Profilaxia antibiotica canada pag 13 prevention of infective endocarditis by Louize Lobato

August/September 2007

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Vol. 21, No. 3

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www.rcdso.org

Prevention of Infective Endocarditis

New AHA/ADA Guidelines

Upfront 4

Future Leaders of Dentistry Step Forward

The Back Page

DISPATCH

48 RHPA Review Signals New Era

Vol. 21, No. 3 August/September 2007 Dispatch is the official publication of the Royal College of Dental Surgeons of Ontario (RCDSO). RCDSO is the regulatory body governing the practice of dentistry in Ontario. Dispatch is published four times a year. The subscription rate is included in the annual membership fee. The editor welcomes comments and suggestions from our readers.

Features 5 6 7 8 10

Avoiding Abandoned Records – From the IPC Meeting with the Fairness Commissioner Baby Oral Health Focus of Educational DVD New Learning Package on Dental Emergencies RHPA Amendments Receive Royal Assent

Editor Peggi Mace Editorial Assistant Aurore Sutton

Departments 13 PEAK

August/September 2007

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Vol. 21, No. 3

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www.rcdso.org

New AHA Guidelines on Infective Endocarditis

Cover Design Public Good Cover Illustration: Josée Masse

17 Dental Ethics 101 – Case Study

Royal College of Dental Surgeons of Ontario 6 Crescent Road, Toronto ON M4W 1T1

Confidentiality of Patient Information

416-961-6555 1-800-565-4591 Fax: 416-961-5814 info@rcdso.org www.rcdso.org

18 Workplace Functioning Addicts

Registrar Irwin Fefergrad, BA, BCL, LLB

24 An Ounce of Prevention What Dentists Should Know About Patient Referrals

27 Complaints Corner No Further Action Required

32 Dental Ethics 101 – Discussion 34 On Appeal

Art Direction and Production Roger Murray and Associates Incorporated

New AHA/ADA Guidelines

Reprint Permission Material published in Dispatch should not be reproduced in whole or in part in any form or by any means without written permission of the College. Please contact the editor for permission.

Environmental Stewardship The paper stock used to print this magazine is 100% chlorine and acid free. It is recyclable. The ink is 100% vegetable based. PUBLICATION MAIL AGREEMENT #40011288 ISSN #1496-2799

DISPATCH • August/September 2007

Ensuring Continued Trust

RCDSO COUNCIL MEMBERS President Dr. Frank Stechey

Professional Practice PRACTICE CHECKS 36 Use of Automated External Defibrillators 38 New Practice Advisories

Vice-President Dr. Elizabeth MacSween Elected Representatives District 1 – Dr. Elizabeth MacSween District 2 – Dr. David Clark District 3 – Dr. Albert Bouclin District 4 – Dr. John Kalbfleisch District 5 – Dr. Ted Schipper District 6 – Dr. George Grayson District 7 – Dr. Peter Trainor District 8 – Dr. Frank Stechey District 9 – Dr. Sven Grail District 10 – Dr. Natalie Archer District 11 – Dr. Marvin Klotz District 12 – Dr. Hartley Kestenberg

Informed Consent & Release/Transfer of Patient Records

39 Use of Botox in Dental Practice in Ontario

News & Views

Appointment by Lieutenant-Governor In Council Kelly Bolduc-O'Hare Little Current Mohammed Brihmi Ajax Parminder Chahal Brampton Ujjal Deol Sarnia Mofazzal Howladar Toronto Kurisummoottil Joseph Thunder Bay Evelyn Laraya Toronto Dr. Edelgard Mahant Toronto Dr. Reza Moridi Richmond Hill Jose Saavedra Woodbridge Abdul Wahid Scarborough

40 40 41 41 42 43 44 45 45 47

Across The Nation College Calendar Annual Report 2006 New Public Member ODA Spring General Meeting Call for PLP Committee IDEALS Congress Dispatch Subscriptions Update on Practice Name Approvals Summit on Dental Care Access

Academic Appointments University of Toronto Dr. R. John McComb University of Western Ontario Dr. Stanley Kogon

issue enclosures Annual Report 2006 (abbreviated version) PEAK: Prevention of Infective Endocarditis Summaries of Recent Discipline Committee Hearings Source Guide Special Addendum Practice Advisory: Informed Consent Issues Practice Advisory: Release and Transfer of Records Information Privacy Commissioner of Ontario: How to Avoid Abandoned Records

DISPATCH • August/September 2007

UpfrontThePresident’sMessageUpfrontThePresident’sMessage

FILLED WITH HOPE FOR THE NEW GENERATION OF DENTISTS

hat a fantastic summer! For me one of the highlights was definitely the opportunity to participate in the convocation ceremonies at both the University of Toronto and the University of Western Ontario. I left each ceremony energized, excited, and filled with hope for the future of our profession. It was such a real pleasure to share this important moment with faculty members, students and their family members. It was a privilege to participate as president of the College and to personally hand the graduants their formal certificate of registration and a letter of welcome to the dental family in Ontario.

DR. FRANK STECHEY

It was an occasion to reflect yet again about the College’s small yet important role in helping to prepare these young women and men to call themselves doctor of dentistry. With about 85 per cent of Ontarians receiving some kind of dental care, what these new dentists understand and appreciate about ethical behaviour will touch almost every person in this province. The College is committed to preparing each new generation of dentists to become responsible and ethical professionals. As many of you may know, a course in jurisprudence and ethics is by law a requirement to receive a certificate of registration to practise in Ontario. That is only one of the many strategies to reinforce the importance of ethical and responsible behaviour. Senior College staff teach ethics at each of the universities where an ethics course is a mandatory requirement for graduation. It is critical that CONTINUED ON PAGE 46

Rempli d’espoir for les dentistes de la nouvelle génération Quel été formidable ! Pour moi, l’un des moments forts a été sans conteste ma participation aux cérémonies d’assermentation qui se sont tenues à l’Université de Toronto et à l’Université de Western Ontario. Chaque cérémonie m’a fait sentir un regain d’énergie, d’enthousiasme, et plein d’espoir pour le futur de notre profession. Cela a été un vrai plaisir de partager ce moment important avec la faculté, les étudiants et leurs familles. Il m’a été donné le privilège, en tant que président du Collège, de remettre aux nouveaux étudiants leur attestation d’inscription et une lettre d’accueil et de bienvenue dans la profession dentaire en Ontario. C’était une occasion de réfléchir à nouveau au rôle, certes petit mais au combien important, du Collège dans la préparation de ces jeunes gens à devenir SUITE À LA PAGE 46

DISPATCH • August/September 2007

Ensuring Continued Trust

IPC PROFESSIONAL GUIDELINES

How to Avoid Abandoned Records in the Event of a Change of Practice COLLEGE CONTACTS

ntario’s Personal Health Information Protection Act (PHIPA) requires dentists and their staff, defined in the Act as health information custodians and their agents, to retain and safeguard records Dayna Simon Assistant to the Registrar, Legal of personal health information in their 416-934-5618 custody and control. The Act also 1-800-565-4591 mandates transferring and disposing of dsimon@rcdso.org records in a secure manner. Dr. Lesia Waschuk Practice Advisor 416-934-5614 1-800-565-4591 lwaschuk@rcdso.org

management, outline the responsibilities of health information custodians under PHIPA, and provide best practices to ensure that health records are never abandoned.

This begs the question: What happens when a custodian dies, retires, falls into bankruptcy, or simply abandons his or her practice?

As the Commissioner said on the public release of these guidelines: “Inadequate records management policies and procedures following a change in practice may not only lead to breaches of privacy, but may also deprive individuals of their right to access and correct records of personal health information.

At the end of May, the Information and Privacy Commissioner of Ontario Dr. Ann Cavoukian released guidelines that provide best practices and clarify the statutory obligations of custodians when there is a change of practice.

“To the extent that records of personal health information are not available to individuals and their health-care providers following a change in practice, the continuity of care of the individuals may be put in jeopardy.”

The College is pleased to distribute the Commissioner’s guidelines and a checklist to organize and identify all necessary procedures to ensure compliance with PHIPA, as an insert with this issue of Dispatch.

The Commissioner is appointed by and reports to the Ontario Legislative Assembly and is independent of the government of the day. More information is available on the IPC website at www.ipc.on.ca.

These guidelines address privacy safeguards and continuity of record

DISPATCH • August/September 2007

Track Record of Support for Access

FIRST MEETING WITH ONTARIO’S NEW FAIRNESS COMMISSIONER COLLEGE CONTACTS Irwin Fefergrad Registrar 416-934-5625 1-800-565-4591 ifefergrad@rcdso.org Robert Lees Manager, Registration 416-934-5613 1-800-565-4591 rlees@rcdso.org

On June 20, the College had its first opportunity to meet with Dr. Jean Augustine, Ontario’s new Fairness Commissioner. Dr. Augustine took on the role of Commissioner at the end of March 2007. College Registrar Irwin Fefergrad made a number of key points during the meeting:

• As the regulatory body of the dental profession, RCDSO was an early supporter of the Irwin Fefergrad, Registrar (left) government’s efforts in Dr. Jean Augustine, Ontario Fairness Commissioner (right) building confidence in the fairness of licensing practices.

• As the review of appeal processes from registration decisions done by George M. Thomson in November 2005 noted, this College has already in place a registration process that is transparent and fair. Our current process includes an appeal process, the possibility of personal appearance by applicant before the registration committee, and written reasons for the decision of the committee.

• This College has taken a leadership role within the Canadian Dental Regulatory Authorities Federation to create a national labour mobility agreement.

• In March of this year, our Council approved in principle the final piece: a national process to address applicants who are internationally trained specialists from non-accredited universities. The Commissioner noted the excellent work of the College, from the Thomson report to the recent regulations passed by Council. She emphasized that she saw her role as working in collaboration and partnership with us. The Office of the Fairness Commissioner is a key component of the Fair Access to Regulated Professions Act, 2006. The Commissioner is responsible for overseeing regular audits to ensure that the registration practices of regulated professions are transparent, objective, impartial and fair.

DISPATCH • August/September 2007

Ensuring Continued Trust

Soon Available for Ontario Dentists

DVD on Baby Oral Health COLLEGE CONTACT Dr. Robert Carroll Manager, Professional Practice 416-934-5611 1-800-565-4591 rcarroll@rcdso.org

The dental profession has always demonstrated a strong commitment to preventive dentistry. The tradition of educating patients on ways to improve their oral and overall health is a longstanding hallmark of dental practice in Ontario. With this commitment to preventive dentistry in mind, the College is pleased to announce that it is distributing a DVD about oral health for prenatal, newborn and infant patients to all RCDSO members free-of-charge early this fall. Called Baby Oral Health, it was produced by Dr. Kiran Kulcarni, Associate Professor of Paediatric and Preventive Dentistry at the Faculty of Dentistry, University of Toronto. This DVD has received widespread acclaim from paediatric and public health dentists across Canada and abroad. The DVD will assist dentists in updating and refreshing their knowledge about prenatal and early childhood preventive dentistry. It will also serve as a helpful inoffice educational tool for appropriate patients, such as new or expectant mothers and parents of infants and babies. “The College has taken the initiative of providing this DVD program to members as a demonstration of our commitment to supporting members in their important role of educating and encouraging patients and parents in good oral health practices,” explained College Registrar Irwin Fefergrad. Members, who wish to do so, will be able to purchase additional copies of the DVD at a reasonable price in order to provide parents with a take-home copy. The University of Toronto’s Faculty of Dentistry will administer the distribution of additional copies. Information on how to order additional copies will be provided in the DVD package.

