The CDC has issued updated recommendations for dental settings. The recommendations incorporate infection control, patient screening and a summary of recent changes. Click here to view the most recent recommendations.

Memorial Day weekend certainly felt different this year. What was once filled with parades, cookouts and fireworks has been replaced with masks, hesitancy and awkward elbow hugs. I can only hope that your return to practice didn’t feel as strange as this. Below are some important updates on the CDC’s recently released guidance and the SBA Paycheck Protection Program—a lot can happen in a week!

CDC Updated Regulations

On May 21, the CDC released updated CDC’s Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response with additional direction for resuming non-emergency dental care during the COVID-19 pandemic. Topics covered in these recommendations include patient management, PPE optimization strategies, sterilization and disinfection, and work practice controls. In the May 26 ADA “Power of Three” Discussion, President Dr. Chad Gehani indicated that a webinar explaining the updated guidance will be released as soon as possible.

The IDA COVID-19 Task Force has reviewed the new recommendations carefully and believes the CDC has provided valuable guidance for dentists nationwide. That being said, the recommendations are just that: recommendations. Where appropriate, healthcare practitioners should defer to the direction of their public health officials, state law and individual judgement. There is no “one size fits all” recommendation that the CDC (or any higher authority) could draft; when determining what is best for your staff and patients, a practitioner should take all variables into account and provide as safe of a work and treatment environment as is feasible.

Click here to read the updated CDC guidance.

The CDC also has a helpful risk assessment chart for health care professionals who have been exposed to COVID-19. The chart is below, and you can view the original version online by clicking on the image.

Insurance Coverage: PPE

We have had many members call in asking whether insurance companies will be bearing the cost of additional PPE or whether that charge should be passed to the patient. At this time, the IDA has heard of no insurance provider releasing or covering a PPE code but we will continue to update you as the situation progresses.

SBA Paycheck Protection Program Updates

Many IDA members and dentists nationwide enrolled in the Small Business Administration’s “Paycheck Protection Program” at the outset of the COVID-19 pandemic. The program, hoping to bolster small businesses affected by the crisis, provides potentially forgivable loans to business owners who use the funds for qualified expenses. On May 22, the SBA released updated guidance on fund usage and information about the application for forgiveness. Critical updates include:

• Establishment of an alternative method for determining when the eight-week period starts for businesses with biweekly pay schedules. As of the date of publication, borrowers can elect an alternative payroll covered period, which begins period the first day of the pay period after they received the funds. For more information on this, speak with your loan provider.
• Expansion of the period for when non-payroll costs must be incurred or be paid to qualify for loan forgiveness. Specifically, the costs must be paid or incurred during the period and paid on or before then next regular billing date, even if that date is after the eight weeks. Meaning that expenses incurred during the qualifying period may be paid off using PPP funds after the end of the period.

 

As your lender will tell you, the importance of keeping detailed records during this time cannot be overstated. While this diligence may be more difficult for providers as you transition back into practice, please remember that billing statements, invoices, payroll records, and several other financial documents may be requested by the SBA during the application for loan forgiveness—a few minutes of document retention now can save you days of headaches later. Congress is expected to debate a few PPP-related bills over the next few weeks, and we will continue to update you as new information becomes available.

Click here to view the updated rule.

 

As always, we thank you for your membership and hope that is has proven to be a productive asset during this unprecedented time.

Sincerely,
Dr. Steve Ellinwood

Brush Dental has developed a helpful flyer in English and Spanish to help kids and parents understand the importance of brushing teeth properly, especially during the COVID-19 outbreak. Click here to view the flyer.

During the IDA’s virtual House of Delegates meeting on June 13, delegates will vote in contested elections, and uncontested candidates and automatic appointments will assume their 2020-21 leadership positions. Thanks to all who have shown their dedication to organized dentistry through these positions!

Click here to view the 2020-21 House of Delegates candidates.

April 22, 2020: Funding for the Paycheck Protection Program has been restored. See below for terms and instructions.

 

April 17, 2020: There is no more funding for the EIDL or Paycheck Protection Program (PPP) at this time. The ADA has been strongly urging Congressional leaders to increase funding for these two programs. We will update this page as more information becomes available.

 

The recently passed $2 trillion COVID-19 response package includes funding for education, individuals, big corporations, small businesses, public health, and state and local governments. Of particular interest to struggling dental practices are the Paycheck Protection Program (PPP) and the Economic Injury Disaster Loan (EIDL). Both funding mechanisms hope to ease the burden on small businesses, especially in the areas of payroll management and expenses. Federal and Small Business Administration guidance on these programs has been released daily and can seem overwhelming, but these two initiatives represent a significant effort by the federal government to ease the burden on everyday business owners.

 

Payroll Protection Program

Click here for the PPP Forgiveness Application

Terms

• 0.50% fixed interest rate
• Two-year term
• No fees for borrowers
• No collateral or personal guarantees
• No prepayment penalty
• Amount borrowed can be for up to two months of your average monthly payroll costs from the last year plus an additional 25 percent of that amount, subject to a $10 million cap.

 

Requirements

• Current economic uncertainty makes the loan necessary to support operations
• The applicant will provide documentation that verifies the number of full-time equivalent employees on payroll and the dollar amounts of payroll costs, covered mortgage interest payments, covered rent payments and covered utilities for the eight weeks after getting the loan.
•  The applicant will use loan proceeds to retain workers and maintain payroll or to make qualifying payments.
  
  -Qualifying payments include: payroll costs (with some exclusions), mortgage interest, rent payments and utility payments.
  
  -Payroll costs include salary, wages, commissions, or tips (capped at $100,000 on an annualized basis for each employee);
  
  -Employee benefits including costs for vacation, parental, family, medical, or sick leave; allowance for separation or dismissal; payments required for the provisions of group health care benefits including insurance premiums; and payment of any retirement benefits.
  
  -State and local taxes assessed on compensation.
  
  -For a sole proprietor or independent contractor: wages, commissions, income, or net earnings from self-employment, capped at $100,000 on an annualized basis for each employee.
  
  -Important note: Payroll costs will be capped at $100,000 annualized for each employee.

 

Foregiveness

The loan will be fully forgiven if the funds are used for appropriate costs (see above) but the forgiveness amount could be reduced as a result of:

• Any reduction in the average number of full-time equivalent employees during the eight-week period; and
• Any reduction in compensation of any employee of more than 25 percent compared to compensation in the most recent full quarter prior to the eight-week period.
• However, you have until June 30, 2020 to restore your full-time employment and salary levels for any changes made between February 15, 2020 and April 26, 2020.

To request loan forgiveness you can submit a request to the lender that is servicing the loan. The request must include documents that verify the number of full-time equivalent employees and pay rates, as well as the payments on eligible mortgage, lease, and utility obligations. You must certify that the documents are true and that you used the forgiveness amount to keep employees and make eligible mortgage interest, rent, and utility payments. The lender must make a decision on the forgiveness within 60 days.

You can apply for the PPP through any existing SBA lender or through any federally insured depository institution, federally insured credit union, and or any Farm Credit System institution that is participating. Other regulated lenders will be available to make these loans once they are approved and enrolled in the program. Visit www.sba.gov for a full list of SBA lenders. In addition, you can also view a sample application.

 

Additional Resources

Small Business Guide to PPP

A Few Cautionary Notes on the COVID-19 Loans

U.S. Department of the Treasury Borrower Fact Sheet

More About PPP

SBA Loan Application

PPP Loan Application Delays

18 FAQs about PPP

ADA SBA Loans Resource Page

 

Economic Injury Disaster Loans (EIDL)

While EIDLs are nothing new, this is the first time in history that a pandemic viral event has been classified as a national “disaster” and thus triggered the availability of these funds. As a result of the natural declaration, businesses in every state and territory are now eligible to apply for EIDLs, which can hopefully help small businesses recover from the economic losses sustained as a result of the pandemic.
Broader than the PPP above, funding through EIDLs can be issued quickly and cover a larger variety of qualifying expenses. However, please note: If you or your practice has chosen to apply for the PPP to cover payroll and other expenses, you may not apply for an EIDL to cover it as well. No double-dipping is allowed.

Terms and Requirements

• Applicant must have been in business on January 31, 2020. (No new businesses or last-minute startups)
• Only sole proprietors, independent contractors and employee stock ownership plans with fewer than 500 employees are eligible to apply.
• Loans will be based on a combination of self-certification and basic credit score.
• SBA will advance up to $10,000 of the proceeds of an EIDL to an applicant on an expedited basis, within three days after the SBA receives an application. If the SBA ultimately rejects the application, the applicant may retain this $10,000 advance without needing to repay it.
• Loan requests greater than $200,000 must come with a personal guarantee.
• Loan requests less than $200,000 do not require a personal guarantee but will require real estate as collateral, and will take a general security interest in business property.
• Update on April 16, 2020: The EIDL Program will now disburse grants at $1,000 per employee with a maximum of $10,000. This was recently amended and people are no longer eligible for a straight $10,000 grant. This decision was made to help with funding overall.

Click here to apply for an Economic Injury Disaster Loan. Note that if you applied before the disaster declaration was made, you may have been rejected because SBA Disaster Loan Assistance was unavailable for Coronavirus related economic impact at the time. (U.S. Dept of Treasury)

 

Additional Resources

ADA Resources on Small Business Loans

SBA Disaster Assistance Site

Forbes: Getting Cash For Your Small Business

From IDA President Dr. Steve Ellinwood

The transition back into practice is not an easy one. From preparing the office to rescheduling a month’s worth of patients, a lot of groundwork needs to be done before reopening an office.

