Volume 10 • 2023 • Issue 2

The Canadian Dental Association Magazine 2023 • Volume 10 • Issue 2 The Burden of Burnout on Dentists Page 21 + IN THIS ISSUE Soothing the Senses to Improve the Patient Experience P. 16 Complying with Employment Laws When Starting or Buying a Practice P. 29 Using Person-First Language in the Dental Office P. 33 PM40064661

CDABoardofDirectors President Dr. Lynn Tomkins Dr. Marc Mollot Manitoba CDAMissionStatement The Canadian Dental Association (CDA) is the national voice for dentistry dedicated to the promotion of optimal oral health, an essential component of general health, and to the advancement and leadership of a unified profession. is the official print publication of CDA, providing dialogue between the national association and the dental community. It is dedicated to keeping dentists informed about news, issues and clinically relevant information. Dr. Brian Baker Saskatchewan President-Elect Dr. Heather Carr Vice-President Dr. Joel Antel Dr. Mark Bochinski Alberta Dr. Dana Coles Prince Edward Island Dr. Viktor Dorokhine NWT/Nunavut/Yukon Dr. Stuart MacDonald Nova Scotia Dr. Bruce Ward British Columbia Dr. Jason Noel Newfoundland/Labrador Dr. Kirk Preston New Brunswick Dr. LouAnn Visconti Ontario 2023 • Volume 10 • Issue 2 Head of Communications Zelda Burt Managing Editor Sean McNamara Writer/Editor Sierra Bellows Gabriel Fulcher Pauline Mérindol Publications & Electronic Media Associate Rachel Galipeau Graphic Designer Carlos Castro Advertising: All matters pertaining to advertising should be directed to: Peter Greenhough Media Partners Inc. 15 Wade Road Ancaster, ON L9G 4G1 Display or web advertising: Peter Greenhough pgreenhough@pgmpi.ca 647-955-0060, ext. 101 Classified advertising: John Reid jreid@pgmpi.ca 647-955-0060, ext. 102 Contact: Rachel Galipeau rgalipeau@cda-adc.ca Call CDA for information and assistance toll-free (Canada) at: 1-800-267-6354 Outside Canada: 613-523-1770 CDA email: publications@cda-adc.ca @CdnDentalAssoc @JCDATweets @CDAOasisLive canadian-dentalassociation CanadianDental Association CDAOasis cdndentalassoc cdaoasis cda-adc.ca CDA Essentials is published by the Canadian Dental Association in both official languages. Publications Mail Agreement no. 40064661. Return undeliverable Canadian addresses to: Canadian Dental Association at 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6. Postage paid at Ottawa, ON. Notice of change of address should be sent to CDA: reception@cda-adc.ca ISSN 2292-7360 (Print) ISSN 2292-7379 (Online) © Canadian Dental Association 2023 Editorial Disclaimer All statements of opinion and supposed fact are published on the authority of the author who submits them and do not necessarily express the views of the Canadian Dental Association (CDA). Publication of an advertisement does not necessarily imply that CDA agrees with or supports the claims therein. The editorial department reserves the right to edit all copy submitted to CDA Essentials. Furthermore, CDA is not responsible for typographical errors, grammatical errors, misspelled words or syntax that is unclear, or for errors in translations. Sponsored content is produced by Peter Greenhough Media Partners Inc., in consultation with its clients. The CDA Essentials editorial department is not involved in its creation. 3 Issue 2 | 2023 |

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Contents The Canadian Dental Association Magazine 2023 • Volume 10 • Issue 2 11 16 29 33 CDA atWork 7 President’s Column: A Crossroads for Dentistry 11 CDA Releases Policy Paper With Guidance for the Federal Government’s Investment in Dental Care News and Events 14 Dental Digest Issues and People 16 Soothing the Senses to Improve the Patient Experience 21 The Burden of Burnout 29 Starting or Buying a Practice: How to Comply with Employment Laws Classifieds 42 Offices and Practices, Positions Available, Advertisers’ Index Supporting Your Practice 33 Words Matter: Person-First Language in the Dental Office 36 Concerned That Inflation Will Affect Your Retirement Plans? 38 Managing an Employee with an Addiction Problem 40 Investing in Your Team’s Mental Health Obituaries 46 Dr. Donald K. Russell 5 Issue 2 | 2023 |

