Is the oral cavity relevant in SARS-CoV-2 pandemic?

The effect of novel vitamin D3 compounds on saliva samples from COVID-19 patients: a lab study

Vitamin D has shown antimicrobial effects. This study aimed to explore the antiviral effects of vitamin D3 on saliva samples collected from patients with coronavirus disease-19 (COVID-19) and compare saliva and swab results to aid in policy development. Saliva and swab samples were collected from adult patients with a positive test for COVID-19 at the King Faisal Specialist Hospital and Research Centre, Jeddah. Patients who were immunocompromised and pregnant and aged < 18 years were excluded. Vitamin D3 compound (100, 300, 800, and 1,200 IU) was added to the first saliva sample in the laboratory (n = 20); the rest of the swab specimens were compared with the saliva samples via real-time polymerase chain reaction. Of the 257 patients, 236 (94.8%) had positive saliva sample test results, 7 (2.8%) had errors, and 6 (2.4%) had negative results. Of the 236 positive tests, 235 (99.6%) had a cycle threshold (Ct) indicating strong positive reactions, and only one (Ct = 28.86) was weak. Among the 236 positive results, 235 (99.6%) exhibited robust positive reactions, indicating a substantial positive sample size. Thus, saliva might be a dependable alternative testing tool when obtaining swab samples from patients is inconvenient or challenging.

Frequency of Oral Lesions, Olfactory, and Gustatory Disorders and Xerostomia in Patients with COVID-19

COVID-19, a respiratory illness with a global impact on millions, has recently been linked to manifestations affecting various bodily systems, including the oral cavity. Studies highlight oral issues, like ulcers, blisters, and white patches, alongside olfactory and gustatory dysfunction, influencing an individual's quality of life. In this context, our study aimed to assess the frequency of oral lesions, olfactory and gustatory disorders, and xerostomia resulting from COVID-19. An observational study was conducted with 414 patients to evaluate the frequency of oral symptoms resulting from COVID-19. Patients were diagnosed with mild symptoms and evaluated through clinical examination of the oral cavity and a questionnaire to assess functional alterations. The findings showed that 139 out of 414 patients presented clinical manifestations, with oral lesions being the most prevalent (19.1%), followed by gustatory disorders (18.1%), xerostomia (14.2%), and olfactory dysfunction (14%). The most prevalent oral lesions were ulcerations (n = 51), candidiasis (n = 8), and erythema or red plaques (n = 7). Unfortunately, 50 (12.1%) patients died during this study. Therefore, oral lesions, olfactory and gustatory dysfunctions, and xerostomia are common symptoms associated with COVID-19.

The role of viruses in oral mucosal lesions

The mucosa of the oral cavity is exposed to a large number of different microorganisms such as archaea, bacteria, fungi, parasites, and viruses. Among those, viruses cause specific infections, which can easily be transmitted from one person to another. The infectious route may not only include patients and their relatives but also the dental professional team. Thus, a wide knowledge regarding specific viral infections is crucial for the daily routine. Signs and symptoms of oral viral infections can be completely absent or develop into a pronounced clinical picture, so that early detection and information determine the further course of the infection and its influence on other inflammatory diseases, such as periodontitis, as well as the safety of family members and the social environment. As the clinical manifestation of viral infections may be highly variable leading to heterogenous mucosal lesions it is, in most cases, mandatory to differentiate them by specific microbiological tests in addition to clinical examination procedures. This article will give an overview of the role of viruses infecting the oral mucosa, and in addition, describe their clinical manifestation and management.

Cetylpyridinium chloride and chlorhexidine show antiviral activity against Influenza A virus and Respiratory Syncytial virus in vitro

BACKGROUND

The oral cavity is the site of entry and replication for many respiratory viruses. Furthermore, it is the source of droplets and aerosols that facilitate viral transmission. It is thought that appropriate oral hygiene that alters viral infectivity might reduce the spread of respiratory viruses and contribute to infection control.

MATERIALS AND METHODS

Here, we analyzed the antiviral activity of cetylpyridinium chloride (CPC), chlorhexidine (CHX), and three commercial CPC and CHX-containing mouthwash preparations against the Influenza A virus and the Respiratory syncytial virus. To do so the aforementioned compounds and preparations were incubated with the Influenza A virus or with the Respiratory syncytial virus. Next, we analyzed the viability of the treated viral particles.

RESULTS

Our results indicate that CPC and CHX decrease the infectivity of both the Influenza A virus and the Respiratory Syncytial virus in vitro between 90 and 99.9% depending on the concentration. Likewise, CPC and CHX-containing mouthwash preparations were up to 99.99% effective in decreasing the viral viability of both the Influenza A virus and the Respiratory syncytial virus in vitro.

CONCLUSION

The use of a mouthwash containing CPC or CHX alone or in combination might represent a cost-effective measure to limit infection and spread of enveloped respiratory viruses infecting the oral cavity, aiding in reducing viral transmission. Our findings may stimulate future clinical studies to evaluate the effects of CPC and CHX in reducing viral respiratory transmissions.

Mouthwash Effects on the Oral Microbiome: Are They Good, Bad, or Balanced?

