prevent routines of eating and personal hygiene;
  • acceptance of poor dental health and appearance;
  • limited access to washing facilities, toothbrush and toothpaste;
  • poverty;
  • lack of awareness of diet and oral hygiene issues;
  • mental health problems and substance misuse (British Dental Association 2003: 13).

12People with dental pain or who have no teeth often eat only soft foods, such as the day-old pastries and coffee offered by dropin day-programs and other social service agencies (Gelberg, Lin and Rosenberg 1988). Frequent consumption of refined carbohydrates and other sugary foods, especially when oral hygiene is poor, quickly leads to rampant caries (Bolden and Kaste 1995; Gaetz and Lee 1995; Han, Wells and Taylor 2003). Undoubtedly, many people who are homeless are acutely aware of the consequences of poor oral hygiene. As one homeless youth in Gaetz and Lee's (1995) study reported: "I left home two weeks ago and I haven't been able to brush my teeth since. I hate that feeling—my teeth all furry. It's kind of embarrassing" (34).

13Tobacco, alcohol and illicit drug use are widespread among homeless people and can have a devastating impact on oral health, with problems such as 'meth mouth' from inhaling crystal meth (Gelberg, Lin and Rosenberg 1988; Conte et al. 2006; Blackmore et al. 1995; Chi and Milgrom 2008). Other studies (Robbins et al. 2010), however, questioned the supposed impacts of 'meth mouth' with the view that the oral diseases might be related more to poverty, homelessness and poor hygiene than to crystal meth. Dental problems are common among injection drug users who are homeless in San Francisco, where 64 percent of participants in a recent study reported a need for oral health care in the past six months (Robbins et al. 2010). Methadone has also been associated with increased incidence of caries, whilst untreated oral disease adds to the complications of hiv and hepatitis C. Frequent substance use can suppress dental pain and therefore mask awareness of dental problems, which explains why the self-assessed need for dental care is usually low in this population (Daly, Newton and Batchelor 2009). Mental health challenges can also lead to a chaotic lifestyle, low priority for oral health care and cravings for sugar and tobacco. Furthermore, dry mouth is a side effect of many medications used to treat mental health challenges. Finally, homeless individuals are at greater risks of trauma generally, and teeth can be knocked out as a consequence of such experiences (Gaetz and Lee 1995; King and Gibson 2003).

Barriers to Access

14It is difficult to access primary health care, including oral health care, if you are homeless (Hwang, Tolomiczenko, Kouyoumdjian and Garner 2005). Access to dentistry is complicated by the private service model that demands direct out-of-pocket payments for service. Consequently, minor problems are often ignored because of treatment costs and, when untreated, lead to pain, infection, swelling and even more costly care (Bolden and Kaste 1995; Gibson et al. 2003; King and Gibson 2003). People in dire poverty may use over-the-counter analgesics for quite severe toothache rather than seek the services of a dentist (Bedos et al. 2003; Bedos et al. 2005), and some people have even been driven to extract painful teeth with household pliers and use other domestic remedies (Cohen et al. 2009; Bedos et al. 2003).

15Hospital emergency departments are used all too frequently by people who are unable to pay for a visit to a dentist (Cohen et al. 2009). Yet emergency departments are not usually prepared or suitably equipped to tackle dental emergencies involving endodontics and are even less prepared for routine restorative dental care and prosthodontics (Daiski 2007; Hwang 2001; Schanzer et al. 2007). Indeed, the level of dental care in emergency rooms rarely involves much more than symptomatic advice or prescriptions for antibiotics and painkillers.

Financial Barriers

16Dentistry is not covered by Canada's system of national health benefits and is available as a tax-based benefit only to Aboriginal peoples, recipients of social assistance, some children, the armed forces and Royal Canadian Mounted Police, veterans of the armed forces and some elderly populations in the Yukon (Health Canada 2011). Approximately 4 percent of Canadians use public dental benefits when paying for dental treatment (Leake 2006), and dental benefits available to homeless people are typically provided through provincial social assistance. Poverty and poor oral health are very closely linked, in part because low incomes limit access to dental care in North America (Lawrence and Leake 2001; Locker 2000; MacEntee, Harrison and Wyatt 2001; Quiñonez et al. 2009b).

