• Oral point-of-care testing
• Dental practices

Kandasamy N, Mital D. (2024) The Utilisation and Roll Out of Point-of-Care-Testing of Blood Borne Pathogens in Dental Practice Settings. JSM Dent 11(1): 1140.

POCT: Point-Of-Care Testing; BBPs: Blood Borne Pathogens

Point-Of-Care-Testing (POCT) has been used for many years across all forums of disease detection and utilised in many typical healthcare and indeed, non-healthcare settings [1]. The benefits of knowing a rapid diagnosis are many fold in terms of ensuring engagement of care for the patient/client, initiating a care pathway protocol for a positive diagnosis, potential rapid treatment for prevention or cure of the disease ascertained and in terms of communicable diseases, potential prevention of ongoing transmission.

The massive success of rolling out the POCT lateral flow testing for SARS-CoV-2 during the early parts of the COVID-19 pandemic in many settings demonstrated this nicely. POCT reagents and devices can use many forms of detection e.g. blood, urine etc. but we would like to argue and advocate the use of salivary fluid for the detection of important pathogens. With the global, ongoing high rates of all Blood Borne Pathogens (BBP) namely Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Syphilis (STS) can lead to long-term complications that may be life-threatening e.g. HBV and HCV can lead to end stage liver cirrhosis and hepatocellular carcinoma.

Dental Practice settings could provide a suitable forum for Oral Point-Of-Care-Testing (OPOCT) for BBPs particularly in areas of high incidence e.g. socioeconomically deprived areas where access to healthcare and conventional testing methods tend to be difficult therefore lower resulting in crucial missed diagnoses and potential increased rates of progression and transmission of disease.

The lack of resources and time allocated for standard and regular testing for patients across all groups particularly for infected patients being asymptomatic and this lack of awareness of diagnosis of their disease increases the likelihood of BBP spreading unknowingly. For example in 2021 approximately 4400 people living with HIV were undiagnosed in the UK [2], and the proportion of those diagnosed ‘late’ i.e. when advanced HIV infection and immunosuppression has already occurred were 5 times more likely to die within 1 year compared to those diagnosed ‘promptly’ [3]. The aim for OPOCT utilisation is to increase undiagnosed BBP earlier access for specialised healthcare, treatment and potential screening of at risk contacts.

Currently the majority of people getting tested for BBP are those who attend designated healthcare settings such as Sexual Health Clinics in the UK Many of which may be asymptomatic. Other avenues for testing for BBPs include the NHS emergency department opt-out testing programme and potentially primary care. These tests are done via standard serology testing and thus takes an additional turnaround time for the results to return back as they tend to be sent to accredited central laboratories which may be off-site.

Dental practices see people returning for check-ups (biannually/annually) and as they are already involved with examining and/or treating the oral cavity, this could be a potential opportunity to provide holistic care by offering OPOCT for BBP. Using saliva requires a non-invasive technique that involves a buccal smear on the inside of the cheek and shows more patient acceptance compliance as opposed to a needlestick fingerprick blood test that many patients feel wary of.

An example of OPOCT that can use oral fluid is OraQuick Rapid HIV-1 antibody test [4] and OraQuick HCV antibody test [5]. There is also research to show that HBV antigens [6] and STS Treponema Palladium DNA [7] are in high enough levels in the saliva to be detected.

It is clear that many relevant stakeholders such as Public Healthcare, Commissioners, Clinicians, Epidemiologists etc will be needed to approach the challenges of funding and delivering an effective OPOCT service [8] and there can be many examples of effective care pathways.

At the point of a patient of entering a Dental Practice within any one community, an appointment is assumed to have been made for a new of follow-up patient and some form verbal informed consent for OPOCT for BBP testing will be necessary particularly with the patient told that preliminary results will be available by the end of the consultation. The dental professional must explain why it is being done, how it will be done, its benefits and any potential risks. The test is then carried out during the examination and prior to any mouthwash being given. In an OPOCT the result will be available by the end of the consultation and must be recorded or ‘photographed’ and form part of the notes. A positive result must be confirmed by validated tests in quality assured laboratories to rule out any false positives and this will require a formal referral to a specialist provider via agreed patient care pathways. With patient consent, the dentist will formally refer them to a designated BBP healthcare provider for further investigations and subsequently treatment and copy in the primary care provider for share care provision. A negative result can potentially lead to a discussions around ‘risk’ behaviours for BBPs and further alert patients for any further healthcare provisions e.g. potential vaccinations, partner testing etc.

Oral POCTs are highly accurate as research has shown the OraQuick Rapid HIV-1 antibody test has sensitivity and specificity above 99% [4]. Nevertheless, there can be false positives and false negatives [9] that can arise e.g. in pregnancy, systemic lupus erythematosus etc. Therefore, any positive OPOCT results need to be re-confirmed by validated serology tests in quality assured laboratories and this is explained when gaining consent. A primary or secondary care provider can usually facilitate this request and patients can be signposted to the designated service available.

The World Health Organisation put in place a set of standards that POCTs must follow real-time connectivity, ease of specimen collection, affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free and deliverable to end users [10].

In order fulfil the criteria of being affordable and reach a large volume of people they must cost less than the per a conventional test however right now they cost £12-15 per test as opposed to a £1 [5] for a serology blood test hence the need for relevant stakeholders needed to analyse utility, cost effectiveness, target area feasibility (particularly areas of high incidence) and health promotion.

These tests can put dental practices under increased amounts of financial and capacity pressure which are already stretched in the UK. With already limited time slots, the additional time required for gaining consent and carrying out the test may be difficult to obtain and appropriate training given to involved and agreeable staff. It is also in the dental practice’s role to ensure it can adhere to quality assurance issues such as safe testing facilities, test collection, test storage requirements and safe incineration of the tests. It is also important to establish role of each staff member and overall responsibility within the Dental Practice.

POCTs have shown their success in a range of settings and there is evidence that there is a role for the oral versions of POCTs in the detection of BBPs thereby solving issues of low uptake of testing rates and therefore hopefully diagnosing BBPs before deterioration and where management and treatment could potentially become less potent. If the various stakeholders work together to allocate the necessary time, money and resources so POCT can fit the WHO ‘REASSURED criteria’, dental practices have potential to make OPOCTs as part of a comprehensive oral health review consisting of an in-depth clinical history taking, examination and effective management processes.

Nil of note.

We declare no conflict of interests

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