Practice Advice and Guidelines

Discussing the most common mistakes made during dental sedation, questions to ask yourself, and how to make patient safety the centre of your practice.

Creating a safety culture within the dental practice is the responsibility of the entire dental team. Patient safety should be at the centre of our practice as health care professionals and there is value in having a team approach to ensure a culture of safety is embedded, reducing the risk to the patient.

Mistake 1

Insufficient pre-screening

Patient pre-assessments are key factors in determining:

• if the patient is a candidate for sedation
• the method of sedation to be used
• drug type/dosage

Sedation can be unpredictable; any drug can produce any level of sedation depending on the patient. For example – if we compare sedation to alcohol – a single glass of wine may have no effect on one person while another person could be unfit to drive, or over the legal limit. If we look at sedation in the same light, it’s easier to understand why every patient must be assessed before, during and after receiving sedation.

Before scheduling a procedure where sedation will be used, every patient must be evaluated to determine if they are a suitable candidate. Then, on the procedure day when the patient arrives, the patient must be evaluated again.

Questions to consider:

1. Does your patient meet the criteria for sedation?
2. Are there any contraindications for sedation with this patient?
3. Is your facility the best place for the patient to undergo the procedure with sedation?
4. Did the patient follow the right pre-appointment instructions?
5. Has the patient taken any medications that could impact the effects of sedation?

Mistake 2

Inadequate training

The College of Dental Surgeons of Alberta (CDSA) sets standards for sedation in dentistry. The CDSA’s standards indicate all sedation team members must:

• be adequately trained
• be competent to carry out the delegated tasks
• have current Basic Life Support (BLS, also known as Healthcare Provider CPR – Level C) training
  The CDSA defines a sedation team members as:
  a responsible adult designated by the regulated member [dentist] to be part of the delivery of sedation services.
  Additionally, they define a sedation monitor as:
  a person designated by the responsible regulated member [dentist] to monitor a patient’s vital signs who is adequately trained, competent and indemnified to carry out the delegated tasks. Must have current Basic Life Support (BLS) training. A sedation monitor must be trained through a sedation monitoring training course approved by the CDSA.

Before assisting with sedation procedures, dental assistants must have adequate training and be able to answer:

1. What drugs are being used, what is the average dosage, and could I recognize if someone is receiving too much?
2. How does mixing sedatives impact the patient response?
3. Do I know when monitoring equipment is required, and does the facility have adequate monitoring equipment?
4. Do I have the theoretical knowledge and clinical competencies to:
   1. appropriately monitor a patient
   2. provide the best care for a patient
5. Can I identify the subtle signs when a sedated patient is having an adverse reaction?
6. What are the risks if I don’t have adequate training?

Mistake 3

Inability to rescue

Sedation is a continuum; knowing and understanding the differing levels of sedation is vital. Practitioners and team members should be able to identify when a patient has unexpectedly slipped beyond the intended level of sedation and be able to rescue the patient.

Ask yourself:

1. Do I know what the responsiveness of the patient should be?
2. Am I able to identify an airway obstruction without relying on monitors to indicate a problem is occurring?
3. Am I able to assist during an emergency and/or an airway crisis?
4. Will the sedation team be able to ventilate the patient if required?
5. Are emergency medications available, present in the operatory, and not expired?
6. Does the office have all necessary equipment to rescue a patient?
7. Is all equipment in good working order and accessible?
8. Have team members used simulated emergency scenarios to practice how to respond?
9. Are there enough sedation team members present to adequately monitor the patient and respond to a patient in crisis?

This table can be found in the CDSA’s sedation standards. Being familiar with the content in this table will aid in patient safety.

* Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

It is the duty of the entire dental team to place the patient’s well-being first. By taking appropriate training and being informed, common mistakes can be avoided, and we can ensure patient safety is at the centre of our practice.

After all, what would you expect if you were the patient?

Highlights of the changes and how they impact your practice.

Health Canada updated Radiation Protection in Dentistry – Recommended Safety Procedures for the Use of Dental X-Ray Equipment – Safety Code 30 to address changes in radiography over the last 20 years. Safety Code 30 provides guidance about radiation safety procedures, equipment performance, and radiation protection for the use of dental X-ray equipment.

So, have you read Safety Code 30? Do you know about the updates? Do you know how they impact your practice or the place you work?

Dental practices and staff need to ensure they are aware of and comply with the current requirements. Here’s what you need to know:

Radiation Dosimetry Monitoring

Safety Code 30 indicates personnel only need to use dosimeters in certain circumstances, however Alberta’s Occupational Health and Safety Code (OHS Code) requires all workers who use or are exposed to radiation to use them. In Alberta we follow the OHS Code as it takes precedence. S. 291.5 requires that “a worker who uses or may be exposed to radiation through the use of any ionizing radiation equipment” must use a monitoring device.

Questions to ask yourself:

• Do we use radiation monitoring devices where I work?
• Do I wear them on a regular basis?
• Do I know where to store them, or where not to store them?
• What monitoring service do we use?

Radiation Safety Officers

They are now referred to as Coordinators of the Radiation Protection Program. A qualified staff member must be assigned to this role and the responsibilities of the coordinator are outlined in Safety Code 30 s. A.1.2.2.

Ask yourself:

• Who is the Coordinator of Radiation where I work?

Thyroid Shields
& Lead Aprons

The patient must be provided with a thyroid shield when it will not interfere with the required diagnostic information. When taking x-rays on children, it is even more important to use the thyroid shield, as the thyroid gland is very sensitive to radiation.

Safety Code 30 s. A.3.2.1, 7 states “With the exception of CBCT procedures, the use of a lead apron is not required for the patient during routine dental X-ray procedures, if all other recommendations for limiting patient radiation exposure are respected, as the dose to the patient will not be significantly affected by abdominal shielding.” Although lead aprons are no longer required for routine X-rays, it is important to think about the comfort level of your patient. They may be used to and expect to be given a lead apron to wear whenever X-rays are taken.

Consider this:

• How will the patient feel if they are no longer given a lead apron?
• What is the difference between a thyroid shield and a lead apron?
• What are the general practices where I work?

Rectangular Collimators

Collimators must now be rectangular instead of circular. Safety Code 30 s. A.3.2.2, 2 states “Rectangular collimation of the X-ray beam must be used, except in occlusal protocols, as it significantly reduces the dose to the patient compared to circular collimation.” Dental practices will need to contact their suppliers about installing aftermarket adaptors as needed.

Keeping in mind the concept of ALARA (As Low As Reasonably Achievable), these are some questions to ask yourself:

• How will the change from circular to rectangular collimation affect the X-rays I take?
• Do I need to refresh my skills for taking radiographs?

Quality Assurance Program

All dental practices must have a quality assurance program (QAP) in place. A QAP ensures that all X-ray equipment is working properly and helps to address issues before exposing patients to radiation. Safety Code 30 s. C.1.2.1 outlines four steps that must be included in quality control procedures. Dental practices may be able to purchase quality assurance kits from X-ray equipment supply companies along with record keeping forms.

Questions to ask:

• Do we have a quality assurance program in place where I work?
• How is quality assurance being tracked and documented?
• Who is performing the quality assurance and when?
• Are we completing the QAP only to comply with requirements, or to provide maximum possible benefit to the patient?
• What is the consequence to the patient if radiography equipment is not producing images of the highest quality or is functioning but damaged?

Now that you are aware of just some of the changes that were made to Safety Code 30, we encourage you to start discussions with your employers, coworkers, and other dental practitioners about how they are applying the updates. Some dental practices may not even be aware of them. The entire dental team has a joint responsibility to put the patient’s well-being first. By taking necessary measures to ensure radiation procedures and equipment are being monitored, and that staff and operators are informed, your practice is patient-centered.

When answering this question, consider things like your practice setting, your patient’s needs, and your employer’s and co-workers’ expectations.

Dental assistants often ask whether they must keep their CPR (cardiopulmonary resuscitation) up to date. The answer will depend on each dental assistant’s situation. Here is some information to guide you, and questions to think about.

Practice Setting

Current CPR is mandatory if you are part of a sedation team (this includes the use of nitrous oxide, oral or intravenous sedation). The College of Dental Surgeons of Alberta (CDSA) sets standards for sedation in dentistry. Those standards indicate all sedation team members must have current resuscitation (basic life support/ BLS, also referred to as CPR) training.

CPR may also be mandatory in other settings, like hospitals, or may be something your employer requires.

Ask yourself:

1. Do we use any form of sedation where I work?
2. Do I work in a setting where CPR is mandatory?
3. Does my employer require that I have current CPR?

