22 X-ray safety requirements for all Ontario dentists

ENSURING CONTINUED TRUST DISPATCH MAY/JUNE 2011

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DISPATCH Vol. 25, No.2 • May/June 2011Dispatch 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.

EDITOR Peggi Mace

EDITORIAL ASSISTANT Angelo Avecillas

ART DIRECTION AND PRODUCTION Roger Murray and Associates Incorporated

COVER DESIGN Public Good Social Marketing Communications

REGISTRAR 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

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

Environmental Stewardship

This magazine is printed on paper certified by the international Forest StewardshipCouncil as containing 25% post-consumer waste to minimize our environmentalfootprint. In making the paper, oxygen instead of chlorine was used to bleach thepaper. Up to 85% of the paper is made of hardwood sawdust from wood-productmanufacturers. The inks used are 100% vegetable-based.

PUBLICATION MAIL AGREEMENT #40011288

ISSN #1496-2799

FRONT & BACK

4 The President’s MessageVictories for fluoridation impact entire province

44 From the RegistrarBuilding today with our sights on tomorrow

DEPARTMENTS

30 PEAKOccurrence of paresthesiaafter dental local anestheticadministration

32 Ethics in ActionMaking comments aboutanother colleague’s work

34 Practice BitesOpen communications helps in improving patient satisfaction

36 Ounce of PreventionReporting of potentialmalpractice claims…help us to help you

39 Mailbag

40 Website SpotlightHPC and sedation andanesthesia forms available on College website

NEWS & VIEWS

38 Source GuideLatest issue now online

42 Calendar of Events

ISSUE ENCLOSURE

PEAK: Occurrence of paresthesia afterdental local anesthetic administration in the United States


3

PRESIDENTDr. Peter Trainor

VICE PRESIDENTDr. Natalie Archer

District 1 Dr. Gary Cousens District 2 Dr. David Clark District 3 Dr. Peter DeGiacomo District 4 Dr. John Kalbfleisch District 5 Dr. Ted Schipper District 6 Dr. Joe StaskoDistrict 7 Dr. Peter TrainorDistrict 8 Dr. Ron Yarascavitch District 9 Dr. Eric LuksDistrict 10 Dr. Natalie Archer District 11 Dr. Robert CarrollDistrict 12 Dr. David Segal

Royal College of Dental Surgeons of Ontario6 Crescent Road, Toronto ON M4W 1T1

416-961-65551-800-565-4591fax: [email protected]

RCDSO COUNCIL MEMBERS

APPOINTED BY LIEUTENANT-GOVERNOR IN COUNCIL

Kelly Bolduc-O’Hare Little CurrentMohammed Brihmi AjaxDr. Harpal Buttar OttawaParminder Chahal BramptonMofazzal Howladar TorontoKurisummoottil Joseph Thunder Bay Catherine Kerr ScarboroughEvelyn Laraya Toronto Dr. Edelgard Mahant TorontoJose Saavedra WoodbridgeAbdul Wahid Scarborough

ACADEMIC APPOINTMENTS

Dr. R. John McComb University of TorontoDr. Stanley Kogon University of Western Ontario

6 New QA Program launches with start of new CE cycle

11 Health ADM congratulates College on its track record of excellence in self-regulation

12 Preparing for a medical emergency in the dental office

14 College speaking out on fluoridation

16 Certificate of Authorization annualrenewals around the corner

18 What you need to know about the use of automated external defibrillators

20 Drug interaction database

22 X-ray safety requirements for all Ontario dentists

26 Nitrous Oxide: The hidden addiction

28 What to know when retaining services of a new dentist/physician administering sedation and/or anesthesia

OOn April 4, the largest city government in the country renewed its

commitment to the fluoridation of municipal drinking water with the

unanimous vote of the Toronto Board of Health to continue with

fluoridation. Then on April 28, the Regional Municipality of Peel voted to

retain fluoridated community drinking water.

That means about 3.7 million people in Ontario will continue to enjoy the

benefits of fluoridated drinking water. Also, Simcoe Muskoka District recently voted

pro-fluoridation too.

Over the past couple of years, two other Ontario cities have also voted to maintain

fluoridation: Hamilton in 2008 and London in February 2011.

The political and social impact of these votes will no doubt be felt not only in

Ontario, but across the country. It goes a long way to counterbalance the two recent

high profile situations, in Waterloo and Calgary, where the anti-fluoridation lobby

got the upper hand. Waterloo decided in November 2010 to discontinue water

fluoridation by the very slim margin of 50.3% to 49.7%.

The votes in Toronto and Peel were extremely important. So important that the

Chief Medical Officer of Health for the province of Ontario, Dr. Arlene King, made a

personal deputation on behalf of the province in support of fluoridation.

Her presentation was very forceful. She stated that municipalities who take away

fluoridation are “putting the oral health of their residents at risk.” She said the

province is watching as events unfold to see what impact municipal discussions

will have.

She went on to say that the removal of fluoridation from municipal drinking water

puts stress on provincial dental programs and that government will be providing the

public with more information on the oral health and the benefits of fluoridation.


4

THE PRESIDENT’S MESSAGE

Victories forfluoridation impact entireprovince

PETER TRAINOR

THE PRESIDENT’S MESSAGE

In his presentation, Toronto’s Chief Medical

Officer of Health, Dr. David McKeown,

shared statistics that showed the value of

fluoridation. Before Toronto began

fluoridating in 1963, children got an average

of five to seven cavities. Today, partly

because of fluoridation, and partly because

of better dental care, they get an average of

one to two.

He cited the situation in the municipality of

Dryden, Ontario that discontinued

fluoridation in 2001 and then the level of

cavities in five-year-olds grew by 26 per cent.

As the College’s presentation pointed out,

tooth decay is a silent epidemic, the number

one chronic disease in children and

adolescents in Canada. It is five times more

common than asthma.

Many deputations, including the

presentations made by the College and our

colleagues at the Ontario Dental Association,

spoke to one of the biggest advantages of

municipal water fluoridation: it equalizes the

benefits right across the population. It

benefits all residents of a community, young

and old, and regardless of your income and

ability to access routine dental care.

As dentists, we know that poor oral health is

linked to diabetes, heart disease and

respiratory conditions. So the health impact

of fluoridation is far reaching.

Fluoridation has to be one of the best deals

going in public health. The city of Toronto

estimates that it costs 77 cents per person per

year to fluoridate its water, while saving

many millions in dental care.

Currently, about 70 per cent of Ontarians

have access to water that is fluoridated. But

we cannot rest. Whenever possible, the

College will continue to actively speak out in

support of the fluoridation of municipal

drinking water systems so that everyone can

enjoy the lasting health benefits.


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La victoire de la fluoration a un impact à l’échelle de la province

Suite à la page 42

LLe 4 avril, le plus grand gouvernement municipal au pays a renouvelé

son engagement en faveur de la fluoration de l’eau potable municipale

par un vote unanime du Toronto Board of Health visant à continuer la

fluoration. Puis, le 28 avril, la Municipalité régionale de Peel a voté afin

de conserver la fluoration de l’eau potable communautaire.

Ceci signifie qu’environ 3,7 millions de personnes en Ontario

continueront à bénéficier des avantages de boire de l’eau potable

fluorée. De plus, le district de Simcoe Muskoka a récemment voté

également en faveur de la fluoration.

Au cours des dernières années, deux autres villes ontariennes ont aussi

voté pour maintenir la fluoration, notamment Hamilton en 2008 et

London en février 2011.

L’impact politique et social de ces votes se fera sans nul doute ressentir,

non seulement en Ontario, mais dans tout le pays. Ceci contribuera

énormément à équilibrer les deux récentes situations à grand

déploiement, à Waterloo et à Calgary, où le groupe de pression opposé

à la fluoration a eu gain de cause. En novembre 2010, Waterloo a

décidé par une très faible marge de 50,3 contre 49,7 % d’abandonner la

fluoration de l’eau.

Les votes de Toronto et de Peel se sont avérés extrêmement importants,

tant et si bien que le médecin hygiéniste en chef de la province de

l’Ontario, la Dre Arlene King, a fait une démarche personnelle au nom

de la province pour appuyer la fluoration.

Sa présentation était très énergique. Elle a déclaré que les municipalités

qui abandonnent la fluoration « mettent en péril la santé orale de leurs

résidents ». Elle a affirmé que la province surveille la suite des

événements afin de constater quelle sera l’incidence des discussions

municipales.

Elle a poursuivi en disant que la suppression de la fluoration de l’eau

potable municipale accroît la pression sur les programmes dentaires

provinciaux, et que le gouvernement fournira davantage de

renseignements au public sur la santé orale et les avantages de la

fluoration.

Dans sa présentation, le médecin hygiéniste en chef de Toronto, le

DECEMBER 15, 2011That’s the launch day for the College’s new Quality Assurance

(QA) Program. It is the first day of the new three-year cycle for

the collection of the required 90 CE points for members under

the QA Program.

What’s it all about? Well, first a bit of history…

In June 2009, new requirements for quality assurance were

created for health care regulatory colleges when the amendments

to our governing legislation, the Regulated Health Professions Act,

were passed as part of the Health Systems Improvement Act.

