Board Certified Periodontist

40 – COVID-19 Testing in the Dental Office

Hi there.

You are listening to the Perio Hygienist Podcast, a podcast for my professional colleagues. My name is Dr. Ben Young, and I am a periodontist actively practicing in San Antonio, Texas. The title of today’s podcast is: “COVID-19 Testing in the Dental Office.”

I have really had trouble figuring out how to discuss this topic. It comes from finding an article written in the Journal of the American Dental Association with that specific title. It came out in the July 2021 edition and was written by three authors: Sajjad Shirazi, DDS, Clark M. Stanford, DDS PhD MHA and Lyndon F Cooper DDS PhD.

Dr. Shirazi is a research specialist in the Department of Oral Biology at the College of Dentistry, University of Illinois in Chicago.

Dr. Stanford is the dean of this institution.

And Dr. Cooper is the associate dean for research of the same institution.

I read through the article twice and also pulled up a review article the three authors referenced that they also wrote which was published in March of this year (2021) entitled Characteristics and Detection Rate of SARS-CoV-2 in Alternative Sites and Specimens Pertaining to Dental Practice: An Evidence Summary. It was published in the Journal of Clinical Medicine.

Essentially, what I think I am looking at are two articles dealing with the same topic published to two groups of readers, the general medical community, comprised primarily of physicians and the general dental community.

So, what is the point here? Why the articles? I encourage you to read the one in the JADA at least and not take my word for anything here.

Let’s now see what it is these authors have to say is their purpose for these two articles.

First, reading from the Abstract on their first article in the Journal of Clinical Medicine.

“Knowledge about the detection potential and detection rates of severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) in various body fluids and sites is important for dentists since they, directly or indirectly, deal with many of these fluids/sites in their daily practices. In this study, we attempt to review the latest evidence and meta-analysis studies regarding the detection rate of SARS-Co-V-2 in different body specimens and sites as well as the characteristics of these sample[s].

Essentially, they break down detection of the virus by looking for one of three biomolecules. The first is nucleic acid, the second are antigens and the third are antibodies. Different tests are required for detecting each biomolecule.

They look at the relative detection for the three viral biomolecules in specimens collected in each of these sites or body solids and fluids: nasopharynx, oropharynx, nose, saliva, sputum, bronchoalveolar lavage, stool, urine, ocular fluid, serum, plasma and whole blood.

What I learned from reading this article is that testing during the incubation period is not particularly helpful. Asymptomatic patients – for the most part – do not have the virus – or they do, but not in enough of quantity to become symptomatic.

Overall, the other screening options we have available in the dental office today – and this is me opining – are a simple question and a simple screening tool:

The question is: “How are you feeling today?”

The second is taking a forehead temperature. If it is elevated and there is no reasonable explanation, then postpone care and see them in a week. In that amount of time, if they were infectious and presymptomatic they will likely become sick to some level and shed the virus somewhere else.

So let’s go to the article in JADA. What is their stated purpose here?

First of all, their methodology for providing the conclusions they do is from consulting “all relevant and current guidelines from the Centers for Disease Control and Prevention and the US Food and Drug Administration, as well as online resources and review articles.” In my mind, this makes this an opinion piece.

What they learned and then passed on through this article is that “routine COVID-19 screening and triage protocols are unable to detect all infected people.”

Let me step away here and simply point out that our current infection control guidelines are to treat all patients as if they are HIV or Hepatitis B positive. These may be transmitted through blood more than COVID – which is airborne, but it is the same attitude we must have with this virus. Follow all hand washing, surface disinfection, instrument sterilization, masking and barrier protections as you have already been trained to provide.

A year plus out from the beginning of the pandemic of this novel virus, we are in a different place. First of all, we understand ways to reduce its spread, second, we are in the cyclical nature of viral spreading having to do with colder and warmer seasons, third, we have learned about preventive methods that reduce risks to include Vitamin D3, Zinc, and if one wishes, to have a vaccine or managing with use of Ivermectin or Hydroxychloroquine.

Back to their comments from the Abstract of this article under “Results.”

“With the advancements in diagnostic tools and techniques, COVID-19 testing at home or in the dental office may provide dentists with the ability to evaluate the disease status of their patients. At home or point-of-care (POC) tests, providing results within minutes of being administered, would allow for appropriate measure and rapid decisions about dental patients’ care process.”