Patient Needs

Patients may assume that all regulated healthcare professionals can respond in an emergency. In patient-centred practice, dental assistants are guided by the patient’s needs. They place the patient’s well-being first.

Questions to ask yourself:

1. What would my patients expect if they had a medical episode? Would they expect me to be able to help them in an emergency?
2. How would my patients feel if I didn’t have current CPR?
3. Which CPR skills might I need in an emergency?
4. If I could make a difference for someone, why wouldn’t I keep my CPR up to date?

Employer and Coworker Expectations

In an emergency, responding quickly is important. Taking time to ask a coworker if they have CPR, or waiting for someone who has it to arrive could impact the outcome for the patient. Coworkers may expect that anyone on the dental team is able to help.

Questions to consider:

1. Am I ready to help in an emergency?
2. Does my employer expect me to be ready to help in an emergency?
3. What would my coworkers expect if they had a medical episode? Would they expect me to be able to help them in an emergency?
4. If I needed help, what would I expect from another regulated health professional?

Current CPR Training

There are lots of options for CPR training providers, CPR levels/skills, course length and how long CPR is valid for after training. The kind of CPR training a dental assistant takes and how often they refresh it will also depend on each dental assistant’s situation.

Ask yourself:

1. Is the training provider reputable?
2. Does my practice setting require a certain kind of CPR?
3. In my practice setting, which CPR skills might I need in an emergency?
4. How much time to do I need to learn the skills?
5. Does my practice setting require that I take CPR annually?
6. How often do I need to take CPR training to be able to use the skills confidently and competently?

After considering this information, you may have decided that keeping your CPR up to date is best practice in your situation. When you take CPR training, you can use it toward your Continuing Competence requirements. CPR/First Aid/AED can be used as a learning objective once every five years. However, you don’t need CPR to renew your practice permit.

PPE is not the First Defence

Working in dentistry has always presented risk due to the possibility of disease transmission. To best protect your patients, coworkers and yourself, you need to understand how diseases are transmitted and how to prevent transmission.

Chain of Infection

Understanding the Chain of Infection is important. This is a chain that is meant to be broken to stop the disease from spreading. Disease transmission is more likely to happen when a practitioner does not have a clear understanding of how to break the Chain of Infection. You will note that while personal protective equipment (PPE) is one tool to break the chain, there are other precautions you must consider as a line of defence.

Pathogen

infectious agent capable of carrying the disease – bacteria, fungi, viruses, prions

Break the Chain through

• understanding infection prevention policies and procedures
• sanitizing or cleaning
• disinfecting
• sterilizing

Reservoirs

in people, equipment, water

Break the Chain through

• patient screening
• reducing the number of staff/patients in contact with each other
• handwashing
• housekeeping
• flushing lines

Portals of Exit

blood, saliva, skin, excretion, aerosols

Break the Chain through

• reduction of aerosols – use of high-volume evacuation and dental dam isolation
• patient/ staff isolation
• respiratory etiquette
• hand washing
• PPE

Modes of Transmission

can be direct or indirect-physical, contact, droplets, airborne

Break the Chain through

• proper PPE fit
• properly donning and doffing PPE
• handwashing
• cleaning, disinfection and sterilization
• redesign or rearrange workplace settings

Portals of Entry

mucous membrane, respiratory system, digestive system, broken skin

Break the Chain through

• handwashing
• PPE
• covering wounds
• physical distancing

Susceptible Host

immune deficient, diabetes, age, surgery

Break the Chain through

• screening patient/staff for level of risk
• stress reduction
• diet and exercise
• immunizations when possible
• intact skin

Use PPE Effectively

If you don’t wear, don and doff PPE properly it will not break the chain. Have a co-worker support you as they watch you put on and take off your PPE. They may notice a breach in infection control practices that you are not aware of.

You also must choose PPE that is appropriate to the level of risk. The Point of Care Risk Assessment can help determine if the task you are about to perform is complying with routine practices guidelines. You will find the Point of Care Risk Assessment in the IPC Guidelines at Appendix D.

Infection Prevention and Control

We – every dental practitioner – must be diligent in applying infection prevention and control practices. Every community dental practice should already have their own Infection Prevention and Control Manual that includes policies specific to the practice. Refer to your manual often. Does it need to be updated? Are there topics missing from it?

