A commentary on

Lamberghini F, Trifan G, Testai F D.

Severe acute respiratory syndrome coronavirus 2 infection in asymptomatic paediatric dental patients. J Am Dent Assoc 2021; 152: 277-283.

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GRADE rating

Commentary

Evidence suggests COVID-19 symptoms in children are usually mild or asymptomatic,1 and therefore, screening questionnaires alone may be unable to identify patients infected with SARS-CoV-2. Asymptomatic and mildly symptomatic SARS-CoV-2-positive patients are an important consideration for virus transmission.2 The dental profession must take appropriate measures to reduce the risk of disease spread during the COVID-19 pandemic.3

This novel cross-sectional study assesses the prevalence of SARS-CoV-2 in asymptomatic paediatric dental patients attending a clinic in Chicago using RT-PCR tests. There is little published evidence in this field. A recent study from Scotland assessed test results from asymptomatic dental patients but this included patients >5 years old and did not solely focus on the paediatric population.4

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© Stefan Cristian Cioata/Moment/Getty Images Plus

Selecting patients due to receive routine treatment involving an aerosol generating procedure or comprehensive treatment under general anaesthetic is highly relevant due to the potential for SARS-CoV-2 transmission. No symptomatic patients were included, although it may have been valuable to know how many patients were excluded following the screening questionnaire.

The authors discuss the limitations of the study, including the findings not being generalisable to the national population. Further studies with larger sample sizes matching the census would be beneficial. It was suggested that salivary tests may be better tolerated, but it is not stated whether any patients were pre-cooperative or unwilling to have the nasopharyngeal swabs taken. It may have been useful to report if all tests processed by the laboratory produced a valid result. Also, while the RT-PCR test has a high specificity for detecting SARS-CoV-2, the possibility of false-negative results cannot be ruled out.5

A higher number of male than female patients had a positive test result, which the authors acknowledged was not statistically significant. An exploratory analysis pooling their findings with two other studies6,7 testing children in healthcare settings suggested male patients had a 1.97% increased risk (95% CI 1.08-3.62) of being positive for SARS-CoV-2 compared to female patients. However, the data used from both additional studies appears to include patients who displayed symptoms before receiving an RT-PCR test.

Population-based measures to control the spread of COVID-19 differ between countries. This study discusses costs, availability of laboratories and patient tolerance as factors to be considered for introducing SARS-CoV-2 testing to dental settings. It is unknown whether positive test results were clustered at a specific time or if they were spread across the timeframe. Information was not provided on whether patients with positive test results were known to each other or from neighbourhoods with high levels of COVID-19.

In summary, the authors have provided insight into a strategy for identifying asymptomatic paediatric dental patients carrying SARS-CoV-2. More research is required to allow these findings to be generalised to different populations before being implemented on a wider scale. Although this study raises several questions, it is important to acknowledge that such research is often conducted rapidly to provide new evidence which may help protect healthcare workers and patients.