TSBDE COVID-19 Emergency Rule

TSBDE COVID Emergency Rule Expires; New COVID-19 OSHA Standards

The Texas State Board of Dental Examiners’ COVID-19 emergency rule dictated the minimum standards for safe dental practice during the COVID-19 pandemic. Versions of the emergency rule have been in place since March 2020, with the most recent version being in place since March 2021, The emergency rule included, among other things, patient and dental staff screening for COVID-19 symptoms and wearing an N95 respirator, KN95 respirator, or their substantial equivalent, within 6 feet of any and all aerosol generating procedures.

The dental board announced during its June 18th meeting that the COVID-19 emergency rule will expire today. However, dentists are encouraged to continue following the Centers for Disease Control and Prevention’s (CDC) COVID-19 “Guidance for Dental Settings” to help stop the spread of COVID-19. Although Governor Greg Abbott lifted the state mask mandate, dentists can still choose to require patients, staff, and those accompanying patients to the dental practice to wear a mask and follow all CDC COVID-19 safe-practice standards for dental offices.

On June 10, 2021, the Occupational Safety and Health Administration (OSHA) issued an emergency temporary standard for COVID-19 in healthcare settings. The final rule version has not yet been published. For the full document, please see 29 CFR 1910, Subpart U. Although dentistry is largely exempt from the new OSHA standard, the American Dental Association (ADA) notes that dental practices must follow key provisions such as pre-appointment patient screenings for COVID-19, screening anyone entering the dental practice prior to entry and denying entry to anyone suspected or confirmed to have COVID-19, and having a written COVID-19 plan. For details on compliance with OSHA’s COVID-19 temporary standard in healthcare settings, visit the ADA’s “OSHA COVID-19 Healthcare Emergency Temporary Standard.”

For more information, go to Patient Messaging.

TSBDE Adopts New COVID-19 Emergency Rule
On February 19, 2021, the Texas State Board of Dental Examiners (TSBDE) voted unanimously (2 absentees) to adopt a new COVID-19 emergency rule—22 Texas Administrative Code §108.7(16). The new emergency rule is in keeping with Governor Greg Abbott’s Executive Order (GA-19) dictating the minimum standards for safe dental practice during the COVID-19 pandemic. Unless Governor Abbott lifts the COVID-19 disaster declaration, the final new COVID-19 emergency rule will be in effect for 120 days. At that time, the dental board will reconvene and decide whether to extend the rule for an additional 60 days.

Highlights of the new emergency rule include:

No longer prioritizing that patient care be performed by dental health care personnel not at high risk for contracting COVID-19;
No longer requiring the removal of magazines, reading materials, toys, and other objects that may be touched by others;
No longer requiring COVID-19 patient screening by phone during scheduling. Patients must still be screened during patient confirmation prior to appointment;
Nolonger prohibiting patient companions. Companions should continue to be screened for COVID-19 during patient check-in;
No longer recommending a pre-procedure rinse; and
Changing the time for a patient to contact the dental office if they experience COVID-19 symptoms from 10 days to 7 days after the dental appointment.

What Must Dentists Do?
- Follow Centers for Disease Control and Prevention (CDC): Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response
- Follow TSBDE COVID-19 Guidelines: 22 Texas Administrative Code §108.7(16)
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
Patient Scheduling and Patient Screening
- Schedule patient appointments to minimize possible contact with other patients in the waiting room.
- Screen all patients during patient confirmation prior to appointment.
- Screen patient companions for signs and symptoms of COVID-19 during patient chick-in.
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. Do you have a fever or felt feverish within the last 21-14 days?
  5. Have you recently lost your sense of smell or taste?
  6. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
  7. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
  8. Have you been in close contact (6 ft) with someone who has tested positive for COVID-19 in the last 14 days?
  9. Have you traveled outside the United States by air or cruise ship in the past 14 days?
  10. Are you age 65 or older?
  - Do you have medical issues like heart disease, diabetes, cancer, or a weakened immune system?
Sample Form: Patient Prescreening and In-Office Screening