If you don’t apply the basics of proper hand hygiene, cleaning and disinfecting, it won’t matter what type of PPE you are wearing. If a surface contains pathogens due to an unclean environment and you touch it while wearing gloves, your glove will continue to transfer the pathogen. If you use an N95 respirator (or equivalent) and don’t have it properly fit tested, you may as well wear any surgical mask that also doesn’t seal.

Understand Why

You need to know why you are doing what you are doing.

• What is the purpose of a face shield as compared to safety glasses?
• If you wear safety glasses, do you ensure that you wash your face before leaving work each day?
• Do you understand the modes of transmission and how an aerosol procedure is different than sitting in an operatory recording information during an exam?
• Are you looking at the manufacturer’s instructions for use for all products you are using?
• Does a disinfectant require a specific amount of contact time to be effective?

Now, more than ever, we all need to look at our habits and find ways that we can work as a team to educate ourselves about infection prevention and control. The College of Dental Surgeons of Alberta’s IPC Standards and the emails we send you with updates to guidelines for practice are resources to help you. Stay informed. Work as a team to support each other in protecting the public and yourselves. Look at methods to reduce risk through engineering and environmental controls. Always put your patients’ safety first.

The world is shrinking! The internet in general, and social media specifically, have connected us in ways that did not exist thirty years ago. With the convenience and ease of expressing ourselves comes a very real responsibility to manage our communications effectively. There are many examples of people losing their employment over inappropriate use of social media.

We acknowledge dental assistants’ rights to express themselves, however, we must maintain the balance between that freedom of expression with protecting the public and maintaining the integrity of the dental assisting profession.

Dental assistants who share offensive content or inappropriate messages may be found guilty of unprofessional conduct if that behaviour or communication violates the Standards of Practice, including violating professional boundaries. Remember, your right to freedom of expression only applies if your expression doesn’t infringe on another’s right to be treated with dignity and respect.

Consider this before you post that comment:

• Would this comment be considered reasonable and professional by my peers?
• Why am I posting this?
• Would I communicate this way in person?
• Who might find this objectionable and why?
• How would I feel if someone posted this about me?

Remember to:

• assume anything you post can be accessed by anyone, repeated by anyone, possibly altered by someone, and never fully removed
• avoid angry, impulsive or derogatory comments

Dental Assistant Social Media Best Practice

NEVER post anything about work – employers, colleagues and especially patients should be off limits

Excerpts from our Standards of Practice

4.4(d) maintain clear distinction between personal and professional relationships

5.2(c) demonstrate professional decorum such as using effective communication and appropriate use of social media

6.2(h) treat others with respect, refraining from all types of discrimination, harassment or bullying behaviour including verbal, written, body language, social media and any other harmful type of communication with patients, colleagues and the public

These guidelines provide information and guidance for appropriate boundaries in the relationships between health care professionals and their patients.

These guidelines provide information and guidance for appropriate boundaries in the relationships between health care professionals and their patients.

It is critical for dental assistants to recognize the difference between therapeutic relationships and non-professional relationships.¹ Establishing appropriate boundaries protects everyone; the patient, health care worker and others.

1. See Appendix A

A therapeutic relationship is one that places the patient and their needs first and foremost. Dental assistants will not exploit the professional relationship for fulfillment of personal needs, personal gain or satisfaction. Boundaries for professional or therapeutic relationships consider these components: power, trust, respect and closeness.

Power

Every therapeutic relationship has an imbalance of power. In the dental assistant/patient relationship the dental assistant holds the balance of power due to their position as a health care provider, specific dental-related knowledge and the patient’s dependence on the dental assistant to provide the care needed. Dental assistants have access to personal information about the patient and have influence over the treatment provided.

Patients may feel vulnerable because they must depend on the dental team including the dental assistant and trust they will receive appropriate care in the patient’s best interest. The health care team, including the dental assistant, must instill confidence the services they provide are in the best interests of the patient including considering patient participation when making treatment choices.

Trust

As discussed in the previous section, patients are vulnerable. They assume the dental assistant has the knowledge, skills, abilities and professional judgment to provide the services the patient needs. The dental assistant has a responsibility to not harm or exploit the patient and to work in the patient’s best interest. Trust that is lost through poor quality, exploitative or harmful care is not easily re-established.