Our challenge was to develop a new QA regulation and program

that met the government’s current expectation that health care

regulatory colleges would take a proactive role in monitoring the

performance of their members, and educating them.


6

New QA ProgramLaunches withStart of New CE Cycle

QUALITY


7

ASSURANCE

s

Our starting point was the comments made by

Health Professions Regulatory Advisory Council

in its New Directions report. That report stated

that regulatory college members “must have confidence that when changes are

identified as necessary in their own practice… there is no link to the discipline

or registration process and no office visits. Rather the link is to enhanced

competence, continuing improvement and outcome evaluation.”

The College wanted its new QA Program to meet all these requirements, plus

incorporate the nurturing, non-punitive philosophy of the College. We wanted

to do this by moving beyond the old traditional QA programs that focused on

office visits. We wanted our QA Program to be all about sustaining, improving

and assuring the professional standards of our members through continuing

education and practice enhancement.

Our new QA Program needed:

• to take into account that the overwhelming majority of dentists in

Ontario are competent practitioners who continually upgrade their

knowledge and skills;

• to meet the demands of changing practice environments and

patient needs;

• to ensure members can and do demonstrate their continued competence.

And we have more than met these goals.

In the new QA Program, members will be encouraged and supported to

participate in a process of lifelong learning. There is:

• no direct link to the discipline process;

• no link to the registration process;

• no pass/fail examination.

OUR PHILOSOPHY


8

Under the new QA Program, you are still

required to obtain at least 90 CE points in

each three-year cycle.

And you still need to keep all the documentation

that demonstrates that you attended CE activities.

In fact, you need to retain all the information for

each three-year cycle for five years from the date

that the three-year cycle ends. For example, if your

CE cycle ends on December 15, 2014, you must

keep your information until December 15, 2019.

QUALITY

Current members (members with a general or specialty certificate)

Your CE cycle begins on December 15, 2011.

New members

Your CE cycle begins on December 15 of the calendar year in

which you register with the College.

Full-time students

Members enrolled in a full-time post-graduate program are

exempt from CE requirements. However, it is the member’s

responsibility to inform the College’s Quality Assurance

department in writing of their educational status so that their

three-year cycle can be adjusted accordingly.

Bonus for New Graduates

All new members registered with the College in the same

calendar year as they completed their undergraduate and/or

post-graduate program are awarded 30 CE points (15 CE points

in Category 1 and 15 CE points in Category 2) for their first year

of a three-year cycle.

THE THREE-YEAR CE CYCLE


9

THE THREE CE CATEGORIES

CATEGORY 1: Core Courses – 15 pointsThese courses are considered by the Quality Assurance Committee to contain information

and knowledge relevant to the practice of the profession and important to promote

members’ continuing competence and maintenance of professional standards.

In approving courses for this category, the QA Committee considers such factors as:

• course providers are recognized experts on the subject;

• the quality of the delivery mode;

• references or links to supportive educational materials;

• absence of any commercial bias;

• whether or not there is an independent assessment component;

• accessibility to all members equally.

Currently the core courses are the College’s LifeLong Learning programs and webinars

plus the Ontario Dental Association’s program on guiding patients to a smoke-free future.

The College is actively encouraging other organizations to become course providers: the

Ontario Dental Association, the Faculty of Dentistry at the University of Toronto and the

Department of Dentistry at the Schulich School of Medicine and Dentistry at the

University of Western Ontario.

CATEGORY 2: Approved Sponsor Courses – 45 PointsThese are courses on clinical dental topics offered by approved sponsors or you can

collect CE points for teaching.

CATEGORY 3: Other CoursesYou can collect any remaining number of CE points from other courses, including those

offered by non-approved sponsors.

It is important to note that attendance at dental conventions is approved for CE points in

this category, with six CE points awarded for a full-day attendance.

If you attend a course/lecture/seminar on a clinical dental topic while at a dental

convention offered by an approved sponsor, you are able to claim this portion

of the CE points in Category 2: Approved Sponsor Courses and the balance in

Category 3: Other Courses.

ASSURANCE

s


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QUALITY ASSURANCE

Questions about the QA Program

Dr. Michael Gardner Manager, Quality [email protected]

Questions about CE PointsJoanne Loy – Quality Assuranceand Continuing Education Assistant416-961-6555, ext. [email protected]

COLLEGE CONTACTS

ELEMENTS OF THE QA PROGRAM1. Practice Enhancement Tool This is a computer-based self-assessment program, also

known as PET, that allows members to evaluate and assess

their practice, knowledge, skill and judgment based on peer-

derived standards.

The online program means that it is easily accessible and it

is designed to the same high standards as the educational

packages in our LifeLong

Learning program.

The College has been

working very closely with

the National Dental

Examining Board in the

development of this tool to

ensure its validity and

integrity.

Each year a certain

percentage of the

membership will be

selected at random to take

the PET peer-derived self

assessment.

PET will be available online right from the College’s website.

2. Practice Enhancement ConsultantAs part of the supportive philosophy of the new QA Program,

there is now a consultant on staff to assist members at any time

in identifying appropriate continuing education or professional

development activities.

The consultant will also help in interpreting or discussing the

results of your self-assessment when you are selected to use the

Practice Enhancement Tool

and assist you in coming

up with a continuing

education plan to address

any deficiencies or

weaknesses.

3. e-PortfolioBy the middle of next year,

you will have secure access

to your own online e-

Portfolio right from the

College’s website. You will

be able to track your own

CE points and see in an instant how many points you need to

collect in each category. No more forms.

As you progress through a three-year cycle, you can keep your

CE activities updated in your online personal e-Portfolio. At a

glance, you will know how many CE points you have in each

of the three categories and how many more you are required to

get to reach the target.

At the end of a three-year cycle, a certain percentage of the

membership will be selected at random and their e-Portfolio

will be reviewed to ensure that they are meeting their

obligations under the QA regulation.

4. Annual DeclarationEach year you will be entrusted with the

responsibility of completing a section on your

registration renewal form to self-declare

whether or not you are in compliance with the

QA Program requirements. This will start with

the registration renewals in 2012.

A


11

At its May 5 meeting, Council was honoured to welcome Suzanne McGurn, Acting

Assistant Deputy Minister from the Ministry of Health and Long-Term Care, to

make an address during its morning session. Ms McGurn leads the

HealthForceOntario health human resources strategy and is responsible for the

development of strategies to address the issues of supply, mix,

demand and distribution of health professionals in the

province. In this role, she reports to both the Ministry of

Health and the Ministry of Training, Colleges and Universities.

In addition, one of her many other responsibilities is the

Health Professions Regulatory Policy and Programs Branch.

That means she is responsible for the policy and program issues

related to all health care regulatory colleges in the province,

including RCDSO.

Ms McGurn was very complimentary about our College and its

understanding and implementation of its role as a regulator:

“You have demonstrated in everything that I have seen come

from your College …you know that your job in protecting the public is beyond

just implementing the rules. It is understanding what the circumstance is,

taking stock of the environment and figuring out how that reflects on where we

are now in health care.”

Ms McGurn went on to state that the College is well respected and “well

recognized for its value and appropriateness in dealing with difficult issues.” She

mentioned the College’s work on the provincial pandemic readiness plan,

dental CT scanners, labour mobility, the pain symposium and our Quality

Assurance Program as specific examples.

She wrapped up her presentation by saying, “I would like to again congratulate you

on your track record of excellence in self-regulation. I am confident that as we

continue to work together we will only increase our effectiveness in both keeping

the public safe and finding new ways to work to benefit the system as a whole.”

Health ADM Congratulates College on its

“Track Recordof Excellence in Self-Regulation”

College President Dr. PeterTrainor and Suzanne McGurn,Assistant Deputy Minister,Health Human ResourcesStrategy Division, Ministry ofHealth and Long-Term Care


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Preparing for a MedicalEmergency in the Dental Office

It is the College’s expectation that all

Ontario dentists and their support staff

are prepared to deal with medical

emergencies when they arise. This

article summarizes ways to ensure that

this expectation is met.

AssessmentThe treatment of a medical emergency

in a dental office begins with

assessment and, if necessary, treatment

of airway, breathing and circulation

by means of cardiopulmonary

resuscitation. Most often, only after

these basics have been addressed

should the use of the emergency kit be

considered.

All members are encouraged to review

the College’s LifeLong Learning CD,

Medical Emergencies in the Dental

Office, that deals extensively with this

subject.

Emergency DrugsThe six basic drugs that should be

included in the emergency kit of every

dental office and their recommended

dosages are listed in the table on the

opposite page.

Additional agents may be appropriate

depending on the nature of the dental

practice.

These emergency drugs should have

current dates and be stored in readily

identifiable and organized fashion (i.e.

labelled trays or bags) or organized in a

kit similar to the one presented in the

Medical Emergencies in the Dental

Office CD.

The arrangement of the emergency

drugs in such a manner assists dentists

and staff in responding to a medical

emergency in a capable and confident

way, despite the emotional stress and

anxiety created by the emergency.

