Home » Ask Oasis » Your Opinion: how would you deal with this situation?

Your Opinion: how would you deal with this situation?

MC picBy Dr. Ian McConnachie

A greater number of families are coming to dental practices with children lacking full immunization against communicable diseases such as measles and mumps. At the same time, we are seeing a significant increase in geographic outbreaks of these diseases across Canada. This raises the issue of whether a dentist can or should refuse treatment to these non-immunized children because of the potential of their spreading such diseases to other patients in the office at the same time.

What are the legal and ethical issues faced by the dentist with respect to accepting or refusing to treat these patients?

Are patients and staff being placed at undue risk if the non-immunized patients are treated?

 

16 comments

  1. I don’t think many dental office medical questionaires ask for immunization status, so most of us would be unaware of the child’s immunity without further questioning. Perhaps a pediatric dental office might include that question in their medical inquiry and I think you could make a good case for refusing treatment, but I think one should consult one’s provincial dental regulatory body before considering any action like this. There’s always legal issues with treatment refusal.

  2. Donna Bereznicki

    If they are symptomatic I would send them home – air borne spread of disease.

  3. If there is a risk, the dentist should refuse to treat the patient. The decision of the parent not to immunize comes with consequences and one of them is that the doctor can refuse to treat someone who can potentially place the doctor and staff at risk. I think it is called taking responsibility for your actions.

    • Shades of AIDS patients!!! We can’t have fish for one and fowl for another.
      Dentists, at all times, should take basic precautions when treating ALL patients, no more no less. Is that not what the government and RCDSO recommend.
      No one should be refused treatment.

  4. Dr. Alan Kilistoff

    Who is at risk here? If the dentist and staff are immunized then their risk should be no greater than a trip to the mall or any other populated area. The non-immunized should only place other non-immunized individuals at increased risk, invoking the consequences part of the argument.

    • Except that not all children who have received immunization shots develop immunity. So you could have a child who has been immunized still be at risk from the un-immunized child. That’s the whole point of “herd” protection.

      • The risk to those who have not developed immunity should be far less in the dental office than in the schoolroom. I do not think that we are expected to reduce all risks to zero in the dental office, but to reduce to acceptable levels those we can. For these reasons I do not think it is practical or reasonable to refuse treatment to those not immunized.

        • I agree. I believe in the freedom of choice. I also believe that, when an immunization becomes mandatory, the regulatory body who implemented it should bear the responsibility for the potential risks associated with that immunization.

      • By your rationale, the immunized kid who is not actually immune would then be refused treatment as well. Therefore, you would need to update records for all patients verifying their immunizations are up to date. And then, how often between checkings do you have it re-checked? every 6 months?
        If you look at how these diseases are still spreading, it is often an immunized person who went overseas, caught the disease, then returned and spread it to other immunized and non-immunized individuals.
        To have herd protection with immunizations, you need over 97% immunization, with current boosters for this to be effective (might actually be 99%, can’t remember the stats, but it is one or the other). Natural immunity (disease aquired) is only 67% for herd protection.

        This is where Alan’s point comes in, the child is at no more risk than going to the mall and picking it up there. Unless the dental office does not believe in infection control and universal precautions.

  5. I think others have said it: Immunized health care staff probably are at very little risk.
    ANY sick patient should be asked to stay home until he/she is better, unless it is a real emergency that they be treated; especially if they are sick with a communicable disease.
    I don’t think that a non-immunized patient should be refused treatment as long as he/she is healthy.

  6. Refusal to treat patients on this basis is completely unethical and without warrant.

  7. I am seeing few issues both with this question and the responses some people are giving.

    If someone is sick with a communicable disease, especially one that has high potential for serious illness, they should not be coming to the dentist. They should be at home focusing on getting well. This is regardless of their immunity status.

    For the “healthy”, whether they have been immunized or not is irrelevant. If you look back at recent outbreaks for things like measles, roughly half the people that got it were immunized, with double immunizations. So, you cannot blame the non-immunized for spreading the disease.

    The problem is, with natural immunity (aquired by having the disease), I believe it is 97% will have life-long immunity (believe this stat was for measles, but is also generalized for similar diseases). For those who have been artifically immunized, a very small percentage may have life-long immunity, most may get 10 years, and many will loose immunity within 3 years.

    So, if one was to refuse treatment to someone who has not been immunized, you need to refuse treatment to anyone who has not been immunized within the last three years, and who did not have their immunization verified. And by that token, just avoid seeing anyone who has been overseas or in contact with someone who has within the last couple weeks as they could be a carrier and not fully symptomatic that day. Or, you can take it even further, any person who does not feel 100%, reschedule as they may be contagious.

    In my opinion, herd immunity was destroyed when immunizations started. They were a good idea at the time as the thought was it would generate life-long immunity with little to no risk. Well, that was not the case. There are risks, and significant ones, especially if you were to do a booster ever 3 years, which is what would be needed for many.

    The key is, whether you immunize or not, you have to stay healthy and focus on building your natural immunity. Those who need the most dental work often have compromised general health and thus compromised immunity. They are the ones that need dentists the most, and if you take this opinion question to the logic source, one’s natural immunity rather than immunization status, the question proposes not seeing patients with compromised immunity, and therefore, not seeing those that need us most.

    Anyone who would refuse treatment to a non-immunized individual needs to spend time doing research as that would not be evidence-based dentistry and in my opinion, a violation of our code of ethics.

  8. I feel quite strongly that it is better to educate than discriminate. With various “health experts” on the internet and television, it is easy for patients to be deceived and misinformed. While this can be frustrating, refusing to treat non-immunized patients (especially if they are in pain) is both extreme and unnecessary. There is likely little evidence to support such a move and there may be legal implications. For public schools, I would say yes, but for dental offices, even pediatric dental offices, I would say definitely not.

  9. The real truth of any immunization program is that it does not confer 100% protection. Therefore all of these questions become irrelevant as unless one can say with 100% certainty that you are protected by the vaccine 100% of the time, in 100% of all situations, there is no “vaccine” protection.

    This is why we as professionals do not refuse HIV patients – it is unethical to do so based solely on that criteria – and we practice using “universal precautions”, and “infection prevention and control protocols” that are beyond reproach.

    I would agree with Donna that should the patient be exhibiting active signs of disease that treatments could be delayed until such time as they are healthy. Otherwise,protocols to deal with these scenarios need to be studied, discussed, written up and then disseminated to our profession so that we do not allow our personal biases to enter into scenarios where we could then be doing a disservice to our patients and or the public, and or place ourselves at risk of legal actions.

  10. While it is in the best interest of everyone (staff, dentist and the population in general) for people to be immunized, it is unethical to refuse treatment to those who are not immunized. (It is another issue if someone has symptoms, as someone just posted above, and in that case they must be sent to emergency care in a hospital). As dentists we care for patients with HIV and Hep, not to mention patients who often do not disclose their communicable diseases.

  11. William Spencer

    It could also be the staff who needs to be updated with their shot, re: studies show we need boosters as we age. Found that out from, (would you believe National Geographic, in the last 2 months with graphs, and reference articles). I, and my staff are getting boosters.

%d bloggers like this: