As many of you know, on Monday, Governor Holcomb issued Executive Order 20-22 to help restore health care services, effectively manage state government, and extend the “stay at home” order for nonessential travel. While this is excellent news for many of our members, it’s important to note that the order may be revisited every seven days and that the governor may require nonessential medical services, dental offices, and other facilities to close again if our state’s COVID-19 cases and mortalities continue to increase. In addition, if the hospitals’ supply of PPE dwindles due to these re-openings, the governor would be within his authority to reorder the closures.
Here at the IDA, we have been working to provide you with accurate and timely information. Just yesterday, the IDA issued a press briefing on the order while also publishing the COVID-19 Task Force Recommended Guidelines. This document—the result of a conjoined effort by all the members of the Task Force—hopes to:
Ease the transition back into practice
Provide a collection of resources on recommended PPE
Give examples of effective office policies to protect your patients and staff
I say ‘patients and staff’ to reemphasize that your employees are also an essential piece of the dental team. As you make plans to reopen your offices, I’d ask that you communicate regularly and hear them out about any safety concerns they might have. During this time of uncertainty, the importance of working as a dental team cannot be understated: Your leadership is needed now, more than ever. Visit this page if you would like more information on managing employee expectations or how to encourage staff to return to the practice. You can also visit the patient safety page for tips and reminders on social distancing in the dental offices and removing potential sources of infection.
The three mains takeaways are this:
While the governor will allow dental practices to reopen on Monday, April 27, you should not return to practice if you do not have a sufficient supply of appropriate (or recommended) PPE.
The IDA has taken no formal position on whether your dental practice should reopen on Monday, April 27. Our obligation is to provide you with the information needed to make that decision: You are the leader of the dental team.
If you choose to reopen your practice immediately (and with sufficient PPE), remember that informed consent between yourself, your patients, and your staff is more than a form or a signature. It is an ever-evolving discussion with one goal in mind: Delivering safe dental care to Hoosiers.
I will keep each of you in my thoughts as we make the long trek to Monday. If you have any questions or concerns, please do not hesitate to reach out—we will get through this together.
The IDA COVID-19 Task Force has developed the following recommendations for PPE and disinfecting procedures in dental practices. Note that this guidance is intended to help dental practices lower (but not eliminate) the risk of coronavirus transmission during the current pandemic. Dental practices should not presume that following the guidelines will insulate them from liability in the case of infection, and they should also be aware of any relevant laws, regulations or rules adopted by the State of Indiana.
Are gowns required or are scrubs sufficient?
The decision and selection of appropriate PPE is an exercise of professional judgment. Where available, cloth or disposable gowns should be considered:
When soiled, disposable gowns should be discarded appropriately.
Cloth gowns should be laundered on site or by a contracted laundry service.
Lab coats should be treated the same as cloth gowns and laundered appropriately.
Change your scrubs!
If scrubs are worn, long-sleeved garments are the preferred option.
The importance of changing between street clothes and scrubs upon entry and exit to the office cannot be understated!
Are head and foot coverings required?
Dentists should use their own professional judgment in deciding whether to wear foot covers or head covers.
Do we have to wear N95s/KN95s for all procedures?
No. It is very dependent upon the procedures being performed.
It should be noted that some infected individuals lack symptoms, so we cannot assume that asymptomatic and healthy appearing patients are COVID-19 free. Without being rapidly tested, we must treat these patients as potentially infectious.
Therefore, masks and PPE should be chosen based on the risk of exposure, especially via aerosols, to staff and other patients in proximity.
The risk of exposure will vary greatly depending upon the type of encounter with the patient.
Do we need a new mask for every patient encounter?
Not necessarily. Use professional judgment on mask removal and replacement.
However, if your mask is soiled, damaged, or hard to breathe through, it must be replaced.
When removing your mask, do so outside of the treatment room and appropriately dispose of it.
How do we properly clean each operatory?
To lessen the likelihood of aerosols still in the air, allow as much time between patients in the same operatory as possible.
Make sure staff are wearing appropriate PPE when cleaning, including: Gloves, a mask, and face shield or goggles.
Dispose of surface barriers after each patient; surfaces should be cleaned using a detergent or soap and water prior to disinfection.
Also, consider special scheduling:
To lessen the likelihood of aerosols still in the air, allow as much time between patients in the same operatory as possible.
Considering scheduling fewer patients to allow more time between patients for operatory disinfecting.
If you have operatories that are not in use, consider rotating operatories between patients to increase the amount of time between patient encounters in each room.
Patients who are elderly or who have health conditions that might make them higher risk might best be scheduled as your first patients of the day.
What happens if my patient tests positive?
If a positive rapid antigen test indicates that the patient may be infectious, no routine dental treatment should be performed on the patient in a traditional office setting.
What if an employee has a temperature or otherwise presents COVID-19 symptoms?
If an employee has a temperature, it is best to confirm a heightened temperature with a second test, in a confidential manner, and to consider any explanation the employee may offer for a heightened temperature.
It is reasonable to send an employee home who has an elevated temperature (100.4 degrees Fahrenheit or higher).
According to current CDC guidance, an individual who has COVID-19, or symptoms associated with it, should not be in the workplace. Read this Employees Q&A from Faeger Drinker.
The dental office is safe for both patients and staff. With all the uncertainty surrounding COVID-19, its long-term prevalence and a lack of vaccine, some dental team members may wonder if they’re safe returning to work at a dental office. Dentists value their staff and the safety of everyone in the office, and we’re working hard to protect you and the patients we serve. Below are some facts and tips to reinforce staff safety and a professional office environment.
For Dental Office Staff
Remember that since the 1980s, dental professionals have been the leader in exercising Universal Precautions to protect both themselves and their patients from any number of communicable diseases. As a hygienist or assistant, your masks, gloves, face shields, eye protection and protective clothing are designed to prevent the spread of viruses and bacteria.
An even more vigorous emphasis on office disinfecting and patient screening should also serve as additional protection for staff.
Here are the recommendations for infection control and PPE from the IDA COVID-19 Task Force. These recommendations include reducing aerosol production as much as possible, and instead prioritizing the use of hand instrumentation. We will continue to monitor research from the CDC and the ADA on aerosols, viruses, and standard PPE recommendations.
If you have concerns, speak to your dentist. Rather than complaining privately, voicing your concerns in a professional manner keeps everyone on the same page and fosters an honest, transparent office environment. If you still feel unsafe returning to the office, this is an employment decision for you to make.
There are a variety of professionally acceptable alternatives for compliance with CDC recommendations. Dentists can use their professional judgement in assessing and determining the proper equipment necessary for your office.
For those currently receiving unemployment benefits from the State of Indiana: If your office re-opens and you are offered your job back, you must either accept the position and stop accepting unemployment, or resign from the practice. As you know, your weekly unemployment request includes the question of whether you have been offered a job, and you will face steep fines if you fail to disclose that you had the opportunity to return to work but declined the offer.
As you prepare to re-open your office, be sensitive to staff concerns about safety. Meet together and be proactive in anticipating worries from your team members.
If your office has the appropriate supply and use of PPE and your staff are still questioning returning to the office, you and your staff will need to have a professional discussion about whether they wish to continue working in your dental practice.
Citing improvement in front line workers’ access to Personal Protective Equipment (PPE), on Monday, April 20, Governor Eric Holcomb announced a staged lifting of the ban on non-essential medical and dental procedures. Read the Executive Order.
The relaxation in restrictions will initially affect clinical and diagnostic procedures being conducted in hospitals, and then will likely expand next week to other medical and dental providers, pending a re-evaluation by the state.
While the re-opening for next Monday appears likely, it is subject to evaluation from the state and is contingent on a sufficient PPE supply: “If our supply inventory holds up as is it is now we will open up those elective procedures in other medical and clinical practices around the state of Indiana,” Holcomb said in his press conference yesterday. “You have this week to prepare for next Monday.”
“Yesterday’s executive orders means that dentists who are prepared with the proper PPE will probably be allowed to begin providing routine treatment beginning on Monday, April 27, ” said IDA President Dr. Steve Ellinwood. “This is welcome news to our members.” The governor’s announcement came two days after the ADA offered additional guidance to dentists in states that are allowing dental offices to reopen.
“In states that are considering reopening, the ADA believes dentists should exercise professional judgment and carefully consider the availability of appropriate PPE to minimize the risk of virus transition,” ADA President Dr. Chad P. Gehani said in a weekend announcement to members. IDA Vice President Dr. Steve Hollar, who also chairs the IDA’s COVID-19 Task Force, described the importance of dentists abiding by new inflection control guidelines. “It is important for dentists to brief themselves on enhanced infection control guidance issued by the ADA. In some cases, dentists will have to postpone providing routine care while they wait for PPE supply lines to be restored. Revised guidelines may be found on the CDC website.”
Dr. Hollar also encouraged dentists to be cautious of ‘gray market’ PPE supplies, primarily being offered through email and websites. “It is best to wait until you can receive PPE from your regular trusted dental supply company,” he said.
“We are reaching out to the governor and health commissioner asking for help in restoring dental supply lines for PPE,” said Dr. Ellinwood. “While we are pleased the new announcement, it is important that they understand we can’t work without the proper supplies and equipment.”
The IDA’s COVID-19 Task Force has developed and a distilled a series of best practices for PPE guidance and patient safety using materials from the Center for Disease Control CDC, the Indiana State Department of Health, the Occupational Health and Safety Administration, and the American Dental Association. On Monday April 20, 2020 Governor Holcomb issued Executive Order 20-22 which raised the likelihood that dental offices will be allowed to return to practice as early as April 27, 2020. This Executive Order allowing non-emergency and routine treatment will be revisited every seven days for the remainder of the crisis.
In anticipation of the majority of Indiana dental offices resuming routine procedures, the Task Force issued Interim Guidelines and Recommendations on office best practices that protect patient and staff safety, ensure proper PPE, and give guidance on office screening and practices. Click here to view the PDF document.
As dental offices in Indiana make preparations to re-open their doors for emergency procedures, patient safety must be a top priority. The precautions below will help minimize infection risk for patients:
Maintaining Social Distancing and Disinfecting Procedures
Ask patients to wait in their cars and call the office to “check in” once they have arrived and have a staff member call or text the patient when a treatment room is available.
Escort the patient directly to the treatment room where he or she may fill out any required paperwork and answer any medical health questions while sequestered.
Wipe down the clipboard and writing utensil after each patient has completed check-in paperwork.
Discourage patients from bringing companions to their appointment, except pediatric patients, people with special needs, elderly patients, etc. In those cases, limit companions to just one.
Remove magazines, reading materials, toys and other objects that may be touched by others and which are not easily disinfected.
Print and place signage in the dental office for instructing patients on standard recommendations for respiratory hygiene/cough etiquette and social distancing.
Schedule appointments far enough apart to minimize possible contact with other patients in the waiting room. Allow time to disinfect and set up the room for the next patient.
Surfaces such as door handles, chairs, desks, elevators, and bathrooms should be cleaned and disinfected frequently.
Effective Screening and Office Practices
Screen patient before the visit. Suggested questions to ask include: (1) Is the patient currently experiencing or has experienced in the last three weeks, signs of acute respiratory illness such as coughing, fever, and shortness of breath? (2) Has the patient had close contact with an individual diagnosed with COVID-19. If available, other testing used could include: temperature, pulse oximeter, and other COVID-19 screening.
If a patient has a fever associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other signs/symptoms of COVID-19 (e.g., fever, sore throat, cough, difficulty breathing), they can be seen in dental settings with appropriate protocols and PPE in place.
CDC recommends that only asymptomatic patients, patients who have tested negative for COVID-19 infection, or recovered patients (after three days since resolution of signs and symptoms) be seen in dental settings.
DHCP should ensure that there are appropriate supplies for infection control etiquette, including (but not limited to) alcohol-based hand rub with 60-95% alcohol, tissues, and no-touch receptacles for disposal at healthcare facility entrances, waiting rooms, and patient check-ins.
Can a staff member refuse to return to work and continue to collect unemployment payments, even after an office re-opens?
