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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 3  |  Page : 290-294

Effect of Covid and its Treatment Protocols on Chronic Generalized Periodontitis- A Prospective Study


1 Department of Periodontics, Government Dental College and Hospital, Afzalgunj, Hyderabad, Kaloji Narayana Rao University of Health Sciences, Warangal, Telangana, India
2 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Kadapa, Dr NTR University of Health Sciences, Andhra Pradesh, India
3 Department of Periodontics, Anil Neerukonda Institute of Dental Sciences, Visakhapatnam, Dr NTR University of Health Sciences, Andhra Pradesh, India
4 Department of Periodontics, Tirumala Institute of Dental Sciences and Research Centre, Nizamabad, Kaloji Narayana Rao University of Health Sciences, Warangal, Telangana, India

Date of Submission02-Feb-2022
Date of Decision04-Aug-2022
Date of Acceptance01-Sep-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Chiranjeevi Vedula
10.282/1, Vasanthapuri Colony, Malkajgiri, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_38_

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   Abstract 


Background: COVID-19 causes an inflammatory response that intensifies and can cause death. Periodontitis is also characterized by an inflammatory response elicited by microbial plaque, which intensifies and inflicts damage to the tissues. To address the effect of immunoinflammatory mechanisms, steroids were used extensively as a lifesaving drug and stayed as the mainstream drug in treating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. The present study aimed to investigate the possible impact of COVID-19 treatment protocols in chronic periodontitis patients. Materials and Methods: A total of 103 COVID-19-positive patients with a hospitalization period of at least 5 days with dental records were enrolled in the study. Based on Periodontal Index (PI) values, the subjects were categorized as having mild, moderate, and severe periodontitis. These patients, after undergoing treatment for COVID-19 were recalled after 6 months for periodontal status evaluation. Statistical analysis was made to test for any significant variation in the periodontal status before and after COVID-19 treatments. Results: The mean comparison of Periodontal Index (PI) values before and after COVID were 4.02 and 4.40, with a statistically significant (P ≤ 0.05). PI values of the patients on Dexamethasone pre and post COVID –b 19 were compared and found to be 3.86 and 4.83, respectively. Conclusion: The present study indicates that COVID-19 and its different treatment protocols were strongly associated with elevated periodontal disease worsening in COVID-19 survivors at 6-month follow-up.

Keywords: COVID-19, dexamethasone, periodontitis, prednisolone


How to cite this article:
Reddy S H, Madu CR, Bathula H, Vedula C, Kunthsam V, Gupta K V. Effect of Covid and its Treatment Protocols on Chronic Generalized Periodontitis- A Prospective Study. J Indian Acad Oral Med Radiol 2022;34:290-4

How to cite this URL:
Reddy S H, Madu CR, Bathula H, Vedula C, Kunthsam V, Gupta K V. Effect of Covid and its Treatment Protocols on Chronic Generalized Periodontitis- A Prospective Study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:290-4. Available from: http://www.jiaomr.in/text.asp?2022/34/3/290/356968




   Introduction Top


A pneumonia outbreak caused by a newly emerged coronavirus; World Health Organization (WHO) declared it a pandemic on March 11, 2020. The virus was officially named SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and the disease COVID-19. This outbreak has established a major setback in the economy globally and has undesirably hampered the general health of the population by influencing the immunopathologic sequences, affecting multiorgan systems.[1] Oral health occupies a specific entity of concern as there are plausible linking mechanisms for respiratory illnesses which may influence the health of tissues of the oral cavity which includes oral mucosa, teeth, and their supporting structures.[2] Besides this long-term hospitalization, the use of steroids and stress may lead to further damage to the general health and health of the oral cavity by impeding the host immune system. COVID being an unprecedented disease, its upsurge has left the medical team in a dilemma as there was no established protocol for following an evidence-based treatment modality. Most of the treatment is targeted over the improvement of respiratory condition, attaining stable oxygen saturation levels, neutralizing the ill effects of the virus and at the same time reducing the viral load. Some patients developed severe COVID symptoms due to excessive host-immune response with overproduction of proinflammatory cytokines like interleukin (IL)-6, tumor necrosis factor (TNF), a response referred to as “cytokine storm” which leads to multi-organ failure and death in some cases.[3] To address the effect of immunoinflammatory mechanisms, steroids were used extensively as a lifesaving drug and stayed as a mainstream drug in treating SARS-CoV-2 infection. Periodontitis also shares common pathophysiology to some extent in causing tissue destruction as seen in COVID disease.[4] The cytokine storm in severe COVID-19 infections carries a similar profile to that of periodontitis, implying a probable link between periodontal disease and COVID-19.[5] The present study investigates the possible impact of COVID-19 disease and its treatment protocols in periodontitis patients.


