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NOTICE TO TEXAS DENTISTS

After TDA’s round-the-clock work fueled by your input, Governor Greg Abbott approved the Texas State Board of Dental Examiners’ (TSBDE) emergency rule allowing dentists to safely reopen their dental practices on May 1, 2020, at 12:01 AM. 

Texas’ dentists choosing to fully treat dental patients starting May 1, 2020, must conduct their dental practices according to Governor Abbott’s Executive Order GA-19 and the TSBDE’s emergency rule dictating the minimum standards for safe dental practice during the COVID-19 disaster. The dental board’s emergency rule shall only remain effective until Governor Abbott’s COVID-19 disaster declaration is terminated. 

It is important for dentists to know and share with their dental teams that neither Governor Abbott’s GA-19 order nor the TSBDE’s emergency rule require dentists to fully reopen. Dentists must use their independent professional judgement to determine if they can comply with the TSBDE’s COVID-19 emergency rule. 

This page will be updated to reflect changes to dental regulations during COVID-19 and to add questions and answers to the FAQ section. 


TDA’s TSBDE COVID-19 Emergency Preparedness Webinar

This webinar complements the resources available on this webpage. It includes an overview of Governor Greg Abbott’s executive orders impacting dentistry and a breakdown of the TSBDE’s COVID-19 emergency rule along with answers to questions frequently posed by dentists.

What Must Dentists Do?


Create, Implement, and Train Dental Health Care Personnel (DHCP) on COVID-19 Office Procedures that Must Include:

  • Patient prescreening protocol
  • In office screening protocol (patients, DHCP)
  • Transmission-based precautions
  • Protocol if DHCP suspects an exposure to COVID-19

Patient Scheduling and Patient Screening

  • Schedule patient appointments to minimize possible contact with other patients in the waiting room.
  • Screen all patients by phone before scheduling and when confirming the patient’s dental appointment.
  • Notify patients that they may not bring a companion(s) to their appointment, unless the patient requires assistance (eg, pediatric patients, special needs patients, elderly patients, etc.).

Sample Prescreening Protocol
Patient Scheduling and Confirming Patient’s Dental Appointment

Example: Advise patients to check their temperature at home. 
Example Administer COVID-19 questionnaire: 

1.  Have you tested positive for COVID-19?
2.  Have you been tested for COVID-19 and are awaiting results?
3.  Do you have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?
4.  Have you recently lost your sense of smell or taste?
5.  Do you have any GI symptoms? Diarrhea? Nausea? 
6.  Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
7.  Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
8.  Have you traveled outside the United States by air or cruise ship in the past 14 days?
9.  Have you traveled within the United States by air, bus or train within the past 14 days?

Additional Resource: Page 3: American Dental Association: Return to Work Interim Guidance Toolkit: Pre-Appointment Screening Process and Sample Patient Screening Form

Patient In-Office Screening Protocol

  • Check patient’s temperature when they arrive at the office.

Sample Patient In-Office Screening Protocol

  • Example: Administer COVID-19 questionnaire: 

1.  Have you tested positive for COVID-19?
2.  Have you been tested for COVID-19 and are awaiting results?
3.  Do you have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?
4.  Have you recently lost your sense of smell or taste?
5.  Do you have any GI symptoms? Diarrhea? Nausea? 
6.  Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
7.  Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
8.  Have you traveled outside the United States by air or cruise ship in the past 14 days?
9.  Have you traveled within the United States by air, bus or train within the past 14 days?

Additional Resources
Page 3 American Dental Association: Return to Work Interim Guidance Toolkit: Pre-Appointment Screening Process
Page 4 American Dental Association: Return to Work Interim Guidance Toolkit: In-Office Patient Registration Procedures

Patient Companion In-Office Screening Protocol

  • If patient companion allowed, they should be screened for signs and symptoms of COVID- 19 during patient check-in.
  • Take companion’s temperature when they arrive at the office.
  • Perform in-office companion screening protocol.

