Journal of International Oral Health

REVIEW ARTICLE
Year
: 2020  |  Volume : 12  |  Issue : 8  |  Page : 90--92

Impact of SARS-CoV-2 on periodontal tissue manifestation


Nanda Rachmad Putra Gofur 
 Department of Health, Faculty of Vocational Studies, Universitas Airlangga, Surabaya, Indonesia

Correspondence Address:
Nanda Rachmad Putra Gofur
Department of Health, Faculty of Vocational Studies, Universitas Airlangga, Surabaya.
Indonesia

Abstract

Coronavirus disease 19 (COVID-19) is a recent infectious disease that is rapidly spreading worldwide and targets human angiotensin-converting enzyme 2 receptors. A recent study found that COVID-19 induces immune responses resulting in periodontal manifestation. The purpose of this study was to investigate the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on periodontal tissue. Periodontal bacteria are implicated in systemic inflammation, bacteremia, and pneumonia. Moreover, it has been shown that 80% of patients with severe COVID-19 had high bacterial load. It has also been reported that the severity of COVID-19 in patients associates with increased levels of inflammatory markers such as interleukin and bacterial invasion. Systemic increase in the inflammatory response reveals the similarity with cytokine storm in COVID-19 patients. These conditions revealed that elevated levels of cytokines detected in locally inflamed gingival tissue through saliva analysis could expand to the systemic circulation, resulting in systemic inflammation and vice versa. It is suggested that there is a possibility of periodontitis due to increased inflammatory responses in host as an impact of SARS-CoV-2 infection. Periodontal impact was seen in COVID-19 patients as localized erythema in margins of gingiva leading to desquamative gingivitis and oral pain. Although COVID-19 might manifest in periodontal tissues, presence of periodontal pathogen could pose a risk of superinfection, and periodontal pocket could be a favorable anatomical niche for the virus, the literature is still lacking to conclude that COVID-19 has an impact on periodontal tissues and more studies are needed.



How to cite this article:
Gofur NR. Impact of SARS-CoV-2 on periodontal tissue manifestation.J Int Oral Health 2020;12:90-92


How to cite this URL:
Gofur NR. Impact of SARS-CoV-2 on periodontal tissue manifestation. J Int Oral Health [serial online] 2020 [cited 2021 May 14 ];12:90-92
Available from: https://www.jioh.org/text.asp?2020/12/8/90/301860


Full Text

 Introduction



Coronavirus disease 19 (COVID-19) is the recent infectious disease that is rapidly spreading worldwide. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and targets human angiotensin-converting enzyme 2 (ACE2). SARS-CoV-2 was first discovered in 2019 in China, which is spreading globally, and has become pandemic as declared by the World Health Organization (WHO).[1],[2],[3],[4],[5]

In a recent 2020 study, patients were diagnosed with COVID-19 in oral cavity and had manifestation and generalized erythematous and edematous gingiva and necrotic interdental papillae in both the maxillary and mandibular regions. Bleeding was seen from the gingival sulcus, and also there was no detectable attachment loss.[6],[7],[8],[9] Here, we review the manifestation of SARS-CoV-2 infection and its pathomechanism especially in periodontal health and possible disease mechanisms.

 Oral Microbiome in Periodontal Tissue and COVID-19 Patients



Firstly, periodontal tissue containing commensals (oral microbiome) plays an important role in oral physiology. In oral physiology, some signals are modulated by a network of microbial and host metabolites.[3],[10],[11] Moreover, when the disease appear, host–microbial networks lead to dysbiosis and considerable burden to the host prior to the systemic impact that extends beyond the oral compartment. The host and microbial signatures of many disease states are currently being examined to identify potential correlations.[12],[13],[14] Bacterial pathogen present in the oral cavity, especially in the periodontal region, could increase the risk factor for patients with COVID-19 due to the risk of bacterial superinfection. Bacteria present in patients with severe COVID-19 infection are usually organisms in the oral cavity such as Prevotella, Staphylococcus, and Fusobacterium.[15],[16]Prevotella intermedia is a common pathogenic bacterium that is involved in the onset and progression of periodontal disease. Other bacterial species such as Streptococci, Fusobacterium, Treponema, and Veillonella also play an important role in the progression of oral diseases. P. intermedia was considered a major etiological bacterial species for several acute periodontal lesions, which, along with Fusobacterium and Treponema species, was found dominant in microbiota present in periodontal disease.[9],[17],[18] SARS‐CoV‐2 infection also might occur as a coinfection of P. intermedia and could worsen periodontal disease. These coinfections are also found in patients with immunotolerance diseases such as HIV and autoimmune disease.[19],[20],[21]

