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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 25-28

Prevalence of oral lesions among coronavirus disease 2019 cohorts: A cross-sectional study


Department of Dentistry, Shivamogga Institute of Medical Sciences, Shivamogga, Karnataka, India

Date of Submission23-Apr-2022
Date of Decision28-Apr-2022
Date of Acceptance04-May-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Sunil Lingaraj Ajagannanavar
Department of Dentistry, Shivamogga Institute of Medical Sciences, Shivamogga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_11_22

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  Abstract 


Background: In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), considered as Pandemic has gained Public importance caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first reported in Wuhan City, Hubei Province, China. World Health Organization declared the outbreak as a Public Health Emergency of International Concern on January 30, 2020. Few cases have reported the presence of oral lesions among Covid Cohorts for which we considered it has a less explored area.
Aim and Objectives: The purpose of this study is to assess the prevalance of oral lesions among Covid19 Inpatients in District Hospital, Shivamogga.
Materials and Methods: A descriptive cross-sectional survey will be conducted to assess the prevalence of oral mucosal lesions among Covid19 Inpatients in District Hospital, Shivamogga, India. The Performa included information on socio-demographic details, habits (tobacco and alcohol), oral hygiene practices and presence and location of oral mucosal lesions according to World Health Organisation, 2013. Considering the prevalence of Oral lesions among Pilot Survey Sampling size will be determined. Informed consent would be obtained from patients and ethical approval from Institutional ethical board. Descriptive statistical analysis would be carried out and Chi-square test will be used for comparisons. Confidence level will be set at 95% and p value 5%, respectively.
Results: A total of 248 In-patients with Covid -19 were included in the study. Almost half of the patients 127(51.2%) complained Aphthous-like oral ulcer, followed by Xerostomia 52(20.96%), herpes-like lesions 47(19%), candidiasis 44(18%), glossitis/depapillation 10(4%), geographic tongue 6 (2.41%), angular cheilitis 3 (1.2%), parotitis 2 (0.8%) Ulceration with ischemic necrosis of palate 11 (4.43%). Oral lesions were scattered throughout mouth in which majority was found in the tongue (35.4%) followed by sulcus (15%), Lips(11.6%), and commissures(10.8%).
Conclusion: COVID-19; SARS-CoV-2 is the major public health burden in the world, along with systemic manifestations it is definitely found to have a significant effect on the oral health varying from small Aphthous like ulcers to necrosis of palate. Several attempts are done to integrate medical and dental services in different healthcare and public health settings to support populations with unmet oral health during this pandemic situation.

Keywords: Aphthous ulcer, COVID-19, oral manifestations


How to cite this article:
Ajagannanavar SL, Srinivas D R, Pushpa R. Prevalence of oral lesions among coronavirus disease 2019 cohorts: A cross-sectional study. Int J Oral Health Sci 2022;12:25-8

How to cite this URL:
Ajagannanavar SL, Srinivas D R, Pushpa R. Prevalence of oral lesions among coronavirus disease 2019 cohorts: A cross-sectional study. Int J Oral Health Sci [serial online] 2022 [cited 2022 Aug 17];12:25-8. Available from: https://www.ijohsjournal.org/text.asp?2022/12/1/25/350988




  Introduction Top


In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), considered pandemic, gained public importance caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first reported in Wuhan City, Hubei Province, China. World Health Organization (WHO) declared the outbreak as a Public Health Emergency of International Concern on January 30, 2020.[1] The WHO later renamed the disease caused by SARS-CoV-2 as COVID-19.[2]

In addition to fever, fatigue, dry cough, myalgias, sore throat, breathing difficulties, and respiratory complications that often deteriorate to the severe acute respiratory syndrome, patients infected by SARS-CoV-2 may develop a myriad of other local and systemic complications, such as acute cardiac damage, acute renal failure, gastrointestinal complications, dysgeusia, anosmia, and neurologic symptoms, including Guillain–Barre syndrome.[3]

