key: cord-0822151-ktdxzpbf
authors: Palla, Benjamin; Callahan, Nicholas
title: What is the rate of COVID-19 infection in a population seeking dental care?
date: 2021-03-02
journal: J Am Dent Assoc
DOI: 10.1016/j.adaj.2021.02.009
sha: 295232acc45160bcacafd435983980aa034ff269
doc_id: 822151
cord_uid: ktdxzpbf

Background Although rates of COVID-19 have remained low among US dentists, we wanted to determine the risk of COVID-19 in patients presenting for oral health care. Methods A retrospective chart review of all emergency department consults was performed from June 2020 to December 2020. Pearson correlation coefficients were used to compare rates to city-wide prevalence (p < 0.05). Results We located 203 encounters with 149 tests, and 10 cases of COVID-19. Cases were strongly correlated with city-wide positivity-rate (R=0.9147, p=0.0039). All positive cases were asymptomatic and afebrile, and half (50%) visited a dentist within a week of consultation. Conclusions The rate of COVID-19 in a population seeking oral health care reflects the community positivity-rate. Asymptomatic or presymptomatic patients present risks to providers, staff, and other patients. Practical Implications Dentists should remain vigilant during the ongoing COVID-19, even with vaccination rollout. The CDC maintains an accessible website with easy access to your state’s positivity rate and case load.

In December 2019, a novel coronavirus was detected in China. 1 On January 8th, 2020 the Chinese Center for Disease Control and Prevention announced a novel coronavirus as the causative pathogen, spreading initially from the Huanan Seafood Wholesale Market in Wuhan, China. 1 On January 30th the World Health Organization (WHO) raised global concerns for the virus, 2 and later gave it the term Coronavirus disease 2019 . 3 The virus soon spread across the globe and by March 11th the WHO declared COVID-19 a global pandemic. 4 As of writing in January of 2021, the globe has now experience the first year of the COVID-19 pandemic, with a total of 100 million confirmed cases and over 2 million deaths. 5 By the time of this articles dissemination, these numbers will undoubtedly increase.

The transmission of COVID-19 is primarily person to person. 6 The virus can achieve high concentrations in respiratory fluid and saliva, and be released in aerosols and droplets -small and large particles -during coughing, sneezing, talking, as well as medical procedures. 7 In addition, COVID-19 may persist on inanimate surfaces for multiple days, although the efficiency of this transmission has a less important role. 7, 8 A significant difficulty that has emerged regarding the high rates of community spread, has been the presymptomatic and asymptomatic populations. 9 Pre-symptomatic and asymptomatic persons may have COVID-19 and spread it to other individuals without any knowledge, and studies estimate that the incubation period for COVID-19 is around 4.6-5.1 days. [10] [11] [12] Some studies have suggested that 50% of COVID-19 cases have been contracted from this population of asymptomatic or presymptomatic individuals. 13 J o u r n a l P r e -p r o o f Healthcare professionals have been a high risk population during the COVID-19 pandemic, with dental professionals affected during the initial spread of COVID-19 in China, Italy, and other areas across the globe. 14 Dental professionals regularly perform aerosol-generating dental procedures (AGDP), and these are a well recognized source for the transmission of infectious diseases. 15 In the US, the American Dental Association (ADA) and the Centers for Disease Control and Prevention (CDC) have created practice guidelines for dentists. 16, 17 A recent web-based survey of dental providers in the US found that 99.7% were utilizing enhanced infection protocols, including various patient screening questions, temperature checks, disinfection, physical barriers, and masks. 18 Approximately 16.6% of dentists in the US responded to the survey stating they have been tested for COVID-19, and an estimated 0.9% of dentists have had or currently have COVID-19 in the US. 18 This rate appears to be similar to the rate found in the Netherlands (0.9%) and China (1.1%). 19, 20 Nearly all dental care in the US is provided in a private practice setting, with few of these practices having the resources or ability to perform same day COVID-19 testing for patients or staff. As practices begin to increase production levels, concerns for patient-patient or patient-provider transmission are a growing and valid concern. 21 With national and global trends displaying an increasing number of cases during the Fall and Winter of 2020, the likelihood of transmission in the dental setting may increase, even as the nationwide vaccine program commences. 5

Oral surgery and hospital based dentistry has a unique position to aid the understanding of risk pertaining to COVID-19 risk in the dental practice setting. Patients who require emergency dental care often present to hospitals and emergency departments (ED) when unable to access care in alternative settings. Many hospital systems have the capabilities to perform routine, rapid COVID-19 testing for patients depending on the protocols and practices in place at each institution.

