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Phases 2 and 3

Updated 7/6/20

On July 6, 2020, Governor Charlie Baker announced that Massachusetts is entering Phase 3—the Vigilant Phase—of the state’s four-phase reopening plan. Phase 3 offers no change for dental practices, which can continue to see patients for all procedures.

On June 6, 2020, Governor Charlie Baker announced Phase 2 reopening details for the Commonwealth. Phase 2, which is referred to as the “Cautious Phase,” allows dental providers to cautiously and incrementally resume all elective, non-urgent procedures and services, including routine hygiene appointments. Phase 2 initially excluded elective cosmetic services, but effective June 24, those procedures are now allowed. Phase 2 incremental dental care is proposed to start on Monday, June 8. The Massachusetts Department of Public Health’s (DPH) Reopening Guidance report provides details for the phased reopening of the state. The Massachusetts Dental Society (MDS) is pleased with this plan, and applauds the contributions of MDS representatives President Dr. Janis Moriarty and former Treasurer Dr. Thomas Trowbridge for their ongoing participation in the Reopening Advisory Board’s stakeholder meetings, their advocacy on behalf of dental facilities, and their commitment to safely and cautiously expanding dental care throughout the Commonwealth. Phase 2 allows dentists to apply their professional judgment to determine what care should be provided for their patients.

In order to move forward into Phase 2, dental providers must maintain ongoing compliance with public health and safety standards identified in Phase 1. Phase 2 is also contingent on Massachusetts’ ability to maintain sufficient statewide hospital bed capacity (>30% ICU and >30% inpatient bed capacity, statewide), which was also included in Phase 1 requirements. As the governor noted, if the data begin to show a backward trend, it is possible that care will again become limited to Phase 1 services.

Dentists should expand services cautiously, using their clinical judgment to prioritize urgent services, emerging services, and preventive care. Prioritization criteria should promote equitable access to care for all populations. Dentists should continue to defer elective cosmetic procedures to future phases. The second phase, which is currently expected to begin Monday, June 8, includes an increase in allowable dental procedures for those providers who are able to meet key public health criteria as set by the DPH.

Building off of the requirements of Phase I, dentists will need to attest to public health standards and specific guidelines:
  • Have current adequate supply of personal protective equipment (PPE) and maintain adequate supply on an ongoing basis without support from the state stockpile
  • Meet public health and safety standards in the domains of workforce safety, patient safety, and infection control
  • Designate a compliance leader at the highest level of the organization
  • Attest to and maintain the attestation form acknowledging that they meet all of the requirements in PPE, health and safety standards, and compliance standards. Practices must retain this attestation for inspection upon request by the DPH.

In addition to the safety standards outlined in Phase I, Phase 2 requires dentists to create an addendum to their Phase 1 attestation form that documents the practice’s prioritization policy for providing and scheduling Phase 2 care. The prioritization plan should focus on the high-priority services (emergency/urgent, emerging needs, and preventive services) that if left untreated could lead to high risk or significant worsening of the patient’s condition if deferred. Dentists should prioritize care for patients as follows:

  1. Emergency or urgent
  2. Previously in the middle of treatment or treated during emergency care
  3. Disease management, trauma, compromised function, and frequently cared for patients
  4. At-risk patients to prevent potential dental emergent and urgent care situations
  5. Continuity of care
  6. Recall preventive and routine comprehensive dental care

The prioritization plan should identify patients and services that, based on the provider’s clinical judgment, are most critical and time sensitive. Elective cosmetic services should be deferred until a future phase. The addendum should be kept with the attestation form and maintained and updated as needed.

We understand this can be a confusing time for staff and patients. Again, the dentist, as the leader of the dental team, is best positioned to assure staff and patients that the work being done is appropriate under the current guidelines and that the dental team is strong, compliant, and following all safety measures.

The MDS has compiled the following questions and answers to offer general guidance to members. You should continue to rely on your best professional judgment. We will continue to update this section as more information becomes available or as information changes.