In addition to having an emergency kit

available with the recommended drugs,

it is advisable that some type of quick

source of glucose also be on hand.

It is important that dentists

update their knowledge on

the management of dental

office emergencies from

time-to-time by including

courses and seminars on

this subject and on dental

pharmacology in their

ongoing continuing

education plans. Reviewing

the College’s LifeLong

Learning Program CD on

Medical Emergencies in the

Dental Office periodically is

also helpful.

I

LIFELONG LEARNING PROGRAM:Medical Emergencies in the Dental Office The CD features a section on office preparedness andthe responsibilities of individual staff members. It alsoincludes instructional material and simulations ofvarious medical emergencies. Step-by-step summarysheets on each of the emergency situations areavailable for downloading. You can keep a hard copy inyour office or access the information from your officecomputer for quick and easy reference when anemergency situation occurs.

Dr. Dan Haas, Professor of Pharmacology in both theFaculties of Dentistry and Medicine at the University ofToronto, is the content consultant and the keypresenter. Dr. Haas is one of the leading authorities inNorth America on this subject and has garneredhonours for his work in this area.

This program was distributed at no charge to membersin 2005. Members can purchase a replacement copy ofthis educational package for $50. There is an orderform online on the College’s website atwww.rcdso.org. Just click on the Quality Assuranceheading in the navigation bar on the left-hand side ofthe home page, and then click on LifeLong Learning.

Other RequirementsIt is also recommended that in all dental offices:

• All dental office staff have CPR training.

• A written emergency protocol is in place in the

office.

• All dental office staff should be aware of this

protocol and the procedures to follow when a

medical emergency arises. This protocol

should be periodically reviewed at staff

meetings so everyone is clear about who does

what when an emergency occurs.

Offices providing conscious sedation, deep sedation

and/or general anesthesia are required to have

specific other emergency drugs and equipment.

These lists can be found in the RDCSO Guidelines

on the Use of Sedation and General Anaesthesia in

Dental Practice. The Guidelines are available on our

website at www.rcdso.org under the heading of

Sedation/Anaesthesia, as well as the heading of

Professional Practice, in the navigation bar on the

left-hand side of the home page, at www.rcdso.org.

Dentists and all clinical staff must have the training

and ability to perform basic cardiac life support

techniques. The College strongly recommends that

all dentists maintain current CPR certification.


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DRUG INDICATION INITIAL ADULT DOSE RECOMMENDED CHILD DOSE

Oxygen Most medical emergencies 100% inhalation 100% inhalation

Epinephrine Anaphylaxis 0.1 mg i.v or 0.3-0.5 mg i.m* 0.01 mg/kg

Asthmatic bronchospasm 0.1 mg i.v or 0.01mg/kg which is unresponsive 0.3-0.5 mg i.m* to salbutamol

Cardiac arrest 1 mg i.v 0.01mg/kg

Nitroglycerin Angina pectoris 0.3 or 0.4 mg sublingual No paediatric dose

Diphenhydramine Allergic reactions 50 mg i.v or i.m* 1 mg/kgor chlorpheniramine 10 mg i.v or i.m*

Salbutamol Asthmatic bronchospasm 2 puffs (100 micrograms/puff) 1 puffinhalation aerosol

ASA Acute Myocardial infarction 160 or 325 mg Not indicated

*The dose suggested for the i.m. route is also appropriate for sublingualinjections. Total paediatric dose should not exceed the adult dose.

COLLEGE CONTACT Dr. Lesia Waschuk – Practice Advisor, Quality Assurance 416-934-5614 [email protected]

TThe College is taking a very activist role in speaking out for fluoridation.

Over the past couple of years, the College has been requested to present

at a number of communities around the province. Our support on this

important oral health issue continues.

College President Dr. Peter Trainor and Vice President Dr. Natalie Archer

have taken the good news about fluoridation to the Toronto Board of

Health and to the Regional Council of Peel during April.

Over the past years, the College has responded to a number of requests

to make public representations in support of fluoridation to city and

town councils around the province. To add more weight to our

argument, at the request of the College, the heads of the two dental

schools in Ontario have released public letters in support of the use of

fluoride in municipal drinking water.

In addition, at its November 2009 meeting, Council passed a motion

indicating our willingness to work with government, if there was

interest, on a province-wide evidence-based study to determine reliable

and meaningful information on the long-term financial implications for

municipalities of maintaining or instituting water fluoridation.

In late 2010, College representatives participated in a meeting organized

by Ontario’s Chief Medical Officer of Health Dr. Arlene King to have

preliminary discussions about how various government ministries and

the College might work together on the fluoridation file.

The College has only two formal policy statements, and one

of them is in support of fluoridation. It is posted online at

www.rcdso.org/Professional Practice.


14

College Speaking Out ForFluoridation

THANKS FROM TORONTO CHIEF MEDICAL

OFFICER OF HEALTH DR. DAVID MCKEOWN

Dear Dr. Trainor,

I wanted to personally thank youfor taking the time to depute atthe Board of Health on the issueof fluoridation on Monday. Yourcontribution to the discussionplayed an important role in theBoard of Health unanimouslyreaffirming its support for thecontinued fluoridation ofToronto's drinking water. Theimportance of the decision inToronto to broader discussions inother jurisdictions across Ontariocannot be underestimated.

Sincerely, David

“There is no

evidence to suggest

that children should

avoid drinking

fluoridated water

at the accepted

levels in Canadian

drinking water

supplies. The big

advantage of water

fluoridation is that it

benefits all residents

in a community,

regardless of age,

socioeconomic

status, education

or employment.”

DR. PETER COONEY

Chief Dental Officer of Canada

“The studies

are clear and

unequivocal and

the benefits of

fluoridation are

well documented…

water fluoridation

reduces dental

caries expenditures,

with an estimated

$38 in avoided costs

for dental treatment

for every $1 invested

in community water

fluoridation…”

DR. ARLENE KING

Chief Medical Officer of Ontario

“Water fluoridation

is known to be one

of the greatest public

health and disease-

preventive measures

world-wide.

Evidence gathered

by the Center for

Disease Control,

National Institute

for Dental Research

and Health Canada

demonstrates that

fluoride treated

water continues

to provide dental

health benefits to

all ages.”

DR. HARINDER SANDHU

Director, Schulich Dentistry

Schulich School of

Medicine & Dentistry

University of Western Ontario

“It is illogical

to deprive our

population,

particularly children,

of the benefit of

water fluoridation

based on

unsupported

speculation while

disregarding sound

scientific evidence

and the advice of

the leading national

and international

authorities.”

DR. DAVID MOCK

Dean, Faculty of Dentistry

University of Toronto


15Peggi MaceCommunications [email protected]

COLLEGE CONTACTS Dr. Michael GardnerManager, Quality [email protected]

Reduction of annual renewal fee if paid on or before July 31The annual renewal fee of $200 is due August 31. If the completed annual

renewal form and fee are received on or before July 31 and you have met the

annual renewal requirements, the fee will be discounted to $175.

To renew your Certificate of Authorization, you will be required to submit

your completed annual renewal form with the following information:

• 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 to the Registrar;

• original current-dated Certificate of Status of the corporation issued by

the Ministry of Government Services not more than 30 days before the

day it is submitted to the Registrar.

Statutory Declaration – Form BThe Statutory Declaration must be sworn in the physical presence of a

commissioner, lawyer or notary public. The legislation requires that the

Statutory Declaration be executed not more than 15 days before the

application for annual renewal is submitted to the Registrar, certifying that

the corporation is in compliance with section 3.2 of the Business

Corporations Act.

What is a Certificate of Status of the Corporation?A Certificate of Status is a one-page document issued by the Ministry of

Government Services which indicates that the corporation is active. The

legislation sets out the requirements for the annual renewal of your

Certificate of Authorization. One of those requirements is that a current-

dated Certificate of Status accompanies your annual renewal form regardless

of how new your health profession corporation is.


16

Certificate of AuthorizationAnnual Renewals Around the Corner

COLLEGE CONTACT Talesia Brown – Administrative Assistant, Registration416-961-6555 ext. 4329 [email protected]

The annual renewalof your Certificate of Authorization for your healthprofessioncorporation is justaround the corner. If you currently holda Certificate ofAuthorization for a health professioncorporation, yourannual renewal form will beforwarded directly to you in June.

HEALTH PROFESSION CORPORATIONS

DO ensure that you are in the physicalpresence of a commissioner, lawyer ornotary public to have your StatutoryDeclaration executed.

DO NOT sign and date the StatutoryDeclaration prior to your attendance withthe commissioner, lawyer or notary publicthat will be swearing your StatutoryDeclaration.

DO ensure that you submit the originalcurrent-dated Certificate of Status of thecorporation and that you submit the annualrenewal form and Statutory Declarationwith original signatures.

DO NOT fax your Certificate of Status,completed annual renewal form orStatutory Declaration to the College.Original signatures and documents arerequired.


17

EXPIRY DATE – AUGUST 31

All Certificates of Authorizationexpire August 31 of every yearregardless of the initial date of issuance. For those dentists who applied for a Certificate of Authorization this year, please note that it is only validuntil August 31.

