WELLNESS 14 Emotional health and the dentist

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2 FRONT & BACK 4 The President s Message Volunteers are the life-blood that keeps the College vital 48 From the Registrar Our QA Program: An innovative idea that really works WELLNESS 14 Emotional health and the dentist Part two in a series of six articles DEPARTMENTS Quality Assurance 18 College provides links to evidence-based websites 21 End of CE cycle Malpractice Matters 22 Dangers of making promises 24 Anatomy of a legal action Professional Practice 28 Collecting co-payments and deductibles 30 Plan approval process of x-ray inspection 38 New sedation and general anesthesia by-law strengthens public protection 40 New process for sedation/anesthesia authorizations and permits 2 DISPATCH Vol. 28, No.2 May/June 2014 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. MANAGING EDITOR SENIOR EDITOR ART DIRECTION AND PRODUCTION COVER DESIGN REGISTRAR Peggi Mace Diana Rickford Roger Murray and Associates Incorporated Public Good Irwin Fefergrad, CS, BA, BCL, LLB (Certified as a Specialist by the Law Society of Upper Canada in CIVIL LITIGATION and in HEALTH LAW) Reprint Permission Royal College of Dental Surgeons of Ontario, All Rights Reserved. This material may not be reproduced, copied, modified or distributed in any form, in whole or in part, without prior written permission of the Royal College of Dental Surgeons of Ontario. Contact info@rcdso.org for requests for permission. Environmental Stewardship This magazine is printed on paper certified by the international Forest Stewardship Council as containing 25% post-consumer waste to minimize our environmental footprint. In making the paper, oxygen instead of chlorine was used to bleach the paper. Up to 85% of the paper is made of hardwood sawdust from wood-product manufacturers. The inks used are 100% vegetable-based. PUBLICATION MAIL AGREEMENT # ISSN #

3 DEPARTMENTS Practice Bites 32 When a patient needs a referral Website Spotlight 34 Online snapshot of College services and programs PEAK 36 Risk of adrenal crisis in dental patients 46 Calendar of Events FEATURES 6 DisAbilities Series Making the attitudinal shift 8 Call for Non-Council members to serve on College committees 12 Colonel Chris Hadfield awarded special licence NEWS 43 Annual renewals for HPC certificate authorization 44 Practising illegally as a dental hygienist 45 Source Guide 2014 ISSUE ENCLOSURES Discipline Summaries PEAK: Risk of adrenal crisis in dental patients Results of a systematic search of the literature RCDSO COUNCIL MEMBERS PRESIDENT APPOINTED BY LIEUTENANT-GOVERNOR IN COUNCIL Dr. Peter Trainor Marianne Park Woodstock Royal College of Dental Surgeons of Ontario 6 Crescent Road, Toronto ON M4W 1T fax: info@rcdso.org VICE PRESIDENT Dr. John Kalbfleisch Dr. Robert Carroll Dr. David Clark Dr. Lawrence Davidge Dr. Sven Grail Dr. John Kalbfleisch Dr. Lisa Mary Kelly Dr. Elizabeth MacSween Dr. David Segal Dr. Joe Stasko Dr. Peter Trainor Dr. Flavio Turchet Dr. Ron Yarascavitch Beth Deazeley Manohar Kanagamany Kelly Bolduc-O Hare Ted Callaghan Kurisummoottil Joseph Catherine Kerr Evelyn Laraya Dr. Edelgard Mahant Jose Saavedra Abdul Wahid ACADEMIC APPOINTMENTS Dr. David Mock Dr. Richard Bohay Oakville Markham Little Current Sudbury Thunder Bay Stevensville Toronto Toronto Woodbridge Scarborough University of Toronto Western University 3

4 The President s Message PETER TRAINOR Volunteers are the life-blood that keeps the College vital Volunteering plays a critical role in strengthening the social fabric of our society. According to Statistics Canada, 1 in 2 Canadians aged 15 and over donate their time, energy and skills to charities and non-profit organizations. The approximately 2 billion volunteer hours they contribute is equivalent to more than 1 million full-time jobs. These are amazing statistics. The dentists who contribute their time, energy and skills on our Council and committees are part of those numbers. This volunteer work is important not only to individual volunteers but to Canadian society as a whole. As the 2011 United Nations State of the World s Volunteerism Report stated,...volunteerism benefits both society at large and the individual volunteer by strengthening trust, solidarity and reciprocity among citizens, and by purposefully creating opportunities for participation. That all sounds very lofty, but the facts are this: without the men and women who volunteer to support the regulation of their profession, this College could not function. As I have said many times before, these are the individuals who put the self into self-regulation. In this issue of Dispatch magazine, there is a call for volunteers to put their names forward to serve as non-council committee members. Then, in the following issue, there will be information about how to stand for election to our governing Council. 4

5 The President s Message I hope that you will consider answering the call. These are wonderful opportunities to enrich your professional life and to make a meaningful contribution to your colleagues and to your broader community. You will join a proud history of volunteerism that stretches back over 145 years to the very beginning of the College. Our longevity and success are due in large part to the contributions of the men and women who decided to take the time away from their family and practice to make a difference. I don t think it is a stretch to say that it is only with this commitment from the profession that we can continue to enjoy the privilege of self-regulation. I encourage you to consider volunteering here at the College. Personally I can say that my time here at the College has been the pinnacle of my volunteer career within organized dentistry. I can think of nowhere else where you are on the frontlines, involved in significant issues that directly impact our profession and the quality of care for our patients. As His Excellency the Right Honourable David Johnston, Governor General of Canada, said on the occasion of National Volunteer Week in April: In Canada, we are truly blessed to live in a society that values generosity and sharing. Canadians recognize that helping one another and supporting worthy causes is both the right thing to do and the bright thing to do. It is both smart and caring. I know that if you speak to any of your colleagues who have sat on committees or on Council, they will also tell you about the strong sense of personal and professional satisfaction and fulfillment that they have gained from the experience. In the end, this is probably the best recommendation of all. Nos bénévoles apportent de l air pur au Collège Le bénévolat joue un rôle critique dans l affermissement du tissu social de notre société. Selon Statistique Canada, un Canadien sur deux de plus de 15 ans a fait don de son temps, de ses énergies et de ses talents à un organisme caritatif ou sans but lucratif. Les deux milliards environ d heures de bénévolat auxquelles les Canadiens ont contribué équivalent à plus d un million d emplois à temps complet. Ces statistiques sont époustouflantes. Les dentistes qui ont fait don à notre conseil et à ses comités de leur temps, de leurs énergies et de leurs talents font partie de ce nombre. Ce travail bénéficie non seulement aux bénévoles eux-mêmes, mais à la société canadienne dans son ensemble. Comme le soulignaient les Nations Unies dans le rapport sur la situation du volontariat dans le monde 2011, «Le volontariat profite à la fois à l ensemble de la société et à la personne qui se porte volontaire en renforçant la confiance, la solidarité et la réciprocité parmi les citoyens et en créant délibérément des opportunités de participation.» Ces propos peuvent sembler un tantinet pompeux, mais ils s appliquent bien à notre cas. Sans le travail bénévole des hommes et des femmes qui permet de réglementer notre profession, ce Collège œuvrerait en vain. Comme je l ai déjà souligné auparavant, voilà les gens qui conduisent l «auto» de l autoréglementation. 5 Suite à la page 46

6 Treating Patients with DisAbilities PART 2 Making the attitudinal shift Attitude is probably the most difficult barrier to overcome when treating patients with disabilities. Maybe we are not sure of the best way to communicate. Sometimes we might be worried that we could offend someone by offering help. Or we even unwittingly act in a discriminatory way because of societal stereotypes. Dentists are ahead of the game as they have important skills that they use every day in order to be successful: they are constantly talking with and listening to their patients to provide the best oral health they can. What else might help? The most important thing is to be honest and sincere. Ask how you can help and listen for instructions. One of the best things you can do is ask: How can I help you? Know your patient. While some special skills may be required to provide care, the most important aspect of caring for a patient with a disability is getting to know what you re dealing with by talking with the patient. Then, you sit down with your team and see how you can best provide care in light of the patient s situation. Engage with a person with a disability as you would like to be treated. Treat persons with disabilities as if they are people with 6 their own needs, and ask yourself what dentistry can do to help them. Be courteous but not condescending. Acceptance means a lot. Listen attentively to your patients with disabilities to understand their background and functional needs. They are experts on their own needs. Work efficiently during procedures. Working with your coordinated dental team and planning the procedures for a visit ahead of time will help to ensure a comfortable visit for everyone. If there are caregivers involved, they can be a valuable resource in treating patients with special needs, since they can instruct dental staff in what to do and what not to do when helping the patient. If you are interested in learning more, check out the Special Care Dentistry Association. SCDA provides a forum for an exchange of clinical ideas and patient management techniques among members. SCDA provides a network of colleagues across the U.S. and Canada who have already faced issues you suddenly find in your practice. SCDA has a resource list for more information on its website at This article and the previous one in the February/March 2014 issue are an educational initiative of the Patient Relations Committee.

