Investigation

The incidence of COVID-19 among dentists

practicing in the community in Canada
A prospective cohort study over a 6-month period
Sreenath Madathil, PhD; Walter L. Siqueira, PhD; Lina M. Marin, PhD;
Farisa Banu Sanaulla, PhD; Nancy Faraj, MSc; Carlos R. Quiñonez, PhD; Mary McNally, MSc;
Michael Glogauer, PhD; Paul Allison, PhD

ABSTRACT

Background. Oral health care settings carry a potentially high risk of causing cross-infection
between dentists and patients and among dental staff members due to close contact and use of
aerosol-generating procedures. The authors aimed to estimate COVID-19 incidence rates among
Canadian dentists over a 6-month period.
Methods. The authors conducted a prospective cohort study of 644 licensed dentists across
Canada from July 29, 2020, through February 12, 2021. An online questionnaire, adapted from the
World Health Organization’s Unity Studies protocols for assessment of COVID-19 risk among
health care workers, was used to collect data on self-reported severe acute respiratory syndrome
coronavirus 2 infections every 4 weeks. A bayesian Poisson model was used to estimate the inci-
dence rate and corresponding 95% credible intervals (CIs).
Results. Median age of participants was 47 years; most participants were women (56.4%) and
general practitioners (90.8%). Median follow-up time was 188 days. Six participants reported
COVID-19 infections during the study period, giving an incidence rate of 5.10 per 100,000 person-
days (95% CI, 1.86 to 9.91 per 100,000 person-days). The incidence proportion was estimated to be
1,084 per 100,000 dentists (95% CI, 438 to 2,011 per 100,000 dentists) and 1,864 per 100,000
people (95% CI, 1,859 to 1,868 per 100,000 people) in the Canadian population during the same
period.
Conclusions. The low infection rate observed among Canadian dentists from July 29, 2020,
through February 12, 2021, should be reassuring to the dental and general community.
Practical Implications. Although the infection rates were low among Canadian dentists, it is
important to continue to collect disease surveillance data.
Key Words. COVID-19; dentists; Canada; incidence; personal protective equipment.
JADA 2022:153(5):450-459
https://doi.org/10.1016/j.adaj.2021.10.006

E
vidence indicates an increased incidence of COVID-19 among health care providers (HCPs)
compared with the general population.1-4 In a systematic review of COVID-19 infection rates
and deaths among HCPs, using data collected through May 8, 2020, researchers reported
3.9% of cases and 0.5% of COVID-19erelated deaths globally were among HCPs.2 Researchers
investigating a cohort of HCPs in New York, New York, found a seroprevalence of severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies of 13.7%.3 Using data available
through July 23, 2020, the Canadian Institute of Health Information reported that 19.4% of cases in
Canada were among HCPs,1 although cases varied considerably across provinces, from 5.4% in
Copyright ª 2022 Saskatchewan to 24.1% in Quebec.1 Dentists, a high-risk group of HCPs, were not included or at
American Dental least not identified as a group in these studies. The available data concerning COVID-19 infections
Association. This is an in dentists and dental care professionals come from studies in the United States,5,6 United
open access article under
Kingdom,7 and France,8 as well as a retrospective case series report of 31 infected oral health care
the CC BY license (http://
creativecommons.org/ professionals from China.9 Investigators from the US study reported a prevalence of 0.9% for
licenses/by/4.0/). confirmed or probable cases of COVID-19 infection among 2,195 dentists who responded to a

