Practice, test and trace
Dental settings are a valuable location for public health monitoring, a new study has shown
“It is very exciting for dentistry to be part of a general public health initiative and could perhaps pave the way for us to be involved in surveillance of other diseases and infections in the future,” says Callum Wemyss, a specialty registrar in oral surgery and honorary clinical teacher at Glasgow Dental Hospital and School.
“Dentists have also had a significant role in the vaccine programme by becoming peer vaccinators. I think, at times during the pandemic, dentists have felt forgotten about by policy makers. The involvement of dentists in both the surveillance programme and vaccine program are just two examples highlighting the importance of dentists in healthcare.”
Callum was reflecting on his participation in a COVID-19 surveillance programme conducted in hospital and public dental services, and a small number of general dental practices, between August and October last year. The programme was the subject of a study published in January1. It aimed to investigate SARS-CoV-2 infection in dental patients in order to “inform community surveillance and improve understanding of risks in the dental setting”.
It has proved that routine dental visits are a suitable, and patient-convenient, touchpoint for this type of intervention
The study outlines how 31 dental care centres across Scotland invited asymptomatic screened patients over five years-old to participate. Following verbal consent and completion of sociodemographic and symptom history questionnaire, trained dental teams took a combined oropharyngeal and nasal swab sample using standardised VTM-containing test kits. Samples were processed by the Lighthouse Lab and patients informed of their results by SMS/e-mail with appropriate self-isolation guidance in the event of a positive test.
Over a 13-week period just over 4,000 patients, largely representative of the population, were tested. Of these, 22 tested positive for SARS-CoV-2. The positivity rate increased over the period, commensurate with uptick in community prevalence identified across all national testing monitoring data streams. All positive cases were successfully followed up by the national contact tracing program. “To the best of our knowledge this is the first report of a COVID-19 testing survey in asymptomatic-screened patients presenting in a dental setting,” said the authors.
“The positivity rate in this patient group reflects the underlying prevalence in community at the time. These data are a salient reminder, particularly when community infection levels are rising, of the importance of appropriate ongoing infection prevention control and PPE [personal protection equipment] vigilance, which is relevant as healthcare team fatigue increases as the pandemic continues. Dental settings are a valuable location for public health surveillance.”
David Conway, Professor of Dental Public Health at the University of Glasgow’s Dental School, and one of the study’s authors, noted: “This is part of the Public Health Scotland COVID-19 enhanced community surveillance programme in dental settings which is informing understanding of and response to COVID-19. The findings have important implications for dental teams to remain vigilant with regard to enhanced PPE and IPC guidelines – and this is particularly important as teams fatigue, as the pandemic continues.”
For the dental teams taking part, it was an opportunity to explore the suitability and value of dental settings in wider healthcare applications. Callum graduated from the University of Glasgow in 2015 and completed his vocational training at Coia & Associates in Partick. He spent four years core training in various specialities and hospitals across Scotland, concluding with a year working at Dumfries and Galloway Royal Infirmary, before starting his specialty training last September. It was there that was asked by his clinical lead if he would like to be responsible for the project within his department.
“At the time, I was also starting an MSc in Patient Safety and Clinical Human Factors and I thought this would link in well, especially since it involved implementing a new system,” said Callum. “This quickly led to me submitting a proposal for a hospital-wide quality improvement project with the aim of increasing the number of swabs carried out. I and a team of other dentists at Glasgow Dental Hospital met on a weekly to discuss progress and plan what we could do to drive change.”
But it quickly became clear that there were a number of barriers to implementing such a project within a dental setting, especially a large secondary care centre., said Callum. “Initially, very few tests were being carried out within the hospital,” he said. “Surveillance was something we, as dentists, were not too familiar with. Clinicians are often very focussed on the clinical task at hand and we found at the start that many would forget to invite their patients to participate. Interestingly, we did find that the majority of patients were very happy to be part of this project when invited. Some would even offer themselves to be re-tested if they were back for another appointment
“It was tough to begin with – however, after several weeks we managed to significantly increase the number of swabs being carried out through staff engagement and training. We spent a considerable amount of time investigating the perceived barriers in implementing and taking part in a surveillance project. This included distributing questionnaires to both dentists and nurses in the dental hospital. We are currently writing up a report on this and we hope to submit this for publication in the near future. I especially enjoyed watching the teamwork displayed from our dental core trainees who took on a significant role in testing patients.”
Callum was clear about the overall benefits of the programme: “[It] will provide a plethora of information about the role of asymptomatic carriers in the transmission of the virus. It will also help to inform the profession of the risks posed by treating asymptomatic patients.”
Among the general dental practices that took part were some of those owned by the Clyde Munro group. Jacqui Frederick, the group’s clinical director, was in discussion with Orkney Health Board and the national swabbing team: “It emerged that our practice distribution could allow for quick involvement in some other health board areas and the Clyde Munro senior management team were very supportive of our practices assisting where possible.”
The limits on personnel interacting made initial co-ordination of the programme across practices a challenge, but the appointment of Mary Smith, Senior Clinical Support at Clyde Munro, who has experience of multi-site projects, to lead the group’s involvement allowed for implementation across health board areas. “We had a very positive response from our dentists, and it was very much welcomed by our patients.” Jacqui added: “As the virus and science evolves, processes will as well. I am not sure where population swabbing will sit in this, [but] it has proved that routine dental visits are a suitable, and patient-convenient, touchpoint for this type of intervention.”
1 SARS-CoV-2 positivity in asymptomatic-screened dental patients
DI Conway, S Culshaw, M Edwards, C Clark, C Watling, C Robertson, R Braid, E O’Keefe, N McGoldrick, J Burns, S Provan, H VanSteenhouse, J Hay, R Gunson, Dental COVID-19 Surveillance Survey Group
medRxiv 2020.12.30.20248603; doi: https://doi.org/10.1101/2020.12.30.20248603