SARS-CoV-2 binds to the angiotensin-converting enzyme 2 (ACE2) receptor, which is detected in the cell membrane of numerous human organs and tissues, including the lungs, kidneys, liver, epithelial cells of the tongue and salivary glands, upper respiratory tract, nervous system, and skeletal muscle, among others.[3]

Multifactorial etiology may explain the involvement of COVID-19 in the oral cavity; the oral cavity serves has a door to the outside world and place a vital role in the transmission of SARS-CoV-2. In-depth analysis has known the role of a metallopeptidase catalyst, i.e., angiotensin-converting catalyst 2 (ACE-2), as a functional receptor for SARS-CoV-2.[4] Various researches have identified the role of a metallopeptidase enzyme, i.e., ACE-2, as a functional receptor for SARS-CoV-2.[4] Apart from localization in the other parts of the body, ACE-2 expression is found extensively in the basal layer of the nonkeratinizing squamous epithelium of nasal and oral mucosa as well as nasopharynx.[5] This could also be responsible for an impaired taste sensation as a temporary symptom. Another school of thought proposed is that a change in immune response or the direct systemic response to the disease can be a reason for oral manifestations of COVID-19.[6] Vieira suggested the role of persistent inflammation acting as an initiator for the coagulation cascade leading to further worsening of the existing untreated periodontitis in the COVID-19-positive patients.[7]

The emotional impact of COVID-19 results in panic behavior with feelings of despair and negative outcomes, and there is a whole shift of focus from daily hygiene maintenance, further worsening the oral health. Drugs therapy used in the treatment of the COVID-19 such as remdesivir, hydroxychloroquine, protease inhibitors, and interferon regimen was also postulated as reasons although they have reported minimal effect on oral health, except lopinavir which may cause taste alteration. COVID-19 is a new disease that presents mainly with respiratory symptoms but also with a varied multitude of signs and symptoms that affect various body systems, and several oral manifestations have also been reported.[8] Very few cases have reported the presence of oral lesions among COVID cohorts for which we considered it has a less explored area.

Aim and objectives

The purpose of this study is to assess the prevalence of oral lesions among COVID-19 Inpatients in District Hospital, Shivamogga.


  Materials and Methods Top


A descriptive cross-sectional survey was conducted to assess the prevalence of oral mucosal lesions among COVID-19 Inpatients in District Hospital, Shivamogga, India. Before the study, ethical clearance was obtained from the Institutional Ethical Committee. Patients above 18 years and who produced laboratory-confirmed (reverse transcription–polymerase chain reaction) were included in the study.

The per forma included information on sociodemographic details, habits (tobacco and alcohol), oral hygiene practices, and the presence and location of oral mucosal lesions, according to WHO, 2013.

Oral mucosa and soft tissues in and around the mouth were examined for every subject using the Oral Health Assessment Form as prescribed by Oral Health Surveys (WHO-2013). Lesions such as malignant tumors, lichenplanus, leukoplakia, ulcerations, ANUG, and abscess were recorded for anatomical locations (vermillion border, commissures, lip, sulcus, floor of the mouth, tongue, Hard & soft palate, alveolar ridges and gingival areas). Abscess was recorded in the vermillion border, commissures, lip, sulcus, the floor of the mouth, tongue, hard and soft palate, alveolar ridges, and gingival areas.

Considering the prevalence of oral lesions among pilot survey, sampling size was determined. Informed consent was obtained from patients. The trained and calibrated investigator performed oral examination with the standard operative procedure as specified by MOHFW.

Descriptive statistical analysis was carried out, and the Chi-square test was used for comparisons. Confidence level was set at 95% and P = 5%, respectively.


  Results Top


A total of 248 inpatients with COVID-19 were included in the study, of which 167 were males and 81 were females.