DISPATCH • August/September 2007

Dental Emergencies New DVD Learning Package in Production

T COLLEGE CONTACT Dr. Robert Carroll Manager, Professional Practice 416-934-5611 1-800-565-4591 rcarroll@rcdso.org

The College and the Faculty of Dentistry at the University of Toronto have joined forces in the production of an exciting new DVD learning package. Called Dental Emergencies: Guide to Treatment of Patients Requiring Urgent Care, it is the natural follow-up to the 2005 production on Medical Emergencies in the Dental Office. This new learning package, containing two DVDs, is slated for distribution to every dentist in Ontario in early 2008. “The College is incredibly excited to work in partnership with our colleagues at U of T. With this production we are able to bring internationally recognized experts to every dentist of Ontario,” said College Registrar Irwin Fefergrad. “Again the information is delivered in innovative animated learning modules.”

(left to right) In the studio: Dean of the Faculty of Dentistry at the University of Toronto Dr. David Mock, College Registrar Irwin Fefergrad, and Cameron Maclennan of the University of Toronto instructional media staff.

The U of T dental faculty is equally excited. “Our faculty has a well-deserved reputation for excellence and we welcome this opportunity to reach out beyond the walls of the university to the broader dental community,” said Dr. David Mock, dean of the U of T Faculty of Dentistry.

DISPATCH • August/September 2007

Ensuring Continued Trust

PARTICIPATING U of T FACULTY MEMBERS Dr. Bettina Basrani • Specialist in Endodontics • Assistant Professor of Endodontics • Co-ordinator of the Postgraduate Endodontic Program Dr. Cameron Clokie • Specialist in Oral and Maxillofacial Surgery • Professor and Head of Oral and Maxillofacial Surgery Dr. Daniel Haas • Associate Dean, Clinical Services • Professor and Head of Dental Anaesthesia

CONTENT LINEUP Patient Management Pain Swelling/Infection Control Trauma Hemorrhage Prosthetics Pediatrics

Dr. Barry Korzen • Assistant Dean Development and Continuing Dental Education Dr. Kiran (Gajanan) Kulkarni • Associate Professor of Pediatric and Preventive Dentistry Dr. Dorothy McComb • Professor and Head of Restorative Dentistry • Director of the Comprehensive Care Program Dr. Howard Tenenbaum • Professor of Periodontology • Associate Dean, Biological and Diagnostic Sciences, Faculty of Dentistry • Professor, Laboratory Medicine and Pathobiology, Faculty of Medicine • Head of Division of Research, Department of Dentistry, Mount Sinai Hospital Dr. Philip Watson • Specialist in Periodontics • Professor and Chair of Biomaterials Science • Member of the Institute of Biomaterials and Biomedical Engineering

DISPATCH • August/September 2007

First Comprehensive Changes In Over 15 Years

RHPA AMENDMENTS RECEIVE ROYAL ASSENT

On June 4, 2007, Bill 171 received Royal Assent putting into effect the most comprehensive changes to the Regulated Health Professions Act since the Act was originated over 15 years ago.

The Bill is now officially entitled An Act to improve health systems by amending or repealing various enactments and enacting certain Acts. It is available online at www.e-laws.on.ca.

COLLEGE CONTACT Irwin Fefergrad Registrar 416-934-5625 1-800-565-4591 ifefergrad@rcdso.org

In addition to the RHPA changes, the Act also amends a long list of other statutes, including the Health Insurance Act, the Ambulance Act, the Health Protection and Promotion Act, the Immunization of School Pupils Act, the Public Hospital Act, the Personal Health Information Protection Act, and the Drug and Pharmacies Regulation Act.

It establishes new regulatory colleges to regulate four more health professions – kinesiology, naturopathy, homeopathy, and psychotherapy – that join the new college for traditional chinese medicine. The government will also establish the first-ever Ontario Agency for Health Protection and Promotion. The Agency is described as a centre for public health excellence that is to provide research, scientific and technical advice and support. It is to be modelled after the US Centers for Disease Control.

That’s the new Act in broad brush strokes. Now let’s zero in and look at some of the amendments that are probably of more direct and immediate interest to us.

DISPATCH • August/September 2007

Ensuring Continued Trust

NEW BROADENED MANDATE FOR HEALTH-CARE REGULATORY COLLEGES One of the key changes in the new legislation is the addition of three new objects for health-care regulatory colleges. The objects outlined in the legislation set the broad parameters of action for each regulatory college. The first new object is the promotion and enhancement of relations with other health professional colleges, key stakeholders and the public. The second is the promotion of interprofessional collaboration among the health profession colleges. This sends a clear signal encouraging colleges to cooperate and share information, and recognizes the global trend towards multidisciplinary collaborative practice. In the third new object, regulatory colleges are mandated to develop, establish and maintain standards and programs to promote the ability of members to respond to changes in practice environments, advances in technology and other emerging issues. As a regulatory college, we continue to be given a sweeping mandate to do anything that Council considers as desirable that relates to human health care.

PRIVACY PROTECTION FOR PATIENTS ENHANCED The new Act expands the protection of patient privacy. Our College members are in good shape in this area with the wealth of information provided since the release of our educational package, Protecting Patient Privacy, several years ago. Our ongoing advice about privacy issues in Dispatch, including the special insert on abandoned records, reprinted as an insert in this issue of Dispatch with special permission from the Office of the Privacy Commissioner/Ontario, ensures members have all the information they need to be in compliance. If you do not have the College’s learning package on privacy, please contact Joanne Loy in our professional

practice area. She can be reached at jloy@rcdso.org, or by phone at 416-961-6555, ext. 4703, or toll-free at 1-800-565-4591.

HUMAN RESOURCES PLANNING The Ministry has created an obligation for the College to collect information and data to assist the Ministry of Health in human resources planning. The use of this information is limited by the Minister for planning purposes only. This new requirement is recognition by the government that the regulation of health professionals is a key element in ensuring that the appropriated registered professionals are in place to meet identified needs. Also, the Ministry has determined this information is needed to adequately coordinate and plan for healthcare delivery during a catastrophic event, such as a pandemic.

NEW INVESTIGATION, COMPLAINTS AND REPORTS COMMITTEE The Executive Committee reviewing members’ conduct, the Complaints Committee and the Board of Inquiry looking into fitness have now been merged into one committee called the Investigation, Complaints and Reports Committee, or the ICR Committee. This new Committee has the same basic functions of the previous separate Executive and Complaints Committees. The idea is that one combined committee will promote a simplified, more timely and transparent approach to inquiries and complaints that is fair to both members and patients. In order for more expeditious processing, the Board of Inquiry has been abolished and its responsibilities have been transferred to the new ICR Committee. Essentially, the ICR will take over many of the functions belonging to these other Committees. The amendments allow the ICR Committee to make interim orders “if the Committee is of the opinion, on

DISPATCH • August/September 2007 11

First Comprehensive Changes In Over 15 Years

RHPA AMENDMENTS RECEIVE ROYAL ASSENT reasonable and probable grounds, that the conduct of the member exposes or is likely to expose his or her patients to harm or injury and urgent intervention is needed.” It also gives authority for the ICR Committee to order rehabilitation courses. Currently, if a member appeals the decision of a Discipline Committee, the order of the Discipline Committee is suspended until a final order is made by the court. The Ministry has recognised that in many circumstances this has led to abuse. Now, in these circumstances, the Act is amended to permit a College to apply to a judge of the Superior Court of Justice to have an order made by a panel of the Discipline Committee to take effect immediately despite any appeal “if the conduct of the member exposes or is likely to expose his or her patients to harm or injury and an urgent intervention is needed.” Obviously this is a high threshold – as it should be – and it is not likely that it will be used very often.

EXPANSION OF PUBLIC PORTION OF THE REGISTER The Ministry has expanded what is required to be listed on the public portion of the Register so that the public can make informed decisions as to their choice of health-care providers. In addition, as we explained in the last issue of Dispatch, there is now a mandatory requirement to have the public portion of the Register accessible on the College’s website. Needless to say, this has created quite a financial and technological impact on the College in order to be in compliance with this requirement. From the website, the public will have access to a member’s general practice information, as well as any current terms, conditions, limitations, suspensions or revocations on the member’s certificate of registration. Also, current and/or historical disciplinary decisions will be posted.

AMENDMENTS TO DENTAL HYGIENE ACT Also included are amendments that permit selfinitiation, under circumstances to be determined by government and the College of Dental Hygienists of Ontario. These will include education and experience criteria.

EXPANSION OF COMMITTEE MANDATES The Quality Assurance Committee’s mandate has been expanded and shall now include continuing education or professional development that is designed to promote continuing competence and continuing quality improvement, address changes in practice environments, and incorporate standards of practice, advances in technology and changes made to entry to practice competencies. The Patient Relations Committee, another statutory committee, has been given an expanded mandate to look at matters beyond just boundaries and sexual abuse.

MANDATORY REPORTING The Act as well amends the mandatory reporting sections where a person operating a facility will have an obligation to report to the College incompetence, incapacity or suspected sexual abuse of a patient if the person has reasonable grounds to believe that a member who practises at the facility is incompetent or incapacitated. In addition, a member must self-report any conviction of an offence or a finding of negligence or malpractice made against him or her to the College.

Once government releases a consolidation of the statute, it will be available on our website for members’ information.

This section of our website, called Dentist Search, is now under construction and will go live later this year.

DISPATCH • August/September 2007

Ensuring Continued Trust

PEAK

Guidelines from the American Heart Association

PREVENTION OF INFECTIVE ENDOCARDITIS

For over 50 years, the American Heart Association (AHA) has made recommendations for the prevention of infective endocarditis (IE), an uncommon but life-threatening infection. With each succeeding iteration, the AHA’s guidelines have evolved over time and, in some respects, grown more complicated for both

PEAK (Practice Enhancement and Knowledge) is a College service for members, whose goal is to regularly provide Ontario dentists with copies of key articles on a wide range of clinical and nonclinical topics from the dental literature around the world. It is important to note that PEAK articles may contain opinions, views or statements that are not necessarily endorsed by the College. However, PEAK is committed to providing quality material to enhance the knowledge and skills of member dentists.

COLLEGE CONTACT Dr. Michael Gardner Assistant to the Registrar, Dental 416-934-5616 1-800-565-4591 mgardner@rcdso.org

patients and health care providers to interpret. In April 2007, the AHA issued new guidelines that include substantial changes to the previous recommendations. According to the AHA, the rationale for these changes was to produce a document that “would be in the best interest of patients and providers, would be reasonable and prudent, and would represent the conclusions of published studies and the collective wisdom of many experts on IE and relevant national and international societies.” In addition, the new guidelines acknowledge that for most patients, the risks of antibiotic-associated adverse events exceed the benefits, if any, from prophylaxis.

DISPATCH • August/September 2007

PEAK

Guidelines from the American Heart Association Prevention of Infective Endocarditis With this issue of Dispatch, PEAK is pleased to offer members the complete text of the new guidelines from the AHA, which was approved by the Council on Scientific Affairs of the American Dental Association as they relate to dentistry. They appeared as an article in the June 2007 issue of the Journal of the American Dental Association. The article reviews the pathogenesis of IE, as well as the rationale for or against prophylaxis. It argues that IE is much more likely to result from frequent random bacteremias associated with daily activities, rather than a specific dental procedure, and that greater emphasis should be placed on improved access to dental care and oral hygiene, as opposed to prophylaxis. The article considers the various underlying cardiac conditions that are associated with IE and concludes that prophylaxis should be restricted to those patients with the highest risk of adverse outcome from IE, who would derive the greatest benefit from its prevention. The dental procedures for which prophylaxis is recommended and the current antibiotic regimens are presented.

key points to consider • Only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures, even if such therapy were 100 per cent effective. • Prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. • For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. • Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. Significantly, prophylaxis is no longer recommended for patients with mitral valve prolapse.

