COVID19 And ORAL HEALTH

 Catherine ROSSI

Dental Surgeon, Paris France

I would like to talk to you today about 2 subjects, both current and worrying.

Firstly, I would like to examine with you the link between oral diseases, (i.e., dental infections or gum disease), and the risk of complications from COVID19.

And secondly, I would like to share with you, what some dental surgeons have found about the aggravation of certain oral pathologies in people who wear the shield all day.

I am Dr. Catherine ROSSI, dental surgeon, founder and scientific director of the blog naturebiodental.com, a movement that unites dentists, doctors and health practitioners as well as patients motivated to put oral health at the heart of health.

Every day we learn a little more about this little-known disease. There is still a high proportion of patients without identified risk factors who suffer from serious side effects and complications. Although COVID19 is of viral origin, it is suspected that in these serious cases, bacterial superinfections may contribute to complications such as pneumonia and acute respiratory distress syndrome.

Articles are beginning to appear in the scientific press, about the links between the mouth and COVID 19. The British Dental Journal, in volume 228, presents a very well documented study on this subject.

What are the risk factors for having a severe form of COVID19?

The risk factors for developing complications of COVID19 disease, caused by the SARS virus COV2, are age, gender and co-morbidities such as diabetes, hypertension, obesity and cardiovascular disease.

The first signs of the disease appear from the 3rd day after infection. Fever and fatigue are the most frequent symptoms, accompanied by a dry cough. 90% of people will present only a mild syndrome, the severity of the disease depending significantly on risk factors:

The average age observed is 69 years old, mainly in men who account for 70% of deaths.

48% of those who died had a health condition altered by hypertension, diabetes or heart disease. Obesity has recently been added as a risk factor. In these people, the main complications manifest themselves by the creation of blood clots, pneumonia, sepsis or septic shock and of course acute respiratory distress syndrome.

What happens in severely affected people?

Patients with severe infections have a much higher neutrophil count and a much lower lymphocyte count than patients with mild infections. As the lymphocyte count decreases, the severity of the disease increases. In severe cases, more than 80% of the patients had an exceptionally high bacterial load, secondary to bacterial superinfection and requiring antibiotics.

Over time, it became apparent that there was still a high proportion of infected patients, apparently healthy, and even young, also healthy, without identified risk factors, who were suffering from serious side effects and complications.

What is the oral health status of patients with severe COVID19?

Researchers wondered whether the high presence of bacteria in the mouth would play a role in bacterial superinfections and complications such as pneumonia and acute respiratory distress syndrome, but also in the sepsis found in severe cases of COVID19.

The lungs, like the oral cavity, contain a bacterial flora necessary for a balanced metabolism. An imbalance in this flora, whatever the cause, can become pathogenic. Infection of the respiratory tract is triggered by inhalation of microorganisms contained in aerosol droplets or by aspiration of oral secretions, associated with oral disease containing pathogenic microorganisms.

The periodontal diseases and the chronic dental infections from the devitalized root canal are the 2 most current oral diseases associated with an imbalance of the pathological bacteria in the mouth.

What is a periodontal disease?

Periodontal disease is a disease of the gum and bone surrounding the dental roots. It is of bacterial origin and the first sign of the periodontal disease is the bleeding of the gums. Researchers of the INSERM published in 2018, the results clearly demonstrating the role of the periodontal disease in the aggravation of diabetes, rheumatoid polyarthritis, the increase of the risks of cardiovascular diseases, in the maintenance of obesity, and the increase of premature childbirth. Bacteria from infected gums have been found in cancerous tumors of the pancreas, breast and stomach and in the brains of people who have died with stroke, dementia and Alzheimer’s disease.

According to a survey by the UFSBD (French Union for Oral and Dental Health), 50% of the population bleeds from the gums and only 9% think it is not normal. This bleeding, which at first can be benign and reversible, especially in young people, can only progress and worsen if left untreated. So much so that today, 50% of Europeans of all ages would be affected by a periodontal disease. One even passes to 70 or even 85% in the people beyond 65 years of age, of which 10% present a severe phase at the stage 4 of the disease, which will lead them to edentulism.

More serious still the survey showed that 46% of the French people did not even know that there was a periodontal disease. That is to say that the association “bleeding gums = periodontal disease” is not made in 1 person out of 2. Many therapists, and even medical doctors, would not be aware of it either.

