Ontario is one of the few jurisdictions that publishes what actually happens when infection prevention and control (IPAC) breaks down in a clinic: the local public health unit posts an investigation summary naming the findings, the order served and the outcome. This article walks through five publicly documented Ontario cases — three dental, one family medicine, one mixed dental — each broken into trigger, what the report documents, the regulatory action, what it cost the practice, and the lesson a clinic can copy into its own procedures. Every fact below is drawn from the public health unit pages or the peer-reviewed write-ups themselves, and each one is linked.
| Quick facts | Detail |
|---|---|
| Public disclosure duty (Ontario) | Ontario Public Health Standards, Infection Prevention and Control Disclosure Protocol, 2022 (as cited by Toronto Public Health) |
| Legal instrument for orders | Health Protection and Promotion Act, R.S.O. 1990, c. H.7, section 13 |
| Toronto posting rule | Summaries stay on the current page while active, move to a previous page at 12 months, and are removed at 24 months |
| Niagara Region posting rule | Results remain posted for 24 months from the date of initial posting |
| Dental regulator (Ontario) | Royal College of Dental Surgeons of Ontario (RCDSO) |
| Biological monitoring requirement (Ontario dental) | One biological indicator (BI) per sterilizer, every day the sterilizer is used, placed in a process challenge device (PCD), and repeated for each cycle type used |
| Enforcement style | Corrective order plus regulatory college referral; the published record, not a fine, is the lasting consequence |
How a private clinic ends up in a public report
An Ontario IPAC investigation does not begin with a scheduled visit. Under the provincial disclosure protocol, a public health unit posts an investigation summary when a lapse has been identified, and the trigger is normally one of four routes: a complaint or referral from a member of the public or a patient, a self-report by the practice itself, a referral from another public health unit, a regulatory college or a ministry, or surveillance that follows a reportable communicable disease. Two details surprise most clinic managers:
- The order can be served on the same day the complaint is received. At College & Dufferin Dental Clinic in Toronto, the health unit became aware on 30 June 2025 and served a verbal order under section 13 of the Health Protection and Promotion Act that same day.
- Publication outlives the problem. Toronto Public Health keeps summaries on its current page while the file is open, moves them to a previous page after 12 months and removes them at 24 months; Niagara Region keeps each result posted for 24 months from initial posting.
That combination — fast enforcement, slow disappearance — is why the reports are worth reading before an inspector arrives rather than after.
Case 1: Bloor West Dentistry, Toronto — a one-day staff error
Trigger. Self-reported. The public report records the cause as "a one-time error by an office staff member" in which unsterilized dental handpieces and scaling tips were used on a limited number of patients on one day. Toronto Public Health became aware on 3 November 2022.
What the report documents. The practice reported itself, and the finding is narrow: instruments that had not completed sterilization were used on patients in a single day. There was no allegation of a repeated process failure.
The regulatory action. No order was issued. The file was referred to the RCDSO, which was notified. Toronto Public Health requested a risk assessment from Public Health Ontario to determine whether patient notification was required; the assessment concluded it was, and patient notification letters were sent on 23 November 2022 — twenty days after the health unit became aware.
What it cost the practice. A full IPAC and reprocessing audit, including a review of how staff verify that sterilization has been completed; the addition of Type 5 integrating indicators to every package before sterilization; retraining of staff in reprocessing; and a patient notification round. The final report, posted 26 June 2023, records the office in compliance with all recommendations and "no known transmissions."
Lesson. Twenty days from trigger to patient letters, for a single staff error on a single day. The corrective package is instructive because it is procedural rather than equipment-based: add an indicator to every pack, and define in writing how staff verify that the cycle worked before the pack leaves the sterilizer.
Case 2: College & Dufferin Dental Clinic, Toronto — the reprocessing room itself
Trigger. A member of the public. The health unit became aware on 30 June 2025.