450 JADA 153(5) n http://jada.ada.org n May 2022

survey sent to 5,479 dentists across all states in June 2020.5 The 6-month cumulative prevalence
from this study remained low at 2.6%.6 Investigators from the French study covered an earlier period
(April 2020) and reported a higher prevalence of 1.9% among dentists and 0.8% among dental
hygienists.8 Researchers with the study from the United Kingdom, however, reported a 16.3%
seroprevalence in May 2020 among oral health care professionals, which included dentists and
other support staff members.7 These reports highlight the geographical heterogeneity in the disease
burden and the need to estimate the same among Canadian dentists.
Oral health care settings carry a potentially high risk of causing cross-infection between dentists
and patients and among dental staff members due to their close contact and aerosol-generating
procedures (AGPs).10-12 Common instruments used for oral health care (for example, high-speed
handpieces) can splash patient saliva or blood directly onto dental staff members and patients
and aerosolize these fluids, potentially suspending them in the air for several hours.10-13 Conse-
quentially, March 15-23, 2020, as the COVID-19 pandemic emerged in Canada, dental regulatory
authorities across Canada obliged dentists to close their offices to routine care and provide emer-
gency care only.14-16
On May 4, 2020, the Saskatchewan and Manitoba provincial governments permitted dentists
to open their offices for routine oral health care after guidelines issued from the relevant dental
regulatory authorities.17,18 This was followed by the other Canadian provinces and territories.
Since this reopening, there have not been any jurisdictional shutdowns of oral health care in
Canada. Early in the reopening phase (May 4-15, 2020), dental regulatory authorities published
detailed infection control and prevention protocols for providing oral health care, and these
varied across provinces. However, the level of evidence supporting the use of particular personal
protective equipment (PPE) or the use of AGPs and the risk of experiencing contamination
with SARS-CoV-2 and contracting COVID-19 remains poor.19 In this context, we initiated a study
in July 29, 2020 to August 12, 2020 with the aim of documenting the incidence of COVID-19
among community-based dentists in Canada over a 12-month period. Here we report our findings
after 6 months.

METHODS
Study design
We used data from an ongoing, prospective cohort study of Canadian dentists. Eligibility criteria
included being licensed to practice general or specialty dentistry in Canada during the study period;
being SARS-CoV-2enegative at recruitment; and having no history of COVID-19. Potential
participants, identified through rosters of 9 provincial dental licensing bodies or dental associations
(Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, Ontario, Manitoba,
Saskatchewan, Alberta, and British Columbia), were invited to participate through the associa-
tions’ email lists. Regular email reminders were sent until we reached the required sample size. The
ethics review boards of the leading institutions (Faculty of Medicine Institutional Review Board,
McGill University, Biomedical Research Ethics Board, University of Saskatchewan) approved
our study.
The sample size for our cohort study was calculated on the basis of estimates of infection rates in
May 2020 in Canada. We calculated a sample size of 380 participants to be followed for 1 year to
estimate an incidence proportion of 1%, with a margin of error of 1%. At least 200 participants were ABBREVIATION KEY
required in a subcohort to estimate an incidence proportion of 0.5% for nonsymptomatic COVID-
AGP: Aerosol-generating
19, with a margin of error of 0.9%.20-22 procedure.
HCP: Health care
Recruitment provider.
Invitations to participate were sent to dentists registered across 9 participating dental licensing PPE: Personal protective
equipment.
bodies or associations in late July 29, 2020. Of 702 participants who consented to participate in our RT-PCR: Reverse
study, 651 completed the baseline survey. Excluding participants who stopped working before transcriptase
November 2019 (n ¼ 2) and prevalent COVID-19 cases, 644 participants were invited to the polymerase chain
longitudinal phase. We invited 226 participants randomly from this group to provide saliva samples reaction.
SARS- Severe acute
every 4 weeks to test for asymptomatic cases of infection. Of these, 2 participants were later
CoV-2: respiratory
excluded owing to logistical challenges in shipping samples from their location, resulting in a final syndrome
sample size of 224 for the subcohort. coronavirus 2.

