Key Challenges for Indigenous Peoples of Canada in terms of Oral Health Provision and Utilization: A Scoping Review

Background The oral health of Indigenous peoples in Canada is lacking compared with their non-Indigenous counterparts. This scoping assessment aimed to investigate the obstacles of providing and using oral healthcare among Indigenous peoples in Canada. Methods The scoping review took place between December 15, 2021 and January 10, 2022. Five key databases were examined: PubMed, Scopus, ISI Web of Science, Embase, and PROQUEST. The data were analyzed using NVIVO software to facilitate understanding of the major themes, subthemes, and codes provided. Results Seven major themes and eighteen subthemes were identified as impacting the oral health provision and utilization of Indigenous peoples in Canada. The major themes are individual characteristics, affordability, availability, accessibility, accommodation, acceptability, and public or government policy. Thus, to improve the oral health of the Indigenous peoples in Canada, an integrated approach is required to address these obstacles. Conclusions To address the oral health disparities among Indigenous peoples in Canada, policymakers should adopt an integrated approach.


Introduction
Oral health is important for good physical, mental, and psychological well-being [1]. Indigenous peoples have long been suffering from disparities in the Canadian healthcare system [2]. ese disparities are even more evident in respect to the oral health of Indigenous peoples. Researchers used already collected data (such as the data from the Canadian Community Health Survey), questionnaires, and examinations to confirm these disparities [3][4][5]. Dental services have been provided to eligible First Nations and Inuit peoples through the Noninsured health benefits (NIHB) program. Different strategies have been implemented to eliminate these disparities, such as the First Nations oral health strategy teeth for life, the Inuit oral health action plan healthy teeth, healthy lives, British Colombia's First Nations and aboriginal oral health strategy healthy smiles for life [6][7][8]. However, the efforts implemented so far are not enough to bridge the gap between the oral health of Indigenous peoples of Canada and their nonindigenous counterparts.
Although the temporomandibular joint function is an integral part of the stomatognathic system [9,10], no studies was published in this aspect related to the oral health of the Indigenous people of Canada.
From our initial scan of research articles published that identify obstacles in the provision and utilization of oral healthcare for Indigenous peoples of Canada, these articles have been limited to specific areas in Canada, specific physical or psychological characteristics, and may not reflect the current situation as they were published years ago. e intent of this scoping review was to thoroughly map the available literature regarding the challenges encountered by Indigenous peoples in achieving good oral health. It will allow us to identify and better understand knowledge gaps and focus on how these challenges could be addressed.

Methods
e approach was based on the five-stage system by Arksey and O'Malley with addition of a sixth stage presented by Levac et al. [11]. e approach is likewise supported by the Joanna Briggs Institute's approach for conducting scoping reviews [12]. us, the six stages included: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, (5) collating, summarizing, and reporting the results, and (6) consultation with pertinent partners (optional) [11].

Identifying the Research Question.
e following research question was used to determine the scope of the review and provide boundaries for the underlying search: 'What are the e research keywords/ methodology was adopted from the study by Bastani et al. [13] with modifications. Five scientific databases were thoroughly searched (PUBMED, SCOPUS, PROQUEST, EMBASE, and Web of Science). In brief, with the support of an experienced librarian at the University of Saskatchewan, a precise search strategy was developed, utilizing particular MeSH terms [14] and keywords to gather pertinent material on the topic of interest.
e Boolean concepts 'OR,' 'AND,' and 'NOT' were combined to generate groups of keywords and medical subject titles. e search strategy was created for Medline using the Ovid interface (Table 1), and then adapted as necessary to enable a similar search on each of the other electronic platforms. Oral health, dental health, oral care, oral hygiene and delivery, provision, providing, utilization, use, access and challenges, problems, barriers, obstacles, Indigenous, native, aboriginal, First Nations, Metis, Inuit, and Canada were used in the search. Between the synonymous terms, the logical operator OR was utilized, and the logical operator AND was used to combine them. e search strategy's eligibility criteria were created as per the PCC (Population-Concept-Context). Studies included in this review were those reporting on Indigenous people in Canada (population) oral health (concept) related to the obstacles of provision (context). Studies published in English language from January 1, 2000 to December 21, 2021 were included. Retained articles were original research articles (qualitative and quantitative). e exclusion criteria included study protocols, reviews, abstracts, opinions, editorials, letters, commentaries, and conference abstracts were excluded as this scoping review targeted peer-reviewed literature. Data collected prior to the date mentioned were excluded. Studies not originally published in English were excluded. e study selection and screening process is in accordance with the Preferred Reported Items in Systematic Reviews and Meta-Analyses (PRISMA) (Figure 1).