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CONTINUEDP.8 Dr. Lynn Tomkins president@cda-adc.ca ACrossroads forDentistry Back in 2019, as I contemplated running for the presidency of CDA, I knew the association was future-focused, dynamic and well-positioned to manage social and economic transformation. The work that had been done for the Future of the Profession initiative since 2016 meant that we would be able to “skate to where the puck was going to be”—a hockey analogy, and yes, I am a proud Canadian. Of course, I didn’t know back then how quickly and thoroughly our abilities to adapt would be tested, first by the COVID-19 pandemic and then by the federal government’s commitment to provide funding to improve access to dental care in Canada. I am tremendously proud of how we cared for our patients during the pandemic under extraordinary conditions. Due to our collective diligence as a profession, there haven’t been any documented cases of COVID-19 transmission between a patient and an oral health care provider in Canada to date. Role of Associations in a DynamicWorld The role of a professional association is evolving along with our changing environment. Historically, a dental association functioned in a variety of ways, including serving as a proponent for standards of practice and education, as an advocate for the public good and as a voice for the profession. In several Canadian provinces, regulatory responsibilities have been separated from dental associations. In Germany, dentists have regulators, unions and associations, and it is the unions that negotiate contracts for dentists. Regulators set professional standards that we must meet, but associations, I believe, are the organizations in which we aspire to achieve the highest ideals of our profession. In an association, we plan for the future—we actively work toward one where dentistry can efficiently, fairly and compassionately serve the health and well-being of all Canadians. One might dismiss this notion as utopian, but dentistry has in many ways been shaped by altruistic ideals. We change lives for the better. We alleviate pain and suffering. We are oral physicians and surgeons. Balancing Public Good with EconomicWell-being We have arrived at a crossroads in dentistry, and in this defining moment, we must consider the implications of the fragile balance struck between our commitment to serve the public good and our need to sustain our economic well-being. This is not a situation unique to dentistry, it is shared by other health care sectors, but we find ourselves in a pivotal position at this time. The pandemic was a turbulent period for small business owners of every kind. Inflation, high interest rates and economic uncertainty are stressful for many dentists who have a high level of financial obligation. And our dental students are now graduating with more debt than ever before. Increasingly, there are non-dentist investors in dental practices with their own business obligations. I believe that because of the rather isolated nature of our work and the way the pandemic shrank our lives, many dentists may feel alone in their struggles, both financial and otherwise. Federal Funding for Dental Care My term as CDA president has been focused largely on the new federal funding for dental care and explaining dentistry’s unique expertise to the government to ensure that their investment is effective, sustainable and reaches the Canadians who need it most. Canada’s oral health care system of predominantly private dental practices is efficient; the public health care system in Canada has capacity issues that dentistry From the President 7 Issue 2 | 2023 | CDA atWork

From the President doesn’t yet face. But the federal funding announcement has brought stress and worry upon dentists, especially in provinces and territories where public funding for dental care has been woefully inadequate. I believe these feelings arise from concern about that balance between our desire to serve the public good and our need to preserve our financial sustainability. We are oral health professionals. We are business people. What happens when the interests of those two identities aren’t easily aligned? A century ago, the dean of my great uncle’s dental school said in his speech to graduating dental students that practising dentistry was an act of service, a noble calling to alleviate human suffering, and an opportunity to make patients’ lives happier and healthier. This ideal has been the foundation of the social contract that accords dentistry respect, self-regulation, and trust from the public. We continually have to earn this respect and trust. To put it plainly, as a profession, we need to put the public good first and our own good second. This is expected of medical doctors, and it’s expected of us. Anything less risks losing the public trust and the confidence of government. As an association, we should not function like a union because, although we serve the dentists of Canada, we can only serve them well if we uphold our professional ideals and the long-term view of what we hope to achieve. We need to think of the people we serve as including our patients, but also the dentists of the future for whom we are stewards of our profession. Looking to the Future I’m very hopeful and excited for the future of dentistry in Canada. Today, dental school graduates have more medical training than ever before and are more oriented towards collaborative practise. Dentistry will continue to be more closely integrated into the overall medical system, while still retaining the unique features that make private practice dentistry so efficient and effective. I believe dentists will need to practise to the maximum of their scope and that this scope may expand. Indeed, we will need everyone on the oral health care team to practise to the maximum of their abilities if we are to reach all people in Canada. I can imagine dentists doing more primary care and screening for common diseases, which would benefit patients and society at large. Dentists providing vaccination—which occurred in some provinces during the pandemic and now also includes administering HPV vaccines in Alberta—is just one example of how dentistry could increase access to care throughout the health care system. If we are going to provide dental care to an additional 9 million Canadians who may benefit from the increased federal funding, we’ll need to collaborate with other health care professions as well. To help build these alliances, I’d like to see dental clinics in every hospital and large long-term care facility. A strong and well-supported Canadian dental education system will enable us to interact as equal partners with physicians. Most of the dentists that I’ve met during my career and through organized dentistry are compassionate, altruistic people. Many of us have treated patients without expectation of remuneration and we are better for it. But we must advocate for a brighter future where no Canadian will need to rely on charity for oral health care. Until we get there, dentists must continue to be healers first. I have been so honoured to serve as CDA president, and my high regard for this association has only grown. For more than a century, CDA has been the voice of the Canadian dental profession and the advocate for optimal oral health for all Canadians. We must continue to be that voice with a clear and consistent message that we are here to serve equally all who put their trust in us, without fear or favour. 8 | 2023 | Issue 2 CDA atWork

