RESEARCH OF MANIFESTATION OF THE ORAL MUCOSA IN COVID-19

Abstract

The oral cavity is one of the main gates for coronavirus (SARS-CoV-2); the oral cavity also suffers greatly from this infection, because it is one of the most vulnerable places. In addition, since the salivary glands can serve as a reservoir for viruses and support their release into the external environment, it was concluded that saliva, as a component of oral fluid, can play an important role in the spread of coronavirus infection. This is mainly due to the ACE-2 receptor, which have a high level of expression in the keratinized surface epithelial cells of the oral mucosa, especially in the epithelial cells of the dorsal part of the tongue, tonsils, vocal cords, salivary glands and sinuses, due to which the virus replicates in and causes both oral lesions and oral symptoms mouth After entering the cell, the virus delays the response of the immune system, allowing the infection to progress, and it becomes much more difficult to fight it. Accordingly, due to the relatively high level of COVID-19-associated complications, timely diagnosis of clinical forms, including high-risk patients with prognosis their clinical course and the selection of drug treatment appropriate to the severity of the clinical course remain quite complex and controversial issues. It was emphasized that in some cases oral symptoms may be the initial or only sign of disease, and dentists should take this into account when performing a thorough clinical examination of the oral cavity.

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Jalolov Sharifjon, & Chaqqonov Faxriddin Xusanovich. (2024). RESEARCH OF MANIFESTATION OF THE ORAL MUCOSA IN COVID-19. European International Journal of Multidisciplinary Research and Management Studies, 114–125. Retrieved from https://inlibrary.uz/index.php/eijmrms/article/view/35585
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Abstract

The oral cavity is one of the main gates for coronavirus (SARS-CoV-2); the oral cavity also suffers greatly from this infection, because it is one of the most vulnerable places. In addition, since the salivary glands can serve as a reservoir for viruses and support their release into the external environment, it was concluded that saliva, as a component of oral fluid, can play an important role in the spread of coronavirus infection. This is mainly due to the ACE-2 receptor, which have a high level of expression in the keratinized surface epithelial cells of the oral mucosa, especially in the epithelial cells of the dorsal part of the tongue, tonsils, vocal cords, salivary glands and sinuses, due to which the virus replicates in and causes both oral lesions and oral symptoms mouth After entering the cell, the virus delays the response of the immune system, allowing the infection to progress, and it becomes much more difficult to fight it. Accordingly, due to the relatively high level of COVID-19-associated complications, timely diagnosis of clinical forms, including high-risk patients with prognosis their clinical course and the selection of drug treatment appropriate to the severity of the clinical course remain quite complex and controversial issues. It was emphasized that in some cases oral symptoms may be the initial or only sign of disease, and dentists should take this into account when performing a thorough clinical examination of the oral cavity.


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RESEARCH OF MANIFESTATION OF THE ORAL MUCOSA IN COVID-19

Jalolov Sharifjon

Samarkand State Medical University Samarkand, Uzbekistan

Chaqqonov Faxriddin Xusanovich

Samarkand State Medical University Samarkand, Uzbekistan

AB O U T ART I CL E

Key words:

COVID-19, oral manifestations, oral

mucosa.

Received:

20.06.2024

Accepted

: 25.06.2024

Published

: 30.06.2024

Abstract:

The oral cavity is one of the main gates

for coronavirus (SARS-CoV-2); the oral cavity also

suffers greatly from this infection, because it is

one of the most vulnerable places. In addition,
since the salivary glands can serve as a reservoir

for viruses and support their release into the

external environment, it was concluded that

saliva, as a component of oral fluid, can play an
important role in the spread of coronavirus

infection. This is mainly due to the ACE-2 receptor,

which have a high level of expression in the

keratinized surface epithelial cells of the oral
mucosa, especially in the epithelial cells of the

dorsal part of the tongue, tonsils, vocal cords,

salivary glands and sinuses, due to which the virus
replicates in and causes both oral lesions and oral
symptoms mouth After entering the cell, the virus

delays the response of the immune system,

allowing the infection to progress, and it becomes

much more difficult to fight it. Accordingly, due to
the relatively high level of COVID-19-associated

complications, timely diagnosis of clinical forms,

including high-risk patients with prognosis their

clinical course and the selection of drug treatment

appropriate to the severity of the clinical course
remain quite complex and controversial issues. It

was emphasized that in some cases oral

symptoms may be the initial or only sign of

disease, and dentists should take this into account
when performing a thorough clinical examination

of the oral cavity.

