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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 239-242

Evidence of oral mucosal manifestation in patients with COVID-19: A cross-sectional study in the Nagpur district of Maharashtra


Department of Oral Medicine and Radiology, VSPM'S Dental College and Research Centre, Nagpur, Maharashtra, India

Date of Submission14-Jul-2022
Date of Acceptance10-Oct-2022
Date of Web Publication14-Nov-2022

Correspondence Address:
Apeksha Dhole
Department of Oral Medicine and Radiology, VSPM'S Dental College and Research Centre, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_101_22

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  Abstract 


Objective: The present study was directed to evaluate the occurrence, onset, and duration of oral manifestation in patients with COVID-19 in Nagpur (Maharashtra) and its periphery. Materials and Methods: The collection of data was by means of validated Google form questionnaire regarding the occurrence of oral mucosal manifestations in patients diagnosed with COVID-19 in the month of March to May 2021. Results: Oral manifestations experienced by the patient were loss of taste 60%, dry mouth 85%, oral ulcers 42.5%, burning mouth 40%, bleeding gums 7.9%, and jaw pain 2.5%. Conclusions: Oral symptoms are evident in patients suffering from COVID-19. Cause for many symptoms poses reasoning with the long-term use of antibiotics and also lies in the pathogenesis of the COVID-19 infection. Dentists are one of the primary health care providers who encounter such oral manifestation of systemic diseases. It is requisite for a dentist to identify such lesion and manage them accordingly to improve the quality of life for such patients.

Keywords: COVID-19, loss of taste, oral manifestation


How to cite this article:
Dhole A, Dube D, Motwani M. Evidence of oral mucosal manifestation in patients with COVID-19: A cross-sectional study in the Nagpur district of Maharashtra. J Dent Res Rev 2022;9:239-42

How to cite this URL:
Dhole A, Dube D, Motwani M. Evidence of oral mucosal manifestation in patients with COVID-19: A cross-sectional study in the Nagpur district of Maharashtra. J Dent Res Rev [serial online] 2022 [cited 2023 Jan 30];9:239-42. Available from: https://www.jdrr.org/text.asp?2022/9/3/239/361131




  Introduction Top


The advent of novel coronavirus in December 2019 has caused a hasty pandemic in the 21st century and has presented as an urgent threat to global health. Doubtlessly, the disease caused by the novel coronavirus and its out run have imposed defiance for health provider worldwide. Initially, named as 2019-nCoV was and officially as severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (WHO, 2020). SARS-CoV-2 occurs from human to human transmission. Respiratory droplets produced by an infected individual during the sneezing and coughing or nudging the contaminated surfaces by hand and further transferring the viral particle to a healthy individual's mouth, nose, or eyes is considered one of the major causes. The cellular receptor known for SARS-CoV is the angiotensin-converting enzyme 2 (ACE2). It is found in oral mucosa, with its known solidity on dorsum of the tongue and salivary glands. The extending symptom spanned from lenient flu-like symptoms to hazardous pneumonia and fatal respiratory distress. Saliva is considered one of the major causes of viral conveyance and hence and the likelihood for the oral presentations of disease. The most usual oral symptoms reported altered taste, vesiculobullous lesions, aphthous-like lesions, oral dryness, and loss of smell.

Oral health is a decisive intimation of general health, welfare, and quality of life. Although there are still researches ongoing regarding the occurrence and severity of oral manifestation associated with COVID-19. The symptoms may range from mild aphthous like lesions to severe EM like lesions. The severity of lesions may vary according to course of disease and older age. The principal predisposing factors for the evolution of oral lesions in COVID-19 patients are absence of oral hygiene, comorbid conditions such as (diabetes mellitus and hypertension), opportunistic infections, stress, and hyper-inflammatory response.[1] Combinations of therapies and experimental drugs have been in use to treat COVID-19. It has seen that with these developing combination of drug therapies patients may develop various side effects including oral manifestation such as the changes in salivary gland function.[2]

The management of oral presentations associated with COVID-19 during and post-COVID has emerged as the need of the hour in dental fraternity. In order to rule the cause of oral lesions associated with this disease, a thorough intraoral examination need to carried out in these patients during and as well as in the post-COVID period. Drugs administered during the course of the disease should be kept into consideration while ruling out the cause of the lesions as antiviral, oral corticosteroids also impose side effects in the oral cavity. Oral physicians need to well verse with the phenomenon and association of these lesions, in context with its onset, course, severity, and duration.

The current literature does not provide enough evidence regarding the actual association of oral involvement in patients with COVID-19. Maharashtra was one the state in India which marked highest number of COVID-19 cases in its second peak and statistical data shows about the peak of this disease in Nagpur city. Literature regarding oral lesions during the highly reactive second phase of COVID is scanty. Therefore, the present study was focused to assess the occurrence, onset, and duration of oral manifestation in patients with COVID-19 in Nagpur (Maharashtra) and its periphery.


