COMMENTARY AND GUIDELINES FOR COVID-19
One major concern that dentists currently have is the chance that a patient could sue them claiming that they or their deceased relative contracted the COVID-19 virus in the dental office and had several complications and expenses or even death as a result. Of course with the Utah Department of Health mandate, dental practices that are still operating should be severely limiting their patient pool to patients with urgent or emergency needs in line with CDC guidelines, not to mention similar ADA recommendations and Utah’s mandate to restrict nonessential “medical, dental and veterinary procedures” to conserve protective equipment needed by doctors treating patients with COVID-19 and to help limit the spread of the virus. For what it is worth, in an extreme case according to Utah law, if a dentist or hygienist violates a public health order such as the limitation on non-essential procedures, that dentist or hygienist could be charged with a class B misdemeanor!
The first question PIE insured are asking is Will PIE cover any claim a patient makes for contracting the COVID-19 virus in my office? The answer is a resounding YES as long as you are practicing within the guidelines and mandates in place in Utah at the time the procedure was performed. This is no different than what the policy has always covered. In other words, if you perform or have assistants perform procedures not allowed by the Dental Practice or Rules in effect in Utah, you do not have malpractice coverage.
So currently you must limit the procedures you do according to the CDC guidelines and ADA information which are in line with Utah Department of Health restrictions. If you are violating these guidelines you will likely have a difficult time defending yourself in a claim anyway. If there is a question about the urgent or emergent nature of a procedure you performed, hopefully your treatment notes will specify why you considered the procedure to be urgent or emergent, and why you considered it in the patient’s best interest to perform the procedure. PIE has also created an informed consent form for you to use that covers COVID-19 issues that is under RESOURCES on this website that you should have all patients you see under the current guidelines review and sign.
Following is a summary of helpful information we have made available to send to PIE insured if they request it via telephone or e-mail. We advise you to be familiar with this information.
Of course the CDC came out with recommendations as of March 16, 2020 that essentially matched recommendations previously issued by the ADA. The basic recommendation remains that dentists initially prioritize but now limit dental care only to urgent and emergency visits and postpone routine dental visits now and for the next several weeks until restrictions are lifted.
The CDC has also outlined high risk populations as follows:
- People aged 65 years and older
- People who live in a nursing home or long-term care facility
- Other high-risk conditions could include:
- People with chronic lung disease or moderate to severe asthma
- People who have heart disease with complications
- People who are immunocompromised including cancer treatment
- People of any age with severe obesity (body mass index [(BM]I)≥40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk
- People who are pregnant should be monitored since they are known to be at risk with severe viral illness, however, to date data on COVID-19 has not shown increased risk.
To date the CDC has not stated that dental offices should close down. However, more and more states, including of course Utah, have ordered health care facilities to suspend all nonemergency dental and medical procedures.
Some dentists still have wondered what is meant by “emergency or urgent” dental procedures. On March 19, 2020, the ADA sent out information which helps to define an emergent or urgent procedure. Most if not all of you should be very familiar with these guidelines, but I have added some commentary in italics to hopefully clarify a few things. The ADA commentary follows:
“The ADA recognizes that state governments and state dental associations may be best positioned to recommend to the dentists in their regions the amount of time to keep their offices closed to all but emergency care. This is a fluid situation, and those closest to the issue may best understand the local challenges being faced.
The following should be helpful in determining what is considered “emergency” versus “non emergency.” This guidance may change as the COVID-19 pandemic progresses, and dentists should use their professional judgment in determining a patient’s need for urgent or emergency care.”
1. Dental emergency
Dental emergencies are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:
- Uncontrolled bleeding
- Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient’s airway
- Trauma involving facial bones, potentially compromising the patient’s airway.
These situations are very straightforward and no dentist would be faulted for seeing any patients with these conditions that nevertheless should be documented as emergencies in the dental records.
2. Urgent dental care
Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe 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 from pulpal inflammation
- Pericoronitis or third-molar pain. Does this indicate that the third molar should be extracted immediately? If the patient’s health would be jeopardized by waiting several weeks to extract the tooth, then the situation should be deemed urgent and the tooth should be taken out immediately. If an operculectomy would solve the problem than that procedure should be done in lieu of the extraction.