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New Phase 2 Highlights

Updated 6/25/20

All dental services may be resumed in Phase 2 with once the following criteria is met:

  • Dentists must first attest, on a form prescribed by DPH, to continuing to meet all Phase 1 criteria and standards, and three additional conditions for Phase 2:

    • Dentists must establish a prioritization policy for the scheduling and delivery of Phase 2 services in accordance with DPH guidance, which includes establishment of daily patient volume limits for non-essential, elective invasive procedures and services in the practice and scheduling of patient visits in a manner consistent with such limits and this guidance.
    • The practice must be in compliance with Centers for Disease Control and Prevention (CDC) requirements and other public health guidance that require all examination, procedural, and surgical areas to be discontinued from use in-between procedures and services for a sufficient time frame for air changes to remove airborne-contaminants prior to thorough cleaning and disinfection of the room and equipment.
    • The practice must establish daily patient volume limits for non-urgent care and schedule visits in a manner consistent with such limits and this guidance. Priority should be given to patients with the most critical and time-sensitive needs, and promote equitable access to care for all populations.

  • The initial and ongoing implementation of this guidance is contingent on Massachusetts meeting a range of relevant capacity and public health metrics. Ongoing performance on these measures will inform additional reopening decisions for future phases.

Patient Volume Limits and Safety Standards for Invasive Procedures and Services

In order to manage statewide PPE consumption rates, reduce COVID-19 transmission, ensure compliance with public health and safety standards, and maintain hospital capacity in case of further peaks in prevalence during Phase 2, dental providers should take steps to cautiously and incrementally resume non-essential, elective invasive procedures and services.

Specifically, for all non-essential, elective invasive procedures and services, providers must attest to establishing and monitoring daily patient volume limits in the practice and must schedule patient visits accordingly.

Daily patient volume limits must ensure ongoing compliance with:
  • The public health and safety guidelines in Phase 1 Guidance (Section IV) including, but not limited to, standards related to PPE supply and use, restricting the number of dental providers in the treatment space to those individuals necessary to complete the service or procedure for the patient, screening patients in advance of a service or procedure, administrative and environmental controls that facilitate social distancing, such as minimizing time in waiting areas and minimizing contact between patients through scheduling modifications; and
  • After patient treatment, dental health care professionals should delay entry into the operatory until a sufficient time has elapsed for enough air changes to remove potentially infectious particles. The CDC’s Guidelines for Environmental Infection Control in Health-Care Facilities (2003) provides a table to calculate time required for airborne-contaminant removal by efficiency.

What are the goals of Phase 2?

To allow dental providers to cautiously and incrementally resume all elective, non-urgent procedures and services, including routine hygiene appointments, with the exception of elective cosmetic services, while preserving sufficient hospital capacity for COVID-19 treatment. 

What is the Phase 2 start date tied to?

The start date for Phase 2 is contingent on sufficient statewide hospital capacity being available (>30% for staffed ICU beds and total inpatient beds, including staffed surge capacity based on a hospital’s 7-day average of availability).

What are the reopening criteria of Phase 2?

Dentists will need to attest to meeting specific requirements and will need to maintain a copy of the attestation form for record-keeping documentation. 

Prior to reopening in Phase 2, dentists must first attest, on a form prescribed by DPH, to continuing to meet all Phase 1 criteria and standards as indicated below, and three additional conditions for Phase 2:

  • Dentists must establish a prioritization policy for the scheduling and delivery of Phase 2 services in accordance with DPH guidance, which includes establishment of daily patient volume limits for non-essential, elective invasive procedures and services in the practice and scheduling of patient visits in a manner consistent with such limits and this guidance.
  • The practice must be in compliance with Centers for Disease Control and Prevention (CDC) requirements and other public health guidance that require all examination, procedural, and surgical areas to be discontinued from use in-between procedures and services for a sufficient time frame for air changes to remove airborne-contaminants prior to thorough cleaning and disinfection of the room and equipment.
  • The practice must establish daily patient volume limits for non-urgent care and schedule visits in a manner consistent with such limits and this guidance. Priority should be given to patients with the most critical and time-sensitive needs, and promote equitable access to care for all populations.

Prior to reopening in Phase 1, all dentists were required to self-attest to the following:

  • Adequate PPE on hand, reliable supply chain and other supplies and policies in place, not reliant on the state stockpile for PPE
  • Infection control readiness (workflow, cleaning, social distancing, etc.)
  • Workforce and patient screening and testing protocols



Where does hygiene fit into the governor’s Phase 2 reopening?

