Frequently Asked Questions - Prevention of Boundary Violations and Sexual Abuse

No, sometimes boundary violations can be unintentional. Despite good intentions, the dentist’s behaviour or words can result in a violation.  

Case scenario number 1 provides an illustration of an unintentional boundary violation.

Unintentional boundary violations also include situations where a dentist immediately recognizes that they have accidentally violated a boundary (for example, if their hand accidentally hits the side of a patient’s body during treatment). In these situations, the dentist may wish to consider apologizing to the patient and re-establishing the boundary. The Standard requires the dentist to record the boundary violation including any relevant observations or statements from the patient, dental staff or others present. A dentist may also consider recording any steps taken to re-establish the boundary, including any conversations with the patient about the incident, and actions taken to ensure the patient’s comfort and safety before continuing to provide care. 

The Standard must align with legislative definitions, because the College uses these definitions to determine if sexual abuse occurred while a person was a patient. This consistency ensures clear guidelines and helps protect patients.

Professional communication involves dentists being respectful when making comments and responding to patients, while explaining that the aim is to achieve better health outcomes. By contextualizing comments this way, dentists can help educate patients about their health.

Patients have a reasonable expectation of privacy around the information they share with their dentist, and they expect personal details not to be disclosed to unauthorized individuals without consent. This expectation helps maintain trust and ensures that sensitive details remain confidential except in specific legal circumstances. If a privacy breach occurs, it can cause a patient to lose trust in their dentist or the public to lose trust in the dental profession, and it can be seen as a boundary violation.

While dentists can communicate with patients on social media, dentists must be aware that anything they say to patients on social media may be considered to be part of their professional role. Accordingly, they can be held accountable for inappropriate communication or violating boundaries.

It is best practice to avoid sharing personal health information with patients over social media due to its lack of security.

For more information on using social media appropriately, please see the College’s Practice Advisory on the Professional Use of Social Media and the associated infographic.

The Standard requires dentists to appropriately manage gift-giving and receiving, to ensure that there are no conflicts of interest, clinical judgment and objectivity are not compromised, and appropriate professional boundaries are preserved. 

Gift-Giving

Examples of gifts that may be appropriate for a dentist to give to patients are teeth cleaning supplies for their own personal use (e.g. toothbrushes, toothpaste, floss, etc.)  and a small toy to a child after an appointment. 

Examples of gifts that are inappropriate for dentists to give to patients are “incentive gifts”, which are gifts given to individuals to become or remain patients (e.g. gift-cards, credits, rebates and other benefits – see the College’s Conflict of Interest Guidelines). 

Gift-Receiving

Examples of gifts that would often be appropriate for dentists to accept from patients are small token gifts such as chocolate for the holidays. It may also be appropriate for dentists to receive gifts of cultural significance, such as a token gift associated with a patient’s cultural New Year. 

Soliciting gifts from a patient could amount to a conflict of interest. 

Additional factors that will help inform whether a gift is appropriate to give or receive can be found in the next question. 

An office policy for gift-giving and receiving will help dentists apply consistent and transparent judgment when deciding whether giving or accepting a gift is appropriate (e.g., whether it might result in a conflict of interest, compromise clinical judgment and objectivity, or compromise professional boundaries). 

Some factors that may be included in a policy are:

• Value – in general, gifts of low or nominal value are more likely to be acceptable. As the value of the gift increases, so does the likelihood that accepting or giving the gift would be seen by the College to be inappropriate. A helpful consideration is whether a dentist would be comfortable with their colleagues or the College knowing about the gift. 
• Nature (e.g. gifts that are intimate or overly personal can compromise professional boundaries)
• Occasion (e.g. a holiday token present would often be appropriate) 
• Cultural significance 
• The patient’s intent and expectation in offering the gift (e.g. will the patient expect anything in return?) 
• The effect on the dentist’s provision of care to the patient (e.g. will the dentist feel that they owe something or have a special obligation to that patient over other patients?) 

The policy can also include effective strategies to lessen risks, such as “de-personalizing” gifts whenever possible, for example, by accepting chocolates from a patient which are then shared with the office staff. 

Dentists can have a process in place when they have declined a gift, but the patient does not take it back. For example, if a patient gives a dentist artwork that they cannot accept, the dentist can consider donating it to a charity. 

Yes, a dentist is allowed to treat their spouse. This is someone they are married to or have been in a common-law relationship with for at least 3 years.