No. If your office has re-opened and you have offered a staff member his or her job back after a firing or layoff, the staff member must either accept the position and stop accepting unemployment, or resign from the practice. Anyone receiving unemployment payments from the state of Indiana must complete a weekly online questionnaire, and one of those questions is whether the recipient has been offered a job. The employee must answer the question truthfully and explain the reason for declining the job offer. He or she can also face steep fines if the state discovers that an offer of employment was made but the employee declined to return to the position and continued to accept unemployment payments.
Should I encourage my employees to file for Unemployment Insurance?
If I lay people off due to COVID-19, will it affect my Merit rate/tax rate next year?
Layoffs due to COVID-19 will not be charged to contributory employers, but will be mutualized to the entire contributory employer pool. More information regarding this will be sent to employers soon. Layoffs by reimbursable employers will be charged to the employer dollar-for-dollar, in the same manner they have always been charged.
If I lay off workers and pay their healthcare insurance coverage through COBRA, how does that impact unemployment insurance (UI) benefits?
If you pay for your employees’ COBRA coverage, this is considered deductible income and must be reported to DWD and could impact the amount of UI benefits a claimant is eligible to receive. (As a reminder, group health plans for employers with 20 or more employees are typically subject to COBRA.)
If I reduce my employees’ hours but they are still employed, are they still eligible for UI benefits?
They may be eligible for benefits, but part-time employment during the week claimed will reduce the amount of benefits paid for that week. If employees do work while receiving benefits, those employees must report any money earned on the voucher for the week they worked, not the week they ultimately get paid for the work. Failure to report money they earned is fraud and can result in denial of benefits, collections actions, and criminal prosecution.
If I pay my employees a bonus during the period of separation, will they be eligible for UI benefits?
Maybe. If you make payments to your employees while they are collecting UI, they may have to declare the payment as deductible income. Sick pay, vacation pay, severance pay, payment in lieu of notice, and holiday pay are all deductible income for the claimant. Bonuses are wages for tax purposes, but they are not deductible income for the claimant, thus they do not impact the employee’s UI benefits.
For more employer frequently asked questions, click here.
Should I file for Unemployment Insurance?
I own and operate my own C or S-type corporation. Am I eligible to apply for unemployment insurance (UI) benefits?
Yes, like any other employee who works for your business, you are entitled to receive employee benefits (including unemployment compensation) so long as you have reported yourself as an employee and paid state unemployment insurance taxes on your wages. Even if you have any hesitation about your eligibility, you are encouraged to apply.
If my employer temporarily shuts down or lays me off because of COVID-19, will I be eligible for unemployment insurance (UI) benefits?
Yes, if an employer must lay off employees due to COVID-19, the employees will be eligible for unemployment insurance (UI) benefits if they have earned enough wages to set up a claim and meet the weekly eligibility criteria. Employees must stay in contact with your employer and be available to work when called back by your employer.
If I am in quarantine based on a directive from my medical professional or my employer due to COVID-19, will I be eligible for unemployment insurance (UI) benefits?
Yes, if you are not receiving sick pay or other leave pay from your employer, meet the minimum amount of wages, and the reason you are out of work is because of the medical quarantine, you will be eligible under Governor Holcomb’s Executive Order during this public health emergency.
If I cannot continue to work because I am caring for one or more children while their school or daycare is closed due to COVID-19, am I still eligible for benefits?
Yes, if you are otherwise eligible, are not receiving sick pay or other leave pay from your employer, meet the minimum amount of wages, and the reason you are out of work is because of the school or daycare closure, you will be eligible under Governor Holcomb’s Executive Order during this public health emergency.
If my hours are reduced but I am still employed, can I apply?
Yes, you may be eligible for benefits, but part-time employment during the week claimed will reduce the amount of benefits paid for that week. To find out if you are eligible, start your application for benefits as soon as you know that your hours are being reduced. If you do work while receiving benefits, you must report any money you earned on the voucher for the week you worked (not the week you ultimately get paid for the work). Failure to report money you earned is fraud and can result in denial of benefits, collections actions, and criminal prosecution.
