Successful treatment of SAPHO syndrome (chronic nonbacterial osteomyelitis and acne) with anakinra and denosumab. Case report and review of therapy.

SAPHO is an acronym derived from capital letters of Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO). SAPHO syndrome is an umbrella term covering a constellation of bone lesions and skin manifestations. A 40-year-old male complained about his jaw and back pain, swelling of multiple joints and weight loss accompanied by physical deterioration and acne type skin lesions. Laboratory tests revealed abnormal elevation of inflammatory markers. Imaging studies illustrated multiple osteolytic bone lesions and paraosseal infiltrates. According to the set of criteria diagnosis of SAPHO syndrome was stated. The patient was treated with glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs), but only high dose dexamethasone and prednisone were effective. Daily subcutaneous administration of anakinra at the dose of 100 mg was initiated due to limited response to more classical therapies. Because of planned mandibular osteosynthesis initiation of denosumab was preferred before bisphosphonates. Therapeutic response was confirmed by FDG-PET/MR after 5 months of anakinra and denosumab therapy, showing decreased accumulation of FDG in periosteal and paraosseal infiltrates. Inflammatory markers significantly decreased, bone pain deferred but skin manifestation receded only partially. Therefore the response was evaluated as partial remission.

Update on Focal Infection Management: A Czech Interdisciplinary Consensus.

BACKGROUND: The focal infection theory has been used to explain several chronic systemic diseases in the past. Systemic diseases were thought to be caused by focal infections, such as caries and periodontal diseases, and dentists were held responsible for these diseases due to the spread of oral infections. As knowledge of the interrelationship between oral microorganisms and the host immune response has evolved over the last few decades, the focal infection theory has been modified in various ways. The relationship between oral and systemic health appears to be more complex than that suggested by the classical theory of focal infections. Indeed, the contribution of the oral microbiota to some systemic diseases is gaining acceptance, as there are strong associations between periodontal disease and atherosclerotic vascular disease, diabetes, and hospital-associated pneumonia, amongst others. As many jurisdictions have various protocols for managing this oral-systemic axis of disease, we sought to provide a consensus on this notion with the help of a multidisciplinary team from the Czech Republic. METHODS: A multidisciplinary team comprising physicians/surgeons in the specialities of dentistry, ear-nose and throat (ENT), cardiology, orthopaedics, oncology, and diabetology were quetioned with regard to their conceptual understanding of the focal infection theory particularly in relation to the oral-systemic axis. The team also established a protocol to determine the strength of these associations and to plan the therapeutic steps needed to treat focal odontogenic infections whenever possible. RESULTS: Scoring algorithms were devised for odontogenic inflammatory diseases and systemic risks, and standardised procedures were developed for general use. CONCLUSIONS: The designed algorithm of the oral-systemic axis will be helpful for all health care workers in guiding their patient management protocol.

Comparison of COVID-19 epidemic among Czech dentists and the Czech general population.

Dentists are one of the professional groups most at risk for COVID-19 infection. Enhanced protective measures in dentistry have been adopted worldwide; however, it is unclear to what extent they were sufficient. To assess whether the protective measures outweighed the high infection risk, we compared COVID-19-related data between Czech dentists and the general Czech population. The data was obtained through a survey study attended by 15.8% of Czech Dental Chamber members. Data of the general population were acquired from the Czech Ministry of Health database. By the end of May 2022, COVID-19 full vaccination and 1st booster dose rates among study participants were 85.8% and 70.1%, respectively, which is significantly higher (p < 0.0001) compared to the Czech general population aged over 24 years (74.9% and 49.4%, respectively). To the same date, PCR/Antigen test verified COVID-19 prevalence among participants was 41.7%, and 49.9% among the general population (p < 0.0001). Prevalence and reinfection rates among individuals who received the 1st booster were significantly lower than among individuals without the booster or full vaccination (p < 0.0001). Persons who received the booster showed a faster return to work, shorter and different types of complications. Willingness to future vaccination was positive among 79.7% of respondents. Mandatory vaccination for healthcare workers and the general population was supported by 62.0% and 49.0%, respectively. The results showed that the high risk of COVID-19 infection associated with dentistry did not lead to higher COVID-19 prevalence among respondents compared to the general population.

The Effect of Priority Access of Dentists to COVID-19 Vaccination in the Czech Republic.

