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Volume 52 • Issue 1 • 2007 21 when tested. In contrast, metabolites are detected in urine for several days after use, beyond the time when the individual shows effects. Sample Issues.—Products are currently available to help individuals “beat” the urine drug test. False-negative results can be achieved with the use of strong oxidizers, enzymes, or soaps to interfere with the urine testing. Even drinking excessive amounts of water alters the drug test with relative ease and effectiveness. Oral fluids are dynamic, so chemical changes reflect changes in flow. With increased flow, the pH of the fluid rises. Passive diffusion rates for drugs from blood to oral fluid are determined by the concentration of free-drug fractions in the circulation. Basic drugs, including opi- ates, amphetamines, and cocaine, are usually found in relatively higher concentrations in oral fluid than in blood, so oral fluids, which are acidic, show enhanced detection abilities for these drugs. Acidic drug metabo- lites, such as the benzoylecgonine metabolite of co- caine, are seen in lower concentrations in oral fluids than in plasma. Cocaine accumulates in the acidic oral fluids and appears within minutes of its use. Generally, if cocaine is found, intake was within the previous 24 hours. Cannabis presents a major exception to the paradigm just described. The major psychoactive component of cannabis (delta-9-tetrahydrocannabinol [THC]) is direct- ly deposited into the oral mucosa during use. Scan drug transfers from the bloodstream to oral fluids because most of the THC in blood is bound to protein. Cannabis detection depends on the amount of drug taken and the frequency of use, but usually it is detected for 12 to 24 hours after use. Transient levels of THC are detectable after passive exposure to cannabis smoke. Background.—Oral fluid testing, or saliva testing, is an accurate, effective, and robust method for detecting the presence of various drugs. All the substances tested for in urine-based drug testing programs can be detected with the use of oral fluid testing. Urine-based drug testing is criticized because of the embarrassment associated with sample collection, because individual privacy issues must be addressed, and because, in providing privacy, there is an increased chance for the sample to be adulterated or even replaced without detection. With oral fluid testing, individuals can be observed during sample collection, min- imizing the chance that the sample is inaccurate. Collection Issues.—The core problem with drug test- ing has been with the collection methods. With oral fluid testing, saliva is readily accessible and its collection does not involve an invasion of privacy. Oral fluid testing can de- tect recent drug use, specifically during the previous 24 to 48 hours. Regardless of the method of intake (swallowing, snorting, or smoking), drugs eventually are absorbed into the bloodstream. The circulation delivers part of the drugs to the salivary glands. The transfer of drug substance to oral fluid continues as long as the drug is in the blood- stream. Furthermore, there is a direct relationship between the drug’s blood levels and its presence in oral fluids. Whether it is the parent drug or metabolites, oral fluid testing can detect the substance in most cases. Usually, the drug detected in oral fluids is the active drug component, which causes the patient to experience psy- choactive effects, euphoria, and impairment. Urine test- ing typically detects only inactive drug metabolites. When a drug is detected in oral fluids, it shows that the drug was present in the individual’s body during sam- ple collection. If the oral fluid test is positive for heroin, it is likely the individual was under the drug’s influence Occupational Risks Oral fluid testing for drugs

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Page 1: Oral fluid testing for drugs

Volume 52 • Issue 1 • 2007 21

when tested. In contrast, metabolites are detected inurine for several days after use, beyond the time whenthe individual shows effects.

Sample Issues.—Products are currently available tohelp individuals “beat” the urine drug test. False-negativeresults can be achieved with the use of strong oxidizers,enzymes, or soaps to interfere with the urine testing.Even drinking excessive amounts of water alters the drugtest with relative ease and effectiveness.

Oral fluids are dynamic, so chemical changes reflectchanges in flow. With increased flow, the pH of the fluidrises. Passive diffusion rates for drugs from blood to oralfluid are determined by the concentration of free-drugfractions in the circulation. Basic drugs, including opi-ates, amphetamines, and cocaine, are usually found inrelatively higher concentrations in oral fluid than inblood, so oral fluids, which are acidic, show enhanceddetection abilities for these drugs. Acidic drug metabo-lites, such as the benzoylecgonine metabolite of co-caine, are seen in lower concentrations in oral fluidsthan in plasma. Cocaine accumulates in the acidic oralfluids and appears within minutes of its use. Generally,if cocaine is found, intake was within the previous 24hours.

Cannabis presents a major exception to the paradigmjust described. The major psychoactive component ofcannabis (delta-9-tetrahydrocannabinol [THC]) is direct-ly deposited into the oral mucosa during use. Scan drugtransfers from the bloodstream to oral fluids becausemost of the THC in blood is bound to protein. Cannabisdetection depends on the amount of drug taken and thefrequency of use, but usually it is detected for 12 to 24hours after use. Transient levels of THC are detectableafter passive exposure to cannabis smoke.

Background.—Oral fluid testing, or saliva testing, is anaccurate, effective, and robust method for detecting thepresence of various drugs. All the substances tested for inurine-based drug testing programs can be detected withthe use of oral fluid testing. Urine-based drug testing iscriticized because of the embarrassment associated withsample collection, because individual privacy issues mustbe addressed, and because, in providing privacy, there isan increased chance for the sample to be adulterated oreven replaced without detection. With oral fluid testing,individuals can be observed during sample collection, min-imizing the chance that the sample is inaccurate.