Respect

Dental assistants must treat all patients with dignity and respect regardless of gender, race, or religious, cultural, physical, social, economic, political or educational background. Dental assistants must respect patients’ rights to be involved in their own care and recognize factors affecting patient decisions.

Dental assistants ensure patients have all the necessary information to give informed consent and recognize that patients may withdraw their consent at any time.

Closeness

Therapeutic relationships place individuals in positions requiring close physical proximity, revelation of emotional or sensitive personal information and psychological (e.g. fears and phobias) disclosure; a closeness not normally experienced in everyday casual encounters. Dental assistants establish boundaries to ensure this closeness is not misinterpreted or misused.

Professional boundaries are necessary to ensure the full benefit of care is focused on the patient. Professional boundaries set limits and clearly define the safe, therapeutic connection between the dental assistant and the patient. Well-defined and respected boundaries empower patients to feel a sense of participation and control in their own health care.

Some boundaries are clearly established in legislation such as the Alberta Human Rights Act, while other boundaries are established by the regulatory bodies through regulation, practice standards and codes of ethics and/or codes of conduct. Dental assistants must exercise professional judgment in establishing therapeutic relationships with each one of their patients.

Dental assistant/patient relationships that lead to abuse, harassment, romantic or sexual relationships are never appropriate. The College of Alberta Dental Assistants is fully committed to investigating all forms of unprofessional conduct that occur in dental assistant/patient relationships.

Boundary Crossings

Boundary crossings occur when the behaviour of the dental assistant deviates from the accepted boundaries of a therapeutic relationship. Normally, behaviours such as giving or receiving gifts and self-disclosure are not part of dental assisting practice or the provision of dental care and are generally inappropriate behaviours in a therapeutic relationship.

Dental assistants must reflect on behaviours that fall outside of normal and monitor for warning signs of boundary crossing.² Dental assistants must ensure their behaviours are focused on fulfilling the established treatment goals for the patient.

Boundary Violations

Boundary violations are deliberate inappropriate behaviours on the part of the dental assistant that violate the therapeutic relationship.³ These behaviours do not contribute to fulfilling the established treatment goals for the patient and are never acceptable.

2. See Appendix B
3. See Appendix C

Establishing Therapeutic Relationships

Interactions with patients can be illustrated on a continuum that identifies the limits between therapeutic and non-therapeutic behaviours. For effective patient care there exists a zone of helpfulness in which the therapeutic relationship occurs. The zone of helpfulness varies with each patient, circumstance, health condition, environment and characteristics of the patient and the dental assistant.

Assuring the Limits of the Therapeutic Relationship

Appropriate professional boundaries are established and maintained when the dental assistant practices to the standards set in the Standards of Practice, Code of Ethics and the Competency Profile for Alberta Dental Assistants.

This includes:

• compliance with all legislation pertaining to dental assisting, professional obligations and any legislation impacting practice and conduct;
• understanding the difference between professional therapeutic relationships and non-professional (personal, social, romantic) relationships;
• understanding communication styles and actively using communication strategies to maintain professional boundaries;
• using a reflective approach to practice including continuous self-assessment of one’s behaviours and interactions to ensure professionalism, integrity and respect are always demonstrated toward patients;
• understanding and setting personal and professional boundaries;
• understanding each patient’s characteristics including their personal boundaries;
• actively managing all situations that may fall outside acceptable limits of a therapeutic relationship;
• promoting patient participation and choices in care through informed decision making and informed consent;
• focusing on the patient and their defined treatment plan and dental health goals; and
• understanding the laws governing privacy, confidentiality and explaining the limits of confidentiality of personal and health information (i.e. third-party payers, members of the health care team, relevant authorities).

This picture provides a visual image of therapeutic vs. non-therapeutic relationships. Beginning with under-involvement on one extreme to over-involvement on the opposite end. Under-involvement includes dental assistants distancing themselves from the patient and disinterest or neglect of the patient and the patient’s care. At the opposite end is over-involvement including boundary crossings, boundary violations and sexual misconduct.

In the centre is the “Zone of Helpfulness” where therapeutic relationships exist. The vast majority of dental assistant/patient interactions fall within the “Zone of Helpfulness.” These are the safe therapeutic connections between the professional and the person seeking care.