JADA 153(5) n http://jada.ada.org n May 2022 451

 Data collection
After providing informed consent, participants completed a baseline survey online. The following 3
domains of information were collected at this stage: demographics and comorbidities, details of oral
health care provided to patients in the previous 2 weeks (for example, number of AGPs performed,
N95 respirator use, and ventilation in clinics [clinical activity form]), and symptoms and infection
status (for example, fever 38 C or higher, respiratory and other symptoms related to COVID-19,
whether the participant has tested positive for SARS-CoV-2, and date and type of test [outcome
form]). Questionnaires were adapted from World Health Organization’s Unity Studies protocols for
assessment of COVID-19 risk among health care workers23 and were available in both official
languages, English and French.
Participants who were negative for SAR-CoV-2 at baseline were invited to the longitudinal
phase of our study and to provide their contact information (for example, telephone number and
email and postal addresses). Every 4 weeks after baseline, participants completed an online ques-
tionnaire through the LimeSurvey platform.24 These follow-up questionnaires included the clinical
activity and outcome forms. In addition to questionnaire data, the participants included in the
subcohort self-collected saliva samples every 4 weeks after baseline (as described below) and mailed
them to the relevant laboratory for analyses.
The end of participant follow-up was defined as the earliest event among the following: self-
reported diagnosis of COVID-19 infection, detection of SARS-CoV-2 RNA in saliva, death,
leave of absence from practice (retirement or parental leave > 3 months), or administrative end for
interim analysis (February 12, 2021).

Saliva sample collection and analysis

Saliva samples were self-collected using a saliva collection kit (SuperSAL universal saliva
collection kit, Oasis Diagnostics) containing RNA stabilizer (RNAlater, Sigma) and proteinase
inhibitors following the instructions for saliva collection that we prepared. The SuperSAL uni-
versal saliva collection kit is a swab device designed for saliva collection that allows the collection of
protein, DNA, and RNA from human and microorganism sources. A total of 1.5 mL of saliva was
collected at each follow-up.
Immediately after collection, saliva samples were shipped to the Salivary Proteomics Research
Laboratory, College of Dentistry, University of Saskatchewan. At the Salivary Proteomics Research
Laboratory, samples were centrifuged at 14,000g for 30 minutes at 4 C to separate pellets con-
taining microorganisms, host cells, and other debris, from saliva supernatant containing the host
and viral proteins and peptides.25 Saliva supernatant was concentrated to one-half its volume using
a centrifugal concentrator. Then, total RNA was extracted from 220 mL of saliva supernatant using
QIAamp Viral RNA Mini Kit (Qiagen) according to the manufacturer’s instructions. Extracted
RNA was used for the qualitative detection of SARS-CoV-2especific RNA in saliva samples with
the RealStar SARS-CoV-2 RT-PCR Kit 1.0 (Altona Diagnostics) and real-time reverse tran-
scriptase polymerase chain reaction (RT-PCR) technology using a CFX96 Touch Real-Time PCR
Detection System (Bio-Rad). Our primary method for identifying COVID-19 cases using saliva
samples was real-time RT-PCR, which is considered the reference standard method for detection of
SARS-CoV-2 RNA in different biofluids.26

Statistical analysis
Longitudinal patterns of in-person oral health care provided by participants and types of PPE used
were summarized using descriptive statistics. We used a bayesian Poisson model to estimate the
incidence rate. Analyses were conducted using data collected from July 29, 2020, through February
12, 2021. To account for the uncertainty in the date of infection due to time lapse between
infection and test dates, we implemented the proposed single random point imputation technique,
which has been reported to be superior to other standard techniques.27-29 The technique imputes a
value for the follow-up duration from the interval from the date of the last reported negative result
through the date of the sample that led to a positive result. This approach is based on the
assumption that the infection could have happened at any point between these 2 visits. A non-
informative prior (Gamma 0.0001, 0.0001) was used for the rate parameter. The model was fit in
JAGS30 using 4 parallel Markov chain Monte Carlo chains with 25,000 burn-in and 25,000 samples
each (see the Appendix, available online at the end of this article, for details of the model). The

452 JADA 153(5) n http://jada.ada.org n May 2022

Table 1. Baseline characteristics, including demographic and professional information, of the participants in the cohort
(n ¼ 644).