What the report documents. Seven findings, and four of them are about the physical reprocessing space rather than the sterilizer: inadequate storage of single-use devices (SUDs); inadequate reprocessing of reusable equipment and reprocessing of SUD files; the reprocessing area had no one-way flow to prevent cross-contamination; unrelated items were stored in the reprocessing area. The remaining findings: no process challenge device (PCD) used to test the sterilizer; incomplete quality assurance and documentation for the ultrasonic cleaning device; no plumbed eyewash station on site.
The regulatory action. A verbal order under section 13 of the Health Protection and Promotion Act was served on 30 June 2025 — the day the health unit became aware — and the matter was referred to the regulatory college. The clinic complied with the order on the day it was served.
What it cost the practice. Reusable endodontic files had to be removed and replaced with single-use instruments where possible, with manufacturer instructions followed; one-way workflow had to be established in the reprocessing area; a PCD had to be brought into routine use; instruments had to be disassembled before reprocessing; and an eyewash station installed. The clinic reported switching to single-use endodontic instruments by 11 July 2025. The final report, posted 17 April 2026, records a reinspection in which all previous infractions were corrected, PCD use and BI documentation were verified, and the plumbed eyewash station was observed on site.
Lesson. "Reprocessing area" is an inspection object in its own right. One-way flow, dedicated storage that excludes unrelated items, and a plumbed eyewash station are structural requirements that cannot be retrofitted the morning of an inspection. They are also the items most likely to survive a fix-the-sterilizer response to a complaint.
Case 3: Toronto East Detention Centre, dental clinic — expiry dates and incomplete logs
Trigger. Referral. IPAC representatives from the Ministry of the Solicitor General contacted Toronto Public Health; the health unit became aware on 2 April 2025 and visited the clinic on 8 April 2025.
What the report documents. Five findings recorded from that visit: use of expired biological and chemical indicators for sterilizer quality assurance; wet reprocessed packages removed from the sterilizer; incomplete quality assurance logs for the sterilizer and the ultrasonic device, and no maintenance logs; dental instruments incorrectly reprocessed in an assembled and/or closed position; and a sterilizer model that was not currently authorized for sale in Canada at the time of the review.
The regulatory action. The investigation involved a member of a regulatory college and the RCDSO was notified. Corrective measures were recommended and implemented, with interim and final reporting.
What it cost the practice. A sterilizer that does not hold a medical device licence cannot simply be documented around — the device question has to be resolved, and the wet-pack, expiry and log failures each had to be closed out through the interim reporting cycle.
Lesson. Two of the five findings are pure stock-management failures. Expired indicators and missing maintenance logs are the least expensive items on the list to prevent and the most embarrassing to explain, because neither requires a capital decision — only a named person checking dates and signing a log. The assembled/closed reprocessing finding is equally worth noting: steam has to reach the surfaces, and instruments reprocessed in a closed position do not present those surfaces.
Case 4: An Ottawa family medicine clinic — a fifteen-year look-back
Trigger. Public health surveillance. In April 2018, Ottawa Public Health identified a large-scale IPAC lapse spanning 15 years, related to inadequate reprocessing of reusable critical medical equipment at a family medicine clinic.
What the report documents. This case is unusual because it was written up in the peer-reviewed literature, in the Canada Communicable Disease Report, so the numbers are precise. Patients who underwent a procedure of concern were identified using Ontario Health Insurance Plan data and individually notified. Of 4,495 patients possibly exposed to improperly reprocessed equipment, 1,496 — 33.3% — underwent testing within six months of notification. The prevalence of hepatitis B, hepatitis C and HIV infection in that group was lower than in the general Canadian population, and the authors found no evidence of transmission. They were careful about the limit of that finding: transmission could not be ruled out conclusively because only a third of possibly exposed patients were tested.