Collection Issues.—The core problem with drug test-ing has been with the collection methods. With oral fluidtesting, saliva is readily accessible and its collection doesnot involve an invasion of privacy. Oral fluid testing can de-tect recent drug use, specifically during the previous 24 to48 hours. Regardless of the method of intake (swallowing,snorting, or smoking), drugs eventually are absorbed intothe bloodstream. The circulation delivers part of the drugsto the salivary glands. The transfer of drug substance tooral fluid continues as long as the drug is in the blood-stream. Furthermore, there is a direct relationship betweenthe drug’s blood levels and its presence in oral fluids.

Whether it is the parent drug or metabolites, oralfluid testing can detect the substance in most cases.Usually, the drug detected in oral fluids is the active drugcomponent, which causes the patient to experience psy-choactive effects, euphoria, and impairment. Urine test-ing typically detects only inactive drug metabolites.

When a drug is detected in oral fluids, it shows thatthe drug was present in the individual’s body during sam-ple collection. If the oral fluid test is positive for heroin,it is likely the individual was under the drug’s influence

Occupational RisksOral fluid testing for drugs

Page 2: Oral fluid testing for drugs

Cone EJ: Oral fluid testing: New technology enables drug testingwithout embarrassment. Calif Dent Assoc J 34:311-315, 2006

Reprints available from EJ Cone, ConeChem, LLC, 441 Fairtree Dr,Severna Park, MD 21146

Clinical Significance.—Drug impairment isan unfortunate but pervasive problem in oursociety. Whether for employees or colleagues,as in a group or partnership practice, aware-ness of drug abuse is essential. Saliva testing of-fers advantages over urine analysis and pro-vides superior results.

Testing Procedures.—An oral fluid collector, usuallya small absorbent pad mounted on a plastic stick, resem-bling a small lollipop, is inserted into the mouth, usuallybetween the cheek and gums. In 2 to 3 minutes, the padabsorbs its maximum load of oral fluid. The collector isthen removed and placed in a sample vial, which is sealedfor transport to a testing laboratory.

Discussion.—Oral fluid testing offers a simple and ef-fective means for detecting drug levels in individuals whilemaintaining dignity and protection against the adulterationor substitution of samples. The procedure is easy, and itsreliability across a broad spectrum of drugs of abuse is sim-ilar to that of traditional urine-based testing.

22 Dental Abstracts

Oral and Maxillofacial PathologyNonspecific findings for malignant tumor of maxillary sinus origin

Background.—Patients whose complaint is maxillarysoft tissue swelling usually have lesions of dental origin,but nondental conditions must also be considered. A casewas reported in which the patient’s symptoms includedswelling, pain, and paresthesia, and the diagnosis turnedout to be a malignant process.

Case Report.—Man, 43, was referred to an acute careclinic with pain and swelling of the left maxillary quadrant.He was previously assumed to have an infection of odon-togenic origin and had undergone a 10-day course ofpenicillin VK, but received little benefit. On clinical exam-ination, he had moderately firm soft-tissue swelling in theleft maxillary buccal sinus area. Palpation elicited mildpain. A panoramic radiograph from the referring dentistshowed multiple missing and decayed teeth plus general-ized moderate to severe periodontal bone loss (Fig 1). Inthe area of the left maxillary sinus there was a poorly de-fined opacification. An incidental dome-shaped radiopaci-ty was found in the right maxillary sinus and believed tobe an antral pseudocyst. The patient also reported slightparesthesia along the distribution of the middle and pos-terior superior alveolar nerves.

With the patient under local anesthesia, teeth 22, 23,24, 25, 27, and 28 were extracted, which yielded some pu-rulent drainage. The involved areas were biopsied to ruleout the possibility of a malignant process. Surgical explo-ration found an irregular bony defect measuring 1 cm by1 cm and filled with granulation-like tissue on the anterior-

facial wall of the left maxillary sinus; this was submitted forhistopathologic analysis. The patient was given clindamy-cin 300 mg every 6 hours for 7 days and scheduled for afollow-up appointment. At follow-up, the swelling was sig-nificantly larger, both extraorally and intraorally (Fig 3). Ona panoramic radiograph the area of opacification now in-cluded the entire left maxillary sinus.

The biopsy specimen proved to be a malignant nonker-atinizing epithelial neoplasm comprising small round cellswith minimal cytoplasm and hyperchromatic nuclei.Further assessment yielded a diagnosis of sinonasal undif-ferentiated carcinoma. On contrast-enhanced computedtomography in the head and neck surgery department,there was significant destruction of the medial and lateralwalls of the maxillary sinus and left orbital floor. The pa-tient submitted to surgical and radiation treatment, whichincluded complete dental clearance. The tumor had ex-tensively infiltrated the maxillary sinus so complete surgi-cal resection with negative margins was not possible.

Discussion.—The patient’s maxillary soft tissueswelling indicated the presence of an odontogenic infec-tion, but the presence of paresthesia along with theswelling and pain eventually led to the discovery of a ma-lignant process. Biopsy confirmed the presence of a raremalignant tumor of maxillary sinus origin. Dental practi-tioners must remain vigilant in analyzing relatively non-specific symptoms so more serious conditions can be rec-ognized early and referred as appropriate.