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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 286-289

Evaluation of orofacial symptoms and oral health-related quality of life among COVID-19 patients attending a tertiary hospital in Thiruvananthapuram: A cross-sectional study


Department of Oral Medicine and Radiology, Government Dental College, Trivandrum, Kerala, India

Date of Submission31-Mar-2022
Date of Decision19-Jul-2022
Date of Acceptance05-Sep-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
M M Mini
Department of Oral Medicine and Radiology, Government Dental College, Medical College P.O., Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_110_22

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   Abstract 


Background: Researchers have been perplexed by the diverse clinical symptoms of COVID-19 spikes, and its oral symptoms are not frequently documented. Objectives: To estimate the prevalence of orofacial symptoms associated with confirmed COVID-19 cases and to assess the oral health–related quality of life among these patients. Methods: After audio consent, a pre-tested structured questionnaire was used to gather data from COVID-19-confirmed patients, and cases from a tertiary dental care facility in Thiruvananthapuram were also included. Results: Out of 200 participants, 86 (43%) were females, and 114 (57%) were males. The mean age was 40 years, ranging from 10 to 75 years. It was found that loss of taste (111, 56%), dry mouth (54, 27%), oral ulceration (18, 9%), white discoloration (12, 6%), burning sensation (9, 4.5%), red discoloration (7, 3.5%), tooth mobility (4, 2%), osteomyelitis (3, 2%), mucormycosis (4, 2%) and gingival bleeding (1, 0.5%) were the orofacial symptoms present in the participants. Conclusion: The prevalence of orofacial symptoms was 68% in COVID-19 patients, with loss of taste, dry mouth, and oral ulcerations as predominant symptoms. The mean oral health impact profile (OHIP) value of the COVID patients who showed oral manifestations was 17.44, whereas for those who did not show oral manifestations, it was only 7.46.

Keywords: COVID-19, OHIP-14, oral manifestation


How to cite this article:
Mini M M, Tinky B C, Fathima S C, Aswathi K, Ramachandran S, Girija K L, Ramesh S. Evaluation of orofacial symptoms and oral health-related quality of life among COVID-19 patients attending a tertiary hospital in Thiruvananthapuram: A cross-sectional study. J Indian Acad Oral Med Radiol 2022;34:286-9

How to cite this URL:
Mini M M, Tinky B C, Fathima S C, Aswathi K, Ramachandran S, Girija K L, Ramesh S. Evaluation of orofacial symptoms and oral health-related quality of life among COVID-19 patients attending a tertiary hospital in Thiruvananthapuram: A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:286-9. Available from: http://www.jiaomr.in/text.asp?2022/34/3/286/356945




   Introduction Top


With symptoms like fever, dry cough, shortness of breath, dysosmia, and dysgeusia, the coronavirus disease 2019 (COVID-19) has quickly grown into a full-fledged global pandemic.[1]

Taste disturbances, generalized oral ulcers, desquamative gingivitis, petechiae, and infections like candidiasis are some of the oral signs and symptoms associated with this condition.[2] It is yet unclear if they could represent a typical clinical pattern or a systemic effect brought on by weakened immunity and unfavorable medical outcomes.[3]

Based on a person's individual experiences with health, the health-related quality of life (HRQoL) predicts their level of well-being. A modified version called oral health impact profile (OHIP-14) is utilized to measure oral HRQoL.[4]


   Materials and Methods Top


This descriptive cross-sectional study was carried out in Thiruvananthapuram's outpatient clinic at a tertiary dental hospital. The Institutional Ethical Committee granted its approval (IEC/E/40/2020/GDCT, dated 15/09/2020). The study was conducted between October 15, 2020, and April 30, 2021. The equation N = 4PQ/d2 was used to compute the sample size, where “P” was the prevalence, “Q” was 100 – P, and “d” was allowable error (5%–20% of P). In our study, P = 38 (prevalence of dysgeusia); Q = 100 − 26 = 74; and d = 20% of P = 5.2, giving us N = 163 participants. The study's objectives were clearly outlined to the participants, and after audio consent, data was collected by means of a pre-tested structured questionnaire. COVID-positive patients who attended the outpatient department (OPD) were also included. Children below 10 years of age and critically ill patients were excluded from the study. In the questionnaire, demographic details, history of contracting the disease, and clinical symptoms including general, dermatological, and oral, were included (duration was calculated as day 1 from the appearance of first symptoms). Test positivity was taken as a reference point for COVID severity, and the medicines taken by the patient were also enquired about. Patients having any new onset of the orofacial symptoms or worsening of any of the symptoms were taken as symptomatic.

The OHIP-14 is a questionnaire designed to assess the oral HRQoL (OHRQoL). Participants were asked to rate the frequency of effect on a 5-point Likert scale, with 0 being the least frequent, 1 being the most frequent, 2 being occasionally, and 3 being extremely frequent. Higher scores on the OHIP-14 scale, which ranged from 0 to 56, indicated worse OHRQoL.