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8 Consider Making A Difference Submit Your Name for Appointment as a Non-Council Member to College Committees E Every two years, a number of Ontario dentists take time from their busy dental practices to make a commitment to help the College deliver on its mandate of responsible self-regulation. It is a challenging job. However, as any of your colleagues who have served as non-council members of any of the College committees will attest, the experience is enormously rewarding and fulfilling. They are finishing their terms with fond memories of the collegiality and goodwill shared with other committee members and College staff. 8

9 How do I know if I am eligible to be appointed to a College committee? You are eligible if you meet the following criteria on the deadline date for receipt of applications, which is November 26, 2014 at 9:00 am. You have filed a signed Application and Eligibility Form for Non-Council Committee Appointment with the College Registrar. You have filed a signed Declaration for Persons Wishing to be a Non-Council Member of a Committee of the College with the College Registrar. You were not randomly selected in the two consecutive selections immediately prior. You have not served on the College Council in all four consecutive terms immediately prior. You are applying for selection in the electoral district in which your designated address is situated. You hold a general or specialty Certificate of Registration. Three years have elapsed since you have been found guilty of a criminal offence or complied with any penalty. You are not in default of any fees or other monies owing to the College, or in default of returning or completing any prescribed forms. You are not currently the subject of any disciplinary or incapacity proceeding. You do not have any terms, conditions or limitations placed on your Certificate of Registration, other than ones that are applicable to all members holding that class of certificate. Three years have elapsed since you complied with all aspects of an order of a Discipline or Fitness to Practice Committee. Three years have elapsed since you were disqualified from sitting on Council or serving as a Committee member. During the previous two years, you have not been a director or other member of the board of directors, governing council, or other governing body, or an officer or appointed official of the Canadian Dental Association, a national or provincial dental specialty association or similar organization. A period of at least two years has elapsed since you were last employed by the College as a salaried employee. You are not, and have not been, engaged as a dental consultant to a third party dental benefits provider during the previous three years. How much time is involved? It really varies from committee to committee. Some committees like Inquiries, Complaints, and Reports meet about once a month. Others, like Fitness to Practice, may only meet three times a year. E 9

10 Consider Making A Difference Submit Your Name for Appointment as a Non-Council Member to College Committees Am I compensated for the time away from my practice? The 2014 rate is $1,030 per day, with $1,235 per day for committee and panel chairs. Other reasonable expenses, such as travel, accommodation and meals, are reimbursed. How long is my commitment? The term is about two years, the same as for Council members. Can I run for elected office and submit my application and resumé for an appointed committee position too? Yes, you can do both. However, if successful in the election, your name will be removed from the random selection process for appointment to a committee. If I am interested, what do I do? The process is quite straightforward. The Application and Eligibility Form for Non-Council Committee Appointment will be available online and an blast will be sent to all members with a link to the form and declaration. Fill out this form, along with the declaration, which will be posted online, along with your resumé, and return it to the attention of the College Registrar Irwin Fefergrad on or before the deadline of November 26, 2014, 9:00 a.m. created with your name on it and sealed in an envelope with the district number on the outside as the only identifying information. At the time of selection, the Registrar opens the sealed envelopes, district by district, in front of two scrutineers. The cards for each district are shuffled and one file card is selected at random. You are only eligible for random selection in the electoral district in which your designated address on the Public Register is situated on the eligibility date. Can I choose which committee I sit on? If your name is selected, the Executive Committee will review your resumé. You may send in a letter listing any committee preferences. The Executive Committee then reviews this information to help them place you on the most appropriate committee. If selected, when do I start? You start with the first committee meeting in 2015, usually within the first month or so of the beginning of the year. You may also be asked to attend special education or orientation sessions. Who do I call if I still have questions? College Registrar Irwin Fefergrad is available to answer any questions. You can reach him on his direct line at , toll-free at or by at ifefergrad@rcdso.org. 10 How does the selection process work? As the applications forms are received at the College, they are reviewed to confirm that all the eligibility criteria are met. Then a file card is

11 What s involved in committee work? INQUIRIES, COMPLAINTS AND REPORTS COMMITTEE 1 day/month Reviews public complaints and Registrar s investigations. DISCIPLINE COMMITTEE 10 days/year Hears and determines allegations of professional misconduct or incompetence. FITNESS TO PRACTISE 3 days/year Determines if a dentist is incapacitated, is suffering from a physical or mental condition or disorder. QUALITY ASSURANCE COMMITTEE 6 days/year Responsible for the continuing competence of all dentists to ensure maintenance of standards of practice. PATIENT RELATIONS COMMITTEE 3 days/year Responsible for College s interaction with the public and dentists on professional conduct issues, especially those of a sexual nature. 11

12 Colonel Chris Hadfield becomes first person granted right to practise on extraterrestials 12 A A very special member joined the College on May 8. He becomes the first person registered to practise on extraterrestials. That person is Colonel Chris Austin Hadfield, one of the best known Canadians internationally. College President Dr. Peter Trainor and Registrar Irwin Fefergrad presented a unique Honourary Member Certificate to Hadfield at the Ontario Dental Association s annual spring meeting. It was a sincere but tongue-in-cheek way to recognize Colonel Hadfield and his amazing interpersonal and interstellar accomplishments. The certificate was awarded under The Martian Chronicles Act the Martian Chronicles was his favourite book as a child. Colonel Hadfield s certificate has a very special number: 69/92/95/2001/2013. These are years that have special significance for him. In 1969, he watched the Apollo moon landing and decided at 10 years old he would become an astronaut. In 1992, he was accepted into the Canadian astronaut program. In 1995, he took his first flight in space. In 2001, it was his first space walk. And finally, in 2013, he was Commander of the International Space Station and this was his final mission. Colonel Hadfield is a pioneer of many historic firsts. In 1992, he was selected by the Canadian Space Agency as a

13 ((left to right) RCDSO President Dr. Peter Trainor, Colonel Chris Hadfield and College Registrar Irwin Fefergrad. PHOTO CREDIT: DAVE MERROW PHOTOGRAPHY NASA Mission Specialist Canada s first fully qualified Space Shuttle crew member. Three years later, aboard Shuttle Atlantis, he was the first Canadian to operate the Canadarm in space, and the first Canadian to board a Russian spacecraft as he helped build space station Mir. In 2001, aboard Shuttle Endeavour, Colonel Hadfield performed two spacewalks the first Canadian to do so. In 2013, he was Commander of the International Space Station the first and only Canadian to ever command a spaceship, so far. During his multi-faceted career, Colonel Hadfield has intercepted Soviet bombers in Canadian airspace, lived on the ocean floor, been NASA s Director of Operations in Russia, and recorded science and music videos seen by hundreds of millions. A heavily decorated astronaut, engineer, and pilot, Colonel Hadfield s many awards include receiving the Order of Ontario, the Meritorious Service Cross, and the NASA Exceptional Service Medal. He was named the Top Test Pilot in both the US Air Force and the US Navy, and has been inducted into Canada s Aviation Hall of Fame. He is the author of the internationally bestselling book An Astronaut s Guide to Life on Earth, and has been commemorated on Canadian postage stamps, Royal Canadian Mint silver and gold coins, and on Canada s newest five dollar bill (along with fellow astronauts Steve MacLean and Dave Williams). 13 Background photo: The International Space Station and the space shuttle

