The American Dental Association (ADA) recognizes the importance of providing the profession with credible information that will protect both patients and dental health care personnel at a time when information is constantly being updated.

We will update this page and make announcements via ADA News and the ADA Morning Huddle as they become available.

This document provides answers to some recent member question regarding:

What should employee dentists do when their employer refuses to close offices per ADA or state guidance?

Legal and ethical considerations are raised. The employee dentist is responsible for their license and to promote and adhere to the standards of the profession. Continuing to work under these circumstances may be both illegal and unethical, jeopardizing their licensure status as well as their professional status. While providing emergency care to patients of record may be necessary, non-essential treatment should be deferred until state and local public health authorities deem it appropriate to proceed. At the height of a public health emergency when social distancing has been ordered at all levels of government and recommended by the ADA, continuing “business as usual,” even with personal protective equipment (PPE) would be irresponsible and unethical. Patients, providers and the public would all be put at greater risk by not adhering to efforts to “flatten the curve.” Dentists, like other health care professionals are obligated to put the interests of patients as their primary concern. The social contract, however, that gives health care professionals their special status in society depends upon their continued support of not just individual well-being, but the well-being of their communities.

Under such circumstances the employee dentist should:

  • Check with local authorities to determine if they are in violation of any law if they continue to work
  • Discuss their concerns with their employer including sharing with the employer the ADA and CDC guidance on non-essential procedures
  • Monitor their own health as well as the health of their immediate contacts
  • Employees who are ill, are at high risk or have close contact with someone who is ill or at high risk should not exacerbate that risk
  • Adhere to all requirements for social distancing, sanitation, sterilization and use of PPE
  • Remember that each individual dentist is responsible for their own license and their own reputation

These very difficult and fluid times will call for very difficult choices. Support through various state and federal plans are being developed to assist individuals with lost income but to whom those apply and how quickly those will be implemented remains to be seen. The compelling ethical obligation to “act for the benefit of others” (Beneficence) should take precedence. In a pandemic, all are at risk and dentists, like other healthcare professionals must act together to mitigate the damage in the most humane way. The social contract of the profession depends upon dentists’ “commitment to society that its members will adhere to high ethical standards of conduct.”

What is business interruption insurance and can it help cover this risk?

During this unprecedented global COVID-19 coronavirus pandemic, there is much uncertainty and growing concerns regarding the short and long-term financial impact it might have on dental practice owners, their employees and families. Members are seeking assistance in navigating their business risk exposures and insurance coverage for lost income or revenues from the temporary shutdown of their practice as a result of the increasing public health emergency state and federal advisories.

Business interruption is commonly made part of a property insurance or business owner’s policy (BOP) and as such, it pays out if the cause of loss is covered by the overarching or primary policy. Business interruption is intended to help cover a business’ lost income or revenues resulting from a disaster or covered peril which causes physical damage to the insured property and loss of occupancy as may be issued by a civil authority mandate. However, it is important to note that property insurance policies may contain a specific exclusion for disease or a virus causing agent in the policy definition of contaminant.

Given that insurance policy language varies by insurance company, state jurisdiction regulations, the date issued and how coverage is structured (optional riders), ADA members are best advised to consult with their personal insurance agent representative and/or legal counsel to carefully review their insurance policies and assess what coverage, if any, may exist for potential claims arising out of the coronavirus risk environment.

As with all legal and insurance documents, the fine print matters!

 

A patient with a confirmed case of COVID-19 is claiming we violated her HIPAA Privacy Rights by contacting her husband and asking him to cancel his upcoming appointment since he’s in close contact with someone who has the disease. She’s threatened to file a complaint with the federal Office for Civil Rights. Does she have a valid complaint? Did we violate HIPAA? We thought we were doing the right thing to protect other patients and our staff.

Unless this patient had previously objected to you communicating with her husband, the answer is no, the patient does not likely have a valid complaint.

