ROYAL COLLEGE OF DENTAL SURGEONS OF ONTARIO. MINUTES OF THE 408th MEETING OF COUNCIL

Transcription

1 ROYAL COLLEGE OF DENTAL SURGEONS OF ONTARIO MINUTES OF THE 408th MEETING OF COUNCIL Thursday, November 19, 2015 DoubleTree by Hilton Toronto Hotel, 108 Chestnut Street, Toronto The 408th Meeting of the Council of the Royal College of Dental Surgeons of Ontario was held on Thursday, November 19, ATTENDANCE: Mr. Derry Millar, Chair Council Members: Elected Representatives: Dr. Elizabeth MacSween District 1 Dr. Benjamin Lin District 2 Dr. Lisa Kelly District 3 Dr. Randy Lang District 4 Dr. Lawrence Davidge District 5 Dr. Joseph Stasko District 6 Dr. Cam Witmer District 7 Dr. Ronald Yarascavitch, President District 8 Dr. Richard Hunter District 9 Dr. Flavio Turchet District 10 Dr. Robert Carroll District 11 Dr. David Segal District 12 University Representatives: Dr. Harinder Sandhu, University of Western Ontario Dr. David Mock, University of Toronto Lieutenant-Governor-in-Council Representatives: Mr. Ted Callaghan Ms. Susan Davis Ms. Beth Deazeley

2 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 2 Mr. Gregory Larsen Mr. Manohar Kanagamany Ms. Catherine Kerr Dr. Edelgard Mahant Ms. Marianne Park Mr. Jose Saavedra Mr. Derek Walter Legal Counsel: Mr. Alan Bromstein Royal College of Dental Surgeons of Ontario Staff: Ms. Nicole Bae, Administrative Assistant, Human Resources Ms. René Brewer, Director, Professional Liability Program Ms. Haydee Bunuan, Administrative Assistant, Professional Conduct and Regulatory Affairs Mr. Mark Edelstein, Investigator, Professional Conduct and Regulatory Affairs Ms. Daphne Everitt, Supervisor, Property and Administrative Services Mr. Irwin Fefergrad, Registrar Ms. Lorissa Ferkranus, Administrative Assistant, Professional Conduct and Regulatory Affairs Dr. Michael Gardner, Manager, Quality Assurance Dr. Helene Goldberg, Senior Dental Consultant, Professional Conduct and Regulatory Affairs Ms. Wanda La, Complaints Administrator, Professional Conduct and Regulatory Affairs Mr. Robert Lees, Manager, Registration Ms. Lori Long, Manager, Professional Conduct and Regulatory Affairs Ms. Peggi Mace, Director of Communications Mr. Greg Moors, Director, Finance, Property and Administration Ms. Camile Ripley, Intake Administrative Assistant, HPC and Membership Ms. Sara Sanfrancesco, Administrative Assistant, Professional Conduct and Regulatory Affairs Ms. Angie Sherban, Executive Assistant Ms. Dayna Simon, Counsel, Regulatory Affairs Dr. Chris Swayze, Supervising Dental Consultant, Professional Conduct and Regulatory Affairs Ms. Brenda Waddington, General Manager, Operations & Facilities

3 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 3 Ms. Wendy Waterhouse, Decision Writer, Senior Investigator, Professional Conduct and Regulatory Affairs Ms. Julie Wilkin, Assistant Manager, Registration 1. CALL TO ORDER The Chair called the meeting to order at 9:15 a.m. 2. ADOPTION OF AGENDA The agenda was adopted, as circulated. MOTION: THAT the agenda for the 409 th Meeting of Council be adopted, as circulated. CARRIED (Unanimously) 3. ROLL CALL Mr. Fefergrad conducted the roll call. 24 Council members were in attendance and a quorum was declared. 4. REMARKS/CHAIR Mr. Millar welcomed members of Council, staff, guests and observers to the meeting. 5. REMARKS/PRESIDENT Dr. Yarascavitch welcomed everyone to the meeting. He formally introduced two new public members of Council, Mr. Greg Larsen from Thunder Bay and Mr. Derek Walter from Kingston. He presented them with a College lapel pin. He highlighted the accomplishments of Council during the year with the overriding theme being the focus of government, the media and how regulators protect the public interest. He emphasized the importance of commitment to transparency and accountability. The government has advised regulators about its new transparency and openness strategy that will modernize the health regulatory framework and involve amendments to the Regulated Health Professions Act, This initiative

4 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 4 will involve government, the public and representatives from other sectors in the provincial health care system. He reported that the College s Registrar, Mr. Irwin Fefergrad was appointed co-chair of the working group for this initiative. He reported on the Advisory Group for Regulatory Excellence (AGRE) the formation of six health regulatory colleges for dentists, nurses, physicians and surgeons, pharmacists, physiotherapists and optometrists. He added that Mr. Fefergrad was appointed Chair of AGRE in the current term. There are also several working groups that have been struck comprised of several senior staff members. Health regulatory colleges were called upon by the Minister of Health and Long- Term Care to account for the role of the Patient Relations Committee in handling issues related to sexual abuse. The College made detailed presentations in writing and in person to Professor Marilou McPhedron, as part of her investigation on the prevention of sexual abuse of patients and the Regulated Health Professions Act. He thanked staff members for the extra effort put into preparing the submissions in a timely manner. A two-year initiative has been approved for the Patient Relations Committee to include an enhancement for support of victims of sexual abuse. Council also endorsed development of strong educational resources for the membership. The College continues to embrace technology to make members communication with the College more efficient. Dr. Yarascavitch anticipated that in 2015 the online renewals would increase to 90%. He thanked Council members for their ongoing enthusiasm and ambition to continue the work for REMARKS/REGISTRAR Mr. Fefergrad encouraged Council to continue to be proactive and reactive to address future activities in the regulatory environment. He reported on the Canada/European Union Trade Agreement where the notion is that regulated professionals from all of the European Union will be eligible to be registered in the countries of the partners of that agreement with Canada being one

5 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 5 of them. The College has concerns with permit-to-permit registration and it is hoped that this will be avoided for Canada. Mr. Fefergrad also reported in-depth on the Trans-Pacific Partnership (TPP) Agreement and how dentistry may be affected by the agreement. He undertook to keep Council apprised on any developments with these agreements. 7. COMMITTEE REPORTS (a) Executive Committee Dr. Yarascavitch, Chair, presented the report and made recommendations on behalf of the Executive Committee. He thanked committee members and support staff for their commitment and availability to deal with issues as required. 1. Signing Contracts It was reported that under the College s current by-laws, the Registrar and President sign contracts on behalf of the College, assuming the amount in the contract is budgeted. In order to be more efficient and avoid delays in getting contracts signed by the President, the Executive Committee recommended that any contract up to a certain amount be signed by the Registrar (as long as the amount is a budgeted expense), together with the Director of Finance and Administration or the Controller. The Registrar would report to the Executive Committee when a contract has been signed. To this end, it was recommended that the Legal and Legislation Committee draft amendments to the College s by-law Article 24(2)(2) to add a new paragraph. MOTION #1: THAT Council refers to the Legal and Legislation Committee to draft an amendment to Article of the College s by-laws to add a new paragraph, a.1, as follows: a.1 in respect of contracts involving an expenditure that has been included in a Council approved budget and where the value of the contract, excluding taxes, is not more than $30,000, the College s Director of Finance and Administration or the College s Controller,

6 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 6 together with the Registrar shall have signing authority and report to the Executive Committee on any contracts signed. CARRIED (Unanimously) 2. Fee Reimbursements for University of Toronto and Western University Dr. Yarascavitch reported that a request was received from the Faculty of Dentistry, University of Toronto, for the College to consider expanding the reimbursement program for retired dentists who offer their services in the university dental clinic. The Executive Committee reviewed the current policy which provides for the College to reimburse each of the Faculty of Dentistry, University of Toronto and the Schulich School of Medicine and Dentistry, Western University, for the annual membership fees for a maximum of 15 members. This is assuming the Registrar is satisfied that each member offers his or her services to the university/dental school, is otherwise fully retired from active dental practice, requires membership with the College for the sole purpose of providing services to the university/dental school in the university/dental school s dental clinic, and has no other source of income from the practice of dentistry. The Executive Committee recommended increasing the number of fee reimbursements for retired dentists who offer their service to the universities from a maximum of 15 to a maximum of 25 per university. MOTION #2: THAT Council amend its existing Policy entitled Reimbursement of Retired Dentists to reimburse each of the Faculty of Dentistry, University of Toronto, and the Schulich School of Medicine and Dentistry, Western University for annual membership fees from a maximum of 15 annual fees to a maximum of 25 annual fees for each faculty/school (provided the Registrar is satisfied that the Policy Criteria have been met). CARRIED (Unanimously)

7 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 7 There was a question raised regarding the term retired dentist and it was suggested that this wording be removed from the policy. It was confirmed that in order to maintain a license, dentists are required to fulfil the Quality Assurance Program requirements, including the Practice Enhancement Tool (PET). 3. Building Renovations Dr. Yarascavitch reported that a joint meeting of the Executive Committee and the Finance, Property and Administration Committee was held on August 20, 2015 to meet with the architectural company and the construction company engaged for the renovations of 6 Crescent Road. He stated that in November 2014 a Council presentation outlined the College s needs for more office space at 6 Crescent Road due to the increase in staff, higher membership, legislative changes, and additional programs that have been put in place. At that meeting, Council approved the budget on the assumptions that the renovations would cost $5.5 million. However, the architects did reiterate that the pricing was an estimate only and may increase. Subsequently, on further inspection of the building, the costs have increased by an estimated $1.5 million to $2.5 million. No increase in member fees will be required to accommodate the additional costs. Dr. Lang, Chair of the Finance, Property and Administration Committee briefly reported on the joint meeting of the two committees on August 20, He stated that the committees believe that the project is well-managed, the renovation is very necessary and the additional funding is affordable. Mr. Fefergrad was asked to introduce Jason Smirnis and John Williamson from BAA Architects and Gino Vettoretto and Jonathan Stefanoff from Marant Construction. He added that the College will continue to occupy the building during the renovation to eliminate leasing costs in another property. BAA Architects and Marant made a presentation to Council of the scope of work required for the building. The presenters outlined the proposed layouts for each floor. The proposed construction timeline is 14 months and the work will be completed in four or five phases.

8 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 8 MOTION #3: THAT Council approves the proposed renovations as presented at a budgeted cost of $7,905, (including HST). CARRIED (Unanimously) The Registrar confirmed that in the event additional financing is required for the project, he would come back to Council for approval. The Executive Committee will be kept apprised regularly of progress on the project and the budgeting. There was discussion on air quality concerns and noise abatement for staff during the construction period. BAA and Marant acknowledged that health and safety is a serious concern and will be taken into consideration during all the construction phases to ensure staff are accommodated. 4. Draft Policy re College Issued Devices Council was asked to consider approving a policy for electronic devices that are in Council members possession during their terms on Council. A draft document was provided for Council s consideration: MOTION #4: THAT Council approves the Policy on Distribution and Retrieval of College Issued Devices for Council Members, as attached at APPENDIX B of the Executive Committee Report to Council. CARRIED (Unanimously) 5. Committee Assignments (a) Professional Liability Program (PLP) Committee The term on Council of the current Chair of the PLP Committee, Ms. Kelly Bolduc-O Hare, expired on August 24, The Executive Committee recommended Mr. Jose Saavedra to replace Ms. Bolduc-O Hare on that committee as a member and Chair, effective August 24, 2015, and Council was asked to confirm the appointment.

9 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 9 MOTION #5: THAT Council confirms the appointment of Mr. Jose Saavedra as a member of and Chair of the Professional Liability Program Committee, effective August 24, CARRIED (Unanimously) (b) Elections Committee Due to the appointment of Mr. Jose Saavedra as Chair of the Professional Liability Program Committee, it was necessary to appoint a new Chair of the Elections Committee. The Executive Committee appointed Mr. Ted Callaghan as the Chair of the Elections Committee, effective August 24, 2015 and Council was asked to confirm the appointment. MOTION #6: THAT Council confirms the appointment of Mr. Ted Callaghan as Chair of the Elections Committee, effective August 24, CARRIED (Unanimously) Mr. Gregory Larsen was appointed as a public member of Council on September 8, 2015 for a three-year term and the Executive Committee appointed him to the Elections Committee to fill the vacancy created by Mr. Saavedra s move to the Professional Liability Program Committee. Council was asked to confirm the appointment. MOTION #7: THAT Council confirms the appointment of Mr. Gregory Larsen as a member of the Elections Committee, effective October 2, CARRIED (Unanimously) (Abstention: 1)

10 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 10 (c) Discipline Committee Mr. Derek Walter was appointed as a public member of Council on August 12, 2015 for a three-year term. The Executive Committee appointed Mr. Walter to the Discipline Committee, effective August 20, 2015 and Council was asked to confirm the appointment. MOTION #8: THAT Council confirms the appointment of Mr. Derek Walter as a member of the Discipline Committee, effective August 20, CARRIED (Unanimously) (Abstention: 1) The Executive Committee also recommended Mr. Gregory Larsen be appointed as a member of the Discipline Committee. MOTION #9: THAT Council appoints Mr. Greg Larsen as a member of the Discipline Committee, effective immediately. CARRIED (Unanimously) (Abstention: 1) 6. Council Meeting Dates 2017 and 2018 Dates for Council meetings in 2017 and 2018 were proposed to Council for approval. MOTION #10: THAT Council set the following dates for regular meetings of Council for each of the years 2017 and 2018: 2017 Wednesday, January 18 and Thursday, January 19, 2017 Thursday, May 11, 2017 Thursday, November 16, 2017

11 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page Thursday, March 8, 2018 Thursday, June 14, 2018 Thursday, November 15, 2018 CARRIED (Unanimously) 7. Remedial Courses/Relationship with University of Toronto Dr. Yarascavitch reported that the Executive Committee recommended that Council approves $15,000 per annum to be paid to the University of Toronto towards the administration of remedial courses for the College. The Executive Committee was appreciative of the usage of staff and administration at the university to organize the remedial courses ordered by the College s Inquiries, Complaints and Reports Committee. It was confirmed that the member taking the course is required to pay for the course. MOTION #11: THAT Council approves $15,000 per annum be paid to the University of Toronto towards the administration of remedial courses for the College. CARRIED (Unanimously) Part B For Information There was discussion on the involvement of European regulators in the International Society of Dental Regulators (ISDR). A Council member asked if the Canadian federal government is aware of ISDR and the worldwide concern about international standards and regulation. Mr. Fefergrad undertook to contact government regarding this issue. (b) Finance, Property and Administration Committee Dr. Lang, Chair, presented the report and made recommendations on behalf of the Finance, Property and Administration Committee. He invited Mr. Greg Moors to do an overview of the operated budget that was provided to the Council for approval. Mr. Moors advised that the development of the annual budget is consultative with the Registrar, department managers and Chairs of committees. It is then presented

12 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 12 in draft to the Finance, Property and Administration Committee for review and recommendation to Council. Mr. Moors satisfactorily answered questions from Council members pertaining to the budget. MOTION #1: THAT Council approves the Operating Budget for 2016, as presented. CARRIED (Unanimously) (c) Discipline Committee On behalf of the Chair of the Discipline Committee, Dr. Rick Bohay, Dr. Hunter presented the report. There were no recommendations made by the committee. Dr. Hunter welcomed Mr. Walter and Mr. Larsen to the Discipline Committee and wished Mr. Saavedra well in his new position on the Professional Liability Program Committee. There was no discussion on the Discipline Committee report to Council. (d) Inquiries, Complaints and Reports Committee Dr. Stasko, Chair, presented the report on behalf of the Inquiries, Complaints and Reports Committee. There were no recommendations made by the committee. He reviewed the report provided to Council and reported that the implementation of the Risk Analysis Tool was working very well. He thanked committee members and support staff for their ongoing efforts. He introduced and viewed with Council the new video developed by the College to explain and promote the Alternate Dispute Resolution (ADR) process. He added that the video would be added to the College s YouTube channel and website. Council was pleased to see this promotional video that will hopefully appeal to more complainants.

13 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 13 (e) Professional Liability Program (PLP) Committee Mr. Saavedra, Chair, presented the report on behalf of the Professional Liability Program Committee. He thanked committee members and staff for their support. There were no recommendations made by the committee. He reviewed the report provided to Council and highlighted the following: PLP s financial performance continues to improve. Year-to-date figures suggest that PLP is on track to have a reduction in payouts of more than $1 million compared to 2014 and more than $2 million compared to PLP s online incident reporting tool made available through the micro website is proving to be popular with members. PLP has increased its risk management speaking engagements. (f) Registration Committee Dr. Turchet, Chair, presented the report on behalf of the Registration Committee. There were no recommendations made by the committee. He thanked the committee members, the Registration Manager and General Legal Counsel for their assistance. (g) Elections Committee Mr. Callaghan, Chair, presented the report on behalf of the Elections Committee. He thanked the past-chair of the committee, Mr. Saavedra, together with committee members, Mr. Larsen and Mr. Kanagamany for their work. Mr. Callaghan reminded Council that College elections take place every two years and the Elections Committee uses the time between to consider feedback from previous elections in an effort to make improvements to the process. 1. Electronic Voting Staff from the Elections Committee, in collaboration with the IT staff, have been working to investigate products that the College can use for electronic voting to ensure security and reliability. The Elections Committee reviewed the information obtained and it was reported that many other Ontario Colleges and regulatory bodies have been using on-line voting technology with much success. Council was provided with a written report of the information obtained by staff.

14 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 14 Mr. Callaghan reported that the estimated cost for a vendor-managed on-line election would be $10, to15, that is considerably less than the current method of a paper election, taking into account printing and mailing costs. He added that other benefits of electronic voting would include increased voter turnout, improved results efficiency, elimination of possible postal delays, and 24/7 technical support from the vendor. Proposed by-law amendments to introduce on-line voting were provided to Council for approval. A Council member asked if the Elections Committee could consider a mechanism where candidates can provide a personal statement to constituents on-line instead of using the College s mailing labels which can be costly. Mr. Fefergrad was asked to respond. He stated that it would not be appropriate for the College to become involved in this way as it may be viewed as the College endorsing those statements. It is also a College policy not to provide members addresses. That said, he agreed to look into it further. Eligibility to Stand for Election Mr. Callaghan reported that effective October 1, 2015 by-law amendments were implemented whereby a notation will appear on the public register for a member required to successfully complete a specific continuing education or remediation program (SCERP) as a result of the Inquiries, Complaints and Reports Committee (ICRC) or attend a panel of that committee for a caution. It was reported that in some of the working groups of the Advisory Group for Regulatory Excellence (AGRE), it was questioned whether it would be appropriate for that member to be eligible for election. The Elections Committee considered adding to the eligibility requirements for election and selection to Council. Namely, that it be a condition for eligibility to stand for election and to be selected as a university representative on Council that the member does not currently have a notation on the public register with respect to a caution or SCERP. The revised eligibility criterion in article 7.2.4, paragraph (e.1) of Appendix B and article 8.1.1, paragraph (e.1) of Appendix D of the Elections Committee Report to Council was provided to Council for its consideration.