14 WELLNESS Emotional Health and the Dentist PAUL H. EARLEY, MD, FASAM Part Two in a series of six articles In our first article, we discussed the importance of emotional health for all of us who work in the medical community. As a group, medical professionals set aside our own needs during training and our careers, focusing on the health of our patients. To illustrate the difficulties inherent in maintaining emotional health, I introduced you to Noah Marshall, a fictional, bright, energetic dentist with a general practice in a moderatesized Canadian town. Noah trained at a prestigious dental program and there met and married his wife who soon became pregnant. Noah changed course from an academic career to begin their family and life together close to her supportive family. Jeanne is pregnant and Noah has just completed his training. 14

15 After the move to their new home, Noah dove into his practice with enthusiasm and excitement. He brought new techniques and approaches in the art and practice of dentistry from his recent training. As a new associate in a practice with an aging partner, his ideas were met with some skepticism and resistance. This frustrated him at times. That said, he did understand the value of proving himself in a new situation and bit his tongue. At home, Jeanne s pregnancy was troubled by gestational diabetes. She was tired and overwhelmed despite the support of her family. Noah, with the demands of his new practice and Jeanne, with the complications of her pregnancy, each experienced their first taste of dissatisfaction with the other. Jeanne soon delivered their daughter, Rachel, and all began anew. They reconnected in the joy fashioned from the first year of Rachel s life. With limited time for recreation and a determination to remain healthy for his wife and daughter, Noah took up running. In the dark early morning hours before his family was out of bed, Noah discovered the solitary pleasure of a morning jog. Slowly the length of his daily run increased. In his youth, Noah focused primarily on academics and Despite its omnipresence, our understanding of emotional health is deeply contradictory and confusing. never had time for sports. He was pleasantly surprised at the benefits his running regime had on his attitude toward life and his work stamina. By the time his daughter was three, Noah s runs were averaging 5 to 10 kilometres per day. One winter morning, Noah set out for his run in the cold dark winter air. Starting out, he felt especially strong and planned to add a bit of distance that day. Six kilometres into the run, Noah slipped and fell twisting his ankle in the dawn light. The fall injured his hip and bruised his face. After brushing himself off and checking for broken bones, he began the long trek home. His walk was barely a hobble at first, protecting a painful right ankle with a hitch in his stride. When the pain subsided, he jogged slowly with an asymmetric cadence the rest of the way home. Arriving home, he realized the pain had worsened. He wrapped his ankle in an elastic bandage. With no time to spare he hobbled off to the office to see his first patient. E 15

16 WELLNESS Emotional Health and the Dentist 16 During his busy day of practice, the pain increased. In a fit of desperation, he took several hydrocodone tablets from the practice s dispensing stock. Somehow the day got better. His energy returned, he was able to work for the remainder of his day. In fact, Noah noticed that he felt better than normal. He had a surfeit of psychological energy. His work seemed smooth and efficient; he engaged with his patients with empathy and support. At the end of his work day, he returned home to Jeanne. His pain had returned. Jeanne called for an appointment with their family physician the next day. After several x-rays and a thorough examination, Noah was diagnosed with a level III sprain of his right ankle. His hip and facial contusions were swollen and beefy. His physician placed him in an immobilizer for his ankle and prescribed hydrocodone for his ongoing pain. He instructed Noah not to run for eight weeks. Secretly, Noah was relieved. Although he could no longer count on the peace and centering that came from his morning jog, he knew he could function with the pain relief provided by the hydrocodone. For the next several days, Noah worked hard as he hobbled about the office. He took the medication regularly and as prescribed, two tablets every four to six hours. The sense of well-being continued. Within a week, his hydrocodone supply was exhausted. Telling himself that his pain should be better, he continued his busy schedule, an exploding workload from the expanding dental practice. He felt tired and a bit irritable, but wrote it off to residual pain and his inability to go on his daily run. Months passed and life returned to normal. His daughter Rachel grew into a healthy, curious and very active toddler. Jeanne became pregnant again. Noah, having worked at the practice for three years with great success, began negotiations to purchase the practice from his aging partner. Despite its success, Noah felt an increasing dissatisfaction with the grind and repetition of his work. Noah s running, once so important to him, CDRAF AND CDA JOINT PROJECT The development and distribution of this article is a joint project of the Canadian Dental Regulatory Authorities Federation and the Canadian Dental Association. The six part series of articles appears on their websites. The goal of the project is to raise awareness of dentists in Canada about addiction disease and the opportunities for treatment and recovery. Dr. Earley was a keynote speaker at the national symposium collaboratively organized by CDRAF and CDA held in Toronto in November 2011 to profile addiction for the organizations leadership.

17 slipped in its frequency and intensity. Citing his busy schedule, he stopped running in local and province-wide races. Late one afternoon after an especially busy day, Noah found himself in an argument with a dissatisfied and angry patient, who complained of poor workmanship and continuing pain from an especially difficult bridge and crown procedure. The patient shouted and these pills are doing nothing to help the pain! slamming the bottle down on the procedure tray. After a thorough examination of the workmanship involved in the procedure, Noah was satisfied that nothing was amiss. The patient was unsatisfied and eventually stormed out of the office after making vague accusations and threats. Always priding himself in the quality of his work, Noah felt bitter and deflated. He asked his staff to give him a few moments alone in the exam room. Suddenly, as if they just appeared in front of his eyes, he saw the half-full bottle of hydrocodone. Without a thought, he opened the bottle and swallowed two tablets. Pocketing the remainder, he stood up and went to see the last patient of the day. Stay tuned for installment three, where we will follow Noah over the next several years. As you might imagine, things are about to change. PAUL H. EARLEY, M.D., FASAM Dr. Earley has been an Addiction Medicine Physician for over 25 years. Over his career, he has treated all types of addictive disorders and specializes in the assessment and treatment of health care professionals. As a therapist, he works with patients already in recovery, providing long-term therapy for those who suffer from this disease. His professional expertise extends to advocacy for professionals before agencies and licensing boards. Dr. Earley is the Medical Director of the Georgia Professionals Health Program, Inc., the Physicians Health Program (PHP) for the state of Georgia in the United States. He is also a consultant to numerous treatment agencies regarding treatment effectiveness and staff development. Dr. Earley speaks nationally and internationally on topics of addiction, its treatment and addiction among health care professionals. He is the author of numerous books and articles on addiction and its treatment, including The Cocaine Recovery Book. He is one of the authors of the American Society of Addiction Medicine (ASAM) Textbook: Principles of Addiction Medicine, including the chapter: Physician Health Programs and Addiction among Physicians. His work was featured in the documentary series on addiction entitled Close to Home by Bill Moyers. He has championed recovery in two appearances on the Oprah Winfrey show. Dr. Earley is a Fellow of ASAM and has been on the board of ASAM for over 10 years in several capacities. He has also served as the Medical Director of two nationally acclaimed addiction programs specializing in the care of addicted health care professionals. 17

18 QUALITY ASSURANCE PROGRAM Information is only as good as its source: links to three websites for reliable evidencebased research 18 E Evidence-based dentistry is not simply the clinical application of new knowledge. Delivery of quality dental services relies upon an appropriate synthesis of the clinician s experience and judgment, complemented by contemporary evidence-based scientific information, taken together with individual patient circumstances. In fact, patients are increasingly knowledgeable and often present to the dental office with apparent evidence in hand. The American Dental Association defines evidence-based dentistry as an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient s oral and medical condition and history, with the dentist s clinical expertise and the patient s treatment needs and preferences. As the busy practitioner seeks to implement such an approach to practise, it is important to remember that the reliability of information is only as good as its source. A readily available, convenient source of information is the dental literature.

