03/12/2023

FROM

Dr. K Lakshmi Kumari MDS

Reader, Department of pedodontics and preventive dentistry

Sri Venkateshwara Dental College and Hospital, Thalambur, Chennai, Tamilnadu

TO

“The Editor”

IP Indian Journal of Conservative and Endodontics

Subject: Submission of manuscript titled “Dental implications of COVID-19-An Insight” for

consideration for publication.

Respected Sir/Madam,

I am herewith submitting a manuscript titled “Dental implications of COVID-19-An Insight” for

consideration for publication in your esteemed journal. Hope the manuscript meets the
scientific standards of your journal.

Thanking You

Yours Sincerely

Dr K Lakshmi Kumari
 Dental implications of COVID-19 - An Insight.
Author details:

1] Dr Ashwath V MDS

Director.

Panchatheertham Health Care Solutions (OPC) Pvt Ltd.

Mail id: [email protected]

2] Dr K Lakshmi Kumari M.D.S [Corresponding Author]

Reader, Department of pedodontics and preventive dentistry

Sri Venkateshwara Dental College and Hospital, Thalambur, Chennai, Tamilnadu

Mail id: [email protected]

3] Dr S Gowrishankar M.D.S

Senior Lecturer, Department of Oral Medicine and Radiology

Sri Venkateshwara Dental College and Hospital, Thalambur, Chennai, Tamilnadu

Mail id: [email protected]

 Dental implications of COVID-19 - An Insight.

Abstract:

COVID-19 is a pandemic viral disease caused by Severe Acute Respiratory Syndrome corona virus

2(SARS -CoV-2). This pandemic has created a massive impact globally and is indeed a challenge to the

mass healthcare management. Despite continuous, untiring efforts of the World Health Organisation

(WHO) and the Health departments of various countries to curb this zoonotic disease, the propensity

of the virus to spread through droplets, replicate and mutate has raised huge public health concerns.

Oral cavity is an index of body’s health. Oral manifestations such as ageusia, angular chelitis,

periodontal diseases, ulcers and fungal infections have been reported commonly in patients with

COVID-19. These oral manifestations are valuable diagnostic criteria for the disease. Periodontal

inflammation has been proved to increase the severity of the disease. Also, Periodontitis can present

secondary to COVID-19 due to compromised immune system in this viral disease. Proper and

adequate oral hygiene, appropriate use of corticosteroids and maintenance of glycemic control can

reduce oral infections in COVID-19. Considering the increased risk of contracting the virus due to their

proximity to the patients in the operating environment, oral health care providers must be aware of

safety protocols and should strictly adhere to the recommendations by the regulatory authorities.

This not only ensures higher safety, but also prevents the dental office from being a source of

transmission for the virus. This review provides an overview on COVID-19 with an insight on its oral

manifestations and a special emphasis on the safety protocols to be followed by dentists.

Key words: COVID-19, Corona virus, immune suppression, oral manifestation, diabetes mellitus, oral

hygiene, dental practice.

Introduction:

The novel human corona virus disease COVID-19, a pandemic disease caused by Severe Acute

Respiratory Syndrome corona virus 2 (SARS- CoV-2) is a severe respiratory disease associated with

high mortality and morbidity. This disease from Wuhan of China is exponentially spreading all over

the world exhibiting severe impact on routine lifestyle, economy and most importantly health. This is

the fifth documented pandemic subsequent to 1918 Spanish flu (H1N1), 1957 Asian flu (H2N2), 1968

Hong Kong flu (H3N2) and 2009 Pandemic flu (H1N1). Its origin has been traced to a province called

Hubei in the Wuhan city of China[1]. In India, the first case of this COVID-19 was reported from

Kerala among 3 medical students who have returned from Wuhan on January 30, 2020[2]. The novel

Corona virus outbreak was declared as a global pandemic by WHO on March 11,2020.