15 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 15 MOTION #1: THAT Council approves, in principle, revoking By-Law No. 7: Elections to Council set out in APPENDIX C to Council and replacing it with the by-law set out in APPENDIX B to the Elections Committee Report to Council; and FURTHER THAT the proposed amendments be circulated to members and stakeholders for at least 60 days for comment. CARRIED (Unanimously) MOTION #2: THAT Council approves, in principle, amendments to chapter 8.1 of By- Law No. 8: Selections to Council to add a new eligibility criterion as set out in article 8.1.1, paragraph (e.1) of APPENDIX D of the Elections Committee Report to Council; and FURTHER THAT the proposed amendments be circulated to members and stakeholders for at least 60 days for comment. CARRIED (Unanimously) 2. By-Law No. 14: Disqualifications, General Under the current by-laws, if a Council member no longer meets the eligibility criteria they are disqualified from continuing to serve. The Elections Committee did not think that an already elected Council member should be automatically disqualified from Council if they become the subject of a SCERP or caution during their term. An amendment is therefore required to the disqualification provisions of the by-law in order to prevent this occurrence. There was discussion on the rationale for this decision and it was explained that after Council members have won an elected seat, they should be entitled to fulfil their two-year term.

16 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 16 One Council member stated that consideration be given to re-assigning a member of the Inquiries, Complaints and Reports Committee or Discipline Committee if that member did have a notation on the public register about a SCERP or caution. MOTION #3: THAT Council approves, in principle, amendments to add article (a) and article (a) to By-Law No. 14: Disqualifications, General as set out in APPENDIX E of the Elections Committee Report to Council, highlighted and overstruck for easy reference; and FURTHER THAT the proposed amendments be circulated to members and stakeholders for at least 60 days for comment. CARRIED (Opposed: 1) 3. By-Law No. 9: Non-Council Committee Members Selection on Merit Mr. Callaghan reported that at the May 2015 Council meeting, the Elections Committee was asked to consider changing the way non-council committee members were selected. Currently, the by-law provides that these important positions are filled by random selection district by district. The Elections Committee is of the view that a merit-based process would be more beneficial. It is recommended that an application process be implemented and the Executive Committee will select the members across the province based on their skill set and experience. The Elections Committee also proposed that the Executive Committee be given flexibility in terms of the number of people selected to allow for more members, if required. It was agreed to review By-Law No. 9, article , as follows: Selection Criteria The Executive Committee s selection of members to present to Council for appointment as non-council committee members shall be based on merit with consideration that it is generally desirable that there be representation of members across the province.

17 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 17 Eligibility for non-council committee members Mr. Callaghan reported that effective October 1, 2015 by-law amendments were implemented whereby a notation will appear on the public register for a member required to successfully complete a specific continuing education or remediation program (SCERP) as a result of the Inquiries, Complaints and Reports Committee (ICRC) or attend a panel of that committee for a caution. The Elections Committee considered an addition to the eligibility requirements for non-council committee members that the member does not currently have a notation on the public register with respect to a caution or SCERP. The new criterion was set out in article 9.2.1, paragraph (k.1) of Appendix F of the Elections Committee Report to Council. Disqualification Unlike the recommendation for a Council member, the Elections Committee was of the view that a non-council committee member who has been chosen by application should be automatically disqualified from continuing to serve if that member becomes the subject of a notation on the public register as a result of a SCERP or caution. MOTION #4: THAT Council approves, in principle, revoking By-Law No. 9: Non- Council Committee Members as set out in APPENDIX G and replacing it with the by-law set out in APPENDIX F to the Elections Committee Report to Council; and FURTHER THAT the proposed amendments be circulated to members and stakeholders for at least 60 days for comment. CARRIED (Abstention: 1) 4. By-Law No. 4: Committees of the College The Executive Committee gave consideration to proposed by-law amendments regarding the composition of the Discipline Committee, the Fitness to Practise Committee and the Patient Relations Committee to allow flexibility to increase the number of non-council committee members by adding the words at least to

18 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 18 articles (c), (c) and (c) of By-Law No. 4. Mr. Callaghan reported that this was being proposed in order to meet the increased workload and requirements of these committees. Mr. Callaghan pointed out that in By-Law 4, as shown at Appendix H of the Elections Committee Report to Council, Fitness to Practise Committee was misspelt and would be corrected throughout the document. Council was in agreement with making the revisions to the Fitness to Practise Committee as a friendly amendment. MOTION #5: THAT Council approves, effective immediately, amendments to chapters 4.4, 4.5 and 4.7 of By-Law No. 4: Committees of the College, as set out in APPENDIX H of the Elections Committee Report to Council, highlighted and overstruck for easy reference to allow for flexibility to increase the number of non-council committee members serving on the Discipline, Fitness to Practise and Patient Relations Committees. CARRIED (Unanimously) MOTION #6: THAT Council approves, effective immediately, the proposed housekeeping amendments to chapters 4.1 and 4.5 of By-Law No. 4: Committees of the College as set out in APPENDIX H of the Elections Committee Report to Council, highlighted and overstruck for easy reference. CARRIED (Unanimously) 5. By-Law No. 9: Non-Council Committee Members To allow the Executive Committee to add additional non-council committee members if needed where By-Law No. 4: Committees of the College provided for at least a certain number of non-council committee members, the addition of a new chapter 9.9, Additional Non-Council Committee Members was reviewed by the Elections Committee.

19 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 19 MOTION #7: THAT Council approves, effective immediately, the addition of chapter 9.9 and the articles contained therein to By-Law No. 9: Non-Council Committee Members as set out in APPENDIX I of the Elections Committee Report to Council. CARRIED (Unanimously) A Council member requested that the changeover date of a public member be shown on the Committee Reports to Council. Following a lunch break, the open session meeting continued at 1:30 p.m. (h) Patient Relations Committee Ms. Kerr, Chair, presented the report and made recommendations of behalf of the Patient Relations Committee. She thanked committee members and staff for their support on the committee. A video on treating patients with disabilities that is accessible on the College s website was shown to Council. Ms. Kerr noted that this topic was a major thrust of the Patient Relations Committee program in 2014/15. Several new video productions are planned for the coming year as part of outreach to members and the public. 1. Policy to enhance support for individuals who have experienced sexual misconduct or boundary violations of a sexual nature Ms. Kerr reminded Council of its approval to develop a policy to enhance support for individuals who have experienced sexual abuse and/or boundary violations of a sexual nature by a dentist. A copy of the draft policy was provided to Council for its approval. MOTION #1: THAT Council approves the policy to enhance support for individuals who are reporting sexual abuse and/or boundary violations of a sexual

20 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 20 nature by a dentist as set out in APPENDIX A of the Patient Relations Committee Report to Council. CARRIED (Unanimously) 2. Revised Practice Advisory regarding the Prevention of Sexual Abuse and Boundary Violations The Patient Relations Committee directed staff to update its Practice Advisory on this topic to include current information and advice to members about issues of sexual misconduct and harassment, boundary violations and mandatory reporting requirements, as it has not been revised since A draft document was provided to Council for its approval. MOTION #2: THAT Council approves the draft practice advisory on the Prevention of Sexual Abuse and Boundary Violations, attached at APPENDIX C of the Patient Relations Committee Report to Council. CARRIED (Unanimously) 3. Revised Practice Advisory regarding Guidance on the Use of Social Media The Patient Relations Committee directed staff to revise and update its Practice Advisory on this topic to reflect the extensive use of social media by members and the public. A draft copy of the Practice Advisory was provided for Council for its approval. MOTION #3: THAT Council approves the draft practice advisory on the Guidance on the Use of Social Media, attached at APPENDIX E of the Patient Relations Committee Report to Council. CARRIED (Unanimously)

21 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page Draft policy regarding Accessibility and Accommodation: Professional Conduct and Regulatory Affairs Procedures This policy was drafted to accommodate parties to the complaints process who may require accommodation in order to facilitate their participation. The focus of the policy is to facilitate patient access to the College s investigation processes, but it may also assist members participation. Once approved, there will be education sessions for the Inquiries, Complaints and Reports Committee and PCRA staff. The approved policy would be posted on the College s website. MOTION #4: THAT Council approves the draft policy regarding Accessibility and Accommodation: Professional Conduct and Regulatory Affairs Procedures, as set out in APPENDIX F of the Patient Relations Committee Report to Council, to formalize procedures for accommodations by putting in place a policy to accommodate Ontario Human Rights Code protected needs, up to the point of undue hardship. CARRIED (Unanimously) Part B For Information There was no discussion on Part B. (i) Quality Assurance Committee Dr. Mock, Chair, presented the report on and made a recommendation on behalf of the Quality Assurance Committee. He thanked committee members and staff for their diligence and hard work on the committee. 1. Guidelines on the Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice Dr. Mock reported that at the November 2014 meeting, Council approved, in principle, draft Guidelines on the Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice. The document was then circulated to members and other stakeholders for review and comment. The comments received were reviewed and considered by the Working Group and a copy of the red-lined version of the

22 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 22 document with the Working Group s revisions was provided to Council for its approval. MOTION #1: THAT Council approves the proposed Guidelines on the Role of Opioids in the Management of Acute and Chronic Pain in the Dental Practice (APPENDIX D of the Quality Assurance Committee Report to Council), and Council directs that it be distributed to members. CARRIED (Unanimously) Dr. Mock thanked Dr. Daniel Haas, Dean of the Faculty of Dentistry, University of Toronto who was in attendance at the meeting to answer questions from Council. 8. ADOPTION OF MINUTES (a) Draft Minutes of the 407 th Meeting of Council dated May 14, 2015 MOTION #1: THAT Council adopts the minutes of the 407 th meeting of Council, as circulated. CARRIED (Unanimously) (Abstention: 4) 9. GOOD AND WELFARE Council members were invited to comment on the meeting. 10. DATE OF NEXT COUNCIL MEETING DoubleTree by Hilton Toronto Hotel, 108 Chestnut Street, Toronto Thursday, March 10, IN-CAMERA BUSINESS Guests were asked to leave the meeting, as the meeting was moved to in-camera for confidential discussion.

23 MINUTES 408 th Meeting of RCDSO Council November 19, 2015 Page 23 MOTION: THAT the public be excluded from the meeting pursuant to clause 7(2)(b) of the Health Professions Procedural Code of the Regulated Health Professions Act, 1991 in that financial or personal or other matters may be disclosed of such a nature that the harm created by this disclosure would outweigh the desirability of adhering to the principle that meetings be open to the public. CARRIED (Unanimously) 12. ADJOURNMENT Following the in-camera discussion, the meeting resumed to open session for adjournment at 2:00 p.m. SIGNED: Signature of Presiding Officer Signature of Recording Officer Date AMS:623558

24 College Policy: Policy on Distribution and Retrieval of College Issued Electronic Devices for Council Members Purpose Members of the Executive Committee and other members of Council at the discretion of the Registrar shall be issued laptop computers and/or other electronic devices by the College for use of College business. When such members of Council cease to serve, these devices will be collected from such Council members and reissued to the new Executive Committee members and others as required. Procedure The College's IT department will maintain a list of all devices issued under this policy. Following the biennial elections for Council every second December, the Registrar's executive assistant shall provide a list of all members of Council who will not be returning in the new year to the College IT department. The IT department will compare that list against the list of individuals to whom computers, cell phones, or IPads have been issued and will contact any outgoing members to arrange for the retrieval of College issued devices from the member. Following the biennial election of the Executive Committee every second January, the Registrar's executive assistant will provide the College IT department of any incoming members of the Executive Committee. The IT department will contact such members to arrange for the provision of a laptop prior to the first Executive Committee meeting following the election. From time to time as public member's appointment term expires, the Registrar's executive assistant shall provide the names of any departing public member. The IT department will determine if such member is In possession of any College issued electronic devices, and if so will contact that member to arrange for the collection of the device. When the Registrar determines that a member of Council other than a member of the Executive Committee should be issued a laptop (s)he shall advise the IT department to that effect and the IT department will make arrangements for the issuance of a laptop to that Council member. At the discretion of the Registrar, cellular phones or IPads may also be issued to Council members. When such a device is required, the Registrar shall inform the IT department, who will make arrangement for the configuration and delivery of such device to the Council member. RCDSO Governing Policies

25 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) 7 ELECTIONS TO COUNCIL 7.1 Timing of Elections Election date A general election shall be held on the second Wednesday of December in 2014 and the second Wednesday of December in every second year thereafter. 7.2 Eligibility Definitions The eligibility date is the day that is four days before the deadline for receipt of nominations set by the Registrar under article Eligibility to vote A member of the College may vote in a general election provided that he or she satisfies all of the following conditions on the eligibility date: a. the member holds a general or specialty certificate of registration; b. the member practises dentistry or resides in Ontario; c. the member is not in default of payment of any fees, fines, or other amounts owed to the College; and d. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws Electoral district The electoral district in which a member is eligible to vote is the district in which the designated Register address of the member is located on the eligibility date Eligibility to stand for election A member of the College is eligible to stand for election to Council in an electoral district provided that he or she satisfies all of the following conditions on the deadline for receipt of nominations: a. the member holds a general or specialty certificate of registration; 33

26 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) b. the member practises dentistry in the electoral district in which he or she wishes to stand for election, or the member is not engaged in the practice of dentistry and resides in the electoral district in which he or she wishes to stand for election; c. the member is not in default of payment of any fees, fines, or other amounts owed to the College; d. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws; e. the member is not the subject of any disciplinary or incapacity proceeding in Ontario or any similar proceeding in any other jurisdiction; e.1 the member does not have a notation on the College s (public) register that the member has been the subject of a caution or required to complete a specified continuing education or remediation program based on a decision of the Inquiries Complaints and Reports Committee; f. the member s certificate of registration is not subject to a term, condition, or limitation, other than one applicable to all members holding that class of certificate; g. the member is not and has not been during the previous two years i. a director or other member of the board of directors, governing Council or other governing body of, ii. iii. iv. officer of, or Executive Director, Chief Administrative Officer, or other appointed official of the Canadian Dental Association, Ontario Dental Association, a national or provincial dental specialty association or organization, or other similar national or provincial association or organization; h. the member is not and has not been a salaried employee of the College during the previous two years; i. the member is not ineligible as a result of article (Cooling off period, elected Council members); j. where the member was found guilty of an offence under the Criminal Code (Canada) or any other criminal offence in any other jurisdiction, a period of at least three years has elapsed since the member fully complied with any penalty imposed as a result of that finding, or where no penalty was imposed, a period of at least three years has elapsed since the finding was made; 34

27 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) k. where the member was the subject of an order of the Discipline or Fitness to Practice Committee or any similar order made in any other jurisdiction in relation to a profession, a period of at least three years has elapsed since the member complied with all aspects of that order; and l. where the member was disqualified by Council from serving as a member of Council as a result of a breach of article 11 (Code of Conduct) or article 13 (Conflicts of Interest), a period of at least three years has elapsed since that disqualification. 7.3 Disputed Eligibility Disputed eligibility to vote Any dispute with respect to the eligibility of a member of the College to vote in a general election shall be decided by the Elections Committee Disputed candidacy A member of the College standing for election to Council in an electoral district may dispute the eligibility of another candidate standing for election in the same district by filing a written notice with the Registrar Registrar to refer Where the Registrar receives a written notice of disputed candidacy under article 7.3.2, or receives information which, if true, may disqualify or render ineligible a candidate for election to Council, the Registrar shall take one of the following actions: a. where the notice or information is received on or before the twenty-second (22 nd ) day before the election, refer the matter to the Elections Committee to determine the candidate s eligibility to stand for election; or b. where the notice or information is received after the twenty-second (22 nd ) day before the election and the candidate is successful in the election, refer the matter to Council to determine if the newly elected member should be disqualified Registrar may postpone dates during dispute Where the Registrar refers a matter to the Elections Committee to determine the eligibility of a candidate under article 7.3.3, the Registrar may postpone the date of the election, the date of mailing of ballots to in the impacted electoral district, or both by a maximum of seven (7) days. 35

28 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) Independent legal consultant In determining a candidate s eligibility in a matter referred to it under article 7.3.3, the Elections Committee may obtain the assistance of an independent legal consultant with respect to any issues of law Full disclosure The Elections Committee shall provide a candidate whose eligibility it is considering with full disclosure of any information it receives with respect to the matter, including any information it receives from an independent legal consultant retained under article Submissions from disputed candidate The Elections Committee shall provide a candidate whose eligibility it is considering with a reasonable opportunity to make written and oral submissions Notice of decision The Elections Committee shall notify the Registrar of its decision concerning the eligibility of a candidate referred to it under article 7.3.3, and the Registrar shall immediately notify the candidate and any member who filed a notice under article of the decision of the Election Committee Decision final A decision of the Elections Committee under article or is final, and an election result is not subject to challenge on the basis that a member of the College was not entitled to vote or a candidate was not permitted to stand for election as result of a decision of the Elections Committee. 7.4 Nominations and Election Procedure Registrar to supervise nominations and elections The Registrar shall supervise the nomination of candidates for and the election of members to Council Registrar to set nominations deadline The Registrar shall set a deadline for the receipt of nominations of candidates for election to Council that is at least forty-five (45) days before the date of the election Registrar to notify The Registrar shall notify every member of the College who is eligible to vote of the following information no later than sixty (60) days prior to the date of an election: 36

