2.4 Abuse and Neglect Reporting, Conflicts of Interest & Patients with Infectious Diseases

2.4 Abuse and Neglect Reporting, Conflicts of Interest & Patients with Infectious Diseases

Quick Answer: Three short Domain 1 competencies are easy to overlook: reporting suspected abuse or neglect (1.3), recognizing and reporting conflicts of interest (1.6), and the legal and ethical care of patients with known infectious diseases (1.7). Across Canada, anyone with reasonable grounds to suspect that a child needs protection must report it directly and promptly to child protection services. Conflicts of interest must be disclosed and resolved in the patient's favour. Patients with HIV, hepatitis B or hepatitis C cannot be refused care because of their diagnosis; Routine Practices already protect everyone.

1. Recognizing Abuse and Neglect

Dental teams see the head, face and mouth at every visit, and these are among the most common sites of physical abuse injuries. The NDAEB Domain Description asks you to report suspected physical, sexual or emotional abuse or neglect and to help with documentation and supports.

Dental neglect is the wilful failure of a parent or guardian to seek and follow through with the treatment needed to keep a child free of pain and infection. Missing one appointment, or having a family that cannot afford care, is not neglect in itself. A pattern of ignoring known disease after barriers have been addressed is.

The same warning signs can appear in older adults (elder abuse, neglect by caregivers) and in adults experiencing intimate partner violence. Typical clues include injuries in different stages of healing, a caregiver who will not leave the room, or dentures and medications withheld.

2. The Duty to Report

Children

• Every province and territory has child protection legislation that requires anyone who has reasonable grounds to suspect that a child is, or may be, in need of protection to report it. Professionals are specifically included. (Ontario's Child, Youth and Family Services Act, 2017 is one example; the age covered and the details vary by province.)
• You do not need proof. Reasonable grounds are what a reasonable professional would suspect from what they saw or heard.
• The duty is personal. You must report directly to the child protection agency (or to police if the child is in immediate danger). Telling the dentist or office manager does not fulfil your duty, even though you should also inform them.
• The duty overrides confidentiality, and people who report in good faith are protected from liability.
• The duty is ongoing. If you see new signs later, you report again.

Adults

• Reporting rules for adults differ by province. Some provinces require reporting abuse of adults who live in care facilities (for example, under long-term care legislation), while abuse of a capable adult living in the community is generally reported only with that person's consent.
• If an adult is in immediate danger, call 911.
• Otherwise, speak privately with the patient, offer information about local supports (victim services, shelters, help lines) and respect a capable adult's decision.

Assisting with Documentation and Supports

1. Record objective findings: location, size, colour and shape of injuries, with tooth numbers in FDI notation and a body or face diagram if helpful.
2. Quote what the patient or caregiver said, in their own words and in quotation marks.
3. Take clinical photographs only according to office policy and consent rules.
4. Record the date and time of the report, the agency contacted, the name of the person you spoke with and any reference number.
5. Keep the information confidential within the record. Do not confront the suspected abuser, and do not question a child in detail; leave investigation to the agency.

3. Conflicts of Interest

A conflict of interest exists when a personal interest (financial, family or social) could influence, or appear to influence, your professional judgment or duties. Conflicts can be actual, potential or perceived; all three must be managed.

Examples in a dental office:

• Accepting gifts, trips or cash from a supplier, laboratory or sales representative in return for promoting a product.
• Recommending a product you sell privately (for example, a whitening kit from a side business) or earning a commission on referrals.
• Recommending a laboratory or specialist because a friend or family member owns it.
• Treating, recording or billing for close family members in ways that bypass normal office procedures.
• Endorsing products on social media while identifying yourself as a dental professional, without disclosing payment.

How to manage a conflict:

1. Recognize it. Ask whether a reasonable patient would worry that your advice was influenced.
2. Disclose it to the supervising dentist (and to the patient when it affects them).
3. Remove yourself from the decision or decline the benefit when disclosure is not enough.
4. Put the patient's interest first. The CDAA Code requires that information gained in the course of duty be used solely in the patient's best interests, and it forbids dishonest behaviour or misrepresentation.
5. Report to the regulator any conduct by others that breaks provincial or federal law, as the CDAA Code requires.

4. Treating Patients with Known Infectious Diseases

Legal and ethical principles

• No refusal of care. Refusing or limiting treatment because a patient has HIV, hepatitis B or hepatitis C is discrimination. Human rights legislation treats these conditions as disabilities, and regulators treat discriminatory refusal as professional misconduct. Under the CDAA Code, dignity, equity and fairness apply to every patient.
• Routine Practices for everyone. Because many infected people do not know their status, the same precautions protect every patient and worker. Disclosing a bloodborne infection does not call for extra barriers, double gloving or booking the patient at the end of the day.
• Confidentiality. A patient's infection status is personal health information. Record it as a confidential medical alert, share it only within the circle of care and never discuss it within earshot of others.
• Transmission-based precautions are different. Airborne or droplet diseases (active tuberculosis, measles, influenza) are spread by everyday contact, unlike bloodborne viruses. For these, elective care is postponed until the patient is no longer infectious, and urgent care is arranged in a suitable setting.
• Informed consent for source testing. After an exposure incident, the source patient may be asked to consent to testing. Testing without consent is not permitted.
• Infected health care workers. Dental assistants living with a bloodborne infection have the same right to privacy. They should follow their regulator's and public health authority's guidance on any procedures that might need review.