If I decide to remain at home because of COVID-19 with no directive from a medical professional or from my employer to do so, will I be eligible for unemployment insurance (UI) benefits?
In most cases, no. However, the facts of each circumstance are important. You can file and DWD will evaluate your claim.
If I am not working due to COVID-19 and am receiving sick pay or other leave pay from my employer, will I be eligible for unemployment insurance (UI) benefits?
No, individuals receiving sick pay or other leave pay are not eligible for unemployment insurance (UI) benefits. However, the facts of each circumstance are important. You can file and DWD will evaluate your claim.
For more employee frequently asked questions, click here.
How to file for Unemployment Insurance
The following instructions were taken from the Indiana Department of Workforce Development application page but were altered to reflect current Executive Orders and changes in law. As the State of Indiana continues to address the state-wide unemployment rate during this pandemic, the IDA will continue to update and modify these instructions with the most recent information.
Please note: Due to the COVID-19 closures and quarantines, all applicants must apply online by using either a computer or smart phone connected to the Internet.
Step 1: Apply
File an initial application for benefits as soon as you become unemployed. The one-week waiting period for payment was waived by the Governor’s Executive Order on March 26, 2020. The waiver is retroactive to the week of March 26, 2020, and is retroactive to the week of March 8, 2020. This means that benefits will be paid for the first week the individual is eligible. This week of benefits may not appear immediately in the claimant’s account, but DWD is working diligently to get this week added on each eligible claim.
You will need the following information when filing:
A valid email account – your email address will become your Uplink Username.
Address, Social Security number, Indiana driver’s license or valid ID, date of birth and phone number.
Last employer’s name, mailing address, phone number, dates of employment and reason you are unemployed.
Most recent paycheck stub.
The bank account and routing number of the account where the payment should be direct deposited.
Step 2: Vouchers
Vouchers must be submitted weekly through the Uplink filing system. Submit your weekly voucher the week following your initial application and each week thereafter. Benefits are paid weekly. Weeks run from Sunday 12:00 a.m. to Saturday 8:59 p.m. EST. Vouchers cover the previous week and may be filed starting on Sunday.
You must submit a weekly voucher even if you have an issue delaying your benefits or are appealing a decision. When a determination is reached all eligible payments will be released.
Step 3: After Filing
Within 10 business days of filing, you will receive a wage transcript and benefits computation form. This does not mean you qualify; it is a statement providing a possible weekly benefit amount and an overall maximum benefit amount should you be eligible. Eligibility will be determined during the first 21 business days if there are no issues with your claim. We encourage you to check your claimant homepage daily throughout this time.
Are your staff safe in the dental office? The points below will help dentists and their office staff keep open communication and understand the legal aspects of returning to work.
Can I require employees to stay home if they are sick?
Yes. The challenge arises regarding whether the employee will be paid during that time, and whether that time off is attributed to vacation or other type of paid time off. Each employer will have to find the right answer for itself. The CDC advises that you can require an employee to be fever- and-symptom-free for 24 hours. Consider a temporary suspension on your illness policy; yes, there may be an employee who will abuse this but a generous policy can potentially stop a serious outbreak within your company.
If an employee contracts COVID-19, does workers’ compensation provide coverage?
An employee who contracts the coronavirus while at work might have coverage under workers’ compensation, but the burden would be on the employee to prove that the illness was contracted through the course of employment and not elsewhere. Your insurance carrier will evaluate each claim on its own individual set of circumstances.
Can I require employees to wash their hands?
Yes, according to the Americans with Disabilities Act. And, according to OSHA, employers have the obligation to provide a reasonably safe workplace. So you should be encouraging employees to take such measures.
Can I ask employees to disclose if they have a compromised immune system or chronic health condition?
No. An inquiry asking an employee to disclose a compromised immune system or a chronic health condition is disability-related because the response is likely to disclose the existence of a disability. The Americans With Disabilities Act does not permit such an inquiry in the absence of objective evidence that pandemic symptoms will cause a direct threat. Such evidence is completely absent before a pandemic occurs.
If one of our employees is quarantined, what information can we share with our employees? Who can we share it with?