Oral cavity is considered a mirror of systemic health. Multiple oral manifestations have been and

are being reported in patients with COVID-19. Few manifestations appear secondary to the COVID-

19 disease and some as a result of the treatment regimen used to contain the disease. Common oral

manifestations include ageusia, anosmia, hypo salivation, ulcers, herpes ulcers, fungal infections like

mucormycosis, submandibular salivary gland enlargement, cervical lymph node enlargement etc.

This article is a comprehensive review on COVID-19 disease, its oral manifestations and the standard

operating protocols to be followed by dentists.

The spiked virus:

The novel corona virus resembles a crown with multiple spikes on it and so it is named as ‘Corona’

which is derived from a Latin word meaning ‘crown’. The spiked structure of the virus can be

appreciated in an electron microscope[4]. It is an enveloped virus that has a single stranded RNA. It

belongs to the genera- beta corona virus and is 26-32 kilobase in size. This virus is also of zoonotic

origin similar to other corona virus. The China horse shoe type of bats is believed to be the zoonotic

species of origin for SARS-CoV-2[5]. The virus enters the host cell either by endosomal membrane
fusion or plasma membrane fusion. There is a glycoprotein in the viral called as the S protein. This

protein helps in binding and facilitate the entry of these organism into the host cell[6]. The S protein

binds to receptor ACE2 (angiotensin-converting enzyme 2) of the host cell. This binding is primed by

TMPRSS2(transmembrane protease serine 2)[7].

The respiratory droplet from the cough and sneeze of the infected patients is a transmitting

medium among humans. This transmission is higher when the exposure area to respiratory droplet is

within 6 feet distance. The transmission can also be from the hands touching the settled droplets

from the sneeze or cough and when the same hands are then taken to mouth and nose[8].

Transmission of infection via faecal-oral route transmission have also been evident in recent

studies[9]. Patients are infectious until symptoms subside. Even after the recovery, patients can be

contagious. These viruses can even stay as droplets on surfaces and survive, if the surrounding

atmosphere favours them. But this can be eliminated with disinfectants such as sodium

hypochlorite[10]. Although multiple ways of transmission has been documented, the most

significant and appropriate way of transmission is by directly getting exposed to the infected

individuals.

Clinical features of COVID-19:

The clinical features this COVID-19 varies among each and every individual. Manifestations range

from asymptomatic to severe acute respiratory distress, at times leading to death. Symptoms

include fever, sore throat, cough, myalgia, fatigue, head ache and in few cases difficulty in breathing.

In a study by Chen et al[11], fever was a manifesting sign in 82 of 99 COVID-19 positive cases. Cough

was present in almost 81 of 99 cases, followed by shortness of breath in 31 cases. More than one

symptom as manifestation was reported in 90% of cases. Fever, cough and shortness of breath were

seen as a triad in almost 15% of cases. Inflammatory cytokines including IL2(interleukin-2),

IL7(interleukin-7), IL10(interleukin-10), G-CSF (granulocyte colony stimulating factor), IP10(inducible

protein 10), MCP1(monocyte chemo attractant protein 1), MIP1A (macrophage inflammatory
protein 1), and TNFα (tumor necrosis factor α )were seen increased. Acute Respiratory Distress

Syndrome was seen in 17% of cases, Acute renal injury in 3% and Acute respiratory injury in 8% of

cases. Septic shock was seen in 4% of cases and Ventilator-associated pneumonia in 1% of cases.

Chest radiograph and Computed Tomography are gold standard diagnostic technique in evaluating

the stage of disease as they detect the condition of lungs affected with pneumonia. A study by

Attaway et al, revealed that about 15-30% of the COVID-19 patients develop acute respiratory

distress syndrome. Diffuse alveolar damage with high thrombus burden in pulmonary capillary is

seen in autopsy of patients who succumb to COVID-19[12]. Initially the disease was seen affecting

and causing death in elderly and immuno-compromised patients, but gradually cases were among

younger patients as well. A severe pneumonia with multiple organ dysfunction was observed in a

case first reported in China[13]. The first case of neonate was also reported from China and was

mild[14].

