Oral Manifestations of COVID 19

 INTRODUCTION

•  The Coronavirus disease 2019(COVID-19) caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2).
• The Virus was first identified in December 2019 in Wuhan, China.
• Pandemic:11th March 2020
• India's first case:30th January 2020

Modes of Spread

Respiratory droplets while sneezing, coughing, speaking.

Morphology

Structure of Coronavirus

Family: Coronaviridae
Genome:ssRNA
Size:120nm
Shape: Crown like or Coronal

General pathogenesis

Oral Pathogenesis

Symptoms

Most common symptoms:

• fever
• dry cough
• tiredness

Less common symptoms:

• aches and pains
• sore throat
• diarrhea
• conjunctivitis
• headache
• loss of taste or smell
• a rash on the skin, or discolouration of fingers or toes

Serious symptoms:

• difficulty breathing or shortness of breath
• chest pain or pressure
• loss of speech or movement

Oral Manifestations of COVID 19

Dysgeusia(loss of taste) is the first recognized oral symptom of novel coronavirus disease (COVID-19).

• Virus distrust cranial nerve 1,7,9,10

1. Dry mouth/Xerostromia: The most common reason for mouth breathing by an individual is due to mask use. Mouth breathing can desiccate oral tissue, especially without frequent hydration. Studies suggest that another biological mechanism involves viral entry into the salivary glands, which are known to be abundant in the ACE2 receptor.
2. Mouth Ulcers: Painful mouth ulcers can be in the tongue, lips,

   

   Mouth ulcers in covid19

    and palate. Coronavirus is known to cause vascularity anomalies due to viral damage of blood vessels. The virus gains entry into the endothelial cells that line blood vessels via the ACE2 receptor and damages them, leading to tissue necrosis, including oral ulcerations. The tissue damage can be further exacerbated by increased inflammation.
   
3. Covid tongue: COVID Tongue, is a symptom that is not very common but is being reported by COVID positive patient. Doctors are trying to identify the reason behind the new symptoms, it can be due to a newer version of mutated covid19virus. Covid tongue mainly starts with irritation, itching, a vague sensation of pain, and extreme dryness of the mouth with the rare occurrence of mouth ulcers. According to the American Academy of Oral Medicine (AAOM), the COVID tongue is an inflammatory disorder that usually appears on the top and sides of the tongue. In the Covid tongue, your mouth fails to produce saliva and you experience dryness, white patches, and bumps on your tongue. Saliva functions as a protection against bad bacteria and in its absence your body will be exposed to them.

   

   Covid Tongue

   • Atrophy of tongue

   • Ulcers on tongue
   • Fissures on tongue
   • Bumps on tongue

4. Gingival inflammation: It can be Due to generalised increase in cytokines and interleukins due to coronavirus19.The inflammatory products can enter the bloodstream through infected gum pockets around the teeth, When inflammatory products from gum disease enter the bloodstream, those products can go to other body organs and potentially cause tissue damage.
5. Herpatiform/zosteriform lesions: Multiple painful, round yellowish-Grey ulcers with an erythematous rim on both keratinised and non keratinised mucosa. Stress and immunosuppression associated with covid 19 is a suggestive cause of the appearance of secondary hepatic gingivostomatitis.
6. Ulcers and erosion: Painful lesions with irregular borders on the tongue, hard palate, and labial mucosa. Different factors such as drug eruption, vasculitis, or thrombotic vasculopathy secondary to covid19 were suggestive as the cause of the development of ulcerative and erosive lesions.
7. White/Red plaques: Reported on the dorsum of the tongue. gingiva and palate of conformed and suspected covid 19 patients. Candidiasis due to long-term antibiotic therapy, poor oral hygiene can be the reason for white and red patches.

8. 

   Petechiae

   Kawasaki-like disease:  Oral lesions including cheilitis, glossitis, Erythematous and swollen tongue(red strawberry tongue)
9. Petechiae: In few cases, petechiae was reported on the lower lip, palate, and oropharynx mucosa. Thrombocytopenia from covid19 infection and prescribed drugs were the suggestive causes of the lesions.
   
10. Erythemamultiforme like lesions: Lesions appears like blisters, desquamative gingivitis, erythematous macules, erosions, painful cheilitis with hemorrhagic crust on the lips.