DISPATCH • August/September 2007

Ensuring Continued Trust

Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is recommended. • Prosthetic cardiac valve • Previous infective endocarditis • Congenital heart disease (CHD)* – Unrepaired cyanotic CHD, including palliative shunts and conduits – Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure† – Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

• Cardiac transplantation recipients who develop cardiac valvulopathy *Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. †Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.

Dental procedures for which endocarditis prophylaxis is recommended for cardiac conditions noted above. All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.* *The following procedures and events do not need prophylaxis: routine anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of primary teeth, and bleeding from trauma to the lips or oral mucosa.

RCDSO ADVICE Members should review the new guidelines from the AHA and implement them in their offices. Members should also note that the new guidelines only address the prevention of IE. To date, there have been no changes to the existing recommendations on antibiotic prophylaxis for dental patients with total joint replacements.

DISPATCH • August/September 2007

PEAK

Guidelines from the American Heart Association Prevention of Infective Endocarditis Regimens For A Dental Procedure SITUATION

AGENT

REGIMEN: SINGLE DOSE 30-60 MINUTES BEFORE PROCEDURE Adults

Children

Oral

Amoxicillin

2 grams

50 milligrams per kilogram

Unable to Take Oral Medication

Ampicillin OR Cefazolin or ceftriaxone

2 g IM* or IV†

50 mg/kg IM or IV 50 mg/kg IM or IV

Allergic to Penicillins or Ampicillin Oral

Allergic to Penicillins or Ampicillin and Unable to Take Oral Medication

Cephalexin‡§ OR Clindamycin OR Azithromycin or clarithromycin Cefazolin or ceftriaxone§ OR Clindamycin

1 g IM or IV 2g 600 mg

50 mg/kg or IV 20 mg/kg

500 mg

15 mg/kg

1 g IM or IV

50 mg/kg IM or IV

600 mg IM or IV

20 mg/kg IM

*IM: Intramuscular. †IV: Intravenous. ‡Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric. §Cephalosporins should not be used in a person with a history of anaphylaxis, angioedema or urticaria with penicillins or ampicillin.

Members are reminded that patients may present with a recommendation from the physician that is inconsistent with the guidelines. This may reflect a lack of familiarity with the guidelines or special considerations about the patient’s medical condition of which the dentist is unaware. In such circumstances, members are encouraged to consult with the physician. Ideally, consensus should be reached among the professionals involved. However, each is

DISPATCH • August/September 2007

ultimately responsible for his or her own treatment decisions. As a result of this consultation, the dentist may decide to follow the physician’s recommendation or, if professional judgment dictates that antibiotic prophylaxis is not indicated, decline to provide it. In the latter circumstance, the dentist may suggest that the physician should prescribe for the patient as she or he deems appropriate.

Ensuring Continued Trust

Ethical Dilemma Case Study DENTAL ETHICS 101

“I’m pregnant. Please don’t tell my parents.” CONFIDENTIALITY OF PATIENT HEALTH AND PERSONAL INFORMATION Mary Smith, a 15-year-old girl, came into a dental clinic for a recall appointment. She had been a patient of Dr. Virginia Jones for many years. While waiting near the clinic’s radiology area, she saw a sign instructing females to inform their dentist if they were pregnant. Mary became upset and asked Dr. Jones why the sign was there. Eventually she confessed that she was pregnant and asked Dr. Jones not to tell her mother. Dr. Jones felt she had an obligation to inform the mother of Mary’s condition. Although she was capable of providing her own consent for treatment, her parents were legally responsible for the payment of the account. Because Dr. Jones knew Mary’s parents, she was convinced that it would be beneficial to Mary if her parents knew and could provide care and support during this difficult period in her life. Dr. Jones is now faced with an ethical dilemma. Which course of action would you recommend for Dr. Jones? ◆ Dr. Jones should try to convince Mary to discuss her pregnancy with her mother and tell Mary that, if she doesn’t inform her mother, she will. ◆ Dr. Jones should contact Mary’s mother and inform her that Mary is pregnant. ◆ Dr. Jones should try to convince Mary to discuss her pregnancy with her mother. Dr. Jones will not inform Mary’s mother and will try to delay dental treatment. Reprinted, in part, from the Texas Dental Journal with the permission of Dr. Thomas K. Hasegawa, Baylor College of Dentistry, Dallas, Texas.

Now turn to page 32 to find the discussion about this ethical dilemma.

DISPATCH • August/September 2007

WORKPLACE

Working Under the Influence

Functioning

ADDICTS

Lyn Garrett thought she was off and running, hired fresh out of university for an internal auditing job at an international company. She recalls her boss inviting the department out for drinks one day. At 19, Ms. Garrett was terribly insecure among her older, worldlier and mostly male colleagues. “The first drink tasted horrible. By the second drink, I was laughing. I felt that I fit in. These people that I worked with were actually laughing at things that I said and I thought that I had found the miracle drink,” Ms. Garrett says about the beginning of her life as an alcoholic.

DISPATCH • August/September 2007

Ensuring Continued Trust

WHEN A RECOVERING ADDICT’S BEST FRIEND IS THE BOSS Paul Ponzi, a 41-year-old onetime cocaine addict, can thank his boss for helping him on his road to recovery. “Mike took a chance with me . . . [he’s] very supportive,” Mr. Ponzi says of his boss at an Auto Glass Magic shop in Toronto. What started as a weekend and “hump day” cocaine habit when he was 22 years old turned into a daily addiction that cost him a number of construction and contract jobs, along with his self-esteem. To finance his addiction, he began seeking work that paid cash daily, such as washing cars or caddying at golf courses, and committing thefts and credit card fraud. Through the odd jobs, his daily earnings totalled about $300 plus whatever he could make illegally – and nearly every penny went to drugs. That was before treatment. Today, Mr. Ponzi, an auto glass technician, is building a life around recovery. Staying clean has become easier now that he’s working for a boss with whom he can be open about his recovery. There are no secrets and no enabling of old habits – a former boss used to offer him crack cocaine to cover his wage instead of cash. Toby Levinson, psychologist and manager of special assessments and interventions at Bellwood Health Services, an addiction treatment centre in Toronto, says that having a supportive boss during recovery and reintegration into the work force is incredibly helpful. When people undergo treatment at Bellwood, their employers are invited to the facility to learn about addiction, recovery and how it affects the workplace. Employees give a presentation to employers explaining what treatment involves and what they are learning. There is an open discussion about what will happen when the employee returns to work, Ms. Levinson says. Questions can include: What do you expect when I come back to work? What can I expect when I come back to work? What adjustments can we each make so that I can follow through with my aftercare program? What do the people in the workplace know about where I’ve been? This open approach is beneficial for employee and the employer because it works against the disease, which is based on denial and hidden shame, Ms. Levinson adds. Written by Amy Brown-Bowers, this article originally appeared in The Globe and Mail Careers Section in April 2007.

People looking for help or resources can go to the Canadian Centre on Substance Abuse at www.ccsa.ca.

DISPATCH • August/September 2007

WORKPLACE

Working Under the Influence Functioning Addicts “Alcohol at that point became a very major part of my life and it made me everything I ever wanted to be. I felt prettier. I felt funnier. I felt smarter. I could say things that not under the influence I would never dream of saying… I had an opinion. I had a voice…” Throughout her early 20s, Ms. Garrett burned her way through bottles of Scotch and promotions, one making her feel that she could better accomplish the other. She was a functioning addict – someone who has a problem with alcoholism or drug addiction but still manages to hold down a job. While it’s nearly impossible to determine the exact number of functioning addicts, studies suggest that most are employed full-time and continue to work long after their addiction has begun to wreak havoc in other areas of their lives. While functioning addicts “try their damnedest” to hide their problems at work – the paycheque funds the addiction – it is inevitable that work will suffer, says Greg Howse, executive director for Simcoe Outreach Services, a Barrie agency for local residents struggling with substance abuse and excessive gambling. The amount of time and energy spent thinking about, looking for and hiding their drugs or alcohol and the rising number of sick days, hangovers and shortened workdays affect performance. As addictions get worse, people may become less socially and sexually inhibited at the office, leading to inappropriate comments and actions. Addictions tend to get worse over time, he says. But more and more employers are realizing that, instead of losing these valuable employees, they can play an integral role in their recovery and aftercare.

DISPATCH • August/September 2007

“If you look at the working population of alcoholics, we are very bright people. If you could look into various corporations and see who the players are, a lot of these people have problems with alcoholism,” says Ms. Garrett, who now operates a Toronto intervention service aimed at helping executives overcome substance abuse. Narcotics Anonymous has 44,000 meeting groups in 125 countries and in 64 different languages. A membership survey in 2003 found that 72 per cent of members were employed full-time, says Jane Nickels, a spokesperson for Narcotics Anonymous World Services, based in Van Nuys, Calif. And 47 per cent of its members were employed full-time in professional, managerial or health-related careers. Mr. Howse says people would be surprised by the number of so-called functioning addicts in the workplace. Of the 2,000 or so referrals his centre gets each year from Simcoe County, about an hour north of Toronto, he estimates that between 85 to 90 per cent of them are people working full-time. “Everyone has this impression that your drunk is the guy you see wandering down Yonge Street with a brown paper bag. Well that’s just so much baloney,” he says. The problem is hidden because functioning addicts become so used to operating under the influence that it becomes nearly impossible to tell that they’re using, says Rick Csiernik, a professor at the University of Western Ontario who specializes in employee assistance programming and addictions. He explains that to achieve homeostasis – internal stability – alcoholics need to have alcohol in their blood. Rather than drinking to

Ensuring Continued Trust

WARNING SIGNS SOURCE: MOUNTAIN VISTA FARM, WWW.MOUNTAINVISTAFARM.COM

Signs that someone at work may be a functioning addict: ◆ Routinely arrives late or leaves early ◆ Often late or absent after lunch ◆ Frequent or long disappearances from the work site ◆ Frequent or long trips to the bathroom or to the stockroom ◆ Misses appointments ◆ Frequent sick days or unexplained absences ◆ Procrastination, pattern of missed deadlines ◆ Phone calls are not returned promptly ◆ Decline in productivity or hours worked ◆ Doesn’t pay attention and forgets things easily ◆ Overreacts to criticism, blames others ◆ Unusual mood swings ◆ Evidence of depression and/or anxiety ◆ Unable to get along with colleagues, staff ◆ Performance declines over the course of the day ◆ Client complaints about performance, accessibility, communication ◆ Seems to make and receive a lot of personal calls ◆ Appears under the influence or smells of alcohol in the office ◆ Gradual deterioration in appearance, hygiene, health ◆ Is always tired ◆ Loses control at social gatherings where professional decorum is expected ◆ Dishonest, manipulative

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WORKPLACE

Working Under the Influence Functioning Addicts feel high or buzzed, they drink to feel stable and steady. “They function best when it’s there,” he says, not unlike the caffeine addict who needs a large double-double before booting up his or her computer. It took about five years before Ms. Garrett’s performance at work took a hit. “I was doing very well. But then I started to screw up at work… [alcohol] started to turn on me and it was suddenly making me everything I didn’t want to be.”