29 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) a. the date, time, place, and method of the election; b. the procedure for standing for election; and c. the deadline for receipt of nominations Nomination procedure A member of the College wishing to stand for election to Council shall submit the following information to be received by the Registrar on or before the deadline for the receipt of nominations set by the Registrar: a. a completed written nomination using the method in and the form approved by Council; and b. a completed and signed written declaration using the method in and the form approved by Council Withdrawal of nomination A member of the College may withdraw his or her nomination as a candidate in an election by notifying the Registrar in writing at least forty (40) days prior to the election date Registrar to provide labels, lists Where an election is to be held in an electoral district, the Registrar shall provide the following items to each member of the College standing for election in that district, immediately after the deadline for receipt of nominations: a. two sets of mailing labels containing the designated register address of each member of the College eligible to vote in the electoral district; and b. one printed list containing the designated register address and telephone number of each member of the College eligible to vote in the electoral district Where no nominated candidates Where no eligible candidate is nominated in an electoral district, the Registrar shall hold a by-election for that electoral district in accordance with the by-laws. 7.5 Acclamation Election by acclamation Where there is only one eligible candidate nominated to stand for election to Council in an electoral district, the Registrar shall declare that candidate to be elected by acclamation. 37

30 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) 7.6 Voting Procedure Electronic Vvoting by mail Voting for a general election shall be conducted by ballot by mail, using the ballot supplied by the Registrar. Voting for eligible candidates shall be by electronic ballot cast in the manner determined by the Registrar Access to a ballot listing all of the eligible candidates and giving voting instructions shall be provided to every member eligible to vote in an electoral district in which an election is to take place on a date to be determined by the Registrar which date shall be not less than fourteen (14) and not more than twentyone (21) days before the election One vote per member A member of the College shall not cast more than one vote in a general election Only ballots cast before 2:00 pm Eastern Standard Time on the day of the election shall be tabulated Registrar to supervise election The Registrar shall supervise and administer the election of candidates and, without limiting the generality of the foregoing, shall a. appoint one or more returning officers and scrutineers; adopt a process to provide members who claim not to have received access to a ballot listing all of the eligible candidates and voting instructions to cast a ballot, provided the Registrar receives notice of that claim at least forty-eight (48) hours prior to the deadline to cast ballots; b. set a deadline for the receipt of ballots; c. establish procedures for the opening and counting of ballots; retain an independent organization to receive the ballots cast and to tabulate the results of each election; and 38

31 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) d. provide for the notification of all candidates and members of the College of the results of the election Registrar to send ballots, etc. The Registrar shall send to every member of the College eligible to vote in an electoral district in which an election is to take place, a list of the eligible candidates in the district, a ballot, and an explanation of the voting procedures Date of mailing ballots The ballots in an election shall be mailed on a date set by the Registrar that is at least fourteen (14) days and no more than twenty-one (21) days before the date of the election Registrar to notify candidates The Registrar shall notify all candidates for election to Council of the date on which ballots will be mailed immediately members will be sent a ballot listing all of the eligible candidates and giving voting instructions, after setting that date Mailing irregularities A failure to mail send the ballots, on the date set by the Registrar, access to a ballot listing all of the eligible candidates and giving voting instructions in an election does not, in and of itself, invalidate the results of an election Mail service interruption Where there is a mail service interruption during the period of nomination or election of members to Council, the Registrar may extend the deadline for receipt of nominations, postpone the date of the election, or both, for such period of time as the Registrar considers necessary to compensate for the interruption Ballots to be opened, counted Ballots received on or before the deadline for the receiving of ballots in an election of members to Council shall be opened and counted on the day of the election by the returning officers and in the presence of the scrutineers appointed by the Registrar. Ballots cast in an election on or before 2:00 pm Eastern Standard Time on the day of an election shall be tabulated by an independent organization appointed by the Registrar. 39

32 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) 7.7 Tied Votes Full equality of votes determined by lot Where in an election to Council all of the candidates in an electoral district receive an equal number of votes, the Registrar shall break the tie by lot in the presence of at least one member of the Elections Committee Partial equality of votes determined by run-off election Where in an election to Council in an electoral district at least two candidates receive the highest number of votes and at least one candidate receives fewer votes, a run-off election shall be conducted between only those candidates who received the highest number of votes in the manner provided in article Run-off election procedure A run-off election shall be conducted in the same manner as provided in chapter 7.6 (Voting Procedure) with such necessary modifications, including that a. chapter 7.3 (Disputed Eligibility) and chapter 7.4 (Nominations Procedure) shall not apply; b. the only candidates for election shall be those who obtained the highest number of votes in the election that gave rise to the run-off election; c. the Registrar shall determine the date of the run-off election and the deadline for receipt of ballots, bearing in mind the need to complete the run-off election prior to the next regular meeting of Council; and d. where the run-off election results in a full or partial equality of votes cast for the candidates, the registrar shall break the tie between those candidates holding the highest number of votes by lot in the presence of at least one member of the Elections Committee. 7.8 Election Results Successful candidate The successful candidate in a general election is the eligible candidate who received the highest number of votes or whose name was chosen by the Registrar by lot in accordance with article or article Registrar to notify As soon as possible following the counting tabulation of the ballots vote in an election, the Registrar shall 40

33 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) a. notify each eligible candidate of the results of the election and the number of votes cast for each candidate; b. notify each eligible candidate that he or she may require a recount; and c. where the registrar broke a tie vote by lot, notify each eligible candidate of the manner in which the tie was broken and who was present when the registrar broke the tie. 7.9 Recounts Candidate may require recount An eligible candidate in an election of the members of Council may require a recount of the results of the election by providing a written request to the Registrar no more than five (5) days after being advised of the results of the election Registrar to hold recount The Registrar shall arrange hold a recount for a re-tabulation of the results of an election no more than five (5) days after receiving a request under article Recount procedure A recount of the results of an election shall be conducted in the same manner as the original counting of ballots except that a. at least one member of the Elections Committee shall be present, and b. each eligible candidate in the election may attend the recount in person or by representative. The results of a recount shall be reported to the Elections Committee and once directed by it, the Registrar shall report the results of the recount to the candidates involved in the recounted election, including the number of votes cast determined to have been cast for each candidate Destruction of ballots Unless otherwise directed by the Registrar, the ballots cast in an election and information held by the independent organization appointed by the Registrar to tabulate the votes cast, shall be destroyed a. following the first regular meeting of Council after the election provided that no recount has been requested under article (Candidate may require recount) and the period of time in which to request such a recount has expired, or b. following the first regular meeting of Council following a recount conducted under article (Candidate may require recount). 41

34 APPENDIX B By-Law No. 7: Elections to Council (Proposed Replacement) 7.10 By-Elections By-election procedure A by-election in an electoral district shall be held in the same manner as a general election in that district, and the provisions of this by-law applicable to a general election shall apply with such necessary modifications, except a. all time limits and deadlines specified for the holding of a general election do not apply with respect to the by-election, and b. the Registrar shall be responsible for all aspects of the by-election, including setting the date of the by-election and determining all other dates and deadlines required to hold the by-election. 42

35 APPENDIX C By-Law No. 7: Elections to Council 7 ELECTIONS TO COUNCIL 7.1 Timing of Elections Election date A general election shall be held on the second Wednesday of December in 2014 and the second Wednesday of December in every second year thereafter. 7.2 Eligibility Definitions The eligibility date is the day that is four days before the deadline for receipt of nominations set by the Registrar under article Eligibility to vote A member of the College may vote in a general election provided that he or she satisfies all of the following conditions on the eligibility date: a. the member holds a general or specialty certificate of registration; b. the member practises dentistry or resides in Ontario; c. the member is not in default of payment of any fees, fines, or other amounts owed to the College; and d. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws Electoral district The electoral district in which a member is eligible to vote is the district in which the designated Register address of the member is located on the eligibility date Eligibility to stand for election A member of the College is eligible to stand for election to Council in an electoral district provided that he or she satisfies all of the following conditions on the deadline for receipt of nominations: a. the member holds a general or specialty certificate of registration; 33

36 APPENDIX C By-Law No. 7: Elections to Council b. the member practises dentistry in the electoral district in which he or she wishes to stand for election, or the member is not engaged in the practice of dentistry and resides in the electoral district in which he or she wishes to stand for election; c. the member is not in default of payment of any fees, fines, or other amounts owed to the College; d. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws; e. the member is not the subject of any disciplinary or incapacity proceeding in Ontario or any similar proceeding in any other jurisdiction; f. the member s certificate of registration is not subject to a term, condition, or limitation, other than one applicable to all members holding that class of certificate; g. the member is not and has not been during the previous two years i. a director or other member of the board of directors, governing Council or other governing body of, ii. iii. iv. officer of, or Executive Director, Chief Administrative Officer, or other appointed official of the Canadian Dental Association, Ontario Dental Association, a national or provincial dental specialty association or organization, or other similar national or provincial association or organization; h. the member is not and has not been a salaried employee of the College during the previous two years; i. the member is not ineligible as a result of article (Cooling off period, elected Council members); j. where the member was found guilty of an offence under the Criminal Code (Canada) or any other criminal offence in any other jurisdiction, a period of at least three years has elapsed since the member fully complied with any penalty imposed as a result of that finding, or where no penalty was imposed, a period of at least three years has elapsed since the finding was made; k. where the member was the subject of an order of the Discipline or Fitness to Practice Committee or any similar order made in any other jurisdiction in relation 34

37 APPENDIX C By-Law No. 7: Elections to Council to a profession, a period of at least three years has elapsed since the member complied with all aspects of that order; and l. where the member was disqualified by Council from serving as a member of Council as a result of a breach of article 11 (Code of Conduct) or article 13 (Conflicts of Interest), a period of at least three years has elapsed since that disqualification. 7.3 Disputed Eligibility Disputed eligibility to vote Any dispute with respect to the eligibility of a member of the College to vote in a general election shall be decided by the Elections Committee Disputed candidacy A member of the College standing for election to Council in an electoral district may dispute the eligibility of another candidate standing for election in the same district by filing a written notice with the Registrar Registrar to refer Where the Registrar receives a written notice of disputed candidacy under article 7.3.2, or receives information which, if true, may disqualify or render ineligible a candidate for election to Council, the Registrar shall take one of the following actions: a. where the notice or information is received on or before the twenty-second (22 nd ) day before the election, refer the matter to the Elections Committee to determine the candidate s eligibility to stand for election; or b. where the notice or information is received after the twenty-second (22 nd ) day before the election and the candidate is successful in the election, refer the matter to Council to determine if the newly elected member should be disqualified Registrar may postpone dates during dispute Where the Registrar refers a matter to the Elections Committee to determine the eligibility of a candidate under article 7.3.3, the Registrar may postpone the date of the election, the date of mailing of ballots to the impacted electoral district, or both by a maximum of seven (7) days. 35

38 APPENDIX C By-Law No. 7: Elections to Council Independent legal consultant In determining a candidate s eligibility in a matter referred to it under article 7.3.3, the Elections Committee may obtain the assistance of an independent legal consultant with respect to any issues of law Full disclosure The Elections Committee shall provide a candidate whose eligibility it is considering with full disclosure of any information it receives with respect to the matter, including any information it receives from an independent legal consultant retained under article Submissions from disputed candidate The Elections Committee shall provide a candidate whose eligibility it is considering with a reasonable opportunity to make written and oral submissions Notice of decision The Elections Committee shall notify the Registrar of its decision concerning the eligibility of a candidate referred to it under article 7.3.3, and the Registrar shall immediately notify the candidate and any member who filed a notice under article of the decision of the Election Committee Decision final A decision of the Elections Committee under article or is final, and an election result is not subject to challenge on the basis that a member of the College was not entitled to vote or a candidate was not permitted to stand for election as result of a decision of the Elections Committee. 7.4 Nominations Procedure Registrar to supervise nominations The Registrar shall supervise the nomination of candidates for election to Council Registrar to set nominations deadline The Registrar shall set a deadline for the receipt of nominations of candidates for election to Council that is at least forty-five (45) days before the date of the election. 36

39 APPENDIX C By-Law No. 7: Elections to Council Registrar to notify The Registrar shall notify every member of the College who is eligible to vote of the following information no later than sixty (60) days prior to the date of an election: a. the date, time, place, and method of the election; b. the procedure for standing for election; and c. the deadline for receipt of nominations Nomination procedure A member of the College wishing to stand for election to Council shall submit the following information to be received by the Registrar on or before the deadline for the receipt of nominations set by the Registrar: a. a completed written nomination in the form approved by Council; and b. a completed and signed written declaration in the form approved by Council Withdrawal of nomination A member of the College may withdraw his or her nomination as a candidate in an election by notifying the Registrar in writing at least forty (40) days prior to the election date Registrar to provide labels, lists Where an election is to be held in an electoral district, the Registrar shall provide the following items to each member of the College standing for election in that district, immediately after the deadline for receipt of nominations: a. two sets of mailing labels containing the designated register address of each member of the College eligible to vote in the electoral district b. one printed list containing the designated register address and telephone number of each member of the College eligible to vote in the electoral district Where no nominated candidates Where no eligible candidate is nominated in an electoral district, the Registrar shall hold a by-election for that electoral district in accordance with the by-laws. 37

40 APPENDIX C By-Law No. 7: Elections to Council 7.5 Acclamation Election by acclamation Where there is only one eligible candidate nominated to stand for election to Council in an electoral district, the Registrar shall declare that candidate to be elected by acclamation. 7.6 Voting Procedure Voting by mail Voting for a general election shall be conducted by ballot by mail, using the ballot supplied by the Registrar One vote per member A member of the College shall not cast more than one vote in a general election Registrar to supervise election The Registrar shall supervise and administer the election of candidates and, without limiting the generality of the foregoing, shall a. appoint one or more returning officers and scrutineers; b. set a deadline for the receipt of ballots; c. establish procedures for the opening and counting of ballots; and d. provide for the notification of all candidates and members of the College of the results of the election Registrar to send ballots, etc. The Registrar shall send to every member of the College eligible to vote in an electoral district in which an election is to take place, a list of the eligible candidates in the district, a ballot, and an explanation of the voting procedures Date of mailing ballots The ballots in an election shall be mailed on a date set by the Registrar that is at least fourteen (14) days and no more than twenty-one (21) days before the date of the election. 38

41 APPENDIX C By-Law No. 7: Elections to Council Registrar to notify candidates The Registrar shall notify all candidates for election to Council of the date on which ballots will be mailed immediately after setting that date Mailing irregularities A failure to mail the ballots in an election on the date set by the Registrar does not, in and of itself, invalidate the results of an election Mail service interruption Where there is a mail service interruption during the period of nomination or election of members to Council, the Registrar may extend the deadline for receipt of nominations, postpone the date of the election, or both, for such period of time as the Registrar considers necessary to compensate for the interruption Ballots to be opened, counted Ballots received on or before the deadline for the receiving of ballots in an election of members to Council shall be opened and counted on the day of the election by the returning officers and in the presence of the scrutineers appointed by the Registrar. 7.7 Tied Votes Full equality of votes determined by lot Where in an election to Council all of the candidates in an electoral district receive an equal number of votes, the Registrar shall break the tie by lot in the presence of at least one member of the Elections Committee Partial equality of votes determined by run-off election Where in an election to Council in an electoral district at least two candidates receive the highest number of votes and at least one candidate receives fewer votes, a run-off election shall be conducted between only those candidates who received the highest number of votes in the manner provided in article Run-off election procedure A run-off election shall be conducted in the same manner as provided in chapter 7.6 (Voting Procedure) with such necessary modifications, including that a. chapter 7.3 (Disputed Eligibility) and chapter 7.4 (Nominations Procedure) shall not apply; 39

42 APPENDIX C By-Law No. 7: Elections to Council b. the only candidates for election shall be those who obtained the highest number of votes in the election that gave rise to the run-off election; c. the Registrar shall determine the date of the run-off election and the deadline for receipt of ballots, bearing in mind the need to complete the run-off election prior to the next regular meeting of Council; and d. where the run-off election results in a full or partial equality of votes cast for the candidates, the registrar shall break the tie between those candidates holding the highest number of votes by lot in the presence of at least one member of the Elections Committee. 7.8 Election Results Successful candidate The successful candidate in a general election is the eligible candidate who received the highest number of votes or whose name was chosen by the Registrar by lot in accordance with article or article Registrar to notify As soon as possible following the counting of the ballots in an election, the Registrar shall a. notify each eligible candidate of the results of the election and the number of votes cast for each candidate; b. notify each eligible candidate that he or she may require a recount; and c. where the registrar broke a tie vote by lot, notify each eligible candidate of the manner in which the tie was broken and who was present when the registrar broke the tie. 7.9 Recounts Candidate may require recount An eligible candidate in an election of the members of Council may require a recount of the results of the election by providing a written request to the Registrar no more than five (5) days after being advised of the results of the election Registrar to hold recount The Registrar shall hold a recount of the results of an election no more than five (5) days after receiving a request under article

43 APPENDIX C By-Law No. 7: Elections to Council Recount procedure A recount of the results of an election shall be conducted in the same manner as the original counting of ballots except that a. at least one member of the Elections Committee shall be present, and b. each eligible candidate in the election may attend the recount in person or by representative Destruction of ballots Unless otherwise directed by the Registrar, the ballots cast in an election shall be destroyed a. following the first regular meeting of Council after the election provided that no recount has been requested under article (Candidate may require recount) and the period of time in which to request such a recount has expired, or b. following the first regular meeting of Council following a recount conducted under article (Candidate may require recount) By-Elections By-election procedure A by-election in an electoral district shall be held in the same manner as a general election in that district, and the provisions of this by-law applicable to a general election shall apply with such necessary modifications, except a. all time limits and deadlines specified for the holding of a general election do not apply with respect to the by-election, and b. the Registrar shall be responsible for all aspects of the by-election, including setting the date of the by-election and determining all other dates and deadlines required to hold the by-election. 41

44 APPENDIX D Excerpt of By-Law No. 8: Selections to Council 8 SELECTIONS TO COUNCIL 8.1 Eligibility Eligibility for selection A member is eligible to be selected as a selected member of Council provided that he or she satisfies all of the following conditions on the date of his or her selection: a. the member holds a full-time appointment of professorial rank in the faculty or school of dentistry that selected him or her; b. the member submitted a completed and signed written declaration in the form approved by Council and that written declaration was received by the Registrar; c. the member is not in default of any fees, fines, or other amounts owed to the College; d. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws; e. the member is not the subject of any disciplinary or incapacity proceeding in Ontario or any similar proceeding in any other jurisdiction; e.1 the member does not have a notation on the College s (public) register that the member has been the subject of a caution or required to complete a specified continuing education or remediation program based on a decision of the Inquiries Complaints and Reports Committee; f. the member s certificate of registration is not subject to a term, condition, or limitation, other than one applicable to all members holding that class of certificate; g. the member is not and has not been during the previous two years i. a director or other member of the board of directors, governing Council or other governing body of, ii. iii. officer of, or Executive Director, Chief Administrative Officer, or other appointed official of 42