Under HIPAA, health care providers are still permitted, in many circumstances, to communicate with the patient’s family, friends, or others involved in their care or payment for care without the patient’s authorization. Even when the patient is not present or able to object, health care providers are generally permitted to determine, using their professional judgment, if communicating with a family member is in the patient’s best interest. When possible, a covered dental practice should get verbal permission from the patient or otherwise be able to reasonably infer that the patient does not object.

The ability to use professional judgment extends to making decisions about communicating with family members when the health and safety of other patients, the dental practice team, and those who come in contact with a patient are at stake. The dental practice may also disclose information about a patient if the dental practice has a good faith belief that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, as long as the disclosure is to a personal reasonably able to prevent or lessen the threat, per 45 CFR 164.512(j). This includes disclosures to family, friends, caregivers, and law enforcement, or anyone who is in a position to prevent or lesson the serious or imminent threat. HIPAA defers to the professional judgment of the healthcare professional in making such determinations. However, disclosures to the media should generally not be done without the patient’s written authorization.

The HIPAA “minimum necessary rule” requires the dental practice to make reasonable efforts to restrict disclosures to the minimum amount of patient information reasonably necessary for the purpose of the disclosure. Keep in mind that there are certain exceptions to the minimum necessary rule, such as disclosures to a healthcare provider for treatment purposes.

Be aware that, if yours is a covered dental practice, you will need to document the complaint, and any other complaints about your HIPAA policies and procedures, and include details regarding how each complaint was resolved, per 45 CFR 164.530(d).

Consult these resources from the U.S. Department of Health and Human Services for more information:

I’m a new dentist and am barely working because of the COVID-19 pandemic. My financial situation is very tight: can I postpone making payments on my student loan until I’m working again?

The COVID-19 pandemic is affecting incomes for people in all professions, including dentists, team members and healthcare workers. Dentists who are concerned about meeting their student debt obligation should contact their student loan servicer or their school’s financial aid office as soon as possible.

A representative of your servicer or school can provide information about any options, such as deferment or forbearance, that may allow you to temporarily stop making payments on your loans or that may allow you to move to a different repayment plan with a lower monthly payment. Dentists who have refinanced or combined their educational debt through Laurel Road, which services the ADA Student Loan Refinancing Program, can contact Laurel Road’s servicing partner (MOHELA) at 1-877-292-6845.

In the meantime, the ADA is waiting for details about the Trump administration’s plans to waive federal student loan interest during the COVID-19 pandemic, retroactive to Friday, March 13. It is unclear whether the student loan servicers will do this automatically or require some type of notification or application. Also unknown is whether and how this might apply to institutions that do not service student loans for the U.S. Department of Education.

Additional information is available from Federal Student Aid, an office of the U.S. Department of Education.

Should I refinance my student loans while interest rates are lower?

The Federal Reserve cut interest rates to near-zero on March 15, making it less expensive for consumers to borrow money in the hope of limiting the economic impact of the COVID-19 pandemic.

For dentists who are currently paying down student loans, it’s possible that a private lender may offer the option to refinance your loans at a lower interest rate, providing that you qualify.

Since only private lenders offer student loan refinancing, the decision to refinance and move any federal loans will make those obligations private loans. Be aware that those with private loans may miss out on novel coronavirus-related student debt relief, such as any waiver of student loan interest during the crisis or other aid that may be on the horizon. Borrowers with private loans also will not be able to take advantage of federal student loan repayment programs, generous payment postponement options, income-driven repayment plans, and other federal benefits.

The ADA recommends contacting your student loan servicer to discuss the benefits and drawbacks of refinancing your student loans during this period of low interest rates.

What should I do if I can’t file my taxes by the April 15 deadline because of the COVID-19 pandemic?

Filing Deadline

The tax filing deadline for 2019 returns is still April 15 2020. If you need extra time to finish your taxes, you can request an extension following the usual process and receive six extra months to complete your return.

Payment Relief

The payment deadline has been extended to July 15, 2020. In other words, if you are an individual who owes up to $1 million in taxes, you have until July 15 to pay—but you must still file your return by Apr. 15 (unless you request an extension).

This payment relief applies to all individual returns (including self-employed individuals) and all entities other than C-Corporations, such as trusts or estates. It also applies to estimated tax payments for the tax year 2020 that would have otherwise been due by April 15.