While Indiana was one of the first states to allow elective dental procedures to resume, there are still offices across the state who have chosen to remain closed—as is their right. Whether due to a lack of proper PPE, staff concerns, or your own concern with resuming practice, you should only reopen your office when you are ready, have the appropriate PPE, and feel comfortable providing care.

For those of you who have reopened, or are planning to reopen in the immediate future, below you will find two areas of concern the IDA has been working to address. We have received a lot of calls from concerned hygienists on these topics. Above all, remember this: You are the leader of the dental team, and it is your responsibility to communicate effectively with your staff and ensure that they be kept safe while working in your practice. A simple conversation can save more time than you know; be open and honest!

 

The Role of the CDC vs. The Power of a State Governor
Citing the CDC’s Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response, we have had several members reach out and express the opinion that dental offices should not be providing elective care in the first place. While as of April 27, 2020 the CDC’s recommendation encourages dentists to “postpone elective procedures, surgeries, and non-urgent dental visits,” it is just that: a recommendation.

Further, earlier in the guidance, when explaining the enhanced role that state government will play during this pandemic, the CDC encourages dental healthcare providers to “consult their state dental boards or other regulating agencies for requirements specific to their jurisdictions, as information is changing rapidly.” That statement is accurate: Regional, state, and local data change daily, if not hourly. As a result of COVID statistics, Indiana and 24 other states and territories have determined that it is appropriate to reopen elective procedures, including dentistry, within their borders. An additional seven states never issued a mandate limiting dentistry. This falls under the proper authority of a state, and Governor Eric Holcomb and his advisors were within their right to do so. For the other 22 states and territories that have not yet determined it appropriate to reopen, the stricter CDC recommendation still stands.

PPE: Do We Have to Provide an N95?
A recent misreading of the ADHA’s Interim Guidance on Returning to Work has resulted in significant confusion among both IDA and IDHA members. Many people have wrongfully interpreted the quote “In the event that neither an N95 nor a U.S. Food and Drug Administration FDA-approved full face shield with a surgical mask is available, it is not safe for you to provide care” as requiring dental offices to operate either with N95 masks, or not at all. This is incorrect. While the sentence may be confusing, the takeaway is this: Either an N95 or face shield (with a surgical mask) is appropriate.

We also feel that the FDA approved N95 equivalent, the KN95, is appropriate, as outlined in the ADA guidelines. As previously stated, the decision and selection of appropriate PPE is an exercise of professional judgment. Where possible, try and aim for the highest form of protection and be sure to change your mask regularly if it becomes soiled, damaged, or difficult to breathe through.

For more information on mask types, click here.

For more information from the ADA’s Return to Work Guidance, click here.

As you transition back into practice, remember you are not alone: You are a valued member of the IDA, and we will all do our part to make the profession’s re-acclimation as smooth as possible. If you have any questions, please do not hesitate to reach out. We value your membership and look forward to the opportunity to continue to serve you in the future. We will get through this together.

Dr. Steve Ellinwood

Today during his daily press conference, Indiana Governor Eric Holcomb announced his plans for a gradual re-opening of every sector of the state. Governor Holcomb had initially announced a Stay at Home order on March 16, and the order was extended several times until today, May 1. The Stay at Home order is officially ending on Monday, May 4.

The governor unveiled the state’s “Back on Track” plan, which outlines stages of opening various aspects of public life, events and companies throughout the state. For full details of the plan, download the Roadmap to Safely Reopen Indiana PDF, or visit backontrack.in.gov.

Note that the governor’s plan, as well as some local ordinances, delay some of the re-opening plans for Marion, Cass and Lake Counties. However, these plans do not include restrictions on seeking routine medical or dental care, so patients are still allowed to travel for essential services, which includes dental and medical appointments in these counties.

The anxiety and uncertainty of the COVID-19 outbreak are without a doubt one of the most stressful situations any of us has ever experienced. Economic fears, combined with the unknowns of this virus, are weighing on everyone’s mind. Below are resources that may be helpful in managing stress and anxiety.

Remember that IDA staff remain available for help and a friendly ear. We are only a phone call or email away for any member who needs practical assistance or just someone to talk to. In addition. Candace Backer will continue to conduct Well Being appointments remotely for dentists with substance abuse issues.

• Under Stress? We’re Here to Help
• The Good, the Bad and the Ugly: An on-demand webinar that addresses how to identify stress, recognize the physical and mental impacts of stress, and how to manage the negative types of stress.
• Mindfulness Techniques May Help You Reduce Your Stress [Videos]
• Keeping Calm in the Coronavirus: You’ve Got This!
• Got Grief? Four tasks to help you recover from the coronavirus blues
• National Suicide Prevention Lifeline: 800-273-8255
• ADA Wellness Resources
• Crisis Text Line: Text HOME to 741741

 

Stuart M. Schrader, PhD, MSW, MA, Clinical Associate Professor in Behavioral Sciences at the IU School of Dentistry has developed a COVID-19 Patient, Staff and Provider Resource List with helpful information on a variety of topics related to COVID-19. Click here to view the PDF.