VOLUME04 ISSUE06

DOI:

https://doi.org/10.55640/eijmrms-04-06-18

Pages: 114-125


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INTRODUCTION

To date, a new strain of COVID-19 has been identified - omicron, which was first identified in South
Africa in November 2021, according to WHO, and has been associated with an increase in regional

infections. This strain contains more than 30 mutations in the spike protein, which contributed to

increased transmissibility compared to previous variants (alpha, beta, gamma, delta), which is

confirmed by detection in more than 30 countries of the world and reduced susceptibility to

neutralizing antibodies, including therapeutic monoclonal antibodies [5]. Given the ongoing trend of

strain modification, COVID-19 represents an unprecedented, serious medical and social problem for all

of humanity that is far from being solved.

Given the continuing trend of strain modification, COVID-19 represents an unprecedented medical and

social problem for everyone, which is far from being resolved [3.4].

To date, it has been established that age over 65 years [10], male gender [3], cardiovascular disease [3],

diabetes mellitus [7], obesity [3], chronic obstructive bronchitis [7], smoking, lack of oral hygiene [3],

tumor disease [11], liver disease [6], opportunistic infections, stress [5], immunosuppression, vasculitis

and hyperinflammatory response caused by COVID-19 are predisposing factors for the occurrence of

oral lesions in patients in this category [11]. COVID-19 causes a range of oral manifestations, ranging
from dry mouth to opportunistic infections. It was emphasized that in some cases oral symptoms may

be the initial or only sign of disease, and dentists should take this into account when performing a

thorough clinical examination of the oral cavity. Oral ulcers caused by stress may be on the rise among

patients due to pandemic-related fears. Also, older age and higher severity of COVID-19 disease are

associated with severe damage to the oral cavity [1,2,7]. Moreover, the oral mucosa is very intensively

supplied with blood, has a relatively large surface area and is a convenient entry point for penetration
and infections into the div, and also serves as a site of colonization and infection by potentially

pathogenic microorganisms in the event of infection and weakening of natural immunity. The div's

defenses are determined by general and local factors. Local protection is provided by the integrity of

the oral mucosa, the microbicidal properties of saliva and lymphoid tissue. The integrity of the oral

mucosa is the best physiological barrier to infection. The protective factors of saliva are determined not

only by its mechanical properties, but also depend on the biological compounds dissolved in it, which

can cause lysis of foreign cells. These substances include lysozyme, which has a bactericidal effect. In
addition, saliva contains polymorphonuclear neutrophils, which have high bactericidal activity. Finally,

secretory immunoglobulin A (IgA), contained in saliva, is a powerful factor of local protection.


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PURPOSE OF THE STUDY

Study of morphological changes in the oral mucosa and taste sensitivity in patients with COVID-19 of
varying severity. To draw the attention of doctors to oral manifestations in patients who have had

COVID-19, with the aim of an etiopathogenetic approach to the treatment of pathologies of the oral

mucosa.

MATERIAL AND METHODS

There were 105 patients under observation (a total of 254 patients), of whom 62 were men and 43

women, aged from 18 to 55 years (average age 41.6±4.7 years). 149 patients were excluded from the

study, since 3 of them were under 18 years of age, and 7 were over 55 years of age, 15 were smokers,
30 were severely obese, 1 patient was pregnant, 87 patients had concomitant diseases, 6 refused to

provide consent to fill out the questionnaire . All patients had a positive polymerase chain reaction test

result for COVID-19. The study design was a cross-sectional questionnaire-based study. This survey

contains the following demographic information: gender, age, weight, height, education level and

general health. The questionnaire was divided into two parts:

1) The first part includes the results of an oral hygiene assessment obtained by a group of dentists.

The second part contains data on the severity of COVID-19, which was obtained through a telephone
call

All patients underwent a daily visual examination of the oral cavity, registration and assessment of the

characteristics of the clinical course of the disease, the severity of temperature, and symptoms of

intoxication.

RESEARCH RESULTS

During the examination, changes in the oral mucosa were noted in 91 patients (86.6%) (see Table 3.1),
which is consistent with literature data.

It is noteworthy that 13 (12.4%) patients had bleeding symptoms on the buccal mucosa, with no burden

of history of this disease. In addition, pinpoint hemorrhages were observed in the mucosa of the lips

and cheeks. Cyanosis of the lips was also noted. The color of the oral mucosa varied from normal pale

pink to cyanotic, due to the appearance of various levels of vascular patterns on the inner mucosal

surface of the lips.