Taxpayers do not need to file any additional forms or call the IRS to qualify for this payment relief.

Note that this payment relief applies only to federal income tax (including tax on self-employment income) payments otherwise due by April 15, 2020, not state tax payments or deposits or payments of any other type of federal tax.

Other Disaster Relief

Check with your tax preparer to see if you are eligible for any disaster-related tax relief.

Additional tax information is available at IRS.gov/coronavirus.

My practice revenue has dropped because of the COVID-19 pandemic. I’m not sure how we’re going to meet fixed expenses, pay my staff and take an income to support my own family. Does the federal government have a program to help small businesses, like dental practices, that have been financially impacted by the pandemic?

Help may be available through the U.S. Small Business Administration’s Economic Injury Disaster Loan program. Under the program, small businesses in areas that have been declared disaster areas and experienced substantial economic injury because of COVID-19 may qualify for low-interest federal disaster loans for working capital.

Economic Injury Disaster Loans are available only to small businesses located in declared disaster areas and without credit available elsewhere. Businesses with credit available elsewhere are not eligible.

The loans, which may offer as much as $2 million in assistance, can be used to pay fixed debts, payroll, accounts payable and other bills that can’t be paid because of the disaster’s impact. Long-term repayment plans, up to a maximum of 30 years, are available. Terms are determined on a case-by-case basis according to each borrower’s ability to repay.

Contact the SBA’s disaster assistance customer service center for more information. They can be reached at 1-800-659-2955 (TTY: 1-800-877-8339), or via e-mail to disastercustomerservice@sba.gov.

Applications for SBA Disaster Loan Assistance Loans are available online. Applicants will be required to provide a signed and dated IRS Form 4506-T: that information gives the Internal Revenue Service (IRS) permission to provide your tax return information to the SBA.

Questions regarding coronavirus, the virus which causes COVID-19

What are the signs/symptoms and risk factors for COVID-19?

Similar to patients with other flu-like diseases, patients with known COVID-19 have reported mild to severe symptoms which can include fever, cough and shortness of breath.  Patients may also report a recent trip to China, or a close contact with someone who traveled to China within the past 14 days.

Where can I find current, credible information about COVID-19?

CDC’s website includes numerous resources for healthcare workers including:

I know it is much more likely that a patient with the flu may come to the office for dental treatment. What are the CDC recommendations for dental staff to receive the flu vaccine?

CDC recommends that all health care workers, including dentists and staff, receive the flu vaccine.

Should staff report to work with acute respiratory symptoms?

  • Staff experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work.
  • Staff who experience ILI and wish to seek medical care should contact their health care providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician’s office, or hospital.
  • Staff who have difficulty breathing or shortness of breath, or are believed to be severely ill, should seek immediate medical attention.

Are traditional disinfectants, such as Lysol and disinfecting wipes, effective at killing this virus?

Coronaviruses are enveloped viruses, meaning they are one of the easiest types of viruses to kill with the appropriate disinfectant product. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for coronavirus in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. Products with EPA-approved emerging viral pathogens claims are recommended for use against coronaviruses. These products can be identified by the following claim:

“[Product name] has demonstrated effectiveness against viruses similar to SARS-CoV-2 on hard non-porous surfaces. Therefore, this product can be used against coronaviruses when used in accordance with the directions for use against [name of supporting virus] on hard, non-porous surfaces.”

The EPA has developed a list of registered surface disinfectant products for use against coronavirus, the coronavirus that causes COVID-19.

We already adhere to standard precautions: can dentists do anything else to prevent transmission in their offices?

Some common sense recommendations include:

  • Screen patients for international travel, signs or symptoms of infection when you update their medical histories.
  • Include temperature readings as part of your routine assessment of the patient prior to performing dental procedures.
  • Make sure the personal protective equipment you are using is appropriate for the procedures performed.
  • Use a rubber dam whenever possible to decrease possible exposure to infectious agents.
  • Use high speed evacuation for all dental procedures producing an aerosol.
  • Autoclave your handpieces after each patient.
  • Have your patient rinse with 1% hydrogen peroxide before each appointment. Coronavirus is vulnerable to oxidation; this will reduce the salivary load of oral microbes.
  • Clean and disinfect public areas frequently, including door handles, chairs, and bathrooms.

