Emotional Support Animals: Rules to Bringing One to the Dental Office

Author’s Note: A few months ago, Today’s RDH featured Max, an “office dog” who hangs out at a Nebraska dental office with his owner, Dr. Kathy DeFord. After reading so many comments on Facebook regarding this article, I felt that further research would be a welcomed adjunct to the light-hearted article about Max.

Emotional support animal (ESA) assistance has become increasingly popular. So much so that some dental offices may have ESAs on-site or “allow” them to accompany their owners at appointments. With this practice becoming more common it must be kept in mind that therapy animals provide people with therapeutic contact, usually in a clinical setting to improve their physical (lowered blood pressure), social (reduced stress levels), emotional (reduced anxiety), and/or cognitive functioning − all of which can be experienced in a dental setting.⁷

What Differentiates a Service Animal From an ESA?

There is the likelihood of confusion surrounding support animals and whether they should be allowed in a healthcare setting. Some animals have specific rights, and others have limited rights depending upon their classification − service animal versus ESA.

A service animal means any animal that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability.⁵ For example, a blind individual would have a professionally trained service dog to assist them with sight; this service dog tends to be the most familiar. Another common service animal is utilized by hearing-impaired individuals. This service animal is known as a hearing/signal dog.

A few other specialized and less commonly known service animals include seizure response, psychiatric, and sensory signal dogs. Seizure response dogs are trained to assist a person with a seizure disorder. The dog may stand guard over the person during a seizure, or the dog may go for help. Some have the innate ability to predict a seizure and warn the person in advance to prepare for the upcoming episode.

Psychiatric service dogs have been trained to perform tasks that assist individuals with disabilities to detect the onset of psychiatric episodes and lessen their effects. Psychiatric service animals may remind the handler to take medication, provide safety checks or room searches, or assist with turning on lights for persons with post-traumatic stress disorder (PTSD), interrupt persons who may do self-harm, as well as assist with dissociative identity disorders, keeping disoriented individuals safe.

Sensory signal dogs assist people with autism spectrum disorders. The key takeaway is that service animals are assisting disabilities and are protected through the Americans with Disabilities Act (ADA).⁵

An ESA is not professionally trained to work as a service animal. They are used as support animals to help someone function normally daily. There is a multitude of reasons that support animals might be necessary for an individual. The animals provide companionship, relieve loneliness, and sometimes help with depression, anxiety, and certain phobias.⁷ It is shown that some states have laws defining therapy animals; however, these animals are not assisting people with disabilities and are not protected by the ADA guidelines.⁵

Considerations for Therapy Animals in Healthcare Settings

While ESAs can be highly effective for some patients, it should be considered that not all who enter a dental practice will find an ESA necessary for their specific needs. In addition, the ESA might present challenges to some patients’ overall well-being. The Dentists Insurance Company suggests:

• All patients should be notified of the presence of animals within the office in case of patient allergies, such as rhinoconjunctivitis, respiratory issues, rash, and acute urticaria.^1,2
• Dentists may also collaborate with an allergist to garner advice regarding certain breeds that may/may not be best suited for the needs of the office.⁸

Best practices should be followed with any therapeutic animal, including consistent bathing that removes loose dander. The animal should be restricted from licking a patient, especially facial licking since saliva can also contain allergens. The support animal should be inspected regularly for open wounds that could pose allergen issues as well. Likewise, any therapy animal should have regular examinations by a veterinarian to avoid disturbed behavior, which could affect the normal temperament due to pain or sickness, which could cause issues surrounding the animal’s ability to assist.³ Infection Control and Hospital Epidemiology suggests:

“That each animal be reevaluated at least every three years. Require that any animal be formally reevaluated before returning to animal-assisted activities after an absence of >3 months. Require that a handler suspend visits and have his or her animal formally reevaluated whenever he or she notices or is apprised (either directly or through the animal visit liaison) that the animal has demonstrated any of the following: 1. A negative behavioral change since the time it was last temperament tested 2. Aggressive behavior outside the health-care setting 3. Fearful behavior during visitations 4. Loss of sight or hearing and, consequently, an overt inclination to startle and react in an adverse manner.”¹²

It is recommended that offices implement policies to meet the needs of staff and prospective and existing patients. All who enter the office should be made aware of the policy; the American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code) can serve as a useful guide for establishing a policy to meet the needs of each dental practice.⁸

How Therapy Dogs Best Assist

When contemplating an ESA in a healthcare setting, there is much to mull over. An ESA should be exposed to training by an expert who will guide the pet’s developing temperament. In addition to this training, the pet and pet handler must undergo regular re‐evaluation, training, and recertification as a team. Certification protocols do vary significantly between organizations. Minimum common prerequisites include immaculate health status, the willingness to interact with unfamiliar people and the absence of behaviors that could jeopardize AAI recipients.^9,10 Unfavorable behaviors include aggression, jumping up or on, mouthing, biting, and dodging. Theses trainings will alleviate the potential for behavior associated issues such as bites, growling, or becoming agitated.¹¹ A well-trained therapy dog will be able to handle the sound of a drill or sudden movement or loud responses from an anxious patient.³

Having a therapy dog present requires thought-provoking systems that guide the staff and patients as to the best practices for the ESA to effectively deliver support. If the office employs the ESA, the system may look like this:

• The ESA will have specific areas they can be present depending upon the procedure being performed − patient’s lap, lying beside the patient on a provided table, or perhaps on the floor adjacent to the patient.³
• The dentist provides patient-centered care while another staff member focuses on monitoring the ESA. The “handler” is responsible for determining any adverse situations and exhaustion in the ESA.³
• The ESA should have a designated resting place away from treatment operatories to recover after lengthy times of work.³
• Adverse events must be investigated, regardless of the absence of harm, to ensure the ESA and its handler in the dental setting are acceptable any risks that may arise in the future.