17Public dental benefits in North America have been criticized as overly restrictive, burdened by red tape and based on payment fees significantly below the fees received by dentists in private practice (Gaetz and Lee 1995; Han, Wells and Taylor 2003). Improving public dental benefits might reduce the financial barriers to accessing dental care by encouraging more dentists to participate in the service (Altieri et al. 2002; Birch and Anderson 2005; Dharamsi and MacEntee 2002; Kalebjian and Murphy-Tong 2001; Patrick et al. 2006; U.S. General Accounting Office 2000). However, people experiencing poverty and homelessness confront many barriers to accessing treatment in general dental practices. Improved public dental benefits might help, but other types of barriers to accessing dental care would likely remain.

Patient-Related Barriers

18Homeless persons have continual difficulties obtaining food, shelter, safety and money. Consequently, dentistry is rarely a priority until a problem surfaces in or around the mouth. Competing priorities are often interpreted as general apathy or a lack of motivation rather than a sign of adaptation to unpleasantness and chaos (Daiski 2007; De Palma and Nordenram 2005; Gelberg, Lin and Rosenberg 1988). Yet this adaptation is usually a source of social embarrassment sufficient to inhibit the search for care.

19A high level of dental anxiety has been reported within homeless populations, for reasons that are not altogether clear but probably relate to personal trauma and mental health issues (Clarke et al. 1996; Kaste and Bolden 1995; King and Gibson 2003; Lee, Gaetz and Goettler 1994; Luo and McGrath 2006; Pizem et al. 1994; Collins and Freeman 2007). Just as a chaotic lifestyle predisposes the individual to poor oral health, it is also makes it all but impossible for them to access care. Keeping appointments is a challenge without a daily routine, a watch, an alarm clock or a daily planner—even more so when confounded by substance use or mental health problems.

20There is a wide gulf of distrust between people living in poverty and the system of dental care around them, as well as a perception among homeless people that dentists will not accept them as patients (Bedos et al. 2003; British Dental Association 2003; Greenberg, Kumar and Stevenson 2008). This can include being very critical of dentists, whom they see as rich, unsympathetic, at the opposite end of the social scale and motivated professionally by money (Daiski 2007; Frankish, Hwang and Quantz 2005; Han, Wells and Taylor 2003). Consequently, when they encounter dental problems, they prefer community dental clinics rather than private dental practices (Bedos et al. 2003).

Private Practice Dentistry

21While 81 percent of Canadian dentists surveyed report supporting government spending on dental benefits, most (70%) report that less than 10 percent of their patients are publicly insureds (Quiñonez, Figueiredo and Locker 2009a; Quiñonez et al. 2010). Similarly, many people on low incomes in Canada feel that their access to dental care is likely to improve only when their relationship with dentists improves (Quiñonez et al., 2009b). Dental care providers often hold misconceptions and negative stereotypes about people receiving social assistance (Bedos et al. 2005; Quiñonez et al. 2010). In defence of this position, dentists cite financial risks, low reimbursement rates, excessive and complicated paperwork, broken appointments, unpredictably disruptive behaviour and a general disregard for oral health as reasons for refusing to accept patients with public dental benefits (Greenberg, Kumar and Stevenson 2008; Levesque et al. 2009; Patrick et al. 2006).

22The reluctance among dentists to accept homeless patients is not just stereotyping, then, but includes a pragmatic awareness of the challenges involved in providing appropriate care to a population facing multiple psychological, social and biological barriers. Patients with mental health or substance use problems can be unpredictable and socially disruptive (Muirhead et al. 2009) and, consequently, tend to be shunned by dentists (Allukian 1995; Clarke et al. 1996; De Palma and Nordenram 2005; Falvo 2009; Lee, Gaetz and Goettler 1994; McCormack and MacIntosh 2001; Pizem et al. 1994).

Community Dental Clinics

23Concern regarding the extent of untreated dental pain and oral infection has led to a growing interest in the potential of community dental clinics (British Dental Association 2003; Leake 2005; Melanson 2008; Wallace 2008). With limited funds available from governments, these clinics are often dependent on the charity of dental volunteers. Typically, they have developed locally, independently of similar experiences elsewhere (Wallace 2008). Some of them operate with charitable donations of time and professional skill to provide emergency care for a few hours each month. Others pay full-time staff members to provide a comprehensive range of dental treatments in well-equipped clinics. However, the financial risks increase as the services expand, because of the relatively low income generated from the low professional fees they must charge to meet the needs of low-income patients (Quiñonez et al. 2010).