19 QUALITY ASSURANCE PROGRAM CLINICAL DECISION-MAKING REQUIRES AN ABILITY TO EVALUATE THE VALIDITY OF THE INFORMATION Dentists are exposed to a voluminous PRESENTED AND TO ASSESS amount of scientific and technical material, whether in print ITS APPLICABILITY TO EVERY publications or various electronic DAY PRACTICE. formats. Clinical decision-making requires an ability to evaluate the validity of the information presented and to assess its applicability to every day practice. The experimental study, as opposed to the observational study, represents the highest level of clinical study design. In the hierarchy of evidence, the randomized controlled trial (RCT) is the best example of an experimental study. In these studies, the effect(s) of an intervention or therapy is evaluated in a treatment group compared to a control group. Even when presented with a strong study design such as the RCT, it is important to appraise these studies based on a number of criteria related to methodology and conclusions. Consideration must be given to such variables as an adequate size of a representative population, whether the patients and researchers were blinded to the treatment, appropriate followup, researcher bias and/or whether the outcome was statistically significant or clinically relevant. In addition, publication in a peer-reviewed journal is preferred. It may not be reasonably possible or ethical, however, to subject participants to certain conditions as required in an RCT, so an observational study is frequently an acceptable substitute. In these types of study, an outcome can be evaluated in a group of people, but there is little control of variables that may affect the results. E 19

20 QUALITY ASSURANCE PROGRAM Information is only as good as its source: links to three websites for reliable evidence-based research The meta-analysis and systematic review of RCTs represent the highest standard of evidence. A systematic review is a rigorous process of literature review that is developed to interpret the available evidence in order to answer a specific question. These are essentially a review of completed studies and may include several study designs other than the RCT depending on their content and applicability. Abbreviated forms of systematic reviews, including critical summaries and treatment recommendations, are available for the busy clinician. Meta-analysis is a statistical technique able to summarize and add precision to the results of several studies. Although the search for evidence and development of critical appraisal skills are important, this does not mean that high-level, unequivocal evidence is always freely available or accessible. For example, The Cochrane Database of Systematic Reviews requires institutional access to a full text format. As The British Dental Journal recently remarked, unfortunately, the evidence base to support the effectiveness of many of the commonly performed treatments in dentistry is limited both in quantity and quality. That said, there are many helpful resources available which focus on evidence-based information. The College provides a link to several websites where such information is accessible. The Centre for Evidence Based Dentistry in the UK ( This Centre is the editorial base for the Evidence Based Dentistry Journal (which is an official publication of the British Dental Association). This journal selects original and review articles which are summarized in abstracts and includes expert commentary. This website also presents evidence from the Cochrane reviews and offers links to the British Dental Journal. Evidentista ( This site includes a database of clinical questions and answers covering a variety of dental topics. It also includes critical summaries from the Evidence Based Dentistry Journal as well as evidence from the Cochrane Library and NICE (National Institute for Health and Clinical Excellence in the UK). American Dental Association Center for Evidence-Based Dentistry ( This site provides a database of systematic reviews and includes appraisal of the evidence through critical summaries. Clinical recommendations, guidelines and links to other resources are also offered. The Canadian Dental Association s Oasis project (Online Advice and Searchable Information System), available at This initiative consists of three complementary components and provides access to peer-reviewed clinical information. JCDA Oasis offers both clinical resources as well as an interactive platform which encourages interdisciplinary communication between colleagues. Evidence-based care is the focus of many continuing education courses, websites and dental literature. An ongoing awareness and review of the evidence will help support clinical decisions and facilitate the provision of quality care to our patients. These links are available at the College s website at rcdso.org/links. 20 COLLEGE CONTACT Dr. Greg Anderson Practice Enhancement Consultant ganderson@rcdso.org

21 QUALITY ASSURANCE PROGRAM End of CE Cycle Time to log your CE credits in your online personal e-portfolio to prepare for the end of the CE cycle F For all members with a general or specialty certificate of registration registered with the College prior to December 15, 2011, your first threeyear Continuing Education (CE) cycle is ending on December 14, In preparation for the end of your CE cycle, you will need to enter and track your CE activities in your personal online e-portfolio, accessible in the Member Resource Centre on the College website. In your e-portfolio, you will also find a snapshot of how many CE points you need to collect in each category to meet the requirements for the threeyear cycle. As a reminder, members are required to obtain at least 90 CE points in each three-year cycle, in the following categories: Category 1: Core Courses At least 15 CE points per three-year cycle must be obtained from successfully participating in core courses approved by the Quality Assurance Committee. Category 2: Approved Sponsor Courses At least 45 CE points per three-year cycle must be obtained from successfully participating in courses on a clinical dental topic offered by approved sponsors or by teaching. Category 3: Other Courses Any remaining number of CE points per three-year cycle may be obtained from other courses, including those offered by non-approved sponsors. Then, starting on February 15, 2015, the College will begin the random selection of 75 members each month to have their e-portfolio reviewed to ensure they are meeting their obligations under the QA Regulation. Those selected members will be notified in writing and given 30 days to submit their CE documentation that demonstrates their successful participation in CE activities. This documentation includes items such as course certificates and other proof of attendance documents. You can find more information on our website at Simply click on the Members section and go to Continuing Education. Other helpful links can be found on the Continuing Education page. KEY POINTS: For all members with a general or specialty certificate of registration who were registered with the College prior to December 15, 2011, your first CE cycle began on December 15, 2011 and will now end this year on December 14. Starting on February 15, 2015, you will be subject to random selection to have your e-portfolio reviewed. Please ensure that you have entered all your CE activities for the cycle by this date and have supporting CE documentation. 21 COLLEGE CONTACT Joanne Loy Quality Assurance and Continuing Education Administrator jloy@rcdso.org

22 MALPRACTICE MATTERS RISK MANAGEMENT ADVICE FROM PLP Talk isn t always cheap: The dangers of making promises The Professional Liability Program (PLP) defends dentists against patient allegations of wrongdoing, which sometimes include a claim that a dentist made a promise he didn t keep. Because the course and outcome of dental treatment are dependent on many factors, some of which are beyond the dentist s control, PLP warns members against guaranteeing results or setting rigid timelines for completing treatment. THE FACTS The patient presented to the member in April 2010 requesting replacement of crowns on teeth 11 and 21 for cosmetic reasons. New crowns were inserted but removed on August 24, 2010 because discoloration of one tooth was visible through the new crown. A second pair was rejected by the patient as being too grey two weeks later. Two further pairs were deemed similarly deficient on September 27 and October 18, A fifth set of crowns was rejected on October 27, 2010 and the patient requested a full refund soon thereafter. PLP provided the member with a release for the patient to sign in exchange for a return of fees. The patient refused to execute the release and commenced a legal action against the member. LEGAL ACTION In addition to negligent dental treatment, the patient alleged that the member s failure to insert permanent crowns by September 10, 2010 and to deliver crowns that were more esthetic than the originals constituted breaches of contract. The member denied the plaintiff s allegations of negligent treatment and the existence of a deadline for final cementation of the crowns or any promises regarding their appearance. 22

23 THE EXPERT The plaintiff failed to produce an expert report in support of her allegations. PLP retained an expert general dentist who opined that: The final crowns were a very good shade match. It is important for the dentist to carefully record what the patient is told about the duration of treatment and possible outcomes. Above all, a member should never use language that could be interpreted by the patient as a guarantee. It is not unusual to send crowns back for reshading, staining or adjustment. There was no evidence to suggest the member breached the standard of care. THE TRIAL The matter proceeded to trial on March 28, 2013 and reasons were released on July 4, The trial judge did not accept the member s assertion that there was no agreement to complete treatment by a fixed date. However, the patient was found to have waived that condition by continuing to see the member after the deadline had passed, and her claim on that point failed. The judge also held that the member promised the new crowns would be an improvement over the old ones, but he accepted the member s evidence that the crowns met that standard. Finally, the judge accepted the opinion of the defence expert that the member was not negligent in his treatment of the patient. In the result, the action was dismissed with costs. TAKEAWAYS The member in this case was dealing with a patient with high expectations who may have heard what she wanted to hear rather than what the member actually said. The he said/she said debate may have been resolved in the member s favour if documentation had been available to corroborate his oral evidence. Especially when treatment is elective or cosmetic, it is important for the dentist to carefully record what the patient is told about the duration of treatment and possible outcomes. And above all, a member should never use language that could be interpreted by the patient as a guarantee. COLLEGE CONTACT René Brewer Director, Professional Liability Program rbrewer@plpservices.org 23