Selecting Studies.
For this study, the screening process was as follows: the title and abstract of all retrieved citations (191 articles) were exported to an excel sheet. After removing duplicates and assessing the remaining articles against the International Journal of Dentistry

First authors and years Study topics Study methodologies Conclusions
Kyoon-Achan et al. [15] Challenges and problems faced by First Nations and Métis parents in meeting the early childhood oral health (ECOH) needs of their children in First Nations and Métis communities in Manitoba Focus groups and sharing circles were conducted with four First Nations and Métis communities in urban and rural communities in Manitoba Challenges identified included poor access to dental care, lack of transportation, lack of evidence-based oral health information to support good oral hygiene practices, experiencing poverty and food insecurity resulting in poor nutritional choices and leading to early childhood caries (ECC) Mehra et al. [16] Prevalence and factors associated with low dental-care utilization amongst Indigenous peoples in Ontario Data from the 2014 cycle of the Canadian Community Health Survey was used Factors identified included being male, a smoker, having fair/poor health, and lack of dental insurance ElSalhy et al. [17] Pediatric residents' perceptions of the feasibility of incorporating preventive dental care into a general pediatric outreach clinic for a First Nations community Qualitative data was collected through focus groups using a semistructured interview guide Challenges included that medical providers had limited knowledge on integrating oral health to pediatric care lack of knowledge and difficulty in applying the fluoride varnish, no financial incentive, access to care, no insurance for the patient, lack of accurate and complete records of patients Shrivastava et al. [18] Perspectives of patients, primary healthcare providers, and administrators at an indigenous healthcare organization regarding barriers and enablers of relational continuity of oral health care integrated within an indigenous primary healthcare organization A multiple case study design within a qualitative approach and developmental evaluation methodology Challenges identified were impermanence and lack of effective communication Farmer et al. [19] Dental hygiene perspectives on improving oral health outcomes in vulnerable populations in Canada A qualitative study comprised of 16 one-on-one interviews conducted with dental hygienists between January and August 2015 Challenges included scarcity of evidence on interventions and their impact on oral health outcomes, including data availability from scientific research as well as mandatory reporting from institutions; logistical aspects related to the administration, structure, and sustainability (budgetary constraints within government) of programmes Martin et al. [20] Oral health perceptions of Inuit peoples and their dental service providers and exploring how differences might pose challenges and opportunities for oral health service delivery in NunatuKavut Data collection included 18 qualitative focus groups (n � 108) and 13 key informant interviews in 6 communities of NunatuKavut in Southern Labrador Findings included that (w)holistic conceptualizations of health are essential to good oral health, achieving optimal oral health is prohibitive for Inuit communities, and communityengaged oral health service delivery is needed.
Mathu-Muju et al. [21] Explore the experiences and opinions of First Nations families whose children had enrolled in the Children's Oral Health Initiative (COHI) Interviews, n � 141, were completed in 13 communities. Six open-ended questions guided the interview process.
Content analysis was used to code transcripts and identify themes Findings were that local, communitybased oral health prevention program needs to be further integrated into traditional aboriginal holistic models of wellness Explores the rise and fall of the dental therapy profession in Canada and the resulting impact on Inuit and First Nations communities in terms of access to basic oral healthcare A policy analysis was conducted using historical and policy documents Factors identified included the following: First Nations communities are often small and scattered across Canada, frequently in rural or remote locations; unique cultural perspectives held by Inuit and First Nations people; blended responsibility for healthcare makes addressing equity issues less than straightforward as the division of federal and provincial powers creates a policy legacy that constrains future policy options Lawrence et al. [5] (i) Assess whether there were associations between oral healthrelated outcomes and self-reported racism and (ii) if they existed, whether associations between oral healthrelated outcomes and self-reported racism persisted after adjusting for significant covariates in our sample.