Hey, me again. No, it wouldn’t. Doing a “rapid test” is not rapid in the first place. Secondly, why administer the test? On everyone? How expensive would this be? We have no data to indicate that this would detect people at a high enough level to justify this test – which is just a screening test – which then means it needs to be confirmed by another more accurate test. This all comes out in the article, by the way, so I do encourage you to read it.

If you do, then you will begin to appreciate how complicated interpreting this type of data really is because the first thing they will review is this list of terminology: Screening testing, Diagnostic testing, Surveillance testing, pretest probability, Diagnostic sensitivity and specificity, Positive and negative percentage agreement, Analytical sensitivity, Analytical specificity, Positive predictive value, and Negative predictive value. My take away from all of this was that when we are attempting to understand the spread of a new virus, we cannot rely on any previous knowledge of its particular spread or pathogenicity, for this reason, we have to modify our understanding as we go and collect the data that will be useable years from now. We are sort of building the plane we are flying on.

Let me jump down to their conclusion, still in the Abstract portion of the article: “Dentists need to be familiar with COVID-19 POC testing options. In addition to contributing to public health, such tests may deliver rapid, accurate, and actionable results to clinical and infection control teams to enhance the safe patient flow in dental practices.”

So, I agree with the first statement, that it is good to be familiar with COVID-19 POC testing options – so read the article and this first objective is then accomplished.

I do not agree with the second statement that “such tests may deliver rapid, accurate, and actionable results to clinical and infection control teams to enhance the safe patient flow in dental practices.”

First off, what is the infection control team, the authors are referring to? Is this some outside entity that is coming into the practice to “enhance safe patient flow?” If it is, then what we are seeing here is a pitch for some academic/university related entity to provide infection control guidance – which can then be justified to receive appropriate funding. The article I think makes it clear that a “rapid” screening test is inaccurate and that it will not at this point provide any additional useful information over patient symptoms and temperature readings. Which, I know, is inconsistent, at least to me, with the Abstract statement.

So, once again, as I said at first, I have had trouble discussing this topic, but none the less, I am compelled to do so. Because – there it is – and I don’t know completely why it is there.

I am not a virology expert, but as you may know by now about me, I’m a skeptic and my spidy-senses go off when I see an article placed into a journal intended for the largest dental population of the nation that goes deeper into the subject of virology than most of us are ready – or even interested – in handling. This is not a knock on us, and I include myself here, as dental practitioners, but a question as to why it was considered a good idea to drop such an article into our general publication.

First, there is a reason this article is here, and it isn’t because many will read it, because they won’t. Which actually may be the point. Busy practicing dentists do not have the time nor the interest to sit down and wrestle with the positive and negative percentage agreement of a particular antigen diagnostic test.

Perhaps we will see some simple testing systems come along to be sold to us for testing patients. It might be here for this reason. If it  is, be very careful.

If someone among us thinks we should be testing people for the virus, we need to ask, first and foremost, what will be the benefit to our patients?

Keep in mind that none of the three article authors are private practitioners.

There is another concern I have about medical testing of patients and that is liability.

I certainly understand the natural desire to want to be useful in the community where we live and practice and I know by experience interacting with dentists my whole life that many feel just a touch inferior to physicians, a little bit of the second-class-citizen syndrome. If this is the case and you personally want to do more, then that’s a good reason to broaden yourself and do whatever the thing is you want to do – but it is unwise, in my opinion, to step into taking on additional services that may open you up to legal exposure. This is true for you dental hygienists as well. Many great dentists and periodontists began as dental hygienists. If you have some strong desire to press into something, pray about it. It might be God calling you to take the next scary step on your own journey.

Back to the topic at hand, I get that it is easy to swab something and look at colors change on a chemical strip, for example, but very different to begin to make the diagnosis that someone has or does not have an infection not specifically associated with our real area of expertise. Also, what might follow our diagnosis? Might we want to then prescribe a medication, or make a report to some public health official while wearing the hat of an expert, when we may have no clue specifically how accurate our particular test is?

Now, I am not saying we shouldn’t be able to utilize laboratories and testing – but I am saying that sometimes, it is easier and actually better to refer to others more qualified than we are in some area of healthcare. I hope this is sounding a bit familiar for those of you who have recently listened to my previous podcast on the subject of Interdisciplinary Treatment Planning. And by all means, ask for the raw data – to see the lab results yourself.

That’s it for today. Let me know what you think. Have a great day.

This has been The Perio Hygienist Podcast and I am still Dr. Ben Young. Thanks for listening. Bye for now.