CHARACTERISTIC DATA
Age, Y

Median (25%, 75%) 48 (38, 56)

 30, no. (%) 30 (4.7)

31-59, no. (%) 514 (79.8)

 60, no. (%) 100 (15.5)

Sex, No. (%)

Female 363 (56.4)

Male 281 (43.6)

Province of Primary Practice, No. (%)

Alberta 27 (4.2)

British Columbia 109 (16.9)

Manitoba 26 (4.0)

Newfoundland and Labrador 2 (0.3)

Nova Scotia 34 (5.3)

Ontario 241 (37.4)

Prince Edward Island 11 (1.7)

Quebec 164 (25.5)

Saskatchewan 29 (4.5)

Yukon 1 (0.2)

Type of Primary Practice, No. (%)

General practice 585 (90.8)

Specialist practice 59 (9.2)

Community Mainly Served, No. (%)

Metropolitan 147 (22.8)

Urban 220 (34.2)

Suburban 167 (25.9)

Rural 103 (16.0)

Remote 5 (0.8)

Missing 2 (0.3)

No. of Primary Offices per Week, No. (%)

1 537 (83.4)

2 83 (12.9)

3 13 (2.0)

>3 10 (1.6)

Missing 1 (0.2)

Follow-Up, d

Median (25%, 75%) 188 (183, 191)

Mean (standard deviation) 182.8 (25.5)

convergence of Markov chain Monte Carlo chains was assessed using trace plots and Gelman-Rubin
Rhat value.31,32 Incidence rates and corresponding 95% credible intervals (CIs) were reported.
COVID-19 prevalence at baseline and incidence proportion were estimated using a bayesian
binomial model with noninformative b(1,1) prior distribution. We also compared the incidence
proportion estimate with the national estimate during the study period, which we obtained from the
Government of Canada’s COVID-19 outbreak update.33

JADA 153(5) n http://jada.ada.org n May 2022 453

Table 2. Details of oral health care provided by participants with at least 1 in-person care provision in past 2 weeks.

VARIABLE BASELINE FOLLOW-UP

1 2 3 4 5
Participants, No. 612 617 612 604 552 588

No. of Patients Who Required an Aerosol-Generating Procedure per Week, No. (%)

None 12 (2.0) 7 (1.1) 5 (0.8) 6 (1.0) 12 (2.2) 8 (1.4)

<7 310 (50.7) 302 (48.9) 300 (49.0) 275 (45.5) 286 (51.8) 253 (43.0)

7 290 (47.4) 308 (49.9) 305 (49.8) 320 (53.0) 254 (46.0) 325 (55.3)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 3 (0.5) 0 (0.0) 2 (0.3)

Provided Oral Health Care for Any COVID-19ePositive Patients, No. (%)

No 610 (99.7) 616 (99.8) 601 (98.2) 595 (98.5) 546 (98.9) 579 (98.5)

Yes 2 (0.3) 1 (0.2) 9 (1.5) 7 (1.2) 6 (1.1) 7 (1.2)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 0 (0.0) 2 (0.3)

Cared for Any Patients Suspected of Having COVID-19, No. (%)

No 605 (98.9) 599 (97.1) 601 (98.2) 591 (97.8) 544 (98.6) 578 (98.3)

Yes 7 (1.1) 18 (2.9) 9 (1.5) 11 (1.8) 8 (1.4) 8 (1.4)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 0 (0.0) 2 (0.3)

RESULTS
The mean age of participants was 47.3 years (range, 24-79 years); most participants were women
(56.4%) and general practitioners (90.8%). As expected, given the general population distribution
in Canada, most of our sample had their primary practices in Quebec and Ontario (62.9%), were
serving a metropolitan or urban community (57%), and practiced in only 1 office per week (83.4%)
(Table 1). The data collection period was from July 29, 2020 through February 12, 2021. Median
follow-up was 188 days (interquartile range, 183-191 days). Eighteen participants (2.7%) were lost
to follow-up during the study period.

