Case Synopsis

The Ontario universal healthcare coverage through the Ontario Health Insurance Plan (OHIP) was established to provide for the health needs of Ontarians ranging from children to the elderly. However, it does not include oral healthcare. Publicly funded programs that provide dental services are offered to children from low income families, recipients of Ontario works, and Ontario Disability Support with no program for seniors. With most seniors already retired and no longer receiving employment derived dental benefits, those in need of dental services would have to purchase private insurance or pay out-of-pocket. The cost of dental treatment for those who cannot afford it serves as a barrier to accessing dental services and leads to poor oral health. Seniors, especially those at a long-term care establishment (LTCE), are more susceptible to dental diseases. With many seniors retaining their natural teeth compared to previous generations, dental diseases tend to thrive and there is the increased need for dental services.

The Vanes Health Unit (VHU) Oral Health Department, under the leadership of Dr. Dawn DaSilva and Dr. Charles Oakswood, identified this vulnerable subgroup and in 2014 decided to take on the challenge to promote seniors’ oral health while working with limited resources. Out of this situation the iSMILE project (improving Seniors’ Mouthcare In Long-term care Establishments) was born. It is a health promotion initiative aimed at improving seniors’ mouthcare by targeting caregivers – personal support workers (PSWs) mainly (in some homes nurses as well). This was done through a needs assessment first to determine what oral health meant to caregivers and their knowledge of its impact on general health, how oral care is carried out in the home, challenges and barriers faced. The project also targeted management staff as a secondary audience.

In May 2014, Michaela Josephs, a new member of the VHU-Oral Health Team, was tasked with the responsibility to carry out the iSMILE project and to eventually develop oral health education and promotional resources that could be used by the caregivers in LTCEs. The iSMILE project was a community funded grant. Michaela had a 12-week timeline to carry out the project based on the amount of funding provided. She reviewed the findings from Dr. DaSilva and Dr. Oakswood’s literature review on causes of poor oral health status of seniors in LTCEs. Michaela also conducted several literature searches and consulted with several experts to gather information about the priority population, the different target audiences, and to gain access into the LTCEs. Having done this she then proceeded to the LTCEs where she conducted a series of focus group discussions and interviews with PSWs and management staff.

Case Objectives

  1. Identify underserved/vulnerable populations.
  2. Appreciate the difference between priority populations and target audience for public health interventions (e.g. a nutrition education program to reduce obesity in children; target audience for the intervention/program is parents but priority population is the children).
  3. Recognize political, economic, social, and other determinants of health in vulnerable populations.
  4. Learn how to conduct a needs assessment:
    a) Identify how to access information already available through literature reviews, expert consultations, and other sources.
    b) Effectively identify and engage all stakeholders – primary and secondary audience, experts and others.
    c) Identify and prioritize needs.
    d) Develop a range of solutions; analyse and appraise each option.
    e) Determine what is feasible given the local context, environmental factors, and resources available.

Case Study Questions

  1. What is the public health challenge Drs. DaSilva and Oakswood are faced with and what is the local context?
  2. Who are the priority population and the target audiences?
  3. What are the identified causes of poor oral health of seniors?
  4. What steps did Michaela take in conducting the needs assessment?
  5. What are the barriers to good oral health for seniors identified by the PSWs?
  6. What dilemma is Michaela faced with?
  7. Discuss the different options and come up with alternative options (while also considering the local context and influencing factors). 8. How should Michaela implement the options?


oral care, needs assessment, personal support workers, seniors, residents, long-term care establishments

Additional Author Information

Edesiri Udoh, BDS, MPH

Maria vanHarten, DDS, MSc, Dental Consultant

Chimere Okoronkwo, BDS, MPH, MSc, Manager, Oral Health

Amardeep Thind, MD, PhD, Professor



Recommended Citation

Udoh, E., vanHarten, M., Okoronkwo, C., Thind, A. (2016). iSMILE Project – Improving Seniors’ Mouthcare In Long-term care Establishments. in: Terry, A.L. & John-Baptiste, A. [eds] Western Public Health Casebook 2016. London, ON: Public Health Casebook Publishing.