NOTES:

Weyant. (2019, January 1). Evidence-Based Dentistry: The Foundation for Modern Dental

Practice. Https://Www.Clinicalkey.Com/#!/Search/Journal%2520of%2520Evidence-

Based%2520Dental%2520Practice. https://www.clinicalkey.com/#!/content/journal/1-

s2.0-S0011853218300788?scrollTo=%23top

Dentistry, as with all branches of medicine, maintains a social contract mandating a

professional obligation to adhere to the highest professional standards, ensuring as first
principles, that practitioners’ decisions and actions are aimed at the well-being and
safety of their patients. Meeting this obligation rests in part on ensuring that the
decisions about what care is delivered is informed by a thorough understanding of the
current best evidence on which approaches to care will provide the best opportunity to
realize patient treatment goals.
Unfortunately, it is well documented that there is a substantial gap between what is
known about effective health care and what is delivered routinely to patients. The
Institute of Medicine characterizes this as the “Know-Do Gap,” with the size of that gap
reflected in the time lag that occurs between when new evidence on effective treatments
becomes available and when that evidence is fully adopted into routine clinical practice. 1

Unfortunately, this time lag between discovery and adoption of beneficial, evidence-
based improvements in patient care often takes years. Why this is so is determined by a
complex interaction of factors. These factors include the effectiveness of the
dissemination of new evidence, how that evidence is perceived by the dental
professional, and the clinical practice environment in which that evidence must be
implemented. Evidence dissemination is rapidly improving, as the availability of full
text online resources expand. The widespread development of clinical practice
guidelines is an important addition to this process and provides an efficient means for
translating scientific evidence into clinical practice. The value of clinical guidelines in
providing an evidence base for much routine clinical care is emphasized in many of the
articles in this issue.

Clinical practice can be characterized as uncertain, ambiguous, and constantly changing,

consisting of ill-structured problems requiring practical reasoning or professional
discretion. 2 However, the best patient outcomes tend to occur when professional
discretion is informed by high-quality evidence and not by the dentist’s personal
preferences, habitual routines, or opinion-driven decisions based on traditional
practices. 2 Bringing evidence-based changes into clinical practice is dependent on
motivated and well-trained dental professionals who are willing to adopt new
approaches to practice and who are operating in an environment that supports
(administratively, financially, and technologically) the ability to make those changes.
Understanding how to shape the clinical environment to make it receptive to change is
the domain of implementation science. The article by Frantsve-Hawley and Rindal
provide an overview of the most important issues that must be attended to in this
regard. The article by Gillette and Balevi provides details on what is required to
construct an evidence-based dental practice. Both articles emphasize the importance of
clinical practice guidelines as an efficient means of translating new evidence into routine
clinical practice.

At a minimum, effective evidence-based practice (EBP) requires dental professionals to

commit to gaining the skills required to find and apply the best available evidence. This
requires training in the five-step approach developed by Sackette and Guyette,
developed in the 1990s. 3 Their approach is what we now call EBP and is the foundation
of the EBP curricula now offered in all health professional schools in the United States.
The article by Weyant provides an overview of what is known about effective teaching of
EBP and is aimed at guiding EBP trainers in course design as well as dentists who may
be selecting an EBP training program.

The overall goal of this issue of the Dental Clinics of North America is to provide
examples of effective use of evidence and to provide strategies for dentists who wish to
increase their use of evidence in routine practice.

COVID-19: The Global Coronavirus Pandemic. (2020, October 28).

Https://Www.Accessmedicinenetwork.Com/Posts/62224-Covid-19-the-Global-

Coronavirus-Pandemic?Channel_id=2610-Accessmedicine-Covid-19-Central.

https://www.accessmedicinenetwork.com/posts/62224-covid-19-the-global-coronavirus-