Oral health providers have little information on rates of positivity for COVID-19 in the patient population seeking dental care. We sought to identify the rate of COVID-19 positivity among the patients seeking oral health care, and compare this rate to the city-wide positivity-rate, tests performed and positive cases. We performed a retrospective review of all ED consults at our institution from June 2020 to December 2020 in order to determine the rate of COVID-19 in a population in need or oral healthcare.

To address the research purpose, the authors performed a retrospective cohort study. The study population was composed of all patients who presented to the University of Illinois Chicago (UIC) Emergency Department (ED) from June 1st, 2020 to December 31st, 2020. This project was granted IRB exemption by the University of Illinois Chicago Office for the Protection of Research Subjects (IRB Protocol #: 2020-1516).

Subjects were included if they met the following criteria: 1) Presented to the UIC ED between June 1st and December 31st of 2020; 2) A consult for the Oral and Maxillofacial Surgery (OMFS) service was ordered; 3) A consult order was completed by a member of UIC oral surgery service. Exclusion criteria included the following: 1) Consult request was placed for patient already admitted to hospital for over 24 hours.

Subjects were identified by two means. First, a consult log maintained by the UIC Department of Oral and Maxillofacial Surgery was reviewed. Second, a chart query was performed through the electronic medical record system at the hospital for all notes with the title "consult", or orders with the word "consult". These results were combined, and duplicate encounters were removed. All subsequent charts underwent hand review for data extraction.

Demographics (age, sex) were taken from the encounter file at time of consult. Authors determined the reason for consultation (infection, trauma, or other) from review of notes and associated procedure codes. Infections included any abscesses of a fascial space including vestibular abscess. Trauma included all dentoalveolar trauma, as well as fractures of the mandible, maxilla, orbit, or zygomaticomaxillary complex. The remaining maladies were grouped as other. A recent encounter with a community dentist was defined as within 7 days from the time of consultation at UIC, and had to be clearly identified in the note details. Any discrepancy was discussed and resolved by an additional faculty surgeon.

COVID-19 testing was included if the lab order was performed within 24 hours from the time of presentation to the ED. Over the course of 12 months, multiple modalities were utilized at our institution to determine presence of COVID-19 infection. The authors included all means of molecular testing. In brief, this included various nucleic acid amplification test (NAAT), polymerase chain reaction (PCR), and antigen testing on samples from either nasopharyngeal swabs, saliva or blood.

All testing results were reported as "Detected" or "Not detected" and considered positive or negative respectively. Descriptive statistics (mean, frequency, and range) were computed for each study variable. Statistical analysis to measure the association between variables of interest was performed with the Pearson correlation coefficient with a significance level of p < .05.

Review of surgical logs and the EMR identified 203 consults that met inclusion criteria (Table 1) . Most subjects presented with infections (62.1%), followed by trauma (19.2%), and 18.7% with other maladies. One-hundred and forty-nine patients were tested for COVID (73.3%), and 10 positive test results were identified (6.7%). Of our 203 consults, 72 records (35.5%) included a clear description of a recent dental visit, and 76.4% of these cases (55 total) presented to the ED for infectious etiology. Other common presentations included bleeding, temporomandibular joint pain, sialadenitis and oral lesions. Table 2 displays the consults by month from June to December 2020 (Figure 1) . Table 3 compares our results to the Chicago City-Wide COVID-19 cases and positivity rate. The Pearson correlation between the COVID-19 cases at UIC was significantly correlated with the city-wide positivity rate (R=0.9147, p=0.0039) and total tests performed (R=0.8098, p=0.0273), and strongly correlated with total cases (R=0.7450) but not significantly (p=0.0547).

We provide the details for each COVID-19 case at UIC (Table 4 ). Upon review, all 10 subjects who presented to the ED were asymptomatic for COVID-19 symptoms. No subjects reported any positive responses to the ED Covid-19 Screening Exam (constitutional symptoms, recent travel/contacts, etc) and all ten subjects were afebrile. Five of the 10 subjects (50%) reported visiting a dental office within 7 days of their presentation to the ED, with two additional subjects stating they had a future dental appointment within 4 weeks to address their complaints.

This study provides an initial assessment of the risk of COVID-19 infection among a population seeking oral health care. Our results show the risk of COVID-19 infection in a population seeking oral health care reflects that current positivity rate in the geographic area of the practice (ie. city, county, state).