Common complications of COVID-19 have similarities to that of diabetes such as biofilms formation and periodontitis.[22],[23],[24] Moreover, the study showed that 80% of patients with severe COVID-19 had high bacterial load.[25] These complications of COVID-19 infection depend on immune response. It has been reported that patients with severe COVID-19 had higher levels of inflammatory markers. They reported in higher neutrophil count and lower lymphocyte count, it is common for a bacterial superinfection that implies in severe activity disease of COVID-19.[20],[21],[26]

Host immune responses are also a potential risk for disease mechanism in COVID-19 patients. A recent study found that there is a “cytokine storm” which exhibited an elevated serum cytokine levels in COVID-19 patients. Higher interleukin levels were found in severe COVID-19 patients. These conditions were involved in the pulmonary edema and tissue damage by SARS-CoV-2.[27] Exaggerated systemic inflammatory responses could result in disease manifestation in oral cavity, especially in the periodontal region. Periodontal disease is an infectious disease with multifactorial pathology mediated by immune responses. Increasing cytokine levels in periodontal tissue and serum were shown in patients with periodontal disease compared to healthy controls.[28],[29]

Systemic increase in the inflammatory responses reveals the similarity with the cytokine storm in COVID-19 patients. These conditions reveal that immune responses could induce inflamed gingival tissue and then could expand to the systemic circulation resulting in systemic inflammation. It could be suggested that the increase in the inflammatory response as the impact of SARS-CoV-2 infection could possibly trigger periodontitis. It also points that the presence of periodontal disease might be a predisposing factor for COVID-19.[20],[21],[22] Furthermore, this association between oral hygiene, periodontal disease, and COVID-19 should be explored to get mechanistic confirmation.

 Periodontal Tissue in COVID-19 Patients



Moreover, a recent study has found that increased protease levels in chronic periodontitis could potentially increase the risk of oral mucosa mediated SARS-CoV-2 infection. ACE2 receptors were found in oral mucosa and gingiva and could be a possible route for SARS-CoV-2 infection. Chronic periodontitis has been shown to exhibit higher levels of osteopontin, stimulate p38 and NF-kB, and increase the level of proteases. Proteases induce IL-6 and caveolin 1 through JNK–AP-1 signaling pathway. Both furin and cathepsin had an impact on enabling the SARS-CoV-2 to infect the host cells. Another study confirmed that these proteases increased the expression of ACE2 and CD147 in gingival and periodontal ligament fibroblasts in rat and human tissues. Thereby, periodontitis could be a reservoir of SARS-CoV-2 infection and vice versa.[27],[28]

In Spain, epidemiological manifestation study of COVID‐19 in 375 cases found that manifestation in oral cavity includes ulcers in palate and localized erythema in the palate and the margins of gingiva. Another case report in May 2020 found oral pain, desquamative gingivitis, ulcers, and blisters as oral cavity manifestations. Mild cases of COVID-19 might not show any oral manifestations, but in severe cases, persistent inflammatory responses trigger inflammatory oral cavity manifestations, especially in periodontal tissue leading to coagulation cascade and increased fibrinogen degradation confirming that COVID-19 has an impact on periodontal tissue.[9],[29],[30]

 Conclusion



Periodontal impact was seen in COVID-19 patients as localized erythema in margins of gingiva leading to desquamative gingivitis and oral pain. Although COVID-19 might manifest in periodontal tissues, presence of periodontal pathogen could pose a risk of superinfection, periodontal pocket could be a favorable anatomical niche for the virus, the literature is still lacking to conclude that COVID-19 has an impact on periodontal tissues and hence, more studies are needed.

Acknowledgement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Author contributions

Not applicable.

Ethical policy and institutional review board statement

Not applicable.

Declaration of patient consent

Not applicable.

Data availability statement

Not applicable.

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