pandemic?channel_id=2610-accessmedicine-covid-19-central

The Centers for Disease Control and Prevention (CDC) and World Health
Organization (WHO) have identified an outbreak of respiratory illnesses
caused by a novel coronavirus originating in Wuhan, China. The WHO
Director-General announced at a media briefing that the COVID-19 outbreak
has been classified as a pandemic. This post is being updated as of October
28, 2020. As of October 28, 2020 there are a total of 44,081,789 global cases
with 1,168,824 mortalities. A total of 8,871,354 cases have been reported in
the United States, which surpasses the total number of cases reported
anywhere else in the world. There have been a total of 226,752 deaths in the
United States. In India, there have been 7,990,322 cases with with an
associated 120,020 mortalities. In Brazil, there have been a total of 5,439,641
cases with an associated 157,946 mortalities. In Russia, there have been
1,553,028 cases with an associated 24,752 mortalities. The Johns Hopkins
map reports updated data on the current case count around the world.
Coronaviruses comprise a large family of viruses and are a frequent cause of
the common cold. Some cause less-severe disease, but more rarely, can
cause severe disease as seen with the 2002 severe acute respiratory
syndrome (SARS) and 2012 Middle East respiratory syndrome (MERS)
outbreaks. The 2002 SARS epidemic, which originated in China, caused
8,300 illnesses and 785 mortalities. A total of 1,879 cases of MERS have
been reported with a 39% mortality rate.

The mode of transmission of COVID-19 is by respiratory aerosol and is

spread from person-to-person. However, all coronaviruses do not spread from
person-to-person. For example, the primary mode of transmission of MERS
was camel-to-human transmission, with the rates of human-to-human
transmission being very low. Initially, the likelihood of human-to-human
transmission of COVID-19 was thought to be very low. The outbreak has a
possible zoonotic origin, as it has been linked to a large seafood and animal
market. However, medical workers caring for patients in Wuhan city have
become infected with the virus suggesting human-to-human transmission.  

The signs and symptoms associated with COVID-19 are variable and can
mimic many other illnesses. According to the CDC,  the following signs and
symptoms are associated with COVID-19 at time of illness onset: fever,
constant or intermittent (77–98%), cough (46%–82%), myalgia or fatigue (11–
52%), and shortness of breath (3-31%). The CDC also noted that while fever
was present in only 44% of patients at the time of hospital admission, 89% of
patients became febrile during their admission. Other possible symptoms
include sore throat, headache, productive cough, nausea, and diarrhea.

The CDC and WHO have been working tirelessly to quickly develop and
implement testing for COVID-19. The CDC developed an rRT-PCR test for
rapid diagnosis. As of May 11, a total of 97 laboratories in the United States
are offering testing. On June 13, the CDC updated its criteria to guide
evaluation of persons under investigation for COVID-19.  On March 27, the
FDA granted emergency authorization for laboratories to being using a new
rapid COVID-19 test produced by Abbott Diagnostics that could provide
results in less than 15 minutes. Details regarding timing of production and
distribution are expected to be forthcoming.

Please visit this post for more detailed information on laboratory testing. In

addition to the PCR test, the CDC notes other common laboratory
abnormalities found in patients with COVID-19. These include: leukopenia (9–
25%), leukocytosis (24–30%), lymphopenia (63%), elevated alanine
aminotransferase and aspartate aminotransferase levels (37%),
thrombocytopenia (36%), and leukopenia (34%).

For all new and updating information concerning the COVID-19 global
pandemic, refer to the AccessMedicine COVID-19 Central channel (and
"watch" the channel to receive alerts when new and updating information
arrives).

COVID-19 - Laboratory Testing in the United States. (2020, October 28). McGraw-Hill

Education. https://www.accessmedicinenetwork.com/posts/62127-covid-19-laboratory-

testing-in-the-us

Viral (nucleic acid or antigen) tests are used to diagnosed COVID-19 by testing

respiratory samples for SARS-CoV-2.  Available tests range from point-of-care tests
(taking less than 1-hour) to taking 1-2 days to result. Antibody testing is also available,
but this is not used to diagnose acute COVID-19 infection. Only viral tests are used to
diagnose acute infection.  The role of serologic testing is currently under exploration.  It
is not clear, at this time, if a positive serologic test confers immunity, so this should not
be assumed.  

Guidelines for collection and handling of laboratory specimens can be found here.

The following information outlining testing guidelines was pulled obtained from the
CDC's website for accuracy and can be found here.