“Employers can play an integral role in their recovery and aftercare.”

She knew her problem was escalating after she was sent on a trip to Los Angeles with a female colleague to perform an audit. “Two days later, our boss was calling us and we hadn’t even made it to the L.A. office yet because we were partying.” Starting to feel uneasy that her addiction would be uncovered, she accepted an attractive job offer in fashion importing. She ended up resigning before being fired. “I was going to lunch and not returning. I would go to a show, and instead of working, I would be partying. I knew my boss was on to me, so I quit. “I basically blew myself up with that one. My performance was zero. I mean, one day I would work, the next day I wouldn’t work,” she says. Worried about her slipping performance, she opted for a geographical cure and took an assistant vice-president’s position in private banking in Palm Beach, Fla. But the stumbling, slurring and blackouts got worse. Rock bottom

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came with a near-arrest for a drunken scene at her boyfriend’s place. The next morning, she called a friend who took Ms. Garrett to a selfhelp group and called the director of her company’s employee assistance program. Because she’d already started self-help, her EAP director, a recovering alcoholic himself, negotiated a leave of absence for her on the stipulation that she continue to attend the self-help group, as well as daily therapy sessions. He also gave her the names of recovering alcoholics in Palm Beach who could support her. It was the beginning of her now 26-year recovery and an example of how an employer’s enlightened approach to addiction can facilitate rehabilitation. “No one has to be a lost cause,” says Bill Wilkerson, co-founder and chief executive officer of the Global Business and Economic Roundtable on Addiction and Mental Health, a Toronto-based not-for-profit corporation that educates companies about the link between business, the economy, mental health, addiction and work. “We can respond within the context of their dignity and [the] requirements of employers, and find a way to preserve [the] investment in that person – and that’s the basic bottom line.” He insists that investing in an employee’s recovery makes financial sense. “You’re protecting your investment. You’re protecting your productive capacity.” Paul Ponzi, a 41-year-old recovering cocaine addict employed in Toronto, says that the worst thing a boss can do is “enable you, by letting you go on with what you’re doing and giving you money and living in denial and pretending it’s not happening.”

Ensuring Continued Trust

He thinks employers should approach employees and offer them a chance to either seek help or get better on their own. If they refuse and their performance is still poor, he says employers should fire them. “If the person’s worth saving, then you go the mile with them but you have to weigh it out. If he’s no good for your business and he doesn’t want help, then you have to let him go,” he says. Mr. Wilkerson believes open communication with the troubled employee is important. “As long as you’re not judging them or trying to intrude upon their own privacy, you can talk straight truth and straight turkey to them.” No judging means keeping the conversation non-accusatory and rooted in facts about job performance. “You want to make it clear that there are performance issues… [and] treat it within the context of your factual responsibilities, which is the performance of that individual or their relationship to others,” Mr. Wilkerson says.

you suspect an employee has a substance abuse problem but can’t detect any changes in work performance, you have no grounds on which to approach him or her. “If someone’s use is heavy on the weekends, the employer has no obligation, in fact, no right, to even question that. It’s if and only if the work performance is affected that the employer has any right or obligation to deal with it,” he says. Under the Ontario Human Rights Code, employers can’t discriminate against someone with a disability, and both addiction and alcoholism are deemed as such. While being drunk or high on the job may be a disciplinable offence, as soon as the employee indicates that he or she has a problem, protections kick in under the code, says Michael Conradi, a Toronto-based labour and employment lawyer. Your obligation as an employer is to offer “protection to the point of undue hardship,” he says. That includes holding that person’s job while they seek treatment, for a reasonable length of time, and offering accommodation upon their return to work.

“No one has to be a lost cause.”

Toby Levinson, a psychologist and manager of special assessments and interventions at Bellwood Health Services, an addiction treatment centre in Toronto, says that detailed documentation is vital because denial is so much a part of the disease. “The immediate supervisor has to document any situation where something has gone wrong. I mean ‘employee seems to come in late every Monday’ or ‘takes off early on Friday’ or ‘is making more mistakes on the job than he used to make and seems to be moody.’ All that should be documented,” she says.

But this shouldn’t be confused with openended accommodation. “If the person ultimately does not change, the manager has no responsibility to perpetuate their employment simply because they feel sorry for them. In the end, you cross a line,” Mr. Wilkerson says.

The flip side of this, Mr. Howse says, is that if

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AN OUNCE OF PREVENTION

What Every Dentist Should Know About PATIENT REFERRALS This feature is prepared by the College’s Professional Liability Program (PLP) to offer guidance to members regarding the prevention of malpractice claims or the minimization of the magnitude of an existing claim.

COLLEGE CONTACT Dr. Judi Heggie Dental Advisor, PLP 416-934-5605 1-877-817-3757 jheggie@rcdso.org

Referral of a patient by a general dentist to a dental specialist is common practice, especially when the general dentist does not feel the treatment required is within the scope of his or her expertise. Unfortunately when some cases come to PLP, there has been inadequate information provided by the general dentist or the dental specialist has not properly reviewed the information provided. As these scenarios illustrate, it is important that the referral be done properly.

SCENARIO ONE No Written Referral Dr. Smith’s receptionist telephoned the office of oral/maxillofacial surgeon Dr. Brown to arrange an appointment for Mr. Jones for the extraction of teeth 42 and 36. When Mr. Jones presented, Dr. Brown took a panoramic radiograph and assumed that the remaining lower left molar was tooth 36, when in fact it was tooth 37. All that remained of tooth 36 was a root tip. He proceeded to extract tooth 37, the 36 root tip and tooth 42. A few days later, Dr. Smith telephoned Dr. Brown to say that tooth 37, which was to be the posterior abutment for a removable partial denture, had been wrongfully extracted. Dr. Smith had wanted tooth 42 and the root tip of tooth 36 extracted, and tooth 37 left intact. Unfortunately, Dr. Brown had extracted tooth 37, thinking it was 36. Subsequently, Mr. Jones filed a claim against Dr. Brown for unnecessary extraction of a viable and strategic tooth. PLP recommended settlement of the claim against Dr. Brown in exchange for a full and final release in Dr. Brown’s favour.

PLP COMMENT A written referral specifying the required extractions and the relevant history could have prevented this error. If this were not possible, there should have been direct telephone communication between the practitioners involved. 24

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Ensuring Continued Trust

SCENARIO TWO Incorrect Radiographs Ms. White presented to Dr. Winter, her dentist, complaining of pain in the upper right. Dr. Winter took a periapical radiograph and diagnosed a vertical fracture involving Ms. White’s endodontically treated and heavily restored tooth 16. He gave Ms. White a copy of the radiograph and referred her to an oral surgeon, Dr. Woods, for the extraction. Unfortunately, the duplicate radiograph was mounted backwards and Dr. Woods extracted tooth 26 instead of tooth 16. Ms. White filed a claim against Dr. Woods for extraction of the wrong tooth. PLP recommended settlement of the claim against Dr. Woods, for which a full and final release in favour of Dr. Woods was obtained.

PLP COMMENT

GENERAL DISCUSSION ◆ If the treatment planned is not within the scope of your

expertise, it is best to refer the patient. ◆ Before referring to another practitioner, discuss the

diagnosis, treatment risks, benefits and alternatives and the reason for the referral with the patient. Document the details of this discussion. ◆ If the initial appointment with the other practitioner will be

for consultation/evaluation rather than for specific treatment, advise the patient and make sure it is clear in the referral notes. If consultation fees are known, provide this information to the patient. ◆ Provide a detailed, written referral note that explains the

reason for the referral, any pertinent medical/dental histories, the (tentative) treatment plan, and duplicates of relevant radiographs.

A dentist is responsible for the treatment he or she provides. Before treating a patient, ensure that the treatment is justified. In this case, a thorough examination would have revealed that the incorrectly mounted radiograph did not represent Ms. White’s upper left quadrant. Tooth 26 had a small occlusal amalgam restoration while tooth 16 had a large 5surface resin. As well, while tooth 15 was present, tooth 25 was missing.

◆ If a patient presents to your office without a referral note,

Ideally, a referral should be in writing. If there is any doubt about the reason for the referral, contact the referring dentist before rendering treatment. If you cannot reach the dentist, then reschedule the patient for another day.

◆ Remember, if you perform treatment on the wrong tooth, call

especially if there is any question about what treatment is required, it is always best to contact the referring dentist in order to discuss the reason for the referral. ◆ If a patient is referred to you for treatment that you do not

feel is in the best interests of that patient, do not proceed with treatment. Call the referring dentist to discuss the treatment in question and also consult with the patient about your treatment recommendations. PLP to protect your right to coverage.

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AN OUNCE OF PREVENTION

What Every Dentist Should Know About Patient Referrals SCENARIO THREE Miscommunication Mr. Wilson presented to Dr. Hill complaining of sensitivity in tooth 16. After the clinical and radiographic assessment, Dr. Hill referred Mr. Wilson to endodontist, Dr. Johnson. Dr. Hill provided a referral note, indicating which tooth required endodontic treatment. Mr. Wilson chose to attend another endodontist, Dr. Peters, and did not take the referral form with him. Two weeks later, Mr. Wilson again presented to Dr. Hill with sensitivity in the upper right area. On examination, Dr. Hill determined that root canal treatment had been completed on tooth 15 rather than 16. She referred Mr. Wilson to Dr. Peters for further assessment of tooth 16. Dr. Peters subsequently performed endodontic treatment on tooth 16 as well. Mr. Wilson concluded that the wrong tooth had been treated and took legal action for compensation. Dr. Peters’s records were very detailed and, as a result, PLP was able to determine that both teeth had required endodontic treatment. In addition, Dr. Peters’s notes clearly showed that she had communicated this to Mr. Wilson. No cause of action existed and Mr. Wilson subsequently abandoned his claim against Dr. Peters.

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PLP COMMENT Typically specialists prefer referral notes and will provide dentists with referral pads. The reason for referral should be outlined on the referral note, along with any relevant history. In addition, a note from Dr. Peters to Dr. Hill outlining the reasons for treatment would have assisted Dr. Hill in understanding the need for the treatment. This would have ensured communication of events between the dentist, patient, and specialist and avoided the perception by the patient that an error had occurred. Litigation would have been unlikely. In this case, there was no referral to Dr. Peters from Dr. Hill. In the absence of a referral from the patient’s dentist, it is always a good idea to contact the dentist in order to discuss treatment, prior to initiating any treatment.

QUESTIONS ABOUT A PARTICULAR SITUATION? Call PLP and one of our claims examiners will be happy to assist you.

416-934-5600 1-877-817-3757

Ensuring Continued Trust

COMPLAINTS CORNER

Many Complaints PanelsDecide

NO FURTHER ACTION IS REQUIRED Complaints Corner is designed as an educational tool to help Ontario dentists and the public gain a better understanding of the current trends observed by the College’s Complaints Committee. These scenarios are an edited version of some of the cases dealt with by the Committee. The law does not allow for either the dentist or the complainant to be identified.

