Dogs and dentistry; Appropriate management in a practice environment

This article was first published in the ADA's News Bulletin, November 2022

There are three situations under which a dog may enter a dental practice. The first is when the patient has a disability and uses an assistance dog (also known as a service dog); the second is when a patient or staff member brings in their own pet with them to the clinic; and the third is when the dental practice has a ‘therapy dog’ which it allows patients to come into contact with in the waiting room in order to reduce anxiety.
 

Assistance or service dogs

These support dogs are rigorously trained to facilitate the participation of people with disability (sight loss, epilepsy, etc) in various aspects of personal and public life, and provide an essential function. The Commonwealth Disability Discrimination Act 1992 (DDA) sets out in Section 9 the legal definition of an assistance animal as a dog or other animal that: (a) is accredited under a State or Territory law to assist a person with a disability to alleviate the effects of disability; or (b) is accredited by an animal training organisation
prescribed in the regulations; or (c) is trained to assist a person with a disability to alleviate the effect of the disability and meets standards of hygiene and behaviour that are appropriate for an animal in a public place. These dogs are permitted in the dental practice, including clinical areas, with a patient.
 

Private pet

There is no obligation to accept the private pets of staff or patients in a dental practice. These animals pose the same risks as will be discussed below for therapy dogs.

Therapy dogs

The literature on using therapy dogs in healthcare is centred around use with conditions such as cancer, chronic pain or dementia, where a trained person accompanies a specially trained dog and completes specific interventions which improve the mental well-being of the patient. The positive results reflect specialised therapy dog training, testing, and certification, as well as careful planning to ensure interactions will be positive, safe, and not disruptive. Part of the handlers’ special training is around infection control protocols.

There are no published studies on the use of therapy dogs in dental practice settings. While some dental clinics in the USA use such animals, they do not follow the types of interventions used in other healthcare settings where the actions of the handler are arguably of equal importance to the interaction with the dog. Likewise, in the USA, therapy dogs must be at least a year old and fully trained and certified. One cannot simply take a cute puppy and start it in the practice from there, as simple as that may sound.

The training process extends well beyond obedience training, including veterinary assessments of the dog’s mental health and physical health (see tdi-dog.org for an example of a certification checklist). Health tests include mandatory vaccinations, and faecal culture at least annually to ensure no gastrointestinal parasites are being carried.

Dentists need to take into account requirements from State public health regulators as well as the hygiene requirements of the Dental Board of Australia. The infection control issues with having dogs in waiting rooms and other public areas have been well canvassed in the literature. Typical protocols include hand hygiene before and after any contacts with the dog, not using the dog with patients when it is unwell, keeping the dog away from patient care areas, and ensuring the dog is not playing with toys that children may handle.

In practical terms this means that two front-desk staff will have been trained up in handling the dog, and can make sure it is appropriately supervised. Two are needed to provide cover when one is absent. These two staff need to organise between them who takes the dog out regularly during the day for comfort stops, who provides its food, water and bedding, who arranges for its periodic veterinary visits for tests and vaccination, and who cares for the dog after hours and when the practice is closed on vacations and public holidays.

The risks of patient infection associated with animal interactions include zoonoses (infections contracted from the dog) and the dog acting as a reservoir for infectious agents being spread (as has occurred with MRSA and other multi-drug resistant bacteria for example). It is also important to remember that other potentially infectious agents can be carried by healthy dogs, include Salmonella spp., Campylobacter spp., Leptospira spp., Giardia spp., dermatophytes, Toxocara spp., and hookworms. Constituents of the normal microbiota of dogs such as Pasteurella spp. and canine periodontal pathogens may also cause infections in susceptible people as a result of saliva contact. The risks of infections being transmitted in this manner are amplified when the dog licks the face of people and when the patient is immunosuppressed.

Finally, dentists need to be aware of the associated legal risks from having a therapy dog, which include personal injury to patients or staff from the dog, as well as property damage to possessions or fittings (which once again the practice owner would be held liable for), and compliance issues with the term of a lease if this did not permit animals. Adverse reactions from patients to a dog must also be considered as a possibility, both psychological and immunological. Some patients have specific fears of dogs, while others may have significant allergies to animal hair. In the latter instance, there may be problems even if the dog is not physically in the same room as traces of hair will still be present.
 

Questions to ask

Some additional practical questions those wishing to use therapy dogs should consider include:

- Insurance coverage (e.g. a small child sees a dog, panics and hurts themselves, or is attacked or otherwise hurt by the dog. Does the clinic’s public liability insurance cover
situations such as these?)

- Will a veterinary immunisation certificate be required?

- What will be the screening process for parasites and skin problems?

- Will animal access be limited for immunosuppressed patients?

- Will all healthcare workers and patients be required to perform hand hygiene prior to (and following) interaction, and what products will be used?

- How will any scratches, bites or inappropriate animal behaviour be reported to healthcare staff?

- What conditions will result in animals being excluded from the facility (e.g. vomiting, diarrhoea, incontinence, sneezing, coughing, use of immunosuppressive or antimicrobial medications, wounds, ear or skin infections, orthopaedic conditions, oestrus)?

- What training will be required of any handlers (e.g. infection control practices including disposal of excrement, accident or injury management, inspections and screening, reading animal body language, patient confidentiality, restricted areas and rooms, etc)?

- What limitations will be placed on the time of sessions to reduce stress to the animal? How frequently will breaks be taken?

- How will the therapy dog be prepared for a patient visit? (e.g. brushing away loose hair, nails kept short, odour considerations, flea and tick inspections, condition and nature of harnesses and leads, opportunity for toileting before visits, etc)?

- How will consent be gained and documented for animal contact?

- How will any allergies or discomfort to the presence of animals be managed?

- How will treats be used (or avoided) in the facility to manage infection control considerations?

Recommended reading

Useful information on animal visits in healthcare facilities can be found in the Position Statement from ACIPC

For more recommended reading on this subject, visit the ADA’s National Digital Library online