   Materials and Methods Top


The present multicenter prospective study was conducted for 6 months from May 2021 to October 2021. COVID-19-positive patients who were hospitalized and underwent treatment for COVID-19 were enrolled in the study. The periodontal status of these patients was evaluated using Russell's Periodontal Index (PI). To balance dropouts, additional participants were included. Around 103 COVID-19 patients with dental records were selected for analysis. All patients were given a written and verbal explanation about the study and were asked to sign an informed consent form. The study was approved by the institutional ethical committee (RMCC/050321/26). The study was carried out in accordance with all the procedures and principles established by the Helsinki 1964 and later) and CONSORT guidelines were followed. [Figure 1] shows the study design followed.
Figure 1: CONSORT flow diagram

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Inclusion criteria

Subjects who tested positive for SARS-CoV-2 with hospitalization for at least 5 days but not more than 18 days and who were discharged without any complications.

Exclusion criteria

  • Smokers, pregnant, and lactating women.
  • Patients without detailed past periodontal records and radiographs.
  • Patients with post COVID delayed complications like Mucormycosis.


Sample size

The sample size was calculated using G power 3.1 software. 30 sites would be sufficient to achieve the required significance under 95% power with an alpha error value set at 0.05.

Screening and examinations

After scrutinizing their hospitalization records showed that all the subjects were treated with a similar COVID-19 protocol with the exception of variations in the duration of usage and drug dosage of steroids as per the severity of disease and period of hospitalization. All measurements were performed by one expert periodontist, allowing an intraexperimental comparison of the values. Percentage agreement with another examiner within 1 mm was >97%. Based on the pre COVID-19 periodontal status records patients were categorized as a mild, moderate, and severe periodontal disease according to the 2017 World Workshop Classification.[6] The function and health were maintained with non-surgical and surgical treatments as a part of periodontal therapy according to the disease severity. None of the patients presented with hopeless teeth indicated for extraction before COVID-19 disease episode. These patients were recalled after 6 months post COVID recovery and their periodontal status was recorded. Periodontal status was also analyzed comparatively in patients who have used Dexamethasone and Methyl Prednisolone. Observer bias was minimized since Russell's Periodontal Index was a standardized observational procedure and the observers were experienced dentists who were well trained.

Statistical analysis

The data was entered into SPSS (statistical package for the social sciences) software 20.00 program (SPSS Inc. Chicago, IL, USA). Statistical analysis was made to test for any significant variation in the periodontal status prior to and post COVID. Wilcoxon signed-rank test was utilized for Russell's Periodontal Index (PI) before and after COVID in Patients treated with Dexamethasone and with Prednisolone. Mann–Whitney U test was used for Russell's Periodontal Index (PI) for comparison in patients treated with Dexamethasone and Prednisolone at Post COVID. Statistical significance was considered when P < 0.05*.


