WHAT DO WE NEED TO KNOW ABOUT THE SYMPTOMS OF COVID-19 IN RELATION TO OUR ORAL HEALTH AND WHAT WE CAN DO ABOUT IT?
The outbreak of novel coronavirus (CoV or Severe Acute Respiratory Syndrome-CoV-2 or SARS-CoV-2) has emerged as a serious public health concern worldwide. On February 11, 2020, the World Health Organization announced the official name for this disease, CoV disease or COVID-19, for short. The virus can cause systemic organ complications which involves the lungs, kidneys, liver, skin, and, with recent studies, the oral cavity.
According to the WHO, dentistry is the most affected profession in terms of exposure to the virus along with the oral implications of it. All dental procedures are with direct contact with saliva and the exposure to aerosols produced by high speed rotatory instruments. As such, the dental community experts along with reliable worldwide health organizations try to study and do further research to address CoVid-19 in relation to oral health issues as well as the necessary protocols for dental practice. One of the studies show that was published in the British Journal of Dermatology identified a new symptom of COVID-19, which is an oral cavity manifestation. A significant number of COVID-19 patients are experiencing bumps on their tongue, along with inflammation and swelling. The study analyzed data from 666 patients at a temporary field hospital in Spain discovered that more than 45% of patients had some form of muco-cutaneous symptoms. This symptom was later termed as “COVID Tongue”.
COMMON ORAL SYMPTOMS
With the continuous study and new discoveries about CoVid-19, researchers were able to interpolate the common oral symptoms of CoVid infection, these are the following:
➢ Loss of Taste or Ageusia
➢ Loss of Smell or Anosmia
➢ Dryness of Mouth or Less Saliva Production
➢ Distortion of Taste or Dysgeusia
➢ Desquamative Gingivitis
➢ Herpetiform Ulcers on Attached Gingiva
➢ Irregular Ulcers on Dorsal Surfaces of the Tongue
➢ Cervical Lymph Nodes Enlargement
➢ Submandibular Lymph Nodes Enlargement
➢ Multiple Ulcers in the Hard Palate
➢ Blisters on Lip Mucosa
PROPOSED MECHANISM OF COVID TONGUE
The mechanism behind this is suspected to be the viral disruption of cranial nerves I, VII, IX, and X, as well as the supporting cells of neural transmission. In addition, direct viral entry into oral cavity cells becomes possible because the oral cavity and tongue has an abundance of angiotensin, a peptide hormone that causes vasoconstriction and an increase in blood pressure and a converting enzyme-2 receptor. There's also presence of aphthous ulcer and bruxism which are possibly caused by stress and reactive response to the viral infection.
These oral symptoms can be linked to the lack of proper oral care and oral examination in a hospital set up as it is at low priority during this pandemic. Aside from all the causes discussed above, the oral ulcers can also be attributed to the vasculitis caused by the excess accumulation of angiotensin II in the vascular cells. Excess accumulation of angiotensin II may cause vasoconstriction, vascular abnormalities, and increased vascular permeability leading to ulcer formation.
Due to these observed possible conditions on CoVid-19 patients, oral hygiene plays a big role in reducing the risk Covid 19 infection. Studies has shown that the use of mouthwash as part of oral hygiene can possibly reduce viral load and possible risk of transmission. This study was demonstrated in cell culture experiments by virologists from Ruhr-Universität Bochum together with colleagues from Jena, Ulm, Duisburg-Essen, Nuremberg and Bremen. High viral loads can be detected in the oral cavity and throat of some Covid-19 patients. The use of mouthwashes that are effective against Sars-Cov-2 could thus help reduce the viral load and possibly the risk of coronavirus transmission.
A well-established mouthwashes containing specific ingredients, can inactivate SARS-CoV-2 in vitro, potentially help mitigate the transmission and decrease the risk of oral cavity diseases in COVID-19. These ingredients include:
➢ 0.05%-0.1% Cetylpyridinium Chloride (CPC): 15 ml for 30 seconds twice a day. In vitro and in vivo studies indicate that mouthwash products containing CPC are able to inactivate SARS-CoV-2 [137-140]. These products are generally considered to be safe, but, downside is the possibility of staining the tongue and teeth.
➢ 0.147% Ethyl lauroyl arginate (ELA): 20 ml for 30 seconds twice a day. In vitro results suggest virucidal activity of ELA against SARS-CoV-2.
➢ 0.2%, 0.4% or 0.5% Povidone-Iodine (PVP-I): 10 ml for 30 seconds twice a day. The use of PVP-I is supported by in vitro and in vivo studies. In one clinical trial, the use of 1% PVP-I mouth rinse resulted in temporary thyroid dysfunction in 42% of COVID-19 patients, suggesting that lower concentrations should be preferred. Contraindications of this are allergy, hyperthyroidism, thyroid dysfunction, pregnancy, lactation, and treatment with radioactive iodine.
Keep in mind that the use of mouthwashes should not replace other daily oral hygiene measures. Mouthwashes should be used after toothbrushing for limited periods due to potential side effects.
The reality is there’s still a lot we don’t know for a fact about CoVid-19 virus and its continuous mutating variants. But, the world is united with the help of the world’s best experts on this field, who are tirelessly working to bring us accurate and evidence-based information. Thus, it is our duty as health professionals to promote and educate our patients properly. And, do our own diligence to research from reliable sources, so, we can do our preventive measures and treatments to our patients accordingly based on science and not on fear.
Dr. Bryan Anduiza - Writer
Dr. Mary Jean Villanueva - Editor
1. Lloyd-Jones G, Molayem S, Pontes CC, Chapple I. (2021) The COVID-19 Pathway: A Proposed Oral-Vascular-Pulmonary Route of SARS-CoV-2 Infection and the Importance of Oral Healthcare Measures. J Oral Med and Dent Res. 2(1):1-25.
2. Dentistry Today Online News: Better Oral Hygiene Can Reduce Covid-19 Severity.
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4. Virucidal efficacy of different oral rinses against SARS-CoV-2. The Journal of Infectious Diseases, 2020; DOI: 10.1093/infdis/jiaa471.