Oral Manifestations of COVID-19:

COVID-19 presents with an array of oral manifestations which appear during the course of the

disease, few lesions manifesting post disease as a secondary infection or as a result of the treatment

for the disease.

Most frequently reported oral manifestations include ageusia, anosmia, hyposalivation, ulcers in

various parts of oral cavity including tongue, glandular enlargement, cervical lymph node

enlargement, angular chelitis, periodontitis, aphthous and herpetic ulcers. Ageusia(loss of taste) and

Anosmia(loss of smell) are the most common oral symptoms[15][16].

Mucormycosis or black fungal infection is a potentially dangerous mycotic infection reported in

COVID-19 patients. Uncontrolled diabetes mellitus, hyperglycemia, immune suppression and

secondary infection, corticosteroid therapy are factors contributing to Mucormycosis as a co-

infection in COVID-10 patients[17]. Another Mycotic disease that has been reported in COVID-19
patients is the invasive yeast infections caused by candida species. Prolonged ICU stays, central

venous catheters and broad spectrum antibiotic use are the key factors leading to onset of invasive

yeast infections in COVID-19 patients[18].

Several other non-specific lesion such as mucositis have been reported in some cases. Exanthema,

enanthema, macules, papules and plaques on tongue, lip, palate, etc have been reported. Vasculitis,

thrombotic vasculopathy, mucosal hypersensitivity,secondary to COVID-19 might be a cause for the

mucositis associated with COVID-19[19].

Guidelines for Dental practice in this pandemic:

COVID-19 is transmitted through respiratory droplets. Dentists are more prone to exposure to the

respiratory droplets as their occupation involves working in oro-facial region. Particularly aerosol

inducing procedures such as scaling, root canal treatment etc transmits the disease and the

probability of getting infected is high. Hence, safety measures are essential to prevent the dentist

from contracting the disease as well as prevent the patient from transmitting the disease. In India,

Dental Council of India has formulated a standard to be followed by every Dentist in his practice[20].

Patient management:

Patient is first encouraged towards a telephonic consultation followed by scheduling of

appointment. Initial screening is done by asking 3 important questions like whether the patient has

come in contact with any COVID-19 patient or suspected patient, their travel history and finally any

symptoms for Covid-19 present. Positive response for any of the three question should be

considered and in such cases the appointment should be delayed for at least 14days and the patient

is advised for a mandatory quarantine. The patient is also advised to consult his general

physician[21].

On patient arrival to the clinic, the patient temperature is measured with an infrared thermometer

or camera with infrared sensors. Any patient presenting with fever or any of the COVID-19
symptoms should be given appointment after 14days. As per Centre for Disease Control(CDC)

guidelines, the suspected patients should be seated 6ft away from the healthy patients. Their

environment should be adequately ventilated[22]. Pharmacological management with antibiotics

and analgesics can be advised to these patients. Patient screening and management should be

followed as in Fig1[23]. Patients are classified into elective, urgent and emergency care for their

treatment and then further treatment is planned. For elective care, appointment is delayed for 2

weeks. For urgent care, pharmacological management is first advised and then a close follow up with

telephone or video call is done. In case of emergency, care a negative pressure room or airborne

infection isolation room is preferred to perform any procedure[23].

Patient should be given 0.2% povidone iodine mouth rinse or 0.5-1% hydrogen peroxide mouth

rinse as these have proven to reduce load of Corona virus in saliva[24][25]. Personal care has to be

taken by the dentist to prevent the disease transmission. Double masking, use of face shield and

personal protective equipment, frequent sanitization of hands can help prevent transmission to the

dentist[22].

Use of Personal Protective Equipments:

There are certain guidelines propsed by Centre for Disease Control and prevention for wearing and

safe removing of Personal Protective Equipment kits. The type of PPE used will vary based on the

level of precautions required, such as standard and contact, droplet or airborne infection isolation

precautions. The procedure for putting on[TABLE 1] and removing PPE[TABLE 2] should be tailored

to the type of PPE.

