MRONJ and COVID-19 Caution P

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CORONAVIRUS patients attend for treatment and possible extremely rare. By looking up grey literature, OHE for spread prevention efects on post-operative recovery. We I have found only one study where only three Sir, there is increasing evidence that a number are confdent that the risk of contracting participants (9%) who received the infuenza of retail mouthwashes and dentifrices can COVID-19 while attending a surgical vaccine got oral side efects associated with inactivate the SARS-CoV-2 coronavirus. It appointment is signifcantly reduced by fu-like symptoms, thus implying that no has been suggested that these products could patient risk assessment, the use of personal statistically signifcant relationship could be potentially be an adjunct to other measures protective equipment, meticulous infection established.3 Owing to the mass vaccination which the public have been advised to adopt prevention and control measures, and strict strategies of COVID-19, dentists among other to reduce transmission of the virus. adherence to the relevant standard operating clinical specialists are supposed to provide Given the safety, ubiquity and high levels procedure. We still could not neglect the care to the recently vaccinated patients – at of use of such products by the public, there COVID-19 risk, albeit negligible. We are this moment, Hill’s criteria of causal inference would appear to be no signifcant downside obliged to inform the patients about the risk and rigorous anamnestic recording should be risk associated with pre-empting the of ‘COVID-19 complications’ based on the strictly followed before jumping to irrelevant outcome of ongoing research in this area, and Montgomery ruling. conclusions. advocating that those travelling on public We therefore added ‘COVID-19 A. Riad, Brno, Czech Republic transport, visiting high street businesses and complications’ as one of the risks in our those making bubble visits perform thorough consent form. Tis has also given us the References oral hygiene procedures beforehand and as opportunity to re-audit our consent process 1. Luyten J, Bruyneel L, van Hoek A J. Assessing vaccine hesitancy in the UK population using a generalized close to the time of contact with others as within primary care oral surgery service amid vaccine hesitancy survey instrument. Vaccine 2019; 37: practical. the pandemic. To date, all patients assessed and 2494–2501. Given the primacy and experience of treated were not averse to being informed of 2. Tarakji B, Umair A, Alakeel R et al. Hepatitis B vaccination and associated oral manifestations: A non- the dental profession in communicating the possible risk of ‘COVID-19 complications’; systematic review of literature and case reports. Ann dental health education to the public and in fact, some expressed their gratitude. Med Health Sci Res 2014; 4: 829. 3. Sawires L. Efects of the infuenza vaccine on the its potential capacity to do so directly J. Liew, M. Winston, Shefeld, UK oral cavity. University of Florida, 2018. Available with patients, there would appear to be an https://doi.org/10.1038/s41415-021-2614-y at: https://stars.library.ucf.edu/cgi/viewcontent. cgi?article=1306&context=honorstheses (accessed argument for assessing the potential for the Oral side efects of COVID-19 vaccine December 2020). profession to convey government-supported https://doi.org/10.1038/s41415-021-2615-x advice, directly to patients, electronically. Sir, vaccine hesitancy (VH) is an emerging MRONJ and COVID-19 caution P. V. McCrory, Stockport, UK public health challenge nourished by https://doi.org/ 10.1038/s41415-021-2605-z misinformation. Last year, a national cross- Sir, of late, monoclonal antibodies including sectional survey-based study found out that tocilizumab and sarilumab have been Informed consent aversion to the potential side efects of vaccines utilised in the treatment of COVID-19. Sir, COVID-19 has had a signifcant impact was the most frequent cause for VH among Both drugs were used in more than 3,900 on the consent processes amid the current population groups in the UK.1 Te oral side COVID-19 cases in 15 countries worldwide, pandemic. As one of the primary care efects following the administration of vaccines with encouraging results.1 A randomised oral surgery service providers within the like polio and diphtheria were inconsistently controlled trial reported a signifcant region, we swifly updated our consent reported with a low level of confdence; they diference in mortality rate between the process for all outpatient oral surgical have never been reported independently, eg group receiving tocilizumab (28%) or procedures under local anaesthesia with or they emerged typically in conjunction with sarilumab (22%) compared to those receiving without conscious sedation. Te current other dermatologic and systemic symptoms.2 standard care (35.8%).1,2 Both act against consent process includes the ‘material risk’ Te oral side efects of non-orally administered interleukin-6 receptors and are commonly of becoming infected with coronavirus as vaccines including infuenza vaccine are used in the treatment of rheumatoid 