45 APPENDIX D Excerpt of By-Law No. 8: Selections to Council iv. the Canadian Dental Association, Ontario Dental Association, a national or provincial dental specialty association or organization, or other similar national or provincial association or organization; h. the member is not and has not been a salaried employee of the College during the previous two years; i. the member is not ineligible as a result of article (Cooling off period, selected Council members); j. where the member was found guilty of an offence under the Criminal Code (Canada) or any other criminal offence in any jurisdiction, a period of at least three years has elapsed since the member fully complied with any penalty imposed as a result of that finding, or where no penalty was imposed, a period of at least three years has elapsed since the finding was made; k. where the member was the subject of an order of the Discipline or Fitness to Practice Committee or any similar order made in any other jurisdiction in relation to a profession, a period of at least three years has elapsed since the member complied with all aspects of that order; l. where the member was disqualified by Council from serving as a member of Council as a result of a breach of By-Law 11 (CODE OF ETHICS) or By-Law 13 (CONFLICTS OF INTEREST), a period of at least three years has elapsed since that disqualification. 43

46 APPENDIX E Excerpt of By-Law No. 14: Disqualifications, General 14 DISQUALIFICATIONS, GENERAL 14.1 General Commissioner Council shall appoint a former justice of the Ontario Superior Court of Justice to act as a commissioner for the purposes set out in these by-laws, on such terms and for such duration as Council deems appropriate Definitions In this by-law, a commissioner means a commissioner appointed under article Council to be mindful In determining what actions to take regarding a member of Council who is the subject of a matter under by-law 14 (DISQUALIFICATIONS, GENERAL), Council shall be mindful of the general principle that sanctions, except in the most extreme cases, should not be used to punish a member, but rather to protect the integrity of the College and its processes Temporary Exclusion Temporary exclusion for default An elected or selected member of Council who becomes in default of a. any fees, fines, or other amounts owed to the College, or b. completing and submitting any form prescribed by the regulations or required by the by-laws, including any default that originates after the deadline for receipt of nominations, in the case of an elected member of Council, or after the member s selection, in the case of a selected member, shall not serve on Council or any committee until the default is remedied Temporary exclusion during proceedings An elected or selected member of Council who becomes the subject of a disciplinary or incapacity proceeding, including any proceeding that originates after the deadline for receipt of nominations, in the case of an elected member of Council, or after the member s selection, in the case of a selected member, shall not serve on Council or any committee until the proceeding is finally completed. 69

47 APPENDIX E Excerpt of By-Law No. 14: Disqualifications, General 14.3 General Disqualification Criteria Elected members of Council Council shall disqualify an elected member of Council where the member is found to meet any of the following criteria: a. the member is determined by Council not to have met any of the eligibility conditions for election, other than that set out in e.1 of article 7.2.4; b. the member ceases to hold either a general or specialty certificate of registration; c. the member ceases to practice or reside in the electoral district from which the member was elected; d. the member has a term, condition, or limitation placed on his or her certificate of registration other than one applicable to all members holding that class of certificate; e. the member is found to have committed an act of professional misconduct or to be incompetent by a panel of the Discipline Committee; f. the member is found to be incapacitated by a panel of the Fitness to Practice Committee; g. the member fails, without reasonable cause, to attend two consecutive regular meetings of Council; h. the member fails, without reasonable cause, to attend three consecutive meetings of a committee of which he or she is a member; or i. the member fails, without reasonable cause, to attend a hearing of a committee for which he or she has been selected Selected members of Council Council shall disqualify a selected member of Council where the member is found to meet any of the following criteria: a. the member is determined by Council not to have met any of the eligibility conditions for selection, other than that set out in e.1 of article 8.1.1; b. the member has a term, condition, or limitation placed on his or her certificate of registration other than one applicable to all members holding that class of certificate; c. the member ceases to hold a full-time appointment of professorial rank in the faculty or school of dentistry that selected the member; 70

48 APPENDIX E Excerpt of By-Law No. 14: Disqualifications, General d. the member has his or her selection rescinded, withdrawn, or otherwise cancelled by the faculty or school of dentistry that selected the member; e. the member is found to have committed an act of professional misconduct or to be incompetent by a panel of the Discipline Committee; f. the member is found to be incapacitated by a panel of the Fitness to Practice Committee; g. the member fails, without reasonable cause, to attend two consecutive regular meetings of Council; h. the member fails, without reasonable cause, to attend three consecutive meetings of a committee of which he or she is a member; or i. the member fails, without reasonable cause, to attend a hearing of a committee for which he or she has been selected. 71

49 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) 9 NON-COUNCIL COMMITTEE MEMBERS 9.1 General Definition In this article, the eligibility date means, in the case of a member of the College applying for appointment as a non-council committee member, 9:00 a.m. on the day upon which applications for the appointment must be submitted to the Registrar, as provided in this article Non-Council committee members Council shall appoint non-council committee members from among eligible candidates in accordance with the by-laws. 9.2 Eligibility Eligibility for non-council committee members A member of the College is eligible for appointment as a non-council committee member provided that the member satisfies all of the following conditions on the eligibility date: a. the member has filed a completed application in the form approved by the Registrar; b. the member is not ineligible for election or selection as a member of Council under article (Maximum term - elected) or article (Maximum term - selected); c. the member is not in default of any fees, fines, or other amounts owed to the College; d. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws; e. the member is not the subject of any disciplinary or incapacity proceeding in Ontario or any similar proceeding in any other jurisdiction; f. the member s certificate of registration is not subject to a term, condition, or limitation, other than one applicable to all members holding that class of certificate; g. the member is not and has not been during the previous two years i. a director or other member of the board of directors, governing Council or other governing body of, ii. officer of, or 44

50 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) iii. iv. Executive Director, Chief Administrative Officer, or other appointed official of the Canadian Dental Association, Ontario Dental Association, a national or provincial dental specialty association or organization, or other similar national or provincial association or organization; h. the member is not and has not been engaged as a dental consultant to a third party dental benefits provider during the previous three years; i. the member is not and has not been a salaried employee of the College during the previous two years; j. where the member was found guilty of an offence under the Criminal Code (Canada) or any other criminal offence in any jurisidiction, a period of at least three years has elapsed since the member fully complied with any penalty imposed as a result of that finding, or where no penalty was imposed, a period of at least three years has elapsed since the finding was made; k. where the member was the subject of an order of the Discipline or Fitness to Practice Committee or any similar order made in any other jurisdiction in relation to a profession, a period of at least three years has elapsed since the member complied with all aspects of that order; k.1 the member does not have a notation on the College s (public) register that the member has been the subject of a caution or required to complete a specified continuing education or remediation program based on a decision of the Inquiries Complaints and Reports Committee; New Provision. l. where the member was disqualified by Council from serving as a member of Council or as a member of a committee, a period of at least three years has elapsed since that disqualification; m. the member has not served as a non-council committee member for more than three (3) consecutive terms, in the case of a member appointed to serve on any committee other than the Professional Liability Program Committee, and two (2) consecutive terms in the case of a member appointed to serve on the Professional Liability Program Committee Vacancy counted An appointment as a non-council committee member to fill a vacancy shall be considered an appointment for the purposes of determining eligibility under article Reappointment permitted 45

51 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) Subject to meeting the eligibility criteria set out in article 9.2.1, a non-council committee member may be reappointed Members of Council disqualified A member of the College may not be a member of Council and a non-council committee member at the same time Automatic termination The appointment of a non-council committee member automatically terminates if the member becomes a member of Council Candidate in election ineligible A member of the College who is at the time standing for election as a member of Council is ineligible to be appointed as a non-council committee member. 9.3 Resignation Resignation by non-council committee member A non-council committee member may resign his or her appointment by giving written notice to the President, Vice-President, or Registrar Effective date of resignation The resignation of a non-council committee member is effective upon the date set out in the written notice or, where no date is specified, immediately upon receipt by the President, Vice- President, or Registrar Resignation irrevocable The resignation of a non-council committee member is irrevocable and may not be withdrawn or rescinded. 9.4 Disqualification Termination by Council The Executive Committee shall terminate the appointment of a non-council committee member where it is satisfied that the member meets any of the following criteria: a. the member ceases to meet any of the eligibility conditions set out in article 9.2.1; b. the member becomes the subject of a referral of specified allegations of professional misconduct or incompetence to the Discipline Committee; 46

52 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) c. the member becomes the subject of a referral to the Fitness to Practise Committee; c.1 the member becomes the subject of a notation on the College s (public) register that the member has been the subject of a caution or required to complete a specified continuing education or remediation program based on a decision of the Inquiries Complaints and Reports Committee, whether or not the decision is subject to review or appeal; d. the member fails, without reasonable cause, to attend three consecutive meetings of a committee of which he or she is a member; e. the member fails, without reasonable cause, to attend a hearing of a committee for which he or she has been appointed; f. the member breaches section 36 of the RHPA (Duty of confidentiality); or g. the member breaches any of the rules respecting conflicts of interest set out in bylaw 13 (CONFLICTS OF INTEREST). 9.5 Procedure Registrar to notify Subject to article 9.5.2, the Registrar shall notify every member of the College of the following information no later than sixty (60) days prior to the anticipated termination of the term of office of a non-council committee member: a. the opportunity to be appointed as a non-council committee member; b. the eligibility date set by the Registrar; c. the eligibility criteria to be appointed as a non-council committee member; and d. the procedure to apply for appointment Exception The provisions of article do not apply where the Registrar is seeking applications to fill a vacancy Registrar to set application procedure The Registrar shall establish the procedure for applying for appointment as a non- Council committee member, in consultation with the Executive Committee Application procedure may include forms, documentation 47

53 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) The procedure to apply for appointment as a non-council committee member shall include the completion of a form set by the Registrar and the submission of relevant documentation, including the applicant s curriculum vitae Mail service interruption Where there is a mail service interruption during the process of seeking application for appointment as a non-council committee member, the Registrar shall may extend the date for the receipt of applications for such period as the Registrar considers appropriate to compensate for the interruption Registrar to prepare list of candidates After the eligibility date or any extension under article 9.5.5, the Registrar shall a. prepare a list of all eligible candidates for appointment as non-council committee members, and b. submit the list, along with any documentation received from the candidates, to the Executive Committee Executive Committee to present slate Following receipt of the list of eligible candidates for appointment as non-council committee members, the Executive Committee shall present a slate of members for appointment for each committee, having regard for the composition requirements of each committee as set out in the by-laws Selection Criteria The Executive Committee s selection of members to present to Council for appointment as non-council committee members shall be based on merit Council to appoint non-council committee members After receiving the recommendations of the Executive Committee and subject to any amendments by Council, Council shall appoint members of the College as non-council committee members to the committees. 9.7 Term of Office Members not on the Professional Liability Program Committee Subject to article 9.7.3, the term of office of a non-council member of a committee other than the Professional Liability Program Committee commences on the date of his or her appointment and terminates at the initial Council meeting following the next general election Members on the Professional Liability Program Committee 48

54 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) Subject to article 9.7.3, the term of office of a non-council member of the Professional Liability Program Committee commences on the date of his or her appointment and terminates at the first regular Council meeting in the third calendar year after the date of appointment Term of office, vacancies The term of office of a non-council committee member appointed to fill a vacancy commences on the date of his or her appointment and continues for the balance of the term of office of the member whom he or she replaced Termination Council may, by resolution, terminate the appointment of a non-council committee member at any time and for any reason without notice, by resolution, with or without cause. 9.8 Vacancies Vacancies A vacancy occurs where for any reason, a member appointed as a non-council committee member ceases to act in that capacity, including as a result of the member s death, resignation, disqualification or termination of the appointment by Council prior to the completion of the term Appointment of replacement member Where a vacancy occurs, as contemplated by article 9.8.1, the Executive Committee may appoint, in accordance with this article and effective immediately, a member who had made application to be appointed to be a non-council committee member when the College last sought applications from members for appointment Verify willingness, eligibility Before making the appointment, the Executive Committee shall verify that the proposed replacement member appointed pursuant to article is both willing and eligible to be appointed as a non-council committee member Eligibility of replacement member A proposed replacement member appointed pursuant to article is eligible to be appointed as a non-council committee member provided that the member meets the eligibility criteria set out in article on the date of his or her appointment. 49

55 APPENDIX F By-Law No. 9: Non-Council Committee Members (Proposed Replacement) Where no eligible member Where no willing and eligible member can be found under article 9.8.2, the Executive Committee shall direct the Registrar to seek applications for appointment in accordance with the procedure set out in article Council to confirm appointment Council shall be asked to confirm an appointment by the Executive Committee under article at its next regular meeting, or such later meeting as Council may determine Council refusal to appoint In the event Council refuses to confirm an appointment to fill a vacancy under article the member appointed shall immediately cease to be a non-council committee member and shall immediately cease to be member of the committee or committees to which he or she was appointed Clarification Subject to the requirements of these by-laws, the Executive Committee may fill a committee vacancy with a member who is currently a non-council committee member of another committee, in which event article 9.8 would not apply

56 APPENDIX G By-Law No. 9: Non-Council Committee Members 9 NON-COUNCIL COMMITTEE MEMBERS 9.1 General Definitions In this by-law, Electoral districts mean the electoral districts as defined in article 6.1.1, with the exception that Electoral District 3A is composed of the territorial districts of Algoma, Cochrane, Manitoulin, Nipissing, Timiskaming and the Regional Municipality of Sudbury, and Electoral District 3B is composed of the territorial districts of Kenora, Rainy River and Thunder Bay; and Eligibility date means, in the case of a member of the College applying for random selection, 9:00 a.m. on the day fourteen (14) days prior to the day on which the random selection is to take place and, in the case of a member of the College applying for appointment to the Professional Liability Program Committee, 9:00 a.m. on the day upon which applications for the appointment must be submitted to the Registrar Non-Council committee members Council shall appoint eighteen (18) non-council committee members selected in accordance with the by-laws Random selection One (1) member of the College per electoral district shall be randomly selected from among eligible candidates in that district, including Electoral Districts 3A and 3B, to be appointed as non-council committee members Professional Liability Program Committee members Five (5) members of the College shall be appointed from among eligible candidates as non-council committee members of the Professional Liability Program Committee. 9.2 Eligibility Eligibility for non-council committee members A member of the College is eligible to be selected for appointment as a non-council committee member provided that the member satisfies all of the following conditions on the eligibility date: 44

57 APPENDIX G By-Law No. 9: Non-Council Committee Members a. the member is not ineligible for election or selection as a member of Council under article (Maximum term - elected) or article (Maximum term - selected); b. the member is not in default of any fees, fines, or other amounts owed to the College; c. the member is not in default of completing and submitting any form prescribed by the regulations or required by the by-laws; d. the member is not the subject of any disciplinary or incapacity proceeding in Ontario or any similar proceeding in any other jurisdiction; e. the member s certificate of registration is not subject to a term, condition, or limitation, other than one applicable to all members holding that class of certificate; f. the member is not and has not been during the previous two years i. a director or other member of the board of directors, governing Council or other governing body of, ii. iii. iv. officer of, or Executive Director, Chief Administrative Officer, or other appointed official of the Canadian Dental Association, Ontario Dental Association, a national or provincial dental specialty association or organization, or other similar national or provincial association or organization; g. the member is not and has not been engaged as a dental consultant to a third party dental benefits provider during the previous three years; h. the member is not and has not been a salaried employee of the College during the previous two years; i. where the member was found guilty of an offence under the Criminal Code (Canada) or any other criminal offence in any jurisidiction, a period of at least three years has elapsed since the member fully complied with any penalty imposed as a result of that finding, or where no penalty was imposed, a period of at least three years has elapsed since the finding was made; j. where the member was the subject of an order of the Discipline or Fitness to Practice Committee or any similar order made in any other jurisdiction in relation 45

58 APPENDIX G By-Law No. 9: Non-Council Committee Members to a profession, a period of at least three years has elapsed since the member complied with all aspects of that order; k. where the member was disqualified by Council from serving as a member of Council or as a member of a committee, a period of at least three years has elapsed since that disqualification; l. where the member is seeking appointment through the random selection process, the member was not randomly selected to serve as a non-council committee member in the two consecutive selections immediately prior; and m. where the member is seeking appointment to the Professional Liability Program Committee, the member has not served as a member of the committee for more than the previous six consecutive years Vacancy counted An appointment as a non-council committee member by random selection to fill a vacancy shall be considered as a selection for the purposes of determining eligibility under article Random selection from electoral district A member of the College is eligible for random selection only in the electoral district in which his or her designated Register address is situated Reappointment permitted Subject to the eligibility criteria set out in article 9.2.1, a non-council committee member may be reappointed Members of Council disqualified A member of the College may not be a member of Council and a non-council committee member at the same time Automatic expiry The appointment of a non-council committee member automatically expires if the member becomes a member of Council Successful candidate in election ineligible A member of the College who has applied to be appointed as a non-council committee member and who is at the same time standing for election as a member of Council is 46

59 APPENDIX G By-Law No. 9: Non-Council Committee Members ineligible to be selected for appointment as a non-council committee member if the member receives the highest number of votes in his or her electoral district s election. 9.3 Resignation Resignation by non-council committee member A non-council committee member may resign his or her appointment by giving written notice to the President, Vice-President, or Registrar Effective date of resignation The resignation of a non-council committee member is effective upon the date set out in the written notice or, where no date is specified, immediately upon receipt by the President, Vice-President, or Registrar Resignation irrevocable The resignation of a non-council committee member is irrevocable and may not be withdrawn or rescinded. 9.4 Disqualification Termination by Council Council shall terminate the appointment of a non-council committee member where it is satisfied that the member meets any of the following criteria: a. the member ceases to meet any of the eligibility conditions set out in article 9.2.1; b. the member is found to have committed an act of professional misconduct or is found to be incompetent by a panel of the Discipline Committee; c. the member is found to be incapacitated by a panel of the Fitness to Practice Committee; d. the member fails, without reasonable cause, to attend three consecutive meetings of a committee of which he or she is a member; e. the member fails, without reasonable cause, to attend a hearing of a committee for which he or she has been selected; f. the member breaches section 36 of the RHPA (Duty of confidentiality); or g. the member breaches any of the rules respecting conflicts of interest set out in bylaw 13 (CONFLICTS OF INTEREST). 47