Safe removal of personal protective equipment (PPE):

There are a variety of ways to safely remove PPE without contaminating our clothing, skin, or

mucous membranes with potentially infectious materials. Remove all PPE before exiting the patient
room except a respirator, if worn. Remove the respirator after leaving the patient room and closing

the door. A proper sequence must be followed in removing the PPE kit(TABLE 2)

Conclusion:

The COVID-19 pandemic is a global crisis due to its propensity to replicate and spread rapidly. It is

indeed extremely challenging to control because of emergence of new mutated versions of the virus.

To avoid exposure to dentists and also prevent the dental office from serving as area for

transmission standard operating protocols by Dental Council of India and from Centres for Disease

Control and prevention should be strictly implemented and followed. To conclude, proper oral

hygiene to reduce severity of COVID-19, appropriate use corticosteroids and maintenance of blood

sugar at optimum level helps prevent severe oral infections that can cause mortality.

References:

1. Chen W, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health

concern. The Lancet 2020;395(10223):470–473.

2. Perappadan, Bindu Shajan (30 January 2020). "India's first coronavirus infection confirmed

in Kerala". The Hindu.

3. Singh G, Priya H, Mishra D, Kumar H, Monga N, Kumari K. Oral manifestations and dental

practice recommendations during COVID-19 pandemic. J Family Med Prim Care

2021;10:102-9.

4. Lan J, Ge J, Yu J, Shan S, Zhou H, Fan S, et al. Structure of the sars-cov-2 spike

receptor-binding domain bound to the ace2 receptor. Nature 2020;581:215-20.

5. Mackenzie JS, Smith DW. Covid-19: A novel zoonotic disease caused by a coronavirus from

China: What we know and what we don’t. Microbiol Aust 2020;41:45-50.

6. Choudhary S, Malik YS, Tomar S, Tomar S. Identification of sars-cov-2 cell entry inhibitors by

drug repurposing using in silico structure-based virtual screening approach. Front Immunol

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7. Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al.

SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven

protease inhibitor. Cell 2020;181:271-80.e8.

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391 cases and 1286 of their close contacts in shenzhen, china: A retrospective cohort study.

Lancet Infect Dis 2020 2020;20:911-9.

9. Gu J, Han B, Wang J. Covid-19: Gastrointestinal manifestations and potential fecal–oral

transmission. Gastroenterology 2020;158:1518-19.

10. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate

surfaces and its inactivation with biocidal agents. J Hosp Infect. 2020 Feb 6. pii: S0195–

6701(20)30046–3.

11. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of

2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet.

2020;395:507–13.

12. Attaway A H, Scheraga R G, Bhimraj A, Biehl M, HatipoÄŸlu U. Severe covid-19 pneumonia:

pathogenesis and clinical management BMJ 2021; 372 :n436

13. Chen F, Liu ZS, Zhang FR, et al. First case of severe childhood novel coronavirus pneumonia

in China. Zhonghua Er Ke Za Zhi. 2020;58:E005.

14. Zeng LK, Tao XW, YuanWH,Wang J, Liu X, Liu ZS. First case of neonate infected with novel

coronavirus pneumonia in China. Zhonghua Er Ke Za Zhi. 2020;58:E009.

15. Vaira LA, Salzano G, Deiana G, De Riu G. Anosmia and Ageusia: Common Findings in COVID-

19 Patients. Laryngoscope. 2020;130(7):1787.

16. Lechien, J. R., Chiesa-Estomba, C. M., De Siati, D. R., Horoi, M., Le Bon, S. D.et al Olfactory

and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the

coronavirus disease (COVID-19): a multicenter European study. European archives of oto-

rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological

 Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and

Neck Surgery, 277(8), 2251–2261.

17. Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of

cases reported worldwide and in India. Diabetes & Metabolic Syndrome: Clinical Research &

Reviews, 2021.

18. Arastehfar A, Carvalho A, Nguyen MH, et al. COVID-19-Associated Candidiasis (CAC): An

Underestimated Complication in the Absence of Immunological Predispositions?. J Fungi

(Basel). 2020;6(4):211.

