Management of Medication-Related Osteonecrosis of the Jaw: An Overview of National and International Guidelines.

There is variability amongst clinicians in the management of medication-related osteonecrosis of the jaw (MRONJ) though numerous guidelines are available. The aim of this critical review is to appraise current international and national guidelines on MRONJ to evaluate areas of consensus or inconsistency, identify areas lacking evidence, and discuss recommendations with agreement and variability across guidelines. A literature search was performed to identify all national and international guidelines published until May 2022 on the prevention and treatment of MRONJ. Included guidelines were compared and critically appraised with Appraisal of Guidelines for Research and Evaluation II (AGREE II). The included sixteen guidelines were published from ten different countries, two of which had international collaborations. AGREE II assessment found four guidelines of high quality. There is consensus to optimise oral health prior to and during therapy, to conservatively manage established MRONJ in earlier stages and consider surgery at advanced stages. There is disparity on strategies to reduce the risk of osteonecrosis such as the avoidance of invasive dental procedures, therapy suspension, and techniques to reduce the impact of invasive surgery. The authors recommend an international lead in the development of dental guidelines to establish a global standardised management approach aiming for better health equality.

Critical Evaluation of Global Infection Prevention and Control Guidelines for Dentistry Published during the First 2 Years of the COVID-19 Pandemic.

Objectives: The outbreak of the coronavirus disease (COVID-19) encouraged immediate actions by governments and healthcare associations across the world to flatten the curve and prevent health systems from being overburdened. As dentistry comprises aerosol-generating procedures (AGPs), which could increase the risk of infection, various guidelines were issued for dental services which focused on infection prevention and control (IPC) measures for COVID-19. This systematic review focuses on dental IPC guidelines, with the aim of comparing these guidelines against a gold standard. Method: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist was employed. Predefined inclusion and exclusion criteria were constructed. Information sources comprised Google Scholar, PubMed, and a manual search from December 2019 to December 2021. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used. Consensus scoring was applied for all guidelines. Results: A total 61 guidelines were included in the review. The UK national guideline was used as a gold standard as it ranked the highest AGREE score (75 out of 84) and thus was established for comparison with each of the included guidelines. Overall, 40% of the included guidelines had a high consensus score in relation to the UK national guideline. Conclusion: This systematic review highlighted the variability in content and quality of advice given by different organizations in response to the COVID-19 pandemic in their efforts to reduce SARS-CoV-2 transmission in dentistry. Establishing a single worldwide fast-acting dental organization would ensure that high-quality standardized guidance is available, to enhance health equality and worldwide dental clinical standards.

The effect of SARS-CoV-2 on the prescribing of antimicrobials and analgesics by NHS general dental practitioners in England.

Aims To ascertain the effect of SARS-CoV-2 on the utilisation of antibacterial agents and analgesics in primary dental care.Methods Antibacterial agents and analgesics (eg paracetamol, aspirin) prescribed in England by general dental practitioners for the periods April-July 2019 and April-July 2020 were analysed.Results Antibacterial agents prescribed during COVID-19 restrictions in 2020 (799,282) were higher than a similar time period in 2019 (654,332) by 22%. Amoxicillin was used the most (2020 = 65.0%; 2019 = 66.3%) followed by metronidazole (2020 = 30.2%; 2019 = 28.7%). Erythromycin was prescribed at a similar rate, with lincosamides (clindamycin) prescribed more frequently in 2020 (2020 = 0.6%; 2019 = 0.5%). Clarithromycin was prescribed twice more often in 2020 (0.6%) in comparison to 2019 (0.3%). Co-amoxiclav (0.5%) and phenoxymethylpenicillin (0.3%) were prescribed at a similar rate. Analgesics use increased by 84% (2020 = 28,563; 2019 = 15,507). Use of dihydrocodeine tartrate increased (2020 = 40.9%; 2019 = 32.9%), followed by diclofenac sodium (2020 = 24.6%; 2019 = 12.8%). The opposite trend was seen in relation to ibuprofen with use decreasing (2020 = 19.4%; 2019 = 39.8%) while paracetamol use only slightly increasing (2020 = 15.1%; 2019 = 14.6%).Conclusions COVID-19 restrictions on dental care in England resulted in a marked increase in prescribing antibacterial agents and a very marked increase in prescription-only analgesics.

An evaluation of sepsis in dentistry.