24 Anatomy of a Legal Action Dentists facing or involved in court proceedings brought against them by patients often have many questions. The following description of the basic anatomy of a legal action will assist members in understanding the process. PLEADINGS AND SERVICE An action for professional negligence is started in Ontario when a claimant (plaintiff) files a document in court outlining the allegations against and amount sought from the person being sued (defendant). Actions for $25,000 or less may be commenced in small claims court; all others are filed in superior trial court. Pleadings are not evidence and they should not be taken at face value. Generally speaking, the filed pleading must be delivered to the defendant personally. Unless the plaintiff agrees otherwise, the defendant must formally respond to the claim within 20 days of service to avoid having judgment entered against him or her. Pleadings sometimes contain factual errors, incendiary accusations, or grossly exaggerated damages estimates. Some plaintiffs counsel also assert demands for punitive, exemplary, or aggravated damages, for which PLP does not provide indemnification. But pleadings are not evidence and they should not be taken at face value. And since damages in most PLP cases are far below the $2 million in basic protection provided by the RCDSO and claims for punitive damages are rarely successful, there is usually no reason for a defendant member to be concerned about personal financial exposure. 24

25 As part of the discovery process, all documents relevant to issues in the proceedings must be disclosed by both sides. LEGAL REPRESENTATION Plaintiffs are often self-represented in small claims court, but are generally assisted by legal counsel in superior trial court matters. PLP retains and instructs the firms and lawyers who represent members sued by patients for malpractice. Pre-trial discovery is designed to give parties insight into the merits of a case so they can decide whether to settle or proceed to trial. As part of the discovery process, all documents relevant to issues in the proceedings must be disclosed by both sides. In PLP cases, these include the defendant dentist s records and may also include the plaintiff patient s other dental and medical records, as well as documents supporting his or her pecuniary demands. Except in small claims matters, pre-trial discovery may involve an examination under oath of a party by the other party s lawyer. There are time limits on these examinations for discovery. Before an action gets to trial, the parties may be required to or voluntarily engage in proceedings designed to narrow the issues between them or resolve the case. Because a litigant s answers on discovery may be used by another party at trial, considerable preparation may be required before a defendant dentist is examined. Though perhaps inconvenient for the member, this investment can pay dividends, since lawyers use examinations for discovery to size up the parties as potential witnesses at trial, often an important consideration in deciding whether a case is worth pursuing. EXPERT INPUT It is almost impossible to succeed in a claim for dental negligence without expert support, and the plaintiff usually obtains a report critical of the dentist. In response, PLP may request input from experienced, well-respected practitioners on whether the defendant met the standard of care and whether anything he or she did or failed to do caused harm to the patient. E 25

26 MALPRACTICE MATTERS RISK MANAGEMENT ADVICE FROM PLP 26 Anatomy of a Legal Action PRE-TRIAL PROCEEDINGS Before an action gets to trial, the parties may be required to or voluntarily engage in proceedings designed to narrow the issues between them or resolve the case. If PLP believes there is a strong defence to an action, defence counsel may be instructed to attempt to have it dismissed summarily, i.e. without a full trial. The defendant dentist may be asked to swear an affidavit in support of the motion and may be cross-examined on his or her evidence before the hearing date. Since summary judgment motions are usually decided on the paper record alone, the member may not be asked to attend the hearing. Other possible pre-trial proceedings in which members may be obliged or requested to participate include mediations, settlement conferences, and pre-trial conferences. Mediations and settlement conferences both involve confidential settlement discussions between the parties facilitated by a third party, but mediations are generally conducted by former or non-judges for a fee, while settlement conferences are presided over by judges or other court representatives at no cost to the parties. Settlement prospects may also be canvassed by a pre-trial conference judge, who sometimes offers an opinion on liability and damages to allow the parties to assess their risks at trial. Pre-trials may also be used to identify the nature and scope of the dispute and confirm witness lists and scheduling. TRIAL AND DECISION Very few actions proceed to trial, but those that do require a significant commitment from the litigants. Defendant members need to devote time to trial preparation and will be asked to attend as much of the trial as possible. A PLP trial may last from a few days to several weeks, depending on complexity. Judgment is not usually delivered at the conclusion of trial and may not be released for many months. The losing party may appeal an adverse trial decision to a higher court. Appeals are decided on the written record and legal arguments and may take months or years to resolve. CONCLUSION The legal process can be intimidating, but PLP staff and defence counsel are on hand to assist members in navigating the system. Any member with questions or concerns about a current or potential action for dental negligence should contact PLP or the lawyer assigned to the file. A PLP trial may last from a few days to several weeks, depending on complexity. Judgment is not usually delivered at the conclusion of trial and may not be released for many months.

27 Typical Legal Action COLLEGE CONTACT René Brewer Director, Professional Liability Program

28 PROFESSIONAL PRACTICE Collecting co-payments and deductibles 28 One of the more difficult issues that the College receives calls about is the collection of co-payments and deductibles. Dentists report that some patients pressure them not to collect co-payments and deductibles, because (they say) some other dentists do not. D Dentists have professional, ethical and legal responsibilities to retain financial records for their patients and to submit accurate dental insurance claims on their behalf. Dentists who agree not to collect co-payments and deductibles that patients are required to pay under the terms of their dental insurance plans risk facing allegations of professional misconduct. Section 2, paragraph 34, of the professional misconduct regulations under the Dentistry Act, 1991, defines professional misconduct to include: Accepting an amount in full payment of an account or charge that is less than the full amount of the account or charge submitted by the member to a third party payer, unless the member has made reasonable efforts to collect the balance from the patient or has the written consent from the third party payer. Not making an earnest attempt to collect co-payments and deductibles may be viewed by a panel of the Inquiries, Complaints and Reports Committee as unethical; in such cases, specified allegations of professional misconduct may be referred to the Discipline Committee.

29 PROFESSIONAL PRACTICE When a dentist signs or authorizes a dental insurance claim to be submitted in his/her name, the dentist declares that the dental insurance claim is accurate and that the amount claimed is the total amount he or she intends to collect. When reasonable steps are taken to collect the co-payment and deductible portion of dental fees, this indicates that the dentist has not accepted payment/ reimbursement from the dental insurance provider under false pretenses. The financial records for a patient must provide an accurate statement of the account, including the date and amount of all fees charged, which must correspond to any amounts submitted to the dental insurance provider. In addition, the financial records must include the date and amount of all payments received from the patient and the dental insurance provider. Notations of the attempts made by dental office staff to collect co-payments and deductibles from the patient should also be recorded. A dentist has the right to charge a reduced fee to a particular patient for a particular service; for example, many dentists charge reduced fees to friends, relatives, staff or patients with financial limitations. The College expects dentists to make sincere attempts to collect co-payments and deductibles. Dentists who continue to provide professional services to patients who have not made payments towards large outstanding amounts, consisting mainly of co-payments and deductibles, may be seen by the College as not taking their responsibilities seriously. The College may also challenge repeated notations that have been made in patients financial records solely to legitimize write-offs of such outstanding amounts. A dentist has the right to charge a reduced fee to a particular patient for a particular service; for example, many dentists charge reduced fees to friends, relatives, staff or patients with financial limitations. In such cases, the dental insurance claim must accurately reflect the discounted fee, which is the total amount that the dentist expects to collect for the service. A dentist cannot submit a dental insurance claim for a customary (higher) fee and then simply write off the copayment or deductible as a means of providing a discount. 29 COLLEGE CONTACT Practice Advisory Service practiceadvisory@rcdso.org