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CDA Releases Policy PaperWith Guidance for the Federal Government’s Investment in Dental Care On February 28, 2023, CDA released Bridging the Financial Gap in Dental Care: Building a sustainable and effective federally funded program, a policy roadmap for the federal government as it seeks to enhance access to dental care for all Canadians. “Canada’s historic investment in dental care comes at both an exciting and challenging time for the oral health profession,” said Dr. Lynn Tomkins, CDA president. “Dentists understand the challenges our patients face more than anyone. By sharing our profession’s unique experiences and CDA’s Main Recommendations: A federally fundedprogramshouldpromote the delivery of dental care primarily through the existing network of dental offices, supplemented by public clinics, as needed. Public dental care programs should remain a payer of last resort, after any privately funded coverage. A federally funded program must be designed to complement and improve the care that Canadians have through existing federal, provincial and territorial programs. Program design should ensure that administrative procedures do not impact or delay the provision of care to patients. The federal government should address human resource challenges and staffing shortages in the oral health sector. Any federal dental care formula should ensure the cost of treatment provided to patients is fully covered. 11 Issue 2 | 2023 |

extensive knowledge, we aim to ensure the effectiveness of this investment so that it can adequately serve those who need it most.” A federally funded dental care program will require a holistic, patientcentered approach—one that covers the full cost of treatment provided to patients and prioritizes preventative care. Read CDA’s full policy paper: bit.ly/3EZV6gD As the federal government considers implementation of a new dental care program, it will be critical to maintain primary delivery through Canada’s existing network of dental offices to not disrupt the system many Canadians rely on. By remaining a payer of last resort (i.e., the government program pays only after all other programs have been pursued for payment) and by implementing a system that continues to preserve and promote employer-provided dental coverage, Canada can deliver a program that is sustainable, effective, and accessible to all Canadians. A federally funded dental care program will require a holistic, patient-centered approach—one that covers the full cost of treatment provided to patients and prioritizes preventative care. To prevent increased wait times, and to ensure Canadians can access the care they need when they need it, a dedicated strategy will be essential to address the current human resource challenges in the oral health sector. “Dentists see firsthand the impact that poor oral health can have on a person’s overall health and are thankful for the opportunity to provide valuable expertise,” said Dr. Tomkins. “We look forward to continued collaboration with Health Minister Jean-Yves Duclos, and his federal colleagues, to develop an approach that will narrow the gaps in access to dental care, while minimizing disruptions for the majority of Canadians who already have dental coverage.” The policy paper reiterates that federal funding for dental care is a once-in-a-generation opportunity tomake a difference in the lives of millions of Canadians. It is imperative that the federal government continues to consult and collaborate with Canada’s dentists, and all relevant stakeholders, on the design of a long-term program that will provide the highest quality care to those who need it most. 12 | 2023 | Issue 2