DOS AND DON’TS OF THE HPC ANNUAL RENEWAL PROCESS

ON THE WEB www.rcdso.orgHealth Profession Corporations

An automated externaldefibrillator (AED) is a portableautomatic device used to restorenormal heart rhythm to patients incardiac arrest. An AED is appliedoutside the body. It automaticallyanalyzes the patient’s heartrhythm and advises the rescuerwhether or not a shock is neededto restore a normal heart beat. If,as a result of the shock, thepatient’s heart resumes beatingnormally, the heart has beendefibrillated.

In the May 2007 Journal of theCanadian Dental Association, aguest article by Dr. Dan Haas,Professor of Pharmacology in boththe Faculties of Dentistry andMedicine at the University ofToronto, outlined the benefits ofthe use of an AED and introducedthe concept of these devicesbecoming standard equipment ina dental office.

QHow is a patient’s outcomeimproved if a sudden cardiac arrest occurs in a dental office?

Out-of-hospital sudden cardiac arrests

have a survival rate of 6 per cent.

Survival from a sudden cardiac arrest

decreases seven to 10 per cent 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.

QIs the training required by a dentist more extensive or much the same as anyperson who may be in aposition 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.

QWhat is the risk associatedwith 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 emphasize this

requirement.

QOn an overall basis, wouldthe possibility of malfunctionor misuse by dentists putpatients at greater risk in theevent of a cardiac emergencythan if dentists did not havean 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.


18

What You Need to Knowabout the use of

AUTOMATEDEXTERNALDEFIBRILLATORS

QIs a dentist put at risk ofcriticism about their clinicalperformance if they have anAED and it was usedunsuccessfully? In otherwords, if a dentist is wellversed in CPR and has thenecessary medical emergencydrugs, why would he or sheneed an AED?

The reality is that the most common

outcome of CPR is that the patient dies.

Having an AED improves that outcome

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 a poorer chance of

a favourable outcome.

QIs there a greater likelihoodthat a patient may experiencea procedure-related suddencardiac arrest in a dentaloffice than in a physician’soffice?

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.

QWhat is the position of theCollege of Physicians andSurgeons of Ontario (CPSO)respecting the use of AEDs inphysicians’ offices?

CPSO does not have a position on AEDs

specifically; however, it does 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.

QGiven the medical training of dentists, would a higherstandard of care andtherefore a higher risk ofliability apply to dentistsusing an AED in a dentaloffice?

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.

QWhat 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 be purchased or

leased at a reasonable cost.

Obviously AEDs cannot be evaluated on

a cost benefit relationship. Fortunately

cardiac arrest in a dental office is 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.


19COLLEGE CONTACT Dr. Lesia Waschuk – Practice Advisor, Quality Assurance

416-934-5614 [email protected]

SSo many dental patients in Ontario have

benefited from the drug interaction database

available online from the College’s website, says

College Registrar Irwin Fefergrad.

“We have now offered this service at no cost to

every dentist in Ontario for more than seven

years. Dentists have told us year after year that

the service is invaluable as they can get

information immediately, even while the patient

is in the chair,” explained Fefergrad. “That kind

of protection for patients is unbeatable.” Called

Adverse Drug Interactions, it is accessible from

the home page of the College’s website at

www.rcdso.org.

The service connects directly to an online

version of The Medical Letter on Drugs and

Therapeutics, an independent, peer-reviewed,

non-profit publication that is independent of the

pharmaceutical industry. The service accepts no

advertising, grants or donations. The Medical

Letter evaluates almost all new drugs and reviews

older drugs when important new information

becomes available on their usefulness or about

adverse effects.

The drug interaction service allows you to list

each of the drugs your patient is taking and

immediately view the possible interactions on

the screen. The online search will handle

interactions from two up to 12 drugs.

In addition, you can view reference citations

pertinent to the interaction. There is also an

index of over 3,000 brand names with generic

equivalents. The program is updated every six

months to keep it current.

Access to the online services provided by The

Medical Letter, Inc. is provided by the College as a

service to its members. The College is neither

involved in the preparation of the materials

contained at The Medical Letter, Inc. website, nor

does the College verify the accuracy or

completeness of the information contained therein.

Users of The Medical Letter, Inc. website agree not

to hold the College responsible for any

consequences occasioned to them as a result of

their use of the site, or as a result of their reliance

upon the information contained therein.

www.rcdso.orgENSURING CONTINUED TRUST DISPATCH MAY/JUNE 2011

20

Free access to onlinedrug information offersimmediate assistanceto dentists and patients

www.rcdso.orgwww.rcdso.orgwww.rcdso.orgwww.rcdso.orgwww.rcdso.org


21

ON THE WEBwww.rcdso.orgLogin Instructions for the Adverse Drug Interaction Program1. Go to the home page of the College’s website at

www.rcdso.org.

2. Click on the special heading – ADVERSE DRUG

INTERACTIONS – on the right-hand side of the home

page. This takes you to a special disclaimer message.

Please read the message. Then, click the ACCEPT button.

3. Now you are on the website of the Medical Letter. Close

the pop-up window that scrolls across the home page by

clicking the “X” in the top-right corner.

4. Scroll to the top-right corner of the Medical Letter

homepage, locate and click the “Login” button.

5. You will be asked for an EMAIL and a PASSWORD.

Please enter your USERNAME in the email field. All

RCDSO members have the same username and

password. If you do not remember the USERNAME and

PASSWORD, please contact Joanne Loy for assistance at

416-961-6555, ext. 4703, toll-free at 1-800-565-4591

or by e-mail at [email protected].

The adverse drug interaction

link is located right below the

member resource centre login

button on the College’s

homepage, www.rcdso.org.

COLLEGE CONTACT Dr. Michael Gardner – Manager, Quality Assurance416-934-5611 [email protected]

www.rcdso.orgwww.rcdso.orgwww.rcdso.orgwww.rcdso.orgwww.rcdso.org

The Healing Arts RadiationProtection Act (HARP),administered by theMinistry of Health andLong-Term Care, waspassed in 1980. Theregulations (X-ray Safety Code) made in 1985, andapplicable to the dental profession, were developed by the Dental Advisory Committee to the HARP Commissionwhose membership included practising dentists anddental educators. This legislation specifies operatorqualifications and technical performance standards for x-ray machines and outlines the procedures and tests that are deemed necessary and their frequency in order to ensure the highest possible level of patient and operator safety.


22

X-ray SafetyRequirements for all Ontario Dentists

OPERATOR QUALIFICATIONSUnder the HARP Act, the following operator

qualifications with regard to patient safety are

outlined:

• No person shall operate an x-ray machine

for the irradiation of a human being unless

he or she meets the requirements set out in

the regulations.

• Under the Act, dentists and dental

hygienists are deemed to have met the

required qualifications and requirements.

Dental assistants, however, must have taken

appropriate training in x-ray safety in order to

take radiographs, and must present proof of

successful completion of such a program, when

requested to do so by X-ray Inspection Service

inspectors. At the present time, most current

Level I and Level II dental assisting programs in

Ontario provide the appropriate training. A

listing of programs that have already been

approved by the HARP Commission, including

private dental assisting programs, co-op high

school dental assisting programs, and out-of-

province programs can be obtained from the

school itself or the X-ray Inspection Service.

REGISTRATION OF X-RAY MACHINESAll dental x-ray machines must be registered by

the owner and new installations must be

approved by the Director of X-ray Safety with

the X-ray Inspection Service (XRIS) of the

Ministry of Health and Long-Term Care. Plan

approval ensures both patient and staff safety

from unnecessary radiation exposure. Approval

consists of a plan of your office layout

accompanied by the required additional forms

and information. Under the Act, written

approval to install and operate the x-ray

machine must be made, in writing, by the

provincial Director of X-ray Safety.

Registration and approval forms can be found

online at http://www.health.gov.on.ca/

en/public/forms/xray_fm.aspx.

If you have recently renovated your office or

purchased an existing practise and made

renovations, it is important that you re-submit

your plans for approval. If you have purchased a

practice from another dentist and do not

renovate, the pre-existing plans, if already

approved by the Director of X-ray Safety, will

suffice. The College recommends that when you

inform the College of any change to the

ownership to the x-ray machines, you also

contact XRIS about the change.

The HARP Act authorizes that inspectors may, at

all reasonable times, enter and inspect the

premises. Inspectors do not have to make an

appointment, but may provide dentists with a

one-week window for office inspection visits.

This is done through correspondence. The

College recommends that you have all the

necessary paperwork, including any forms or

plans associated with the installation and


23

s

operation of dental x-ray machines, readily

available at the office. The inspector visits your

dental facility on average once every three to

five years and on average for less than an hour

or two depending on the number of x-ray

machines, size of your practice and availability

of required documents.

If an inspector visits your office and finds that

the plan does not conform to the approved

plan, he or she will issue an order indicating

that you are in violation of the HARP Act. This

can result in a stop use order preventing further

use of the x-ray equipment. The dentist-owner

of the practice must submit a new plan with the

actual layout for approval, or redesign his or her

office to match the approved plan on file with

the Ministry.