There may be times when a dental assistant intentionally crosses a professional boundary to benefit the therapeutic relationship. When the actions, such as self-disclosure, fall outside of what is normal in the therapeutic relationship, the dental assistant needs to consider the following questions prior to crossing the boundary:

• Am I doing something for the patient that the patient needs in order to meet the agreed-upon treatment goals?
• Who benefits most from what I am doing?
• Do I benefit in any way from what I am doing, including financially?
• Can this need be met in any other way or with other resources?
• Is there potential for my actions to confuse the patient or could they be considered inappropriate in a therapeutic relationship?
• What will the patient gain by my actions?
• What would another reasonable, professional dental assistant do in similar circumstances?
• Would I tell my colleagues or my employer about what I am doing?
• Does what I am doing create a real or perceived conflict of interest?

In situations where there is potential for the dental assistant’s actions to be questioned and/or misinterpreted, it is up to the dental assistant to ensure the patient does not misunderstand or develop an unusual dependency or unreasonable expectations of the patient/dental assistant relationship. If a boundary is crossed it is up to the dental assistant to re-clarify and re-establish the boundaries. Where this isn’t possible, the dental assistant may have to discontinue the patient/dental assistant relationship by having a colleague provide the required health care services for the patient. Speaking with the employer and/or trusted colleagues may help the dental assistant to determine the best strategy to maintain boundaries and ensure the patient’s welfare remains first and foremost.

There are occasionally circumstances where behaviour normally considered inappropriate in a therapeutic relationship may actually be beneficial to the patient.

Self-disclosure

Normally it is inappropriate for a dental assistant to disclose details of their personal lives to patients. Talking about ourselves takes the focus away from the patient and their needs. However, consider the following:

Mary has seated an elderly patient in the dental chair and begins to discuss the treatment for the day, seeking to confirm consent. The patient seems unsure about the proposed treatment and discloses that since her husband passed away, just a short time ago, she has experienced difficulty making decisions. Mary tells the patient of her own mother’s similar reaction after Mary’s father passed away and tells the patient that talking with a counsellor helped her mother to work through her feelings of loss and learn to cope with difficult decisions.

Mary has revealed just enough to validate the patient’s feelings and to provide an option for the patient to consider in learning to cope with the loss. This disclosure will not likely change the therapeutic relationship.

Accepting Gifts from Patients

Dental assistants must never expect or encourage gifts from patients, however, there may be times where it is socially or culturally appropriate to accept a gift. Consider the following:

A patient has been receiving treatment frequently over the course of a few months and Mary has been the dental assistant for most of the appointments. Mary has had significant impact helping the patient cope with a deep-seated fear of dentistry. Mary has been encouraging, patient and kind. The patient brings Mary a small bouquet of flowers with a card expressing gratitude at the final treatment appointment.

This token of thanks is not likely to change the patient/dental assistant relationship or create an expectation of special treatment in the future and is probably fine for Mary to accept.

On the other hand, what if the patient had offered Mary and her family the use of the patient’s condo in Hawaii for two weeks at no charge? Mary would have to graciously decline the gift because the value of the gift far exceeds a token of appreciation. There is potential for such a grand gift to change the therapeutic relationship and create expectations for a different standard of care.

Treating Friends, Family and Acquaintances

Sometimes dental assistants find themselves in situations where they are providing services for family and friends. This can create difficulties in clearly defining the boundaries of the therapeutic relationship. It may even appear there is a conflict of interest. Consider the following:

Mary, a dental assistant, and her neighbour, Joan, have a mutual acquaintance named Ramona. Joan knows Ramona was having trouble with a tooth and was scheduled for an extraction. Joan sees Mary outside in the garden and comes over to ask Mary how Ramona’s extraction went. Mary must maintain professional boundaries and respect Ramona’s right to privacy. Mary tells Joan she must ask Ramona for that type of personal information. Mary has respected the therapeutic relationship by protecting Ramona’s privacy.

Treating family members such as a spouse or children happens frequently for dental assistants, however, if the dental assistant experiences difficulty in carrying out the dental treatment or in helping the patient to make informed choices (bias, personal rather than professional concern, etc.), the dental assistant must consider referring the patient to a colleague who can provide the services within a therapeutic relationship and appropriate boundaries without bias.

Dental assistants need to establish and maintain appropriate therapeutic relationships with patients to ensure safe, effective and ethical care. This means dental assistants respect the nature of therapeutic relationships and continuously strive to find the right balance between open, friendly communication and over- or under-involvement with patients.

