An Overview On Oral Manifestations Of Covid-19

Keywords

SARS-CoV-2; COVID-19; Oral Manifestation; Management.

Introduction

Severe Acute Respiratory Syndrome CoronaVirus-2 (SARSCoV- 2) or COVID-19, were at the start, reported in December 2019 by the officials in Wuhan City, China (WHO, 2020-a). Concerned by the continuous rise in the cases, WHO on March 11, 2020, assessed the situation could be characterized as a pandemic before declaring the outburst as a Public Health Emergency of International Concern (PHEIC) on April 27, 2020 (WHO, 2020- b). The outbreak has affected more than 148 million people causing more than 3.1 million deaths worldwide (WHO, n.d.). Commonly seen symptoms include fever, dry cough, and fatigue , loss of taste or smell, diarrhea, nasal congestion, nausea or vomiting, headache, chills or dizziness, conjunctivitis different types of skin rashes, sore throat, and muscle or joint pain (WHO, 2020-c). As with any other viruses, COVID-19 is also evolving overtime, resulting in thousands of mutations (WHO, 2021). The three widely known mutations are B.1.1.7 (first reported in the United Kingdom), B.1.351 (first reported in South Africa), and P.1 (first reported in Brazil) (“How Many New Coronavirus,” 2021). The United States has discovered about 677 mutants whereas India has detected over 24,000 mutants in 7,000 variants (Haseltine, 2021; IANS, 2021).

Pathogenesis

In early infection, SARS-CoV2 attacks specific cells like bronchial epithelial,nasal cells and pneumocytes. This is mainly via the viral structural spike(S) protein that binds to the angiotensin-converting enzyme 2 (ACE2) receptor. Corona virus entry into the host cells is mediated by SARS- CoV2 S protein which is activated by cleavage of ACE2. Also, The viral uptake is upgraded by, Type 2 trans-membrane Serine Protease (TMPRSS2) existing in the host cells.

SARS-CoV-2 infects and destroys the T lymphocytes. The viral inflammatory response, impedes lymphopoiesis and enhances lymphocyte apoptosis.During later stages of viral infection, especially when viral replication is rushed, epithelial-endothelial barrier integrity is found to be compromised. Also, dysfunctional alveolarcapillary oxygen transmission, and diminished oxygen diffusion capacity is caused due to bradykinin-dependent lung angioedema. When COVID-19 infection is severe, the immediate activation of coagulation and exhaution of clotting factors occurs in inflamed lung tissues and pulmonary endothelial cells may result in microthrombi formation and contribute to the thrombotic complications, such as deep venous thrombosis, pulmonary embolism stroke and Myocardial Infarctions.

Concerning to the oral cavity, prescence of ACE2 in the cells of oral mucosa and tongue, indicates that the mouth is likely infectious route of SARS CoV2 and therefore advocates an a relatedness between this viral infections and oral ulcers associated with COVID-19.

Clinical features:The newer variants of COVID-19 have a wide range of symptoms and medical complications (ANI, 2021). The primary symptoms of the variants include fever, muscle pain, loss of smell and taste, and dry and persistent cough. The additional symptoms which is seldom found include conjunctivitis, sore throat, headache, rashes, upset stomach, and discoloration of fingers and toes (Pandey, 2021).

Oral Manifestations: According to Froum (2020), physicians are examining the direct connection between COVID-19 and oral disease, as the survivors who battled against the disease for weeks to months, found a decline in their oral health resulting in sensitive gums, teeth cracking, teeth falling out, and teeth turning grey. Some studies suggest that the mouth might be the most vulnerable area to the virus because of the abundant Angiotensin Converting Enzyme (ACE2) receptors found in the oral tissue. The common oral manifestations associated with COVID-19 are gingival inflammation, xerostomia (dry mouth), oral ulcerations and gingival tissue breakdown, and loss of taste and smell. Thus considering the importance of oral health and the relationship between oral health and COVID-19, the present study aimed at examining out the prevalence of oral manifestations of COVID-19 and the suggested management.

Method

Information search

Electronic search engines such as PubMed, Scopus, ScienceDirect, and Web of Science were used. To access the gray literature, a manual search was performed on Google Scholar. All the articles that were published till April 25, 2021, were included. The search keywords include: “Symptoms”, “Oral Manifestation”, “Mouth disease”, “COVID-19”, “SARS-CoV-2”, and “India”.

Study selection

Those studies which included oral manifestation of COVID-19, preferably in prevalence, and those which included details about management at different levels were included in this review.

Inclusion and exclusion criteria

The studies which were published on oral manifestations with the percentage indicated, preferably in the Indian context were included in the review. Studies that were published in languages other than English were excluded from the review.