The regulatory action. A mass notification and testing programme rather than a single order. The same paper places the case in a wider context: between 2008 and 2017 the US Centers for Disease Control and Prevention recorded 61 healthcare-associated outbreaks of hepatitis B and C associated with deviations from IPAC practice, with more than 115,000 potentially exposed patients notified, 179 hepatitis B cases and more than 295 hepatitis C cases identified — and 95% of those outbreaks (58 of 61) occurred in non-hospital, community-based settings.
What it cost the practice. The financial and reputational weight of this case is the look-back itself: 4,495 people individually notified, a laboratory testing programme, and a public health response measured in years. The clinical outcome was reassuring; the operational cost was not.
Lesson. When reprocessing records do not exist, the look-back window is defined by the point at which the records stop — not by the point at which the problem started. Fifteen years of missing documentation meant fifteen years of patients to notify. This is the single strongest argument for keeping a legible sterilization log: the log is what allows an investigator to bound the problem.
Case 5: A dental hepatitis C investigation — and the professional pushback
Trigger. Surveillance. A public health unit in Ontario was notified through routine disease reporting of a newly diagnosed hepatitis C infection, genotype 2, in a patient who had attended two different dental clinics during the viral incubation period and had no other reported risk factors.
What the report documents. An IPAC investigation was launched at both facilities. A second case — previously positive, with chronic hepatitis C of the same uncommon genotype — was identified at one facility, seen on the same day and prior to the index case, and was treated as epidemiologically linked. Patient rosters were collected from both practices, and case look-back was performed using laboratory information system data. No other epidemiologically linked cases were identified. Among the stated challenges: a lack of adherence to IPAC standards in one of the dental settings, low uptake of laboratory testing by patients, and coordination with regulatory bodies and public health experts.
The regulatory action and the notification. Patients who had dental procedures at the second facility between 10 November of year 0 and 21 February of year 1 were notified in writing of the potential risk of exposure to hepatitis C and advised to be tested for hepatitis C, hepatitis B and HIV. A total of 264 initial notification letters, signed by the Medical Officer of Health and the Dental Surgeon and accompanied by a blood test requisition, were mailed on 25 May of year 1. A further 167 letters were sent recommending repeat testing six months after the patient's dental appointment, and each patient was followed up by telephone. A media release was issued.
The counter-argument. This case is worth reading alongside the commentary published in the same journal, which argues that the investigation was conducted with minimal knowledge of nosocomial infections of dental origin and rested on the false premise that an infection control lapse had occurred. The commentary notes that historical and current investigations have failed to show dental instruments acting as vectors of transmission, and that there are no confirmed cases of HIV, hepatitis B or hepatitis C transmitted in Canadian dental practices. Both documents are linked below. Clinic managers should read them together, because they show that enforcement decisions are made under uncertainty and are themselves subject to professional challenge — which is exactly why documentation matters more than argument.
Lesson. Written notification, a test requisition, a defined exposure window and a repeat test six months later are the standard package. A practice that cannot produce a patient list and a procedure date range cannot support or contest that process.