Dental assistants will place the patient’s interest first, establishing and maintaining therapeutic relationships that focus on the best outcomes for the patient.

Professional vs Non-Professional Relationships

There may be warning signs a dental assistant has or may be about to cross a boundary. Some warning signs include:

• spending time with the patient beyond the scheduled dental appointment or normal office hours;
• providing the patient with your personal contact information;
• sharing personal information with the patient;
• swapping patient assignments, or providing less thorough care to one patient to allow more time with the patient;
• acting or feeling possessive about the patient;
• providing a different standard of care to that particular patient than to the rest;
• keeping secrets with the patient;
• responding defensively or guardedly when questioned about interactions with the patient;
• selective rather than complete record keeping or reporting;
• making exceptions to office rules and protocols for the patient;
• denying that the patient is a patient; and/or
• denying you have crossed a boundary from a therapeutic relationship to a non-therapeutic relationship.

Boundary Violations

There are some behaviours that are NEVER acceptable in a therapeutic relationship because they are harmful and counterproductive to meeting the patient’s needs. Any form of abuse is unacceptable. Abuse breaches trust and has no part in patient care.

Emotional/Verbal Abuse

Dental assistants must avoid verbal and non-verbal communications which may be considered by a reasonable person to be discriminatory, disrespectful, or abusive. Examples of verbal and non-verbal abusive behaviours include, but are not limited to:

• sarcasm
• manipulation
• teasing or taunting
• retaliation
• intimidation including threatening gestures or actions
• profanity
• cultural slurs
• disrespectful comments
• insensitivity to patient preferences
• inappropriate tone of voice such as anger, impatience, exasperation

Physical Abuse

Dental assistants must avoid treating patients in a manner that may be perceived as violent, threatening or may inflict pain and/or physical harm. The dental assistant must avoid rough treatment and the use of force.

To avoid the misconception of force or roughness, the dental assistant should develop simple signals the patient may employ if they feel the need to stop or take a break in treatment due to discomfort, pain or adverse reaction to treatment. When dental assistants are employed in settings where patient behaviours may be unpredictable, the dental assistant should seek additional education, training or mentoring in dealing with difficult patients without force or rough treatment.

Sexual Abuse

Sexual abuse of a patient by a dental assistant is unprofessional conduct. Even if the patient initiates a sexual relationship, the dental assistant is responsible and accountable for maintaining the boundaries of the therapeutic relationship. The crossing of boundaries may begin with seemingly innocent comments or disclosures which escalate into more. The progression of crossing the boundaries to violating the boundaries can be subtle. The dental assistant must be ever vigilant to subtle behaviours that could lead to boundary crossing or violation.

Behaviours that may be considered by the patient or a reasonable person to be sexual abuse include, but are not limited to:

• physical sexual relations
• touching of a sexual nature
• behaviour and/or remarks that may have a sexual connotation
• suggestive, seductive, exploitative, derogatory or humiliating behaviours/comments

Financial Abuse

In the provision of dental assisting services, dental assistants must avoid engaging in activities that could result in monetary, personal or material benefit, gain or profit for the dental assistant, and/or in monetary or personal loss to the patient.

Financially abusive behaviours include, but are not limited to:

• unethical or dishonest billing practices
• encouraging patients to purchase items or services not directly related to their treatment goals and resulting
  in financial or other material gain for the dental assistant
• accepting gifts from patients that exceed tokens of appreciation

Neglect

Neglect occurs when a dental assistant fails to meet the basic needs of the patient. Behaviours demonstrating neglect include, but are not limited to:

• ignoring the patient’s needs
• withholding information
• withholding services or providing less than standard of care
• ignoring patient’s rights

Discrimination, Bias, Cultural Insensitivity

Given the diverse society we live in, it is important for dental assistants to demonstrate understanding and tolerance. Cultural competence acknowledges and incorporates the importance of culture, the assessment of cross-cultural relations, awareness of dynamics resulting from cultural differences and the adaptation of services to meet culturally-unique circumstances.

Dental assistants must treat all patients with dignity and respect regardless of the patient’s values, culture, religious beliefs or sexual orientation.

We acknowledge the College of Physical Therapists of Alberta (operating as Physiotherapy Alberta – College and Association) for giving us permission to adapt their Therapeutic Relationships: Establishing and Maintaining Professional Boundaries publication for the use of dental assistants.