Message from the President
March 23, 2020
ANSWERS TO QUESTIONS

When can we reopen the dental office and return to work as usual?
What are the urgent and emergency procedures we are allowed to perform?
What changes do I need to implement in the office to see emergency patients?
There is no money coming in. What are my options for paying the staff and overhead?

SFDS is hearing all your questions and sifting through the continually changing information to bring you the latest intelligence we glean. This Covid-19 outbreak will change how dentistry is delivered today and in the future. 9-11 changed airline travel forever and Covid-19 will change how we practice dentistry.

These are the best answers we have to the above questions, at this time. The answers will not be complete and will direct you to links where you can find more information. The information is changing daily and we all need to stay up on what is changing so that we can take appropriate action. The SFDS does not set regulations and is purely trying help you access the agencies and the information they can provide.

When can you reopen the office to provide full services?
The San Francisco shelter in place order is in effect through April 7 th . The CDA originally had March 30 th as the date, but now there is no definite date to resume seeing all patients.

“THE CDA STRONGLY RECOMMENDS THAT DENTISTS PRACTICING IN CALIFORNIA SUSPEND ALL IN-PERSON DENTAL CARE WITH THE EXCEPTION OF EMERGENCY TREATMENT, UNTIL FURTHER NOTICE.”

For the most up to date information go to cda.org/covid19

What types of dental emergency procedures can we provide?
According to the ADA you can provide Emergency or Urgent dental care as described below:

“Potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:
  • Uncontrolled bleeding
  • Cellulitis or a soft tissue bacterial infection with intra-oral or extra oral swelling that potentially compromises the patient’s airway.
  • Trauma involving facial bones, potentially compromising the patient’s airway.

Urgent Dental Care (ADA) - Urgent dental care focuses on the management of conditions that require immediate attention to relieve pain and or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible. 
  • Severe dental pain
  • Pericoronitis or third molar pain
  • Surgical post-operative osteitis, dry socket dressing changes
  • Abscess, or localized bacterial infection resulting in localized pain and swelling
  • Tooth fracture resulting in pain or causing soft tissue trauma
  • Dental trauma with avulsion / luxation
  • Dental treatment required prior to critical medical procedures
  • Final crown/bridge cementation if the temporary restoration is lost, broken, or causing gingival irritation
  • Extensive dental caries or defective restorations causing pain
  • Manage with interim restorative techniques when possible (silver diamine fluoride, glass ionomers)
  • Suture removal
  • Denture adjustments on radiation/oncology patients
  • Denture adjustments or repairs when function is impeded
  • Replacing temporary filling on endo access openings in patients experiencing pain
  • Snipping or adjustment of an orthodontic wire or appliances piercing or ulcerating the oral mucosa
  • Biopsy of abnormal tissue

What changes do I need to implement in the office to see these patients?
The recommendations from the CDC and OSHA vary. I would recommend you look at both sets of recommendations and follow the strictest one until more definitive guidelines are available.

Covid-19 is believed to be mainly transmitted in airborne droplets. It is classified as an airborne infectious pathogen, and as such, you will need different protocols to protect yourself than you currently use for blood borne pathogens. Go to the CDC and OSHA sites to see the complete recommendations as they are too long to include here. It is important to note that to use an N95 respirator, it needs to be properly fitted, with prior testing and training. It is necessary to evaluate the N95 fit and seal prior to entering the contaminated area and to keep it on until out of the affected room. So, let’s assume you have decided that you will limit your dental procedures to the emergency/urgent procedures specified by the ADA. You can find OSHA’s guide, along with other safety and practice management resources, at  ADA.org/virusresources .

Some guidelines you may wish to consider implementing to minimize exposure include:
  • Screen your dental team members each morning and throughout the day – to include temperature & an overall health check-in. A forehead scanning thermometer is a good investment.
  • Do not take walk-in appointments – pre-screen all potential cases over the phone.
  • Use of phone calls and other forms of HIPAA-compliant telemedicine as a means of communicating with patients during this time is highly encouraged. One option is Zoom, which is offering free 40-minute services and may be an option for virtual check-ins with patients. To register and complete tutorials, visit: https://zoom.us/.
  • Schedule enough time between patients to allow for social distancing in the waiting room and operatories.
  • Consider having patients wait in their cars to be called or texted when the dental chair is available.
  • Schedule enough time after a patient and before cleaning—to allow for any patient aerosol particulates to settle (30 minutes or more). It is thought that spread is through human aerosols and droplets that take at least 30 minutes to settle and the virus is thought to be active during this time.

While we’ve had no specific PPE recommendations beyond standard infection control procedures, if we assume that all patients could be potentially infected, whether symptomatic or not, then it makes sense that more precautions are necessary.
                              
What are my options to deal with the financial impacts of this suspension of services?
As with the PPE, there is a lot of talk about relief to small business and to employees. How practices are managed, the practice policies you may already have, may dictate how you will handle financial and staffing questions. As we stated last week, there are multiple layers on this front. And we expect changes nationally, statewide, and in San Francisco as various government agencies begin to work with businesses and respond to staff questions. In the meantime, we are providing some useful links to information that may answer some of your questions:

HR for Health, a CDA endorsed provider, held a webinar last week that is available here at CDA.org and may provide answers to your most pressing questions. You can also visit their website at www.hrforhealth.com .

Also, for SF dentists, there is additional information about SF paid sick leave that has been extended by an additional five (5) days beyond the current mandate.   SF OLSE Paid Sick Leave

Help for small businesses is growing, yet quickly changing. This is unsettled territory, yet there are SBA disaster relief loans and SF Resiliency Funds available for smaller employers: 


Finally, a central component of the third COVID-related economic stimulus package, the Cares Act , is giving the Treasury Department the authority to disburse hundreds of billions of dollars in emergency federal loans to businesses hurt economically by the coronavirus. About $500 billion is earmarked for airlines, businesses, cities and states. There would also be an additional $350 billion in loan guarantees for small businesses to help them avoid layoffs. The ADA is keeping a close eye on this legislation and will continue to keep us all informed. 
We are all navigating these uncharted waters together. We would like to extend a huge thank you to our members for their support and understanding as we work to take care of our families, our staff, our practices and each other.

Sincerely,
President Nogueiro
Carlos Nogueiro, DDS
President, San Francisco Dental Society
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