Longitudinal patterns of in-person oral health care provision and PPE use
Most participants ( 80%) continued to provide in-person oral health care across the baseline and
follow-up visits. Among this subgroup of participants, most performed AGPs for at least 1 patient
during the study period. However, a low proportion of participants provided care for patients who
were known to be COVID-19epositive or who were suspected of having COVID-19 (Table 2).
During the follow-up period, use of N95 respirators or higher-specification respirators increased
from approximately 40% through 60% (Table 3 and Figure 1). Furthermore, the proportion of
participants using both N95 respirators or higher-specification respirators and visors for all in-person
oral health care procedures doubled during the follow-up period (9.3%-19.6%). Most participants
(> 90%) used goggles or eyeglasses during all types of dental procedures throughout the follow-up
period.

Incidence of COVID-19
During the follow-up period, 6 participants reported receiving a diagnosis of COVID-19, resulting in
an incidence rate of 5.10 per 100,000 person-days (95% CI, 1.86 to 9.91 per 100,000 person-days).
The cumulative incidence curve is presented in Figure 2. The incidence proportion was estimated to
be 1,084 per 100,000 dentists (95% CI, 438 to 2,011 per 100,000 dentists). In other words, we
estimated that 1.08% (95% CI, 0.44% to 2.01%) of Canadian dentists were COVID-19epositive
during the study period from July 29, 2020, through February 12, 2021. The incidence proportion
among the general population during the same period was 1,864 per 100,000 people (95% CI, 1,859
to 1,868 per 100,000 people).
None of the participants in the subcohort who provided saliva reported ever testing positive for
COVID-19 during the study period. As expected, no SARS-CoV-2 was detected in any of the saliva
samples from 224 participants during the study period.

454 JADA 153(5) n http://jada.ada.org n May 2022

Table 3. Pattern of use of facial coverings during in-person oral health care provision* during past 2 weeks.

VARIABLE BASELINE FOLLOW-UP

1 2 3 4 5
Providers, No. 612 617 612 604 552 588

Routine Use of Surgical Masks, No. (%)

None 50 (8.2) 50 (8.1) 76 (12.4) 91 (15.1) 105 (19.0) 121 (20.6)

For all procedures 471 (77.0) 488 (79.1) 448 (73.2) 412 (68.2) 357 (64.7) 371 (63.1)

For AGPs only 11 (1.8) 6 (1.0) 3 (0.5) 5 (0.8) 5 (0.9) 3 (0.5)

For non-AGPs only 80 (13.1) 73 (11.8) 83 (13.6) 94 (15.6) 85 (15.4) 91 (15.5)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 0 (0.0) 2 (0.3)

Use of N95 Respirators or Higher-Specification Respirators, No. (%)

None 372 (60.8) 388 (62.9) 329 (53.8) 290 (48.0) 225 (40.8) 218 (37.1)

For all procedures 100 (16.3) 105 (17.0) 141 (23.0) 165 (27.3) 189 (34.2) 211 (35.9)

For AGPs only 139 (22.7) 124 (20.1) 139 (22.7) 146 (24.2) 138 (25.0) 157 (26.7)

For non-AGPs only 1 (0.2) 0 (0.0) 1 (0.2) 1 (0.2) 0 (0.0) 0 (0.0)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 0 (0.0) 2 (0.3)

Use of Goggles or Eyeglasses, No. (%)

None 23 (3.8) 18 (2.9) 24 (3.9) 20 (3.3) 18 (3.3) 23 (3.9)

For all procedures 552 (90.2) 569 (92.2) 558 (91.2) 554 (91.7) 512 (92.8) 542 (92.2)

For AGPs only 27 (4.4) 19 (3.1) 13 (2.1) 16 (2.6) 12 (2.2) 11 (1.9)

For non-AGPs only 10 (1.6) 11 (1.8) 15 (2.5) 12 (2.0) 10 (1.8) 10 (1.7)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 0 (0.0) 2 (0.3)

