Dental Complications After COVID-19 Mucormycosis-Understanding the Pathophysiology-Case Series Part-1

INTRODUCTION

Corona virus (COVID-19) a pandemic disease affecting respiratory system, still dissolute to impact a major portion of world’s population frightening the health care workers displaying its new strains and pathogenicity.¹ Systemic inflammation is one of the important characteristic of dental condition.² This emerging respiratory disease has resulted in over 75 million confirmed positive cases with 1.6 million death by Dec 22nd,2020.³

While few patients of covid-19 present with mild symptoms⁴,14% cases may develop severe condition. Covid-19 severe cases with ARDS⁵ generally show exacerbated immune response, presenting excessive levels of cytokines and widespread area of tissue damage. Covid-19 cases has been seen associated with increased levels of C-Reactive Protein(CRP), D-dimer, interleukin-6(IL-6) and ferritin,⁶ suggesting a link between severity and virality of non resolving inflammation.

It is still controversial to point out the role of oral cavity in covid-19,but few evidence based studies suggest role of oral cavity mucosa in transmission and pathogenicity of covid-19.⁷ Demonstrating oral diseases as a marker for increased severity of covid-19. In this we discuss about the case which was first looked upon as a regular dental infective case but later was co-related with covid-19 complication.

CASE REPORT-1

A 35year old male patient reported to our clinic with chief complaint of pain along with pus discharge from upper left tooth region upon clinical examination it was found that patient had multiple small abscess with suppuration ,gingiva was found to be inflammatory and oedematous.(Figure 1.a)Patient responded upon palpitation.

Intra oral examination revealed diffuse swelling in palatal mucosa of affected side.(Figure 1.b)Patient also presented with history of covid-19 infection.(Figure 2)

In the starting patient was assumed to be of regular dental case but later was thought it might be a complication of post covid -19 infection. So to rule out we referred the patient to undergo for haematology analysis and CT scan.

CBC findings of patient showed increased level of platelet count, low haemoglobin level.(Figure 3)

BT and CT were in normal ranges, while random blood glucose(321mg/dl),SGPT (192 U/L)) and SGOT (161 U/L) showed a peak rise in their values.(Figure 4a,b,c)

To rule out further damage and analyse the case CT scan with 3D reconstruction findings were suggestive of:

• ill marginatedpermeative lytic lesion in left upper maxillary alveolus and hard palate with extent, morphology and dimensions were suggestive of likely maxillary osteomyelitis.
• mucosal thickening with non enhancing secretions causing complete opacification of left maxillary sinus and blocked osteometal complex.
• mucosal thickening and retained secretions also in bilateral ethmoid ,sphenoid and right maxillary sinus with opacification of bilateral concha bullosa suggestive of panrhinosinusitis.(Figure 5 a, b and c)

After going through the test reports ,the case as based upon clinical as well as pathological and radiographic investigations was suggestive to be of maxillary necrosis.

Treatment given : surgery was carried out by raising the flap and extraction of all the teeth except 3rd molar in affected area along with local debridement of necrosed tissue was done.(Figure 6 a,b,c)(Figure 7). 3rd molar was left to provide further support for prosthesis fabrication.

Patient was followed with a course of antibiotics and analgesics.to check for recovery patient was recalled with one month follow up and was delivered with removal prosthesis with clasps.(Figure 8.a,b)

Post operative one month follow up OPG was taken to look for the bone healing.(Figure 9)

DISCUSSION

Covid-19 a pandemic disease started to spread in December 2019 causing pneumonia of unknown etiology originated from seafood market of Wuhan, China.⁸ Before it was identified as Novel corona virus, later known to be severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and disease called to be covid-19.⁸

Osteomyelitis means bone marrow inflammation, this term was coined by Nelaton in 1844.⁹

Osteomyelitis has more incidence in males (80.36 %) then females (19.64 %)¹⁰

Osteomyelitis is an opportunistic infection which may emerge as a complication of some underlining condition.¹¹

However, specific mechanism and pathological pathway have been noticed linking periodontal diseases with systemic diseases, showing translocation of bacteria to blood, induced auto immune damage a systemic inflammation.¹²

Here in this case report we discuss a case of male patient as a regular dental infection which later on was co-related with covid-19 complication based upon systemic and radiographic findings presenting extra pulmonary manifestations of covid -19 depicting necrosis of maxilla due to some underlining systemic condition which may be a covid-19 post infection complication.

CONCLUSION

Osteomyelitis is mostly seen in patients with diabetes and immuno-suppression. In covid-19 individual have low immune response which may give rise to secondary infections other than respiratory distress. Care should be taken in diagnosis of such cases through radiographic investigations and other histopathological findings while treating patients in clinics. Clinicians should be aware of such pathologies which may be due to complication of some underlining infection.

REFERENCES