Management of oral lesions

Conclusion

• Oral Symptoms can also be considered initial symptoms of covid-19.
• Oral manifestation of covid 19 has been widely recognised, however, the pathognomic lesions of covid 19 are still uncertain
• Oral manifestations that may appear in covid19 patients can be important for early detection and prevention of transmission, because oral manifestations in covid 19 could mimic other viral manifestations, including herpes zoster.
• studies are recommended to determine the relationship between covid 19 and manifestations in the oral mucosa.

XEROSTOMIA OR DRY MOUTH

Xerostomia, commonly called dry mouth, is a condition of oral dryness. In many, but not all cases, it is caused by reduced or absent saliva flow due to impaired salivary gland function. While oral dryness may not sound serious, xerostomia can in fact be a contributing factor in a number of oral health problems, including increased risk of plaque, tooth demineralization, dental caries, dental erosion, oral yeast infections, and ulcers of the tongue.

Common Causes of XerostomiaMedications/Medical Treatments:
commonly prescribed drugs can cause xerostomia.Some medications—such as sedatives, antidepressants, antihistamines, opiates, antipsychotics, anti-Parkinson agents, and antianxiety agents—interfere with the function of salivary gland receptors, reducing salivary production and volume.
Others, such as antihypertensives and diuretics, interfere with the body's salt, water, and electrolyte balance. This changes the composition of saliva so it contains less of the lubricating agent mucin, as well as low concentrations of ions needed in remineralization. Polypharmacy—taking multiple medications everyday—has also been associated with dry mouth, with the risk being the highest when more than three different drugs are taken daily.Cancer treatments, such as chemotherapy, or radiotherapy to the head and neck, can also cause dry mouth if the treatment has affected salivary glands. Sometimes affected salivary glands maintain some functional ability, but sometimes cancer treatments can destroy them completely.

Systemic Diseases and Other Health Conditions:A number of systemic diseases have been linked to impairments in saliva secretion or compositional changes in saliva. These include autoimmune diseases such as Sjögren's syndrome, rheumatoid arthritis, autoimmune thyroiditis, and systemic lupus erythematosus; chronic infections such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV); and hormonal conditions such as diabetes or menopause.Other conditions that have been implicated in dry mouth include eating disorders such as bulimia or anorexia nervosa; neurological disorders such as depression, bipolar disorder, Bell's palsy, or cerebral palsy; and local salivary diseases such as salivary gland cancer, salivary duct stones, or salivary gland infections. Chronic use of alcohol and other drugs, such as cannabis and methamphetamines, have also been linked to xerostomia.

Who Is Most at Risk?The elderly tend to be most at risk for dry mouth. This isn't because age itself causes the condition, but rather because this age group is more likely to have systemic diseases and health conditions linked to xerostomia. The elderly are also more likely to be taking medications, and engaged in polypharmacy.
Particular attention should also be paid to women between the ages of 40 and 60, since they are undergoing hormonal changes as they transition to menopause that affect salivary gland function, inducing dry mouth.10 This group is also most at risk for the autoimmune condition Sjögren's syndrome (SS), the most common disease that causes xerostomia. In SS, the body's immune system attacks secretory glands (such as the salivary glands and tear glands), so they lose their ability to produce sufficient lubricating fluid. This causes dryness of all mucosal linings of the body, including the mouth, eyes, and digestive tract.
Medications to Help Patients Manage Dry Mouth:While the ideal scenario is one in which you could help a patient identify the underlying cause of dry mouth and take steps to minimize the cause, this may not always be possible. In addition to helping patients manage their symptoms with the tips recommended above, some may benefit from medications that substitute saliva or increase salivary flow.
Over-the-counter saliva substitutes are products that mimic saliva to replace moisture, and make the mouth feel more lubricated. Many are also formulated to supply calcium, phosphate, and fluoride ions, to counteract the demineralization and increased caries risk that accompanies dry mouth. Studies have found that they also help decrease plaque levels, and reduce gingivitis and oral yeast infection risk. These come in the form of sprays, lozenges, or mouthwashes.Another type of medication that may help some patients with dry mouth—depending on if their salivary glands are still able to function—is a salivary stimulant. These include over-the-counter lozenges and tablets; and prescription medications, such as pilocarpine and cevimeline, which activate the receptors to increase saliva production.