Additional Resources:
Page 4: American Dental Association: Return to Work Interim Guidance Toolkit: Pre-Appointment Screening Process and Sample Patient Screening Form
Pages 6-7: The Governor’s Report to Open Texas
CDC: Symptoms of Coronavirus
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
Patient In-Office Screening Protocol
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. Do you have a fever or felt feverish within the last 21-14 days?
  5. Have you recently lost your sense of smell or taste?
  6. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
  7. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
  8. Have you been in close contact (6 ft) with someone who has tested positive for COVID-19 in the last 14 days?
  9. Have you traveled outside the United States by air or cruise ship in the past 14 days?
  10. Are you age 65 or older?
  - Do you have medical issues like heart disease, diabetes, cancer, or a weakened immune system?
Sample Form: Patient Prescreening and In-Office Screening

Additional Resources:
Page 4 American Dental Association: Return to Work Interim Guidance Toolkit: Pre-Appointment Screening Process
Page 5 American Dental Association: Return to Work Interim Guidance Toolkit: In-Office Patient Registration Procedures
Pages 6-7: The Governor’s Report to Open Texas
CDC: Symptoms of Coronavirus
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
Patient Companion In-Office Screening Protocol
Patient Companion In-Office Screening Protocol
- Screen patient companions 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 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. Do you have a fever or felt feverish within the last 21-14 days?
  5. Have you recently lost your sense of smell or taste?
  6. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
  7. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
  8. Have you been in close contact (6 ft) with someone who has tested positive for COVID-19 in the last 14 days?
  9. Have you traveled outside the United States by air or cruise ship in the past 14 days?
  10. Are you age 65 or older?
  - Do you have medical issues like heart disease, diabetes, cancer, or a weakened immune system?
Sample Form: Patient Companion Screening Form

Additional Resources:
Page 4 American Dental Association: Return to Work Interim Guidance Toolkit: Pre-Appointment Screening Process
Page 5 American Dental Association: Return to Work Interim Guidance Toolkit: In-Office Patient Registration Procedures
Pages 6-7: The Governor’s Report to Open Texas
CDC: Symptoms of Coronavirus
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
DHCP Considerations
DHCP Considerations
- DHCP experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work.
- 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 Resources:
Page 9 American Dental Association: Return to Work Interim Guidance Toolkit: Staff Protection Strategies
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
DHCP In-Office Screening Protocol
DHCP In-Office Screening Protocol
- 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.
Sample DHCP In-Office Screening Protocol
- Take DHCP’s temperature when they arrive at 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 felt feverish within the last 21-14 days?
    3. Have you recently lost your sense of smell or taste?
    4. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
    5. Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
    6. Have you been in close contact (6 ft) with someone who has tested positive for COVID-19 in the last 14 days?
Sample Forms: DHCP Screening Form and DHCP Screening Log

Additional Resource:
Page 9 American Dental Association: Return to Work Interim Guidance Toolkit: Staff Protection Strategies
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.