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DENTAL DIGEST The FDI World Dental Federation, in collaboration with the International Society of Oral Oncology and with the support of Zendium, has developed a new mobile application called ONCOllab: The Oral Care Guide for Cancer Care Teams. The app is designed to help health care professionals in the cancer care team manage any oral complications that may arise due to cancer therapy. Dr. Deborah Saunders, medical director of dental oncology at the Northeast Cancer Centre in Sudbury, Ontario, was interviewed about ONCOllab on CDA Oasis. She talked about the impact that some cancer therapies can have on dental patients and she demonstrated some of ONCOllab’s key features. The ONCOllab app can also be used as a preventive measure as it has risk calculators that it incorporates for different disease sites. This information can then be printed or emailed to patients to give them further details about their treatment. ONCOllab: An Oral Care Guide for Cancer Care Teams First Visit, First Tooth Program Update ADA Releases Report on AI in Dentistry Due to a steady decline in requests, CDA’s First Visit, First Tooth in-person teaching kit will be discontinued as of April 30. CDA strongly supports that infants are seen by a dentist within 6 months of the eruption of the first tooth or by age 1. For more information about the importance of early dental visits, please visit the CDA website and see our position statements on first visit to the dentist and early childhood caries. The printable First Visit, First Tooth dental office poster will continue to be available for download from the CDA website. A new white paper, published by the American Dental Association (ADA) Standards Committee on Dental Informatics, explores applications of Artificial Intelligence (AI) and Augmented Intelligence (AuI) in dentistry. Published in February 2023, the ADA white paper examines the use of AI and AuI in clinical matters such as prevention, caries and periodontal disease, implants, oral and maxillofacial surgery, endodontics, imaging and orthodontics. It also includes discussions on potential non-clinical uses of AI and AuI, including in areas like claims processing, payment integrity and dental practice administration. Watch the interview with Dr. Deborah Saunders on CDA Oasis at: bit.ly/41Q6dTl See: bit.ly/3SXgZmz Download the ADA white paper at: ada.org/ dentalstandards 14 | 2023 | Issue 2

LABOUR SHORTAGES, WORKING CONDITIONS AND THE CARE ECONOMY Report of the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities Robert J. Morrissey, Chair FEBRUARY 2023 44th PARLIAMENT, 1st SESSION On February 6, 2023, the House of Commons Standing Committee on Human Resources, Skills and Social Development (HUMA) published its report on labour shortages, working conditions and the care economy. To help inform the report, HUMA held a series of meetings in 2022 with key stakeholders, including Dr. Aaron Burry, CDA CEO, and Dr. Richard Holden, CDA’s immediate past-president. Among the HUMA report’s 16 recommendations, it included two that CDA has long been advocating for: • That the Government of Canada (GOC) work with the provinces, territories, and other stakeholders to promote the alignment of educational and training opportunities in health care and other care economy sectors with future skills and labour needs; and further, that it consider supporting a wide range of strategies to make training in care-related fields more accessible, including through online learning, flexible training options such as microcredentials, and upskilling options for workers already in the care economy. HUMA Report on Labour Shortages, Working Conditions and the Care Economy The HUMA report is available at: bit.ly/3F3i3Qa • That the GOC consider offering additional permanent residency pathways to temporary foreign workers with indemand skills or experience, including in the care economy and skilled trades. CDA will continue to emphasize that any government initiatives that seek to address labour concerns in Canada’s health care sector should consider the significant portion of health care that is delivered outside of Canada’s publicly funded system, in private settings such as dental offices. Introducing the 3M™ Filtek™ Matrix. The 3M™ Filtek™ Matrix is a digitally-designed customized anterior matrix system. This new solution streamlines conservative, composite treatments – bringing a smile to you and your patients. Big news in beautiful smiles. � Diagnose and scan patient’s teeth � Approve the digitally designed restoration � Use the 3M™ Filtek™ Matrix The 3M™ Oral Care Portal is an open, web-based platform that helps you confidently deliver treatment: Predictability Efficiency Esthetic Results Conservative Design Experience the benefits of the 3M™ Filtek™ Matrix: Learn more at 3M.ca/FiltekMatrix 11416_2210-25209-E_OHJ_FiltekMatrix_7x4_875_ad_EN_v01.indd 1 2023-01-04 9:38 AM 3M and Filtek are trademarks of 3M or 3M Deutschland GmbH. Used under license in Canada. © 2023, 3M. All rights reserved. 2210-25209 E

Soothing the Senses to Improve the Patient Experience How dental office design can improve dental care for people with special health care needs When Dr. Alison Sigal designed her pediatric dental office, she wanted her patients, many of whom have special health care needs, to feel as calm and comfortable as possible. “In Holland in the 1970s, an idea emerged that an environment that interacts positively with the five senses and that an individual can control might help ease stress and anxiety,” says Dr. Sigal. “Think about how you feel when you walk in a forest. As you smell the fresh air, hear the birds chirping, feel a cool breeze, the environment impacts you on both a subconscious and conscious level.” Dr. Alison Sigal is a pediatric dentist and founder of Little Bird PediatricDentistry in Milton, Ontario. Patient relaxing in a noise‑canceling sound shell chair. 16 | 2023 | Issue 2