More information on the approval process can

be obtained from:

X-ray Inspection Service (XRIS) Licensing,

X-ray and Lab Inspections Unit

Ministry of Health and Long-Term Care

55 St. Clair Ave. W, 8th Floor

Toronto, ON M4V 2Y7

416-327-7937

PATIENT SHIELDINGThe HARP Act requires that protective

accessories are available for use by persons who

may receive exposure to x-rays. The College

recommends the use of both gonadal and

thyroid shielding devices where possible and

practical.

QUALITY ASSURANCE REQUIREMENTSA key component of the HARP Act is the

requirement that a Photographic Quality

Assurance Program (QA) relative to x-ray shall

be instituted in every dental office.

Photographic Quality Assurance is defined as a

program of activities designed to ensure that

diagnostic imaging is carried out with the

maximum benefit to the patient, at a minimum

of risk. The goal of the program is to confirm

that the dentist is providing the highest quality

care possible with respect to the use of x-rays.

In a dental facility, the primary objective of a

Photographic QA program is to ensure that:

• Every imaging procedure is necessary and

appropriate to the clinical problem at hand

and is prescribed by a dentist.

• The images generated contain information

critical to the solution of that problem.

• The examination results in the lowest

possible radiation exposure, cost and

inconvenience to the patient consistent

with the diagnostic information

requirements.

• Repeat films and exposure will be kept to a

minimum.

• Accurate functioning of the x-ray

equipment will be monitored.

RADIATION PROTECTION OFFICERThe responsibility for ensuring that quality

assurance testing is carried out rests with the

Radiation Protection Officer, who must be a

dentist qualified to take x-rays. He or she is also

responsible for all other matters of radiation

safety related to the taking of x-rays in the

dental office, such as ensuring that only HARP

qualified personnel are permitted to take

radiographs, and that the office has received

Ministry of Health and Long-Term Care’s

approval for the installation of x-ray equipment.


24

X-ray Safety Requirements for all Ontario Dentists

PRESCRIBING OF DENTAL X-RAYSThe HARP Act requires that dental x-rays be

prescribed by a dentist before they can be taken.

A clinical rationale for taking the x-ray or x-rays,

therefore, must first be determined by the

dentist. The HARP Act precludes taking a set

number of exposures or time sequence

radiographs (i.e. every six months, every year

etc.) without an individualized prescription for a

particular patient, which is based on the results

of a clinical examination.

IN CONCLUSIONThe guiding principle behind the HARP Act is

that every dental patient in Ontario has the right

to expect a high quality x-ray examination with

as small an amount of risk as possible. The

Quality Assurance Program described in this

article, as well as the other elements of the

legislation, is meant to assist Ontario dentists in

achieving this goal.

The College acknowledges the assistance of Leo Tse,

Program Manager, Licensing, X-ray and Lab

Inspections, Ministry of Health and Long-Term Care

in the preparation of this article.


25

PHOTOGRAPHIC QA TESTINGThe HARP Act also sets out certain requirements for

photographic quality assurance tests for dental offices,

clinics and facilities. The minimum requirements of an

acceptable photographic QA program include the

following:

ANNUAL TESTING

• patient entrance exposure measurements

• collimation testing

• half value layer testing

These tests must be carried out every 12 months and

upon alteration or servicing of the machine. They can be

accomplished by using a mail-in testing service, if

available, or by arranging for a qualified service

technician to come to the dental office.

DAILY TESTING

• photographic quality control testing

For conventional dental x-ray units, these tests must be

performed every operational day and can be carried out

by keeping a log referring to the number of films

processed and the change cycle of the processing

solutions, using a thermometer in the manual processing

tank or a back-up thermometer in automatic processors,

and recording and logging the temperature on a daily

basis. It may also be helpful to compare the quality of a

test film each day (the first exposure of the day) with

that of a reference radiograph that was processed when

film quality was known to be optimal. A step-wedge can

also be used. Any variance from the ideal should be

noted and corrected. For offices using digital

radiography, daily photographic control testing is not

required at this time.


Dentistry is a stressful profession and those whopractise it may be placed at an increased risk of divorce,depression, alcoholism, drug addiction and suicide.1

Many factors influence these risks. They include dentistry’s inherent stress, the

isolation of the practitioner, physical and emotional demands, prescription

writing privileges and the availability of drugs.2

Isolation is a critical factor as it provides a fertile climate for addictive and self-destructive

behaviour. The office often becomes a safe haven for the dentist that drinks and uses other

drugs. These factors play a part in what can be seen as dentistry’s own specialized addiction,

one that involves the abuse of and dependency on nitrous oxide.3

The nitrous oxide abusing dental professional is basically confined to his or her dental

office due to the constraints of the equipment needed to administer the substance.4

Nitrous oxide was first discovered in 1772 by Joseph Priestley. By 1800, nitrous oxide was

being used as a purifying gas by practitioners of pneumatic medicine, a practice that used

inhalation of specific gases to purify the body of ailments.

One of these practitioners was an English physician named Thomas Beddoes. It was

Beddoes’ assistant Humphrey Davy, who did extensive writings on the effects of nitrous

oxide inhalation. He also held demonstrations of the subjective effects of nitrous oxide by

providing it to random subjects at public displays where they would act intoxicated after

inhalation of the gas.

The American dentist Horace Wells attended one of these demonstrations in 1844. He

observed one subject accidently injure himself while he was under the influence of the gas

with the subject appearing totally unaware of the injury or the pain that most surely

accompanied it. Dr. Wells recognized the potential of the gas as an anesthetic and

proceeded to experiment in its possible use in dentistry and surgery.

As a result, nitrous oxide has become one of the most widely used inhalation anesthetic


26

NITROUS OXIDE:The HiddenAddictionDR. GRAEME CUNNINGHAM, RCDSO WELLNESS PROGRAM CONSULTANT

gases in medicine and dentistry and has

become the almost exclusive inhalation

analgesic used for the reduction of anxiety.5

At lower to moderate concentrations, nitrous

oxide produces analgesic and emotional effects

similar to the narcotic analgesics. Recent

studies indicate that nitrous oxide may exhibit

its analgesic effects by influence in the body’s

own endogenous opioid system or directly at

the opioid receptor sites of neural synapses.3

By acting as an opioid, the inhalation of

nitrous oxide produces similar euphoric effects

that drive the addictive properties of other

narcotic analgesics such as morphine and

hydrocodone.

Researchers have called for the reclassification

of nitrous oxide as an opioid and to have it

regulated as such.

Chronic nitrous oxide abuse exhibits certain

physical health risks. Most notable is a

peripheral neuropathy that manifests itself as a

loss of sensory perception, initially beginning

in the hands and feet of the abuser. This

neuropathy has been shown to be the result of

demyelination as a result of a disruption of

vitamin B12 metabolism.

The clinical presentation of the chronic abuser

of nitrous oxide is the same as the clinical

presentation of an individual afflicted with

pernicious anemia (vitamin B12 deficiency).

This anemia is a severe medical condition

caused by the absence of intrinsic factor, the

protein necessary for the absorption of vitamin

B12 (cobalamin) by the intestine.

Along with the neural toxic effects already

mentioned, nitrous oxide abuse can also result

in severe, megaloblastic anemia.

In summary, chronic nitrous oxide abuse can

produce abnormalities in bone marrow activity

as a result of the interference with enzymes

containing cobalamin.

Many times nitrous oxide abuse/dependence is

a silent addiction within the dental profession.

Individuals afflicted with this addictive disease

can go undetected until significant physical

and personal damage has occurred.

An increase in the number of nitrous oxide

cylinders used in the office in a month, an

increase in the amount of time spent at the

dental office alone after hours and on

weekends, loss of coordination while handling

dental instruments or a stumbling gait may all

be signs that someone is abusing this

anesthetic agent.

Dentists, dentist’s family members and dental

office staff are encouraged to contact me on

the confidential hotline if you have any

concerns regarding nitrous oxide abuse or

dependency and any other substance use

disorders. This service emphasizes individual

advice, support and direction without any

requirement for College involvement.

References

1. Mandel, I.D. (1993). Occupational risks in dentistry:comforts and concerns. Journal of the American DentalAssociation, 124, 41-49.

2. Gropper,J.M. & Porter,T.L.(2000) Addiction andprogressive self-destructive behaviour in dentistry, Clark'sClinical dentistry, Philadelphia,PA: Harper&Row.

3. Eger II, E.I. (1985). Nitrous Oxide N2O. New York, NY: Elsevier.

4. Jasak,J.T.(1991).Nitrous Oxide and its abuse. Journal ofthe American Dental Association,122(2),48-52.

5. Gillman, M.A. & Lightfield, F.J. (1994). Opioid properties of psychotropic analgesic nitrous oxide (Laughing gas). Perspectives in Biology andMedicine, 38(1), 125-138.


27HOW TO REACH DR. CUNNINGHAMDedicated Direct Line: 647-867-6025All calls are private and confidential.

Dr. Cunningham is available for addressing assessment andtreatment needs of dentists by helping them find suitableassessors, treatment providers and residency programs.