Other objectives of the study were (i) to compare the prevalence of selfreported racism among the three countries collaborating on an early childhood caries preventive trial and (ii) to compare the findings with prevalence estimates reported in First Nations-governed national health surveys in Canada "Baby Teeth Talk (BTT)" study, a community-based early childhood caries (ECC) randomized controlled trial, which is testing a multipronged behavioral and preventive intervention among 544 pregnant Canadian aboriginal women and their children living in urban and on-reserve communities in the provinces of Ontario and Manitoba Findings included that one-third of participants experienced racism in the past year determined by the Measure of Indigenous Racism Experience and that racism experienced by aboriginal women can be a barrier to accessing dental-care services Cidro et al. [23] Describe how infant feeding practices, including breastfeeding, are a part of the larger maternal Indigenous knowledge transmission process that can aid in promoting healthy infants, including oral health e Baby Teeth Talk study (BTT): a total of twenty interviews were held and four focus groups. e participants were primarily grandmothers and mostly great grandmothers, some of whom were former and current primary healthcare providers in various capacities, both in traditional health as in the biomedical field Findings included the importance of understanding that cultural health traditions are essential for those working in oral public health capacities to ensure there is community acceptance of the interventions Naidu et al. [24] Explore oral health beliefs and practices and factors related to child oral health promotion in the Algonquin community of Rapid Lake, Quebec Participants included children, parents, educators, healthcare workers, youth workers, and elders. Semistructured interviews were conducted with key informants. e following two focus group interviews were conducted: one with parents and one with school children Findings included that a gap existed between oral health knowledge and oral health behaviors; challenges for oral health promotion included attitudes and beliefs, access, and priorities; parents needed to be further integrated into health promotion strategies Prowse et al. [25] Examine the knowledge and beliefs of parents and caregivers from four different cultural groups with respect to early childhood oral hygiene (ECOH) and early childhood caries (ECC) A qualitative study design using focus groups was chosen to explore parent and caregiver views on ECOH and ECC Challenges identified included uncooperative children, the cost and inability to purchase oral hygiene supplies, lack of time, difficulty in getting their children to see the dentist, previous negative experiences (they had been scared or hurt during previous dental encounters or feared needles), and lack of knowledge about the link between baby bottles at bedtime and dental decay International Journal of Dentistry inclusion criteria, 18 articles were included in the study. e method is summarized in a flowchart (Figure 1).

Charting the Data.
e complete texts of the included articles were examined one-by-one, and the researcher used a data charting method (form) to extract the key study features. e author's name, year of publication, research title, study subject, study abstract, study design, and outcomes were included in the form.

Collating, Summarizing, and Reporting the Results.
A summary (Table2) was generated of the included studies [11] to synthesize and summarize the findings. Qualitative descriptive analysis of the content was undertaken using NVivo V.12. e research questions were answered using a thematic analysis. We added to/modified the major themes published earlier in the Canadian Academy of Health Sciences (CAHS) report 'Improving access to oral health care for vulnerable people living in Canada' [31]. e codes are categorized depending on how closely they are related and linked [32,33].