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Pigmentation in the gingival attachments of the upper and lower jaws was observed in 45 patients

(42.8%) and in 5 patients (4.7%) in the hard palate. In addition, lentigines (brown spots caused by
melanin accumulation) were raised on the mucosal surfaces of the upper and lower lips in 13 (12.3%)

patients.

Mycological culture analysis was performed in all patients and was positive in 6.6% (n = 7 ). Other

mucosal symptoms included aphthous stomatitis in 10.5% (n = 11) and mucositis in 5.7% (n = 6); 8.5%

of patients (n = 7) complained of glossalgia, consisting of a burning sensation on the tongue or

throughout the oral mucosa.

In addition, the most common manifestation of changes in the mucosa of the tongue was angulus of the
mouth, consisting of inflammation of the corners of the mouth, characterized by the formation of

fissures, crusts, and redness on the mucosa in this area, which was present in 26 (24.7%) patients.

Of particular note was transient U-shaped papillitis seen in 15 patients (14.3%), and edema of the

tongue was seen in 8 patients (7.6%). Inflammatory disease of the tongue characterized by glossitis

with localized alopecia was noted in 5 patients (4.7%).

Plaques on the tongue mucosa were found in 90 patients (85.7%), varying in color from white to light

cinnamon and brown. At the same time, the plaques were easily removed by abrasion, and the papillae
were evenly expressed on the entire tongue surface.

Changes in the oral mucosa in hospitalized patients with COVID-19 (n=105)

Types of change

n (%)

Changes in the oral mucosa

91 (86.6)

Plaque of the mucous membrane of the
tongue

90 (85.7)

Parageusia

64 (60.9)

Pigmentation in the area of gum
attachment to the upper and lower jaw

45 (42.8)


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Angular cheilitis

26 (24.7)

U-shaped papillitis

15 (14.3)

Hemorrhagic manifestations on the
buccal mucosa

13 (12.4)

Lentigo

13 (12.4)

Aphthous stomatitis

11 (10.5)

Glossalgia

7 (8.5)

Swelling of the tongue

8 (7.6)

Oral candidiasis

7 (6.6)

Mucositis

6 (5.7)

Pigmentation of the hard palate

5 (4.7)

Glossitis with focal depapilation

5 (4.7)

Dysfunction of the olfactory organ

Parosmia

85 (81)

Anosmia

11 (10.5)

A perversion of taste sensitivity, i.e., parageisia, in which the sense of taste appeared without a

corresponding stimulus, was present in 60.9% of patients (n = 64) and was often combined with a

distorted sense of smell complaint (parosmia) in 81% of patients (n = 85) after 5 days of observation.

In addition, 10.5% (n=11) of patients had a lack of odor perception - anosmia.

According to the results of the initial oral status questionnaire, COVID -19 was severe in 84 patients

(80%) and mild in 21 patients (20%).


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Correlation between oral health and severity of COVID-19 (n=105)

Oral health status

Severity of

COVID

-19

R

Severe degree

Lightweight

degree

Bad condition

n

62

1

<0.001

%

73.8%

4.7%

Satisfactory

n

17

17

%

20.2%

80.9%

Good

n

5

3

%

5.9%

14.2%

General
indicator

n (%)

84 (80%)

21 (20%)

Analysis showed that severe COVID-19 was statistically significantly associated with poor oral
hygiene (p < 0.001). Thus, patients with good oral hygiene were found to have a significantly lower

incidence of severe COVID-19. The relationship between the clinical course of the disease and the

initial oral hygiene status at the first and second week of observation was p<0.001.

Analysis of subgroups by severity of COVID-19 showed that patients with good, satisfactory, and poor

initial oral hygiene had a mild course at the first week of observation (79.4%, 17.4%, and 3.2%,


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respectively). Patients with good, satisfactory, and poor initial oral hygiene had a severe course of

9.1%, 25.7%, and 65.2%, respectively, in the first week of observation.

At the second week of observation, deterioration was significantly higher in the group of patients with

poor initial oral hygiene in 73.8% of cases (p<0.001) compared to those with good initial oral hygiene

(5.9%). The deterioration of clinical course in the second week in patients with good initial oral

hygiene was 20.3%, which was significantly lower than in patients with poor initial oral hygiene

(p<0.001). Thus, at the second week of admission, minor progress was observed in 80.9% of patients

with good oral hygiene, 14.4% of those with good oral hygiene, and 4.7% of those with poor oral

hygiene.