30 PROFESSIONAL PRACTICE Information about the plan approval process of the X-Ray Inspection Service 30 W While the College frequently receives inquiries about the installation of dental radiographic machines and related requirements under the Healing Arts Radiation Protection Act, 1990 (HARPA), it is actually the X-Ray Inspection Service (XRIS) of the Ministry of Health and Long-Term Care that is responsible for reviewing and approving plans for such equipment. XRIS has asked the College to highlight a few points of information in Dispatch to assist dentists and help expedite their applications for plan approval. Approval is required from the XRIS in writing before installing a new dental x-ray machine, replacing an existing dental x-ray machine, or making changes to the installation of an existing dental x-ray machine (excluding routine maintenance procedures using OEM replacement parts). The owner of the dental x-ray machine is required to submit a new schematic plan in electronic format with every application. The shielding should be indicated on the schematic plan and described on the application forms. It is not only helpful to include shielding calculations but also strongly encouraged as it will determine the exact amount of shielding required for the x-ray room, which requires consideration of the usage or workload of the dental x-ray machine. If a third party vendor is hired to submit the plan application, the vendor should ideally consult with the Radiation Protection Officer to determine the maximum anticipated workload of the dental x-ray machine, taking into consideration whether it has increased since the last installation of a dental x-ray machine. Daily photographic quality control records may be helpful in this regard, especially to determine if the volume of patient x-rays has increased. XRIS has developed new application forms in February 2014 and information brochures about the plan approval process and general HARPA requirements in April For further information about the plan approval process, or to obtain the enhanced plan application forms and informational brochures, please contact the X-Ray Inspection Service of the Ministry of Health and Long- Term Care at

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32 PRACTICE BITES What is required when a patient needs a referral? 32 On occasion, dentists may find that they have to refer their patients to a specialist for treatment. However, what if the dentist does not know any specialists who can provide the treatment? What if the dentist practises in an area in which a specialist is not available in a timely fashion or at all? The following details of a complaint to the Inquiries, Complaints and Reports Committee illustrates one such scenario. A A parent of a minor child complained of a dentist s refusal to provide appropriate assistance after treating her daughter. Initially, the mother took her daughter to the dentist because the child was experiencing pain near one of her wisdom teeth and her face was swollen. The dentist examined the patient and advised that she had an impacted wisdom tooth that should be extracted. The dentist prescribed antibiotics and suggested that the patient see an oral and maxillofacial surgeon for the extraction. When the parent requested a referral, she was told that she should look through the Yellow Pages. The mother contacted her own dentist s office and was provided with the names of two oral surgeons. The mother then provided these names to her daughter s dentist and requested a referral. The dentist again refused to provide a referral.

33 PRACTICE BITES In his response to the complaint, the dentist explained that, when the patient attended at his office, he examined her and confirmed that she had an impacted wisdom tooth. The dentist said that he had explained the risks and benefits of the required surgery and provided a prescription for antibiotics. The dentist also informed the patient s mother that, although there were two oral surgeons in the area, one had retired recently and the other was fully booked for up to 12 months. The dentist then advised that, although he was not aware of another dentist who could do the surgery, the parent could contact other dentists to see if one of them might be willing to provide the treatment. The mother found the name of an oral surgeon practising in another area and asked the dentist for a referral. The dentist said, since he did not know the oral surgeon or anyone else in that area, he could not provide a referral. The panel reviewed the complaint and decided that the dentist should have done more to assist the patient in obtaining the required treatment. While the dentist asserted that he could not provide the While the dentist asserted that he could not provide the referral because he did not know the oral surgeon suggested by the patient s mother, in the panel s view it was not acceptable for the matter to end there. referral because he did not know the oral surgeon suggested by the patient s mother, in the panel s view it was not acceptable for the matter to end there. The panel suggested that the dentist could have contacted other dentists to ask who might be able to provide the treatment, or could have contacted his local dental society for the same purpose. The panel went on to say that the dentist could have also contacted specialists outside of his area to see if they could treat the patient. While the panel ultimately took no action in this case, it clearly noted its concerns about the dentist s failure to assist the patient. The panel advised the dentist that he should familiarize himself with the referral options for specialists in his area. 33

34 WEBSITE SPOTLIGHT An online snapshot of College services and programs W When the College launched its redesigned website in December 2012, we also launched an orienteering microsite tailored to new College members. We felt it was important to extend a warm welcome to new members of the profession and explain how we partner with all members to ensure patients receive the highest quality of oral health care as we work to maintain the public s trust. While much of the information on the microsite may be familiar to members, it doesn t hurt to refresh your memory about the many services offered by the College. The microsite contains information on the role of the College, the Quality Assurance program, our wellness program, membership renewal, practice advisory, the Professional Liability Program and many other College services. You will find links to other relevant information on our website and also contact information for staff or program areas at the College that can help answer your questions. You can access the microsite by going to orienteering.rcdso.org, or by visiting our website, The site design is optimized for smartphones and tablets, so you can surf on any device. Remember that we also have a history microsite to help members and the public understand the evolution of the College and the many achievements and milestones reached by the profession. You can access this microsite by going to history.rcdso.org. 34

35 WEBSITE SPOTLIGHT Microsite Splash Page: A visual introduction. Microsite Content Page: Typical pages are broken down into sections for easy browsing and reading. 35 COLLEGE CONTACT Angelo Avecillas Communications Specialist , ext aavecillas@rcdso.org

36 PEAK Risk of Adrenal Crisis in Dental Patients PEAK (Practice Enhancement and Knowledge) is a College service for members. The goal is to regularly provide Ontario dentists with copies of key articles on a wide-range of clinical and non-clinical 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. Situated on top of the kidneys, the adrenal glands are small, triangular-shaped endocrine glands composed of an outer cortex and inner medulla. The adrenal cortex makes up about 90 per cent of the gland and manufactures three classes of adrenal steroids: glucocorticoids, mineralocorticoids and androgens. Cortisol, the primary glucocorticoid, has several important physiologic actions related to metabolism, cardiovascular function, the immune system, and the maintenance of homeostasis during periods of physical or emotional stress. Adrenal insufficiency (AI) is characterized by an inadequate production of adrenal steroids, which can manifest in two forms. Primary AI (i.e. Addison s disease) is caused 36

37 PEAK Although rare in dental practice, the onset of an adrenal crisis may be rather sudden and, without prompt recognition and treatment, lead to hypovolemic shock and cardiovascular failure. by a progressive destruction of the adrenal cortex, resulting in a deficiency of all adrenal steroids. The more common form, secondary AI, may be caused by hypothalamic or pituitary disease, or from the chronic administration of exogenous corticosteroids, resulting in a selective deficiency of glucocorticoids. During a stressful event, such as an invasive and/or painful dental procedure, a patient with chronic AI may experience an adrenal crisis due to the diminished adrenal reserve to secrete sufficient amounts of cortisol. Although rare in dental practice, the onset of an adrenal crisis may be rather sudden and, without prompt recognition and treatment, lead to hypovolemic shock and cardiovascular failure. To provide members with a comprehensive look at this potentially lethal condition, PEAK is pleased to offer the following article with the current issue of Dispatch: Risk of adrenal crisis in dental patients: Results of a systematic search of the literature, from the February 2013 issue of the Journal of the American Dental Association. The article begins with a review of adrenal insufficiency and description of an adrenal crisis. It then presents the results of a systematic search of the literature to analyze the frequency of and factors associated with adrenal crisis in dental patients. The article continues with a discussion of precipitating risk factors associated with adrenal crisis related to dental treatment, including: significant and unrecognized AI poor health status and stability at the time of dental treatment (e.g. acute illness, fever) pain infection extractions or invasive procedures that cause bleeding and discomfort use of general anaesthesia with a barbiturate The article concludes that the risk of adrenal crisis may be reduced through proper evaluation of the patient, identification of risk factors and following preventive measures, including pain control and steroid supplementation when indicated. COLLEGE CONTACT Dr. Michael Gardner Manager, Quality Assurance mgardner@rcdso.org 37

38 PROFESSIONAL PRACTICE New sedation and general anesthesia by-law strengthens public protection 38 A A new by-law for sedation and anesthesia formalizes and streamlines the College s existing process and incorporates specific provisions providing the Registrar with the necessary powers to deal with situations where there is a risk of harm to the public. The new by-law, By-Law No. 13: Sedation and General Anesthesia, was passed at the June 12 Council meeting. Here are highlights of the by-law related to practitioners wishing to administer sedation and/or general anesthesia in dental practice: Practitioners newly entering the process are required to submit an application form, pay a fee and meet the requirements set out in the Standard of Practice for the Use of Sedation and General Anesthesia in Dental Practice for the modalities they wish to administer and the type of authorization they wish to obtain. Once the practitioner is approved by the College and issued an authorization, their name, the modality and the type of authorization issued to them will appear on the College s roster which can be found in the member resource centre starting August 1, 2014, by facilities wishing to engage their services. Practitioners initially receive a Provisional Authorization, which may be replaced by an Annual Authorization once the College has had the opportunity to review the sedation/anesthetic records maintained by the practitioner. Practitioners will be subject to an annual renewal. As part of the renewal process, practitioners are required to provide proof of currency of life support certification and pay a fee each year, and have a satisfactory inspection every three years.