The CDC describes five categories of people for SARS-CoV-2 testing with viral

tests (i.e., nucleic acid or antigen tests):
  Testing individuals with signs or symptoms consistent with COVID-19
 Testing asymptomatic individuals with recent known or suspected exposure to SARS-
CoV-2 to control transmission
 Testing asymptomatic individuals without known or suspected exposure to SARS-CoV-2
for early identification in special settings
 Testing to determine resolution of infection (i.e., test-based strategy for Discontinuation
of Transmission-based Precautions, HCP Return to Work, and Discontinuation of Home
Isolation)
 Public health surveillance for SARS-CoV-2

Generally, viral testing for SARS-CoV-2 is considered to be diagnostic when conducted

among individuals with symptoms consistent with COVID-19 or among asymptomatic
individuals with known or suspected recent exposure to SARS-CoV-2 to control
transmission, or to determine resolution of infection. Testing is considered to be
surveillance when conducted among asymptomatic individuals without known or
suspected exposure to SARS-CoV-2 for early identification, or to detect transmission
hot spots or characterize disease trends.

Recommended testing for individuals with signs or symptoms

consistent with COVID-19

CDC recommends using authorized nucleic acid or antigen detection assays that have

received an FDA EUA to test persons with symptoms when there is a concern of
potential COVID-19. Tests should be used in accordance with the authorized labeling;
providers should be familiar with the tests’ performance characteristics and limitations.

Clinicians should use their judgment to determine if a patient has signs

or symptoms compatible with COVID-19 and whether the patient should be tested. Most
patients with confirmed COVID-19 have developed fever and/or symptoms of acute
respiratory illness (e.g., cough) but some infected patients may present with other
symptoms as well. Clinicians are encouraged to consider testing for other causes of
respiratory illness, for example influenza, in addition to testing for SARS-CoV-2
depending on patient age, season, or clinical setting; detection of one respiratory
pathogen (e.g., influenza) does not exclude the potential for co-infection with SARS-
CoV-2. Because symptoms and presentations may be different in children, consider
referencing the CDC guidelines for COVID in neonates and for multisystem
inflammatory syndrome in children (MIS-C).

The severity of symptomatic illness due to infection with SARS-CoV-2 may vary. Among
persons with extensive and close contact to vulnerable populations (e.g., healthcare
personnel [HCP]), even mild signs and symptoms (e.g., sore throat) of possible COVID-
19 should prompt consideration for testing. Additional information is available in
CDC’s Interim U.S. Guidance for Risk Assessment and Public Health Management of
Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with
Coronavirus Disease 2019 (COVID-19).
Recommended testing for asymptomatic individuals with known or
suspected exposure to SARS-CoV-2 to control transmission

Testing is recommended for all close contacts of persons with SARS-CoV-2 infection,

especially initial testing during an outbreak or pandemic due to the high likelihood of
exposure. Because of the potential for asymptomatic and pre-symptomatic
transmission, it is important that contacts of individuals with SARS-CoV-2 infection be
quickly identified and tested.

 In areas where testing is limited, CDC has established a testing hierarchy; refer to
the Interim Guidance on Developing a COVID-19 Case Investigation and Contact
Tracing Plan for more information.
 CDC specifically recommends testing for all neonates born to women with COVID-19,
regardless of whether there are signs of infection in the neonate.

In some settings, broader testing, beyond close contacts, is recommended as a part of

a strategy to control transmission of SARS-CoV-2.  This includes high-risk settings that
have potential for rapid and widespread dissemination of SARS-CoV-2 (e.g., meat
processing plant) or in which populations at risk for severe disease (e.g., long-term care
facilities, including nursing homes, intermediate care facilities for individuals with
intellectual disabilities, and psychiatric residential treatment facilities) could become
exposed.  Expanded testing might include testing of all contacts in proximity to someone
with SARS-CoV-2 infection, or even testing all individuals within a shared setting (e.g.,
facility-wide testing). Currently CDC recommends expanded contact testing in the
following guidance documents:

 Testing guidance for nursing homes.

 Following identification of SARS-CoV-2 infection in a worker in a high-density critical
infrastructure workplace

Recommended testing for asymptomatic individuals without known or

suspected SARS-CoV-2 exposure for early identification in special
settings

Certain settings can experience rapid spread of SARS-CoV-2, resulting in substantial

adverse effects. This is particularly true for settings that house vulnerable populations in
close quarters for extended periods of time (e.g., long-term care facilities, correctional
and detention facilities) and/or settings where critical infrastructure workers (e.g.,
healthcare personnel, first responders) may be disproportionately affected.

A strategy aimed at reducing introduction of SARS-CoV-2 into the setting through early
identification could reduce the risk of widespread transmission in these situations.