Study Selection.
A total of 18 articles were used in the study (Table 2). For description, even though Indigenous peoples is the terminology presently in use in Canada, Four determinants of oral health were protective factors: higher family incomes, community water fluoridation, and drinking milk and drinking fruit juices after the child began to walk Schroth et al. [30] Report findings from interviews with primary caregivers on their knowledge and attitudes toward preschool oral health and ECC from 4 communities in the province of Manitoba, Canada, that took part in an epidemiological study of early childhood dental health Participation was restricted to those younger than 72 months of age. Children and their primary caregivers who participated in an institutional review board (IRB)-approved study of the prevalence of ECC in 4 Manitoba communities served as the sample for this report Findings included that caregivers who believed that baby teeth are important were more likely to have children with better oral health (i.e., less decay) than those who thought otherwise, but also caregivers of children with ECC were more likely to disagree that dental decay could affect a child's overall health 6 International Journal of Dentistry

Study Characteristics.
e CAHS outline from the report 'Improving access to oral health care for vulnerable people living in Canada' report was used as a framework. However, we added to the outline as it was not inclusive of all the factors. ere were 7 major themes and 18 subthemes that outline the challenges of oral health utilization by Indigenous peoples in Canada (Table 3). Figure 2 shows a better understanding of the challenges that may be impacting the provision and utilization of oral healthcare.

3.3.
e Impact of Individual Characteristics. Age, sex, medical status, psychological status, education, employment, oral health literacy, habits, lifestyle, and historical background were identified as the subthemes of the individual characteristic theme. ese subthemes highlighted how Indigenous peoples' personal qualities might impact and shape oral healthcare utilization. In respect to age, young age or children are affected by early childhood caries (ECC), which can have long-lasting negative effects on their development [21,25]. In addition, the elderly population seemed to experience more challenges in oral health [24,34]. In respect to sex, in some studies [16] being a male is a risk factor, whereas in other studies being a woman, especially a pregnant woman [5], is a risk factor of having challenges with oral health. e link between poor physical/medical health and poor oral health has been pointed out [16]. e psychological status, such as the fear of dentist/needles and children being uncooperative, is a risk factor toward oral health utilization [25]. Having a higher education and employment were significantly related to better oral hygiene habits [26]. Limited oral health knowledge and habits such as smoking further reduce the quality of oral health of the individual [24,26,30,35]. Insufficient knowledge of or inability to access healthy food choices is considered a barrier to good oral health [4,20,29]. Other factors such as poor access to clean water, fluoridated water, adequate sewage systems, electricity, or paved roads have affected oral health negatively [36]. Behaviors that do not support oral health and the gap between proper oral health knowledge and behavior have been mentioned as a limiting factor to achieving adequate oral health [24]. We should also keep in mind the shadows of historical factors (isolation, discrimination, and alienation) as a negative determinant to oral health [28].

e Impact of Affordability, Availability, and Accessibility.
Affordability was represented as a major theme, with economic status as a subtheme, and encompasses lack of dental insurance, lack of affordability of oral hygiene supplies, and healthy food. Low income and scarce housing are risk factors for poor oral health experienced by Indigenous peoples in Canada [15,17,37]. Availability was a factor, which correlates to the lack of human resources, funding, and the uncertainty of many oral health programs [17,36]. Accessibility also has an effect on oral health outcomes, and studies revealed that living in remote areas with no transportation affect the person's ability to access oral care services [26,36].
3.5. e Impact of Accommodation, Acceptability, and Public/ Government. Limitations in respect to the major theme of accommodation that compromise the provision of oral care include lack of financial incentive for the oral care provider and lack of accurate and complete health records [17,28,36]. is is further complicated by language barriers. Factors related to acceptability theme play a significant role in achieving good oral health. e lack of understanding/integration of the wholistic conceptualization causes a lack of community engagement [5,17,20]. Finally, the public/government as a major theme, with a policy subtheme shows a negative impact on oral healthcare due to low prioritization of oral health, budgetary constraints, and the policy gap between the federal and provincial powers [22]. Decision makers use the lack of scientific evidence about the effectiveness of certain modules to their hesitation to keep funding them [19].