The lack of vaccines in the first half of 2021 led to the need to prioritize access to vaccination. This approach has been associated with a number of issues, including ethics and effectiveness. However, analyses providing data on this topic are scarce. This work describes the effect of a priority approach to vaccination on the different development of the pandemic between Czech dentists and the Czech general population. The dentist-related data were obtained from survey studies published in 2021 and 2022, and the Czech general population data were mined from the Our World in Data online database. The analysis shows that until the beginning of vaccination, i.e., in December 2020, the prevalence of laboratory-confirmed COVID-19 infection among dentists was higher than in the general population by 22.5% (8.65% vs. 6.70%). This trend was reversed already in the first month after the start of vaccination, and the difference increased every month. Finally, in June 2021, priority vaccination statistically significantly (p < 0.0001) reduced the resulting prevalence among dentists (12.67%) compared to the general population (15.55%), which is a difference of 18.5%. This represents a prevalence shift between the populations by 40% during 6 months of priority vaccination. The results support the conclusion that the priority vaccination of healthcare workers was not only ethical but also rational and effective.

Paediatric Deep Neck Infection-The Risk of Needing Intensive Care.

Deep neck infections are potentially dangerous complications of upper respiratory tract or odontogenic infections. The pathophysiology, clinical presentation, and potential spreading depend on the complex anatomy of the neck fascia. These infections can lead to severe pathological conditions, such as mediastinitis, sepsis, and especially airway impairment with difficult management. Because of the risk of life-threatening emergency situations and the possible impacts on the overall health status of affected children, their early recognition is of utmost importance. Torticollis, drooling, and stridor are the most common signs of advancing disease. Children presenting with these symptoms should be admitted to the paediatric intensive care unit for vital function monitoring, where the airway could be readily secured if function is compromised.

COVID-19 Vaccination among Czech Dentists.

This work describes and evaluates vaccination against COVID-19 among members of the Czech Dental Chamber during the pre-booster vaccination phase. A cross-sectional online survey was conducted between 23 June and 4 September 2021, among 2716 participants, representing 24.3% of all chamber members. A total of 89.5% of respondents stated that they were registered for vaccination against COVID-19, their vaccination had started or been completed, or had a medically relevant reason to avoid vaccination. A total of 79.6% of respondents stated that they were fully vaccinated, most of them with the Comirnaty (Pfizer−BioNTech) vaccine (88.3%). The vaccination rate among males was significantly higher than among females (p = 0.001, OR 1.48). The main reasons for vaccination were professional (91.5%). The share of fully vaccinated participants was significantly higher (p < 0.0001, OR = 8.17) compared to the Czech general population (30.8%). A COVID-19 vaccine breakthrough infection rate was 0.42%. The study shows that both the willingness to vaccinate and the proportion of fully vaccinated individuals among Czech dentists are high, and only about 10% of them refused vaccination based on reasons classified as not medically relevant.

COVID-19 among Czech Dentistry Students: Higher Vaccination and Lower Prevalence Compared to General Population Counterparts.

The restrictions on medical students' clinical education during the COVID-19 pandemic has affected their professional readiness and often lengthened their training. These negative impacts are often considered a necessary price as clinical education is hypothesized to be associated with a high risk of pandemic spread. This work assesses this hypothesis based on COVID-19 epidemiological data among Czech dentistry students and their comparison to data of the Czech general population of similar age. We addressed two of the five Czech medical faculties (Charles University, Faculty of Medicine in Hradec Kralove and in Pilsen) providing dentistry study program with a survey. A total of 240 students participated, representing a 66.9% response rate. Over 75% of respondents participated in clinical education during the pandemic. The school environment was identified as a place of infection by only 9.8% of respondents who were aware of where they were infected. Overall, 100% of students used FFP2 respirators, and 75.3% used face shields or protective glasses while working with patients. By the end of May 2022, COVID-19 full vaccination and 1st booster rates among students were 93.8% and 54.6%, respectively, which is significantly higher (p < 0.0001, OR 7.3, 95% CI 4.4−12; p < 0.0001, OR 3.7, 95% CI 2.9−4.8, respectively) compared to their peers from the general population (67.1% and 24.4%, respectively). A total of 75.4% of respondents supported mandatory COVID-19 vaccination for healthcare professionals. To the same date, PCR and/or antigen test verified COVID-19 prevalence among students was 37.1%, while among peers from the general population, it was 45.1% (p = 0.015, OR 1.2, 95% CI 1.0−1.5). The combination of extensive protective measures and high vaccination against COVID-19 led to significantly lower COVID-19 prevalence among the students compared to their general population counterparts.

Denosumab-related osteonecrosis of the external auditory canal-benefit of the early surgical management.

Background: Antiresorptive drugs are widely used to reduce bone mineral loss in patients with osteoporosis and to prevent skeletal-related events in patients with metastatic cancers and multiple myeloma (MM). Both the bisphosphonates (BP) and denosumab typically used in this indication were shown to be effective and relatively safe. Obviously, this medication could have some adverse effects; one of them is osteonecrosis of the external auditory canal. Only sporadic cases of external auditory canal osteonecrosis have been published yet. Here, we provide a case of denosumab-related osteonecrosis of the external auditory canal successfully treated surgically in the early stage of the disease.Case report: A 68-year-old patient with breast cancer underwent comprehensive oncological treatment, including denosumab administration. She was diagnosed with osteonecroses in the jaw and ear canal. The necrotic bones in both regions were resected with primary wound closure. Both affected sites healed well with no signs of necrosis recurrence.Conclusions: Osteonecrosis of the external auditory canal is a rare but probably underdiagnosed complication of antiresorptive medication. It has a negative impact on patient quality of life if left untreated. Early surgical treatment appears to be effective. The authors highlight several similarities with medication-related osteonecrosis of the jaw. Therefore, an analogous disease staging and treatment rationale is suggested.