 

 

Questions regarding Personal Protective Equipment (PPE), including masks

What do we do about the shortage of masks?

The increased world-wide demand for personal protective equipment (PPE) has resulted in apparent regional areas of shortage in the United States. The U.S. Food and Drug Administration (FDA) regulates and monitors the availability of medical devices, including masks, and continues to closely monitor the supply chain whose components are needed to manufacture PPE.

On Feb. 27, 2020, the FDA reported that it had contacted 63 manufacturers, representing 72 facilities in China that produce essential medical devices. “Essential medical devices” are those that could be prone to potential shortage if there was a disruption in the supply chain. Several of these facilities reported being adversely affected by COVID-19 and experiencing workforce challenges due in part to the necessary quarantine of workers.

While the FDA reported that it has heard reports of increased market demand and supply challenges for certain PPE, the agency has said that it is not aware of specific widespread shortages of medical devices, although the CDC and other U.S. partners have seen increased ordering of some medical products through distributors as some healthcare facilities in the U.S. prepare for anticipated needs in the event of a more severe outbreak. The FDA also reported that the agency has taken proactive steps to establish and remain in contact with medical device manufacturers and others in the supply chain.

FDA encourages manufacturers and healthcare facilities to report supply disruptions to the device shortages mailbox: deviceshortages@fda.hhs.gov. The agency reports that the mailbox is closely monitored and is an important surveillance resource to augment FDA efforts to detect and mitigate potential supply chain disruption.

Should masks be only single use?

CDC’s guidance for single-use disposable facemasks has not changed. These masks are tested, and regulated by FDA to be single use. CDC’s position is that a new facemask should be for each patient. CDC’s specific guidance for facemasks is on page 41 of the Guidelines:

  1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering of blood or other body fluids;
  2. Change masks between patients, or during patient treatment if the mask becomes wet.

Should we close the practice if we run out of masks and our vendors and distributors have put caps on how much, and how often, we can get new shipments?

Practices experiencing difficulty obtaining PPE may have to triage patients as a way to ensure that adequate PPE is available for patients whose appointments are most urgent. If your office is concerned about a potential or imminent shortage of PPE, CDC recommends you alert your state/local health department and local healthcare coalition, as they are best positioned to help facilities troubleshoot through temporary shortages. You can also report the shortage to the FDA at deviceshortages@fda.hhs.gov. CDC recommends that Dental Health Care Personnel (DHCP) concerned about healthcare supply for PPE regularly monitor Healthcare Supply of Personal Protective Equipment for updated guidance. They should also be familiar with the Interim Infection Prevention and Control Recommendations.

I have noticed it is easier to purchase ASTM Level 1 masks than Level 2 or Level 3. What is the difference between the levels? How do I know which to buy?

ASTM International, formerly known as the American Society for Testing and Materials, is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services including masks. ASTM has established performance levels for masks based on fluid resistance, bacterial filtration efficiency, particulate filtration efficiency, breathing resistance and flame spread.

Masks that have been rated Level 1 have the least fluid resistance, bacterial filtration efficiency, particulate filtration efficiency, and breathing resistance. These can be worn for procedures where low amounts of fluid, spray or aerosols are produced, for example, patient evaluations, orthodontic visits, or operatory cleaning.

Level 2 masks provide a moderate barrier for fluid resistance, bacterial and particulate filtration efficiencies and breathing resistance. These can be used for procedures producing moderate to light amounts of fluid, spray or aerosols. Some examples of procedures are sealant placement, simple restorative or composite procedures or endodontics.

Level 3 masks provide the maximum level of fluid resistance recognized by ASTM and are designed for procedures with moderate or heavy amounts of blood, fluid spray or aerosol exposure. Some examples of these procedures are crown or bridge preparations, complex oral surgery, implant placement, or use of ultrasonic scalers.