Clinical recovery at weeks 4 and 6 of clinical follow-up was significantly greater in COVID-19 patients

with poor baseline oral hygiene (41.2% and 48.4%, respectively) compared to those with good

baseline oral hygiene (8 .9% and 5.3%, respectively) (p<0. 001). A period of rapid recovery (week 2 of

observation) was observed significantly more often in COVID-19 patients with good initial oral

hygiene (85.8%) compared to those with poor baseline oral hygiene (10.4%) (p<0.001).

Clinical recovery in patients with good oral hygiene was observed in 56.8% of cases by the 2-week

clinical observation, compared to 4-week (33.4%) and 6-week (9.8%) observations for this category
of patients.

Secondary Endpoint Study. Relationship between initial oral status and clinical recovery time. **p

<0.001

It is noteworthy that a negative correlation was found between initial oral status and clinical recovery

time for COVID-19 patients (p <0.001, r = -0.614)

Correlation between the initial state of the oral cavity and the period of clinical recovery

(n=105)

Parameter

Clinical recovery period

Initial oral health status

r

-0.614

P

0.001


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N

105

Impact of COVID-19 severity on clinical recovery (n=105)

Secondary study endpoint

Severity of

COVID

-19

R

Severe
degree

Lightweigh
t

degree

Clinical
recovery
period

6 weeks

n

42

2

<0.001

%

50.0%

9.5%

4 weeks

n

35

4

%

41.6%

19.0%

2 weeks

n

7

15

%

8.3%

71.2%

General indicator

n (%)

84 (80%)

21 (20%)

The rate of delayed clinical recovery in the sixth week of clinical follow-up was significantly higher in
the group of severe patients with COVID-19 (50.0%) compared to the group of patients with mild

clinical course (9.5%).

Clinical recovery in the second week of observation was observed 7 times more often in the group of

COVID-19 patients with a clinically mild course (71.2%) compared to the group of patients with a severe

course (8.3%) (p <0.001), when in the fourth week week of observation in the group of COVID-19


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patients with a mild clinical course, clinical recovery was found in 19.0% of cases, and in the group of

patients with a severe course this figure was 41.6% (p <0.001).

CONCLUSION

A high level of damage to the oral mucosa was detected in 91 (86.6%) patients. 13 (12.4%) patients had

hemorrhagic manifestations on the buccal mucosa, and the history of this disease was not burdened.

There were also pinpoint hemorrhages on the mucous membranes of the lips and cheeks, and cyanosis

of the lips. The color of the oral mucosa varied from the usual pale pink tint to cyanotic due to the

appearance of different levels of vascular pattern on the mucous membrane of the inner surface of the

lips. Pigmentation in the area of gum attachment to the upper and lower jaw was found in 45 (42.8%)
patients, in 5 (4.7%) patients pigmentation was observed in the area of the hard palate. Lentigo, a brown

spot resulting from the accumulation of melanin, rising above the surface of the mucous membrane of

the upper and lower lips, was present in 13 (12.3%) patients. Mycological culture analysis was positive

in 7 (6.6%) patients. Other mucosal manifestations were aphthous stomatitis (10.5%) and mucositis

(5.7%). 8.5% of the patient complained of glossalgia, which consists of a burning sensation of the tongue

or the entire oral mucosa. In addition, the most common manifestation of changes in the mucous

membrane of the tongue was pronounced angular cheilitis, consisting of inflammation of the corners of
the mouth, characterized by the formation of cracks, crusts and redness of the mucous membrane of

this area of the mouth in 26 (24.7%) patients. Particular attention was drawn to transient U-shaped

papillitis, detected in 15 (14.3%) patients, while 8 (7.6%) had swelling of the tongue. Inflammatory

disease of the tongue, characterized by glossitis with focal depapilation, was observed in 5 (4.7%).

Plaque on the mucous membrane of the tongue, the color of which varied from white to light cinnamon

and brown, was diagnosed in 90 (85.7%). The plaque was easily removed by scraping. Papillae of
uniform severity were also noted over the entire surface of the tongue. Perversion of taste sensitivity,

the appearance of taste sensations in the absence of a corresponding stimulus - parageusia - was

determined in 60.9% of patients. Often this symptom was combined with complaints of distorted

perception of odors - parosmia - in 81% of patients. In addition, 10.5% of patients had no perception of

smell - anosmia.

1. A high level of manifestation in the form of damage to the oral mucosa (oral manifestation) indicates

the highest expression of ACE-2 receptors in the oral cavity, which requires special attention in
organizing dental treatment and preventive consultations with patients.


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2. Active treatment of oral diseases and compliance with all clinical recommendations developed by the

European Federation of Periodontology helps prevent the oral-vascular-pulmonary spread of the
COVID-19 virus.

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