COLLEGE CONTACT Irwin Fefergrad Registrar 416-934-5625 1-800-565-4591 ifefergrad@rcdso.org

In reviewing patient complaints, the Regulated Health Professions Act (RHPA) provides a number of options for the College’s Complaints Committee panels to consider in making their decision. These include referral to the Discipline Committee for professional misconduct or incompetence concerns, referral to the Executive Committee if they feel that the member may be incapacitated, requiring the member to appear before them to be cautioned, or take any other action that is not inconsistent with the Dentistry Act, the RHPA’s Procedural Code, the College’s professional misconduct regulation or our by-laws. In many cases, after carefully reviewing the matter, a panel may decide not to choose any of the above options and instead recommend that no further action be taken.

completed. Two weeks later a crown was inserted.

CASE ONE

The prosthodontist stated that the patient asked that the crown on tooth 44 be made taller, in order to “level her bite.” In addition, she stated that she hoped to have a new bridge fabricated that would span from tooth 44 to the posterior implants.

COMPLAINT SUMMARY A patient filed a complaint with the College regarding a general dentist, complaining about a “badly sized” crown placed and the resulting “bite problems.”

The dentist noted that he was not advised by the patient of her concerns about the crown until after her credit card payment had been declined on four occasions. He stated that he attempted to schedule an appointment to address her concerns; however, the patient did not keep any of the scheduled appointments. As part of its investigation, the College obtained records from the patient’s subsequent treating prosthodontist. The records indicated that she presented with a complete upper denture and numerous missing teeth on the lower left posterior and lower right posterior. The prosthodontist’s treatment plan included the placement of implants and new crowns and the fabrication of a new bridge and a new upper denture.

DENTIST’S PERSPECTIVE

DECISION OF COMPLAINTS COMMITTEE PANEL

In his response, the dentist stated that the patient first attended his office in March 2001 for an examination, diagnosis and treatment plan. In September 2004, she returned in pain. Endodontic treatment of the lower right first bicuspid (tooth 44) was indicated and

The panel members reviewed all correspondence and records obtained during the course of the College’s investigation. They were of the opinion that the radiographs from the subsequent treating prosthodontist showed that the crown fabricated for tooth 44

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COMPLAINTS CORNER

Many Complaints Panels Decide No Further Action Is Required was within the standards of the profession. They noted that it appeared that the height of the crown in question was similar to that of the adjacent teeth and therefore was appropriate. In its decision, the panel took the opportunity to advise the patient that a dentist cannot level an occlusal plane with just one crown. In order to do so would require more complex and comprehensive treatment, like the treatment proposed by the prosthodontist. The panel was pleased to see that the dentist had offered to try and resolve the patient’s concerns about his treatment; however, the complainant did not return to the dental office and cancelled several appointments that were booked for her. For the reasons stated above, the panel decided to take no further action with respect to the complaint.

CASE TWO COMPLAINT SUMMARY The College received a complaint from a patient about the conduct of a periodontist. The patient stated that the specialist had failed to address his primary concern about his periodontal health in relation to his medication for hypertension. Also, the patient said the specialist also failed to release a copy of his dental records to his general dentist as a way of harassing him. He also alleged that the dentist had intended to take advantage of his dental insurance plan and had harassed him on the telephone.

DENTIST’S PERSPECTIVE In the response to the complaint, the periodontist stated that the patient contacted him for care, as a result of advice that he should receive periodontal treatment due to

DISPATCH • August/September 2007

his cardiac hypertensive medical condition. At his first attendance at office, the patient’s medical history was gathered and reviewed and a comprehensive and systematic periodontal examination was carried out. The recommended full mouth series of radiographs were not taken since the patient advised that his previous dentist had recently taken radiographs. Instead, the patient agreed to provide the office with the name of the dentist, so that the radiographs could be obtained. The patient was advised that no definitive diagnosis or prognosis would be provided until the radiographs were received. In the interim, the patient was:

• Provided with an initial diagnosis of moderate to advanced chronic periodontitis, with pocket depths ranging up to 6mm in the lower molar areas.

• Given the proposed treatment plan (periodontal scaling, root planning, soft tissue curettage), risks and benefits of treatment, and consequence of no treatment.

• Told that re-evaluation and consultation would be required following the initial periodontal sanative therapy.

• Advised of the need for supportive periodontal maintenance care. According to the dentist, he specifically reviewed in detail the medication being taken by the complainant and informed the patient that the 2005 Compendium of Pharmaceuticals and Specialties advised that none of these medications would have an impact on his gums, gingival tissues or periodontal status. The patient was also advised of the interrelationship between periodontal plaque and heart disease. After the diagnosis and treatment plan were Ensuring Continued Trust

learning points ◆ While patients may not be happy about certain treatment results, if a panel of

the Complaints Committee is of the view that the resultant treatment was within practice standards and norms, a decision may be made by the panel to take no further action with respect to the complaint in question. ◆ Conduct/communications complaints against dentists and their staff may be

difficult or impossible to resolve. Experience has shown that each side often has its own recollection of the matter. When such matters cannot be fairly assessed, a Complaints Committee panel may have no choice but to decide that no further action be taken. ◆ It is vitally important that patient records include both detailed entries

regarding treatment that has been rendered and notes of conversations between the dentist and his or her staff and the patient and the patient’s reaction to this discussion. This would include advice given, recommendations for referral, and patient management issues or problems. It is important that these entries be written in a timely fashion and in an objective and professional way.

given to the patient by the dentist, a staff member met with him and reviewed the financial implications of the treatment plan, appointment scheduling, professional fees, and how his dental insurance would be handled. The office’s form called Patient Consent: Periodontal Sanative Therapy was also discussed with the patient. He was also advised that the office did not accept the assignment of insurance benefits, so the patient would be responsible for payment of fees on the date services are rendered and any insurance benefits would be paid directly to him. According to the dentist, there were a number of telephone conversations between the patient, his staff and himself regarding the patient’s concerns about the cost of treatment and his limited insurance coverage. Some of these calls took place after regular business hours. The patient was also informed by the dentist to call the office during business hours to discuss financial arrangements so he could

speak with a staff member who was better able to assist him in understanding his dental insurance and possible financial arrangements. Shortly thereafter, the office received a voice message requesting that information about the patient be sent to another dental office. Due to privacy concerns, the patient was contacted to confirm his desire that information be sent to his subsequent treating general dentist’s office and to have the necessary authorization forms signed. According to the dentist, when informed of the written authorization requirement for the release of his record/treatment information, the patient called the office and was “difficult and argumentative” with a staff member, and therefore, the call was transferred to him. After he explained the legal authorization requirements, the patient became “rude, argumentative and belligerent.” A few days later, the office received a proper

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COMPLAINTS CORNER

Many Complaints Panels Decide No Further Action Is Required request for the transfer of certain patient records from another office. When contacted, that office indicated that they just required radiographs. Since no radiographs were taken, no records were sent. However, the new dentist was provided with the diagnosis and treatment recommendations.

DECISION OF COMPLAINTS COMMITTEE PANEL The panel reviewed all correspondence and records obtained during the course of its investigation. Regarding the patient’s complaint that the periodontist did not address his concern about his periodontal health and the medications he was taking, the panel accepted the dentist’s assertion that he informed the patient that the medications he was taking have not been shown to have an impact on a patient’s gums, gingival tissues or periodontal status. The panel also accepted that the patient was informed about the potential interrelationship between periodontal plaque and heart disease. Regarding the allegations that the dentist had intended to abuse the patient’s insurance policy and there had been harassing telephone conversations between the dentist and the patient, the panel was of the view that this issue was a case of “he said/he said,” with each party having a differing version of events. Accordingly, the panel was unable to make a determination as to which version of events was more accurate. However, the panel did allow that, from its review of the x-rays taken by a previous dentist, the patient had bone loss and would therefore have benefited from the recommended treatment. Based on the above, the panel decided to take no further action with respect to this complaint.

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CASE THREE COMPLAINT SUMMARY The father of a minor child complained about a paediatric dentist. In his communication with the College, he expressed concern about the use of local anaesthetic in conjunction with nitrous oxide oxygen conscious sedation during his son’s dental appointment. He noted that it was necessary to place an emergency call for paramedics who transported his son to the emergency department of a local hospital for subsequent investigation for a possible heart problem.

DENTIST’S PERSPECTIVE In his response, the dentist stated that the child and his parents had attended at his dental office for a consultation on July 3, 2006. The patient was referred by his general dentist, as he was not able to complete restorative treatment. The dentist made note of the child’s asthmatic condition and also noted that no known allergies were reported by the parents. An examination revealed no obvious visible caries, but the dentist informed the parents that he wished to view x-rays taken by the general dentist. The parents agreed to bring the x-rays to the next appointment. The dentist explained that, in his view, the use of nitrous oxide oxygen sedation was indicated and he advised the parents that the child should not eat anything for four hours prior to the treatment appointment. At the next appointment, the child returned with his father with the x-rays from the general dentist. The member noted no definitive decay and therefore, additional x-rays were taken to confirm the need for treatment. The new xrays revealed decay on teeth 54 (upper right first primary molar) and 74 (lower left first primary molar).

Ensuring Continued Trust

The dentist proceeded to “show and tell,” explaining to the child what would happen during treatment. The father remained in the operatory for the duration of the appointment. Treatment of tooth 54 was undertaken using a combination of nitrous oxide oxygen conscious sedation and local anaesthetic. The dentist had no record of the patient vomiting in the waiting room subsequent to treatment, as was alleged by the parents. At the third appointment (for treatment of tooth 74), the dentist again used a combination of nitrous oxide oxygen conscious sedation and local anaesthetic. While placing the composite material, the gas flow was changed to 100% oxygen and the child became restless and fidgety. The dentist had to open the patient’s mouth and asked the father to hold down the child’s hands in order to complete the treatment. Following treatment, the child seemed restless and wanted to leave. He was discharged into the care of his father. About five minutes after leaving the operatory, the member was told that the child was not feeling well and was lying on his side. The dentist immediately took the child back to an operatory, noting that fainting can occur when children are very apprehensive. The dentist tried to get the child to lie down and allow an oxygen mask to be placed. The child continued to struggle and appeared to be getting weaker and unstable. Seeing this, the dentist had his staff call 911 and returned to the operatory to monitor the patient. Once the paramedics arrived, the dentist provided the paramedics with information about the medication and dosages used during the treatment. The child was transferred to hospital for further evaluation.

In his response to the College, the dentist noted that the child had received the same agents at a previous appointment with no adverse effect. The dentist stated that, while it was unfortunate that there was an unforeseen incident, it was his opinion as a paediatric dentist that the use of nitrous oxide oxygen conscious sedation alone or in conjunction with local anaesthesia was very safe and not a factor in this event.

DECISION OF COMPLAINTS COMMITTEE PANEL The panel members reviewed all correspondence and records obtained during the course of its investigation. They were of the opinion that the child’s reaction was likely caused by a pre-existing condition and was unrelated to the use of nitrous oxide or local anaesthetic. In their view, both nitrous oxide oxygen sedation and local anaesthetic are commonly used in dentistry and have a very safe history and a low risk of adverse reaction. The panel noted that in the letter from the child’s father, he mentioned that none of the physicians consulted subsequent to this event had identified a link between the use of local anaesthetic and nitrous oxide oxygen sedation and the resulting symptoms experienced by his son. It was their view that the incident was an unfortunate occurrence and not caused by the dentist’s treatment. In fact, it was their opinion that the dentist handled this emergency in an appropriate manner. Based on the above rationale, the panel ordered that no further action be taken with respect to the complaint.

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Ethical Dilemma Discussion DENTAL ETHICS 101

“I’m pregnant. Please don’t tell my parents.” CONFIDENTIALITY OF PATIENT HEALTH AND PERSONAL INFORMATION The Dental Ethics 101 Ethical Dilemma Case Study appears on page 17.