Snoezelen snapshots (top to bottom): Waiting room with tactile toys; operatory with video screen on ceiling; providing accessible care to patients. CONTINUEDP.19 She explains that the idea, called Snoezelen, hypothesized that by providing soothing stimuli to all five senses and allowing people to have some control over their environments, people with special health care needs could have more positive and effective experiences in health care settings. This idea was tested by measuring bio-feedback, including blood pressure, heart rate and respiratory rate, in Snoezelen environments and regular health care environments. “Data showed that people experienced less stress in Snoezelen environments,1” says Dr. Sigal. As well, feedback from patients, caregivers, support workers and health care providers suggested that patients felt calmer and were more cooperative. By providing soothing stimuli to all five senses and allowing people to have some control over their environments, people with special health care needs could have more positive and effective experiences in health care settings. In 2016, when Dr. Sigal opened her office, which includes as many Snoezelen elements as possible, she also started tracking data about how her patients’ responded to the environment. In 2021, she and Dr. Michael Sigal, a pediatric dentist and Alison’s father, published an article that both explained how she had applied Snoezelen principles to a dental environment and how it had impacted the oral health care of her patients.2 “About 85% of our patients had received dental care in a hospital setting before they came to us,” Dr. Sigal said. “And about 50% of them required general anesthesia to receive dental care. These same patients can mostly receive their care without general anesthesia at our office, as only about 5% still required general anesthesia.” Feedback surveys showed that 90% of new patients said that care, cooperation, and experience were improved compared to previous medical and dental visits. When asked why, 98% stated the environment and staff approach to care were the primary factors. “What is most exciting is that the creation of a more comfortable environment can improve access to dental care for people with special health care needs,” Dr. Sigal says. “This population faces diverse barriers to care and oral health, but a soothing environment designed with these patients in mind can help.” 17 Issue 2 | 2023 | Issues and People

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Snoezelen comes from the Dutch words “snuffelen,” which means to explore, and “doezelen,” which means to relax. A Snoezelen room is a controlled, multisensory, therapeutic environment that soothes and helps reduce anxiety. Traditionally, health care environments have bright, fluorescent overhead lights. Consider having all lights on dimmers so that light levels can be adjusted. “In most of our spaces, the lights are either off or notably dimmed for maximal patient relaxation and comfort,” Dr. Sigal says. Patients often say that natural light is an important element for their comfort. Consider windows with adjustable blinds in as many spaces as possible. Walls in most areas of Dr. Sigal’s office are painted in soft, neutral colours. “We don’t use bright colours, even though we are a space designed for children, because they can sometimes be too stimulating,” says Dr. Sigal. The office is scent free. “Smell greatly influences our emotions, but it is quite subjective depending on the person, so we felt it would be better to be scent free,” Dr. Sigal says. Spaces have adjustable music. “Music is also deeply emotional and can really help with calming feelings,” Dr. Sigal says. “It’s very important that patients can choose the music and how loud it is.” In the operatory, Dr. Sigal has a ceiling-mounted TV with a streaming service above the dental chair so that patients can select a program to watch during care. Patients are offered weighted blankets with Velcro closures that provide comfort and gentle protective stabilization. Thepanorex room is designed for thepatient to facea large window, looking outside, providing a sense of openness and other focal points of distraction. The panorex unit itself is a side-entry machine that is accessible, allowing image capture for those in wheelchairs or using assisted devices. “We also have a mirror situated to allow for patients, especially those who are hearing impaired, to be able to see our clinical staff while the image is being taken for feedback,” Dr. Sigal says. The waiting rooms at Dr. Sigal’s office offer other options for the senses. There are tactile toys, a rebounding trampoline for jumping, and a ball wall. There is a noise cancelling sound shell chair, which is a soft-cushioned chair that incorporates music and vibration. There are private spaces where patients and their caregivers can relax before or after treatment. The space room has a laser stars projector aimed at the ceiling and space-themed design features. With adjustable lighting and music, the room can be controlled to suit a patient’s wishes. The underwater room is located behind the waterfall feature, where the flowing water creates a shimmer throughout the room, and is decorated with underwater-themed images. Dr. Sigal says that a Snoezelen environment might also be helpful for people with dental anxiety. “We all are influenced by our sensory stimuli,” she says. “We know intuitively that factors such as enclosed spaces or artificial light can affect how we feel.” She also recognizes that dentistry has some features that can’t be altered, but the principles of a calming environment can be applied to settings such as the lobby References: 1. Lotan M. Gold C. Meta-analysis of the effectiveness of individual intervention in the controlled multisensory environment (Snoezelen®) for individuals with intellectual disability. J Intellect Dev Disabil. 2009;34:3:207-15. 2. Sigal A, Sigal M. The multisensory/snoezelen environment to optimize the dental care patient experience. Dent Clin North Am. 2022 Apr;66(2):209-28. Incorporating Snoezelen Elements in a Dental Practice or entrance, common areas, elevators, clinics, waiting areas, preadmission areas and patient treatment rooms. “I’m always looking for ways to improve. For some patients, the sound of the drill can cause anxiety. But the sound of cascading water can cancel out some of the high frequencies of the drill.” Her office has a floor-toceiling water feature that patients can touch and it can be heard from every room. 19 Issue 2 | 2023 | Issues and People