Phase 2 allows dental providers to cautiously and incrementally resume all elective, non-urgent procedures and services, including routine hygiene appointments. Phase 2 excludes elective cosmetic services. 

Mandatory Safety Guidelines for Phased Reopening

  • The governor has released general reopening guidelines, including Mandatory Safety Standards for Workplaces that all businesses must adhere to. The MDS will be issuing additional sub-guidance for dental practices.
  • The MDS is participating in a work group convened by the administration to inform guidance applicable to dental practices and other non-hospital providers.
  • The governor has released reports for Phase 1 and Phase 2.

What if my office does not have sufficient PPE?

  • Availability of the recommended PPE should be a significant factor as you determine how your office can expand care over the course of Phase 2 re-opening. There is no defined amount of days’ supply you need to have on hand; you must use your own professional judgment on the inventory of PPE you need to have on hand to care for your patients.
  • We recommend that dental offices continue contacting their supplier(s) to acquire appropriate levels of supplies.
  • PPE suppliers have communicated that they expect availability of supplies to begin increasing over the next few weeks.
  • You may be able to extend the life of your current PPE by following guidance from the ADA or by participating in Battelle decontamination services.
  • State officials are urging dentists to refrain from contacting state agencies for PPE. Due to the Commonwealth’s limited supply of PPE, all requests are being prioritized for urgent and emergent needs (e.g., practitioners providing emergency care with less than five days of PPE supplies on hand) and not for building supply stock.
  • The MDS/ADA is in constant contact with suppliers, the Massachusetts Emergency Management Agency (MEMA), and Federal Emergency Management Agency (FEMA) to ensure proper availability of PPE for dental offices. The MDS is also evaluating possible options for large group purchases or other ways to support member dentists.

When Are N95 Respirators Required?

According to the American Dental Association, N95 initial fit testing is only required if the wearing of an N95 mask is required. OSHA has not required N95 masks for dental personnel unless:


1. Treating known or suspected COVID-19 positive patients or
2. The dentist’s own airborne hazard assessment reveals a need for N95 masks.

However, any time an N95 mask is being chosen as the safest PPE, an initial fit test and medical clearance is recommended, even if not required. The fit test can be performed, with a kit, in the office. The medical clearance is recommended because there is greater resistance in the N95 and some may not be able to wear one. Medical clearance is a required part of the protocol if the N95 is required.

Are patients required to wear face masks?

Yes, providers must require that all patients and companions wear mouth and nose coverings. However, the provider may consider waiving the requirement for mask and nose coverings for patients and/or companions in special circumstances.

Do I need to have my patients sign a COVID-19 waiver?

What are the required public health criteria and safety standards for the dental practice?

  • All workers must have appropriate PPE to perform the service/procedure. If appropriate PPE is not available to protect the health care worker, the service/procedure should be cancelled.
  • Health care providers and staff must wear surgical face masks at all times.
  • Facility or office must ensure social distancing for providers and staff to the maximum extent possible.
  • Eye protection (goggles, visor, or mask with visor) must be provided and worn by all health care professionals while engaged in direct patient care for procedures with increased potential for droplet aerosolization.
  • Providers must take steps to minimize the number of health care workers in the facility or office to those individuals necessary to complete the surgery/procedure.
  • Providers must have a written protocol in place for screening all employees for symptoms of COVID-19 prior to entering the facility or office.
  • Providers must adopt written policies that address worker safety and well-being.

What are the required public health criteria for safety standards for patient safety?

  • Providers must have a process for screening patients and companions for symptoms of COVID-19 prior to entering the practice
  • Providers must have policies and procedures for screening patients in advance of a service or procedure, including policies and procedures for testing patients for COVID-19 when medically appropriate, as well as for determining whether a procedure should go forward if a patient tests positive.
  • Providers must develop policies permitting patient companions only in special circumstances or otherwise in adherence with Massachusetts Department of Public Health (DPH) and CDC guidance when necessary for the patient’s well-being. Special circumstances and populations may include pediatric patients and other special populations such as patients with disabilities or patients with intellectual or developmental disorders (e.g., autism, Down syndrome, etc.). These policies must be accessible to patients seeking care.
  • Providers must require that all patients and companions wear mouth and nose coverings. However, the provider may consider waiving the requirement for mask and nose coverings for patients and/or companions in special circumstances.