Sample Patient Companion In-Office Screening Protocol

Example Administer COVID-19 questionnaire:

1.  Do you have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?
2.  Have you recently lost your sense of smell or taste?
3.  Do you have any GI symptoms? Diarrhea? Nausea? 
4.  Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
5.  Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
6.  Have you traveled outside the United States by air or cruise ship in the past 14 days?
7.  Have you traveled within the United States by air, bus or train within the past 14 days?

Additional Resources
Page 3 American Dental Association: Return to Work Interim Guidance Toolkit: Pre-Appointment Screening Process
Page 4 American Dental Association: Return to Work Interim Guidance Toolkit: In-Office Patient Registration Procedures

DHCP Considerations

  • DHCP experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work.
  • DHCP who are of older age, have a pre-existing, medically compromised condition, pregnant, etc., are perceived to be at a higher risk of contracting COVID-19 from contact with known or suspected COVID-19 patients. 
  • DHCP who do not fall into these categories (older age; presence of chronic medical conditions, including immunocompromising conditions; pregnancy) may be prioritized to provide patient care. 
  • DHCP self-monitor by remaining alert to any respiratory symptoms (eg, cough, shortness of breath, sore throat).
  • DHCP check their temperature twice a day, regardless of the presence of other symptoms consistent with a COVID-19 infection. 

Additional Resource: Page 8 American Dental Association: Return to Work Interim Guidance Toolkit: Staff Protection Strategies


DHCP In-Office Screening Protocol

  • DHCP self-monitor by remaining alert to any respiratory symptoms (eg, cough, shortness of breath, sore throat).
  • Take DHCP’s temperature when they arrive at the office. 

Sample DHCP In-Office Screening Protocol

  • Take DHCP’s temperature upon arrival to the office. 
    Example Administer COVID-19 questionnaire:

1.  Do you have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?
2.  Have you recently lost your sense of smell or taste?
3.  Do you have any GI symptoms? Diarrhea? Nausea? 
4.  Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
5.  Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
6.  Have you traveled outside the United States by air or cruise ship in the past 14 days?
7.  Have you traveled within the United States by air, bus or train within the past 14 days?

Additional Resource: Page 8 American Dental Association: Return to Work Interim Guidance Toolkit: Staff Protection Strategies


Transmission-Based Precautions

Considering that patients who are asymptomatic may still be COVID-19 infectious, it should be assumed that all patients can transmit disease.


Additional Resources: 
FDA: Approved Manufacturers N95 Equivalent During COVID-19
CDC Get Your Clinic Ready for COVID-19
Page 5 American Dental Association: Return to Work Interim Guidance Toolkit: Reception Area Preparation Strategies
Page 6 American Dental Association: Return to Work Interim Toolkit: Chairside Checklist

Transmission-Based Precautions: Clinical Technique

  • DHCP shall use only hand instruments and low speed polishing tools for hygiene services.
  • Patients perform pre procedure rinse, if medically safe.
  • Reduce aerosol production as much as possible, as the transmission of COVID-19 seems to occur via droplets or aerosols.
    • DHCP may prioritize the use of hand instrumentation.
    • DHCP should use dental isolation if an aerosol-producing procedure is being performed to help minimize aerosol or spatter.
  • After patient’s dental care:
    • Instruct patient to contact the dentist’s office if they experience COVID-19 symptoms within 14 days after the dental appointment.


Additional Resource
: Page 6 American Dental Association: Return to Work Interim Guidance Toolkit: Chairside Checklist


Protocol if DHCP Suspects an Exposure to COVID-19

  • DHCP experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work.
  • If DHCP document fever and/or COVID-19 symptoms during the workday, have the DHCP immediately leave the workplace. 
  • If DHCP is caring for an individual that tests positive for COVID-19, the DHCP should not report to work. 
  • ADA: What to do if Someone on Your Staff Test Positive for COVID-19

Additional Resources: 
CDC Interim Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with COVID-19
CDC Phone Advice Line Tool for Possible COVID-19 Patients
CDC Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19 (Interim Guidance): Updated April 30, 2020. 
US Food and Drug Administration: FAQs of Diagnostic Testing for SARS-CoV-2
ADA: COVID-19 Employment Law FAQs

Notes and Additional Resources

NOTE: The CDC definition of DHCP includes dentists, dental hygienists, dental assistants, dental laboratory technicians (in-office and commercial), students and trainees, contractual personnel, and other persons not directly involved in patient care but potentially exposed to infectious agents (eg, administrative, clerical, housekeeping, maintenance, or volunteer personnel). 

