TSBDE COVID-19 Emergency Rule

On August 24, 2020, the Texas State Board of Dental Examiners (TSBDE) unanimously voted to adopt a new COVID-19 emergency rule (22 Texas Administrative Code §108.7(16)). This rule is adopted in response to Governor Greg Abbott’s Executive Order (GA-19) dictating the minimum standards for safe dental practice during the COVID-19 pandemic. The rule went into effect August 25, 2020 and will remain in effect until December 23, 2020, unless Governor Abbott’s disaster declaration is terminated.

It was once again TDA’s effective advocacy with the TSBDE, Governor Abbott, and the governor’s team that resulted in a new dental board emergency rule so that dentists can continue to effectively treat patients during the pandemic. Highlights of the new emergency rule include:

Allowing dentists to manage patient workflow according to their independent professional judgment and no longer require dental health care personnel (DHCP) to complete the full treatment of one patient before leaving the treatment area and moving on to another patient
Allowing DHCP to use high-speed instruments (eg, cavitron) for hygiene services; and
Allowing DHCP to remove PPE, without needing to also change from scrubs, before returning home.

The newly amended rule is 22 Texas Administrative Code §108.7(16).

Texas’ dentists choosing to fully treat dental patients starting May 1, 2020, must still conduct their dental practices according to Governor Abbott’s Executive Order GA-19 and the TSBDE’s new amended emergency rule.

***Coming Soon! Updates to All the Drop Down Sections of the Newly Amended Emergency Rule.***

***Coming Soon! Updated COVID-19 Webinar!***
This free on-demand webinar for TDA members will update on Governor Greg Abbott’s recent executive orders impacting dentistry, explain changes to the dental board’s newly amended COVID-19 emergency rule, and answer COVID-19 questions received from member dentists.

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 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. 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
- 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 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 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 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
- Remove magazines, reading materials, toys and other objects that may be touched by others and which are not easily disinfected.
- 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 complete the full treatment of one patient before leaving the treatment area to treat another patient.
- DHCP must follow standard sequence of donning and doffing PPE.
  - Example from CDC: PPE Sequence
  - Example from CDC: Using Personal Protective Equipment
- DHCPs should change from scrubs and PPE to personal clothing 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
- DHCP shall use only hand instruments and low speed polishing tools for hygiene services.
  - Example of Hand Instruments and Low Speed Polishing Tools
- 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 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 6/01/20

Dental Health Care Personnel
As part of source control efforts, DHCP should wear a facemask at all times while they are in the healthcare facility. 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.

Patients
Minimize overlapping dental appointments.

As part of aggressive source control measures, healthcare facilities should consider implementing policies requiring everyone entering the facility to wear a cloth face covering (if tolerated) while in the building, regardless of symptoms. Ask patient to re-don their face covering at the completion of their clinical dental care when they leave the treatment area.

Infection Control
Clean and disinfect the dental operatory after a patient without suspected or confirmed COVID-19, wait 15 minutes after completion of clinical care and exit of each patient to begin to clean and disinfect room surfaces. This time will allow for droplets to sufficiently fall from the air after a dental procedure, and then be disinfected properly.

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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