Dentists are responsible for maintaining appropriate boundaries with their patients at all times, including outside of work hours. While the dentist may have had good intentions to offer helpful recommendations to his patient for her trip, it was not appropriate for the dentist to e-mail the patient for a reason not relating to dental care without her consent. In addition, sending personal photographs of himself may be considered a boundary violation. 

Even though it was the patient that asked the dentist to meet her for coffee, it was the dentist’s responsibility to consider the implications that meeting would have on the therapeutic dentist-patient relationship. In many cases, dentists may feel it is best to decline social invitations from patients and explain that it would be beyond the scope of their professional relationship to meet.

In addition, the dentist should have considered that befriending the patient on social media using a personal Instagram account could blur boundaries and lead to a boundary violation¹. 

These kinds of events can quickly lead to other events that are more likely to violate boundaries and result in an unprofessional dentist-patient relationship. Dentists must engage in risk management from the very beginning of the relationship, to ensure appropriate professional boundaries are maintained.

 ¹ See the Practice Advisory on Professional Use of Social Media (March 2018).

Making sexualized comments about a patient’s appearance can be considered as “remarks of a sexual nature” which is part of the definition of “sexual abuse” under the Regulated Health Professions Act, 1991.¹

It is important for dentists to monitor their comments on a patient’s appearance so that they do not constitute boundary violations or sexual abuse, even if they are intended to be compliments. This is especially relevant for dentists that may be involved in work that pertains to the appearance of a patient’s mouth area. In this case, the surgeon could have commented on the alignment of the patient’s jaw from a clinical perspective and could have asked the patient about her satisfaction with the surgery to gauge her feelings about her new appearance.

¹ s. 1(3) of the Health Professions Procedural Code (HPPC), Schedule 2 of the Regulated Health Professions Act (RHPA), 1991 S.O. 1991, c.18.

A sexual relationship with a patient is sexual abuse under the Regulated Health Professions Act, 1991 and dentists have a legal duty to report sexual abuse when there are reasonable grounds to believe that it has occurred.¹ They must file a report immediately if there are continued risks to a patient.² In this case, while the dentist may feel happy for her colleague, she has a legal and ethical obligation to report her colleague to the College. Given that administrative staff confirmed that the dentist’s colleague was dating the patient, including them travelling together, there was enough information to constitute reasonable grounds to believe that sexual abuse had occurred.³

Dating a patient involves placing a dentist’s personal interests over the best interests of the patient and takes advantage of the power imbalance inherent in the dentist-patient relationship. It may also affect clinical objectivity in the therapeutic dentist-patient relationship. Both of these factors put a patient at risk, even if the patient consents to the relationship. Patient consent is never a defence to sexual abuse. 

Every dentist must ensure that they follow their duty to report sexual abuse. Failure to do so may result in a finding of professional misconduct under the Professional Misconduct Regulation⁴ of the Dentistry Act, 1991.
 
¹ s. 85.3(1) of the HPPC, Schedule 2 of the RHPA, 1991.
² s. 85.3(2) of the HPPC, Schedule 2 of the RHPA, 1991.
³ It should be noted that no legal action or proceeding can be brought against a dentist for making a report in good faith under s. 85.6 of the HPPC.
⁴ O.Reg. 853/93 under the Dentistry Act, 1991.S.O. 1991, c. 24. 

Under the Regulated Health Professions Act, 1991, the person is a patient of the dentist, as the dentist received payment from the person for the service provided (i.e. the cleaning and examination) and contributed to the health record of the person.¹ In addition, in dentistry, it is common for there to be a gap in care provided to patients and that does not result in a patient no longer being a patient of the dentist. In this case, it had been 6 months since the person last saw the dentist for care, but the person would still be considered a patient of the dentist. 

Under the Regulated Health Professions Act, 1991, there is a prohibition on becoming involved in a sexual relationship with a patient for at least one year after the dentist-patient relationship has ended.² In this case, the dentist-patient relationship was never terminated so the patient was still a patient during the 6 months since her last treatment. Proceeding with dating the patient would constitute sexual abuse under the Regulated Health Professions Act, 1991.^3
 
1 O. Reg. 260/18. Patient Criteria Under Subsection 1(6) of the HPPC, Schedule 2 of the RHPA, 1991.
² s. 1(6) of the HPPC, Schedule 2 of the RHPA, 1991.
³ s.1(3) of the HPPC, Schedule 2 of the RHPA, 1991.

While the dentist did not solicit the hockey game tickets from his patient and the patient got them for free, the dentist should have considered the effect accepting the tickets would have had on himself and the patient. In particular, there was the risk of the patient misinterpreting the dentist accepting the tickets as meaning that she was entitled to a favour or special treatment by the dentist in the future. There was also the risk of the dentist feeling like he would owe the patient something in the future.  

Even though the hockey tickets were free, they still had value that could influence the dynamics of the professional relationship with the patient. Accepting the tickets eventually caused the dentist to feel like he had to give the patient special treatment and prioritize her care over others who had a more urgent need to see him.

The dentist could have thanked the patient for her kindness and declined the gift, explaining that accepting it could lead to misinterpretations that could compromise the boundaries of his professional role. If the dentist had an office policy on gift-giving and receiving in place, the dentist could have quoted or shared the policy with the patient, explaining that it was necessary to decline the gift to ensure appropriate professional boundaries could be maintained.

Being a close friend to a patient can result in compromising a health professional’s clinical objectivity and judgement. The risk to a patient increases when the nature of care required is more complex. Given that the surgeon felt emotional and the nature of the surgery that was required was complex, it would have been best for the surgeon to politely decline providing care to his friend while explaining that it would be in the friend’s best interest to seek care elsewhere. The surgeon could have then offered to provide a referral to another appropriate surgeon.  

In this case, the orthodontist should have been conscious of her role as an authority figure alongside her friendship. She should have ensured that her friend did not feel pressured to follow her recommendation. For example, the orthodontist could have told her friend that while she was providing an opinion on her child’s care, she should feel free to obtain a second opinion and that the orthodontist would not feel offended if she did so. In addition, the orthodontist could have asked her friend if she wanted a referral to an oral surgeon or if she wanted some time to think about it, instead of unilaterally making that decision for her, even if the orthodontist thought that it would be in the child’s best interest to have the jaw surgery done.

It is important for dentists to be sensitive to non-verbal cues from a patient in response to touch and the practice environment and respond accordingly. In this case, even though the patient said that she was okay and had not disclosed any trauma to her dentist, her behaviour suggested that she may be uncomfortable. The dentist could have told the patient about what to expect for the first step of treatment and how long that would last. He could have also asked her to let him know if she needed to take a break at any time and if she needed anything to feel more comfortable for the treatment, such as offering to put on the television.