60 APPENDIX G By-Law No. 9: Non-Council Committee Members 9.5 Random Selection Notice to members The Registrar shall notify every member of the College of the following information no later than forty-five (45) days prior to the date of the random selection: a. the opportunity to be appointed as a non-council committee member; b. the eligibility date; c. the eligibility conditions to be selected for appointment as a non-council committee member; and d. the procedure for becoming a candidate for random selection Candidacy procedure A member of the College seeking to become a candidate for random selection for appointment as a non-council committee member shall submit the following to be received by the Registrar on or before the deadline set by the Registrar: a. a completed written application in the form approved by Council; and b. a completed and signed written declaration in the form approved by Council Timing of random selection; Registrar to supervise The random selection of members of the College for appointment as non-council committee members shall take place on the same day as the general election under the supervision of the Registrar Registrar to determine eligibility The Registrar shall determine whether each member who has been put forward for consideration is eligible for selection for appointment as a non-council committee member Registrar to notify where ineligible Where the Registrar determines that a member of the College who has been put forward for consideration is ineligible for appointment as a non-council committee member, the Registrar shall notify the member as soon as possible of a. the reasons why the Registrar believes the member is ineligible, and 48

61 APPENDIX G By-Law No. 9: Non-Council Committee Members b. the opportunity to make submissions to the Executive Committee under article Member may contest ineligibility A member of the College who is found by the Registrar to be ineligible for random selection under article (Registrar to determine eligibility) may make written submissions to the Executive Committee contesting the Registrar s finding Executive Committee to determine eligibility The Executive Committee shall, in its sole discretion, determine whether a member of the College making a submission under article is eligible for appointment as a non- Council committee member Decision final A decision of the Executive Committee regarding eligibility for appointment as a non- Council committee member is final Random selection procedure When conducting a random selection under article 9.1.3, the Registrar shall a. appoint two scrutineers to observe the random selection process, b. place the name of each eligible candidate for random selection into thirteen (13) separate boxes segregated by electoral district, and c. select one name at random from each box in the presence of the two scrutineers Registrar to notify selected candidates The Registrar shall notify each member of the College selected for appointment as a non- Council committee member as soon as possible following the random selection Written notice Where the Registrar is unable to contact a member selected for appointment as a non- Council committee member within two (2) days of the random selection, the Registrar shall send a written notice to the member by courier informing the member of his or her selection and of the requirement under article

62 APPENDIX G By-Law No. 9: Non-Council Committee Members Selected candidates to submit curriculum vitae Each member of the College randomly selected for appointment as a non-council committee member shall submit to the Registrar a copy of his or her curriculum vitae within five (5) days of being notified of his or her selection, or such longer time as determined by the Registrar Disqualification A member of the College who fails to provide a copy of his or her curriculum vitae as required by article shall be disqualified Mail service interruption Where there is a mail service interruption during the process of obtaining candidates for random selection for appointment as non-council committee members, the Registrar shall extend the date of the random selection for such period as the Registrar considers appropriate to compensate for the interruption Where no eligible candidates Where there are no eligible candidates for random selection for appointment as a non- Council committee member in an electoral district, the Executive Committee may select, in such manner it considers appropriate, a member of the College whose designated Register address is in the electoral district, to recommend to Council for appointment Council to appoint non-council committee members After receiving any recommendations of the Executive Committee, the Council shall appoint the randomly selected members of the College to committees, other than the Professional Liability Program Committee, in accordance with the by-laws Council may reassign Council may remove a non-council committee member appointed under article and reappoint him or her to another committee. 9.6 Appointment to the Professional Liability Program Committee Registrar to notify The Registrar shall notify every member of the College of the following information no later than sixty (60) days prior to the anticipated expiry of the term of office of a member of the Professional Liability Program Committee: 50

63 APPENDIX G By-Law No. 9: Non-Council Committee Members a. the opportunity to be appointed as a member of the Professional Liability Program Committee; b. the eligibility date set by the Registrar; c. the eligibility criteria to be appointed as a non-council committee member; and d. the procedure for becoming a candidate for appointment Registrar to set candidacy procedure The Registrar shall establish the procedure for becoming a candidate for selection for appointment to the Professional Liability Program Committee with the approval of Council or the Executive Committee Candidacy procedure may include forms, documentation The procedure for becoming a candidate for appointment as a member of the Professional Liability Program Committee may include the completion of a form set by the Registrar and the submission of relevant documentation, including the applicant s curriculum vitae Mail service interruption Where there is a mail service interruption during the process of obtaining candidates for appointment to the Professional Liability Program Committee, the Registrar shall extend the date for the receipt of applications for such period as the Registrar considers appropriate to compensate for the interruption Registrar to prepare list of candidates After the eligibility date, the Registrar shall a. prepare a list of all eligible candidates for appointment to the Professional Liability Program Committee, and b. submit the list, along with any documentation received from the candidates, to the Executive Committee Executive Committee to rank candidates Following receipt of the list of eligible candidates for appointment to the Professional Liability Program Committee, the Executive Committee shall a. select candidates from the list at least equal in number to the number of anticipated positions on the committee to be filled, b. rank the selected candidates in order of preference, and 51

64 APPENDIX G By-Law No. 9: Non-Council Committee Members c. submit the ranked list of selected candidates to Council as recommended appointments Council to appoint non-council committee members After receiving the recommendations of the Executive Committee, Council shall appoint members of the College to the Professional Liability Program Committee from among the eligible candidates. 9.7 Term of Office Randomly selected members The term of office of a non-council committee member appointed through random selection commences on the date of his or her appointment and terminates at the initial Council meeting following the next general election Professional Liability Program Committee members The term of office of a non-council member of the Professional Liability Program Committee commences on the date of his or her appointment and terminates at the first regular Council meeting in the third calendar year after the date of appointment Term of office, vacancies The term of office of a non-council committee member appointed to fill a vacancy commences on the date of his or her appointment and continues for the balance of the term of office of the member whom he or she replaced. 9.8 Vacancies Random selection of replacement candidate Where a vacancy occurs as a result of the resignation, disqualification, or other termination of a non-council committee member who was appointed through random selection, the Registrar shall randomly select a replacement candidate from among the balance of eligible candidates from that electoral district as at the previous selection date Registrar to verify willingness, eligibility Where the Registrar has selected a replacement candidate for a non-council committee member vacancy under article 9.8.1, the Registrar shall contact the candidate to determine whether he or she is both willing and eligible to be considered for appointment as a non-council committee member. 52

65 APPENDIX G By-Law No. 9: Non-Council Committee Members Eligibility of replacement candidate A replacement candidate selected pursuant to article is eligible to be appointed as a non-council committee member provided that a. the candidate s designated Register address remains in the same electoral district from which he or she was selected, and b. the candidate meets the eligibility criteria set out in article on the date of his or her random selection Where replacement candidate unwilling, ineligible Where the replacement candidate selected under article is either unwilling or ineligible to be appointed as a non-council committee member, the Registrar shall repeat the random selection process provided for in that article until a willing and eligible candidate is selected Where replacement candidate selected Where a willing and eligible replacement candidate is selected under article 9.8.1, the Executive Committee shall recommend the candidate to Council to be appointed as a non-council committee member to fill the vacancy Where no replacement candidate Where no willing and eligible replacement candidate can be found as a result of the random selection process under article 9.8.1, the Executive Committee may select, in such manner it considers appropriate, a member of the College whose designated Register address is in the applicable electoral district, to recommend to Council to be appointment as a non-council committee member to fill the vacancy Council to appoint replacement non-council member The Council shall appoint the replacement candidate recommended by the Executive Committee under article or as a non-council committee member to fill the vacancy Vacancy on Professional Liability Program Committee If a vacancy occurs as a result of the resignation, disqualification, or other termination of a non-council committee member who was appointed to the Professional Liability Program Committee, the Executive Committee shall select a replacement candidate from among the balance of eligible candidates as at the previous eligibility date to recommend to Council. 53

66 APPENDIX G By-Law No. 9: Non-Council Committee Members Executive Committee to verify willingness, eligibility The Executive Committee shall verify that the replacement candidate it selects under article is both willing and eligible to be considered for appointed as a non-council committee member Eligibility of replacement candidate, PLP A replacement candidate selected pursuant to article is eligible to be appointed as a non-council committee member provided that the candidate meets the eligibility criteria set out in article on the date of his or her selection Where no eligible candidate, PLP Where no willing and eligible candidate can be found under article 9.8.8, the Executive Committee may select, in such manner as it considers appropriate, a member of the College to recommend to Council to be appointment as a non-council committee member to fill the vacancy on the Professional Liability Program Committee Council to appoint replacement non-council member, PLP After receiving the recommendation from the Executive Committee under article or , the Council shall appoint a replacement non-council committee member to fill the vacancy on the Professional Liability Program Committee. 54

67 APPENDIX H Excerpt of By-Law No. 4: Committees of the College 4 COMMITTEES OF THE COLLEGE 4.1 Executive Committee Composition HOUSEKEEPING CORRECTION The Executive Committee shall be composed of the following members: a. the President; b. the Vice-President; c. two (2) public members of Council elected by Council; and d. one (1) other member of Council elected by Council. The Executive Committee shall be composed of five (5) members of Council, three (3) being elected or selected members of Council and two (2) being public members of Council President and Vice-President The President and Vice-President shall be two (2) of the five (5) members of the Executive Committee President as chair The President shall act as the chair of the Executive Committee, but he or she may delegate the function to another member of the Executive Committee Registrar as secretary The Registrar shall act as the secretary of the Executive Committee Quorum A majority of members of the Executive Committee constitutes quorum Procedure for meetings The procedure for the calling and conduct of meetings of the Executive Committee shall be determined by the Executive Committee Invitation to attend The Executive Committee may invite officers, members of Council, members of College staff, or any other individuals to attend meetings of the Executive Committee and to participate in the discussion and consideration of the affairs of the College as determined by the Executive Committee. 17

68 4.1.7 Powers of the Executive Committee Between the meetings of Council, the Executive Committee has all the powers of Council with respect to any matter that, in the Executive Committee s opinion, requires immediate attention, other than the power to make, amend or revoke a regulation or bylaw Report to Council If the Executive Committee exercises a power of the Council under article (Powers of the Executive Committee), it shall report on its actions to the Council at the Council s next regular meeting. 4.2 Registration Committee Composition The Registration Committee shall be composed of the following members: a. three (3) members of Council who are members of the College; and b. one (1) public member of Council. 4.3 Inquiries, Complaints and Reports Committee Composition The Inquiries, Complaints and Reports Committee shall be composed of the following members: a. at least five (5) members of Council who are members of the College; b. at least four (4) public members of Council; and c. at least three (3) non-council committee members. 4.4 Discipline Committee Composition The Discipline Committee shall be composed of the following members: a. at least four (4) members of Council who are members of the College; b. at least four (4) and not more than six (6) public members of Council; c. at least five (5) non-council committee members. 18

69 4.4.2 Vice-chair, Discipline Committee Council shall appoint a vice-chair of the Discipline Committee from among the members of the Discipline Committee Powers of vice-chair, Discipline Committee The vice-chair of the Discipline Committee shall have all of the authority of the chair of the Discipline Committee where any of the following occurs: a. The chair requests the vice-chair to assume any or all of the duties of the chair. b. The position of chair becomes vacant for any reason. c. The Registrar is unable to reach the chair despite reasonable efforts, and there is a matter of urgency that requires the action of the chair. 4.5 Fitness to Practise Committee Composition The Fitness to Practice Committee shall be composed of the following members: a. two (2) members of Council who are members of the College; b. two (2) public members of Council; and c. at least two (2) non-council committee members. 4.6 Quality Assurance Committee Composition The Quality Assurance Committee shall be composed of the following members: a. two (2) members of Council who are members of the College; b. one (1) public member of Council; and c. two (2) non-council committee members. 4.7 Patient Relations Committee Composition The Patient Relations Committee shall be composed of the following members: a. one (1) member of Council who is a member of the College; b. two (2) public members of Council; and 19

70 c. at least two (2) non-council committee members. 4.8 Audit Committee Composition The Audit Committee shall be composed of the following members: a. the President; b. two (2) elected members of Council; and c. one (1) public member of Council Terms of reference The Audit Committee shall study and make recommendations to Council or the Executive Committee on the following matters: a. the appointment or reappointment of an Auditor, after reviewing the remuneration and other terms of such appointment; b. the scope of the Auditor s examination, the nature and level of support provided by the College s internal accounting function, and any staff reports arising from these matters; c. the approval of non-audit services that may be provided by the Auditor; d. the College s annual audited financial statements; e. the effectiveness of the external audit function and any matter which the Auditor wishes to bring to the attention of the College; f. periodic reports from the Director of Finance and Administration; g. appropriate systems of internal control over financial reporting; h. reports from College staff on the adequacy of the College s financial reporting, accounting and internal control procedures; i. any litigation, claim or other contingency that could have a material effect upon the financial position or operating results of the College; and j. such other matters as may be assigned by Council or the Executive Committee Report to Council The Audit Committee shall report to Council at least once per year. 20

71 APPENDIX I Proposed Addition to By-Law No. 9: Non-Council Committee Members 9.9 Additional Non-Council Committee Members Additional non-council committee members Where the Executive Committee believes that one (1) or more additional non-council committee members is required by the College, the Executive Committee may appoint, in accordance with this article, and effective immediately, one (1) or more members who had previously made application to be appointed to be a non-council committee member when the College last sought applications from members for appointment Verify willingness, eligibility Before making the appointment, the Executive Committee shall verify that the proposed additional member appointed pursuant to article is both willing and eligible to be appointed as a non-council committee member Eligibility of additional member A proposed additional member appointed pursuant to article is eligible to be appointed as a non-council committee member provided that the member meets the eligibility criteria set out in article on the date of his or her appointment Where no eligible member Where no willing and eligible member can be found under article 9.9.1, the Executive Committee shall direct the Registrar to seek applications for appointment in accordance with the procedure set out in article Council to confirm appointment Council shall be asked to confirm an appointment by the Executive Committee under article at its next regular meeting, or such later meeting as Council may determine Council refusal to appoint In the event Council refuses to confirm an appointment to fill a vacancy under article 9.9.1, the member appointed shall immediately cease to be a non-council Committee member and shall immediately cease to be member of the Committee or Committees to which he or she was appointed.

72 W RO YAL COLLEGE OF DENTAL SURGEONS OF ONTARIO College Policy: Support person for individuals who have experienced sexual abuse and/or boundary violations of a sexual nature DRAFT The purpose of the policy is to enhance support for individuals where sexual abuse and/or boundary violations of a sexual nature by a dentist has been alleged. The resource person will provide support, at the College's expense, for those who have come forward through the process with complaints or reports of sexual abuse and/or boundary violations of a sexual nature. The College recognizes that the reporting and discussing, and the experience of being questioned about the details of alleged sexual abuse, can be difficult and distressing. Commencing in June 2015, the College will retain a registered social worker or other appropriate registered and regulated professional to provide support for those individuals who have made allegations that they have been the subject of sexual abuse and/or boundary violations of a sexual nature and: are inquiring about the College' s investigative processes; are in the complaints or registrar's investigation process; or are testifying at a discipline hearing. The support service is provided by a qualified health professional with expertise in the area of sexual abuse and will continue until the matter is disposed of. It is confidential and independent support to facilitate an individual ' s ability to access the College' s regulatory processes. No specific complainant information is provided to the College. Individuals who use this service may, if they wish, provide anonymous feedback to the College as to the usefulness of this service. On a monthly basis, the support person will report to the College the number of individuals who have contacted her/him and the general nature of the support provided. Passed by Council: RCDSO Governing Policies 1

73 Prevention of Sexual Abuse and Boundary Violations * (Th is Practice Advisory replaces the Prevention of Sexual Impropriety in the Dental Office advisory issued by the College in November 2003.) The Practice Advisories of the Royal College of Dental Surgeons of Ontario contain practice parameters and standards which should be considered by all Ontario dentists in the care of their patients. It is important to note that these Practice Advisories may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained. Introduction Ontario government legislation requires all health care regulatory colleges to have in place a patient relations program that includes measures for preventing and dealing with the sexual abuse of patients. These mandated measures under the Regulated Health Professions Act, 1991 (RHPA) include: establishing educational requirements for members; setting guidelines for the conduct of members with their patients; training College staff; providing information to the public. The College's Council and Patient Relations Committee were instrumental in developing and revising the guidance which is contained in this Practice Advisory, as well as in promoting educational initiatives for dentists and patients. Royal College of Dental Surgeons of Ontario Ensu.ri11g Co11tinued Trust

74 Sexual Abuse Sexual abuse is the misuse of the power imbalance in the patient-dentist relationship which may be characterized by boundary violations and/ or boundary crossings. The RHPA defines sexual abuse of a patient by a dentist as being: (a) sexual intercourse or other forms of physical sexual relations between the member and the patient; (b) touching of a sexual nature of the patient by the member; or (c) behaviour or remarks of a sexual nature by the member towards the patient. Boundary Violations Boundaries define the limits of the professional role. In answering the question: "Is this action a part of my role?" the dentist should consider whether their self-interest supersedes or replaces that of the patient's interest or iftheir conduct crosses from professional to personal. Forms of boundary violations may also be described as sexual abuse. Sexual abuse is often the end point of a slippery slope and is preceded by numerous boundary crossings and violations. Frequently, the starting point is increased familiarity with a patient. This may include inappropriate disclosure of personal information by the dentist, the dentist questioning a patient about highly personal information not relevant to the clinical situation, or even the dentist having a social coffee with a patient. The dentist-patient relationship is based on integrity, respect, trust and consideration of the dignity of the patient. Sexual abuse is a violation of these principles. The College considers sexual abuse in any form as an extremely serious matter. It is a betrayal of the dentist-patient relationship. Consent of the patient is never a defence for boundary violations of a sexual nature or sexual abuse of the patient, even if the patient initiates the contact. Dentists need to be aware that if a staff member is treated in the office, the staff member is considered a patient. Therefore, the relevant patient specific provisions of the RHPA apply to this patient relationship. As a guiding principle, dentists should consider what someone objective looking in on their interaction with a patient would think. Dentists should consider whether their conduct is appropriate given the level of professionalism required in the dentist-patient relationship. Practice Advisory I DATEXX 2015

