Why are so few dentists willing to travel to NWT communities?

Long hours, insufficient workspaces and lower wages.

Those are some of the conditions dentists face when traveling to remote NWT communities.

Earlier this year, the territorial government sent four Requests for Proposals (RFPs) for services in different communities.

CBC recently reported that two of those RFPs were canceled in March after neither received an offer. One pertained to the Sahtú, the other to Gamètì, Whatì and Fort Resolution.

The RFPs for the Beaufort-Delta and Dehcho have received one bid each, but no contracts have yet been awarded, making it unclear when dental visits will take place in communities.

Equipment in disrepair

Dr. Pirjo Friedman is a dentist at Adam Dental Clinic in Yellowknife who has traveled extensively to communities over the past 12 years.

She says broken equipment has been one of the biggest challenges, especially after the pandemic.

She was in Fort Simpson last September when the device for rinsing patients’ mouths broke and couldn’t be easily turned off.

Friedman says she has to fill out an equipment condition form after every trip. She says she reported that the tool malfunctioned for nearly two years before it broke. Despite this, a trip scheduled for January was canceled as it was still unresolved.

“We would have drowned patients,” she joked.

In October, Friedman was in Délı̨nę when an air compressor broke down. She says no resolution was possible and it was community members who helped fly in a replacement for Tulita. She lost a day and a half out of the five she was in the community.

Todd Sasaki, spokesman for the area’s procurement services, said the recent RFPs list equipment available in each community. Dentists would be required to bring compressors and air purifiers to those who don’t have them. Even portable compressors can weigh 18 to 32 kilograms.

Friedman says that’s “unreasonable,” especially if you’re going to fly-in communities.

It is not clear who is responsible for repairing equipment. Jeremy Bird, spokesman for the Territorial Department of Health and Social Services, said dentists are responsible for “carrying out minor repairs”. But Friedman says she’s been warned in return for do repairs.

Dental services in the area’s communities are funded through Canada’s Indigenous Services uninsured health benefits program (NIHB). In 2022-2023, the area received $18.4 million to manage NIHB; $595,000 went toward dental trips to communities.

There is currently no contribution agreement for the management of NIHB for 2023-2024.

Indigenous Services Canada (ISC) also provided funding to the area in 2019 ($207,355) to purchase equipment and in 2020 ($508,000) to assess, purchase and modify equipment to implement COVID-19 protocols. to follow.

“Discussions are ongoing about financial support for dental equipment in communities,” said Carolane Gratton, spokesperson for ISC.

Salary reduction

Dentists who work in communities where most people are NIHB clients make less money than if they stayed in a standard clinic.

That’s because NIHB rates are lower than those in the guide prepared by the Territorial Dental Association.

For example, if a resident Crown to cover a damaged tooth, dentists receive about 20 percent less: $943 for NIHB patients versus $1,165 for other patients.

For other common procedures, such as cavities and root canals, dentists receive about 25 and 15 percent less respectively.

“That could certainly be something that dentists see as a disadvantage when they go out to the communities,” Friedman said.

NIHB also has stricter limits on cleaning and polishing. These services are billed in units of 15 minutes. Adult NIHB customers are limited to four units per year – and again at a reduced rate. Friedman says many private insurance companies will cover up to 12 units.

Since dentists run private businesses, ISC says, “NIHB cannot dictate the rates a dental provider charges.” But the NIHB fee guide is the maximum reimbursement that dentists can receive for their services under the program.

“If that was more equal, I’m sure that would be much more helpful in getting dentists into 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 such as inflation, labor shortages and an urban-rural divide that have led to the rising cost of doing business.

“The cost side of the equation is growing faster than the revenue side,” he said. “This is especially true in the remote communities, where NIHB is the predominant form of dental insurance.”

To balance that equation, he said, NIHB would ideally match the fees set by dental associations.

Hours to set up, weeks to travel

The NWT health department says there are dedicated workspaces for dentists in every community health center (except Wekweètì).

But Friedman says she often arrives to find rooms full of boxes and other supplies that need cleaning before they can see patients.

“Sometimes you used cardboard boxes and promotional packs to have enough space for all the equipment we have,” she said. “It takes me and my assistant several hours to set up and then unpack. All the while, the assistant gets paid, but the dentist doesn’t.”

And in the recent RFPs, dentists are charged a daily rate.

“The room rent was included as a means of offsetting the cost of space and maintenance of tools and equipment,” Sasaki said.

Dentists would also be limited to 23 kilograms of “consumables” per dental visit that would qualify for reimbursement from the NIHB.

But Friedman says she often visits multiple communities for five to 10 days at a time, that weight wears off quickly.

That kind of schedule, she adds, can also be a deterrent for dentists to take on remote services.

“When you have a family you don’t really want to go for weeks at a time. I think shorter trips are preferable for me, and also for the assistant,” she said.

So who is responsible for the itinerary?

“ISC is responsible for travel,” said Bird of the NWT government.

Gratton acknowledged that ISC plans the number of days for communities but “plays no role in planning visits to remote communities”.

She later added that ISC planned to contact the health department to clarify each government’s role.

Dental work in communities ‘desperately needed’

Despite submitting the only bid in March, Adam Dental has still not been awarded a contract to provide services in the Dehcho.

“I was off work for two months and I could have done some dental work in communities where they need it so much,” Friedman said.

The latest delay comes after services were interrupted for nearly three years in some communities during the pandemic.

Thelma Tobac, a mother of three from Fort Good Hope, previously told CBC that she struggled to get dental care for her children during that time.

Two of her children have recently been referred to Edmonton for more dental work.

She says travel would be covered through NIHB for both children, as would surgery for her five-year-old son, but she will have 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, customers will have to pay out of pocket. They can then apply for compensation within a year.

Tobac says she has no money to pay in advance. She has also tried to get help Jordan’s Principlebut says she didn’t qualify because dental services are covered by NIHB.

“Just wait for the money to come, I guess,” she said. “[It’s] kind of stress.”

Dene National Chief Gerald Antoine said the current situation has “reached a crisis level”.

“I am concerned that the lack of dental care will further undermine the overall health of people in our communities,” Chief Antoine said.

Friedman says more regular visits to communities can help prevent a buildup of oral health problems.

She gave the example of Fort Resolution, where she has been going for 10 years.

“You could definitely tell the difference from regular maintenance,” she said. “Patients came in for checkups and cleanings and X-rays, and sometimes you don’t have to do anything.”

At 71, Friedman says she still enjoys going out 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 should contact their health center to request an appointment outside of their community.

Bird said the NIHB then decides whether to approve the request or not; if approved, waiting times for urgent requests are two to four weeks.

He added that “emergencies” that are “potentially life-threatening” do not require NIHB approval.

Gratton says ISC is aware of many of the challenges outlined above and is working with the area to address them.