Understanding the risk of infection and the mitigation of that risk, is critical to the delivery of oral health care. Oral health providers must exercise caution as we progress into the future stages of this global pandemic, and ensure lessons are cultured for the future. Ninety percent of these COVID-19 cases we detected occurred from October to December 2020, when the average positivity rate in Chicago was over 10%, and the city-wide number of cases ranged from 26,347 to 57,457. Prior to this period, from June to September 2020, cases ranged from 6,311 to 9,980 with a positivity rate of 4.1-5.1%, and during this time we detected only one case of COVID-19.

We know of one recent article that looked at COVID-19 infections in an asymptomatic population of children seeking dental care. 22 Lamberghini et al. also performed their study at the University of Illinois Chicago. Lamberghini found a positivity rate of 2.3% among 921 children who were tested from May 2020 to August 2020, when the average city-wide positivity-rate was 5.1% in Chicago. 23 Our study focused on COVID-19 cases in the months following this study, when a significant rise in positivity rate happened to occur in Chicago. The positivity rate in our cohort was 6.7%, and this reflects this rise in cases during the Fall and Winter of 2020 in Chicago. These findings further emphasize the relationship between the positivity rate in the community, and the positivity rate in patients seeking oral care.

Estrich found 91.1% of dentists reported providing emergency oral health care during the COVID-19 pandemic. 18 Of our own ED cohort, at least 1/3rd had recently been to a dentist. We expect this actual rate is much higher, as we were reliant on retrospective chart review of provider notes. We did find that among the 10 cases of COVID-19 at UIC, half had seen a dentist within a week, and two others stated they had a future appointment within the next month. Many other notes during this review detailed the difficulties patients had with accessing dental care during the pandemic due to closures or long waits. Regardless, this data shows a shared population moving throughout the community for oral health care.

With the rollout of a nationwide vaccine program, oral health providers, like all Americans, have incredible hope for the end of this pandemic. However, it is clear from observation of other countries that a second and third wave of the virus, and the development of viral variants with possible resistance, is possible and precautions should remain high. Some studies suggest that resurgence of COVID-19 could extend into 2024. 6 Oral health providers can also correlate lessons from this pandemic, with not only future pandemics, but for the prevention and mitigation of seasonal pathogens as well. When community spread is high, risk to oral health providers, staff and patients is also high.

Perhaps the most significant finding of our study, was that all ten COVID-19 cases were asymptomatic when they presented to the ED. These subjects likely included pre-symptomatic cases, as well as asymptomatic cases. Presymptomatic transmission may account for 44% of COVID-19 transmission, and studies have shown infectiousness peaks around 2 days prior to symptom onset. 13 All 10 of our cases were afebrile as well, and reported no recent contact on screening questionnaires, displaying the importance of universal precautions even with other appropriate measure in place. Recent studies have supported this finding, with approximately 70-76% of COVID-19 positive patients presenting afebrile (<38C). 24,25 A more specific clinical finding may be anosmia, or the loss of a persons sense of smell. 26 Dentists should also be aware that although many practices are now open or beginning to do so, many are actually seeing fewer patients. The CDC guidelines in March 2020 to postpone elective procedures led to the closure of many practices. Starting in May 2020 to August 2020 more practices opened and increased patient volumes. 21 However, around November 2020, dentists actually saw a smaller and smaller patient volume. perhaps in response to the increased spread of COVID-19 in the Fall and Winter of 2020. 21 The economic burden of this pandemic is shared.

Although rates of infection among dentists may be low, certainly all practices have had to cope with patients or staff reporting a recent illness or a positive COVID-19 test. Dealing with these unknown risks to themself, staff and other patients can be frustrating. Our data displays that the risk of encountering a patient with COVID-19 is high when community spread is high, and risk is low when community spread is low.

Oral health providers should be aware of the current COVID-19 status of their geographic area. The Centers for Disease Control and Prevention (CDC) maintains an up to date map of each state and county in the US, which provides the number of cases and number of deaths, as well as a 7 day average rate. 27 Links to each state's public health department are also provided for further resources.

The primary limitation of this study is bias from our study population. The demographics and socioeconomic status at a state-hospital are not identical to private dental practice. Our cohort was limited to ED visits, and included diagnosis that may be beyond the practice of most general dentists. Even with the inclusion of 7 months of data and over 200 patient encounters, only 10 cases of COVID-19 were located.

Dentists should maintain an up to date knowledge of the current disease prevalence in their community. Our study demonstrates that patients in need of dental care will have a rate of infection that reflects the geographic region at that time. J o u r n a l P r e -p r o o f 

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cases (grey) and positivity rate (blue) in the City of Chicago from June to December compared to the number of positive cases at UIC over the same period of time