What is at stake in this case? Is Dr. Jones obligated to tell Mary’s parents that she is pregnant? When Mary confides this information to her dentist, should this confidence be respected? What moral obligations are required of dentists to respect the confidentiality of the dentist-patient relationship? Are there special considerations in this case because Mary is not legally independent?

CONFIDENTIALITY AS A CORE VALUE Mary’s case illustrates the fact that dentists, as health professionals, are responsible for managing the personal information revealed by their patients. This moral responsibility is referred to as confidentiality, a core value in the doctor-patient relationship and is cited in codes of ethics. It is based on trust, and may be broken only in certain extraordinary circumstances. Codes of ethics provide an insight into the central values of a profession. These codes may change and evolve, just as a dentist’s practice, patients and third party interests change and evolve. Keeping the confidences of patients is a core value/ethical principle in most Canadian dental codes of ethics, including the RCDSO Code of Ethics.

DISPATCH • August/September 2007

Ensuring Continued Trust

One of the ethical principles contained in the RCDSO Code of Ethics states that an ethical dentist should “protect the confidentiality of the personal and health information of patients.” While the principle of confidentiality is an ethical core value and legal responsibility for health professions, the value of confidentiality underscores the necessity of trust in the relationship of patients and their doctors. This also is addressed in the core value of integrity contained in the RCDSO Code of Ethics, which is defined as “being truthful, behaving with honour and decency and upholding professional standards.”

THE IMPORTANCE OF TRUST

Reprinted, in part, from the Texas Dental Journal with the permission of Dr. Thomas K. Hasegawa, Baylor College of Dentistry, Dallas, Texas.

Dentists also trust the patient will keep appointments, fulfill financial obligations, and take responsibility for the maintenance of his or her own oral health. From the patient’s view, the dentist is trusted to abide by the dental code of ethics. Mary Smith has asked Dr. Jones to keep confidential information that has serious social and economic implications for her. Confidentiality is a central means of assuring patients that their doctors will not misuse facts about their lives pertinent to understanding their illnesses. Unlike the trust that must be earned, as in a friendship, the patient assumes a trusting relationship because of the dentist’s training and special role in society.

To understand the role that trust plays in a successful doctor-patient relationship, it must be viewed from the perspective of both the dentist and the patient.

CONCLUSION

From the dentist’s view, sound therapeutics begins with the patient’s trust because dentists ask patients to share personal and sensitive information necessary to properly assess their health and to determine proper therapeutics.

Keeping confidences promotes trust and openness between doctors and patients and allows the patient autonomous control over personal or private information about them. Confidentiality affirms and protects the fundamental value of privacy and the social status of the patient and encourages patients to seek professional help when it is needed.

Dentists are privy to information about serious health conditions, such as cancer and heart disease; conditions that may have profound social implications, such as HIV status and substance abuse; and sensitive personal experiences, such as child abuse and eating disorders. Without accurate and complete information openly communicated by the patient, the dentist’s care could harm rather than benefit the patient.

Dr. Jones is bound to keep Mary’s confidence and cannot tell her parents about the pregnancy without Mary’s permission.

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ON APPEAL

ON APPEAL COLLEGE CONTACT Dayna Simon Assistant to the Registrar, Legal 416-934-5618 1-800-565-4591 dsimon@rcdso.org

When the Complaints Committee issues a decision, either the member or the complainant has a right of a review by the Health Professions Appeal and Review Board (HPARB) – as long as it is not a referral of specified allegations to the Discipline Committee.

Case #1

Under the Regulated Health Professions Act, HPARB hears appeals and reviews decisions made by the self-governing regulatory agencies of all the regulated health professions.

The patient claimed that, if he had understood that the lower teeth would have eroded or that the bridge might have become loose over time, he would have never agreed to the treatment.

These summaries of some HPARB reviews are published in Dispatch as an educational resource for both members and the public. Institutional parties may be named, but individual parties will not.

THE COMPLAINT A patient complained to the College about treatment provided to him for about 10 years, specifically that over time the dentist did bridgework that continually loosened and prematurely wore out the patient’s lower teeth.

The member responded by providing proper records that documented the process of informed consent, including risks of treatment and options for treatment.

DECISION OF COMPLAINTS COMMITTEE The panel was satisfied with the records and on balance believed the dentist on the issue of informed consent. Further, on examination of the radiographs, models taken etc., the panel was of the view that the work recommended and the way it was done was appropriate. The panel ordered no further action.

HEALTH PROFESSIONS APPEAL AND REVIEW BOARD The complainant was dissatisfied and appealed to the Health Professions Appeal and Review Board. The Board was persuaded that the records were thorough and accurate, and gave a fair representation of what likely transpired in the process of informed consent. Therefore, the Board dismissed the appeal.

DISPATCH • August/September 2007

Ensuring Continued Trust

Case #2

Case #3

THE COMPLAINT

The patient complained that, in the course of surgery, the dentist videotaped the dental appointment. The dentist responded by advising the Committee that the patient had to be aware that treatment was videotaped since there was a camera quite visible in the room.

The patient complained to the College about work done by the dentist. The dentist placed bonded Empress Crowns on six of the patient’s upper teeth. The patient was of the view that veneers rather than crowns should have been used. The patient said that the crowns were too thick, did not look or feel natural, caused difficulty with her speech and created numerous other problems. She also complained that she experienced paraesthesia and facial edema following the work.

DECISION OF COMPLAINTS COMMITTEE The panel of the Complaints Committee issued a caution to the member. The panel was concerned that the treatment was videotaped without the patient’s expressed consent. The charts and records had no notation of the patient’s knowledge, consent, or any specific document that confirmed that the consent had been provided. While the panel stated that the use of a video camera in and of itself is not problematic, it must used only with the patient’s expressed consent.

HEALTH PROFESSIONS APPEAL BOARD The dentist was dissatisfied with the decision of the Complaints Committee to issue a caution and appealed to the Board. The Board took no issue with the adequacy of the investigation and decided that the decision of the Complaints Committee was reasonable. The Board confirmed that the dentist, in using the video camera, “acted in a deceptive, clandestine, and underhanded fashion without the patient’s knowledge.” This was further supported by the materials in the record of investigation filed with the Board. The Board also reviewed the videotape and noted that the patient was unaware that taping was taking place. The Board supported and confirmed the decision of the Complaints Committee.

The dentist responded by stating that, if there were old fillings, something more than a front veneer would be required. He also clarified that “Modified Empress Veneers” was the name of a product that wrapped around in a similar manner to a crown. It was also very clear that the dentist reviewed the options and there was a good process of informed consent that was appropriately recorded.

DECISION OF COMPLAINTS COMMITTEE The College staff retained an expert who provided a letter of opinion stating that the dentist’s work met acceptable clinical standards. In fact, the expert found that the crowns were excellent. As to anything else that might have been complained about, such as paraesthesia, the expert could not make any cause or link between the dental treatment and the paraesthesia or the edema. The panel ordered no further action.

HEALTH PROFESSIONS APPEAL BOARD The complainant was dissatisfied with the decision of the Complaints Committee and appealed to the Board. The Board reviewed the investigation and was particularly impressed with the expert opinion that supported the work of the dentist. The totality of the information was assessed by the Board, and the Board supported and confirmed the decision of the Complaints Committee. DISPATCH • August/September 2007

PRACTICE CHECK

Common Questions USE OF AUTOMATED EXTERNAL DEFIBRILLATORS An automated external defibrillator (AED) is a portable automatic device used to restore normal heart rhythm to patients in cardiac arrest. An AED is applied outside the body. It automatically analyzes the patient’s heart rhythm and advises the rescuer whether or not a shock is needed to restore a normal heart beat. If, as a result of the shock, the patient’s heart resumes beating normally the heart has been defibrillated. Recently, two high profile incidents, one involving a National Hockey League player and the other a fan at a Toronto Maple Leaf game, brought these devices to public attention. In both cases, the individuals suffered a cardiac arrest and their lives were saved by the use of an AED. In the May 2007 Journal of the Canadian Dental Association, a guest article by Dr. Dan Haas outlined the benefits of the use of an AED and introduced the concept of these devices becoming standard equipment in a dental office. The purpose of this article is to open discussion on this topic and to address many of the common questions that members are asking the College’s Practice Advisory Service about AEDs.

COLLEGE CONTACT Dr. Lesia Waschuk Practice Advisor 416-934-5614 1-800-565-4591 lwaschuk@rcdso.org

How is a patient’s outcome improved if a sudden cardiac arrest occurs in a dental office? Out-of-hospital sudden cardiac arrests have a survival rate of 6%. Survival from a sudden cardiac arrest decreases 7 to 10% with every one-minute delay in receiving CPR and defibrillation. This rate is improved by half with immediate basic CPR, but even then early defibrillation is the key to saving the victim’s life.

DISPATCH • August/September 2007

Is the training required by a dentist more extensive or much the same as any person who may be in a position to use it? It is the same. You have to know basic CPR very well, and then there is an additional small amount of formal training. A study published in 1999 showed that a class of Grade 6 students easily learned how to use an AED correctly.

What is the risk associated with operator error? The only error an operator can make is failing to ensure that there is no one touching the patient before pushing the button for the shock. Dentists should have comprehensive training in the use of AEDs, which would include an emphasis on this requirement.

On an overall basis, would the possibility of malfunction or misuse by dentists put patients at greater risk in the event of a cardiac emergency than if dentists did not have an AED? There is no evidence to suggest the misuse or malfunction of an AED has led to a poorer patient outcome than if the AED was not available. The equipment is designed to only provide the electrical shock when it reads the condition in which a shock should be delivered. If the machine does not function properly, the dentist would proceed with CPR which would be the case if the machine was not available. Ensuring Continued Trust

Does a dentist put him or herself at risk of criticism respecting their clinical performance if they have an AED and it was used unsuccessfully? In other words, if a dentist is well versed in CPR and has the necessary medical emergency drugs, why would he or she need an AED? The reality is that the most common outcome of CPR is that the patient dies. Having an AED improves that a great deal, but is not a guarantee that everyone will live. The dentist pretty much has two choices. The first is to use an AED in an attempt to save the patient’s life, knowing that it may or may not save the life. The second is to not have an AED, and then only do basic CPR, which has less of a chance for a favourable outcome.

Is there a greater likelihood that a patient may experience a procedure related sudden cardiac arrest in a dental office than in a physician’s office? There is no evidence one way or the other. Due to the fact that patients receiving dental treatment are under more stress than they generally experience in most medical offices, one would expect that the overall incidence may be higher in a dental office.

What is the position of the College of Physicians and Surgeons of Ontario (CPSO) respecting the use of AEDs in physicians’ offices? CPSO does not have a position on AEDs specifically; however they provide members with a Guide to Safe and Effective Office-Based Practices. In the emergency preparedness section of this guide, there is a tool to help members assess their need for specific

equipment. This information can be found on the CPSO website at www.cpso.on.ca .

Given the medical training of dentists, would a higher standard of care and therefore a higher risk of liability apply to dentists using an AED in a dental office? If the AED is used in the dental practice, its use would certainly fit into the definition of “covered services” from a PLP perspective. The proviso, as for all techniques and equipment, would be that the dentist was capable of using it. The AED training provided in a CPR course would be considered acceptable training. In addition, the Chase McEachern Act, which was recently passed by the provincial government as part of the omnibus bill, the Health Systems Improvement Act, 2007, protects health-care providers, including dentists, and the public from civil liability when using an AED in good faith.