   Results Top


Of 149 participants with chronic periodontitis, 21 were excluded for a recent diagnosis of COVID-19 disease, i.e., within 6 months, 13 were excluded for incomplete previous dental records and 12 patients were excluded for presenting with some of the other systemic diseases. A total of 103 COVID-19 patients with dental records were retained for analysis. On reviewing the treatment protocols, 92 patients were on Methyl Prednisolone and 11 patients were on Dexamethasone. [Table 1] demonstrates the mean comparison of periodontal index values before and after COVID. The mean value increased from 4.02 to 4.40 with a statistically significant P value. [Table 2] shows the comparison of periodontal index values of the patients who were treated with Dexamethasone. The Mean value increased from 3.86 before COVID to 4.83 after COVID. The P value was noticed to be statistically significant (0.003). [Table 3] shows the comparison of periodontal index values of the patients who were treated with Prednisolone. The Mean value increased from 4.04 before COVID to 4.35 after COVID with a statistically significant P value. Wilcoxon signed-rank test was used in the above statistical analysis. A Comparison of post COVID periodontal index values of the patients on Dexamethasone and Prednisolone are shown in [Table 4]. The mean value decreased from 4.83 to 4.35 with a statistically significant P value. Mann–Whitney U test was used in comparing these values. Results were also clinically significant.
Table 1: Mean comparison of Russell's Periodontal Index (PI) before and after COVID

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Table 2: Mean comparison of Russell's Periodontal Index (PI) before and after COVID (Patients treated with Dexamethasone)

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Table 3: Mean comparison of Russell's Periodontal Index (PI) before and after COVID (Patients treated with Prednisolone)

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Table 4: Mean comparison of Russell's Periodontal Index (PI) of patients treated with Dexamethasone and Prednisolone at Post COVID

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   Discussion Top


This study has shown a strong association between periodontitis and COVID-19 disease. The disease course and its treatment protocols showed deterioration of periodontal health and worsening of periodontitis. The outbreak of this pandemic opened several doors in the field of research and in particular inflammatory disorders. Periodontitis being a chronic inflammatory disease shares common risk factors with COVID-19 and they might influence each other in either way. There are several studies supporting the worsening of COVID-19 outcomes in periodontitis patients, considering periodontitis to be the risk factor for complications, assisted ventilation and death. A common connecting link between these two inflammatory diseases is excessive host immune response with overproduction of proinflammatory cytokines such as interleukin (IL)-6, tumor necrosis factor, etc. Severe acute respiratory distress in COVID-19 can be attributed to the host's response to the disease, referred to as a “cytokine storm.” Research in this context has taken a lead since the onset of understanding of the pathogenesis of the pandemic. On the contrary effect of COVID-19 disease and the impact of the treatment protocols on periodontal disease remained unattended. This study is aimed to assess the extent and severity of the deterioration of periodontal health in COVID survivors. Other factors to consider include the treatment protocol, psychological stress, depression due to isolation, and failure to cope financially with an unprecedented disease resulting in compromised health and self-care, all of which affect general health and oral health.

Experimental animal models showed that elevated circulating proinflammatory cytokines induced vascular inflammation.[7] A dose-response mode is found with stress and an increased risk of acute respiratory illness and infections.[8] Genco et al.[9] showed that subjects with financial strain and inadequate coping lifestyle exhibited a higher risk of severe attachment loss (odds ratio = 2.24) and alveolar bone loss (odds ratio = 1.91).[9] He found that psychosocial factors such as financial strain and distress, which will be expressed as depression, are substantial risk factors for periodontal disease severity. Inflammation is the result of chronic stress through proinflammatory cytokines.[5] When considering the interaction of stress, cytokines, and inflammation, the likelihood of periodontal disease deteriorating can be considered. Individuals suffering from chronic stress and hospitalization may neglect oral hygiene care which contributes to the accumulation of plaque deposits which is the primary etiologic factor for periodontitis.

Since the onset of the pandemic coronavirus has shown its dynamic virulence by undergoing several mutations and presenting with diverse clinical symptoms, ensuing ambiguity in the treatment protocol. Besides limiting the viral load, decreasing the tissue destruction has been addressed by using steroids which have been successful in attaining control over the lethal effects of the disease. A systematic review (Brasil-Oliveira)[10] provided a causal relationship between the use of corticosteroids and periodontitis. Corticosteroids may lead to immunosuppression, hyperglycemia, loss of bone mineral density, and osteoporosis. Although these effects have faint evidence on the short-term usage of steroids, the association between the drug and periodontitis holds sound evidence. Subjects in this study have been treated using dexamethasone or methylprednisolone during the treatment period. It has been observed that there is a significant change in the periodontal indices before and after COVID-19 in these subjects. Patients who were treated using dexamethasone showed greater deterioration of periodontal status compared to those treated with methylprednisolone.