Use of Visors (Face Shields), No. (%)

None 161 (26.3) 178 (28.8) 154 (25.2) 150 (24.8) 127 (23.0) 129 (21.9)

For all procedures 242 (39.5) 217 (35.2) 245 (40.0) 245 (40.6) 243 (44.0) 246 (41.8)

For AGPs only 204 (33.3) 220 (35.7) 209 (34.2) 206 (34.1) 177 (32.1) 210 (35.7)

For non-AGPs only 5 (0.8) 2 (0.3) 2 (0.3) 1 (0.2) 5 (0.9) 1 (0.2)

Missing 0 (0.0) 0 (0.0) 2 (0.3) 2 (0.3) 0 (0.0) 2 (0.3)

* Aerosol-generating procedure (AGP).

DISCUSSION
Authors of several articles have highlighted oral health care professionals as being at high risk of
becoming infected with SARS-CoV-2.34-37 Previous reports on COVID-19 risk among HCPs in
general also pointed toward this direction.38-40 Results of studies from the United States and France
conducted during the early phase of the pandemic showed low prevalence compared with the general
population. However, to our knowledge, no researchers have reported the incidence rates of SARS-
CoV-2 infections among Canadian dentists. We presented results from an ongoing, prospective
cohort study of COVID-19 incidence rates in Canadian dentists working in the community.
After the initial phase of the pandemic and the reopening of dental offices to routine oral health
care across the country in the spring of 2020, most participating dentists provided some form of in-
person oral health care to patients during the study period. We found that infection rates in our
study were lower than those documented for the general population, according to provincial and
federal surveillance data during the study period (July 29, 2020-February 12, 2021).33 However, due
to the relatively short follow-up period, dynamic nature of the infection rates among the general
population, and the fact that dentists are included in the data available from the public domain, this
comparison must be interpreted with caution.
Notwithstanding the need to be cautious in interpreting the apparently lower infection rates in
our sample compared with the general population, a lower rate may have been a reflection of an
array of interacting factors, including but not limited to preprocedure screening of patients,

JADA 153(5) n http://jada.ada.org n May 2022 455

 100

80

Proportion of participants, %
60

40

20

Baseline Follow-up 1 Follow-up 2 Follow-up 3 Follow-up 4 Follow-up 5

Visits
N95 respirator or higher-specification respirator Surgical mask Visors Goggles

Figure 1. Longitudinal trends in the use of different facial coverings for any in-person oral health care procedures
during the past 2 weeks. The change over time in use of 4 major types of face coverings.

0.015
Cumulative incidence %

0.010

0.005

0.000

0 50 100 150 200

No. of days of follow-up

Figure 2. Cumulative incidence of self-reported COVID-19 infection among participants during the study period. The
solid line represents the point estimate and the dashed lines represent the 95% confidence limits.

adherence to rigorous infection prevention and control protocols used during these procedures,
public health measures (for example, physical distancing and masking), and increased awareness
and precautionary behavior of dentists in general and outside their work place. For example, the
follow-up period of the study primarily spanned the second wave of COVID-19 in Canada when,
although more cases were reported than in the first wave, more stringent social distancing measures
were imposed (for example, curfews and restriction on interregional travel). Also, only a few par-
ticipants provided oral health care to patients who had confirmed cases of COVID-19 or were
suspected of having COVID-19, so this may be an initial signal that the event rates are driven
mainly by means of community contacts rather than any in-clinic transmission. In addition, most
participants in the study used multiple face coverings during most procedures. Although the use of
N95 respirators or higher-specification respirators was low during the initial follow-up, it has
increased over time, which may reflect an increase in the availability of this PPE.