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.
- Immediately contact your local health department if you suspect a patient has COVID-19. This helps prevent transmission to DHCP and other patients.
  - See Texas Department of State Health Services Map: COVID-19 Testing Sites
- Prominently display signage instructing DHCP and patients on standard recommendations for respiratory hygiene/cough etiquette and social distancing.
  - Example from the CDC – Stop the Spread of Germs
- DHCP adhere to standard precautions, which include but are not limited to hand hygiene, use of personal protective equipment (PPE), respiratory hygiene/etiquette, sharps safety, safe injection practices, sterile instruments and devices, clean and disinfected environmental surfaces.
  - Example: Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60– 95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
  - Example: Install physical barriers (eg, glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.
  - Example: Place chairs in the waiting room at least six feet apart.
  - Example: DHCP should wear a surgical mask, eye protection (goggles, protective eyewear with solid side shields, or a full-face shield), and a gown or protective clothing during procedures likely to generate splashing or spattering of blood or other body fluids.
  - Example: EPA only recommends use of the EPA identified surface disinfectants against the virus that causes COVID-19.
  1. Resource: CDC Guidelines for Infection Control in Dental Health-Care Settings 2003, (MMWR Vol. 52, No. RR-17)
  2. Resource: Summary of Infection Prevention Practices in Dental Settings: Basic Expectation for Safe Care
  3. Resource: CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
  4. Resource: CDC: Hand Hygiene in Healthcare Settings
- DHCP within six (6) feet of any and all procedures likely to involve aerosols must use N95 respirator masks, KN95 masks, or their substantial equivalent.
  - Clarification from TSBDE (May 1, 2020): “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."
     -  Respirator - Trusted-Source Information
     -  Counterfeit Respirators / Misrepresentation of NIOSH-Approval
  -  NIOSH-Approved Particulate Filtering Facepiece Respirators
  -  ADA’s Tips to Avoid Counterfeit Masks
- DHCP must follow standard sequence of donning and doffing PPE.
  - Example from CDC: PPE Sequence
  - Example from CDC: Using Personal Protective Equipment
- DHCP should remove PPE before returning home.
Additional Resources:
FDA: Approved Manufacturers N95 Equivalent During COVID-19
CDC Get Your Clinic Ready for COVID-19
Page 6 American Dental Association: Return to Work Interim Guidance Toolkit: Reception Area Preparation Strategies
Page 7 American Dental Association: Return to Work Interim Toolkit: Chairside Checklist
Transmission-Based Precautions: Clinical Technique
- 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.
  - Example of Hand Instruments and Low Speed Polishing Tools
- After patient’s dental care:
  - Instruct patient to contact the dentist’s office if they experience COVID-19 symptoms within 7 days after the dental appointment.
Additional Resource:
Page 7 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.
- Report to the team that a team member tested positive for COVID-19 while protecting team member’s confidentiality under HIPAA and state privacy laws.
- Report to your local health department.
- Dentists and team members testing positive and having known close contact (6 ft) with patients while positive, must notify those patients. Document that the communication occurred. In your patient communications, protect the team member’s confidentiality under HIPAA and state privacy laws. A template notification letter from the CDC is available HERE for use or modification as you or your professional advisors deem appropriate.
- Refer to the Texas Department of State Health Services’ “Letter to Texas Employers. May 9, 2020.”
- ADA: What to do if Someone on Your Staff Test Positive for COVID-19
- See Texas Department of State Health Services Map: COVID-19 Testing Sites
Additional Resources:
CDC Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19)
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 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 Clinician Phone Center
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
CDC: Contact Tracing
General Considerations: Updated CDC Recommendations
Updated 12/20

General Considerations: Updated CDC Recommendations

Dental Health Care Personnel
As part of source control efforts, DHCP should wear a facemask or cloth covering at all times while they are in the dental setting, including in breakrooms or other spaces where they might encounter co-workers. When available, surgical masks are preferred over cloth face coverings for DHCP; surgical masks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Some DHCP whose job duties do not require PPE (such as clerical personnel) may continue to wear their cloth face covering for source control while in the dental setting. Other DHCP (such as dentists, dental hygienists, dental assistants) may wear their cloth face covering when they are not engaged in direct patient care activities, and then switch to a respirator or a surgical mask when PPE is required.

Patients
Patients and visitors should, ideally, wear their own cloth facemask covering (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a facemask covering, they should be offered a facemask or cloth face covering, as supplies allow.
- Patients may remove their cloth facemask covering when in their rooms or patient care area but should put it back on when leaving at the end of the dental treatment.
- Facemasks and cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
Infection Control
DHCP should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient (however, it is not necessary that DHCP should attempt to sterilize a dental operatory between patients). Clean and disinfect the room and equipment according to the Guidelines for Infection Control in Dental Health-Care Settings—2003pdf icon.

ADA: COVID-19 Hazard Assessment
This document is an adjunct to the ADA Return to Work Interim Guidance Toolkit. The ADA’s Advisory Task Force on Dental Practice Recovery created this hazard assessment to help dentists mitigate risk to the dental team and reflects recommendations by the Occupational Safety and Health Administration’s (OSHA’s) Recommended Practices for Safety and Health Programs.

Emergency Treatment: Patients Confirmed or Suspected COVID-19
If emergency dental care is medically necessary for a patient who has, or is suspected of having, COVID-19, DHCP should follow CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, including the use of PPE.

Resources:
CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. May 18, 2020.
CDC: Guidance for Dental Settings Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response. May 19, 2020.
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.

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