24Community dental clinics in Canada have emerged with little documentation or scrutiny, other than the observations that they are either run as a charity or on a not-for-profit basis, and in community drop-in centres and health care centres (Wallace 2009). Many dentists also provide charitable dentistry in private practice as well as in teaching clinics for dental personnel attached to colleges and universities in larger cities.

Charitable Volunteer-Operated Dental Clinics

25The dental services provided by charitable clinics vary greatly around the country, but they usually limit their activities to relief of pain and gross infection by extracting teeth. The Calgary Urban Project Society, for example, offers free emergency dentistry with volunteer staff and supplies donated by local supply companies. In Toronto, the Shout Clinic and Evergreen Health Centre for Street Youth were established and serviced by volunteer dentists to provide dentistry for minimal professional fees. The Ottawa Mission Dental Clinic is also an active volunteer-based clinic providing a range of preventive and restorative treatments. Likewise, in British Columbia, the population in Vancouver's Downtown Eastside can get relief of pain and infection without charge by the East Side Walk-In Dental Clinic. The Kelowna Gospel Mission opened a free dental clinic with funds from the national Homelessness Strategy, while dental volunteers in Prince George operate a community dental clinic several evenings a month without charge, to relieve dental pain for low-income residents. The most compelling concern about the limited services provided by most charitable clinics is that they might become the basic and legitimate standard of care for low-income and vulnerable populations, which some believe is an unacceptable breach of human rights and tiering of an important health service (Dharamsi and MacEntee 2002; McNally 2003).

Non-profit Dental Clinics

26Community dental clinics resemble community health centres (chcs) and are often part of integrated health settings focused on providing primary health care that is accessible, affordable, comprehensive and well-integrated. There is very little information available on how these clinics operate, other than that they usually have full-time hours and employ dentists and other dental professionals to provide a full range of emergency and comprehensive treatments including prevention. These clinics can have relatively large operating expenses, which require secure funding. Some operate in part with government funding to supplement pro bono treatment. However, most of them rely on reduced fees paid by patients. Therefore, these are social enterprises operating as non-profit businesses with significant financial risks. Examples of non-profit dental clinics are Edmonton's Boyle McCauley Community Health Centre; Winnipeg's Mount Carmel Clinic; Toronto's Queen West Community Health Centre and Regent Park Community Health Centre; Vancouver's reach Community Health Centre, Mid-Main Community Health Centre and Strathcona Community Dental Clinic; and Victoria's Cool Aid Community Health Centre. While most operate within integrated health settings such as a chc, some are integrated within other settings. For example, the Strathcona Clinic operates within an inner-city school, while the Portland Clinic is administered as part of Vancouver's Downtown Eastside housing projects and supervised drug consumption service.

Teaching Clinics

27In cities with teaching clinics for students of dentistry, dental hygiene, denturism or dental assisting, there is opportunity for oral care from students at a reduced fee. All of the dental schools in Canada offer students opportunities for community service learning (Brothwell 2008; Brondani et al. 2008). Consequently, teaching clinics are an integral part of the oral health care system in Canada as in most other industrial countries.

28The Centre Local de Services Communautaires (clsc) des Faubourges Clinic operated by L'Universite de Montreal provides preventive and restorative dental care to young homeless persons in Montreal and is integrated with other health and social services for homeless youth in the city (Allison, Allington and Stern 2004; Wallace 2008). The University of Manitoba operates the Centre for Community Oral Health (ccoh), which provides dental care for inner-city poor. The University of British Columbia operates on- and off-campus teaching clinics for dental and dental hygiene students, while the general practice residency program rotates young dentists through various community clinics in the province. Although they offer care at reduced fees, teaching clinics rarely operate without professional fees, and frequently these can exceed the financial resources of people in extreme poverty.

Future Research

29While existing research confirms that homelessness is directly associated with poor oral health and a lack of access to oral health care, future research should inform responses to address these inequities. One recent exploratory study of the oral health of the homeless population in Toronto (Figueiredo, Hwang and Quiñonez 2013) recommends future research that includes mixed method study designs with adequately large sample sizes in order to explore all subgroups of the homeless population and, most importantly, to investigate the potential for alternative models of service provision for this population. Currently, though, there remains a dearth of evidence to inform responses to best meet the complex needs of these populations and no evaluations of alternative care models in Canada.

