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Updated 6/25/20

Considering that patients who are asymptomatic may still be COVID-19 infectious, it should be assumed that all patients can transmit disease. Use the highest level of PPE available when treating patients to reduce the risk of exposure. Dentists must exercise their independent professional judgment and carefully consider the availability of appropriate PPE to minimize risk of virus transmission.

CDC reminds dentists to, “Ensure that you have the appropriate amount of personal protective equipment (PPE) and supplies to support your patient volume. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first.”


PPE Availability

Both the American Dental Association (ADA) and TDA are aware of members’ concerns about the availability of Personal Protective Equipment (PPE).  On May 26, 2020, TDA started shipping 300,000 N95 respirators that Governor Abbott made available to the TDA for distribution to Texas dentists. This is an extraordinary benefit to TDA members and the dental patients they safely care for. 


Texas Dental Association

The TDA has worked diligently with the State of Texas and Governor Abbott to secure needed PPE for members and dentists across the state. The TDA successfully secured N95 respirators from the state and contracted with a third party vendor to facilitate the order and delivery process.

The TDA has heard concerning reports of credit card compromise from dentists who ordered N95 respirators through this program. Although no confirmed correlation has been made between the online ordering portal, credit card processing company and the credit card compromise, out of an abundance of caution and concern, the TDA has requested that orders be temporarily suspended while security measures are tested and validated. Orders may resume once security measures are confirmed.

The TDA will update the membership as soon as additional information is available.


American Dental Association

The ADA has been working closely with FEMA and other government agencies on PPE for dental professionals and as of May 4, 2020, dentists and dental professionals are now fourth on the FEMA priority list for PPE. This is a significant accomplishment by the ADA government affairs team as dental professionals were originally excluded from the priority list and then moved to number seven. 


Emergency PPE for Texas Dentists – TDA Partners with State

In addition to TDA working with Governor Abbott and the Texas Division of Emergency Management to secure PPE for dentists, TDA has been simultaneously working with the Department of State Health Services to ensure that dentists can access PPE through the state’s Regional Advisory Councils (RAC). Here’s how that works:

When Texas dentists exhaust all options to obtain PPE, and are nearing depletion, they may submit a request for a PPE distribution through a State of Texas Assistance Request (STAR). 

The PPE receive through this request and distribution system is free. The PPE is acquired by the state and is meant for

emergency purposes

Each RAC may process STAR applications differently. Be sure to follow the directions to complete the STAR for the RAC servicing your area. You will need to provide all relevant details for your request, to include type of item, point of contact information, and delivery address.


Free Decontamination Services
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. 

Resources:
CDC: Decontamination and Reuse of Filtering Facepiece Respirators

Extending the Use of PPE
Demand is exceeding supply due to extreme patient surge from COVID-19. Given decreases in exports from select countries and the increases in demand, manufacturers of select types of PPE are reporting challenges in meeting the increased order volume. There are strategies available to extend the life of PPE until the supply chain challenges are resolved. Remember that any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses.  

Resources:
ADA: Extending the use of N95 Masks
CDC: Strategies for Optimizing the Supply of Isolation Gowns
CDC: Strategies to Optimize the Supply of PPE and Equipment
CDC: Strategies for Optimizing the Supply of Facemasks
CDC: Strategies for Optimizing the Supply of N95 Respirators
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
FDA: N95 Respirators and Surgical Masks (Face Masks)


Purchasing PPE
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. 

Resources:
CDC: Factors to Consider When Planning to Purchase Respirators from Another Country
CDC: Strategies for Optimizing the Supply of N95 Respirators
CDC: NPPTL Respirator Assessments to Support the COVID-19 Response. May 22, 2020.
FDA: Emergency Use Authorizations


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.

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. Because D1999 is a ‘by report’ code, Box 35 of the ADA Claim Form must include the explanation for charges reported against this code. When additional charges for PPE are being billed, an entry of ‘PPE’ may suffice for Box 35.”

Remember that if the dentist is not participating in the patient’s insurance network, they are able to balance bill the patient a PPE fee. However, if the dentist is a contracted provider with the patient’s insurance plan, they may not be able to bill the patient a PPE fee. Dentists in signed participating agreements with insurance companies need to check their agreements to determine whether they can bill the patient a PPE fee.

Check the ADA’s COVID-19 Coding and Billing Interim Guidance PPE to see if any insurance companies you contract with are offering programs to provide financial support for reopening or recovery of dental offices and/or to support the cost of PPE.

If you charge a patient directly, be sure to provide them with a “plain language” written explanation for the charge prior to their appointment. This notice is consistent with dental board regulations governing fair dealing and fees.

Resource: 
ADA: Statement on Third Party Payer Reimbursement for Costs Associated with Increased Standards for Personal Protective Equipment

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 Dental Health Care Personnel (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
Three Key Factors for an N95 Respirator to be Effective

Resources ADA:
Conducting Respirator Fit Tests and Seal Checks
Respirator Guide
OSHA Guidance for Dentistry for Workers and Employers