Discussion
ere are many obstacles and limitations faced by Indigenous peoples in Canada when it comes to accessing and utilizing oral healthcare. Earlier studies [36] identified four types of variables as barriers to oral health treatment among Indigenous peoples in Canada. ese variables are affordability, accessibility, accommodation, and acceptability. Two more variables were added by our study-individual characteristics and public/ government.
Individual characteristics, such as age (especially in children and the elderly), sex, medical status, psychological status, education, employment, oral health literacy level, habits, lifestyle, and behaviors, all have been found to reduce oral health usage among Indigenous peoples.
is is in accordance with our previously published research where we found that age; gender; medical status; poor habits, such as smoking; limited level of education; and no employment resulted in poorer self-predicted oral health [3]. Bastani et al. reported similar findings for the Australian Indigenous population [13]. e economic status of Indigenous peoples has affected the affordability of oral health services. Low-income individuals cannot afford dental care, oral hygiene supplies, and healthy food. A similar pattern was reported in other parts of the world [38,39]. e limited availability of oral health resources negatively impacted the oral health of the Indigenous peoples in Canada. For example, the lack of human resources on reserves in addition to the lack of funding for community programs and facilities led to the disruption of some dental International Journal of Dentistry services. Many programs operate on uncertain year-to-year funding cycles. Watt et al. reported a similar pattern, as he showed how resources facilitated access to oral healthcare [39].
Our results showed that living in remote areas, where the only oral health provider is miles away with no transportation services, significantly limits regular access to oral care. Such a barrier is clearly indicated in the First Nations" report [36]. e absence of financial incentive for pediatric residents, as an example, to do oral exams or apply fluoride is a limiting factor. eir busy schedules and a lack of accurate or complete medical records can make it even more challenging to provide oral healthcare [17]. e language barrier for some Indigenous peoples in Canada, as they do not speak English or French, has limited their access to oral health and made them more reliant on their community healers [34,40].
Community acceptability plays an important role in integrating oral health programs. Racism and ignoring or undermining the traditional medical practice, through the lack of integration of the wholistic conceptualization of health, led to the lack of trust between the community and the oral health providers. is is because of the lack of proper training of the oral health providers [5,34,41].
Indigenous communities face numerous competing challenges, and this has led to low prioritization for oral healthcare. When there are budgetary constraints, oral healthcare programs often suffer the most. is is because of the lack of scientific research results that show the importance of these programs to the federal and provincial governments. National and local policymakers may consider designing and managing successful population-level initiatives to meet the oral health needs of all socially excluded communities, including the Indigenous population [13].
Given the multitude of factors that have been identified as having an effect on oral healthcare provision and utilization for Indigenous peoples in Canada, alternative approaches are necessary to bridge the gap and improve oral health outcomes. One approach is to provide oral care in an integrated form. Integrated care is emphasized as one of the basic concepts of primary care and defined as a coherent and coordinated set of services that are planned, managed, and delivered to individual service users across a range of organizations and by a range of cooperating professionals and informal carers [42].

Limitations.
is review used previously published literature related to the oral health of Indigenous peoples in Canada.
e number of studies included is not large. However, a similar pattern was recognized among medical health providers. We see a similar pattern in other parts of the world, such as in Australia.

Conclusion
Our findings suggest factors related to the individual characteristics, affordability, availability, accessibility, accommodation, acceptability, and public/government can limit Indigenous peoples' access to and provision of oral healthcare. Policymakers should look at addressing each one of these obstacles in a practical and interdisciplinary way to improve the oral health of the Indigenous peoples in Canada.
Data Availability e data are included in the Materials and Methods section.

Conflicts of Interest
e authors declare that they have no conflicts of interest.