COVID-19 Prevalence among Czech Dentists.

This work evaluates the prevalence of coronavirus disease (COVID-19), a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), among members of the Czech Dental Chamber. The assessment was based on an online questionnaire filled out by 2716 participants, representing 24.3% of all chamber members. Overall, 25.4% of the participants admitted they were diagnosed with COVID-19 by 30 June 2021, with no statistical differences between the sexes. While in the age groups under 50 the reported prevalence was around 30%, with increasing age, it gradually decreased to 15.2% in the group over 70 years. The work environment was identified as a place of contagion by 38.4% of the respondents. The total COVID-19 PCR-verified positivity was 13.9%, revealing a statistically lower prevalence (p = 0.0180) compared with the Czech general population, in which the COVID-19 PCR-verified positivity was ~15.6% (fourth highest rank in the world). The total infection-hospitalization ratio (IHR) was 2.8%, and the median age group of hospitalized individuals was 60-70 years. For respondents older than 60 years, the IHR was 8.7%, and for those under 40 years, it was 0%. Of the respondents, 37.7% admitted that another team member was diagnosed with COVID-19, of which the most frequently mentioned profession was a nurse/dental assistant (81.2%). The results indicate that although the dentist profession is associated with a high occupational risk of SARS-CoV-2 infection, well-chosen antiepidemic measures adopted by dental professionals may outweigh it.

The use of platelet-rich fibrin in the surgical treatment of medication-related osteonecrosis of the jaw: 40 patients prospective study.

OBJECTIVES: Medication-related osteonecrosis of the jaw (MRONJ) is defined as exposed bone in the maxillofacial region persisting for more than eight weeks in patients who are or were treated with antiresorptive or antiangiogenic agents and had no radiation therapy to the craniofacial region or obvious metastatic disease of the jaws. It is a recognised side effect of antiresorptive or antiangiogenic medication. To date, there is no specific gold standard treatment for MRONJ cases. The aim of this study was to evaluate the successful rate of surgical treatment with adjuvant local application of platelet rich fibrin. METHODS: 40 patients treated with necrotic bone resection and adjuvant local application of platelet-rich fibrin (PRF) were included. Treatment outcomes were evaluated after 12 months. RESULTS: The outcome of surgical treatment was successful in 34 of all 40 patients (85%), in 12 months follow-up. If we evaluate only cases where removal of all necrotic bone was possible the success rate was increased to 94%. A significant association between size of necrotic bone and treatment response was found (P=0.014, Wilcoxon rank sum test with continuity correction). CONCLUSIONS: Surgical treatment of MRONJ with adjuvant local PRF application proved to be very effective and safe, especially in early stages when all necrotic bone can be easily removed.

Osteonecrosis of the external auditory canal associated with oral bisphosphonate therapy: case report and literature review.

OBJECTIVE: To present the first case of a patient with oral bisphosphonates-associated ear canal osteonecrosis (BPECO), review previously published cases, and suggest a definition of BPECO. PATIENT: A 79-year-old woman with left otorrhea and earache was treated for otitis externa for 2 months. The examination revealed a deep floor of the left ear canal defect. The bisphosphonates were discontinued. By the end of the 6-week-course of intravenous antibiotics, the bone defect progression ceased. Already a month later, the defect was lined from approximately 50%. Unfortunately, the patient was lost to follow-up at this stage. She was on oral bisphosphonates for 10 years for severe osteoporosis. She had never been exposed to radiotherapy or had any surgery in the left ear. She admitted to be a habitual cotton bud user for aural toilet. RESULTS: A CT scan showed an aggressive lobulated mass consistent with carcinoma. A biopsy suggested osteomyelitis with no evidence of malignancy. The final diagnosis was agreed to be the first case of oral BPECO. INTERVENTION: Debridement, intravenous antibiotics, and cessation of bisphosphonates CONCLUSION: The BPECO is not very well-known clinical diagnosis among ENT surgeons and, therefore, often misdiagnosed for ear canal cholesteatoma, malignant otitis externa, or temporal bone malignancies. It seems reasonable to re-review patient's medical history with focus on BP medication in cases with negative biopsy. Although the BP osteonecrosis is a rare phenomenon, the large volume of BP prescription makes the number of patients at risk significant.