75 Power Imbalance The dentist-patient relationship is always a relationship ofunequals: the patient comes seeking the expertise of the professional and is dependent upon the dentist to provide this service. This power imbalance is the key reason that a sexual relationship between a dentist and a patient is considered sexual abuse. As part of this dynamic, dentists have an obligation to be impartial and objective in their interactions with patients and to put their patients' health care needs first and foremost. Exploitation of this power differential is a violation of those principles that ground the professional relationship. Patient Background Dentists will see patients from many diverse cultures, religions, sexual orientations and socioeconomic backgrounds. It is incumbent upon dentists to be aware that their actions and conversations with patients are experienced by patients within the context of the patients' personal background. Dentists should be aware that comments or actions, even if made with the best of intentions, may be perceived by patients as inappropriate boundary crossings or violations depending on the background of the individual patient. For example, a male dentist extending his hand to shake the hand of a female patient may be culturally inappropriate for some patients. In addition, dentists should be aware that, for religious, cultural or other reasons, some patients may want to be treated by a health care provider of a specific gender. Respecting Personal Space Personal space represents the zone of comfort around a person. The size and comfort of that zone will vary among patients. Variation in the size of personal space can be a factor related to a person's background and life experiences. Some cultures may in general prefer greater space and minimal touching. Others may find talking at short distances and much touching commonplace. Dentists work in close proximity to their patients. As such, they should be aware of their behaviour within this space and act accordingly. Issue oftouch Touch may be perceived by individual patients in very different ways. Given the high rates of childhood abuse and sexual assault, many dental patients may have experienced sexual abuse in the past. For these patients, touch may be perceived as a threat and invasion of their personal space. It may lead to anxiety and avoidance of dental care. For example, a pat on the arm may be viewed as an invasion of personal space, even ifthe dentist's intention was to offer comfort. Again, it is the patient's perception of the interaction and not the dentist's intention that is important. Dentists should be mindful that it is inappropriate for them to hug or kiss a patient, even as a greeting or as an attempt to offer comfort. Prevention of Sexual Abuse and Boundary Violations

76 There will be times when a clinical examination, diagnosis and treatment will require touch beyond the oralfacial complex. In these circumstances, the procedure needs to be explained to the patient and permission sought in advance of the action. The College is aware that there may be times when it may not always be possible to explain the need for non-clinical touching; for example, when a patient is under deep sedation or general anesthesia, or in cases of life-threatening emergency. In such circumstances, the dentist should clearly document in the patient record the exact nature of the touching beyond the oral-facial complex and the reasons for doing so. As stated in the College's Standard of Practice on the Use of Sedation and General Anesthesia in Dental Practice, specified staff should be present in the treatment room at all times whenever sedation or general anesthesia is used. In addition, whenever possible, a staff member or third party should be present when treatment is rendered outside of regular office hours. Dentists should use draping practices that respect a patient's privacy and ensure that the placement of patient bibs or drapes is carried out in a professional manner. Dentists should not place dental instruments or supplies on a patient's chest, lap or shoulder/neck area. Blurring Lines in the Dentist-Patient Relationship As set out in the RHPA, dentists are prohibited from having sexual relationships with patients. As described, this includes comments and touching of a sexual nature as well as sexual intercourse and other sex acts. Boundary crossings or violations are often the slippery slope that leads to more intimate forms of sexual conduct. Even the most casual dating relationship may result in forms of affectionate behaviour that would fall under the RHPA definition of sexual abuse. If dentists need advice about how to conduct themselves in specific circumstances, they should contact the College. The legislation clearly prohibits health care practitioners from engaging in sexual relationships or other forms of affectionate or sexual behaviour with patients. Accordingly, a patient is legally unable to consent to sexual activity with a dentist. Verbal Communication Care and effort must be taken to be considerate and demonstrate respect in all professional interactions. Dentists are distinguished by their cognitive and clinical skills, and also by their commitment to professionalism in their interactions with patients. Communication is both verbal and non-verbal. It is affected by such things as context, tone, word choice and body language. Behaviours, gestures Practice Advisory I DATEXX 2015

77 and/ or remarks that may reasonably be perceived by patients as romantic, sexual, exploitive and/ or abusive vvill be captured under the definition of sexual abuse in the RHPA. Dentists should not tell sexually suggestive jokes, make comments about a patient's or staff member's body, appearance or clothing, and/ or make inquiries about intimate aspects of the lives of patients or staff members. For example, dentists should not make inquiries about a patient's sexual problems, preferences and/ or fantasies or disclose their own. In addition, personal disclosure by patients should not be deemed permission for dentists to reveal detailed personal information about their own lives. For example, if a patient tells the dentist about a history of sexual abuse, this should be used to help the dentist provide services in a sensitive and appropriate way rather than an opportunity for the dentist to share their own personal history. Written Communication Dentists are reminded of their obligation to maintain professionalism in their written communication, which includes content on websites and social media. The College has also produced a Practice Advisory entitled Guidance on the Use of Social Media, which provides specific advice on this issue. It is critical for dentists to be aware of how the inappropriate use of social media or websites can negatively impact their practice and how others perceive them. Documentation Proactive documentation serves both the dentist and the patient interest. A prudent practitioner should document in the patient record any time there has been a boundary crossing or violation by the patient and/ or the dentist. For example, there may be an occasion when it is appropriate to comfort a severely distressed patient using touch. Or, if a patient has made sexual comments and/or advances to the dentist, this too should be documented in the patient chart. Such documentation should be made as soon as possible after the incident occurs and should contain statements from both the dentist and any dental staff who were present. Workplace Environment Dentists are obligated to maintain a professional workplace. This means the workplace environment does not include the posting or distribution of sexually suggestive jokes, posters, pictures and/ or documents which may be offensive to patients and/ or staff. In addition, dentists should be mindful of patient perceptions regarding the conversations they have with staff members during treatment. This College takes the abuse and harassment of staff members very seriously. Dentists should be aware that there are provisions set out in the College's Professional Misconduct Regulation that are used to impose sanctions for this type of behaviour. For example, a member may be found guilty of professional misconduct for sexual harassment of staff or boundary violations with staff, Prevention of Sexual Abuse and Boundary Violations

78 under the provision of engaging in conduct that would reasonably be regarded by members as disgraceful, dishonourable, unprofessional or unethical. If such a case is referred to the Discipline Committee, the penalty imposed will be at the discretion of the Committee based on the individual circumstances ofthe case and may include the full range of discipline penalties. Consequences for the Sexual Abuse of Patients The RHPA sets out specific orders of a Discipline Committee ifthere has been a finding that a dentist has committed an act of professional misconduct by sexually abusing a patient, if the abuse includes any of the following: sexual intercourse; genital to genital, genital to anal, oral to genital, or oral to anal contact; masturbation of the member by, or in the presence of, the patient; masturbation of the patient by the member; or encouragement of the patient by the member to masturbate in the presence ofthe dentist. If such a finding is made, the Committee is required to reprimand the dentist and revoke the dentist's certificate of registration for a period not less than five years. If there is a finding of sexual abuse of a patient related to behaviour or remarks of a sexual nature or if there is a finding of disgraceful, dishonourable, unprofessional or unethical conduct regarding sexual abuse or harassment of a staff member, the penalty imposed is at the discretion of the Discipline Committee. Funding for Therapy and Counselling The College is required to provide funding for therapy or counselling for patients who have been sexually abused by dentists. A patient is eligible to apply for funding if there has been a finding of guilt by the Discipline Committee that a patient has been sexually abused by a dentist. This funding is administered through the College's Patient Relations Committee. Support for Individuals Reporting Allegations of Sexual Abuse or Boundary Violations of a Sexual Nature The College recognizes that reporting and discussing details of alleged sexual abuse or boundary violations of a sexual nature can be difficult and distressing. It is also aware that the timing of the reporting of such instances may vary greatly. There are many reasons why a patient may delay reporting or not even report incidents of sexual abuse. Often, it is the power imbalance inherent in the dentist-patient relationship that is the basis for a reluctance or delay in reporting. In addition, many patients who have experienced sexual abuse are those in society who are marginalized, disenfranchised or otherwise feel that they are outsiders. There may be an overwhelming fear about not being believed, of retaliation or about being ostracized from the community. Others may not 6 Practice Advisory I DATEXX ZD15

79 know who to contact about the dentist's misconduct or may misperceive that the conduct was not serious enough to warrant an investigation. As a result, patients or staff may not bring concerns about a dentist's conduct to the College's attention until a number of months, or even years, have passed. In addition, not all patients respond to boundary violations or sexual abuse in the same way. Some patients may appear detached or withdrawn, others may avoid the situation or try to carry on as if nothing occurred, while others may become confrontational or aggressive. The College recognizes that patients may employ various coping strategies or try to solve the situation in a variety of different ways. For this reason, the College offers an independent support service to dental patients and others reporting concerns to the College about sexual abuse or boundary violations of a sexual nature by a dentist. This support service is provided by a qualified regulated health professional with expertise in the area of sexual abuse. The service is confidential and is provided by someone who is not on College staff. Spousal exemption As ofjuly 10, 2014, a regulation setting out an exception made under subsection 1 (5) of the Health Professions Procedural Code of the RHPA was passed by government which allows the treatment of spouses by Ontario dentists. The regulation states that conduct, behaviour or remarks of a sexual nature would not constitute sexual abuse of a patient if the patient is the dentist's spouse and the dentist is not engaged in the practice of dentistry at the time that the conduct, behaviour or remarks occur. The intention of the exemption is to allow dentists to treat their spouses as patients while continuing consensual sexual relations within a spousal relationship. For the purposes ofthe regulation, the definition of spouse is set out in the Family Law Act or is defined as someone who has lived with the dentist in a conjugal relationship outside of marriage continuously for a period of not less than three years. The spousal exemption provision does not provide blanket protection for a dentist from findings of professional misconduct for abuse of a patient if the spouse was subjected to abusive behaviour. This College does not condone the sexual abuse of anyone and that includes spouses. Mandatory Reporting Under the RHPA, if a dentist has reasonable grounds, obtained in the course of practising the profession, to believe that another dentist or a member of another health care regulatory college (i.e. physician, nurse, dental hygienist, chiropractor, pharmacist, etc.) has sexually abused a patient, the dentist must submit a report to the Registrar of the College of the member who is the subject ofthe report. It is important for dentists to be aware that, in addition to obligations to report incidents of sexual intercourse, genital to genital, genital to anal, oral to genital, or oral to anal contact, and/or masturbation, a report must also be submitted to the appropriate College Registrar if the conduct relates to touching, behaviour or remarks of a sexual nature. Prevention of Se xual Abuse and Boundary Violations 7

80 Dentists should remember that it is not necessary to have spoken directly to the patient in order to have reasonable grounds to suspect sexual abuse. Sometimes information will come to the dentist's attention through a family member, friend or caregiver of the patient. The College advises that it is better to err on the side of public interest protection and to file a report when allegations of sexual abuse come to light. Dentists should make best efforts to advise the patient of their requirement to file a report before doing so. It is the College's expectation that the dentist will file the report as soon as possible. The Act sets out that a health care practitioner will file the report with the Registrar of the appropriate College within 30 days of receiving the information. However, if the dentist believes that the other practitioner will continue to sexually abuse the patient or will sexually abuse other patients, the report must be filed immediately. Failure of the dentist to file a report within the required timeframe, or at all, may result in an investigation by the College and a finding of professional misconduct by the Discipline Committee. Also, the RHPA sets out a fine of not more than $25,000 for the first offence and not more than $50,000 for a second or subsequent offence. It is the College's expectation that, at a minimum, the report should be fulsome and must contain the following: the name of the person filing the report; the name of the health care practitioner who is the subject of the report; an outline of the alleged sexual abuse; what occurred, when it occurred and where it occurred, as well as any other relevant information; the name of the patient, only if the patient has provided written consent to the dentist to include his/her name in the report. Even if the patient has not consented to include their name in the report, the dentist must still file a report but without the patient's name. This Practice Advisory should be read in conjunction with the Regulated Health Professions Act, 1991 and the Professional Misconduct Regulation made under the Dentistry Act. Royal College of Dental Surgeons of Ontario Ensuring Continued Trust 6 Crescent Road Toronto, ON Canada M4W 1T1 T: f: Toll Free:

81 Guidance on the Use of Social Media *(This Practice Advisory replaces the advisory issued by the College in June ) The Practice Advisories of the Royal College of Dental Surgeons of Ontario contain practice parameters and standards which should be considered by all Ontario dentists in the care of their patients. It is important to note that these Practice Advisories may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained. Maintaining professional boundaries in all forms of communication, technology-related or not, is vital to maintaining the public trust and appropriate professional relationships with patients and staff. Boundaries define the role of the dentist, delineating the professional role. Dentists need to be aware of the numerous challenges and the ramifications associated with the use of social media. In a single keystroke, a dentist can move outside the professional role and profoundly compromise his/her professional image. As we have seen in the media, reputations and careers have been destroyed by a single tweet. So before you hit that key and post anything, decide: "Would I be okay reading this in the news or seeing it on television?" If the answer is "no" or "not sure"- hold that keystroke and consider how your comments could be perceived or interpreted. The information in this practice advisory is based on several fundamental principles: the maintenance of professionalism for the comfort and respect of patients; the importance of privacy and confidentiality to the development of trust between the dentist and patient; the legal obligation of dentists to adhere to requirements of the Personal Health Information and Privacy Act as custodians of personal health information about their patients; respect for colleagues, co-workers and staff in the inter-professional environment oftoday's health care system. Royal College of Dental Surgeons of Ontario nsuri11g Conlinued Trust

82 Although dentists are free to take advantage of the many personal and professional benefits that social media offer, it is important to be aware of the potential risks involved. Social media can be effective when used cautiously and professionally. They are powerful tools for research and professional development. But the capacity to record, store and transmit information in electronic format brings new responsibilities with respect to privacy of patient information and ensuring public trust. Social media can blur the boundaty between an individual's private and professional lives. In the current social media age there is no distinction between personal and professional content. All is accessible. Dentists should not divulge detailed personal information about themselves during face-to-face consultations with patients or through social media. The accessibility of content on social media raises the possibility that patients may have unrestricted access to their dentist's personal information if the necessary privacy settings are not maintained. Given the greater accessibility of personal information, entering into informal relationships with patients on sites like Facebook, Instagram, Snap chat and Twitter can increase the likelihood of inappropriate boundary transgressions, especially when previously there had existed only a professional relationship between doctor and patient. Electronic messages are not anonymous. They can be tracked, misdirected and manipulated and they live forever on the Internet. Social media sites create and archive copies of every piece of content posted, even when deleted from online profiles. Once information is digitized, the author relinquishes all control. As the Privacy Commissioner of Ontario has said, Internet users leave behind personally identifiable information everywhere they have been on the Internet. These are the "digital breadcrumbs" that we scatter throughout cyberspace. Dentists need to weigh a number of considerations when maintaining an online presence: l. Dentists should be aware of the standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online. Extra care needs to be taken in small communities, where a very small amount of shared information on a website can lead to patient identification as the information spreads. Practice Advisory I XX 2015

83 Although individual pieces of information about patients may not alone breach patient confidentiality, the sum of published information could be sufficient to identify a patient or their relatives. 2. When using the Internet for social networking, dentists should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute. Even when health professionals use privacy settings, research has shown that 50 per cent of health professionals do not maintain their privacy settings. Plus, once information is posted on the Internet, content is likely there permanently. 3. If dentists decide to interact with patients on the Internet, they must maintain appropriate boundaries of the patient-dentist relationship in accordance with professional ethical guidelines and the law, just as would be done in any other context. 4. To maintain appropriate professional boundaries, dentists should consider separating personal and professional content online. If a dentist decides to follow-up post-procedure with a patient via or other web communication, the dentist should use an or web link that is a dedicated professional site, not his/her personal communication website. Remember, information about patients such as post-surgical follow-up or finances need to be part ofthe patient record. Accordingly, all or other internet communication must be clearly documented and maintained in the patient record. 5. Many dentists now maintain professional websites to inform patients about their practice, to enhance patient learning and for professional advertising (see the final note of this advisory). These are appropriate activities and should provide minimal personal information about dentists and should not be for personal use. If a dentist has another site, such as an unprotected Facebook site, current and prospective patients will be looking at it too. Again, the dentist should ensure that appropriate privacy settings are in place for their personal social media sites. 6. When a dentist receives an online friend request from a patient, they should politely refuse and explain to the patient the reasons why it would be inappropriate for them to accept that request i.e. to do so would be beyond the scope of their professional role. Text messaging with patients is inappropriate and can be the start of a slippery slope that can lead to informal dialogue and boundary crossings and violations. Remember it is always the dentist's responsibility to maintain professional boundaries; responsibility cannot be abdicated to the patient. Guidance on the Use of Social Media,,

84 7. Dentists are increasingly using forums on the Internet to fully engage in debates about issues that impact their professional lives. However, they sometimes feel less inhibited when posting comments online and, as a result, may say things they would not express in other circumstances. Group comments can spread rapidly and go viral in a moment. As stated, privacy settings will rarely be maintained by all members all the time. Any mistake can be misused, tweeted and sent to a much wider audience. 8. Posting comments under a username does not guarantee anonymity as any comments made online can often be traced back to the original author. Once posted it is impossible to retract. 9. Dentists need to exercise sound judgment when posting online and avoid making gratuitous, unsubstantiated or unsustainable negative comments about individuals, groups or organizations. Dental professionalism encompasses a broader, less well-defined set of standards that lie outside the scope of the regulator. These principles have evolved with health care practice over time and, while not legally binding, they represent the standards of conduct broadly expected of health professionals by their peers and society. Although the way dentists use social media in their private lives is a matter for their own personal judgment, dentists should consider whether the content they upload onto the Internet could compromise public confidence in the dental profession and compromise their own professionalism. Poor judgment in such actions can put them at risk for behaviour that may be viewed as unprofessional and/or dishonourable. One final note: Nowadays the Internet is one of the first places that many people go to when looking for a new dentist. That is why, for many dentists. a website has replaced print advenisements as the main focus of their marketing plan. But just like a more traditional print advertisement, your web presence is a reflection not only of your practice, but also of the profession. Websites are really a professional advertisement. Some forms of social media may also be considered advertising. That means the legal and professional responsibilities outlined in the College's Practice Advisory on Professional Advertising apply to websites or any other kind of Internet-based marketing. The regulations made under the Dentistry Act are very clear about what would be considered unprofessional. Royal College of Dental Surgeons of Ontario Ensuring Co11tinued Trust 6 Crescent Road Toronto, ON Canada M4W 1T1 T: F: Toll Free:

85 ~ ROYAL COLLEGE OF DENTAL SURGEONS OF ONTARIO College Policy: Accessibility and Accommodation: DRAFT Professional Conduct and Regulatory Affairs Procedures Overview The College is committed to providing services in a manner that reflects the aims of the Ontario Human Rights Code ("Code"). In providing its services to the public the College will meet its obligation to accommodate Human Rights Code-protected needs, up to the point of undue hardship. A Code protected need is a need related to a person's: race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex (including pregnancy), sexual orientation, gender identity, gender expression, age, marital status, family status, and disability. Requests for Code-related Accommodation During a College Investigation If a person indicates during an inquiry or investigation that they require Code-related accommodation in order to access the College's investigation processes, the responsible investigator shall: 1. Ensure that: a. Where this is necessary and appropriate, the notes related to the accommodation request are kept separate from other file materials in order to avoid inappropriate disclosure of personal health information and/or personal information b. Personal health information and other personal information disclosed to the College are not disclosed to the other parties to an investigation except with the requester's consent or as necessary to ensure a fair investigation process 2. Ask the requester to provide the College with a written request for accommodation that specifies: RCDSO Governing Policies

86 ~ ROYAL COLLEGE OF DENTAL SURGEONS OF ONTARIO a. The Code-related ground to which the request is related; b. The reason for the request; and c. The nature of the accommodation sought 3. Direct the requester to this policy, which shall be posted on the College's website, and emphasize that the College will collaborate with the requester in order to devise an accommodation that is necessary to ensure the requester can fully access the College's process 4. Explain that: a. The fact of a request for accommodation and the provision of accommodations by the College (if any) will be included in the record of investigation b. The requester may be required to provide supporting documentation (i.e. medical documentation) to verify/support their request for accommodation c. The accommodation process is a collaborative process between the party and the College, which requires the cooperation and involvement of the party 5. Notify the Registrar or his/her delegate so that the accommodation request may be reviewed. All accommodations require approval by the Registrar or the Registrar's delegate. If the requester and the College cannot agree on what type of accommodation is appropriate in any case, the Registrar will make a determination as to what accommodation, if any, is to be provided. The Registrar's decision is final. Tracking and Records Maintenance The Registrar will select a College staff member who acts as the Human Rights Protocol Officer. The responsible investigator will notify the Human Rights Protocol officer of any requests for accommodation. The person who acts as the College's Human Rights Protocol Officer will track all requests for accommodation and the nature of accommodations offered during the course of an investigation. Procedures Where a Party Alleges a Staff Person's Breach of the Code If a person alleges that a College staff person has breached the Code in the course of a College investigation then the person with a concern should be directed to set out their concerns in writing to the Registrar. Any concerns relating to the breach of the Code by College staff in the course of a College investigation will be investigated and determined by the Registrar or his/her delegate. When the investigation is completed the Registrar will communicate in writing to the person who has raised concerns regarding the result of the investigation. The Office of the Registrar will maintain all records relating to investigations of alleged breaches of the Code by College staff. RCDSO Governing Policies 2

87 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 1 GUIDELINES Approved by Council Month 2014 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice The Guidelines of the Royal College of Dental Surgeons of Ontario contain practice parameters and standards which should be considered by all Ontario dentists in the care of their patients. It is important to note that these guidelines may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained. CONTENTS INTRODUCTION... 2 MANAGEMENT OF ACUTE PAIN... 2 MANAGEMENT OF CHRONIC PAIN Chronic Pain Primarily of Oral-Facial Origin Temporomandibular Disorders Neuropathic/Neuralgic Pain... 7 Chronic Pain Not Primarily of Oral-Facial Origin MANAGEMENT OF RISK FOR OPIOID USE Assessing Risk... 9 Patient Education... 9 Detecting Aberrant Drug-Related Behaviour Managing the High-Risk Patient Dealing with a Shortage of Interprofessional Support DRAFT ADDITIONAL ISSUES Use of Analgesics for Pediatric Patients Content of Prescriptions Clarity of Prescriptions Securely Issuing Written Prescriptions Safeguarding the Dental Practice Securing and Monitoring In-Office Drugs Staff Education A r l Collett of D llt l Surteollt ol Ollt rlo.._...a.a.,.~ 6 Crescent Road Toronto, ON Canada M4W 1T1 T: F: Toll Free: APPENDICES Screening Tools: The CAGE-AID Questionnaire and the Opioid Risk Tool Additional Resources and Reference Materials Available on the Internet... 15

88 2 Guidelines MONTH 2014 Introduction particularly when complications begin to exceed their competence to manage independently. The management of pain is an important component of dental practice. In this context, dentists frequently consider the use of analgesics and other drugs to manage the patient s condition, which requires appropriate knowledge, skill and professional judgment to be effective and maintain safety. Before prescribing any drug, dentists must have current knowledge of the patient s true health status and clinical condition. This can only be acquired by obtaining a medical history and conducting an appropriate clinical examination of the patient in Patients presenting in acute pain deserve effective, order to make a diagnosis or differential diagnosis, or timely and safe management of their condition. otherwise establish a clinical indication for the use of This should involve active intervention through a drug. There must be a logical connection between dental procedures (e.g. caries removal, pulpectomy, the drug prescribed and the diagnosis or clinical incision-and-drainage, extraction) that are carried indication. out as soon as possible, whenever possible. For many dentists and patients, the management For the majority of patients, postoperative pain will of pain and the use of opioids are often linked. be most significant for approximately two to three However, in most instances, dental pain is days, after which it is expected to diminish. Thus, best managed with effective, timely and safe in most situations, analgesics should be prescribed treatment, and the use of non-opioids, including for the management of postoperative pain for three acetaminophen and non-steroidal anti-inflammatory days, with declining amounts needed thereafter. drugs (NSAIDs). In those instances in which the patient s pain cannot be managed with non-opioids, Before recommending or prescribing any drug for dentists must consider whether an alternate postoperative pain, the following principles should treatment or drug is clinically appropriate. be considered: DRAFT Dentists must exercise reasonable professional judgment to determine whether prescribing an opioid is the most appropriate choice for a patient. These drugs are highly susceptible to misuse, abuse and/or diversion, and may result in harm. If there are no appropriate or reasonably available alternatives, the benefits of prescribing an opioid must be weighed against its potential risks, especially when used long-term. In addition, dentists who prescribe an opioid for a patient should place reasonable limits on their prescriptions and consider opportunities for collaborating with other health care professionals, The purpose of this document is to guide dentists in the appropriate role of opioids in the management of acute and chronic pain in dental practice, and to present best practices for their use. Management of Acute Pain Patients deserve effective, timely and safe pain management. The source of the patient s pain should be eliminated directly through dental procedures that are carried out as soon as possible, whenever possible. The use of any drug involves potential risks. The use of an analgesic should be individualized, based on the patient s medical history and the level of anticipated post-operative pain. A non-opioid (i.e. acetaminophen or an NSAID) should be maximized before adding an opioid. A preoperative and/or loading dose of an NSAID may be beneficial.

89 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 3 Algorithm for Management of Acute Pain Mild to moderate pain expected Acetaminophen Acetaminophen 1000 mg provides NO sufficient pain relief Add codeine to NSAID, acetaminophen or ASA OR add oxycodone to acetaminophen or ASA The dose and frequency of an analgesic should be optimized before switching to another analgesic. Long-term use of any analgesic should be avoided, whenever possible. The analgesic dose should be reduced in older individuals. For children, the analgesic dose should be calculated on the basis of weight. From a risk/benefit standpoint, acetaminophen should be the first analgesic to consider and is usually sufficient for mild to moderate pain. Studies of acute pain in dentistry demonstrate that an appropriate dose of an NSAID should manage the vast majority of moderate to severe pain experienced by dental patients. Only in a minority of situations is an opioid required. Moderate to severe pain expected NSAID If more analgesia required Contraindication to NSAIDs? (see text)!! NO YES Add codeine to acetaminophen OR add oxycodone to acetaminophen Attribution: Adapted with permission from Haas, D.A. (2002). An Update on Analgesics for the Management of Acute Postoperative Dental Pain. Journal of the Canadian Dental Association, 68(8), The above algorithm suggests the following approach: 1. First consider acetaminophen. If professional judgment determines that an adult dose of 1,000 mg q4h (maximum of 4 g per day) is, or will be, insufficient, then consider point Consider an NSAID. If deemed insufficient, then consider point Consider a combination of acetaminophen or an NSAID with codeine mg, q4-6h prn pain. If deemed insufficient, then consider point Consider a combination of acetaminophen or an NSAID with codeine mg or oxycodone 5 10 mg, q4-6h prn pain. DRAFT

90 4 Guidelines MONTH 2014 Before prescribing an analgesic for any patient, consider the following: Only in a minority of situations is an opioid required. Is pain estimated to be mild-to-moderate? If yes, then consider: If the use of an opioid is determined to be Acetaminophen mg q4h (maximum of appropriate, then: 4 g per day) for adults Acetaminophen mg/kg q4h (maximum of Limit the number of tablets dispensed for any 65 mg/kg per day) for children opioid prescription. For most patients, consider the following limits: Is pain estimated to be moderate-to-severe? for codeine 15 mg combinations (e.g. Tylenol#2 ): If yes, then consider: maximum of 36 tablets 1. Is the patient in good health with no for codeine 30 mg combinations (e.g. Tylenol#3 ): contraindications to NSAIDs? maximum of 24 tablets If yes, recommend or prescribe an NSAID, such for oxycodone 5 mg combinations (e.g. Percocet ): as ibuprofen 400 mg q4h prn or an appropriate maximum of 24 tablets dose of flurbiprofen, diflunisal, naproxen, ketorolac, ketoprofen, floctafenine or etodolac. 2. Does the patient have a contraindication to NSAIDs, such as an allergy, gastric bleeding issues or severe asthma? If yes, recommend or prescribe a combination of acetaminophen with codeine or oxycodone. Is pain estimated to be severe? If yes, then consider: A local anesthetic block with bupivacaine A higher dose of an NSAID, such as ibuprofen 600 mg (assuming there are no contraindications) Adding codeine mg to the NSAID or acetaminophen Adding oxycodone 5 10 mg to the NSAID or acetaminophen (such as Percocet ) Before prescribing an opioid for any patient, consider the following: Is the patient s pain well-documented? Is the patient currently taking an opioid? Does the patient s medical history suggest signs of substance misuse, abuse and/or diversion (see section below on Assessing Risk)? Given the efficacy of non-opioids, do the benefits of prescribing an opioid outweigh the risks? In some situations, dentists may consider exceeding the suggested maximum number of tablets for a single opioid prescription. Dentists are expected to exercise reasonable professional judgment in determining when this is justified, which should be documented. Such situations, however, should be considered the exception, and not common practice. If the patient returns complaining of unmanaged pain, and this is confirmed by history and clinical examination, then: Reassess the accuracy of the diagnosis and/or source of the patient s pain. Consider non-pharmacologic management of the patient s pain, including direct treatment (e.g. pulpectomy, incision-and-drainage, extraction). Consider recommending or prescribing the maximal dose of the NSAID or acetaminophen and discontinuing the opioid. Consider prescribing the maximal dose of the NSAID or acetaminophen and the same dose of the opioid. Prescribing an increased dose of the opioid should be considered last. DRAFT

91 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 5 If the patient returns again complaining of unmanaged pain after a 2 nd prescription for an opioid, and this is confirmed by history and clinical examination, then: Reassess the accuracy of the diagnosis and/or source of the patient s pain. Consider non-pharmacologic management of the patient s pain, if appropriate. Consider recommending or prescribing the maximal dose of the NSAID or acetaminophen and discontinuing the opioid. Consider the risk for opioid misuse, abuse and/or 3 rd Appointment diversion. If this is suspected, consider consulting patient returns complaining of unmanaged pain with the patient s physician (or other primary possible 3 rd prescription for an opioid and patient medical care provider) and/or pharmacist regarding advised that no further prescriptions for an opioid drug history and management of risk. will be issued without consultation/referral Consider prescribing the maximal dose of the NSAID or acetaminophen and the same dose of the opioid. If a 3 rd prescription for an opioid is issued, then advise the patient that no further prescriptions for an opioid will be issued without consulting with the patient s physician and/or a dental specialist with expertise in pain management and referring as appropriate. Dentists who prescribe an opioid for a patient If the patient returns again complaining of independently should limit the number of unmanaged pain after a 3 rd prescription for an consecutive prescriptions to a maximum of 3, using opioid, and this is confirmed by history and clinical the suggested maximum number of tablets. Further examination, then: prescribing should take place only in consultation DRAFT Refer the patient to his/her physician or a dental specialist with expertise in pain management for management of pain and assessment of opioid misuse, abuse and/or diversion. Avoid prescribing any further opioids until consulting with the patient s physician and/ Summary of appointments (assuming the same diagnosis and/or source of the patient s pain): 1 st Appointment day of procedure/first appointment prescription for an opioid is issued 2 nd Appointment patient returns complaining of unmanaged pain possible 2 nd prescription for an opioid 4 th Appointment patient returns complaining of unmanaged pain patient referred for pain management and any further prescriptions for an opioid are issued only in consultation with the patient s physician and/or a dental specialist with expertise in pain management with the patient s physician and/or a dental specialist with expertise in pain management. Management of Chronic Pain or a dental specialist with expertise in pain The diagnosis of chronic pain refers to pain that is management and referring as appropriate. prolonged, generally of 3 to 6 months duration, and Consider recommending or prescribing the subsumes chronic nociceptive pain, central pain maximal dose of the NSAID or acetaminophen and sympathetically maintained pain. These may alone, until an interprofessional consultation all cause a chronic pain syndrome, often with a has been conducted. behavioural or psychosocial component.

92 6 Guidelines MONTH 2014 Chronic Pain Conditions in Dental Practice Primarily of Oral-Facial Origin Not Primarily or Solely of Oral-Facial Origin Temporomandibular Disorders Muscular/Myofascial Intra-articular Degenerative/Inflammatory Neuropathic/Neuralgic Pain Trigeminal Neuralgia (Tic Douloureux) Secondary Trigeminal Neuralgia from Facial Trauma Postherpetic Neuralgia (Trigeminal) SUNCT Syndrome (Shortlasting, Unilateral, Neuralgiform Pain with Conjunctival Injection and Tearing) Unclear But Likely Neuropathic Pain Glossodynia and Sore Mouth (also known as Burning Mouth Syndrome) Atypical Facial Pain (Atypical Facial Neuralgia, Migratory Odontalgia, etc) In dental practice, patients may present with chronic pain primarily of oral-facial origin or as part of, or in conjunction with, another primary pain diagnosis. If the patient s pain is primarily of oral-facial origin, DRAFT the dentist or dental specialist may be the primary caregiver. However, if it is not primarily or solely of oral-facial origin, the dentist should collaborate with or refer to a physician or medical specialist, who may assume the responsibility of the primary caregiver. Even if the patient s pain is primarily of oral-facial origin, the dentist should consider collaborating with other health care professionals, particularly when appropriate pharmacotherapy involves the use of drugs with which the dentist lacks experience or complications begin to exceed his/her competence to manage independently. Tension-Type Headache (Muscle Contraction Type Headache) with facial pain Secondary Trigeminal Neuralgia from Central Nervous System Lesions Cervicogenic Headaches with facial pain Temporal Arteritis Cluster Headache Migraine Headache Chronic Pain Primarily of Oral-Facial Origin The management of acute pain implies the elimination of a causative disease or disorder, whereas the objective with chronic pain is generally management of the patient s symptoms and any related dysfunction. This may involve various modalities, including physical treatment, pharmacotherapy, cognitive/behavioural methods, and complimentary or alternative therapy. In rare cases, surgical intervention may be considered as a last resort. Temporomandibular Disorders For muscular/myofascial pain, in general, the most effective first line of therapies are the physical and cognitive/behavioural modalities. If parafunctional habits are contributing to the patient s symptoms,

93 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 7 a stabilizing-type oral appliance may be helpful. If sleep disordered breathing is suspected, a referral for a sleep assessment, followed by appropriate management, may be considered. In severe cases of muscular/myofascial pain or if nocturnal parafunction is contributing to the symptomatology, a muscle relaxant may be prescribed, such as cyclobenzaprine, orphenadrine, tizanidine or methocarabamol. Generally, these drugs are prescribed for short periods of 2 to 4 weeks, but occasionally a longer course is appropriate with regular monitoring. If additional pain management is necessary, acetaminophen or an NSAID may be recommended. Benzodiazepines are generally not recommended for long-term use because of their significant potential for misuse, abuse and/or collaboration with a physician or medical specialist diversion. For intra-articular, degenerative or inflammatory disorders, the physical and cognitive/behavioural modalities may again be considered. Although the evidence for their use is weak, stabilizing-type oral appliances may be helpful. responsibility of principal prescriber to the patient s physician or an appropriate medical or dental For mild to moderate pain management, specialist, while maintaining a collaborative role in acetaminophen is the drug of choice. Daily adult the patient s care. At minimum, the dentist or dental dose should be tailored to the minimum necessary to manage the pain (maximum of 4 g per day). The risks of hepatotoxicity, nephropathy, anemia and DRAFT thrombocytopenia increase with duration of use. NSAID s are a useful adjunct, both for their analgesic effect and, when appropriate, anti-inflammatory activity. All NSAID s risk gastrointestinal bleeding and cardiovascular thrombotic events, including stroke and myocardial infarction. With celecoxib, the gastrointestinal risks are lessened, but there is evidence that the cardiovascular risks may be increased, especially in patients with a history of myocardial infarction or cerebral vascular accident. Although adverse effects are not always related to dose or duration, long duration in particular increases risk. Unlike acute pain, pharmacologic management of chronic temporomandibular pain implies long-term use, which may result in drug tolerance, escalating dosage and increased risks of adverse effects. Opioids are rarely indicated. For more detailed information about the management of temporomandibular disorders, refer to the Guidelines on the Diagnosis and Management of Temporomandibular Disorders & Related Musculoskeletal Disorders, which is available on the College s website at Neuropathic/Neuralgic Pain For neuropathic/neuralgic pain, whether (apparently) primarily of oral-facial origin or not, is advisable to confirm that it is not part of a more generalized/systemic pain disorder and rule out a central space occupying lesion. Brain and/or base of skull imaging are recommended. In addition, if the dentist is not experienced in prescribing the appropriate drugs, s/he should transfer the specialist s role includes monitoring for a local/ dental cause or contributing disorder. Generally, neuropathic/neuralgic pain is best managed pharmacologically, although other adjunctive modalities are often helpful. Anticonvulsants are usually the drugs of choice for neuropathic/neuralgic pain, including carbamazepine, gabapentin and pregabalin. Prior to prescribing carbamazepine or related agents, liver function tests are mandatory to establish a baseline, with follow-up testing periodically. Certain antidepressants, particularly the tricyclic amines, are also useful in selected situations. Opioids are rarely indicated, except for the most severe cases, unresponsive to the first line of therapy.