39 PROFESSIONAL PRACTICE Under specific provisions of the by-law, a practitioner must agree immediately to cease the administration of sedation and/or general anesthesia in the event the Registrar notifies the practitioner that the Registrar has determined, either as a result of an inspection or by any other means, that there is risk of harm to the public should the practitioner continue to do so. Here are the highlights of the by-law related to facility permit holders: Only members who own a dental facility can obtain a facility permit from the College to use sedation and/or general anesthesia at a specified location. Members newly entering the process are required to submit a completed application form for the type of facility permit they wish to obtain and pay the required fee. Prior to issuing a facility permit, the facility will be inspected to confirm that it is in compliance with the requirements of the Standard of Practice for the Use of Sedation and General Anesthesia in Dental Practice. Once a permit is issued, the facility permit holder will no longer have to wait for the College to add an authorized practitioner to the record before booking sedation cases. The facility permit holder is able to search the College s roster, that will become available August 1, 2014 on the member resource centre, for practitioners authorized to administer any modality of sedation and/or general anesthesia. The facility permit is subject to an annual renewal. As part of the renewal process, the facility permit holder is required to pay a fee each year and have a satisfactory inspection every three years. There are also specific provisions that require the holder of the facility permit to agree to immediately cease to use sedation and/or general anesthesia at the facility in the event the Registrar notifies the member that the Registrar has determined, either as a result of an inspection or by any other means, that there is risk of harm to the public should the facility continue to do so. 39 COLLEGE CONTACT Katya Shtrachman Program Administrator, Sedation /CT Scanners ext kshtrachman@rcdso.org

40 PROFESSIONAL PRACTICE The new process for sedation and anesthesia authorizations and facility permits 40 FOR AUTHORIZATIONS There are two categories of practitioner authorizations under the new by-law: Practitioners who perform sedation and/or general anesthesia at a dental facility that provides and has present at all times all of the equipment and emergency drugs needed to meet the requirements of the Standard of Practice for the Use of Sedation and General Anesthesia in Dental Practice Visiting practitioners who perform sedation and/or general anesthesia at a dental facility and who will provide all of the equipment and emergency drugs needed to meet the requirements set out in the Standard of Practice for the Use of Sedation and General Anesthesia in Dental Practice FOR FACILITY PERMITS The by-law establishes two categories of facility permits: Type A Facility Permit a facility permit that requires the facility to provide and have present at all times all of the equipment, emergency drugs, needed to meet the requirements as set out by the Standard of Practice for the Use of Sedation and General Anesthesia in Dental Practice Type B Facility Permit a facility permit that requires a visiting practitioner, who administers sedation and/or general anesthesia, to provide at all times all of the equipment, emergency drugs, needed to meet the requirements as set out by the Standard of Practice for the Use of Sedation and General Anesthesia in Dental Practice

41 PROFESSIONAL PRACTICE 41 E

42 PROFESSIONAL PRACTICE The new process for sedation and anesthesia authorizations and facility permits TRANSITIONAL PHASE FOR AUTHORIZATIONS Practitioners currently registered to administer sedation and/or general anesthesia in dental practice will be required to confirm the type and modality of their training and qualifications they have currently registered with the College by completing an application form. No fee shall be charged for the initial issuance of the authorizations under the transitional phase. By now, you should have received your authorization and forms from the College. You are required to complete the documentation and submit it to the College within the next few months to ensure your authorization is eligible for renewal. Effective August 1, 2014, your name, type of authorization and the highest modality you are authorized to administer will be added to the College s roster. Each authorization will expire on March 31, 2015 and is subject to renewal. To be renewed, each practitioner is required to complete a renewal form and pay a fee. TRANSITIONAL PHASE FOR FACILITY PERMITS Under the by-law, current facility permit holders will be required to confirm the type and highest modality of sedation and/or general anesthesia currently administered at the facility by completing an application form for a facility permit. No fee shall be charged for the initial issuance of the Type A and Type B facility permits under the transitional phase. By now you should have received your permit(s) and forms from the College. You are required to complete the documentation and submit it to the College within the next few months to ensure your permit is eligible for renewal. Each facility permit will expire on March 31, 2015 and is subject to renewal. To be renewed, each facility permit holder is required to renew and pay a fee. Those facilities due for inspection in 2014 will be inspected as scheduled. 42 COLLEGE CONTACT Katya Shtrachman Program Administrator, Sedation /CT Scanners ext kshtrachman@rcdso.org

43 NEWS Annual Renewals of HPC Certificate of Authorization in the Mail During June FEE REDUCTION FOR EARLY PAYMENT The annual renewal fee of $200 is due by August 31. This fee is discounted to $175 if the College receives your completed annual renewal form and fee on or before July 31 and you meet the annual renewal requirements. To renew your Certificate of Authorization, you are required to submit the completed annual renewal form, along with the following: Applicable Fee: Payable to the Royal College of Dental Surgeons of Ontario. Statutory Declaration: Form B executed by a director of the corporation before a commissioner, lawyer or notary public not more than 15 days before the annual renewal form is submitted. Current-dated Certificate of Status: Issued by the Minister of Government Services not more than 30 days before the day it is submitted to the College and dated prior to the execution of your Statutory Declaration. STATUTORY DECLARATION FORM B The Statutory Declaration certifying that the corporation is in compliance with Section 3.2 of the Business Corporations Act must be sworn in the physical presence of a commissioner, lawyer or notary public. Provincial legislation requires this Statutory Declaration to be executed not more than 15 days before your application is submitted. CERTIFICATE OF STATUS A certificate of status is a one-page document issued by the Ministry of Government Services that indicates the corporation is active. Provincial legislation requires that a current-dated Certificate of Status accompanies your annual renewal form, regardless of how new your HPC is. DOS AND DON TS ABOUT HPC RENEWAL PROCESS DO ensure that you are in the physical presence of the commissioner, lawyer or notary public to have your Statutory Declaration executed. DO NOT sign and date the Statutory Declaration prior to your attendance with the commissioner, lawyer or notary public that swears your declaration. DO ensure that you submit a current-dated Certificate of Status of the corporation, which is dated prior to the execution of your Statutory Declaration. DO NOT fax your paperwork to the College as the annual renewal form and the Statutory Declaration must have original signatures. Note: All Certificates of Authorization expire August 31 of every year, regardless of the initial date that it was issued. That means for dentists who applied for a Certificate of Authorization this year, it is only valid until August 31. For more information check out the health profession corporation section in the Member Resource Centre at rcdso.org. COLLEGE CONTACT Stephanie Bickford, Intake Administrative Assistant sbickford@rcdso.org 43

44 NEWS Practising as a dental hygienist without a licence The College of Dental Hygienists of Ontario (CDHO) has notified RCDSO that an order from the Superior Court of Justice Ontario has been received against Lisa Ann Campbell-Rousselle (also known as Lisa Campbell-Rousselle and as Lisa Rouselle) who practised as a dental hygienist when she was not registered with CDHO. Ms.Campbell-Rousselle is prevented from using the title dental hygienist, from holding herself out as a person qualified to practise in Ontario as a dental hygienist, and from performing any controlled acts including scaling teeth or root planing. The court also ordered Ms. Campbell-Rousselle to pay costs to the College of $12,000. On investigation, CDHO had found that Ms. Campbell-Rouselle had continued to practise at her long-time practice location in Kanata after she was suspended from the College as of February 22, 2011 and resigning her certificate of registration on May 7, For further information, contact the College of Dental Hygienists of Ontario at or REMINDER: END OF CE CYCLE For all members with a general or speciality certificate of registration registered with the College prior to December 15, 2011, your first CE cycle began on December 15, 2011 and will end on December 14, What does this mean? Starting February 15, 2015, you will be subject to random selection to have your e-portfolio reviewed. Ensure all your CE activities for this cycle have been entered in your online personal e-portfolio by this date and you have supporting CE documentation. See page 21 for further details.