WWhen a member applies, a facility permit is issued by the College

after a review of the training and qualifications of those

administering sedation and/or anesthesia services, as well as a

satisfactory on-site review to ensure that:

• all necessary equipment and monitors are in place and are

maintained properly;

• all emergency drugs are available and current;

• all other requirements and conditions set out in the College’s

Guidelines for the Use of Sedation and General Anaesthesia in

Dental Practice are met.

If you are thinking of retaining the services of a new physician or

dentist to administer sedation and/or anesthesia in your dental

practice, please note the important points on the opposite page.


28

Retaining the Services of a New Dentist or Physician toAdminister Sedation and/orAnesthesia in Your Dental Practice?

COLLEGE CONTACT Stephanie Bickford – Administrative Assistant, Registration416-961-6555 ext. 4325 [email protected]

Here Are SomeThings You Need to Know

The RCDSO Regulation and RCDSO Guidelines on the Use ofSedation and General Anaesthesia in Dental Practicerepresent the standard of practice in relation to inducinggeneral anesthesia, deep sedation or conscious sedation withrespect to dental services in Ontario.

Since the contravention of the Regulation and Guidelinesmay be considered as professional misconduct, dentistsemploying any modality of drug-induced sedation or generalanesthesia must be familiar with the content, beappropriately trained and regulate their practicesaccordingly.

The Guidelines require that all dental facilities that provideoral moderate sedation, parenteral conscious sedation, deepsedation or general anesthesia must be registered with theCollege and obtain a facility permit. Permits are not requiredfor offices that use nitrous oxide and oxygen conscioussedation and/or oral minimal sedation.

These permits are granted subject to a review of thequalifications and training of the person administering thesedation/anesthesia and conformance with all aspects of theGuidelines and subject to a satisfactory on-site inspectionand evaluation by RCDSO.

The permits are also subject to annual renewal and a periodicreinspection of the facility.


29

General Informationabout the Anesthesiaand Sedation FacilityPermit Process

It is your responsibility to inform the College of

this change in writing prior to booking any

sedation/anesthesia cases with this new dentist or

physician. You need to ensure that this new

person is, in fact, on file with the College as

approved to administer sedation and/or general

anesthesia in a dental practice.

In addition, if this new physician or dentist brings

his or her own sedation equipment, emergency

drugs, etc., to your dental facility, please note that

it is also your responsibility to ensure that the

sedation equipment has been inspected by the

College and is in full compliance with the

College’s Guidelines.

Once you have informed the College of any

changes about who is administering sedation

and/or general anesthesia in your dental practice,

the College will confirm, in writing, that the

individual that you are planning to engage is

qualified to do so. The College will then also issue

a new facility permit reflecting this change.

If this new physician or dentist will be using a

sedation/anesthesia modality that is different

from the one currently being administered, you

also need to inform the College about this

change.

ON THE WEB www.rcdso.orgUse of Sedation and General Anaesthesia in Dental Practice

PROFESSIONAL PRACTICE/GUIDELINES

LLocal anesthetics are safe, effective and essential drugs for

dentistry. As with all drugs, however, their use may involve

complications.

Paresthesia following the administration of a local anesthetic

for routine nonsurgical dental care is a rare occurrence. It is

so rare, in fact, that dentists are not legally required to warn

patients about the possibility of temporary or permanent

paresthesia as part of the informed consent discussion that

they have with their patients prior to treatment.

Still, the scientific literature has shown that certain local

anesthetics are associated with a statistically greater rate of

paresthesia.

In 2005, the College issued a Practice Alert, advising

members about a higher incidence, although still very low,

of paresthesia when four per cent solutions, namely articaine

and prilocaine, are used for mandibular block injections

(www.rcdso.org/bulletin/Dispatch_Summer_05_Page_26.pdf).

This finding was based on a number of studies, including a

1995 paper by Dr. Daniel Haas and Dr. Deena Lennon that

analyzed 21 years of claims information provided by the

College’s Professional Liability Program (PLP).


30

PEAK

Occurrence ofParesthesia after Dental Local AnestheticAdministration

PEAK (Practice Enhancementand Knowledge) is a Collegeservice for members, whosegoal is to regularly provideOntario dentists with copiesof key articles on a widerange of clinical and non-clinical topics from the dentalliterature around the world.

It is important to note thatPEAK articles may containopinions, views or statementsthat are not necessarilyendorsed by the College.However, PEAK is committedto providing quality materialto enhance the knowledgeand skills of member dentists.

Since then, additional studies have been

published on this subject, including a compelling

study by Dr. Gabriella Garisto, Dr. Andrew Gaffen,

Dr. Herenia Lawrence, Dr. Howard Tenenbaum

and Dr. Daniel Haas that was featured as the cover

story for the July 2010 issue of the Journal of the

American Dental Association. With this current

issue of Dispatch, PEAK is pleased to offer

members this same article: “Occurrence of

paresthesia after dental local anesthetic

administration in the United States.”

The current study analyzed all adverse event

reports involving local anesthetics available in the

United States that were voluntarily submitted to

the Food and Drug Administration’s Adverse

Event Reporting System from November 1997 to

August 2008.


31

PEAK


Studies conducted on adverse event reports fromOntario, Denmark, Northern California and nowthe United States as a whole have repeatedlyshown that the four per cent local anestheticsolutions used in dentistry, namely articaine andprilocaine, are more highly associated with thedevelopment of paresthesia than are those oflower concentration.

In the current study, the lingual nerve wasinvolved in 89 per cent of reports. This finding isconsistent with those of the previous studies.

The mechanism underlying nonsurgicalparesthesia is unknown, but evidence suggeststhat neurotoxicity of the local anesthetic incombination with minor trauma by the needlemay be the cause.

Results from randomized controlled clinical trialsgenerally have not shown that either four per centarticaine or four per cent prilocaine is superior totwo per cent lidocaine in achieving mandibularnerve block.

Dentists should consider these results whenassessing the risks and benefits of using four percent local anesthetics for mandibular blockinjections.

It is the College’s view that prudentpractitioners may wish to consider thescientific literature before determiningwhether to use four per cent localanesthetic solutions for mandibular blockinjections.

KEY POINTS

RISK MANAGEMENT ADVICE

TThis can be a challenging professional dilemma for any dentist.

There are whole chapters in dental ethics textbooks devoted to

working through this ethical problem.

As clinical dentists, our primary obligation is to place the well-being

of patients ahead of our own personal interests. First and foremost,

we must give patients complete and truthful information about

their current oral health status.

However, when patients ask about the efficacy of another dentist’s

therapy, it is not unethical or unprofessional to remember that the

burden of proof regarding faulty or bad treatment, not just the

outcome of that therapy, is demanding.

It is important to draw the distinction between less than ideal

outcomes of appropriate treatment and bad outcomes attributable to

sub-standard work. We all know that bad outcomes can occur with

our therapy even when all proper methods are followed.


32

ETHICS IN ACTION

Making Commentsabout AnotherColleague’s Work

I see patients who have had poor qualitytreatment, such as open contacts and poormargins. The patients complain of foodimpaction, sensitivity and costs. How do Irespond when patients ask me to commenton the work of their previous dentist?

A prudent dentist must exercise great caution

before making comments about another

dentist’s treatment.

How a dentist responds to questions like these

from a patient can have both ethical and legal

implications.

The principles in the College’s Code of Ethics

state the following:

Only make evaluative remarksabout the work of others aftermaking reasonable efforts tounderstand the prior treatmenthistory of patients.

In other words, it is unwise to speculate on

when the treatment may be less than ideal or

is failing without the knowledge of all the

relevant facts and patient history. Any

comments should be objective in nature not

subjective nor unduly critical. Remember, you

most likely don’t have the necessary

information at hand to speculate on the cause

of the patient’s problems.

If a new patient presents with severe

periodontal disease, is the cause the

supervised neglect of the previous dentist or is

it because the patient smokes, habitually

misses appointments and has diabetes? Can

you take the patient’s word for their dental

history and base your opinion and criticism

on only one side of the story?

When you are faced with a request from a

patient for an opinion about why a treatment

has failed or requires repair or replacement,

the wisest course of action is to suggest that

the patient return to the dentist who provided

the treatment in question for an explanation.

Your legal and ethical duty is to advise the

patient of your findings, your treatment

recommendations and other treatment

alternatives, as well as the risks, benefits,

expected outcomes and costs.

Try putting the shoe on the other foot, as the

saying goes. If a patient was complaining

about your work to a new dentist, wouldn’t

you want the opportunity to discuss the

situation with the patient directly rather than

being blindsided by some hasty and

inopportune remarks made by the other

dentist?

Fairness is one of the core values outlined in

the College’s Code of Ethics to guide the

ethical behaviour of College members.

Fairness is defined as:Treating all individuals,patients and colleagues in ajust and equitable manner.

That fairness includes your interaction with

your patients and with your colleagues too.


33

ETHICS IN ACTION

COLLEGE CONTACT Dr. Lesia Waschuk – Practice Advisor, Quality Assurance416-934-5614 [email protected]


34

PRACTICE BITES

Open CommunicationHelps In ImprovingPatient Satisfaction

Studies of health care practitioners have

demonstrated a clear link between

effective communications and not just

fewer complaints, but happier patients

with better adherence and improved

outcomes.