Should clinical staff wear N-95 respirators?

The type of personal protective equipment (PPE) that should be worn will depend upon the procedures being performed. Under OSHA, PPE is considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

If the decision is made to use respirators in your facility, OSHA does maintain requirements for medical evaluation and fit-testing in their toolkit for health care use of respirators.

OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) requires that workers be protected from exposures to blood and body fluids that may contain bloodborne infectious agents. OSHA’s Personal Protective Equipment standard (29 CFR 1910.132)and Respiratory Protection standard (29 CFR 1910.134) require protection for workers when exposed to contact, droplet and airborne transmissible infectious agents.

CDC has more information on the differences between N-95 respirators and surgical masks.

 

 

Questions regarding communicating with patients

What questions should we ask our patients in order to identify their symptoms and decide whether to cancel an appointment?

The ADA recommends updating a patient’s medical history at each visit. These screening questions may be asked when confirming appointments or when the patient presents for treatment. Appropriate questions to screen patients for coronavirus could include asking if the patient has traveled internationally in the last 14 days or has been in close contact with another person who has been diagnosed with or under investigation for COVID-19, and whether the patient has a cough, fever or shortness of breath.

Encourage patients who respond “yes” to those questions to contact their primary physician or public health department as soon as possible to determine if they should be seen or tested.

What should we do if we suspect a patient has COVID-19? Do we notify the local or state health department?

Contact your local health department immediately if you suspect a patient has COVID-19. You can also contact your state health department.

HIPAA’s Privacy Rule allows covered entities to disclose needed protected health information to public health authority responding to a public health emergency.

What if a patient has the virus, but urgently needs dental treatment? How do we proceed to provide care?

If a patient with a confirmed case of COVID-19 requires urgent dental treatment, the dentist and the patient’s medical providers should work together to determine the appropriate precautions on a case-by-case basis: this coordinated approach is critical in order to ensure that the risk of potential spread of disease among patients, visitors, and staff is kept as low as possible.

Because dental settings are not typically designed to carry out all of the Transmission-Based Precautions that are recommended for hospital and other ambulatory care settings, dentists and medical providers will need to determine whether the facility is an appropriate setting for the necessary services for a potentially infectious patient. It may be necessary for treatment to be performed in a healthcare setting that offers the additional protections that should be maintained in these cases.

 

 

Questions regarding maintaining the practice’s physical environment

Should we ask patients to wait in their cars until we can treat them so they aren’t sitting in crowded waiting rooms or reception areas?

The CDC recommends using “social distancing” whenever possible as an effective way of decreasing the likelihood of transmitting coronavirus. On March 7, 2020, the agency updated its definition of social distancing to mean “remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.”

With that advice in mind, consider implementing these steps in your practice:

  • ask patients to arrive on time for their appointments, rather than too early, since that will minimize the amount of time they spend in your waiting room or reception area
  • remove magazines, reading materials, toys and other objects that may be touched by others and which are not easily disinfected
  • schedule appointments to minimize possible contact with other patients in the waiting room

Should we have glass partitions between the front office staff and the waiting room when possible to decrease the risk of staff exposure?

While physical barriers may reduce or eliminate exposure to coronavirus, installing glass partitions may not be feasible in all practices.

 

 

Questions regarding communicating with staff

Since coronavirus can spread via aerosol transmission, should my staff be using scaling instruments or hand pieces any differently than we usually do?

Every procedure and every patient is unique. Appropriate personal protective equipment should be available when instruments that produce an aerosol are used and it’s a good idea to consider using high speed evacuation in those cases since aerosol spread is one way that coronavirus can be transmitted. Of course, since no single answer can apply to every possible situation, dentists and hygienists should use their best professional judgment to determine what instrumentation should be needed for a particular procedure.

I’ve seen a lot of information about managing patient exposures: what should we do if there’s a case of potential or actual employee exposure?

Follow the same procedures you would with a patient suspected to have, or confirmed to have, COVID-19: report the individual to your local health department and/or state health department. Those agencies will conduct any appropriate follow-up.