Statistical analysis

The Statistical Package for the Social Sciences (SPSS) version 21 software was used for statistical analysis. For baseline variables, descriptive statistics were generated. Age and the length of a symptom were two examples of continuous variables for which mean, median, and standard deviation were determined. For categorical characteristics including gender, education, and symptom site, proportions were computed. The Chi-squared test was used to examine the relationship between orofacial symptoms and age, gender, COVID severity, and infectivity period. With a 95% confidence interval (CI), prevalence was expressed as a proportion or percentage. P values below 0.05 were deemed statistically significant.


   Results Top


Out of 200 samples, 86 (43%) were women and 114 (57%) were men. Age ranged from 10 to 75 years, with a mean age of 40. The mean infectivity period was 11 days with a range of 7–20 days. Analyzing the COVID severity of patients 166 (83%) were mild, 29 (15%) moderate, and 5 (3%) were severe and in Co morbidities; 15 (8%) were diabetic Mellitus, 13 (7%) hypertensive, 2 (1%) breathing disorders, and 8 (4%) had other systemic diseases. Thirty-eight (19%) were taking systemic drugs for these comorbidities. Three (2%) were under oral mucosal treatments [Table 1].
Table 1: Demographic details, infectivity period, and severity

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Fever (70%) and loss of smell (64%) were the most frequently found general symptoms [Graph 1]. The most common combination of symptoms was fever and loss of smell [Graph 2]. Loss of smell was observed in 128 (64%) participants and loss of taste in 111 (55%). Prevalence of orofacial symptoms was 68% (95% CI 73.5%–61%). Of these, loss of taste (111, 56%), dry mouth (54, 27%), oral ulceration (18, 9%), white discoloration (12, 6%), burning sensation (9, 4.5%), red discoloration (7, 3.5%), tooth mobility (4, 2%), osteomyelitis (3, 2%), mucormycosis (4, 2%), and gingival bleeding (1, 0.5%) were observed [Table 2].
Table 2: Orofacial symptoms

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Oral manifestations which appeared as prodromal symptoms included dry mouth (12, 6%), loss of taste (32, 16%), oral ulcerations (6, 3%), burning sensation (1, 0.5%), and white color changes (1, 0.5%). Symptoms that appeared within the first three days included dry mouth (24, 12%), loss of taste (64, 32%), oral ulceration (18, 9%), burning sensation (2, 1%), and white color changes (3, 2%). Symptoms that appeared on days 4–6 included dry mouth (24, 12%), loss of taste (46, 23%), burning sensation (4, 2%), white color changes (2, 1%), and red color changes (3, 2%). Oral manifestations which persisted even after 14 days included dry mouth (3, 2%), loss of taste (4, 2%), burning sensation (3, 2%), white color changes (2, 1%), red color changes (2, 1%), gingival bleeding (1, 0.5%), tooth mobility (2, 1%), osteomyelitis (3, 2%), and mucormycosis (4, 2%) [Graph 3].



The mean OHIP value of the COVID patients who showed oral manifestations was 17.44, whereas the value of those who did not show oral manifestations were only 7.46. The mean value of the OHIP score in the descending order of oral symptoms was the following: 36 for mucormycosis, 21 for burning sensation, 20.43 xerostomia, 18.92 for keratotic changes, 18.72 for oral ulceration, and 17.73 for dysgeusia [Table 3].
Table 3: Distribution of OHIP-14

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   Discussion Top


General Symptoms

Viral infections do not itself produce symptoms but rather are produced by the host's immune system, previous studies on common cold viruses were unsuccessful in identifying the virus based on clinical symptoms.[1] In our study, general symptoms reported in the decreasing order of prevalence included fever (70%), loss of smell (64%), muscle pain (46%), cough (32%), headache (27%), breathing difficulty (24%), facial pain (24%), diarrhea (16%), running nose (13%), skin lesions (4%), loss of appetite (2%), nausea and vomiting (3%) and facial skin difficulties (1%). Two patients had petechial spots on the cheek region. Forty-seven patients had facial pain in the temporomandibular joint region and 54 had headache.

Olfactory dysfunction

Olfactory impairment was shown to be 40% prevalent. More than 25% reported anosmia as their first symptom, according to Kaye et al.[5] In line with earlier studies, 35% of participants in the current study had olfactory impairment, and 29% said it was their first sign of the illness.