Sometimes there is a miscommunication

between dentists and their patients. The

ways in which a dentist addresses and/or

minimizes such miscommunication plays a

pivotal role in the disposition of these

types of complaints by the Inquiries,

Complaints and Reports Committee (ICRC).

CASE 2: ALL THE FACTS PLEASE

Many patients want to restrict their dental fees to the

amounts that their insurer will cover. For some

patients, any deviation in the dental fees beyond the

insured amount can be a problem.

In this case, the complainant’s daughter came in for a

consultation appointment for the extraction of her

wisdom teeth. The dentist provided a written estimate

and a predetermination was sent to the insurer.

When the patient later returned for the extractions, the

dentist found that the procedure was less complicated

than he had initially anticipated. So he changed the

treatment codes he submitted and billed the insurer for

the treatment that was rendered.

However, the complainant’s insurer did not cover as

much of the fee for this less complicated procedure.

The complainant was unhappy about the difference.

The complainant also alleged that the treatment codes

were changed because there had been a misdiagnosis.

The dentist pointed out that a predetermination is an

estimate not a quote and denied there was a

misdiagnosis.

The ICRC panel found that the codes submitted for

treatment were appropriate. The panel also indicated

that the percentage of any fee covered by the insurer is

not determined by the dentist. The panel stated that

dentists have no obligation to inform patients of

alternate fees if a deviation from the initial estimate is

not anticipated.

While the panel decided to take no further action in

this matter, it advised the dentist that, in the future, it

would be good practice to advise patients immediately

following the treatment that a less complicated

procedure was performed and that the fees would be

adjusted accordingly.


35

PRACTICE BITES

CASE 1: TELL IT LIKE IT IS UPFRONT

The patient made an appointment with her regular

dentist’s associate. The patient was examined, a filling

was recommended and treatment was rendered that

day. When the appointment was over, the dentist

informed the patient that her tongue had constantly

been in the way during the treatment. The dentist’s

assistant also advised the patient that her tongue would

be sore once the freezing wore off.

Once the anesthetic wore off, the patient discovered

that her tongue had been cut during treatment.

However, the dentist did not disclose this adverse

incident to her at the end of the treatment.

When the patient later called the office to discuss her

concerns, the dentist admitted that he had cut her

tongue with a drill and acknowledged he should have

informed her about the injury and how to treat it. He

offered to reimburse the patient the entire cost of the

appointment. The patient refused the offer and said she

intended to leave the practice.

In reviewing this situation, the ICRC panel

acknowledged that injuries can occur even when strict

and appropriate precautions are taken. However, the

panel determined that the member had a responsibility

to immediately advise the patient of her injury and to

provide guidance on how to address the situation.

The panel ultimately took no further action in this

matter, due in part to the dentist’s recognition and

admission of his errors. It noted, however, that the

member’s conduct, including his failure to document

the incident, was troubling.

The panel also pointed out that simply providing the

patient with an explanation of how the injury

occurred, and how to deal with it, might have been

enough to satisfy the patient.


36

OUNCE OF PREVENTION

Reporting of PotentialMalpractice Claims…Help Us to Help You

What is the benefit of reporting a potential claim?Providing PLP with notice of a claim or potential claim in a timely

fashion protects your right to coverage. There is absolutely no

downside to filing a report. It can only be to your benefit.

One of the conditions of your malpractice insurance policy is that

you must immediately report to PLP any incident/occurrence that

causes you to believe that a patient may make a claim against you.

PLP is here to help resolve demands made for compensation and

ensure that any and all discussions with the patient or authorized

representative do not make matters worse. PLP staff work on your

behalf to ensure that you are properly advised and protected.

Does it cost anything to report a potential claim?If you report a potential claim and the claim never develops or is

eventually dropped without any payment of money by PLP and

no outside expenditures were required, no individual deductible

payment is required.

A deductible is only payable when PLP has incurred legal costs to

defend a claim, pay an expert to assess the validity of the claim or

pay a settlement of a claim. A settlement may be either in

QUESTIONS ABOUT A PARTICULAR SITUATION?If you have questions about how to handle aparticular situation with a patient, do not hesitate to call the College.

PLP Claims Examiners

416-934-5600 • 1-877-817-3757

Practice Advisory Service

416-934-5614 • 1-800-565-4591

A FINAL WORDIf you are ever uncertain whether the facts of a particularsituation or problem should be reported, you areencouraged to at least call PLP and seek advice anddirection. A few minutes of your time could prevent theneedless worry that often arises whenever a dispute witha patient arises or an unexpected result occurs.

Remember! When in doubt, call PLP!


37

OUNCE OF PREVENTION

accordance with a court judgment or by

agreement of the parties (with the prior

consent of the dentist).

What happens when I call PLP?PLP staff are always available to provide

assistance to members with demands

for compensation and with risk

management advice.

When you call to report a possible claim,

your first contact with PLP will usually

be with an intake administrative

assistant who will take sufficient

information so that a file can be opened.

It is very helpful if you have the patient’s

chart with you when you make that call

so you can easily provide three key

pieces of information:

• brief details of the incident

• date when you knew there was a

problem

• demographic information about the

patient: name, address, date of birth

The file will then be assigned to one of

PLP’s experienced claims examiners.

Our service standards are very high. You

can expect a return call, either on the

same day or, at the very least, within 24

hours. The claims examiner will need

some time to review the matter with

you. Again, it helps speed things along

when you have the patient record handy

to provide information, such as

treatment date and treatment details.

You may be asked to provide a narrative

summary of your care of the patient,

along with your original records,

including radiographs, and a typed

transcript of the chart entries.

What if I have received courtdocuments?If you have been served with a Statement

of Claim alleging malpractice, you will

also be asked to provide PLP with a copy

of the Statement of Claim without delay.

Since time is required to properly review

matters/incidents, the claims examiner

will try to obtain a waiver from the

patient’s lawyer to extend the time

within which PLP is required to respond

formally to the Statement of Claim.

Is any of the information that Iprovide to PLP shared with theregulatory arm of the College?All matters reported to and inquiries

made of PLP are kept in strict

confidence. No information is ever

divulged to other areas of the College

without your express permission.

However, a complaint filed with the

College may also contain a demand for

compensation or may lead to a demand

at a later date. So if you believe monetary

issues are also at stake with respect to a

complaint that has been filed against

you, you should consider notifying the

PLP area of the College as well.

While PLP staff cannot provide advice

regarding the nature of your response

to a particular complaint, a file can

be opened so that PLP can deal

appropriately with the monetary aspects

of the complaint.

COLLEGE CONTACT Dr. Judi Heggie – Dental Claims Advisor 416-934-5606 [email protected]

TThe 2011 version of the membership listings,

a.k.a. the Source Guide, is now posted on the

College’s website. This electronic version is

easy to search to find the specific information

you need, like practice addresses and fax and

phone numbers for a particular dentist.

As usual, the information is divided into a

number of key categories that are all easily

searchable to find the information that you

and your staff need:

• dental specialists by specialty

• dentists in alphabetical order

• dentists by geographical area

• health profession corporations.

The electronic version can be printed off in

its entirety, or you can print off specific pages or sections. You can search

the document to look 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. Because 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, 2011. 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 www.rcdso.org.

If you have questions or concerns about your personal listing, please

contact staff in the registration area of the College.


38

MAILBAG

COLLEGE CONTACT Peggi Mace – Communications [email protected]

Latest Issue of SOURCE GUIDENow Online


39

MAILBAG

IN THE

College Mailbag

Anesthesia Specialty Dear Mr. Fefergrad,

I am writing this letter to express my

gratitude to RCDSO, you as Registrar

and the staff of the College for giving

me the opportunity to sit for the

anesthesia specialty exam.

I am honoured to be a member of the

College that took the bold initiative to

make dental anesthesia a specialty. At

some point, I expect that other

regulatory bodies will follow your lead.

I also wish to commend College staff,

especially Julie Wilkin and Kim Vivash,

who were extremely courteous and

accommodating to me throughout the

process of the written and oral

components of the examination.

Needless to say, I am thrilled to have

passed. Thank you very much to all

concerned.

DR. JAMES W. BLACKMORE

Hamilton

Fluoridation Dear Dr. Trainor,

I just wanted to let you know how

much I appreciated you taking the time

to attend and participate in the Board of

Health meeting dealing with the

continuation of the fluoridation of

Toronto’s drinking water. Your presence,

contribution and comments played an

important role in assisting the Board of

Health in unanimously affirming its

continued support for water

fluoridation in Toronto.

It is important that we continue to

collaborate on important health issues

that affect us all.

Thanks again and I look forward to

continue working with you.

DR. HAZEL STEWART

Director, Dental and Oral Health Services

Toronto Public Health

Jury Duty SummonsDear Mr. Fefergrad,

I recently received my second Summons

to Jury Duty in under six years. The

Summons indicated that the trial was

expected to last five weeks. I left a

mildly panicked voice mail that same

evening. College staff replied the next

morning at 9:00 a.m. The College’s

response to the Court was sent to me by

courier that same afternoon and I

received my excusal from attending in

under two days. I was surprised and

impressed that the College had gone to

Court in similar situations to advocate

on an individual dentist’s behalf.