What are the links between periodontal diseases and pneumopathies?

Japanese researchers have shown that, many pneumopathies, especially among the old people, would have for origin a periodontal disease, because the bacteria in significant quantities in the infected gums are swallowed and inhaled.

The cytokines, coming from the sick periodontal tissues, can infiltrate in the saliva by the gingival fluid and be aspirated to cause an inflammation or an infection of the lungs. The cytokines would support the adhesion of the bacteria to the respiratory mucous membranes.

Therefore, absent or insufficient oral hygiene can increase the risk of interbacterial exchanges between the lungs and mouth, increasing the risk of respiratory infections and potentially post-viral bacterial complications.

Studies have shown that pneumonia has decreased significantly in people who have received periodontal therapy. Good oral hygiene has been recognized as a means of preventing respiratory tract infections, particularly in people over 70 years old.

A systemic study revealed that 1 death out of 10, related to pneumonia in the elderly, could be avoided by improving oral hygiene.

 of pulmonary complications.

In addition, the 4 major co-morbidities associated with an increased risk of complications and death due to COVID19 (i.e., diabetes, cardiovascular disease, hypertension and obesity) are also associated with altered oral bacterial flora and periodontal disease, hence the suggested link between poor oral health and complications of COVID19.

Periodontal bacteria have been found in the metagenome of patients severely infected with SARS COV2, where high values of prevotella, staphylococci and fusobacteria have also been found.

We could therefore consider poor oral hygiene as a risk for post-viral complications. Improved oral health could thus contribute to reducing the risk of complications from COVID19.

Does wearing the shield degrade oral health?

Wearing the shield continuously over a long period of time has been shown to aggravate oral problems. Every day, dental surgeons observe an increase in the inflammation of the oral mucosa, the appearance of gingivitis or the aggravation of pre-existing periodontal diseases in people who wear a mask all day long.

One does not need to have made 10 years of studies to understand that the wearing of the mask decreases the oxygen supply, increases the CO2 concentration and supports the development of certain bacteria in the mouth. Bacteria that need oxygen die, bacteria that prefer to live without oxygen grow. This explains the appearance of bad breath, which is indeed a sign of the abnormal multiplication of certain bacteria.

The oral microbiota is therefore destabilized by wearing the shield continuously.

Under the shield, people, in lack of oxygen, by a survival reflex, start to breathe through the mouth. This provokes a dry mouth and a thickening of the saliva whose PH becomes more acidic, which makes the ground favorable to the appearance of dental caries.

As I already said to you, this imbalance of the oral flora and the development of periodontal diseases are officially recognized in the aggravation of the cardiovascular problems, the aggravation of diabetes, arterial hypertension, which we find in the comorbidities favoring the serious cases of COVID 19.

What should also be known is that the lack of oxygen will stimulate the sympathetic system, which can cause or aggravate tooth clenching. In addition to the stressful period we are living through, the number of patients complaining of bruxism, clenching teeth and pain in the jaw joints is increasing. The number of dental fissures and fractures has increased considerably, requiring root canal treatments or extractions, followed by the placement of implants and crowns.

Is the quality of the shield reliable?

In addition, it has been realized that some batches of shield manufactured in China must contain toxic substances because their prolonged wearing causes headaches, dizziness, nausea, loss of consciousness, irritates the respiratory tract and causes skin allergies.

As a dental surgeon who has been working with a shield for many years, I would like to share my experience and that of my team with you. Since the month of May, following the deconfinement, we have not been able to be restocked with the brands of shield we used to use. Some of the shield currently supplied are proving to be unbearable, they give off such a strong smell that we are obliged to wash and especially to rinse them abundantly before using them. In addition, we have suffered headaches, rhinitis, coughing fits, redness around the lips, not to mention cuts behind the ears due to too short elastics.

In summary :

There are scientifically proven links between periodontal diseases, dental infections and illnesses which are great risk factors of aggravation of the COVID19.

The periodontal disease and the dental infections should join the peloton of the comorbidities at risks favoring the serious forms of the COVID19

Further research on this topic is urgently needed to establish the importance of oral hygiene and treatment of pre-existing oral infectious diseases, in reducing the risk of complications and mortality from COVID19.

Have a nice day and take care of your teeth!

Catherine ROSSI

Dental Surgeon, Paris France.