NOTE: OSHA standards for PPE including standards for respiratory protection have always included the requirement for employer dentists to conduct a hazard assessment. Hazard assessments identify the hazards DHCP may face, evaluate that risk, and select, implement and ensure DHCP use the controls you put in place to minimize risk. Refer to the OSHA Guidance for Dentistry Workers and Employers for guidance in performing a hazard assessment.

ADDITIONAL RESOURCES

Frequently Asked Questions and Answers

(Updated 5/8/20)

Q: Does the CDC’s guidance supersede Texas’ authority to open dental practices for non-emergency care?
A:
 No. The CDC does not have regulatory authority over the operation of dental practices. CDC guidance issued on April 27 is a non-binding recommendation.  Final decisions about how dental practices operate in Texas are made by our governmental authorities. CDC guidance includes that, “Dental health care professionals should regularly consult their state dental boards or other regulating agencies for requirements specific to their jurisdictions.”

Q: Does OSHA’s guidance supersede Texas’ authority to open dental practice for non-emergency care?
A:
 No. OSHA guidance is just that, guidance. Final decisions about how dental practices operate in Texas are made by our governmental authorities. For example, according to OSHA’s Guidance on Preparing Workplaces for COVID-19 —"This guidance is not a standard or regulation, and it creates no new legal obligations.” Additionally, OSHA’s Guidance for Dentistry Workers and Employers issued on May 1, 2020, is a guidance document does NOT establish new requirements.  It is offered as guidance only.

Q: What is the difference between OSHA guidance and OSHA standards? Must dentists comply with applicable OSHA standards?
A:
 According to the ADA, an OSHA standard equates to a regulation for enforcement purposes. OSHA standards are published by the agency to serve as “criteria for measuring whether employers follow OSHA laws.” Employers must comply with all applicable OSHA standards. OSHA standards are enforced in Texas by federal OSHA.

Q: Is a properly fitted surgical mask substantially equivalent to N-95 respirator masks/KN-95 masks?
A:
 No: According to the TSBDE, “Equipment that qualifies as a substantial equivalent to a N-95/KN-95 mask DOES NOT include the combination of a surgical mask and a face shield. CDC provides guidance on equipment that qualifies as a "substantial equivalent" to a N-95/KN-95 mask."

Q: Do DHCP have to wear N95/KN95 or their substantial equivalent masks when delivering all types of dental care?
A:
 No. DHCP must only wear an N95 respirator mask, KN95 mask, or their substantial equivalent if DHCP will be within 6 feet of any and all procedures likely to involve aerosols.

Q: How long will the TSBDE’s emergency rule (22 Texas Administrative Code §108.7(16)) remain in effect?
A:
 State emergency rules can remain in effect for up to 120 days and can be extended for an additional 60 days if needed—Texas Government Code §2001.034, Emergency Rulemaking. This is the standard for state agency emergency rule making regardless of the subject of the emergency rule or the agency issuing the emergency rule. Emergency rules are not created to go on indefinitely, but they are designed to be flexible so that state agencies can make changes without having to go through an entirely new emergency rule-making process. 

Dentistry’s emergency rule will remain in place until Governor Abbott’s COVID-19 disaster declaration is terminated at which time the dental board would rescind the emergency rule. The TSBDE could amend  dentistry’s emergency rule if Governor Abbott issues a new executive order governing dentistry or modifies GA-19.  

Q: Is an ultrasonic scaler used on a low setting (eg, Cavitron) the same as a low-speed polishing tool for hygiene services as required by the TSBDE’s COVID-19 emergency rule?
A:
 No. Although ultrasonic scalers (eg, Cavitron) have a range of settings, it is not considered a low-speed polishing tool for hygiene services according to academic literature including: G. JS, SR, SD. Revised Reprint Fundamentals of Periodontal Instrumentation & Advanced Root Instrumentation, eighth edition. Examples of hand tools and low speed instruments are included HERE

Q: Are DHCP limited to using only hand instruments and low speed polishing to provide hygiene services?
A: 
Yes. According to the TSBDE’s COVID-19 emergency rule, “DHCP shall use only hand instruments and low speed polishing tools for hygiene services.“ Hygiene services include routine/general cleanings (adult or child prophylaxis).