What are the required public health criteria for safety standards on infection control?

  • Providers must demonstrate adherence to social distancing and relevant guidelines from the Massachusetts DPH and CDC regarding infection control and prevention to maintain a safe environment for patients and staff.
  • Providers must adopt administrative and environmental controls that facilitate social distancing, such as minimizing time in waiting areas, including by asking patients to wait outside until their appointment begins if possible.
  • Providers must have signage to emphasize social restrictions (i.e., distancing, coughing etiquette, wearing of mouth and nose coverings, hand hygiene) and must provide liberal access to hand sanitizer for patients and staff. 
  • Providers must have an established plan for thorough cleaning and disinfection of all common and procedural areas, including between treatment room turnarounds, which may require hiring environmental services staff and reducing patient hours to allow for more frequent cleaning.

Do practices need to appoint a compliance officer to manage the public health criteria?

Yes, you must attest to designate a compliance leader at the highest level of the organization to ensure compliance with the clinical and safety standards.

Who has the authority to monitor and assess compliance with public health criteria?

The DPH maintains the authority to monitor and assess compliance and require remedial action or suspend Phase 2 services as warranted.

What staff should I bring back to work in Phase 2?

You need to determine the staffing that you need in your practice in order to provide expanded service to include emergent and soon-to-be emergent care.

Is it possible that we will move into Phase 2 and have a setback that requires us to revert back to Phase 1 or emergency care only?

Yes. It is critical that the state maintain greater than 30% capacity of ICUs. As Governor Baker noted, if the data begin to show a backward trend, it is possible that care will again become limited to Phase 1 or emergencies only.

The DPH will continue to monitor statewide bed availability and may require that a health care provider suspend or limit provision of any of the services based on its determination that statewide bed capacity is deemed to jeopardize the health system’s ability to respond to patient demand.

Can I bill patients for PPE expense?

The MDS is recommending that dental offices use CDT code "D1999 - unspecified preventive procedure, by report" to document and report the use and cost of additional PPE. The ADA and the MDS have been urging third-party payers to alter their fees to account for the increasing cost of personal protective equipment (PPE) that dentists are using to protect themselves, their staff, and patients. 

Dentists can use this code once per patient visit/claim to attempt to cover the cost of PPE. Dentists should develop a standard office policy to document the additional PPE that will be used across all patients. This documentation methodology will justify a standard fee across all patients. Alternatively, dentists may wish to add a note in the patient’s record to document the details of PPE uniquely necessary for the visit when charging different fees based on the level of PPE used.

What are the waiting room requirements?

The Massachusetts Department of Health and Human Services says that providers must adopt administrative and environmental controls that facilitate social distancing, such as minimizing time in waiting areas, which may include asking patients to wait outside the building until their appointment begins if possible. It is recommended that you inform your patients in advance of your polices.

Do I need to have a written protocol on how I am screening employees for COVID-19?

Yes, providers must have a written protocol in place for screening all employees for symptoms of COVID-19 prior to entering the facility or office.

Do I need to have a written protocol on how I am screening patients and their companions for COVID-19?

Yes, providers must have a process for screening patients and companions for symptoms of COVID-19 prior to entering the facility or office. Providers must have policies and procedures for screening patients in advance of a service or procedure, including policies and procedures for testing patients for COVID-19 when medically appropriate as well as for determining whether a procedure should go forward if a patient tests positive.

Can I limit patients from bringing companions with them to appointments?

Yes, you are required to limit the amount of people in your waiting area/office. Providers must develop policies permitting patient companions only in special circumstances or otherwise in adherence with DPH and CDC guidance when necessary for the patient’s well-being. Special circumstances and populations may include end-of-life care, pre-natal/labor and delivery, pediatric patients, and other special populations such as patients with disabilities, patients with intellectual or developmental disorders (e.g., autism, Down syndrome, etc.), or populations as otherwise identified by the DPH. These policies must be accessible to patients seeking care.