Chas Rampenthal, general counsel at LegalZoom.com, suggests: “As a business owner, you can be held liable if an animal you allow in the workplace injured an employee, customer, or even the delivery guy. There are plenty of dog-bite attorneys out there that see nothing but dollar signs when they can name a company in the lawsuit.”¹³

He further recommends that pet owners provide insurance that will cover any injuries caused by the pet. He believes that it is not too much to require the employee to sign an indemnification agreement that will require the employee to pay the cost of defending any dog bite that comes your company’s way.¹³

What About Infection Control?

Comments following the previous article written indicated that dental professionals wanted more information surrounding infection control measures. Infectious Disease Advisor indicates:

“Risks to patients from exposure to animals in the healthcare setting may be associated with the transmission of pathogens through direct or indirect contact or, less likely, droplet/aerosol transmission. However, insufficient studies are available to produce generalizable, evidence-based recommendations, and as a result, substantial variations exist in policies and practice across healthcare institutions.”⁴

The Centers for Disease Control and Prevention states:

“No evidence suggests that animals pose a more significant risk of transmitting infection than people; therefore, service animals should not be excluded from such areas unless a patient’s situation or a particular animal poses risks that cannot be mitigated through reasonable measures. If healthcare personnel, visitors, and patients are permitted to enter care areas (e.g., inpatient rooms and public areas) without taking additional precautions to prevent transmission of infectious agents (e.g., putting on gloves, gowns, or masks), a clean, healthy, well-behaved service animal should be allowed access with its handler.”⁶

No reports have been published regarding infectious diseases that affect humans originating in service dogs. Standard cleaning procedures are enough following the occupation of an area by a service animal. Cleanup of animal urine, feces, or other body substances can be accomplished with blood/body substance procedures as outlined in the Centers for Disease Control and Prevention 2003 dental guidelines.⁶ Understanding these recommendations can allow dental professionals some peace of mind when making considerations surrounding ESAs in their offices.

Ultimately, each office must determine how they can best serve their patients. Some may see the relevance to inviting therapy animals into their dental home, while others might maintain a different approach. Dentistry is not a profession where one size fits all; therefore, it is valuable to have a vast array of choices. Being educated on recommendations and regulations can allow thoughtful decision making when contemplating ESAs as one of the choices that may enlist an array of happy patients.

Now Listen to the Today’s RDH Dental Hygiene Podcast Below:

References

1. Chan, S.K., Leung, D.Y.M. Dog and cat allergies: Current state of diagnostic approaches and challenges. Allergy, Asthma & Immunology Research. 2018; 10(2), 97-105. Retrieved from https://doi.org/10.4168/aair.2018.10.2.97
2. Davila, I., Domínguez‐Ortega, J., Navarro‐Pulido, et. al. Consensus document on dog and cat allergy. Allergy: European Journal of Allergy and Clinical Immunology.2018 June; 73(6), 1206–1222. Retrieved from https://doi.org/10.1111/all.13391
3. Gussgard, A.M., Weese, J.S., Hensten, A., Jokstad, A. Dog‐assisted therapy in the dental clinic: Part A-Hazards and assessment of potential risks to the health and safety of humans. Clinical and Experimental Dental Research. 2019 Dec; 5(6): 692-700. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1002/cre2.240
4. Weber, J.D, Murthy, R.K., Vivek, P. Animals Visiting Healthcare Facilities. Infectious Disease Advisor. 2019, January 20. Retrieved from https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/hospital-infection-control/animals-visiting-healthcare-facilities/
5. Service Animals and Emotional Support Animals. Americans with Disabilities Act National Network. 2020, January 9. Retrieved from https://adata.org/guide/service-animals-and-emotional-support-animals
6. Service Animals in Dental Health Care Settings. Centers for Disease Control and Prevention. 2016, March 1. Retrieved from https://www.cdc.gov/oralhealth/infectioncontrol/faqs/animals.html
7. Emotional Support Team. What is an Emotional Support Animal? Emotional Pet Support. 2019, July 9. Retrieved from https://www.emotionalpetsupport.com/2016/09/emotional-support-animal/
8. Wilson, R.J. The ethics of emotional support animals in the dental office. Journal of the American Dental Association. 2019 Aug; 150(11): 982-984. Retrieved from https://jada.ada.org/article/S0002-8177(19)30294-6/fulltext
9. Ng, Z., Albright, J., Fine, A.H., Peralta, J. Our ethical and moral responsibility: Ensuring the welfare of therapy animals. In Handbook on Animal-Assisted Therapy: Foundations and Guidelines for Animal-Assisted Interventions, 4th ed.; Fine, A.H., Ed.; Elsevier: San Diego, CA, USA, 2015; pp. 357–377.
10. Mongillo, P., Pitteri, E., Adamelli, S., Bonichini, S., Farina, L., Marinelli, L. Validation of a selection protocol of dogs involved in animal assisted intervention. J. Vet. Behav. 2015, 10, 103–110. [CrossRef]
11. Glenk, L. (2017). Current Perspectives on Therapy Dog Welfare in Animal-Assisted Interventions. Animals, 7(12), 7. doi: 10.3390/ani7020007
12. Murthy, R., Bearman, G., Brown, S., Bryant, K., Chinn, R., Hewlett, A., Weber, D. J. (2015). Animals in Healthcare Facilities: Recommendations to Minimize Potential Risks. Infection Control & Hospital Epidemiology, 36(5), 495–516. doi: 10.1017/ice.2015.15
13. Rampenthal, C. (2012, August 16). Dogs in the Office: Is it Legal? Retrieved from https://www.inc.com/chas-rampenthal/dogs-in-the-office-is-it-legal.html