94 8 Guidelines MONTH 2014 When prescribing anticonvulsants and/or antidepressants, these drugs should be started at a low dose and then slowly increased until relief is accomplished, while not exceeding the maximum dose. Similarly, these drugs must not be discontinued abruptly, but rather patients should be weaned from them carefully. Again, the dentist should consider collaborating with the patient s physician, particularly when appropriate pharmacotherapy involves the use of drugs with which the dentist may lack experience or when complications begin to exceed his/her competence to manage independently. Chronic Pain Not Primarily or Solely of Oral-Facial Origin For pain that is not primarily or solely of oral-facial origin, in general, the dentist or dental specialist is not the primary care provider. Possible exceptions to this rule include cases involving tension-type headache when a muscular/ myofascial temporomandibular disorder is a significant component. In such cases, the College s Guidelines for the Diagnosis and Management of Temporomandibular Disorders & Related Musculoskeletal Disorders are applicable. Otherwise, the dentist s or dental specialist s role is complementary to the physician or medical specialist, principally in monitoring and/or controlling the oral-facial and/or dental component of the patient s complaint. DRAFT It should be recognized that chronic pain may be a function of psychosocial and/or physical factors, and that a history of trauma (either psychological or physical) may precipitate and/or perpetuate pain in general. In addition, it should be acknowledged that addiction to any substance, including opioids, may be precipitated by the experience of pain. Management of Risk for Opioid Use In some instances, the prescription of opioids may be deemed necessary to manage a patient s pain. However, opioids are often prescribed in excess of what is required. Many factors may contribute to the over-prescribing of opioids in dentistry, including: habit or convenience; lack of knowledge regarding the efficacy of non-opioid analgesics; patient demands and expectations; and desire to avoid conflicts or complications. Frequently, dentists choose to prescribe opioids to manage potential postoperative pain with limited regard to the possibility of misuse, abuse or diversion. While dentists typically prescribe a limited quantity of opioids for acute pain (e.g. 24 tablets), excess tablets often remain after the patient s condition has been successfully managed. These excess tablets may then become a source for recreational drug abuse or diversion by the patient, a relative or a friend. It should be emphasized that a dentist has no obligation to prescribe any drug, including opioids, if he or she does not believe it is clinically appropriate, even if the patient has been prescribed them in the past and despite any demands or expectations. In appropriate instances, a dentist must have the clarity of purpose and conviction to refuse a patient s request for opioids when it appears to be unjustified or suspect, in order to protect him or her from unnecessary medication and abuse potential, and to limit the diversion of these drugs to the streets. The dentist should strive for adequate pain management, while simultaneously assuming the responsibility of limiting the potential for drug misuse, abuse and/or diversion.

95 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 9 Assessing Risk When prescribing opioids, a dentist must have current knowledge and ensure comprehensive documentation of the patient s pain condition and general medical status. This should include a review of the patient s alcohol and other substance use. If additional assessment is desirable regarding a patient s risk for opioid misuse, abuse and/or diversion, various screening tools may help with this determination. Examples include the CAGE-AID Questionnaire adapted to include drugs and the Opioid Risk Tool (refer to Appendix 1). OpioidsEnglishJan2014.pdf A discussion about potential benefits, adverse effects, complications and risks assists the dentist Unintended Consequences: Sometimes and patient in making a joint decision on whether medications end up in unusual places... Like Trail to proceed with opioid therapy. Mix Parties Before prescribing opioids, the dentist should ensure documents/unintendedconsequencesaug2012.pdf the patient s expectations are realistic. The goal of analgesic therapy is rarely the elimination of pain, Youth and prescription painkillers: What parents but rather the reduction of pain intensity. need to know Patient Education It is recommended that dentists advise patients on the safe use and storage of opioids by communicating the following: DRAFT Read the label and take the drug exactly as directed. Take the right dose at the right time. Follow the other directions that may come with the drug, such as not driving, and avoiding the use of alcohol. Store opioids in a safe place out of the reach of children and teenagers, and keep track of the amount of drugs. Never share prescription drugs with anyone else, as this is illegal and may cause serious harm to the other person. Return any unused drugs to the pharmacy for safe disposal, in order to prevent diversion for illegal use and to protect the environment. Drugs must not be disposed of in the home (e.g. in the sink, toilet or trash). In addition, dentists should advise patients about what to do if they miss a dose, and remind them that crushing or cutting open a time-release pill destroys the slow release of the drug and may lead to an overdose with serious health effects. Patient information pamphlets and other educational materials regarding opioid use are available on the internet, including: Are you thinking about taking opioids (painkillers) for your pain? documents/areyouthinkingabouttaking resources_families/documents/youthand Misuse%20E.pdf Detecting Aberrant Drug-Related Behaviour When prescribing opioids, dentists must be alert for behaviour that suggests patients are misusing or abusing prescription drugs, or seeking them for diversion purposes. It may be difficult to determine whether a patient is misusing or abusing prescription drugs, or seeking them for diversion purposes. Common aberrant drug-related behaviours can be divided into three groups: escalating the dose (e.g. requesting higher doses, running out early); altering the route of delivery (e.g. biting, crushing controlled-release tablets, snorting or injecting oral tablets);

96 10 Guidelines MONTH 2014 engaging in illegal activities (e.g. double-doctoring, prescription fraud, buying, selling and stealing drugs). The following chart lists aberrant drug-related behaviours potentially indicative of opioid misuse. Dentists may take practical steps to help prevent drug misuse, abuse and/or diversion: If the patient is not well known to you, ensure her or his identity has been verified; for example, by requesting two or three pieces of identification (e.g. health card, driver s licence, birth certificate). Verify the presenting complaint and observe for aberrant drug-related behaviour. Screen for current and past alcohol and drug (prescription, non-prescription, illicit) use. Consider using screening tools (refer to Appendix 1). Consider whether the patient may be misusing, abusing and/or diverting opioids if s/he: requests a specific drug by name and/or states that alternatives are either not effective or s/he is allergic to them; refuses appropriate confirmatory tests (e.g. x-rays, etc.). Ask to speak with the patient s physician and/or pharmacist. Ask the patient if s/he has received any opioids in the last 30 days from another practitioner and look for any signs of evasiveness. Under the Controlled Drugs and Substances Act, 1996, a person who has received a prescription for a narcotic, such as an opioid, shall not seek or receive another prescription or narcotic from a different prescriber without telling that prescriber about every prescription or narcotic that he or she has obtained within the previous 30 days. Managing the High-Risk Patient Dentists who are considering prescribing opioids or other drugs with abuse potential for patients with a history of aberrant drug-related behaviour should clarify the conditions under which they will prescribe, including consultation with the patient s physician. The physician may consider, Indicator ExampleS Altering the route of delivery Accessing opioids from other sources Unsanctioned use Drug seeking Repeated withdrawal symptoms Accompanying Injecting, biting or crushing oral formulations Biting, chewing, swallowing or injecting topical preparations (e.g., sustained-release analgesic patches) Taking the drug from friends or relatives Purchasing the drug from the street Double-doctoring Multiple unauthorized dose escalations Binge rather than scheduled use Recurrent prescription losses Aggressive complaining about the need for higher doses Harassing staff for faxed scripts or fit-in appointments Nothing else works Marked dysphoria, myalgias, GI symptoms, craving Currently addicted to alcohol, conditions cocaine, cannabis or other drugs Underlying mood or anxiety disorders not responsive to treatment DRAFT Social features Deteriorating or poor social function Concern expressed by family members Views on Sometimes acknowledges being the opioid addicted medication Strong resistance to tapering or switching opioids May admit to mood-leveling effect May acknowledge distressing withdrawal symptoms Attribution: From Prescribing Drugs (Policy Statement # 8 12), 2012, College of Physicians and Surgeons of Ontario

97 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 11 in appropriate circumstances, monitoring for aberrant drug-related behaviour (e.g. urine drug screening) and the use of a treatment agreement. A treatment agreement may be an effective tool, especially for a patient who is not well known to the dentist or at higher risk for prescription drug misuse, abuse and/or diversion. A treatment agreement is a formal and explicit written agreement between a practitioner and a patient that sets out terms regarding adherence to the therapy. An agreement may state that: the patient will use the drug only as directed; doctor or a nurse practitioner who is accepting new the patient acknowledges that all risks of taking the drug have been fully explained; the patient will use a single pharmacy of his or her consulting with an experienced colleague regarding choice to obtain the drug. A treatment agreement helps to establish the dentist s expectations of a patient before prescribing begins and the circumstances in which it may stop. The consequence for not meeting the terms of the agreement should also be clear: the dentist may decide not to continue prescribing opioids. Dealing with a Shortage of Interprofessional Support The College recognizes that at times, dentists may be DRAFT faced with the prolonged management of a patient s pain in undesirable circumstances, especially when there is a shortage of interprofessional support; for example, the patient does not have a physician (or other primary health medical care provider) or the referral to another practitioner with expertise in pain management is not possible for an extended period of time. The paramount responsibility of dentists is to the health and well-being of patients, which is an expression of the core ethical value of beneficence. This requires dentists to maximize benefits and minimize harm for the welfare of patients. In some situations, determining what may be beneficial versus harmful is difficult. Nevertheless, dentists must attempt to provide care in a way that upholds these principles as best as possible. Traditional interprofessional support may not always be available. Even in such situations, the principles of patient management described in this document still apply. When dealing with a shortage of interprofessional support, dentists should make reasonable attempts to leverage whatever resources are at hand. For example, a dentist may consider: referring the patient to Health Care Connect, which helps Ontarians who are without a family health care provider to find one. People without a family health care provider are referred to a family patients in their community ( gov.on.ca/en/ms/healthcareconnect/public/); patient management; consulting with the patient s pharmacist to verify the patient s history of prescription drugs and discuss options/alternatives; consulting with the local public health unit regarding available resources in the community; consulting with the College. Additional Issues Use of Analgesics for Pediatric Patients Acetaminophen is usually considered the drug of choice for pediatric patients. It should be administered in a dose of mg/kg q4-6h, up to a maximum of 65 mg/kg per day. Ibuprofen can also be used in a dose of 10 mg/kg, q6-8h. ASA is contraindicated for pediatric patients, because it can potentially induce Reye s syndrome. Health Canada has recommended that codeine only be used in patients aged 12 and over. This is due to the potential of the rare complication of ultra-rapid metabolism of codeine leading to morphine overdose.

98 12 Guidelines MONTH 2014 Content of Prescriptions Dentists must provide the following information with a prescription: name of the patient; full date (day, month and year); name of the drug, drug strength and quantity or duration of therapy; full instructions for use of the drug; refill instructions, if any; printed name of prescriber; address and telephone number of dental office where the patient s records are kept; signature of prescriber or, in the case of electronically produced prescriptions, a clear and unique identifier, which signifies to the dispenser that the prescriber has authorized the individual prescription. For prescriptions that vary from common practice, dentists should consider providing additional information for the pharmacist. If the prescription is for a monitored drug, as defined in the Narcotics Safety and Awareness Act, 2010, dentists must also provide their registration number, as well as an identifying number for the patient (e.g. health card number) and the type of identifying number it is (e.g. health card). DRAFT Dentists should be aware that pharmacists are responsible for confirming the authenticity of each prescription, which may require direct confirmation with the prescriber before the prescription is filled. Clarity of Prescriptions Dentists must ensure that all written and verbal prescriptions are clearly understandable. generic name, and the reason for prescribing the drug). When writing prescriptions, dentists must pay particular attention to the use of abbreviations, symbols and dose designations, and should avoid using abbreviations, symbols, and dose designations that have been associated with serious, even fatal, medication errors. According to medication safety literature, the use of verbal prescriptions (spoken aloud in person or by telephone) introduces a number of variables that can increase the risk of error. These variables include: potential for misinterpretation of orders because of accent or pronunciation; sound-alike drug names; background noise; unfamiliar terminology; patients having the same or similar names; potential for errors in drug dosages (e.g. sound-alike numbers); misinterpretation of abbreviations. In addition, the use of intermediaries (e.g. office staff) has been identified as a prominent source of medication error. Dentists must have protocols in place to ensure that verbal prescriptions are communicated in a clear manner. The more direct the communication between a prescriber and dispenser, the lower the risk of error. Accordingly, if dentists use verbal prescriptions, it is recommended that they communicate the verbal prescription themselves. If this is not possible, it is recommended that dentists consider asking a staff person who has an understanding of the drug and indication to communicate the prescription information, unless the prescription is a refill. Written prescriptions must be legible. It is recommended that dentists use the generic name of the drug to ensure prescriptions are clear and consider including more information, when appropriate (e.g. include both brand name and When verbal prescriptions are used, it is recommended that the accuracy of the prescription be confirmed using strategies such as a read back of the prescription and/or a review of the indication for the drug. It is recommended that the read back include:

99 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 13 spelling of the drug name; spelling of the patient s name; dose confirmation expressed as a single digit (e.g. one-six rather than sixteen ). In addition, to reduce the risk of error due to patients having the same (or similar) names, it is advisable to communicate at least one additional unique patient identifier to the dispenser. Securely Issuing Written Prescriptions In issuing prescriptions for opioids, dentists should consider taking the following precautions: If using a paper prescription pad: write the prescription in words and numbers; draw lines through unused portions of the prescription; keep blank prescription pads secure. If using desk-top prescription printing: use security features, such as watermarks; write a clear and unique signature. If faxing a prescription: confirm destination and fax directly to the pharmacy, ensuring confidentiality; destroy paper copy or clearly mark it as a copy. Safeguarding the Dental Practice Securing and Monitoring In-Office Drugs DRAFT Opioids require increased storage security than other drugs. It is recommended that drugs stored in a dentist s office be kept in a locked cabinet and out of sight. Dentists are advised to avoid storing drugs in any other location, including their homes, and never leave drug bottles unattended or in plain view. A drug register must be maintained that records and accounts for all opioids, as well as other narcotics, controlled drugs, benzodiazepines and targeted substances, that are kept on-site. The register should also be kept in a secure area in the office, preferably with the drugs, and reconciled on a regular basis. Whenever drugs in the above-mentioned classes are used or dispensed, a record containing the name of the patient, the quantity used or dispensed, and the date should be entered in the register for each drug. Each entry should be initialled or attributable to the person who made the entry. In addition, this same information should be recorded in the patient record, along with any instructions for use. When dispensing monitored drugs for home use by patients, dentists are also required to record an identifying number for the patient and the type of identifying number it is in the drug register, as well as in the patient record. Dentists are required to report the loss or theft of controlled substances, including opioids and other narcotics, from their office to the Office of Controlled Drugs and Substances, Federal Minister of Health, within 10 days. Staff Education Dentists should use staff training sessions and meetings to discuss the dangers of drug and substance abuse, to remind staff of the safeguards and protocols in the office to prevent misuse of supplies, and to provide information about resources that are available to dental professionals to assist with wellness issues. It should be emphasized that there is no provision for dentists or their staff to access in-office supplies of opioids or other drugs that normally require a prescription for their own use or by their family members. Dentists should take reasonable precautions to prevent the unauthorized use of in-office supplies of opioids or other drugs by staff and other individuals with access to the office.

100 14 Guidelines MONTH 2014 Appendix 1 Screening Tools: The CAGE-AID Questionnaire and the Opioid Risk Tool The CAGE Questionnaire Adapted to Include Drugs (CAGE-AID) 1. Have you felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? Score: /4 2/4 or greater = positive CAGE, further evaluation is indicated Attribution: Wisconsin Medical Journal. Brown, R.L. & Rounds, L.A. (1995). Conjoint screening questionnaires for alcohol and drug abuse. Wisconsin Medical Journal, 94, Opioid risk tool Family history of substance abuse Female Alcohol 1 3 Illegal drugs 2 3 Prescription drugs 4 4 Personal history of substance abuse Alcohol 3 3 Illegal drugs 4 4 Prescription drugs 5 5 Age (mark box if between 16 and 45) 1 1 History of preadolescent sexual abuse 3 0 Psychological disease Attention deficit disorder, obsessive-compulsive disorder, bipolar, schizophrenia 2 2 Depression 1 1 Scoring: Low risk: 0 3 points Moderate: 4 7 points High: 8+ points Male DRAFT D D D D D D D D D D D D D D D 0 D D D D Attribution: Lynn R. Webster, MD; Medical Director of Lifetree Medical, Inc., Salt Lake City, UT 84106

101 The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice 15 Appendix 2 Additional Resources and Reference Materials Available on the Internet Are you thinking about taking opioids (painkillers) for your pain?, 2014 National Pain Centre, McMaster University Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, 2010 National Pain Centre, McMaster University Controlled Drugs and Substances Act, 1996 Government of Canada Diagnosis & Management of Temporomandibular Disorders & Related Musculoskeletal Disorders (Guidelines), 2009 Royal College of Dental Surgeons of Ontario Health Care Connect Government of Ontario, Ministry of Health and Long-Term Care Narcotics Safety and Awareness Act, 2010 Government of Ontario Ontario s Narcotic Strategy DRAFT Government of Ontario, Ministry of Health and Long-Term Care Prescribing Drugs (Policy Statement # 8 12), 2012 College of Physicians and Surgeons of Ontario Unintended Consequences: Sometimes medications end up in unusual places... Like Trail Mix Parties, 2014 National Pain Centre, McMaster University Youth and prescription painkillers: What parents need to know, 2013 Centre for Addiction and Mental Health

102 DRAFT Royal College ol Dental Surgeons of Ontario Bmuring Continued Tn.!.rt 6 Crescent Road Toronto, ON Canada M4W 1T1 T: F: Toll Free: _07/14