| Case | Setting | How it surfaced | Order issued | Public outcome |
|---|---|---|---|---|
| Bloor West Dentistry (2022) | Dental clinic, Toronto | Dental office self-reported | None; RCDSO notified | Patient letters 20 days after trigger; final report records full compliance, no known transmissions |
| College & Dufferin Dental Clinic (2025) | Dental clinic, Toronto | Reported by member of the public | Verbal section 13 order, served same day | Reinspection April 2026 confirmed all infractions corrected |
| Toronto East Detention Centre dental clinic (2025) | Dental clinic, correctional facility | Ministry referral | Corrective measures; RCDSO notified | Interim and final reporting through 2025 |
| Ottawa family medicine clinic (2018) | Family medicine | Public health surveillance | Mass notification programme | 4,495 patients notified; 1,496 tested; no evidence of transmission |
| Ontario dental hepatitis C investigation (2021) | Dental practices (two sites) | Routine disease reporting | Look-back and notification | 264 plus 167 notification letters; no further linked cases |
More public records worth reading
The five cases above are not a sample of the worst. They are an arbitrary slice of a routine file. Eight more Ontario records are publicly posted today, and each is readable in a few minutes:
| Record | Date health unit became aware | What it shows |
|---|---|---|
| Bathurst Walk-In Dental Centre, Toronto | 6 May 2022 | RCDSO referral; letter of recommendation issued; one exposed patient notified; corrected 25 May 2022 |
| Victoria Medical Group, Toronto | 3 Jan 2024 | Verbal order 8 Jan 2024; expired chemicals and medication, reuse of single-use devices, no dedicated reprocessing room, inadequate staff training |
| Planned Parenthood Toronto (community health centre) | 20 May 2025 | Semi-critical instruments sterilized without packaging; no biological indicators for the sterilizer before April 2025; order served 21 May 2025 |
| Dr. Yae Dentistry and Associates, Toronto | 10 Sep 2025 | Referral from another public health unit; no one-way flow, no PCD in use, cleaning product not prepared per manufacturer instructions |
| Dr Nicholas VJ Pairaudeau, Toronto (physician's office) | 1 Apr 2026 | Patient complaint; over-dilution of high-level disinfectant, transvaginal ultrasound probe reprocessing; verbal order 9 Apr 2026 under section 13(7) |
| Algoma Public Health, Sault Ste. Marie | Nov 2015 | Lack of proper cleaning and sterilization of reusable surgical instruments; registered letters to patients with procedures on or after 1 April 1998; testing for hepatitis B, C and HIV |
| Niagara Region, Welland and Niagara Falls | 2026 | South Pelham Dental (30 Mar 2026), Molon Orthodontics (4 Mar 2026) and others listed with findings and addresses |
| Peel Region and York Region | ongoing | Both regions maintain equivalent public IPAC investigation pages |
Five patterns that repeat across the cases
- A person starts the file, not a schedule. Complaint, self-report or referral appears in every case above. A practice that self-reports controls the narrative; a practice that waits does not.
- Paperwork fails more often than hardware. Quality assurance records, logs and dating appear in the majority of the public summaries, and they are the findings that make an investigator's other questions harder to answer.
- The reprocessing room is inspected as a room. One-way flow, dedicated storage, no unrelated items, and a plumbed eyewash station recur across unrelated practices.
- Correction is fast; publication is not. Repeated re-inspections confirm compliance within weeks. The record stays visible for 12 to 24 months depending on the health unit.
- The cost is the look-back. Notifications of 264, 1,496 and 4,495 patients in three different files show where the expense concentrates. Whether the exposure window is three months or fifteen years depends almost entirely on how far back the records go.
Related reading on this site: a line-by-line comparison of Ontario's enforcement bodies, the documented triggers behind infection control investigations in Canada, a cost analysis of a single Ontario sterilization lapse, and the underlying RCDSO daily biological indicator requirement explained. For a quote on a monitoring programme for multiple chairs or sites, our business account page covers volume terms.
Frequently Asked Questions
Does Ontario publish infection control investigations involving dental clinics?
Yes. Public health units publish investigation summaries when an infection prevention and control lapse has been identified, under the provincial disclosure protocol. Toronto Public Health, Niagara Region, Peel Region and York Region all maintain public pages listing the premises, the date the health unit became aware, the findings, any order issued and the final outcome.What triggers an infection prevention and control investigation in Ontario?
A complaint from a member of the public or a patient, a self-report by the practice, a referral from another public health unit, a regulatory college or a ministry, or surveillance following a reportable communicable disease. In the cases reviewed here, patient and public complaints and self-reports were the most common routes.What is a section 13 order under the Health Protection and Promotion Act?
Section 13 of the Health Protection and Promotion Act, R.S.O. 1990, c. H.7 gives a medical officer of health the power to issue orders to a person or premises to remedy a health hazard. In the public reports, orders are often verbal and served on the day the health unit becomes aware of the lapse. The section 13(7) power was used to direct corrective steps in a physician's office in April 2026.How long do public IPAC investigation reports stay online?