19. Iranmanesh B, Khalili M, Amiri R, Zartab H, Aflatoonian M. Oral manifestations of COVID-19

disease: A review article. Dermatologic Therapy. 2021;34: e14578

20. Dental clinics protocol – final. Dental Council of India(May 7,2020).

21. Wang Y, Wang Y, Chen Y, Qin Q. Unique epidemiological and clinical features of the

emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control

measures. J Med Virol 2020.

22. Centers for Disease Control and Prevention. Infection control: severe acute respiratory

syndrome coronavirus 2 (SARS-CoV-2). Available at:

https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-

recommendations.html. Accessed 9 March, 2020.

23. Ather A, Patel B, Ruparel NB, Diogenes A, Hargreaves KM. Coronavirus Disease 19 (COVID-

19): Implications for Clinical Dental Care. J Endod. 2020 May;46(5):584-595.

24. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate

surfaces and its inactivation with biocidal agents. J Hosp Infect 2020;104:246–51.

25. Peng X, Xu X, Li Y, et al. Transmission routes of 2019-nCoV and controls in dental practice.

Int J Oral Sci 2020;12:9.

 26. Centers for Disease Control and Prevention recommendations for putting on and removing

personal protective equipment for treating COVID-19 patients. From:

https:/www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf. Site accessed March 17, 2020.

LEGENDS TO TABLES:

Table 1: Procedure to wear a Personal Protective Equipment (PPE) - Centre for Disease Control and

prevention

Table 2: Procedure for safe removal of PPE kit - Centre for Disease Control and Prevention

LEGENDS TO FIGURES:

Fig1: Clinical Dental Care of COVID-19 patients [Adapted from Ather A et al 23

TABLE 1: Procedure to wear a Personal Protective Equipment (PPE) - Centre for Disease Control

and prevention26

1. GOWN

• Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back

• Fasten in back of neck and waist

2. MASK OR RESPIRATOR

• Secure ties or elastic bands at middle of head and neck

• Fit band to nose bridge

• Fit snug to face and below chin

• Fit-check respirator

3. GOGGLES OR FACE SHIELD

• Place over face and eyes and adjust to

4. GLOVES

• Extend to cover wrist of isolation gown

USE OF SAFE WORK PRACTICES TO PROTECT YOURSELF

AND LIMIT THE SPREAD OF CONTAMINATION

• Keep hands away from face

• Limit surfaces touched

• Change gloves when torn or heavily contaminated

• Perform hand hygiene

TABLE 2: Procedure for safe removal of PPE kit - Centre for Disease Control and Prevention26

1. GLOVES

• Outside of gloves are contaminated!

• If your hands get contaminated during glove removal, immediately wash your hands or use

an alcohol-based hand sanitizer.

• Using a gloved hand, grasp the palm area of the other gloved hand and peel off glove

• Hold removed glove in gloved hand

• Slide of ungloved hand under remaining glove at wrist and peel off second glove over glove

• Discard gloves in a waste container

2. GOGGLES OR FACE SHIELD

• Outside of goggles or face shield are contaminated!

• If your hands get contaminated during goggle or face shield removal, immediately wash your

hands or use an alcohol-based hand sanitizer

• Remove goggles or face shield from the back by lifting head band or ear pieces

• If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a

waste container
3. GOWN

• Gown front and sleeves are contaminated!

• If your hands get contaminated during gown removal, immediately wash your hands or use an

alcohol-based hand sanitizer

• Unfasten gown ties, taking care that sleeves don’t contact your body when reaching for ties

• Pull gown away from neck and shoulders, touching inside of gown only

• Turn gown inside out

• Fold or roll into a bundle and discard in a waste container

4. MASK OR RESPIRATOR

• Front of mask/respirator is contaminated — DO NOT TOUCH!

• If your hands get contaminated during mask/respirator removal, immediately wash your hands or

use an alcohol-based hand sanitizer

• Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without

touching the front

• Discard in a waste container

5. WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING

ALL PPE
Fig1: Clinical Dental Care of COVID-19 patients [Adapted from Ather A et al 23