Table 2 Themes and subthemes generated from interviews (n=9) with supporting quotations

Theme 1. Lack of financial resources

Issues with current system-level dentistry funding

“It’s actually not legal for you as a dentist to take a tooth out without an x-ray. So, when OHIP doesn’t cover the cost of the x-ray of the tooth that you need to take out, you need to make the choice: are you going to charge the patient for the x-ray or are you not going to charge the patient and write that off as a cost?” (participant 1)

“But you may have an OHIP-covered procedure, that if a dentist renders it in a hospital-based dental clinic, for a cancer patient, it would be a covered procedure. But because it’s being done in a private dental office, OHIP denies the claims. So it’s beyond the fact that there is a limitation in hospital-based resources. It also limits the patient’s ability to access OHIP-covered procedures.” (participant 5)

Inadequate remuneration of dentists in the public system

“These patients are more medically complex, they take more time to take care of, the care is harder to render, recuperating your billing is harder to do, and you get paid less. So ultimately, you spend way more time and get paid way less money for it, as a general dentist, to do the same thing on medically complex patients, compared to healthy patients.” (participant 5)

“The people who decide to do this are doing it out of interest… And you get paid, but you’re not making nearly as much as you would in the [community]. So, you need to find people who have a passion for this…. Part of it is they enjoy this type of challenge and so they’re willing to do it, but not all of their remuneration is coming from this facility.” (participant 2)

Theme 2. Heterogeneity in dentistry care provision

Differences in resource availability and use among centers

“It would be great if we could have an oral and maxillofacial surgeon here at least one day a week, but we don’t…. He comes maybe once every two weeks, once every three weeks, which is below what we require because of the high level of surgery.” (participant 2)

“We don’t have an in-hospital clinic for dentists to be able to utilize, so we’re depending upon private offices to provide care…. We’re missing that as a modality of treatment for these patients that really require it.” (participant 5)

Workflow differences among centers

“One of the advantages I think we have over every other dental oncology unit is, we have a 10-to-15-year-old database filled with every single patient and everything about them…. We have ready access to data and some really interesting data sets, probably that most people don’t have access to so readily.” (participant 2)

“We many times have to involve communication teams, social workers, back and forth with dental offices. It’s not a well streamlined process as we would like it to be…. There are a lot of pieces outside of our control there.” (participant 9)

Differences in patients’ demographics and mindsets

“We engage in virtual care, but our internet is not excellent across the province, especially when you go up north. So providing virtual care in an ideal world is wonderful, but it isn’t possible in a lot of our regions.” (participant 1)

“I think a lot of patients don’t really understand why they need to see a dentist or what the purpose is in seeing a dentist. We’ve actually had patients in the past who’ve refused to schedule appointments because they didn’t see the purpose in it. I think, when they get their diagnosis and they realize they’re going through cancer treatments, they think teeth are the least of their concerns at that point.” (participant 4)

Theme 3. Gaps in the continuity of care

Consequences of gaps in dental services on patients

“Sometimes we recommend cleanings and fillings, and patients just can’t afford it. And then, that causes problems down the road in terms of losing those teeth in the future, and osteoradionecrosis of the jaw.” (participant 3)

“Some patients who were not seen prior to radiation and needed extractions post-treatment, it turned out that there were complications with osteoradionecrosis. I had more than one patient say, why didn’t anybody tell me? And I’m thinking, well, unfortunately, they must have slipped through.” (participant 8)

“So most of [the community dentist referral process] happens behind the scenes, but obviously, the patients also have some frustrations in terms of just being anxious about will this be covered, how timely can this be, and all of that.” (participant 9)

Actions of champions of dental services to mitigate care gaps

“I’ve had homeless individuals come in who had to have up to 28 teeth removed, and they can’t pay for it. There are many patients [for whom] I do all the work pro bono.” (participant 2)

“The salaries and fees that our oral surgeons would have generated when they come in, they volunteer their time to come in and work. Any billings that they generate go into a patient care fund, and that’s out of their own generosity from that oral surgery group.” (participant 6)