Resource: 22 Texas Administrative Code §108.7(16)(B)(vi)
 
Q: Are DHCP limited to only using hand instruments and low speed polishing tools to provide periodontal procedures/treatment to patients?
A:
 No. According to the TSBDE’s COVID-19 emergency rule, DHCP are prohibited from using ultrasonic devices for routine/general cleanings (adult or child prophylaxis) but are permitted to use ultrasonic devices for periodontal treatment procedures when deemed medically necessary as part of a dental treatment plan.

Resource: 22 Texas Administrative Code §108.7(16)(B)(vi)

Q: If an N95 respirator is worn and a level 2/3 mask is placed over the N95 respirator, can the N95 respirator be worn for more than one patient if the level 2/3 mask covering is changed between patients? 
A: Please refer to CDC Strategies for Optimizing the Supply of N95 Respirator and CDC Decontamination and Reuse of Filtering Facepiece Respirators.

Q: Can a gown be worn for more than one patient if there was no aerosol/splash/splatter generated and the gown is not visibly soiled? 
A: Please refer to CDC: Strategies for Optimizing the Supply of Isolation Gowns
Specifically, “Crisis Capacity Strategies—Extended Use of Isolations Gowns, Re-use of Cloth Isolations Gowns, and Prioritize Gowns.”

Q: Is a gown necessary for patients where there will be no aerosol/splash/spatter, like a typical hygiene check or emergency exam where no treatment is being performed? 
A: Please refer to CDC Standard Precautions and CDC Transmission-Based Protocols.

Q: Under the dental board’s COVID-19 emergency rule, can I leave the treatment room of one patient to treat a different patient? For example, can a dentist check hygiene patients’ in-between treatment they are performing on other patients?
A:
 No. The dental board’s emergency rule clearly states that DHCP must complete the full treatment of one patient before leaving the treatment area to treat another patient. 

TDA understands that this current standard differs from typical patient workflow prior to COVID-19. However, the Governor and the Strike Force are utilizing a phased approach to opening Texas. Dentistry was fortunate to be part of Phase 1. The focus remains on safely delivering dental care to Texans and at this stage it includes following the TSBDE’s minimum standards for safe practice during COVID-19 as approved by the governor’s office. Right now, this means fully completing the treatment of one patient before leaving the treatment area to treat another patient. If the state’s COVID-19 data progresses favorably, then TDA will ask Governor Abbott to revisit this standard, and others, as part of his continuing phased approach to reopening Texas.

Q: Does the dental board’s COVID-19 emergency rule require fit-testing of respirators?
A:
Fit testing is not a requirement per the TSBDE’s COVID-19 emergency rule—22 Texas Administrative Code §108.7(16) and the dental board does not have authority to issue sanctions for violations of OSHA standards. OSHA is a federal regulation.

Regarding fit-testing respirators, dentists are required to comply with OSHA’s respiratory protection standard. Dentist employers have always been required to comply with this standard.
Dentist employers must conduct hazard assessments identifying the hazards DHCP may face, evaluate that risk, and select, implement and ensure DHCP use the controls you put in place to minimize risk. Refer to the OSHA Guidance for Dentistry Workers and Employers for guidance in performing a hazard assessment.

Resources OSHA:
March 14, 2020: Temporary Enforcement Guidance for Enforcing the Respiratory Protection Standard
April 8, 2020: Expanded Temporary Enforcement Guidance on Respiratory Protection Fit-Testing for N95 Filtering Facepieces in All Industries During the Coronavirus Disease 2019 (COVID-19) Pandemic
Seven Steps to Correctly Wear a Respirator at Work

Resources CDC:
Key Factors of Respiratory Protection
Property Fit and Wear A Disposable Respirator

Personal Protective Equipment

TDA continues securing leads and resources on respirators that meet the requirement in the TSBDE’s emergency rule for dental practices. TDA’s advocacy team is working directly with Governor Abbott’s office and Nim Kidd, Chief of the Texas Division of Emergency Management (TDEM) regarding this issue. We will share information as it becomes available. 