However, marrying a person (that is not a common law spouse as defined in the Standard) does not mean that a dentist did not sexually abuse them while they were a patient, if they started a sexual relationship with the person before marriage, while they were a patient or less than one year after the dentist-patient relationship ended. In these circumstances, a dentist can still be found guilty of sexual abuse and agreement from the person to marry the dentist is irrelevant.

No, a dentist cannot treat a romantic partner that is not their spouse as defined above.

This means that dentists cannot treat:

• Someone they are engaged to that is not their common-law spouse as defined above
• A boyfriend or girlfriend or significant other
• Someone they are in an intimate or sexual relationship with that is less than three years.

The only exception to this is when care is provided in emergency circumstances or the care provided is minor in nature and the dentist has taken reasonable steps to transfer the care of their romantic partner to another regulated health professional or there is no reasonable opportunity to do so.

Yes, dentists are allowed to treat their family members and friends. However, dentists are advised that this introduces risks to both the dentist and the patient (e.g. compromised clinical judgment on the part of the dentist and patient discomfort in raising questions or concerns), which must be managed in accordance with the requirements set out in Provisions #10-12 of the Standard. This includes being sure that they can provide care objectively, focusing on the best interests of their friend or family member as a patient. 

When considering whether it is appropriate to treat a family member or friend, dentists can consider whether the person will feel inhibited about making their own decisions, asking questions, sharing sensitive personal health information, disagreeing with the dentist or asking for a second opinion. If the patient is a minor, the dentist can consider whether the parent that is making decisions on behalf of the minor feels free to do the same. 

The Standard requires dentists to make sure that conflicts of interest are recognized and managed appropriately when treating friends or family. Conflicts of interest happen when decisions made by the dentist are based on the dentist’s interests rather than the patient’s best interests. For example, if a dentist has a financial interest in an appliance company and recommends to some patients to purchase appliances from that company that are unnecessary for their care and without disclosing the dentist’s financial interest, that would be a conflict of interest. 

If a dentist does not feel confident that they can meet their professional obligations while providing care to a friend or family member, the Standard requires the dentist to end the treating relationship with their friend or family member in accordance with the College’s Practice Advisory on Maintaining a Professional Patient-Dentist Relationship. 

The considerations and requirements mentioned above also apply to dentists treating those in small/remote communities where there is a likelihood that the dentist would know a patient on a personal level. If a patient has no other dentist they can see and the dentist feels conflicted about providing care to the patient, the dentist can consult other colleagues regarding the patient’s care. This may include arranging a virtual consultation. 

The Standard advises dentists to avoid entering into personal relationships with persons closely associated with patients. In the event a dentist is considering such a relationship, the Standard provides factors to consider in determining the appropriateness of the relationship to ensure a patient’s trust or care is not undermined. 

Certain factors can increase the risk of the patient’s care being undermined. These include (as examples): the complexity of the clinical care being provided and the degree to which the patient is dependent on the person emotionally and/or as a substitute decision-maker (e.g. the patient is a minor). 

Ultimately, it is important for a dentist to feel confident that they can prioritize the best interests of the patient while providing care to them. This means that a dentist would not allow their clinical judgment or objectivity to be affected by anyone they are in a relationship with. 

In addition, it is important for a dentist to consider whether a patient would feel comfortable seeking care from the dentist while the dentist is in a relationship with the person closely associated with them. This includes the patient feeling that they can trust the dentist to maintain their privacy and confidentiality of their personal health information, unless the person closely associated with the patient is authorized by law to know that information (e.g. being a substitute decision maker).

While dentists are allowed to treat their staff members, to lessen the risk of boundary violations and patient care being undermined, dentists can consider entering into an agreement with another dental practice to treat their employees and vice-versa. If this is not possible, it is important to recognize that treating a staff member means that they are both a dentist’s employee, and their patient, which results in risks that must be managed in accordance with the requirements set out in the Standard.

It is important for dentists to keep in mind that interactions with staff who are patients will result in two different kinds of relationships: 

• Treating relationship – providing care to the staff member 
• Working relationship (i.e. the employer-employee relationship) – this encompasses carrying out workplace duties. Within this context, there is also a social relationship, where interacting with staff in a social way fosters team bonding in an appropriate and professional manner. 

When dentists have a treating, working and social relationship with a staff member, dentists may want to consider the treating relationship as paramount (i.e. considering the staff member as a patient first). The boundaries of the treating relationship can then inform the boundaries of the working and social relationships. In particular, in all relationships held by dentists with the staff member, the requirements of the Standard and Code of Ethics would apply, including maintaining professionalism and appropriate boundaries.