Analysis of the ranking of oral mucosal lesions among COVID-19 inpatients revealed that almost half of the patients, 127 (51.2%), complained aphthous-like oral ulcer, followed by xerostomia 52 (20.96%), herpes-like lesions 47 (19%), candidiasis 44 (18%), glossitis/depapillation 10 (4%), geographic tongue 6 (2.41%), angular cheilitis 3 (1.2%), parotitis 2 (0.8%), and ulceration with ischemic necrosis of palate 11 (4.43%) as shown in [Table 1].
Table 1: Prevalence of Oral mucosal lesions among COVID-19 patients

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Oral lesions were scattered throughout mouth of which the majority were found in the tongue (35.4%), followed by sulcus (15%), lips (11.6%), and commissures (10.8%), as shown in [Table 2].
Table 2: Occurrence of oral lesions according to anatomical locations

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  Discussion Top


A wide variety of lesion diagnoses forms an essential part of dental practice that too suffering from COVID-19 would gain the prime importance in the public health aspect.

Apart from dental caries and periodontal diseases, oral mucosal lesions constitute a significant problem in society. The prevalence of oral mucosal lesions is a crucial parameter in evaluating the oral health of any population, and also the prevalence data of all the oral mucosal lesions becomes a requirement for planning oral health-care services.

While planning for oral health programs, a lack of data may lead to a risk of overlooking diseases of the soft tissues in and adjacent to the oral cavity.

According to Health Bulletin in Karnataka, COVID cases saw a peak in the second wave during May 2021 and COVID hospitalization stood at 21%.[9] The highest number of active cases during the second wave was recorded on May 15, 2021 (over 6 lakh) compared to the first wave. It was during this time where there was high demand for oxygen beds and injection ramdesvir.

Shimoga, a district in Karnataka, reported 807 deaths during May 2021. It was during this time we had to examine COVID patients for the oral lesions. In our study, we found some of the patients complaining of mixed lesions. The present study was conducted over a period of 2 months, from May 2021 to July 2021, upon a convenient sample of 248 COVID cohorts. The age of the patients ranged from 24 to 86 years, and the mean age of the patients was found to be 42 years.

In our study, we found almost half of the patients, 127 (51.2%), complained aphthous-like oral ulcers which was in par with case series of 8 cases conducted by Thais et al.[10] with oral necrotic ulcers and aphthous-like ulcerations which developed early in the course of disease after the development of dysgeusia and affected the tongue, lips, palate, and oropharynx. The author also proposed that after infection of the oral keratinocytes/glandular tissues, there is an increase in the permeability of the cell walls to foreign pathogens and viral replication in the cells lining the oral mucosa, leading to ulcers and necrosis. He also suggested that ACE2 expressing epithelial cells of the tongue and of the salivary glands may be susceptible to SARS-CoV-2 infection which is in par with our current study results where we found almost half of the patients (127) had aphthous-like oral ulcers and most common site involved was tongue. In addition, COVID patients undergo enormous emotional stress and lack of sleep which could be the confounding factor for the ulcer presentation.

Our study also found some of the lesions which were diversified which is in line with studies conducted by Martn Carreras-Presas et al.[11] where it resembled almost herpes simplex lesions yet not confirmed through biopsies.He also reported three cases with ulcers, of which one was infected by the SARSCoV2 virus and two were suspected patients infected by the SARSCoV2 virus.

In our study, 96 patients (42%) were found to be with comorbidities (blood pressure and hypertension), etc., which could also be confounded with the results. Amorim Dos Santos et al.[12] reported a 67-year-old Caucasian male who tested positive for coronavirus and presented oral manifestations such as recurrent herpes simplex, candidiasis, and geographic tongue. Soares et al. reported a 42-year-old patient who tested positive for SARS-CoV-2 with a painful ulcer on the buccal mucosa.[13] Oral examination showed that, besides the ulcerated lesion, multiple reddish macules of different sizes were scattered along the hard palate, tongue, and lips. They believed that SARS-CoV-2 can cause oral lesions. They think that these may be COVID patients presenting with oral manifestations. Additional studies need to investigate whether SARS-CoV-2 infection directly causes oral ulcerations or whether oral lesions are a coincidental event with COVID-19 progression.

As a part of the limitations of our study, no histopathalogical correlations were made for the lesions because of time, cost, and workforce factors. Considering the limitations with diagnostic resources, saliva analysis was not checked for the virulence of the COVID-19 virus. As this is a cross-sectional study, this study only aimed to show the prevalence of oral lesions at specified time. Further various analytical studies are suggested for better understanding of the pathogenesis of this disease.


  Conclusion Top


COVID-19, SARS-CoV-2 is the major public health burden in the world, along with systemic manifestations, it is definitely found to have a significant effect on oral health varying from small aphthous-like ulcers to necrosis of palate. Several attempts are done to integrate medical and dental services in different health care and public health settings to support populations with unmet oral health during this pandemic situation. Strong inter-sectorial collaboration and the design of effective prevention and control strategies are the key factors for the decrease in numbers.

As oral health-care providers, it is important for us to join hands with the medical fraternity so that screening could be done with ease. Further, as dental practitioners, it is indispensable for us to spot such lesions and manage them adequately to reinforce the recovery process and improve the standard of life of COVID-19 patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harapan H, Itoh N, Yufika A, Winardi W, Keam S, Te H, et al. Coronavirus disease 2019 (COVID-19): A literature review. J Infect Public Health 2020;13:667-73.  Back to cited text no. 1
    
2.
Naming the Coronavirus Disease (COVID-19) and the Virus That Causes It; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and -the-virus-that-causes-it. [Last accessed on 2022 Mar 07].  Back to cited text no. 2
    
3.
Brandão TB, Gueiros LA, Melo TS, Prado-Ribeiro AC, Nesrallah AC, Prado GV, et al. Oral lesions in patients with SARS-CoV-2 infection: Could the oral cavity be a target organ? Oral Surg Oral Med Oral Pathol Oral Radiol 2021;131:e45-51.  Back to cited text no. 3
    
4.
McLachlan CS. The angiotensin-converting enzyme 2 (ACE2) receptor in the prevention and treatment of COVID-19 are distinctly different paradigms. Clin Hypertens 2020;26:14.  Back to cited text no. 4
    
5.
Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol 2004;203:631-7.  Back to cited text no. 5
    
6.
Dziedzic A, Wojtyczka R. The impact of coronavirus infectious disease 19 (COVID-19) on oral health. Oral Dis 2021;27 Suppl 3:703-6.  Back to cited text no. 6
    
7.
Vieira AR. Oral manifestations in coronavirus disease 2019 (COVID-19). Oral Dis 2021;27:770.  Back to cited text no. 7
    
8.
Schiffman SS, Zervakis J, Heffron S, Heald AE. Effect of protease inhibitors on the sense of taste. Nutrition 1999;15:767-72.  Back to cited text no. 8
    
9.
Available from: https://covid19.karnataka.gov.in/govt_bulletin/en. [Last accessed on 2022 Mar 07].  Back to cited text no. 9
    
10.
Brandão TB, Gueiros LA, Melo TS, Prado-Ribeiro AC, Froelich Alo Nesrallah AC, Boas Prado GV, et al. Oral lesions in patients with SARS-CoV-2 infection: Could the oral cavity be a target organ? Oral Surg Oral Med Oral Pathol Oral Radiol 2021;131:e45-51.  Back to cited text no. 10
    
11.
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. 11
    
12.
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. 12
    
13.
Soares CD, Carvalho RA, Carvalho KA, Carvalho MG, Almeida OP. Letter to editor: Oral lesions in a patient with COVID-19. Med Oral Patol Oral Cir Bucal 2020;25:e563-4.  Back to cited text no. 13
    



 
 
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