Are there signage requirements in place on social restrictions?

Yes, providers must have signage to emphasize social restrictions (i.e., distancing, coughing etiquette, wearing of mouth and nose coverings, and hand hygiene).

Do I need to have hand sanitizer available to patients and staff?

Yes, you must provide liberal access to hand sanitizer for patients and staff.

Do I need to put together a plan for cleaning and disinfecting my office?

Yes, providers must have an established plan for thorough cleaning and disinfection of all common and procedural areas, including between treatment room turnarounds, which may require hiring environmental services staff and reducing patient hours to allow for more frequent cleaning.

Do I need to close my office if a patient or employee tests positive for COVID-19?

Additional guidance from the CDC provides that you should do the following if an employee or visitor to your office reports a positive COVID-19 diagnosis:

  • If it has been less than seven days since that person was in the office, you immediately should close off any areas used for prolonged periods of time by that person. You also should arrange to have the office cleaned and disinfected in accordance with CDC guidelines.
  • If it has been seven days or more since that person was in the office, additional cleaning and disinfection is not necessary per current CDC Guidelines. You should continue routine cleaning and disinfecting of all high-touch surfaces.

The CDC does not appear to offer any special guidance for cleaning or disinfecting dental offices in connection with COVID-19 and there is no set amount of time the office needs to be closed, other than long enough to get the cleaning accomplished.

The CDC provides that if a dental patient or staff member develops COVID-19, you should notify all patients who were treated within 48 hours after the person was in the office. With respect to staff, ordinarily you would contact trace and notify any staff member who has been in close contact with the sick person in the past 14 days and require that they remain out of work. However, the standards are a little different for health care personnel (which dentists qualify as). Instead, health care professionals do not necessarily need to be excluded from work if they were wearing the appropriate PPE. Learn more in the CDC’s Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.

Resources

6/6/20

The Baker Administration is providing information and resources (e.g., control plan template, posters, and information on supply vendors) to help businesses, including eligible dental practices, meet the self-certification requirement to reopen. All businesses must meet these requirements before reopening. Resources you will need include:

  • COVID-19 control plan template – Template that satisfies the written control plan requirement for self-certification
  • Compliance attestation poster – Poster that customer facing businesses are required to print, sign, and post in an area within the business premises that is visible to workers and visitors
  • Employer and Worker posters – Posters that businesses can print and display within the business premises to describe the rules for maintaining social distancing, hygiene protocols, and cleaning and disinfecting

View State Resources


Other Resources 

Sample PPE and Emergent Care Text for Clinical Notes

The MDS recommends that any dentist providing care during Phase 1 should consider documenting in the clinical record why the treatment being prescribed during the phase is not simply routine or elective care and record your PPE usage. To help members, the MDS has developed sample text that you can use in your patient’s record to document your adherence to the Phase 1 criteria.

Emergent Care Documentation Sample Text

In compliance with Phase 1 guidance issued by the Massachusetts Department of Public Health and in accordance with all applicable laws and regulations, this procedure was deemed clinically appropriate at the time the service was provided.

PPE Documentation Sample Text

In compliance with Phase 1 guidance issued by the Massachusetts Department of Public Health and in accordance with all applicable laws and regulations, all necessary personnel were properly trained for the personal protective equipment (PPE) used and all PPE were properly worn during the duration of the procedure.

Likely to Become Emergent Guidance

The MDS created the Likely to Become Emergent Guidance document to assist providers in identifying situations that are likely to become emergent if care is deferred.


Updated CDC Guidance for Dental Practices

On May 19, the Centers for Disease Control and Prevention (CDC) updated its Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response to provide recommendations for dental practices resuming non-emergency dental care during the pandemic. The CDC has added new information regarding facility and equipment considerations, sterilization and disinfection, and considerations for the use of test-based strategies to inform patient care. It also offers expanded recommendations for the provision of dental care to both patients with COVID-19 and patients without COVID-19.


Respiratory Protection Program

This program is a resource from the California Dental Association that is part of regulatory compliance pertaining to N95 fit testing.  Learn more.