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major health concern and causes substantial morbidity and mortality. It is imperative that the signs of sepsis are identified early in both adult and paediatric patients and appropriately escalated to initiate early treatment and improve prognosis. This paper aims to discuss the change in classification from the previous systemic inflammatory response syndrome (SIRS) criteria to the current definition in adults and also the unchanged definition in children. The hallmark signs of sepsis (both red and amber flags) are discussed in relation to their underlying cellular mechanisms to provide a comprehensive overview for clinicians in primary care, hospital and community settings. The rise of antimicrobial resistance is also an increasing global health concern with resistant bacteria from common infections likely to result in greater patient morbidity and worse outcomes.A literature search identified reported sepsis cases in dentistry through searches in Ovid Medline and Embase from January 1990 to December 2019. Only primary studies were included with no restrictions on languages. Four articles were identified which reported sepsis associated with tooth extractions, dental abscess and submental/submandibular cellulitis. It is well known that locoregional infections of dental origin have the potential to cause sepsis. Therefore, dental healthcare professionals need to be vigilant and understand the specific signs and escalation protocols to ensure patient safety.

Fallow time determination in dentistry using aerosol measurement in mechanically and non-mechanically ventilated environments.

Aim To calculate fallow time (FT) required following dental aerosol generating procedures (AGPs) in both a dental hospital (mechanically ventilated) and primary care (non-mechanically ventilated). Secondary outcomes were to identify spread and persistence of aerosol in open clinics compared to closed surgeries (mechanically ventilated environment), and identify if extraoral scavenging (EOS) reduces FT and production of aerosol.Methods In vitro simulation of fast handpiece cavity preparations using a manikin was conducted in a mechanically and non-mechanically ventilated environment using Optical Particle Sizer and NanoScan at baseline, during the procedure and fallow period.Results AGPs carried out in the non-mechanically, non-ventilated environment failed to achieve baseline particle levels after one hour. In contrast, when windows were opened after AGPs, there was an immediate reduction in all particle sizes. In mechanically ventilated environments, the baseline levels of particles were very low and particle count returned to baseline within ten minutes following the AGP. There was no detectable difference between particles in mechanically ventilated open bays and closed surgeries. The effect of the EOS on reducing the particle count was greater in the non-mechanically ventilated environment; additionally, it also reduced the spikes in particle counts in mechanically ventilated environments.Conclusion High-efficiency particulate, air-filtered mechanical ventilation, along with mitigation (high-volume suction), resulted in reduction of fallow time (ten minutes). Non-ventilated rooms failed to reach baseline level even after one hour of fallow time. There was no difference in particle counts in open bays or closed surgeries in mechanically ventilated settings with an extraoral suction device reducing particulate spikes. This study confirms that AGPs are not recommended in dental surgeries where no ventilation is possible.

The COVID-19 pandemic and dentistry: the clinical, legal and economic consequences - part 1: clinical.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus which causes COVID-19, is highly contagious. Dentistry is a high-risk profession for occupational virus transmission because of the close proximity of the operator to the patient during treatment and the procedural generation of aerosols.The impact on the provision of dental care has been profound, with routine care restricted or paused for a period around the world. There have been adverse consequences for dental education and clinical research. Emergency and urgent care provisions have generally proceeded. However, even when a patient's condition is deemed urgent, access to the appropriate care may not have been possible due to lack of the recommended personal protective equipment. The common dental diseases of caries and periodontitis usually present with signs and symptoms after some advancement, hence the recommended regular dental examination so that these may be diagnosed early by a professional with suitable lighting, instruments and radiography. Conditions such as oral cancer similarly present in their early stages without symptoms. Many countries introduced telephone and video consultations for patients with symptoms but much disease has gone undiagnosed and without management.It is difficult to ascertain the full effect of the disruption to dental services, education and research but it is likely to be substantial. The immediate future will focus on return to routine care provision with likely longer-term permanent changes.

The COVID-19 pandemic and dentistry: the clinical, legal and economic consequences - part 2: consequences of withholding dental care.

As routine care was suspended in most countries, one could anticipate progression of undiagnosed and managed oral disease. Patients are usually unaware of the development of oral disease as it is not visible to them and largely asymptomatic, especially in its early stages. The natural progression of conditions such as caries and periodontitis is inevitable without diagnosis and management. The full extent of patient harm because of the suspension of routine dental care can only be estimated when routine oral examinations are fully re-established, and even then, we will probably never know the number of individuals impacted or the extent of disease progression and harm.In first-world countries, there has always been a back-up emergency treatment system for dental problems. For example, in the UK, the safety net for life-threatening swellings and for acute pain relief is the accident and emergency services. This system remained in place during the COVID-19 pandemic. Courts could be expected to understand the coronavirus context and would take this into account should there be a complaint against the clinician about access to care.The suspension of routine dental care to save lives will lead to the closure of many dental practices due to substantial financial impact. The return to routine care will be slow, with prioritisation of non-aerosol generating procedures while we look to further understand methods to mitigate transmission risk via infected aerosol and spatter. Inevitably, the cost of personal protective equipment and the lower volume of patients pose a continued threat to businesses.

The efficacy of an extraoral scavenging device on reduction of splatter contamination during dental aerosol generating procedures: an exploratory study.