45 NEWS 2014 Source Guide Now Online The 2014 Source Guide of membership listings is now available on the College s website. This electronic PDF version allows you to easily search and find specific information you may need, such as practice addresses and phone numbers of any dentist in Ontario. The information is divided into key categories that are searchable and conveniently help you find the information that you and your practice staff may need: dental specialists by specialty dentists in alphabetical order dentists by geographical area health profession corporations The electronic version can be printed in its entirety, or you can print off specific pages or sections. The document can be searched for exactly what you need; for example, a specific dentist by name. Just type the dentist s name in the Find field and press enter. You will be taken to the first page that contains information on that dentist. Since some dentists share the same surname, if the first match is not who you were looking for, continue to press enter to scroll through the list of matches. The information in the Source Guide is as accurate as possible as of March 31, For the most current information in real time, please use the Dentist Search Register function available from the home page of the College website at The register is easy to use and you can filter by city and specialty. If you have questions or concerns about your personal listing, please contact staff in the registration area of the College at registration@rcdso.org. COLLEGE CONTACT Diana Rickford, Communications Officer ext drickford@rcdso.org 45

46 Chronique From the Registrar du Président Nos bénévoles apportent de l air pur au Collège Suite de la page 5 Le présent numéro du magazine Dispatch invite des bénévoles à joindre les rangs des comités autres que ceux du conseil. Dans le prochain numéro, vous trouverez de précieux renseignements sur la manière de présenter votre candidature au conseil d administration. J espère que vous n hésiterez pas à répondre à l appel, car voilà une splendide occasion d enrichir votre vie professionnelle en faisant don d un peu de vos talents à vos collègues et à toute la dentisterie. Vous ajouterez ainsi votre nom à ceux des valeureux bénévoles dont l œuvre comprend plus de 145 ans d histoire et remonte aux premiers balbutiements du Collège. Le secret de notre longévité et de notre succès réside en grande partie dans le travail de ces hommes et de ces femmes qui ont su mettre au second plan leur famille et leur pratique pour consacrer du temps au bien commun. Je ne crois pas qu il soit exagéré de dire que, sans cet engagement de nos professionnels, nous ne pourrions pas bénéficier du privilège de l autoréglementation. Je vous invite à vous porter bénévole au bénéfice du Collège. Je peux pour ma part affirmer que mon travail au Collège a constitué le pinacle de ma carrière de bénévole auprès de mes collègues dentistes. Nulle part ailleurs n est-il possible d être au front des importantes questions qui touchent directement notre profession et la qualité des soins que nous prodiguons à nos patients. Comme l a déclaré en avril son Excellence le très honorable David Johnston, gouverneur général du Canada, à l occasion de la Semaine de l action bénévole : «Au Canada, nous avons la chance incroyable de vivre dans une société qui apprécie la générosité et le partage. Les Canadiens sont conscients qu en s entraidant et en appuyant de bonnes causes, ils agissent pour le mieux intellectuellement et moralement. Ils agissent de manière avertie et bienveillante.» Discutez avec vos collègues qui ont siégé aux comités ou au conseil. Il vous diront la forte satisfaction personnelle et professionnelle et la plénitude qu ils y ont trouvées. C est peutêtre la meilleure recommandation qu ils pourront vous donner de les imiter. Calendar of Events MARK YOUR CALENDAR 2014 COUNCIL MEETINGS Thursday, November 13 Meeting location: Metropolitan Hotel, 108 Chestnut Street, Toronto Council meetings are open to the public. The only exception is for any in camera portion of the meeting dealing with personnel matters or other sensitive or confidential items. Meetings usually start at 9:00 a.m. The agenda is available either at the meeting or in advance on request. PLEASE NOTE: Seating is limited so if you wish to attend, please contact Angie Sherban in advance. RCDSO WELLNESS CONSULTANT Dr. Graeme Cunningham, RCDSO Wellness Consultant, is available for addressing assessment and treatment needs of dentists by helping them find suitable assessors, treatment providers and residency programs. 46 COLLEGE CONTACT Angie Sherban Executive Assistant asherban@rcdso.org HOW TO REACH DR. CUNNINGHAM Dedicated Direct Line: All calls are private and confidential.

47 From the Registrar Our QA Program: An innovative idea that really works. Continued from page 48 Instead, we opted for a more nurturing, positive approach in which dentists accept the primary responsibility for their continuous professional and personal learning. The major components of our QA program are the Practice Enhancement Tool, which is an open book online assessment of a range of competency areas, a personalized online e-portfolio for members to track their continuing education credits, and a practice enhancement consultant who is always available to offer personal support, encouragement and tailor-made CE resources. It was an innovative and courageous approach to quality assurance. We were confident that it was the right thing to do. So how did we do? Well, a year and a half since our launch and the reviews are in. From our most important audience, our members, we ve had a pretty positive response. Dentists have told us the selfassessment is very fair and well-administrated, fair for the average clinician, educational and actually fun, comfortable, very user friendly, challenging and rewarding, and surprisingly enjoyable. Not bad at all. But what about the integrity and validity of this testing methodology? Here s what we heard from the experts based on the anonymized results for the over 800 members that completed the PET selfassessment last year. Dr. Vicki LeBlanc, who is Associate Professor at the University of Toronto Faculty of Dentistry and Associate Director and Scientist at the Wilson Centre at both the University Health Network and University of Toronto, says: Overall, the PET appears to be a reliable innovative tool that allows RCDSO members to evaluate their knowledge relevant to the broad practice of dentistry. Furthermore, the PET does not appear to disfavour members based on their domain of practice or their geographical location of practice. Dr. Jack Gerrow, executive director and registrar of the National Dental Examining Board, says that we have produced a very useful and reliable tool. We are proud of this success. We believe we have created a QA Program that uniquely balances the valuable informal, experiential learning that occurs during the normal course of dental practice with more structured professional development like programs and courses. It also provides dentists with the knowledge and flexibility to manage their own learning activities. This is all supported by our LifeLong Learning program that has a number of online or CDbased learning resources that qualify as core courses. Of course, the QA program is not an end in itself. The overall purpose is to help improve the safety and quality of care provided to the public. We believe that our new QA Program does just that in a fair, robust and responsible way. Update: The response from members to my invitation to share ideas and thoughts about the College has been overwhelming. It is one heck of a lot of lunches. Seriously, the thoughtfulness and suggestions from members to make the College even better at its job is very gratifying. 47

48 From the Registrar IRWIN FEFERGRAD Our QA Program: An innovative idea that really works. 48 Innovation means doing things differently, exploring new territory, and taking risks. There has to be a reason for rocking the boat a vision of what could be or a concern of what might happen if things don t change. That s the challenge. Health care regulators, in fact regulators of any kind, are not renowned for rocking the boat. But RCDSO decided it was worth the risk when it came to designing our quality assurance program. We know that dentists don t need much encouragement when it comes to continuous learning. Dentistry has a long history of very active professional development activities through a network of dental societies across the province. Dentists understand and appreciate that learning does not end with the completion of formal post-graduate training. The challenge was how to capitalize on this learning culture. How could we ensure in a meaningful and organized way that this continuous learning is helping to improve the safety and quality of care provided for patients and the public? We knew what we didn t want. The College did not support the usual approaches to quality assurance, like office visits. We believed that this approach would not really tell the true story of a practitioner s competence. It also had a paternalistic, punitive tinge to it. We wanted to break out of the traditional mold of forced requirements for licence revalidation, office visits, and linking QA to licensure or discipline. Continued on page 47