Conclusions

30Non-profit dental clinics serving homeless communities have the capacity to:

  • Reduce the financial barriers to accessing dental care for patients who have low incomes and are uninsured or without public dental benefits: Community dental clinics address the financial barriers to accessing dental care by reducing the fees for individuals who lack dental coverage and the ability to pay private practice dental fees. For individuals with public dental benefits, the clinics are able to subsidize additional care at lower rates by billing public benefit plans. Still, while fees are reduced and pro bono services provided when possible, even at these reduced fees the costs can be prohibitive, notably for significant procedures such as root canals or dentures.
  • Provide dental care within integrated care settings to reduce barriers to care within the general social and health needs of this population: In addition to addressing the financial barriers experienced by most patients of community clinics, there are additional barriers that community clinics must address to effectively meet the diverse needs of specific vulnerable groups. Community dental clinics are often integrated within community health centres, providing a medical and dental home for persons who are homeless and facilitating the delivery of complex oral health care that can often be associated with other medical co-morbidities.
  • Provide a full range of dental diagnostic and restorative services similar to the distribution of services available from private dental practices: Volunteer-charitable clinics are demonstrating the value in providing emergency, relief-of-pain dental treatment (notably extractions) for free. Meanwhile, the other model of community dental clinics is demonstrating the ability to provide a full range of diagnostic and restorative services; the distribution of services provided are similar to the distribution of services in private practices.
  • Accommodate a high frequency of missed appointments and emergency needs: Private practice dentistry is challenged to accommodate the high numbers of missed appointments that can be expected when treating individuals in crisis and facing significant challenges to self-sufficiency. The clinics similarly report a high rate of missed appointments; however, there is also high demand for unscheduled emergency treatments. These challenges actually complement each other, and the clinics can keep their clinicians very busy despite the broken appointments.
  • Sustain a pool of dental professionals employed in community-based dentistry and paid competitive salaries: It appears that recruitment and retention of dental staff may be challenging but not an absolute barrier. If community treatment alternatives are to expand, it would be beneficial if the curriculum for dental professionals could support the development of dental graduates with the interest and skills to work in these settings.

31Charitable dentistry by unpaid volunteers cannot adequately address the enormity and complexity of unmet dental needs experienced by those who are experiencing dire poverty. These 'band-aid' responses, while valuable and laudable, risk becoming an accepted standard of care for low-income populations. The financial sustainability of community-based clinics depends on relatively small but regular financial subsidies from government combined with some fees recovered from patients with public dental benefits. The recommendation to support and expand community dental clinics is vital, yet limited. While clinics can play a critical role in a response to the oral health needs of people experiencing homelessness, the safety net they provide has limited capacity to overcome the overwhelming barriers to accessing dental care (Slott 2005). Ultimately, the social determinants of oral health of homeless persons must provide the framework to locate the various components of a comprehensive response.

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Table des illustrations

Titre Table 8-1. Select published studies of the oral health status of homeless people
URL http://books.openedition.org/uop/docannexe/image/796/img-1.jpg
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Titre Table 8-1. (Continued)
URL http://books.openedition.org/uop/docannexe/image/796/img-2.jpg
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Auteurs

Postdoctoral Fellow with the Centre for Addictions Research of British Columbia. His primary research focus is the role of community health centre (chc) dental clinics in improving access to dental care. As a social worker who has been actively engaged in community-based research focused on the issues of homelessness, poverty, health and equity, Dr. Wallace brings a unique interdisciplinary perspective to oral health issues

Dentist currently researching the oral health of the homeless in Toronto for a master of science in Dentistry degree at the University of Toronto

Professor of prosthodontics and dental geriatrics with the Faculty of Dentistry at the University of British Columbia. He is past President of the Royal College of Dentists of Canada. Dr. MacEntee received the Distinguished Scientist Geriatric Oral Research Award from the International Association for Dental Research and is the senior editor of the book Oral Healthcare and the Frail Elder: A Clinical Perspective (Wiley)

Assistant Professor in the Faculty of Dentistry at the University of Toronto and Associate Researcher with the Centre for Research on Inner City Health at St. Michael's Hospital. His research explores dental health services, with an emphasis on barriers to dental care among marginalized populations

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