- 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. In this situation, if there is a near pulp exposure, and waiting several weeks to perform root canal therapy could create an urgent emergency situation for the patient, then a pulpotomy or even complete root canal therapy could be considered urgent and necessary.
- 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. Additionally, if the tooth could be jeopardized by waiting several weeks to seat a crown or the dentist is worried about supra-eruption, then seating the crown could be considered urgent.
3. Other urgent dental care
- Extensive dental caries or defective restorations causing pain. This is a judgment call. A group of incipient or “board lesions” would not constitute urgent care and could wait a few weeks.
- Manage with interim restorative techniques when possible (silver diamine fluoride, glass ionomers)
- Suture removal
- Denture adjustment on radiation/oncology patients
- Denture adjustments or repairs when function impeded. In addition, if a patient has a severe sore caused by an ill-fitting denture that may interfere with his/her ability to eat or function that the patient considers urgent, it is the dentist’s judgment call to determine whether the procedure should be completed. If the patient falls into a high risk category for contracting the virus, the adjustment should probably wait.
- 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
4. Dental non-emergency procedures
These are some of the areas where certain dentists and hygienists are trying to push the envelope because they want to keep working! However, as I will explain later, a patient having these procedures done that who claims to have contracted the virus from a dental office will have a case that is hard to defend or may even be excluded by an insurance carrier since violates a mandate from the CDC and the state health department.
A. Routine or non-urgent dental procedures include but are not limited to:
- Initial or periodic oral examinations and recall visits, including routine radiographs
- Routine dental cleaning and preventive therapies
- Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma)
- Extraction of asymptomatic teeth
- Restorative dentistry including treatment of asymptomatic carious lesions
- Aesthetic dental procedures
If a dentist has any reason to contest that some of these procedures could be considered as urgent and essential, he/she should contact their malpractice insurance carrier to see if they would be covered if the patient or their family made a claim later of COVID-19 contraction in the office as a result of that appointment.
In several memos the ADA has stated that they are committed to providing the latest information to the profession in a useful and timely manner. They have encouraged dentists to visit ADA.org/virus for the latest information. This webpage contains updated information and handouts dentists can use to stay abreast of the latest developments in the virus saga.
Now, I will review some of the most pertinent items that can help dentists deal with the patients that do fall under the guidelines of emergent or urgent care.
1. The first thing to consider is a basic primer on the symptoms and what to look for as far as your employees or a patient that presents to your office. The basic symptoms that all dentists should have memorized by now include:
- Fever of more than 100.5 degrees Fahrenheit or 38 degrees Celcius
- New or worsening cough that is considered a dry cough
- New or worsening shortness of breath
- Close contact (6 feet or less) for a duration of 15 minutes or more with someone diagnosed with COVID-19
- Recent travel to a country at a Level 3 CDC designation
- Diminished sense of smell and/or taste.
As a precaution to helping to spread the virus office personnel are encouraged to:
- Wash their hands with soap and water regularly
- Avoid touching their eyes, nose or mouth
- Regularly clean and disinfect surfaces
- Practice social distancing by limiting exposure to crowds, avoiding handshaking and personal contact with others
2. How should I handle existing and new emergency patients at this time?
A. All patients should be asked the following questions before they enter the operatory. For HIPAA and privacy concerns these questions should not be asked in the waiting room if other patients are present. A separate room in the office should be used in that case.
- Have you traveled on an airplane during the past 10 days? If so, where did you travel from?
- Have you had any of the symptoms listed in section #1 above such as a fever over 100.5 degrees F or 38 degrees C, and so forth.
- Do you have any objection to our treating you today for your urgent or emergency condition? Or, would you rather wait? Record these discussions in your chart.
- Are you able to wait 3-4 weeks as COVID-19 restrictions change such that more people are asked to stay home? Record their response in their chart.
For the latest information from the ADA: ADA.org/virus
For the latest information from the CDC: https://www.cdc.gov/coronavirus/2019
For the latest information from the Utah Department of Health:
For the latest information from the UT Department of Workforce Services:
Richard C. Engar, DDS