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The Burden of Burnout In a survey conducted by the American Psychiatric Association in 2021, 79% of workers said they’d experienced work stress in the last month. This stress caused cognitive weariness in 36%, emotional exhaustion in 32% and physical fatigue in 44% of respondents. Among the professions, teaching and health care tend to have higher rates of burnout, and these rates have only been exacerbated by the pandemic. CDA Essentials reached out to Canadian researchers to find out how burnout has affected dentists in the past few years. 21 Issue 2 | 2023 |

CONTINUED Studying Trends in Mental Health in Dentistry and Other Professions A research team, called the Healthy Professional Worker Partnership, has been investigating mental health, leaves of absence and return to work among people from seven professions in Canada, including dentistry. “When you are the practice leader, it’s really hard to take a break, because your team also goes down with you. It’s hard to get away. You know, it’s not so easy,” one dentist told the team of researchers when asked why they didn’t go on leave when suffering from mental health challenges. “The pandemic happened while we were collecting data,” says Dr. Ivy Bourgeault, University of Ottawa professor and research chair in Gender, Diversity and Professions and director of the partnership. “And of course it was a significant factor for health care workers, including dentists. We saw a large increase in those experiencing burnout.” In some preliminary findings, the researchers found that compared to other professional groups, dentists were the least likely to report having mental health issues, such as burnout. The average across all professions in the study, which includes medicine, academia, and nursing, was 58%, while 44% of dentists reported such issues. “It’s possible that some dentists are reluctant to talk about their own mental health issues, because of stigma,” says Dr. Tracey Adams, co-investigator on the dentistry team and a professor at Western University. “There might be a fear that if word gets out, it may affect their practice.” “Despite the fact that it is so common, there is still stigma around mental illness in dentistry,” says Dr. Mario Brondani, dentistry lead investigator and professor in the faculty of dentistry at the University of British Columbia. “Indeed, the stigma may be why there has been so little research into mental health and dentistry.” Among dentists who reported experiencing mental health issues, 54% made changes at their place of work, most commonly by reducing workload, taking sick days, and seeking medical help. Though 28% of these dentists considered taking a leave of absence, only 13% took one. When dentists did take a leave of absence, just over half returned to work, while 41% left the profession. “Other professions were far more likely to take a leave of absence in the first place,” says Dr. Bourgeault. “And when they did, they were more likely to come back to work afterward. In dentistry, there are a lot of barriers to taking a leave of absence and, once a dentist takes one, it is harder to come back than in other professions. Or those people were so exhausted, they just could not “There was a striking increase in distress and burnout during COVID compared to before,” Dr. Bourgeault says. Before the pandemic, dentists said their mental health was very good, scoring an average of 3.68 on a scale of 4.0. During the pandemic, dentists reported that their mental health was good, falling to an average of 2.92 on the scale. The number of dentists who reported one or more symptoms of burnout increased. “We also found that female dentists reported more burnout than their male colleagues.” Stress often comes from both work and other sources; research into the pandemic has shown that women had increased family obligations compared to men, related to childcare. Ultimately, the research teamplans to create interventions and tools to promote better mental health and provide support to dentists that addresses the specific problems facing dentists. “The employment model for dentistry is different from many other health care professions in Canada, so dentists experience stress related to managing their practices and the debt they take on to own and run them,” says Dr. Bourgeault. “For example, dentists say that difficulty finding locums to keep the practice running with a source of income while on leave prevents them from being able to properly take care of their mental health. So an accessible pool of locums would be an important mental health support for dentists.” “Dental schools are a great place for early intervention,” says Dr. Brondani. “Many dental schools are already talking about mental health. If the stressors that cause burnout for dentists are related to their business model, we should talk about mental health strategies related to managing a practice.” return to the dental office.” When asked why dentists chose not to take a leave, the data shows that most often they didn’t feel that their mental health issues were severe enough to warrant the resulting impact on patients and staff, along with financial losses. In dentistry, there are a lot of barriers to taking a leave of absence and, once a dentist takes one, it is harder to come back than in other professions. 22 | 2023 | Issue 2 Issues and People