If an employee is confirmed to have COVID-19, employers should inform fellow employees of their possible exposure to COVID-19 in the workplace. Employers should not, however, disclose to co-workers the identity of the quarantined employee because confidentiality requirements under federal law such as the Americans with Disabilities Act or state law may apply.
Can employers force employees to come to work, even if there is a known exposure-potential situation?
Currently, yes, employers can generally require employees to continue working their scheduled hours as assigned, onsite, as a condition of continued employment, with absences addressed under the applicable attendance policy. Before issuing any ultimatum, however, we recommend communication to employees about what the employer is doing to mitigate the risk to the extent reasonably possible. This may allay fears enough that the employee will be willing to meet attendance expectations.
In situations of known potential exposure, can employers require employees to be tested for coronavirus?
No. Only health care providers can order testing, and with tests still in short supply, even individuals with symptoms consistent with coronavirus may not be tested if, based on age and medical condition, it is unlikely they would suffer severe serious effects even if infected.
Based on CDC advice that older people as well as those with serious chronic medical conditions stay home as much as possible, should employers require employees aged 60 or older or with health conditions to work remotely or not at all? We do not recommend taking that action based on federal, state and local protections against age discrimination, as well as disability discrimination laws intended to provide equal employment opportunities to people with disabilities. These disability discrimination laws generally do not allow employers to remove employees from situations based on a medical condition for preventive purposes unless and until the situation poses a direct that to the employee’s health and safety that cannot be effectively alleviated through other measures. Circumstances could conceivably rise to that level at some point, but as things stand now, presence in most workplaces would not rise to that “direct threat” standard.
For most of us dentists, the regulation deadline for installation of an Amalgam Separator is July 14, 2020. For new “Source Generators,” “Transfer Generators” and those that do not place or remove amalgams, refer to details listed in Regulation 40 CFR Part 441.
In addition to installing this apparatus, you will be required to properly handle and dispose of waste amalgam as well. There are also provisions within this new law that stipulate cleansing of vacuum lines using an approved vacuum line cleaner with a pH between 6 and 8. Safe handling and disposal of these wastes need to be properly documented as to when, where and how they are disposed of as well.
Lastly, all dental dischargers must submit a One-Time Compliance Report to a Control Authority by October 12, 2020, or within 90 days after transfer of ownership of a dental practice. Please refer to Form OMB No. 2040-0287 for details of this requirement; a listing of Control Authorities and further details can be located on the EPA website.
Regarding installation of your Amalgam Separator: First of all, make certain it is compliant with the stipulations of the law; and secondly, don’t wait until the last minute to install it. It took me about a month to find a person to install my particular Amalgam Separator. I chose the Solmetex NXT Hg5 Amalgam Separator because: it complied with all the Standards of the law; it was easy to install and maintain; and it didn’t cost me an arm and a leg to purchase and install. Your IDEA negotiated a very reasonable price for this apparatus and Solmetex was very helpful in assisting me meet compliance standards.
Regarding installation, I have very limited space in my utility closet where my vacuum system is located. As a result, I chose a plumber rather than a “dental supplier technician.” He installed the unit in about an hour and charged me about $200. All in all, choosing and installing the AS went relatively easy and the Solmetex Compliance Paperwork is going to make my life easier in dealing with and tracking these regulation standards. One could argue that these regulations are a bit of a hassle, but thanks to the IDEA and its parent association, the IDA, much of the legwork was minimal comparatively speaking. I don’t think anyone is necessarily in favor of more regulations, but they seem to be a fact of life; at least we have an organization to help us get over these hurdles when they occur.
Good luck with your installation; just remember not to wait until the last minute. July will be here all too soon!
Dr. Tom Murray practices in Princeton and is the current chair of the Indiana Dental Enterprises Association (IDEA), which selected Solmetex as the IDA vendor partner for amalgam separators.
With dentists currently unable to treat non-urgent cases, many are asking about teledentistry. The ADA and the IDA have issued some guidelines on issues related to the ethics, coding, billing and general practice of teledentistry. See the resources below for information:
Louisville, KY 