What is the cost of an AED? AEDs have come down in price considerably over the last few years. They have also been designed to be much more user-friendly and easy to include as part of a normal dental office’s equipment. An AED, which is reliable, small, easy to store, easy to use and be trained on, can now be purchased for less than $1,800. At today’s current lease rates, that is less than $30 per month. Obviously AEDs cannot be evaluated on a cost benefit relationship. Cardiac arrest in a dental office is, fortunately, a very rare occurrence. Many members will likely never see one during their practice career. However, they do occur and occasionally death has resulted. As the population ages and as a greater percentage of that population seeks dental care than previous generations, the possibility that more dentists will experience this unfortunate event grows. DISPATCH • August/September 2007

PRACTICE CHECK

Two Practice Advisories INFORMED CONSENT ISSUES AND RELEASE AND TRANSFER OF PATIENT RECORDS The College has now issued two practice advisories and they are distributed with this issue of Dispatch. Both of these advisories are also available online at www.rcdso.org.

COLLEGE CONTACT

INFORMED CONSENT ISSUES

Dr. Robert Carroll Manager, Professional Practice 416-934-5611 1-800-565-4591 rcarroll@rcdso.org

This Practice Advisory on Informed Consent Issues Including Communication with Minors and with Other Patients Who May Be Incapable of Providing Consent replaces the Guidelines on Communicating with a Patient Incapable of Providing Consent.

RELEASE AND TRANSFER OF PATIENT RECORDS This practice advisory amends information in the section on financial considerations about the cost of copying records that could be passed on to patients.

The new information in this advisory on consent issues involving minors reflects the high number of inquiries that the College receives on this issue.

DISPATCH â&#x20AC;¢ August/September 2007

Ensuring Continued Trust

PRACTICE CHECK

USE OF BOTOX

in Dental Practice in Ontario COLLEGE CONTACT Dr. Lesia Waschuk Practice Advisor 416-934-5614 1-800-565-4591 lwaschuk@rcdso.org

LEGISLATIVE BACKGROUND

RCDSO POSITION

In Ontario, the scope of practice statement contained in the Dentistry Act, 1991, speaks to the diagnosis, treatment and prevention of a disease, disorder or dysfunction of the oralfacial complex. The College has always interpreted this to mean that there must be an oral component to any treatment rendered by a dentist.

Based on the legislative considerations already outlined, it is the College’s view that Ontario dentists are not permitted to carry out the injection of Botox™, or any other agent material, into the extra-oral/facial tissues of a patient for cosmetic procedures. This position is consistent with those of other dental regulatory bodies in Canada.

Dentists are authorized to administer a substance by injection, but the ability to perform this controlled act is limited to the management of conditions that fall within the • The legislation that governs the scope of practice of the practice of dentistry in Ontario profession. This does not include does not permit the injection of the injection of Botox™, or any Botox™, or any other agent or other agent or material, into the material, into the extraoral/facial tissues of a patient extra-oral/facial tissues of a for cosmetic purposes. patient for cosmetic purposes.

NEED TO KNOW

• The unauthorized use of any agent or material may jeopardize a member’s coverage under the PLP policy, and may expose him or her to substantial costs in the event of a claim.

WHAT IS HAPPENING IN OTHER PROVINCES

A survey of other dental regulatory bodies in Canada regarding the use of Botox™ in dentistry in their jurisdictions revealed that such usage, if at all permissible, is very restrictive, and generally considered to fall outside the scope of dentistry.

One possible exception would the use of Botox™ for certain temporo-mandibular disorders, as the management of such conditions clearly falls within the scope of the practice of dentistry. However, such use of this agent is currently considered off-label and experimental, and should only be employed by highly-trained and very experienced practitioners, usually in a hospital-based multidisciplinary clinic.

PLP PERSPECTIVE Since it is the College’s view that the use of Botox™, or any other agent or material by injection into the extra-oral/facial tissues of a patient for cosmetic purposes, would not be considered a professional service as defined under the PLP policy, errors and omissions coverage may not apply. This would depend on a case-by-case basis and the particulars of any Statement of Claim.

DISPATCH • August/September 2007

NEWS & VIEWS

ACROSS THE NATION Manitoba REGULATED HEALTH PROFESSIONS LEGISLATION

Across the Nation provides a snapshot of activities of the dental regulators across Canada that may be of interest to dentists in Ontario.

COLLEGE CONTACT Peggi Mace Communications Director 416-934-5610 1-800-565-4591 pmace@rcdso.org

The provincial government has initiated discussions with 21 health professions to prepare for an umbrella Health Professions Act that will include common principles for all health-care professions with regard to registration, licensing, discipline, continuing competency, and the separation of regulatory bodies from membership associations. The legislation is to come into effect in the fall of 2008.

DENTAL HYGIENE TRANSITIONAL COUNCIL It is expected that the organizational structure and transfer of licence responsibilities to the new College of Dental Hygienists of Manitoba will occur for licence renewal of January 2008.

DENTAL ASSISTING REGISTRATION The transition to a regulated profession is proceeding. Intra-oral dental assistants are now required to register and obtain an annual renewal of registration certificate in order to be delegated intra-oral duties in a dental office. The Manitoba Dental Assistants Association is developing the organizational structure to support and provide professional services for the about 800 registered dental assistants in the province.

Calendar of Events

RCDSO Council meetings are open to the public, with the exception of any in camera portion dealing with personnel matters or other sensitive or confidential material. Meetings begin at 9:00 a.m. The agenda is available either at the meeting or in advance on request.

COLLEGE CONTACT Angie Sherban Senior Executive Assistant 416-934-5627 1-800-565-4591 asherban@rcdso.org

Mark Your Calendar… RCDSO Open Council Meetings: November 15, 2007, March 6, 2008, June 12, 2008, November 13, 2008 Location: Westin Prince Hotel, 900 York Mills Road, Toronto Seating is limited so if you wish to attend please let us know in advance by contacting the College.

DISPATCH • August/September 2007

REGISTRAR TO RETIRE Dr. Mike Lasko, Registrar of the Manitoba Dental Association, has given notice of his intent to retire at the end of 2008. The Board has approved the development and terms of reference for a search committee. The committee’s first task is to determine if a search outside the profession of dentistry is warranted.

NEW FACULTY DEAN Dr. Anthony Iacopino has been appointed dean, Faculty of Dentistry for a five-year term beginning July 1. Iacopino will also hold a tenured professorial appointment in the department of restorative dentistry.

Alberta MOBILE DENTAL CLINICS In April, the mobile dental clinics rolled down the road at the Jasper Dental Congress. The pilot project to provide care to residents of long-term care facilities is funded by ADA+C and the Alberta Government and supported by a number of dental supply companies. Each mobile clinic is a 38-foot Winnebago with three operatories complete with chairs and units with handpieces, intra-oral cameras, and LCD monitors. There is also a laboratory and a sterilization area. Satellite dishes link the clinic to the Internet and assist with data transmission for billing. Staffing is a joint effort among dentists, allied health professionals, and the University general practice residency and undergraduate dentistry students.

HONOURARY MEMBERSHIP Dr. Peter Cooney, Chief Dental Officer of Canada, received an honourary membership in recognition of his outstanding contribution to the dental profession. He is the first person to hold the position of Chief Dental Officer in Canada. Dr. Cooney is a RCDSO member.

Ensuring Continued Trust

Annual Report 2006: Continuing Commitment to Self-Regulation COLLEGE CONTACT Peggi Mace Communications Director 416-934-5610 1-800-565-4591 pmace@rcdso.org

As the 2006 annual report states: Transparency, accountability and accessibility are the guiding principles of all that we do. “The College has an outstanding record of public protection and that is clearly outlined in our 2006 annual report for all to see,” said College Registrar Irwin Fefergrad. “We take those three words – transparency, accountability and accessibility – very seriously.” Under the RHPA, the College is required to report to the Minister of Health on an annual basis on our activities and financial affairs. The College uses this report as an opportunity to share our good news story by sending a copy of the complete annual report each year to all provincial MPPs. The full annual report is also loaded on our website for public viewing. “Then to fulfill our commitment to members, every year we include a condensed version of the annual report containing the auditors’ report and the audited financial statement with Dispatch magazine,” explained Fefergrad. The full version of the annual report is now available on the College’s website at www.rcdso.org.

New Public Member Appointed to Council Dr. Edelgard Mahant traces her background to the central European maelstrom of World War II. She considers British Columbia her home, though she also has a few soft spots for northern Ontario.

Dr. Mahant

She is a professor of Political Science at York University’s bilingual Glendon College, where she bemoans her part-time status (because the Ontario government did not abolish mandatory retirement soon enough). Her academic specialization consists of European politics and foreign policy, and she has published widely in these fields.

International – and politics. She also enjoys keeping in touch with former students, reading (especially Canadian fiction), travel and cooking (in moderation). Edelgard’s biggest fault is also her major virtue: she is seldom afraid to speak up and speak out. She lives in Toronto’s Greektown and can communicate in English, French and German. Her immediate family consists of her husband, an adult son and daughter, and two grandchildren, who all live in the Toronto area.

Her other interests include human rights – she is a long-standing member of Amnesty

DISPATCH • August/September 2007

NEWS & VIEWS

ODA Annual Spring Meeting 2007 Full House at College Session on Ethics COLLEGE CONTACT Peggi Mace Communications Director 416-934-5610 1-800-565-4591 pmace@rcdso.org

Dental ethics is more than abstract theoretical concepts. The challenge comes in taking these concepts and applying them in your everyday practice. Interested in learning more? Well, a capacity crowd at this year’s ODA Annual Spring Meeting certainly were. College Registrar Irwin Fefergrad and Dayna Simon, Assistant to the Registrar, Legal, led an Dayna Simon, Assistant to the Registrar, Legal (right) interesting and challenging session to help the audience through common scenarios from the dental office. They shared practical advice about issues such as informed consent, responsibility to treat, human rights issues, treatment of the medically disabled, informed refusal, and the requirement to work during a pandemic. The other session led by the College focused on complaints and malpractice proofing your dental practice. Over one-third of the complaints or PLP problems involve one or more of these issues: inadequate recordkeeping, insufficient informed consent process, poor communications, and failure to follow standards of practice. A team of senior College staff illustrated how to avoid these types of problems and to minimize risk. This session was lead by Dr. Don McFarlane, Director of the College’s Professional Liability Program; Dr. Judi Heggie, Dental Advisor, from the College’s Professional Liability Program; and Dr. Michael Gardner and Dr. Chris Swayze, Assistants to the Registrar, Dental.

DISPATCH • August/September 2007

Ensuring Continued Trust

Get Involved. PLP Committee Openings Dr. Don McFarlane Director, Professional Liability Program 416-934-5609 1-877-817-3757 dmcfarlane@rcdso.org

The terms of two of the current dentist members of the College’s Professional Liability Program Committee will expire at the end of this year. As a result of these openings, interested dentists are invited to apply. These opportunities might especially appeal to dentists who have experience and/or are interested in the legal process. Also, because of the Committee’s work, its composition benefits from a mix of specialists, as well as some seasoned general practitioners. What is the mandate of the Professional Liability Program (PLP) Committee? The Professional Liability Program Committee makes recommendations to the RCDSO Council on the policies and practices of the professional liability program and authorizes some claim settlements. How do I know if l am eligible to be appointed to the PLP Committee? You are eligible if you can say “yes” to each of the following criteria on the deadline date for receipt of nominations.