I can’t thank you enough for dealing

with this potentially disastrous

professional disruption for me, my staff

and my patients. I must also send a

special commendation to the College

staff person, Angie Sherban, I dealt with

who was the perfect combination of

warmth, friendliness and efficiency and

went a good ways towards calming me

down.

PETER FRIEDMAN, DDS

Toronto

DispatchDear Mr. Fefergrad,

I always continue to enjoy and learn

from the RCDSO Dispatch. As a council

member here in Alberta, I read and

respect the thoroughness that this

publication presents in each issue. The

latest issue with the supplement “Risk

Management in Clinical Practice” was

timely as I still find that many dentists

do not have a “formal” consent for

treatment process.

TERRY CARLYLE, DDS, MSC. FRCDC

Council Member

Alberta Dental Association and College:

Edmonton and District

*

*

*

*

COLLEGE CONTACT Peggi Mace – Communications Director416-934-5610 [email protected]

We want to hear from you. We welcome your feedback on anything thatyou read in Dispatch or on any of the College’s policies, programs, andactivities. Sometimes a letter may not be printed with the author’s nameeither on request or due to its confidential nature. All letters printed inMailbag are used with the author’s permission. The College reserves theright to edit letters for length and clarity.

I

HPC and sedationand anesthesia forms available on the College website

WEBSITE SPOTLIGHT

If you receive a copy of Dispatch, chances are that you

have already gone through the College’s registration

process in one way or another. But what if you plan on

applying for a Certificate of Authorization for a Health

Profession Corporation (HPC)? Do you need a facility

permit to administer oral moderate sedation or general

anesthesia? There is one central online location where

you can do all this and more.

The College’s website contains all of the necessary forms

and information kits to process any number of

registration, licensing, facility permit and HPC requests.

The website’s homepage links to a broader

registration/licensing section, a section on HPCs and one

on sedation and anesthesia.

The registration section includes applications for a Letter

of Standing and a Certificate of Standing. If you plan on

moving out of province and require a Letter of Standing

or if you are an out-of-province dentist and require a

Certificate of Standing, you can download the package of

forms directly from the website.

Website Spotlight is a newregular feature that highlightsimportant content found onthe College’s website,www.rcdso.org. Adventuroustypes who eagerly await thenext spotlight can visit oursite and tour the many e-resources available online,such as practice guidelines,standards of practice andinformation on the College’sLifeLong Learning andcontinuing educationprograms.


40

The HPC section links to all the necessary forms and

reference articles on HPCs, including notice of change of

shareholders, statutory declaration and certificate of

authorization application forms, among others.

The section on sedation and anesthesia contains

information on how to register with the College to

receive a facility permit for the administration of

multiple sedative drugs.

The facility permit application form covers three

methods of administering anesthesia:

• Oral Moderate Sedation

• Parental Conscious Sedation

• Deep Sedation

• General Anesthesia.

The facility permit application form, along with all

registration, HPC and sedation and anesthesia forms

located on the website, is a PDF fillable form. This means

that you can download the form from the College

website, fill it out on your computer and print it for

submission to the College.


41

WEBSITE SPOTLIGHT

COLLEGE CONTACT Julie Wilkin – Supervisor, Registration416-934-5612 [email protected]

Dr David McKeown, a fait état de statistiques

montrant la valeur de la fluoration. Avant que

Toronto n’entreprenne la fluoration en 1963, les

enfants avaient en moyenne cinq à sept caries.

Aujourd’hui, en partie en raison de la fluoration,

et en partie en raison de soins meilleurs

dentaires, ils n’ont en moyenne qu’une ou deux

caries.

Le Dr McKeown a cité la situation de la

municipalité de Dryden, en Ontario, qui a

abandonné la fluoration en 2001; comme

résultat, le niveau des caries chez les enfants de

cinq ans a augmenté de 26 pour cent.

Comme l’a souligné la présentation du Collège, la

carie dentaire est une épidémie silencieuse qui se

situe à la première place des maladies chroniques

chez les enfants et adolescents au Canada. Elle est

cinq fois plus fréquente que l’asthme.

De nombreuses délégations, y compris les

présentations effectuées par le Collège et par nos

collègues de la Ontario Dental Association, ont

abordé un des plus grands avantages de la

fluoration de l’eau

municipale : elle répartit à

degré égal les avantages

dans toute la population.

Elle est avantageuse pour

tous les résidents d’une

collectivité, jeunes et vieux,

sans égard à leur revenu et à

leur capacité d’accéder à des

soins dentaires courants.

En tant que dentistes, nous savons qu’une santé

orale médiocre est liée au diabète, aux maladies

cardiaques et aux troubles respiratoires. L’impact

de la fluoration est par conséquent considérable.

La fluoration doit donc être un des meilleurs

avantages pour la santé publique. La ville de

Toronto estime qu’il en coûte 77 cents par

personne par an pour fluorer son eau, tout en

économisant des millions en soins dentaires.

À l’heure actuelle, environ 70 pour cent des

Ontariens ont accès à l’eau fluorée. Nous ne

devons cependant pas nous reposer sur nos

lauriers. Lorsque c’est possible, le Collège

continuera activement à parler en faveur de la

fluoration des réseaux municipaux

d’alimentation en eau potable, de sorte que tous

puissent bénéficier des avantages durables sur la

santé.


42

La victoire de la fluoration a un impact à l’échelle de la province

Suite de la page 5

CHRONIQUE DU PRÉSIDENT

MARK YOUR CALENDAR… 2011 COUNCIL MEETINGS

November 17Sutton Place Hotel, 955 Bay Street, Toronto

Seating is limited so if you wish to attend please let us know

in advance by contacting the College.

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.

Calendar of Events

COLLEGE CONTACT Angie Sherban – Executive Assistant 416-934-5627 [email protected]

FROM THE REGISTRAR


43

The goal is that members will have the

convenience of managing most of their

interactions with the College online from

our website. That means renewing

memberships, tracking CE credits, or

registering for College educational events

like the webinars. It means no more filling in

forms online but still having to print them

off and fax them into the College.

Already we are

seeing the payoff

for our efforts.

Last fall we

inaugurated a

webinars pilot

project. It was a

great success. The

webinars were

simulcast live here

in Ontario and to

dentists and

dental hygienists

in British

Columbia using

the latest in

technology. Members could even interact in

real time with the presenters by submitting

questions online. This fall we will launch our

second exciting series of webinars.

We have started using broadcast e-mails, or

e-mail blasts as they are often called, to

reach members quickly and cost-effectively.

Council Highlights now goes out by e-mail

blast to reach the over 7,000 dentists who

have chosen to give us their e-mail addresses

for College business. We used e-mail blasts to

promote the webinars series too.

Just last month we used the same technology

to reach out to members with the

consultation on the Standard of Practice on

Dental CT Scanners to meet the incredibly

tight deadlines set by the Ministry of Health

and Long-Term Care.

Early next year, our website will undergo a

complete transformation. The site gets

around one million hits a month and the

traffic on the site just keeps growing month-

by-month. With a new fresh design, it will

be easier to find the answers you need. The

dentist search

register and the

members’ resource

centre will be

revamped too.

Two of the most

exciting projects are

the new e-Portfolio

and the Practice

Enhancement Tool

that will form the

backbone of our

new Quality

Assurance Program.

There are more

details elsewhere in the magazine about the

exciting new QA Program. Both these parts

of the QA Program will be accessible to every

member right from the College website.

Technology is changing how the College

operates to better serve its members. But as

we move forward we never want to give up

that personal touch, such as our receptionist

at the switchboard or the dentist at the end

of the phone for those urgent practice

management questions, that is such an

important manifestation of the humanistic

and caring values of the College.

Building today with oursights on tomorrow

Continued from page 44

Technology is changing

how the College operates

to better serve its members.

But as we move forward

we never want to give up

that personal touch…


44

FROM THE REGISTRAR

Building todaywith our sights ontomorrow

Continued on page 43

SSmarter technology. That is our motto when it comes to

leveraging IT resources to help us work smarter and faster to

better serve our members. Here at the College we are looking at

the big picture, analyzing how we can create more flexibility in

our services and increase efficiency. Obviously, as a regulator,

security and privacy concerns trump all other requirements.

Not that long ago I read about a survey of several thousand

mothers in United States, Canada, Japan, Australia, New Zealand and

the EU. They all had Internet access and children aged two to five.

The results of the study are revealing:

• 58 per cent of the children knew how to play a basic computer

game, while only 43 per cent knew how to ride a bike;

• 19 per cent could play with a smartphone application while

only nine per cent knew how to tie a shoelace;

• more small children knew how to open a Web browser than

knew how to swim;

• and as many girls as boys could play a computer game or make

a mobile phone call.

These children are growing up in an environment that would be

unrecognizable to their parents, let alone their grandparents.

The world is changing so rapidly and so are the needs of our

members, government and the public. We need to keep pace.

IRWIN FEFERGRAD

Documents

22 X-ray safety requirements for all Ontario dentists