Facilities are encouraged to work with local, territorial, and state health departments to
help inform decision-making about broad-based testing. Before testing large numbers of
asymptomatic individuals without known or suspected exposure, the facility should have
a plan in place for how it will modify operations based on test results.

Approaches for early identification of asymptomatic individuals include:

 Initial testing of everyone residing and/or working in the setting,

 Regular (e.g., weekly) testing of everyone residing and/or working in the setting, and
 Testing of new entrants into the setting and/or those re-entering after a prolonged
absence (e.g., one or more days)

Settings for which these approaches could be considered include:

 Long-term care facilities

 Correctional and detention facilities
 Homeless shelters
 Other congregate work or living settings including mass care, temporary shelters,
assisted living facilities, and group homes for individuals with intellectual disabilities and
developmental disabilities
 High-density critical infrastructure workplaces where continuity of operations is a high
priority

CDC guidance currently addressing such testing includes:

 Pre-admission or pre-procedure testing as part of the evaluation of patients could be

considered to inform decisions about deferring elective care (e.g.,
certain dental procedures) or procedures and the use of personal protective equipment.
 Testing guidance for nursing homes
 Procedure for broad-based testing

Julie Grishaw, ACNP

Senior Editor, McGraw-Hill Education

COVID-19 - Laboratory Testing in the United States. (2020, October 28). McGraw-Hill

Education. https://www.accessmedicinenetwork.com/posts/62127-covid-19-laboratory-

testing-in-the-us

1) How did COVID-19 begin?

According to the World Health Organization, on 31 December 2019, the WHO China
Country Office was informed of cases of pneumonia of unknown etiology (unknown
cause) in Wuhan City, Hubei Province of China. On January 7, 2020, this virus was
identified as a novel type of coronavirus. On January 11 and 12 2020, the WHO
received information that the outbreak may have been associated with exposures to a
seafood market in Wuhan City, China. This led to the initial hypothesis that the spread
was animal-to-human. However, it was later discovered that person-to-person spread
was occurring. It is now known that the mode of transmission of COVID-19 is by
respiratory aerosol and is spread from person-to-person.

2) What is the incubation period for COVID-19?

According to the CDC, the median incubation for COVID-19 is 4-5 days, but may extend
up to 14 days.  

3) What are risk factors for severe illness associated with COVID-19?

Data reported from the CDC indicates the elderly (adults >65) are at a higher risk of
developing severe complications due to COVID-19. They also report that the elderly are
at higher risk of death due to these complications. Individuals of any age with underlying
comorbid conditions such as heart disease, lung disease, cancer, liver disease, kidney
disease, diabetes, those with a BMI >30 and those with immunocompromised states are
at higher risk to develop serious illness. Those with asthma, HIV, and those who
are pregnant are also considered potential high groups. 

Regarding pregnancy, the CDC states now states that pregnant individual may be at

greater risk severe illness associated with COVID-19. Mortality rates do not differ from
that associated with the general population.

Please see here for more information on COVID-19 and pregnancy.

Specifically regarding the elderly, the CDC urges this population to exercise increased

caution as this age group is particularly vulnerable to COVID-19 related illness and has
an increased risk of hospitalization and subsequent mortality. The CDC reports that 8
out of 10 COVID-19 hospitalizations have occurred in individuals 65 years and older.
Out of all COVID-19 cases reported in the US that required hospitalization 31-59% were
adults age 65-84 and 31-70% were adults 85 years old and older. Of those that required
admission to an ICU, 11-31% were 65-84 years old and 6-29% were 85 years old and
older. Of those who died 4-11% were 65-84 years old and 10-27% were 85 years old
and older.  

4) What are signs and symptoms of COVID-19 in adults?

The signs and symptoms associated with COVID-19 are variable and can mimic many
other illnesses. According to the CDC, the following signs and symptoms are associated
with COVID-19 at time of illness onset: fever, constant or intermittent (83-99%), cough
(59%–82%), fatigue (44-70%), anorexia (48-80%), shortness of breath (31-40%),
sputum production (28-33%), myalgias (11-35%), and/or new lost of taste or smell. The
CDC also noted that while fever was present in only 44% of patients at the time of
hospital admission, 89% of patients became febrile during their admission. Other
possible symptoms include sore throat, headache, productive cough, nausea, and
diarrhea, but these occurred in <10% of patients.