Gustatory dysfunction

Prevalence of gustatory dysfunction in our study was found to be 55%. Amorim et al.[2] and Karthika et al.[6] reported it as 45% and 49.8%, respectively. Cirillo et al.[7] observed a prevalence range of 5.6% to 96%. A person's nation or ethnicity, age, gender and the severity of the disease may influence or be related to the prevalence and traits of the gustatory impairment caused by COVID-19. Gustatory dysfunction is seen as an early symptom of COVID-19.[6],[8] The median time for the beginning of taste and odor changes, according to studies by Abalo-Lojo et al.,[9] was four days. Thirty-two percent of the patients reported taste alteration within the first three days from the onset of the initial symptom. Two percent complained about persisting taste alteration even after the test report became negative in our study. In our study, 89% also had anosmia. Klopfenstein et al.[10] reported it as 85%. Only 1.2% of people had dysgeusia without anosmia. Altin et al.[11] demonstrated the strong relationship between taste and smell modification. Studies show strong correlation between olfactory and gustatory dysfunction,[12],[13] and there is either no link between the two symptoms or that gustatory dysfunction is more common than rhinorrhea.[14],[15]

Xerostomia

In our study, prevalence of xerostomia was found to be 27%, whereas Chen et al.[16] reported a prevalence of 46.3%. In the present study, only 6% reported it as a prodromal symptom. Twelve percent reported the symptom within three days from the onset of the first symptom, and 2% complained of persisting symptoms even after the test negativity. The prevalence of xerostomia was assessed by Freni et al.[17] Thirty-two percent had xerostomia, which lingered in 2% even after the COVID-19 symptoms subsided. In a retrospective study, xerostomia was reported to be present in 74.5% of patients, prior to receiving a COVID-19 diagnosis.[18]

Additional oral symptoms

Oral ulceration (9% prevalence), erosive lesions (4%) and burning sensation (5%) were observed in addition to gustatory dysfunction and xerostomia. Tongue and labial mucosa were the most affected sited by oral ulcers. The reported prodromal symptoms included oral ulceration for 3%burning sensation and keratotic changes were shown by 1 each. Symptoms that appeared within three days and persisted even after 14 days included burning sensation (2%), keratotic changes (1%), and erosive change (2%).

Ulcerative lesions were most commonly reported among oral manifestations with single ulcers,[19–21] which was similar to our study, and with several small painful ulcers in three studies.[21–23] In our study, labial mucosa was the most affected site. Chaux et al.[20] found that oral ulceration was the first symptom, and in our study oral ulceration was 3%, which presented as prodromal symptom, and 9% within the first three days. Studies carried out laboratory tests and found no herpes antibodies,[19],[21],[22] which implied a relation to COVID-19. Oral ulceration may be related to coinfections, weakened immunity, or negative drug reactions during COVID-19 treatment.[3],[16]

Post-COVID complications like osteomyelitis and tooth mobility were noted in 5 patients, of whom 4 were confirmed with mucormycosis. These patients reported the onset after the second week of the onset of symptoms.

The mean OHIP-14 value of the COVID patients who showed oral manifestation was 17.44, whereas that of those who did not show oral manifestations were only 7.46. Mean value of OHIP score in the descending order of oral symptoms was the following: 36 for mucormycosis, 21 for burning sensation, 20.43 for xerostomia, 18.92 for keratotic changes, 18.72 for oral ulceration, and 17.73 for dysgeusia.

Limitation

Most of the data were recorded using subjective methods based on a questionnaire. A proper diagnosis of the lesions was not made since the majority of oral symptoms can go unreported and because it was challenging to examine the oral cavity due to the risk of contamination and exposure.

Future prospects

Further clinical investigations using large cohorts of patients with various COVID-19 variants are strongly advised in order to document all COVID-19-linked orofacial symptoms as COVID-19 outbreaks continue to occur.


   Conclusion Top


Multiple variants of COVID surges have puzzled researchers with various clinical manifestations. Prevalence of orofacial symptoms was 68% in the present study. By recognizing oral symptoms, dentists can, in fact, be crucial allies in the fight against COVID-19. Therefore, dentists should be knowledgeable about various COVID-19 oral symptoms that could occur.[23]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Biadsee A, Biadsee A, Kassem F, Dagan O, Masarwa S, Ormianer Z. Olfactory and oral manifestations of COVID-19: Sex-related symptoms—a potential pathway to early diagnosis. Otolaryngol Head Neck Surg 2020;163:722-8.  Back to cited text no. 1
    
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Amorim dos Santos J, Normando AGC, Carvalho da Silva RL, Acevedo AC, De Luca Canto G, Sugaya N, et al. Oral manifestations in patients with COVID-19: A living systematic review. J Dent Res 2021;100:141-54.  Back to cited text no. 2
    
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Agrawal Koirala SB, Shrestha A. Assessment of oral health impact profile (OHIP-14) among villagers of JyamirgadiVdc, Nepal: A cross-sectional study. Eur J Biomed Pharm Sci 2017;4:400-3.  Back to cited text no. 4
    
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Kaye R, Chang CWD, Kazahaya K, Brereton J, Denneny J III. COVID-19 anosmia reporting tool: Initial findings. Otolaryngol Head Neck Surg 2020;163:132-4.  Back to cited text no. 5
    
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Karthika P, Rathy R, Jayanthi P, Harish R, Ameena M, Krishnasree R. Oral manifestations of COVID-19 patients: A systematic review. J Orofac Sci 2021;13:73-81.  Back to cited text no. 6
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Mao L, Jin H, Wang M. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. J Am Med Assoc Neurology 2020;77:683-90.  Back to cited text no. 8
    
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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