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Dr. Ivy Bourgeault Dr. Tracey Adams Dr. Mario Brondani Learn about the Healthy Professional Worker Partnership’s work at healthyprofwork.com because many of those people had said they didn’t have the emotional resources to go through something like SARS again, so one might hypothesize that that group would fare worse during COVID,” Dr. Styra says. But they were equally resilient. “They’d been through it before, and so they rolled up their sleeves and worked through another crisis. It was an encouraging outcome for the overall health care system; health care workers were there to care for their patients.” At the beginning of the pandemic, when most dental offices closed, I can imagine that dentists felt a lot of stress about not being able to care for their patients. A Study of Health Care Worker Mental Health During Crisis In 2003, Dr. Rima Styra, a psychiatrist and associate professor at the University of Toronto, studied how the SARS outbreak affected the mental health of health care workers. “That outbreak caused a lot of stress, so we looked at symptoms of depression, anxiety, and post-traumatic stress disorder,” she says. “Many of the health care workers we surveyed said they couldn’t go through something like SARS again. It was too much.” At the beginning of the COVID-19 pandemic, Dr. Styra and her team performed the survey again with 3,500 health care workers in a variety of settings.1 “We found high levels of anxiety, depression, and symptoms of post-traumatic stress,” she says. The survey also gathered information about how people were coping with stress, with questions about alcohol use, sleep aids, social supports and formal mental health support. “Our results showed that most people got their support though colleagues and family, and that this support positively impacted resilience.” A subset of the people who were surveyed had worked during both SARS and COVID-19. “This was intriguing The SARS outbreak didn’t last as long as the COVID-19 pandemic, which means the two events have different impacts on the mental health of health care workers.2 The staffing issues caused by COVID-19 and the long-term nature of pandemic stress make burnout of particular concern for health care workers, including dentists. “At the beginning of the pandemic, when most dental offices closed, I can imagine that dentists felt a lot of stress about not being able to care for their patients,” she says. “When we feel a moral obligation, but we can’t meet it because of external barriers, that can be very stressful.” This experience is called moral injury or distress. “It might also come up in times when the needs of patients exceed the resources that a dental office can offer. During COVID, often we had limited resources and time due to increased need, and that can be very hard.” Dr. Styra believes that not being able to bond with colleagues and team members during the pandemic has also affected mental health. “Not having coffee with the people we work with or chatting with them casually in the break room may seem like a small thing, but social connections matter,” she says. She also suggests that dentists, who often work in separate offices, can also benefit from building strong relationships within the profession. Support from colleagues who understand Members of the Healthy Professional WorkPartnership, examiningmental health, leaves of absence and return towork. Issues and People

Dr. Rima Styra the sources of stress common to dentists can be very helpful and effective. Staffing shortages have caused work overload in hospitals, and Dr. Styra says that the same problem can happen in dental offices. “It’s hard to deal with individual work-life balance when there are systemic things happening around us, like a pandemic or an industry-wide staffing shortage,” Dr. Styra says. “So how do we reconcile this? Some of the solutions to burnout need to be organizational or at a systemlevel. We have to work together on solutions, because only so much can be done on an individual level.” Dr. Styra says that, anecdotally, the stress of the pandemic has been clarifying for some people. “In moments like these, we ask ourselves the big questions,” she says. “What about my work is most meaningful to me?What do I need to be resilient? References: 1. Styra R, Hawryluck L, Mc Geer A, Dimas M, Sheen J, Giacobbe P, et al. Surviving SARS and living through COVID-19: Healthcare worker mental health outcomes and insights for coping. PLoS One. 2021 Nov 10;16(11):e0258893. 2. Styra R, Hawryluck L, McGeer A, Dimas M, Lam E, Giacobbe P, et al. Support for health care workers and psychological distress: thinking about now and beyond the COVID-19 pandemic. Health Promot Chronic Dis Prev Can. 2022 Oct 12;42(10):421-30. Are there changes that I need to make? Are there challenges that can be addressed? Do I have work-life balance? These are important questions to ask ourselves.” Dr. Styra is an associate professor of psychiatry at theUniversity of Toronto and staff consultation-liason psychiatrist at Toronto General Hospital. 26 | 2023 | Issue 2 Issues and People