456 JADA 153(5) n http://jada.ada.org n May 2022

 Uptake of vaccinations could be a possible explanation for low infection rates. However, our
study accumulated more than 4 months of follow-up at the time the COVID-19 vaccination
campaign began in Canada. At the time of our interim analysis (February 12, 2021), the proportion
of participants who had received at least 1 dose of the COVID-19 vaccine was low (z 5%) and
cannot explain the low infection rates.
The cumulative incidence curve (Figure 2) indicates the speed at which infections were reported
in the study population. A rapid increase in the slope of this curve during the study period may
reflect a cluster of infections or is possibly an outbreak. Figure 2 illustrates that the infection rate is
stable, although with wide confidence intervals.
Saliva samples were analyzed using RT-PCR, with the aim of detecting asymptomatic COVID-
19 cases among the participants. We did not detect any SARS-CoV-2 RNA in any of the
monthly samples analyzed from the 224 participants who provided saliva samples during the
study period. We cautiously conclude that there were no symptom-free cases of COVID-19
infection in our sample during the study period. However, we acknowledge the limitations of
our technique. Nasopharyngeal swabs are standard for population-wide screening for SARS-
CoV-2; however, saliva samples are logistically more feasible and have been reported to have
similar sensitivity to the former.41 The time gap between consecutive saliva samples may have
played a role in null detection. For example, if a participant was infected immediately after
providing a saliva sample and never developed any symptoms, the viral RNA may be reduced to
a nondetectable level at the time of the next saliva sample 1 month later. More frequent sample
collection schedules might have caught such infections, but they would have been logistically
challenging and may have burdened participants.
Accuracy of RT-PCRebased detection of SARS-CoV-2 RNA in saliva samples may have also
played a role in our results. However, results from several systematic reviews have shown that saliva
sampleebased tests have comparable sensitivity and specificity to nasopharyngeal swab sample tests
and offer a cost-effective alternative for screening.41-43 Furthermore, results from a study comparing
nasopharyngeal swab and saliva samples among asymptomatic participants showed more than 99%
specificity for saliva samples and high concordance with results from nasopharyngeal swab
samples.44
Saliva samples were only collected from a subcohort of the participants who consented to provide
samples every month. This subsampling may have resulted in a selection bias if the participants who
consented to provide saliva systematically had a lower risk than the rest of the study population.
However, given that most (> 80%) of the participants at baseline consented to provide saliva and
we randomly selected participants from this consenting group, the possibility of selection bias in our
results was reduced.
Owing to low event rates to date, we were not able to investigate factors such as demographics
and PPE use, which could be associated with COVID-19 infections, in the analyses we reported.
Future follow-up data and additional analysis from the project will explore these factors. Further-
more, comparing infection rates among different oral health care professionals (that is, dental hy-
gienists and dental assistants) with other HCPs is also warranted.
Finally, it is important to recognize the nature of the sample, which, although it included par-
ticipants from multiple provinces, is a convenience sample of dentists who voluntarily responded to
an invitation to participate. Invitations were sent to most of the dentists in the country, but only a
small proportion responded. However, the distribution of demographic characteristics among the
study population was comparable with national data on Canadian dentists obtained from the Ca-
nadian Dental Association as of July 30, 2020 (eTable, available online at the end of this article)
(Department of Clinical and Scientific Affairs, Canadian Dental Association, unpublished data,
April 2021).

CONCLUSIONS
To our knowledge, this is the first report on COVID-19 risk among Canadian dentists. The low
infection rate observed during the 6-month follow-up period should be reassuring to the dental and
general community. By means of providing the disease surveillance data, the results of our study may
help decision makers adapt and optimize clinical guidelines for infection prevention and control
during this pandemic and potentially future waves. n

JADA 153(5) n http://jada.ada.org n May 2022 457

 SUPPLEMENTAL DATA
Supplemental data related to this article can be found at: https://doi.org/10.1016/j.adaj.2021.10.006.