See TDA Perks Supplies for details on PPE supplies in stock and available for order including: level 2 masks, face shields, coverall safety suits, and infrared thermometers.

See Battelle Company for details on a free decontamination service for reuse of N95 and N95-equivalent respirators. FDA authorized emergency use of the Battelle Decontamination System.

Associated PPE Costs

Given PPE changes resulting from the COVID-19 pandemic, ADA and TDA recognize that the cost for treating patients will increase. TDA is currently discussing with state-regulated insurance companies the need for them to reimburse dentists for these increased associated costs.

American Dental Association: Statement on Third Party Payer Reimbursement for Costs Associated with Increased Standards for Personal Protective Equipment (PPE)

According to the ADA, “Prior to such adjustments taking effect, dental offices may wish to use CDT code ‘D1999 - unspecified preventive procedure, by report’ to document and report the use and cost of additional PPE. Dentists can use this code once per patient visit/claim to attempt to cover the cost of PPE.”

Point-of-Care COVID-19 Testing

TDA consulted with the TSBDE and their position right now is that the Dental Practice Act does not give dentists the ability to administer medical tests such as the serology test for immunity and the molecular test for the virus itself. Both are considered medical tests.  

Separate from the current regulatory environment, there are concerns about the accuracy of the antibody testing versus antigen testing. The ADA  advises dentists to stay away from “so-called ‘gray market’ point-of-care tests for COVID-19” and “recommends dentists follow direction issued by the FDA regarding testing procedures in dental practices.”

TDA is closely watching the point-of-care testing debate and agrees that dentists need a fast point-of-care test that accurately predicts the presence or absence of COVID-19 virus in real time. If  COVID-19 point-of-care testing becomes scientifically sound, TDA will advocate that dentists be able to use COVID-19 point-of-care testing to screen patients for COVID-19 as it is not a diagnostic test for dentists, since dentists aren’t treating COVID-19 as an illness.

Insurance Advocacy

TDA continues to work with and strongly encourage third party payers and dental managed care organizations (Medicaid/CHIP) to offer financial compensation to dentists resulting from COVID-19 related PPE and infection control changes. TDA is also advocating for financial compensation to dentists via our contacts with the National Association of Dental Plans and Texas Association of Health Plans. 

TDA confirmed with the Texas Department of Insurance (TDI) that dentists can file a complaint with the agency to help resolve situations in which a dentist’s insurance company clearly violates the terms of the dentist’s policy covering business interruption insurance as the policy may apply to COVID-19 closures. 

However, TDI is often unable to resolve certain contract disputes between policyholders and their insurers, particularly if they involve a disagreement over insurance policy language not already interpreted decisively by the courts. According to TDI, business interruption policies are the subject of ongoing litigation, including multiple federal class action lawsuits, related to the COVID-19 pandemic. 

Dentists are encouraged to closely review the terms of any business interruption policy coverage they may have. Individual policy language and terms vary. For example, a related product is contingency business interruption insurance, which covers indirect losses when suppliers or customers are affected.


Patient Messaging

Essential messaging to build patient confidence
Safe access to dentists is key to protecting Texans’ health

We know that Texas dentists are eager to get back to the important work of keeping your patients healthy. We also know that most dental practices in our state are small businesses and that the COVID-19 shutdown has been very difficult financially. As you get ready for the full opening of your clinics, it will be important to send a signal of hyper focus on patient and staff safety. This will build on the longstanding trust dentists enjoy.

Now is an excellent time to educate the public on the role of dentistry in whole-body health and preventing illness. Because of this, TDA has prepared the below messages for you to use in your staff and patient communications as well as any mailings, social media or advertising you may choose to do. Used consistently, we can raise public awareness and confidence in safely reopening dental practices.

Download Messaging Document