As a reminder, when providing dental care to a patient who is also a staff member, the treating relationship is paramount and the staff member is a patient first.  

Some best practices dentists can consider are:  

• Being professional in their social interactions with their staff, including at social events after working hours
• Being mindful of their discussions with staff and behaviour in the office 
• Avoiding the potential for boundary violations when travelling with staff and attending professional conferences, such as by not sharing hotel rooms 
• If the staff member requires complex care and the dentist feels their clinical judgment and objectivity will be influenced by the social or working relationship, the dentist can consider referring the staff member to a colleague. 

Discussions with Staff Members Before They Become Patients

Given the power imbalance that naturally exists in the employer-employee relationship, it would be important for the dentist to consider whether the staff member’s autonomy as a patient in the treating relationship can be preserved. This means that the staff member should feel free and comfortable to make their own decisions about their care, including voicing any concerns or disagreement with the dentist. 

Dentists may also want to establish a clear understanding of what will happen to a staff member’s dental care when the dentist-patient relationship or employment relationship ends. 

It is important to understand how common trauma and ongoing violence is in the general population and the impact that it can have on a patient. 

While a dentist can include an optional question on a medical history questionnaire for a patient to indicate whether they have experienced trauma, the Standard requires dentists to assume that a patient has experienced trauma and/or violence and act accordingly. Case scenario #8 provides an example of this.

There are several resources that a dentist can use to learn more about how to integrate this approach into their dental care practice.  Please see: 

Written Resources

Trauma and Violence Informed Care Tool - Equip Health Care

Trauma Informed Care – Ontario Dental Association (requires ODA membership)
CAMH - Trauma Informed Practice - Ontario Dental Association (requires ODA membership)
Handbook for Sensitive Practice – Government of Canada

Trauma and violence-informed approaches to policy and practice – Government of Canada
Dentistry and Trauma-Informed Care – AboutFace
Trauma Informed Care and Oral Health – Recommendation for Practitioners – The Illinois ACEs Response Collaborative – Health & Medicine Policy Research Group

Videos

Trauma-informed Care in the Dental Office Video – Canadian Dental Association  
Trauma-Informed Care – A CSDH/AboutFace Panel Discussion – Canadian Dental Association

The College advises registrants to use the “ADVR” approach if they suspect that a patient is being domestically abused.

The steps are as follows:

Ask – ask about abuse in a professional way (e.g. “Sometimes when I see a loose tooth like this, it means the patient is being hurt by someone. Is this happening to you?”)

Validate – validate that being hurt is wrong, while confirming the victim’s worth (e.g. “Nobody deserves to be hurt and should feel safe at home.”)

Document – document the presenting signs and symptoms of abuse such as:

• Location, size, duration, colour and shape of physical injury
• Patient disclosures, including any names, locations and witnesses shared

Refer – offer a list of local domestic violence resources/referrals in private.

Please visit this webpage for a list of resources, such as crisis services, legal help and shelters that can be shared with patients.

If a patient initiates inappropriate physical contact, it is important for the dentist to re-establish the professional boundary between themselves and the patient. Since the Standard requires dentists to document any incidents of boundary violations in the patient record, the dentist must document the inappropriate physical contact from the patient. The dentist may also want to consider documenting how they responded to it, in the event a question arises in the future about how the dentist managed the incident. If the behaviour continues, it may be appropriate to end the relationship in accordance with the College’s Practice Advisory on Maintaining a Professional Patient-Dentist Relationship.

Sexual abuse can include inappropriate sexual comments, gestures and behaviour towards a patient. For example, saying something sexually suggestive, making sexual jokes, or asking questions about a patient’s sexual preferences can be sexual abuse. 

Under the Regulated Health Professions Act, 1991, aside from the spousal exemption, having a sexual relationship with a patient is considered to be sexual abuse even if the patient agrees to it. 

Under the Regulated Health Professions Act, 1991, aside from the spousal exemption, a dentist cannot enter into a sexual relationship with a person during the time they are a patient and for one year following the end of the dentist-patient relationship. If a dentist fails to meet this legislative requirement, they can be found guilty of sexual abuse. 

RCDSO has zero tolerance for sexual abuse. Dentists who are found to have sexually abused a patient are subject to serious consequences including a reprimand and suspension or revocation of their certificate of registration (see section 51(5) of the Regulated Health Professions Act, 1991 for more information).