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KNOWTHE LAW Starting or Buying a Practice: How to Comply with Employment Laws Inna Koldorf is a partner in the Employment and Labour Law Group at KPMG Law LLP in Toronto. Her work includes helping employers with managing their workforce, providing advice, representing employers in litigation and conducting workplace investigations. When you start a new dental practice or buy an established one, you become an employer. Being an employer comes with specific rights and responsibilities under the law. “Employment standards legislation in Canada that pertains to dentistry is provincial or territorial, not federal,” says Inna Koldorf. “The provinces that have common law are all fairly similar. Quebec is very different from other jurisdictions. While it’s important to learn about the laws in your own jurisdiction, there are some best practices that all dentists in Canada can use.” What does a new practice owner need to know? “There are a few key policies, such as a health and safety policy and a harassment and violence policy, that you need to have in place right from the beginning,” says Koldorf. “That way, you’ll be compliant with your initial obligations, and you’ll be ready if you are visited by an inspector from your provincial or territorial Ministry of Labour.” 29 Issue 2 | 2023 |

For dentists starting a new practice, Koldorf recommends working with a lawyer or a human resources (HR) consultant familiar with employment law in your area to create the required policies. For dentists purchasing an existing practice, all existing policies should be reviewed to ensure they are up to date. “Typically, you should have a corporate lawyer help with the transaction of buying a practice. They will often involve an employment lawyer to give advice on any employment law implications, and will likely be able to alert you to any red flags,” she says. Checklist of Policy Requirements* z Health and Safety Policy “This is a basic policy that states that the employer is going to provide a safe and healthy workplace, and outlines the responsibilities of the various workplace parties,”says Koldorf. “There are many sample policies online but, like everything else online, some are good and others are not so great.” In addition to the policy itself, employers are required to have a program in place to implement the policy. The program will ensure that employees are trained on health and safety and address certain risks that are specific to the workplace. z Harassment and Violence Policy “These are legally required in Ontario. If you have five or more employees, then you are required to have these as formal written policies,”says Koldorf.“But I recommend all dental offices to have these written policies from the beginning in every jurisdiction. Even if you start with fewer than five staff, you will likely grow in the future.” She says that a harassment and violence policy is more complex than the health and safety policy because it involves defining parameters for employees to make complaints and how an investigation should proceed.“Who do you have to notify internally?What kind of information do you have to provide after the investigation? The law requires specific information to be included in these policies,”says Koldorf. z Accessibility Policy “In Ontario, the law requires employers to create policies mandating how they will remove and prevent barriers for staff, patients and members of the public with disabilities. These policies outline how you will make the office physically accessible, as well as making sure that the practice’s website and marketing materials are also accessible, among other things,” says Koldorf. z Electronic Monitoring Policy “This is an employment standard that was introduced recently for organizations with 25 employees or more,” says Koldorf.“It’s a written policy that discloses whether and how the employer monitors its employees electronically, on office computers, for example.” z Disconnecting fromWork Policy Employers with 25 or more employees are required to have a policy that addresses disconnecting from work.“The policy does not have to actually permit employees to disconnect from work during certain times, but it does have to define the term ‘disconnecting from work’ and note the date that the policy or any changes to it came into effect,” says Koldorf. Other Best Practices z Employment Contracts “If you are already working with a lawyer or HR consultant, it’s advisable to set up contracts that your employees sign before they start working,” says Koldorf. “These contracts will protect your practice in case something goes wrong with the employee’s performance and there is a need to terminate the employee,or the employee decides to resign.” z Policies Handbook “While there are only a handful of policies that are required to be in place, it is often helpful to have other policies in place to address time off work,disciplinary processes,overtime,and other issues that come up with employees.These aren’t legally required, but often, as dental practices grow, they support the growth of the business and help to manage staff easily,” says Koldorf. “It’s also helpful for new employees to have these written policies in hand before they start working, so that they clearly know what to expect and what is expected of them.” z Ministry of Labour Posters “In Ontario, it used to be required that all employers displayed a poster from the Ministry of Labour about employment standard in their place of business,” says Koldorf. “Now posting is optional, but the poster must be distributed to employees within 30 days of their date of hire. It includes information about employees’ rights and contact information for employees who need to contact the Ministry of Labour.” Ontario employers are also required to post a poster about health and safety at work. Both posters can be found on the Ministry of Labour website. * The policies and best practices referenced above focus on Ontario labour and employment laws, so please visit the Ministry of Labour website in your region for more details. 30 | 2023 | Issue 2 Issues and People