 arthritis. Tere has also been some evidence complacency (perception of risk, severity Te BDA would like to ensure those to associate tocilizumab with medication- of disease), trust and confdence (efcacy, dentists who are going above and beyond related osteonecrosis of the jaw (MRONJ).3,4 safety), convenience (barriers, access), sources are recognised by their peers and by our While other monoclonal antibodies such of information and socio-demographic Association, so I urge you to consider if you as denosumab have been proven to be truly characteristics (eg education, sex, ethnicity, know of anyone, through your Branch or associated with MRONJ, we must take into religion, post-vaccination behaviour).2 Section, your LDC or another professional account the potential efects in relation to As healthcare professionals, our patients group, to please nominate them for our BDA oral health. In light of this, readers should may come to us with questions regarding this Honours and Awards this year. be aware of the increased use of tocilizumab new vaccine, and we must equip ourselves Te deadline for this year’s round is 28 May. and sarilumab, as they may encounter a with the knowledge to answer these queries We are also keen to ensure younger dentists higher number of patients requiring dental and put their minds at ease. We are trained are recognised and our Joy Harrild Award extractions with an increased risk of MRONJ to interpret scientifc information, follow seeks nominations for dentists up to ten years in the future. Even though further studies are evidence-based research, and portray post-qualifed; the deadline for this is 30 April. required, it is worth keeping this in mind as a this information in an accessible and Details of how to nominate are on our website possible impact of the pandemic. comprehensible way. Directing patients at bda.org/honours-awards. Please note that A. Hasan, Birmingham, S. Alraisi, London, UK to reliable sources of information, such self-nominations are not accepted. I would as the WHO website, which provides a like to thank all those who have worked so References ‘mythbusters’ page collating the main hard during these difcult times and also to let 1. Davis N. Arthritis drugs could help save lives of Covid misinformation coronavirus messages, could you know we are there to support you if you patients, research fnds. The Guardian (London) 2021 2 January 7. Available at: https://www.theguardian. be useful. While personal opinion and need us – fnd out how we can help at bda.org/ com/world/2021/jan/07/covid-arthritis-drugs-could- choices cannot be overlooked, collectively, stress. help-save-lives-of-seriously-ill--patients-research-fnds we can work towards dismantling R. McMullan, Chair, BDA Honours and Awards (accessed January 2021). 2. REMAP-CAP Trial. REMAP-CAP response to the COVID- misinformation and protecting public health. Committee, UK 19 pandemic. Available at: https://www.remapcap.org/ E. Elleray, London, UK https://doi.org/10.1038/s41415-021-2618-7 coronavirus (accessed January 2021). 3. Mupparapu M, Akintoye S. New groups of drugs suspected in the medication-related osteonecrosis of References DHSC is not listening the jaws (MRONJ). J Orofac Sci 2017; 9: 67. 4. Bindakhil M A, Mupparapu M. Osteomyelitis of the 1. Mills M C, Rahal C, Brazel D et al. COVID-19 vaccine Sir, on 8 June 2020, practices in the UK mandible exhibiting features of medication-related deployment: behaviour, ethics, misinformation and reopened afer the lockdown precipitated osteonecrosis in a patient with history of tocilizumab policy strategies. The Royal Society, 21 October 2020. treatment. J Orofac Sci 2018; 10: 53–55. Available at: https://royalsociety.org/-/media/policy/ by the pandemic. Since then, dentists have https://doi.org/10.1038/s41415-021-2616-9 projects/set-c/set-c-vaccine-deployment.pdf?la=en- rejigged their practices at some expense to GB&hash=43073E5429C87FD2674201CA (accessed December 2020). maintain full cross-infection control and Public vaccine distrust 2. World Health Organization. Coronavirus disease social distancing in line with a series of (COVID-19) advice for the public: Mythbusters. 23 Sir, I am surprised and concerned November 2020. Available at: https://www.who.int/ standard operating procedure guidelines that, according to a report on the emergencies/diseases/novel-coronavirus-2019/advice- issued by the Department of Health and Social for-public/myth-busters (accessed December 2020). behavioural aspects of vaccine update and Care (DHSC). In time, output ramped up misinformation, published by the British https://doi.org/10.1038/s41415-021-2617-8 so that most practices are currently working Academy and Royal Society, around 36% of at what they consider to be a safe speed Nominations sought the UK population are either uncertain or commensurate with a safe environment, unlikely to be vaccinated against COVID-19.1 Sir, since last March, I know that so many something around 20% of pre-COVID levels. Vaccinations are one of the most successful dentists are stepping up and doing truly Te profession was dismayed to learn public health measures in history, preventing extraordinary things to ensure our patients in December 2020 that, as of 1 January multiple diseases, hence saving millions of receive the best possible care, and the 2021 and with only a few days’ notice, the lives and also bringing about large-scale profession is represented and supported DHSC was demanding that output was to societal and economic benefts. For this to during this COVID-19 pandemic. Over the be increased to 45%. Tis fgure would be be successful, a community-level vaccine last few months, I have also seen colleagues accompanied by a return to the invidious coverage of 80%+ for COVID-19 will working long hours to give consistent UDA as a measure of output along with a be required.1 Misinformation regarding evidence-based advice at this time of complex set of bands which determined the vaccine is driven by fve key factors: uncertainty, so we can protect our patients, levels of clawback if targets were not reached. distrust of science and selective use of staf, families and ourselves. Tese are truly Regrettably, the Department has not expert authority, distrust in pharmaceutical unprecedented times for dentistry. In my listened to and, in reality, has completely companies and government, simplistic long career, I have never seen our profession ignored the arguments of the GDPC that this explanations, use of emotion and anecdotes put under such unrelenting pressure for target was untenable for a number of reasons, to impact rational decision-making, and such a sustained period of time. I am these being: development of information bubbles and proud of how brilliantly our profession has • Practices are currently working to echo chambers. Behavioural factors include responded. capacity, taking into account high levels 