Dr. Madathil is an assistant professor, Faculty of Dentistry, McGill Univer- Disclosure. None of the authors reported any disclosures.
sity, Montreal, Quebec, Canada. Address correspondence to Dr. Madathil,
Faculty of Dentistry, McGill University, 2001 McGill College Ave, Room This research was funded by grant VR4-172757 from the Canadian In-
533, Montreal, Quebec H3A1G1, Canada, email sreenath.madathil@ stitutes of Health Research and by the COVID-19 Immunity Task Force.
mcgill.ca. Sreenath Madathil is a recipient of a Career Award from the Fonds de
Dr. Siqueira is a professor, College of Dentistry, University of Saskatch- Recherche du QuébeceSanté.
ewan, Saskatoon, Saskatchewan, Canada. Data availability statement. The data pertinent to the article will be
Dr. Marin is a postdoctoral fellow, College of Dentistry, University of available on reasonable request for collaborative research.
Saskatchewan, Saskatoon, Saskatchewan, Canada.
Ethics statement. This study received ethical approval through the McGill
Dr. Sanaulla is a postdoctoral fellow, College of Dentistry, University of
University Faculty of Medicine and Health Sciences Institutional Review
Saskatchewan, Saskatoon, Saskatchewan, Canada.
Board (A06-M49-20A [20-06-018]).
Ms. Faraj is a research assistant, Faculty of Dentistry, McGill University,
Montreal, Quebec, Canada. The authors would like to acknowledge the following organizations for
Dr. Quiñonez is an associate professor, Faculty of Dentistry, University of their support: Canadian Dental Association, Provincial Dental Board of
Toronto, Toronto, Ontario, Canada. Nova Scotia; Dental Association of Prince Edward Island; Association des
Dr. McNally is a professor, Faculties of Dentistry and Medicine, Dalhousie chirurgiens dentistes du Québec; the Ontario Dental Association; the
University, Halifax, Nova Scotia, Canada. Manitoba Dental Association; College of Dental Surgeons of Saskatch-
Dr. Glogauer is a professor, Faculty of Dentistry, University of Toronto, ewan; School of Dentistry, University of Alberta; College of Dental Sur-
Toronto, Ontario, Canada. geons of British Columbia; and Newfoundland and Labrador Dental
Dr. Allison is a professor, Faculty of Dentistry, McGill University, Mon- Association.
treal, Quebec, Canada.

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JADA 153(5) n http://jada.ada.org n May 2022 459

 APPENDIX
Bayesian model to estimate incidence rate
# Inputs
# Ncase: Number of events
# start: length of follow-up till the second last date of follow-up (for each participant with an event)
# stop: length of follow-up till the last date of follow-up (For each participant with an event)
# py_deno: Person-time accumulated among the participants without an event
model{
for(i in 1:Ncase){
py[i] w dunif(start[i],stop[i]) # Uniform distribution for imputation
}
py_case <- sum(py[1:Ncase])
py_total <- py_case þ py_deno # Person-time
Ncase w dpois(py_total*lambda) # Poisson likelihood
lambda w dgamma(0.0001,0.0001) # Non-informative prior
}

eTable. Comparing participant characteristics with overall Canadian dentist population.

CHARACTERISTIC OUR STUDY, % CANADIAN DENTAL ASSOCIATION,%*

Age, Y

< 30 4.7 5.1

31-59 79.8 74.2

 60 15.5 20.7

Sex

Male 43.6 59.8

Female 56.4 40.2

Type of Primary Practice

General dentistry 90.8 87.9

Speciality dentistry 9.2 12.1

Province of Primary Practice

Alberta 4.2 11.0

British Columbia 16.9 14.7

Manitoba 4.0 3.0

Newfoundland and Labrador 0.3 0.9

Nova Scotia 5.3 2.3

Ontario 37.4 43.0

Prince Edward Island 1.7 0.3

Quebec 25.5 21.1

Saskatchewan 4.5 2.1

Yukon 0.2 0.1

New Brunswick 0 0.1

Northwest territories 0 0.1

Nunavut 0 1.3

* Data as of July 2020.

459.e1 JADA 153(5) n http://jada.ada.org n May 2022