Analysis

Author(s), year of publication, type of publication, country where the study was done, different types of oral manifestations, and the methods used to manage the symptoms were collected for the present review. Frequencies, the average (mean), largest observation (maximum), and smallest observation (minimum) were calculated from the available data.

Results

The present review sampled 22 papers which include 13 research articles, 7 review articles, 1 short communication, and 1 general article.

As shown in table 1, most of the papers were published in 2020 (63.6%) while the rest were published in 2021 (36.4%). More than half the papers sampled the Indian population (53.3%) followed by The United States (13.3%).

As shown in table 2, the most common oral symptoms are enanthema (58.5%), oral lesions (48.5%), dysgeusia (27.84%) followed by the sore throat (25.43%) followed by. The other common symptoms are and oral bleeding (22.95%).

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Table 1:

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Table 1. Clinical periodontal & radiographic parameters in both studied groups throughoutthe experimental period.

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Table 2:

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Table 2. Clinical periodontal & radiographic parameters in both studied groups throughoutthe experimental period.

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Table 3:

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Table 3. Clinical periodontal & radiographic parameters in both studied groups throughoutthe experimental period.

Discussion

The present systematic review was to find the prevalence of oral manifestations and to suggest the management to those affected with COVID-19. The results based on 10 papers show that sore throat and dysgeusia are the most common oral manifestations. The others include enanthema, oral lesions and bleeding.

Sore throat

Though sore throat is very common, it can be the result of a nonserious illness to a dangerous one. Sore throat as a sole symptom can be rare as only 5-10% of COVID-19 patients have it, when in other cases, it is accompanied by other symptoms (Harris, 2021).

Dysgeusia

Dysgeusia which is the distortion of the sense of taste can be caused by numerous medical conditions like heart disease, Alzheimer's disease, upper respiratory viral infection,etc. (Lozada-Nur, Chainani-Wu, Fortuna & Sroussi, 2020). Zahra, Iddawela, Pillai, et al., (2020) found that symptoms of dysgeusia are not enough to diagnose an individual with COVID-19, even though it is frequently reported. But if dysgeusia is present for a longer duration, it could lead to an increase in the severity of COVID-19.

Enanthema

Enanthema or enanthem is the result of viral infections causingrashes or spots on the mucous membranes. The cause of the symptom might be due to different diseases like chickenpox, measles, hand-foot, and mouth disease, and also COVID-19. Considering the short time in which some COVID-19 patients show enanthema, the symptom suggests a strong association with the virus (Lubell, 2020).

Oral lesions and bleeding

Oral lesions, gingival inflammation and bleeding or simply are suggested tobe the result of the inflammation initiated by COVID- 19 (Froum, 2020). Whereas there are also claims that these manifestations are not the result of viral infection but rather a secondary infection caused by the deteriorating health or medications used for COVID-19 treatment.(Dos Santos, Normando, da Silva, et al., 2020).

Fungal infections

A few cases were reported related to fungal infection, mostly mucor mycosis as a post covid manifestation. It was mainly found in patients with altered immunity and in patients with pre-existing immunosuppression.

Management

General manifestations are managed by: Broad spectrum systemic antibiotics (ceftriaxone, doxycycline), antivirals (oseltamivir, favipiravir, remdesivir), antihistamines (Diphenhydramine). The use of fluticasone nasal spray and triamcinolone medications were found to be helpful in the recovery of smell and taste sensation within a week (Singh, Jain & Parveen, 2021).

Iranmanesh, et al., (2020), Halboub, et al., (2020), andCorchuelo & Ulloa (2020) observed the various management protocols for oral manifestation of COVID 19 and found that chlorhexidine, an antiseptic mouthwash, is effectively used to reduce the gingival inflammation. Other managements involves application topical or systemic corticosteroids, benzalkonium chloride mouth rinses, normal saline gargling, use of artificial saliva, topical a tifungals (nystatin, oral fluconazole), topical anesthetics (benzocaine 5% gel).

Conclusion

Even though enough researches are required to establish a relationship between the oral manifestation and COVID-19, looking out for the oral symptoms might also play a vital role in the timely diagnosis of COVID-19. The surge in the oral manifestations among COVID-19 patients might be the result of the direct effect of virus in the oral cavity, due to secondary infection as a result of compromised immunity or due to adverse reaction of medications used. Therefore, it is important to include dentists in the multi-disciplinary team assisting the COVID- 19 patients so that the clinical dental examination could be accentuated, considering the requirement for support and pain control for the patient and thereby improving their quality of life.