Introduction This study was conducted in light of the SARS-CoV-2 pandemic, which brought UK dentistry to a standstill. The market has seen a recent influx of unproven extraoral scavengers (EOSs), which claim to reduce the risk of particulate spread.Aims To investigate the efficacy of a commercially available EOS device on contamination reduction during dental aerosol generating procedures (AGPs). The secondary aim was to investigate differences between open and closed dental operatories.Method Dental procedures were simulated on a dental manikin using citric acid (10%) added to the water lines with universal indicating paper (UIP) placed in strategic locations in the operatory, on the clinician and assistant. Chromatic change related to settling of splatter containing citric acid on the UIP was analysed to calculate percentage intensity of splatter contamination.Results EOSs resulted in 20% reduction in frequency and 75% reduction in mean intensity of contamination of operatory sites. There was a 33% and 76% reduction in mean intensity contamination for clinician and assistant, respectively. Use of rubber dam and four-handed dentistry resulted in further reduction.Discussion This exploratory study demonstrates contamination by splatter in a simulated dental setting. The concern in dentistry regarding aerosol requires further quantitative investigation of smaller particles.Conclusions The routine use of four-handed dentistry and rubber dam should continue where possible to maximise risk mitigation during AGPs. However, on the basis of our findings, the use of an EOS device can further mitigate the magnitude and concentration of splatter.

Quantitative analysis of particulate matter release during orthodontic procedures: a pilot study.

Introduction Transmission of SARS-CoV-2 through aerosol has been suggested, particularly in the presence of highly concentrated aerosols in enclosed environments. It is accepted that aerosols are produced during a range of dental procedures, posing potential risks to both dental practitioners and patients. There has been little agreement concerning aerosol transmission associated with orthodontics and associated mitigation.Methods Orthodontic procedures were simulated in a closed side-surgery using a dental manikin on an acrylic model using composite-based adhesive. Adhesive removal representing debonding was undertaken using a 1:1 contra-angle handpiece (W&H Synea Vision WK-56 LT, Bürmoos, Austria) and fast handpiece with variation in air and water flow. The removal of acid etch was also simulated with the use of combined 3-in-1 air-water syringe. An optical particle sizer (OPS 3330, TSI Inc., Minnesota, USA) and a portable scanning mobility particle sizer (NanoScan SMPS Nanoparticle Sizer 3910, TSI Inc., Minnesota, USA) were both used to assess particulate matter ranging in dimension from 0.08 to 10 µm.Results Standard debonding procedure (involving air but no water) was associated with clear increase in the 'very small' and 'small' (0.26-0.9 µm) particles but only for a short period. Debonding procedures without supplementary air coolant appeared to produce similar levels of aerosol to standard debonding. Debonding in association with water tended to produce large increases in aerosol levels, producing particles of all sizes throughout the experiment. The use of water and a fast handpiece led to the most significant increase in particles. Combined use of the 3-in-1 air-water syringe did not result in any detectable increase in the aerosol levels.Conclusions Particulate matter was released during orthodontic debonding, although the concentration and volume was markedly less than that associated with the use of a fast handpiece. No increase in particulates was associated with prolonged use of a 3-in-1 air-water syringe. Particulate levels reduced to baseline levels over a short period (approximately five minutes). Further research within alternative, open environments and without air exchange systems is required.

The oral mucosal and salivary microbial community of Behçet's syndrome and recurrent aphthous stomatitis.

BACKGROUND: Behçet's syndrome (BS) is a multisystem immune-related disease of unknown etiology. Recurrent aphthous stomatitis (RAS) is characterized by the presence of idiopathic oral ulceration without extraoral manifestation. The interplay between the oral microbial communities and the immune response could play an important role in the etiology and pathogenesis of both BS and RAS. OBJECTIVE: To investigate the salivary and oral mucosal microbial communities in BS and RAS. METHODS: Purified microbial DNA isolated from saliva samples (54 BS, 25 healthy controls [HC], and 8 RAS) were examined by the human oral microbe identification microarray. Cultivable salivary and oral mucosal microbial communities from ulcer and non-ulcer sites were identified by matrix-assisted laser desorption/ionization time-of-flight analysis. Mycobacterium spp. were detected in saliva and in ulcer and non-ulcer oral mucosal brush biopsies following culture on Lowenstein-Jensen slopes and Mycobacterial Growth Indicator Tubes. RESULTS: There was increased colonization with Rothia denticariosa of the non-ulcer sites of BS and RAS patients (p<0.05). Ulcer sites in BS were highly colonized with Streptococcus salivarius compared to those of RAS (p<0.05), and with Streptococcus sanguinis compared to HC (p<0.0001). Oral mucosa of HC were more highly colonized with Neisseria and Veillonella compared to all studied groups (p<0.0001). CONCLUSIONS: Despite the uncertainty whether the reported differences in the oral mucosal microbial community of BS and RAS are of causative or reactive nature, it is envisaged that restoring the balance of the oral microbial community of the ulcer sites may be used in the future as a new treatment modality for oral ulceration.