• You are in active practice in Ontario for a minimum of 500 hours during the previous 12 months.

• You have engaged in clinical practice for a minimum of five years.

• You hold a general or specialty certificate of registration, and are actively practising dentistry.

• You are not in default of any fee or fine payments to the College, or are in default of returning or completing any prescribed forms.

• You are not currently the subject of a disciplinary or incapacity proceeding.

• Three years has elapsed since you complied with an order from the Discipline Committee or the Fitness to Practise Committee.

• You do not have any terms, conditions or limitations placed on your certificate of registration, other than ones that are applicable to all members.

• Three years has elapsed since you were disqualified from sitting on Council because of a breach of the Colleges code of conduct for Council members, or the conflict of interest by-law.

• During the previous three years, you have not been a member of the governing boards, or an appointed official, of the Canadian Dental Association, or the Ontario Dental Association, or similar organizations where you were in a decisionmaking capacity. Please note that being a committee chair or committee member is not included in this exclusion.

• You are not, and have not been, engaged as a dental consultant to a third party dental benefits provider during the previous three years. What is the time commitment? The time commitment for the PLP Committee is about four to five days a year. Am I compensated for my time away from my practice? Yes, your compensation would be the same as for Council members. The current honorarium is $890 per day to basically cover your office overhead. Other reasonable expenses, such as travel, accommodation and meals, are reimbursed. CONTINUED ON PAGE 45 DISPATCH • August/September 2007

NEWS & VIEWS

Resounding Success – International Dental Ethics and Law Congress (left to right) Irwin Fefergrad, Registrar, Royal College of Dental Surgeons of Ontario; Dr. Michèle Aerden, President of the World Dental Federation; Dr. Richard Speers, Chair of the Congress Organizing Committee; Dr. Wolter Brands, Judge and Professor at Radboud University, Nijmegen, The Netherlands; Dr. Abbyann Lynch, Director of Ethics at Health Care Associates of Toronto.

The 7th International Dental Ethics and Law (IDEALS) Congress wrapped up a successful three day event at St. Michael’s College at the University of Toronto at the end of May. This was the first time that the IDEALS Congress has been held in Canada. The conference chair was Dr. Richard Speers of Ontario with support from many other individuals and groups, including another RCDSO member Dr. Chris McCulloch, and the Canadian Dental Association. The theme of the Congress was oral health and human rights. Participants in the Congress came from countries as far away as France, Italy, Norway, The Netherlands, Australia, Sweden, Finland and the United States. College Registrar Irwin Fefergrad participated in a plenary session on May 25 dealing with the topic of safeguarding human rights. Joining him on the session panel were Dr. Abbyann Lynch, a leader in the field of medical ethics and the founding Director of the Bioethics Department at The Hospital for Sick Children in Toronto, and Dr. Michèle Aerden of Belgium who is the President of the World Dental Federation. Dr. Wolter Brands of the Radboud University in Nijmgen, The Netherlands, acted as session chair. More information about IDEALS is available on its website at www.ideals.ac.

DISPATCH • August/September 2007

Ensuring Continued Trust

Update on Practice Name Approvals COLLEGE CONTACT Dr. Fred Eckhaus Assistant to the Registrar, Dental 416-934-5624 1-800-565-4591 feckhaus@rcdso.org

As you may know, under the regulations of the Regulated Health Professions Act, the Executive Committee must approve any practice name other than one that is “reasonably referable to and describes the location of the practice.”

Following a recent retreat to review and discuss a number of issues related to advertising and practice names, the Executive Committee has agreed to now approve practice names that do include the word “smile.”

Historically, the Executive Committee has not approved any practice names that included the word “smile.” However, that is about to change.

It is important to note that any names that include adjectives or descriptive terms used to describe the word “smile,” for example, adjectives like big, wide, white, winning etc. will not be approved.

Keeping in Touch: Dispatch Subscriptions Did you know that dentists who have resigned or retired have the option of continuing to receive the College’s Dispatch magazine? To get your name on the complimentary mailing list for Dispatch magazine is quite

simple. All we need is a current mailing address.

Send your request and your up-to-date mailing address to: Greg Moors at gmoors@rcdso.org.

Get Involved. PLP Committee Openings CONTINUED FROM PAGE 43

How long am I committed? These positions are for a three-year term (2008 – 2010). What is the selection process for the PLP Committee? After the deadline for receipt of applications, the Registrar prepares a list of all eligible candidates. This list, plus the resumés, are given to the Executive Committee which, in turn, prepares a list of recommended appointments, ranked in order of preference. Then, at the first Council meeting after the

Executive Committee has made its ranking, Council confirms the selection. If selected, when do I start? You would start with the first committee meeting in 2008. You may also be asked to attend an education/orientation session. I am interested. How do I submit my name? It is easy. Just submit a letter of application and a current resumé to the College’s Registrar Irwin Fefergrad. Your application must be received by November 15, 2007. DISPATCH • August/September 2007

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Filled With Hope for The New Generation CONTINUED FROM PAGE 4

students understand that almost every decision they make in ordinary clinical practice has an ethical and legal context.

and emphasizes the link between the dental profession and the ageless values of trust and integrity.

The issue of ethics is reinforced at the annual White Coat Ceremony held at both dental schools for incoming students. The ceremony helps to emphasize to the students, right from their first days at dental school, that they are entering a profession firmly based in the public trust, and this trust begins as soon as they enter the door of the dental faculty.

It is now nearly 40 years since I stood on a similar stage and formally began my career in one of the greatest professions in the world. And I am still filled with the same enthusiasm and hope for the great things that we can do as dentists to make society a better place for our children and grandchildren.

The Registrar participates in each ceremony and leads the students in the recitation of the Oath of Commitment. The Oath was developed by the College

After my short time spent with all these excited and enthusiastic new dentists, I know that the future of our profession is in excellent hands.

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Rempli d’espoir for les dentistes de la nouvelle génération SUITE DE LA PAGE 4

docteurs en médecine dentaire. Environ 85% de la population de l’Ontario reçoit des soins dentaires. Ce que ces nouveaux dentistes comprennent et apprécient quant à l’éthique aura un impact sur presque l’ensemble de la population de cette province. Le Collège s’engage à encourager chaque nouvelle génération de dentistes à devenir des professionnels responsables et intègres. Comme beaucoup d’entre vous le savent, la réussite à un examen concernant les normes de déontologie et la jurisprudence est l’une des exigences à remplir afin de pouvoir obtenir un permis d’exercice en Ontario. Il s’agit là seulement de l’une des nombreuses stratégies utilisées pour renforcer un comportement éthique et intègre. Des membres seniors du personnel enseignent l’éthique dans chacune des universités où ce cours est obligatoire pour l’obtention du diplôme. Il est essentiel que les étudiants reconnaissent que presque toutes les décisions qu’ils seront amenés à prendre dans l’exercice de leur profession s’inscrivent dans un contexte juridique et moral.

DISPATCH • August/September 2007

L’importance de l’éthique est réaffirmée lors de la Cérémonie annuelle de la blouse blanche tenue à chacune des deux facultés de médecine dentaire pour les étudiants de première année. Cette cérémonie aide à souligner aux étudiants, dès leur premier jour à la faculté, qu’ils entrent dans une profession reposant fermement sur la confiance du public, et que cette confiance commence aussitôt qu’ils franchissent la porte de la faculté. Le Registrateur prend part à chaque cérémonie et mène les étudiants dans la récitation du serment professionnel des dentistes. Le serment a été créé par le Collège et marque le lien entre la profession dentaire et les valeurs immortelles de confiance et d’intégrité J’ai commencé ce magnifique métier il y a presque 40 ans maintenant et ma passion est toujours aussi vivace. Je suis rempli du même enthousiasme et espoir pour les grandes choses que nous pouvons faire en tant que dentistes afin d’aider à bâtir un monde meilleur pour nos enfants et petits-enfants. Après avoir passé ce court moment avec tous ces nouveaux dentistes, je sais que l’avenir de notre profession est entre de bonnes mains. Ensuring Continued Trust

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RHPA Review Signals New Era CONTINUED FROM PAGE 48

example, there will be huge costs incurred in putting in place the behind-the-scenes computer systems and securities to allow for real time public access to the public register. Likewise, there will be additional costs in creating the administrative framework to meet the requirements of the new Fair Access to Regulated Professions Act. Whatâ&#x20AC;&#x2122;s ahead in the next 15 years? The only sure thing is change itself. I can guarantee that our work as a regulator must continue to evolve and change. I took a look back at the special report we prepared in October/November 2002 after our innovative leadership conference, The Future of Dentistry. In my opening message, I talked about the difficult issues then ahead for us: the growing demand for openness and transparency at all levels of operations at the College; the philosophical shift in regulation

from a punishment to a rehabilitation model; the major demographic shifts impacting the kind of dental care patients need; a trend to a collaborative model with other dental and health-care practitioners; and the need for a greater involvement by the College in providing liability coverage. Five years later, and every one of those issues is now a reality. And this College has successfully found creative solutions to deal with each one of these issues. So, based on our experience, we have every reason to be filled with confidence for the next five years. I have yet to see anything that would tell me the profession and our Council is not up to the challenges ahead. Best of all, we are moving forward from a point of strength and an enviable record of success.

SPECIAL ANNOUNCEMENT

Summit on Access to Dental Care APRIL 9, 2008 RCDSO and the Ontario Dental Association have just announced plans to jointly host a one-day summit to formally kick-off the provincial dialogue to find workable solutions to expand access to dental care. Participants will include advocacy groups, experts, associations, regulators, government, and representatives from the dental community. Watch for more details in upcoming issues of Dispatch and Ontario Dentist!

DISPATCH â&#x20AC;˘ August/September 2007 47

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RHPA REVIEW SIGNALS NEW ERA IN HEALTH-CARE REGULATION

round the world we are entering a new era of health-care regulation. The current amendments to the Regulated Health Professions Act now put regulators in a good position to deal with the unending changes and demands of society in the years ahead. As a health-care regulatory college, of course, our fundamental purpose remains the same. Our primary purpose is to ensure the safety and quality of oral health care for patients. However, it is amazing to think of what has happened since 1991 when the Act was first passed. It is no exaggeration to say it is indeed a whole new world.

IRWIN FEFERGRAD

The Health Professions Regulatory Advisory Council gave a clear and powerful outline of the demands of this changed world in its report, called New Directions, delivered to the Minister in April 2006. This report formed the basis for the RHPA amendments passed late this spring. The report described a world in which the use of technology is pervasive. Patients and others use the Internet to find health-care practitioners, and want to use this same technology to review qualifications, their professional record, and get a sense of the quality of care they provide. Demographic shifts and the threat of global pandemics have added a new immediacy to the need to make health human resources policy and planning a priority. Moving the delivery of health care beyond the walls of traditional institutions into the community has meant a growing need for experimentation and innovation in how health-care practitioners work together. Multidisciplinary and collaborative practice is seen as the foundation for the changes that will define health-care delivery in the years ahead. Then, add to the mix the growing demands from consumers and governments for more accountability and transparency to ensure that health-care professions continue to deserve the privilege to self-regulate. And finally, the influences that impact us come from far beyond our provincial borders. As we have seen recently at our College, we are directly impacted by global events, such as immigration trends, labour mobility agreements and international educational standards. Of course, responding to these massive external pressures come at a price. For

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DISPATCH â&#x20AC;˘ August/September 2007

Ensuring Continued Trust