5) Are children at increased risk of developing COVD-19?

According to the CDC, otherwise healthy children do not appear to have a higher than
average risk of contracting COVID-19 as compared to adults, nor do they manifest a
greater severity of illness based on available data. Children have actually shown to be
at a lower risk for severe illness than adults. In the United States, <2% of all COVID
cases have occurred in those <18 years of ago. According to data provided by the CDC,
among children in China, illness severity was lower in COVID positive children with 94%
having asymptomatic disease, mild or moderate disease, only 5% having severe
disease, and <1% having critical disease. A very small percentage of children have
developed multisystem inflammatory syndrome in children (MIS-C) associated with
COVID-19.

Please see here for more information on COVID-19 and children.

6) What are treatments for COVID-19?

Treatments for COVID are discussed in full here.

7) What is the mortality rate of COVID-19?

Age and underlying medical conditions are key in predicting outcomes of patients with
COVID-19. The overall case fatality rate has been reported as 2.3%. The case fatality
rate for those requiring ICU admission is 39-72%. As per data provided by the CDC,
among U.S. COVID-19 cases with a known disposition, the proportion of persons who
were hospitalized was 19%. The proportion admitted to the intensive care unit (ICU)
was 6%. The elderly are at greatest risk of dying from COVID-19. Early data from the
US as reported by the CDC indicates the case fatality is highest in persons aged ≥85
years (10%–27%), followed by 3%–11% for ages 65–84 years, 1%–3% for ages 55–64
years, and <1% for ages 0–54 years.

8) Can patients become reinfected with COVID-19? 

The CDC reports that confirmed and suspected cases of COVID-19 reinfection have

been reported, but remain rare. Studies are ongoing to determine factors such as
likelihood of reinfection and severity of illness following reinfection.

9) Can my pet contract COVID-19?

The CDC reports there have been a small number of cases of domestic and zoo animal
infections with COVID-19 in the United States. Most cases have been human-to-animal
spread. The risk of animal-to-human spread is considered to be low. Current
recommendations from the CDC indicate that individuals infected with COVID-19 on
home isolation should restrict interaction with household pets, in addition to
following other prevention measures just as they would to protect other household
members from COVID-19. Specifically, while a person with COVID-19 is symptomatic,
they should maintain separation from household animals. If possible, a household
member should be designated to care for the pets. If a person with COVID-19 must care
for pets or other animals, they should ensure they wash their hands before and after
caring for them. In accordance with the Americans with Disabilities Act service animals
should be permitted to remain with their handlers. Guidance for testing in animals can
be found HERE.

10) What are the differences between a surgical mask and an N95 mask?

Please see this infographic from the CDC to understand the differences.

11) Should individuals wear a mask when going out in public to prevent
contracting COVID-19?

At this time, the CDC is recommending cloth face coverings when less than 6-feet apart
from other people or indoors.  This is to help slow the spread of the virus and help
asymptomatic individuals from transmitting it to others. The CDC recommends that N95
masks be reserved for healthcare providers, used under the current CDC guidelines. 

12) What are restrictions for critical workers exposed to individuals with COVID-
19?

CDC guidelines were updated September 11, 2020 stating that critical infrastructure
workers may be permitted to continue work following potential exposure to COVID-19,
provided they remain asymptomatic and additional precautions are implemented to
protect them and the community. The full CDC statement along with the additional
recommended precautions, including pre-shift temperature screening, can be
viewed HERE.

13) What are the rates of asymptomatic COVID-19 infection and how does that
impact transmission?

According to the CDC, the rates of asymptomatic COVID-19 infection are not fully
known since routine testing does not occur in asymptomatic individuals. One study
found that as many as 13% of positive children were asymptomatic. Another study
reported by the CDC reported that as many as half of COVID-19 positive skilled nursing
facility residents were asymptomatic or pre-symptomatic at the time of testing. The
exact degree of virologic shedding that confers transmission of COVID-19 is not yet
known. Therefore, the risk of transmission during asymptomatic infection is also not
known. The risk of infection is thought to be greatest during times when patients are
symptomatic and viral loads are highest.

Julie Grishaw, ACNP

Senior Editor, McGraw-Hill Education

Guidance for Dental Settings. (2020, August 28). Center for Disease Control and Prevention.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html