  Materials and Methods Top


The collection of data was by means of validated questionnaire regarding the occurrence of oral manifestation in patients diagnosed with COVID-19. The Google form questionnaire consists of 6 set of questions regarding the occurrence of oral mucosal manifestations in patients diagnosed with COVID-19 in the month of March to May 2021 along with the demographic details of patients. The questionnaire was distributed through the Google forms to the participants selected for the study through Whatsapp link or E-mail. The responses from the questionnaire were obtained analyzed. The study comprised of sample size of 120 patients.


  Results Top


A total of 120 participants were included in the study of age range from 20 to 70 years with most of the participants being in the age group of 21–30 years of age 24.2% (29) and least in the age group of 65–70 years 6.7% (8). 60% (72) of total participants were male and 40% (48) were female. A total of 60% (62) of individuals were affected with comorbidities such as diabetes mellitus and hypertension, i.e., 55% (34) and 53.5% (33), respectively. The most prevalent generalized symptom experienced by patients in the descending order was fever, sore throat, body ache, breathlessness, loss of smell, and diarrhea. The most prevalent drug prescribed to patients was azithromycin 90.4% followed by Vitamin C 77.4%, Zinc 73%, and corticosteroid 70.4% and antiviral 62.6%. Oral manifestations experienced by the patient were loss of taste 60%, dry mouth 85%, oral ulcers 42.5%, burning mouth 40% and bleeding gums 7.9%, and jaw pain 2.5% [Table 1]. The most prevalent oral manifestation experienced by the patient was loss of taste 60% (105) with majority of experiencing them within 0–7th day from the onset of infection and lasting up to more than 21 days in 71.5% of people. Another symptom which was prevalent among patients was dry mouth, 85% (102) with onset on 0–7th day of the infection, and lasting for about 21 days in 74.6% of people. Oral ulceration and burning sensation and bleeding gums were seen along with the onset of the disease and subsided within 7 days of infection. Jaw pain was one of the symptoms which marked its onset postinfection [Table 2].
Table 1: Illustrating onset of oral manifestation

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Table 2: Illustrating duration of oral manifestation

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  Discussion Top


Novel coronavirus and its manifestation and consequences have given rise to a challenge for health caregivers worldwide. With various ongoing research and evident literature and publications, there is emerging evidence on oral manifestations in COVID-19 patients. Nagpur district of Maharashtra has seen one its peak cases in the 2nd wave along with infectivity affecting by different variants of COVID-19. No literature has been quoted regarding absolute oral presentations in COVID-19 patients along with comprehending the pattern of oral presentations with respect to the onset and duration in the region of Nagpur, Maharashtra, thus making our study distinctive. Flu-like symptoms such as fever, dry cough, myalgia, arthralgia, headache, diarrhea, dyspnea, and fatigue were reported among the COVID-19 patients. Loss of taste, xerostomia or dry mouth, burning sensation, mouth ulcerations, and gum bleeding, with different prevalence was observed in our study subjects. The data were relevant as it had similarities with other research findings.

Research literature shows that coronavirus binds via the angiotensin-converting enzyme (ACE2) receptor. Expressions of these receptors are abundant in epithelial cells present on the tongue. Ageusia or loss of taste and loss of smell is ascribed to the presence of these receptors in inflated numbers in the epithelial corresponding to oral tissues and nasal mucosa. These consequences are due to unmediated damage to the gustatory and olfactory receptors by the SARCoV2 virus.[2] Loss of taste sensation which was one of the most usual oral presentations found in our study with the prevalence of 60% lasting for more than a week in 71.5% of people was similar to results inferred by Muthyam et al. in South Indian population.[3] Freni et al. also reported with gustatory dysfunction with a prevalence of 70% in population of Italy.[4]

Dry mouth or xerostomia and burning mouth could be ascribed to poor hydration, prolonged antibiotic course. The prevalence of xerostomia is 85% and burning mouth is 40% in our study. The study conducted by Ganesan et al. showed the frequency of 28% (140) of patients affected by dry mouth and only 4% of patients affected by burning sensation.[5] One of the common feature of viral infections is xerostomia may be because of dehydration and atrophy of acinar cells in salivary glands, guiding to burning mouth hence suggesting the presence of COVID-19 infection could be the source of xerostomia.

Our study inferred that 42.5% of people affected by COVID-19 experienced oral ulcerations which are much higher than the results found out by other authors. Martín Carreras-Presas et al. outlined cases of oral ulceration, glossodynia in COVID-19 patients.[6] Ganeshan et al found out the occurrence of mouth ulceration only in 10% of the total patients and also quoted various case reports which manifest oral ulcerations with different frequencies.[5] Peculiar oral symptoms were presented in a study done by Iranmanesh et al. in Iranian population like aphthous ulcers, herpetiform lesions, ulcers, erosions, and white and red plaques.[7] Factors such as drug eruption (to NSAID in one case), vasculitis, or thrombotic vasculopathy secondary to COVID-19 were put forward as causes for the evolution of ulcerative lesions.[8]

In our study only 7.5% of total participants has experienced symptoms of periodontal diseases. Similar results were observed by Marouf et al. in which 258 patients out of the 568 presented periodontitis in a State of Qatar population.[9] Being a questionnaire study the severity of periodontitis was not assessed with severity of COVID. The possible co- relation between periodontitis and COVID was COVID induced pro-inflammatory cytokines and oxidative stress.