We have observed that all the patients who were affected and treated for this disease showed significant progression in periodontal disease. Two patients with moderate to severe periodontitis before the disease presented with significant tooth loss after recovery. Many factors have influenced periodontal health out of which the pathophysiology of the disease and its treatment protocols might have a major influence on the disease progression. Other factors like host susceptibility, genetics, and obesity could have biased the 6-month follow-up of the periodontal status.

This study has some limitations as some information regarding the total daily dosage and method of administration of steroids, fluctuation of oxygen saturations, and quality of treatment received has been unclear. The present study evidenced appropriate adverse effects of COVID-19 disease and its treatment protocols on the deterioration of periodontitis in systemically healthy individuals. More extensive studies with a greater sample size would be helpful to ascertain this evidence. Precise know-how of the behavior of the SARS-CoV-2 virus and its mutant variants, a thorough study of the disease course and established evidence regarding the treatment protocol may provide a clear idea of periodontal health and disease.


   Conclusion Top


Most concomitant illnesses linked to COVID-19 severity (e.g., diabetes, hypertension, COPD, cardiovascular disease, and cerebrovascular disease) exacerbate periodontal disease. Furthermore, COVID-19 and its treatment protocols are significantly associated with an elevated risk of periodontal disease worsening. Steroids used in the treatment of COVID-19 worsened the periodontal status of the patients. The results of the present study conclude that COVID -19 and its different treatment protocols were significantly associated with an increased risk of periodontal disease worsening in COVID-19 survivors at 6 months of follow-up.


   Limitations and Future Prospects Top


The study was conducted for a short period, although study results showed a significant relation between periodontal heath and COVID-19, a detailed study which included larger sample size and across all age groups will be more apt to determine the exact relationship, furthermore this study has opened a window for establishing study protocols for future investigations in this subject.

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.

Key message

Periodontal health is dictated by numerous health conditions, and COVID-19 is also a potential factor that can alter periodontal health; in this study, the effect of COVID-19 and its treatment protocols on previously diagnosed chronic periodontitis patients was evaluated, and it was found to have a deteriorating effect over the periodontal health over a long run.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.  Back to cited text no. 1
    
2.
Xu H, Zhong L, Deng J, Peng J, Dan H, Zeng X, et al. High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral Sci 2020;12:1-5.  Back to cited text no. 2
    
3.
Acharya AB, Thakur S, Muddapur MV, Kulkarni RD. Cytokine ratios in chronic periodontitis and type 2 diabetes mellitus. Diabetes Metab Syndr 2017;11:277-8.  Back to cited text no. 3
    
4.
Gupta S, Sahni V. The intriguing commonality of NETosis between COVID-19 and Periodontal disease. Med Hypotheses 2020;144:109968.  Back to cited text no. 4
    
5.
Sahni V, Gupta S. COVID-19 and Periodontitis: The cytokine connection. Med Hypotheses 2020;144:109908.  Back to cited text no. 5
    
6.
Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, et al. A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification. J Clin Periodontol 2018;45(Suppl 20):S1-8.  Back to cited text no. 6
    
7.
Lu XT, Zhao YX, Zhang Y, Jiang F. Psychological stress, vascular inflammation, and atherogenesis: Potential roles of circulating cytokines. J Cardiovasc Pharmacol 2013;62:6-12.  Back to cited text no. 7
    
8.
Ye Q, Wang B, Mao J. The pathogenesis and treatment of the 'Cytokine Storm' in COVID-19. J Infect 2020;80:607-13.  Back to cited text no. 8
    
9.
Genco RJ, Ho AW, Grossi SG, Dunford RG, Tedesco LA. Relationship of stress, distress and inadequate coping behaviors to periodontal disease. J Periodontol 1999;70:711-23.  Back to cited text no. 9
    
10.
Brasil-Oliveira R, Cruz ÁA, Souza-Machado A, Pinheiro GP, Inácio DDS, Sarmento VA, et al. Oral health-related quality of life in individuals with severe asthma. J Bras Pneumol 2020;47:e20200117.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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