It depends on the health unit. Toronto Public Health moves summaries to a previous investigations page 12 months after the investigation completion date and removes them 24 months after the investigation end date. Niagara Region states that results remain posted for 24 months from the date of initial posting.Can a clinic avoid a public report by fixing the problem during the inspection?
No. Publication follows identification of a lapse. Fixing the problem during or immediately after the inspection is recorded in the same public document, which is why many summaries end with a fully compliant re-inspection. The corrective speed is visible to anyone reading the file, but the file itself is still published.How far back can a patient look-back reach?
As far back as the records allow. In one Ontario file the notification covered patients with procedures on or after 1 April 1998. In another, the lapse spanned 15 years and 4,495 patients were individually notified using provincial health insurance data. The practical determinant is when trustworthy reprocessing records stop.What biological monitoring does Ontario require in a dental office?
The RCDSO standard of practice requires a biological indicator to be placed in a process challenge device and used to test the sterilizer each day it is used, and for each type of cycle that is used. That daily requirement is an Ontario position. The weekly interval sometimes quoted comes from United States guidance such as AAMI ST79, which has historically described biological monitoring at least weekly, preferably daily, and is not the Ontario baseline.Sources
- Toronto Public Health, Infection Prevention and Control (IPAC) Investigations
- Toronto Public Health, Previous IPAC Investigations (Bloor West Dentistry, Bathurst Walk-In Dental Centre and others)
- Niagara Region, Infection Control Lapse Investigations
- Peel Region, Infection prevention and control investigations
- York Region, Infection prevention and control lapses
- Cadieux G, Spatz Friedman D, Tilley L, Mazzulli T, McDermaid C. Infection prevention and control lapse involving medical equipment reprocessing at a family medicine clinic in Ottawa, Ontario, 2018. Can Commun Dis Rep 2020;46(2-3):40-47
- Same article, publisher copy
- Johnston et al. A public health response to a newly diagnosed case of hepatitis C associated with lapse in Infection Prevention and Control practices in a dental setting in Ontario, Canada. Can Commun Dis Rep 2021;47(7-8)
- Hardie J. A commentary on a flawed public health investigation. Can Commun Dis Rep 2021;47(11):500-502
- Algoma Public Health, Certain Patients of Dr. E.E. Beduhn Informed to Get Tested for Hep B and C and HIV (23 November 2015)
- Health Protection and Promotion Act, R.S.O. 1990, c. H.7
- Ontario Regulation 136/18 (personal service settings) for comparison with clinic settings
- RCDSO, Standard of Practice: Infection Prevention and Control in the Dental Office (v3)
- Public Health Ontario, Infection Prevention and Control resources
- College of Physicians and Surgeons of Ontario, IPAC Checklist for Clinical Office Practice: Reprocessing of Medical Equipment/Devices
- Lakelands Public Health, Infection Control Lapse Reporting
Where this leaves a clinic
The published record is public, permanent for 12 to 24 months, and structured. Reading it is the closest thing to seeing the inspection before it happens. If you want the underlying monitoring workflow — daily biological indicators in a process challenge device, incubated and read on a fixed schedule — the sterilization compliance hub collects the reference material, and the dental compliance hub covers the Ontario-specific obligations. For the monitoring consumables themselves, the 24-hour self-contained biological indicator is the daily-use format, the dry block incubator holds the incubation temperature, and the Class 5 steam chemical integrator is the package-level check that Bloor West Dentistry added after its notification round. If you are setting up the whole monitoring workflow from scratch, our sterilization monitoring collection covers the full range. Clinics that want to see how a daily indicator programme is recorded before committing to a full case can request a 5-pack biological indicator trial and run it alongside their current log.
CliniEco Medical holds MDEL #35334.
Related reading: RCDSO-compliant sterilization records — a free tool that generates the RCDSO field set and exports to CSV or print.
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