As the study was carried out in the 2nd wave of COVID-19 where post-COVID oral manifestation such as oral mucormycosis was prevalent, but only 2.5% of participants were found be manifesting symptoms such as jaw pain in our study. The study inferred that patient experiencing jaw pain was after the manifestation of COVID-19 infection. This outcome is however not a parameter for the assessment of COVID-19 infection like other oral manifestation which occur during the course of disease. These results were not similar with the study conducted by Karayanni et al. where 78 patients out of 319 patients reported with TMD associated pain The difference in the results of the study conducted by Karayanni et al and our study is because of retrospective study design.[10] The psychological stress during COVID is the possible co relation to all symptoms of TMD and jaw pain.[10]

The presence of generalized symptoms such as fever, sore throat, bodyache, breathlessness, loss of smell, and headache showed no observable significant difference based on demographic variations.

The study also observed oral manifestation occurring in asymptomatic individuals with no generalized signs and symptoms. In our study, more than 90% of patients experienced major oral manifestation such as loss of taste, burning mouth, and dry mouth. As oral physicians are the first and foremost persons to screen the oral cavity, so people with such manifestation can be identified and diagnosed in its asymptomatic and carrier state and thus lowering the transmission rate. However, the present study has certain limitations regarding severity of the infection to individual patients and the findings were self-reported by patients which might have led to reporting bias.


  Conclusion Top


Oral symptoms are evident in patients suffering from COVID-19. The cause for many symptoms poses reasoning with the long-term use of antibiotics and also lies in the pathogenesis of the COVID-19 infection. Dentists are one of the primary healthcare providers who encounter such oral manifestation of systemic diseases. It is requisite for a dentist to identify such lesion and manage them accordingly to improve the quality of life for such patients.

Ethical statement

ECR/885/Inst/MH/2017; approval no: IEC/VSPMDCRC/32/2021.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Amorim Dos Santos J, Normando AG, Carvalho da Silva RL, De Paula RM, Cembranel AC, Santos-Silva AR, et al. Oral mucosal lesions in a COVID-19 patient: New signs or secondary manifestations? Int J Infect Dis 2020;97:326-8.  Back to cited text no. 1
    
2.
Nasr MJ, Alizadeh Khatir A, Babazadeh A, Ebrahimpour S. The role of ACE2 receptors of the olfactory system in anosmia in COVID-19: An overview. Neurology Research International 2021;2021:1-5. 5776801.  Back to cited text no. 2
    
3.
Muthyam AK, Reddy MP, Kulkarni S, Srilatha A, Sahithi K, Satyanarayana D. Oral manifestations in COVID-19 patients: An observational study. J Family Med Prim Care 2022;11:1000-5.  Back to cited text no. 3
  [Full text]  
4.
Freni F, Meduri A, Gazia F, Nicastro V, Galletti C, Aragona P, et al. Symptomatology in head and neck district in coronavirus disease (COVID-19): A possible neuroinvasive action of SARS-CoV-2. Am J Otolaryngol 2020;41:102612.  Back to cited text no. 4
    
5.
Ganesan A, Kumar S, Kaur A, Chaudhry K, Kumar P, Dutt N, et al. Oral Manifestations of COVID-19 Infection: An Analytical Cross-Sectional Study. Journal of maxillofacial and oral surgery 2022:1-0.  Back to cited text no. 5
    
6.
Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez AF, Jané-Salas E, Somacarrera Pérez ML. Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Dis 2021;27 Suppl 3:710-2.  Back to cited text no. 6
    
7.
Iranmanesh B, Khalili M, Amiri R, Zartab H, Aflatoonian M. Oral manifestations of COVID-19 disease: A review article. Dermatol Ther 2021;34:e14578.  Back to cited text no. 7
    
8.
Rusu LC, Ardelean LC, Tigmeanu CV, Matichescu A, Sauciur I, Bratu EA. COVID-19 and its repercussions on oral health: A review. Medicina 2021;57:1189.  Back to cited text no. 8
    
9.
Marouf N, Cai W, Said KN, Daas H, Diab H, Chinta VR, et al. Association between periodontitis and severity of COVID-19 infection: A case–control study. Journal of clinical periodontology 2021;48:483-91.  Back to cited text no. 9
    
10.
Karayanni H, Dror AA, Oren D, Sela E, Granot I, Srouji S. Exacerbation of chronic myofascial pain during COVID-19. Advances in Oral and Maxillofacial Surgery 2021;1:100019.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 

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