This narrative review describes the oral microbiome, and its role in oral health and disease, before considering the impact of commonly used over-the-counter (OTC) mouthwashes on oral bacteria, viruses, bacteriophages, and fungi that make up these microbial communities in different niches of the mouth. Whilst certain mouthwashes have proven antimicrobial actions and clinical effectiveness supported by robust evidence, this review reports more recent metagenomics evidence, suggesting that mouthwashes such as chlorhexidine may cause "dysbiosis," whereby certain species of bacteria are killed, leaving others, sometimes unwanted, to predominate. There is little known about the effects of mouthwashes on fungi and viruses in the context of the oral microbiome (virome) in vivo, despite evidence that they "kill" certain viral pathogens ex vivo. Evidence for mouthwashes, much like antibiotics, is also emerging with regards to antimicrobial resistance, and this should further be considered in the context of their widespread use by clinicians and patients. Therefore, considering the potential of currently available OTC mouthwashes to alter the oral microbiome, this article finally proposes that the ideal mouthwash, whilst combatting oral disease, should "balance" antimicrobial communities, especially those associated with health. Which antimicrobial mouthwash best fits this ideal remains uncertain.

Delivery of biologics: Topical administration

Biologics are unaffordable to a large majority of the global population because of prohibitively expensive fermentation systems, purification and the requirement for cold chain for storage and transportation. Limitations of current production and delivery systems of biologics were evident during the recent pandemic when <2.5% of vaccines produced were available to low-income countries and ∼19 million doses were discarded in Africa due to lack of cold-chain infrastructure. Among FDA-approved biologics since 2015, >90% are delivered using invasive methods. While oral or topical drugs are highly preferred by patients because of their affordability and convenience, only two oral drugs have been approved by FDA since 2015. A newly launched oral biologic costs only ∼3% of the average cost of injectable biologics because of the simplified regulatory approval process by elimination of prohibitively expensive fermentation, purification, cold storage/transportation. In addition, the cost of developing a new biologic injectable product (∼$2.5 billion) has been dramatically reduced through oral or topical delivery. Topical delivery has the unique advantage of targeted delivery of high concentration protein drugs, without getting diluted in circulating blood. However, only very few topical drugs have been approved by the FDA. Therefore, this review highlights recent advances in oral or topical delivery of proteins at early or advanced stages of human clinical trials using chewing gums, patches or sprays, or nucleic acid drugs directly, or in combination with, nanoparticles and offers future directions.

Effectiveness of interventions to reduce aerosol generation in dental environments: A systematic review

Certain dental procedures produce high levels of aerosols containing pathogenic microorganisms, posing a risk for the transmission of infections in dental settings. This study aimed to assess the effectiveness of various aerosol mitigation interventions during clinical dental procedures in real-world environments. A systematic literature search was conducted in PubMed/MEDLINE, Scopus, Web of Science, and Embase for English studies up to March 2023 according to the PRISMA guidelines. Only peer-reviewed controlled clinical trials (CCT) or randomized controlled trials (RCT) studies involving human subjects were included. The risk of bias of selected researches were evaluated by two independent authors using the Cochrane Collaboration tool. The literature search yielded 3491 articles, of which 42 studies met the inclusion criteria and were included in this study. Most studies evaluated bacterial contamination in bio-aerosols, while the viral and fungal contamination was assessed in only three studies. Overall, various approaches have been applied in reducing aerosol contamination in clinical scenarios, including high-volume evacuators (HVE), mouse rinses and rubber dams, air cleaning systems, and high-efficiency particulate air (HEPA) filters. The available evidence suggests that various aerosol mitigation strategies could be implemented to decrease the risk of cross-infection during clinical dental procedures in real-world environments. However, further clinical trials are necessary to establish statistical validity in measuring aerosol contamination and mitigation, as well as to evaluate the risk of infection transmission for viral and fungal contamination.

Oral manifestations of COVID-19 in unvaccinated patients: a cross-sectional study

BACKGROUND

Early studies have highlighted the possible development of dysgeusia and anosmia in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and these manifestations should be considered a potential indication of coronavirus disease 19 (COVID-19). As potential contributors to these symptoms, dentists should perform careful oral and oropharyngeal examinations and document suspicious oral lesions in patients with COVID-19, especially in those who complain of loss of taste and smell. The study's objective was to assess the prevalence of oral manifestations among ambulatory unvaccinated symptomatic patients with suspected COVID-19 during the acute phase of the disease.

METHODS

This cross-sectional study evaluated oral manifestations in adults (aged ≥ 18 years) with suspected and confirmed SARS-CoV-2 infection. Chi-square and Fisher's exact tests were used to compare data between the groups (rRT-PCR-positive and rRT-PCR-negative patients).

RESULTS

One hundred thirty-six participants were included. Most were female (n = 79; 58.1%), with a mean age of 39.53 (± 14.17) years. Of these, 54 (39.7%) had a positive rRT-PCR test, and 82 (60.3%) had negative rRT-PCR results. Oral manifestations were observed in 40 participants (74.1%) in the rRT-PCR-positive group and 67 participants (81.7%) in the rRT-PCR-negative group. The most common oral manifestations were xerostomia (n = 85; 62.5%) and dysgeusia/ageusia (n = 57; 41.9%). Different rates of gingivitis (n = 12; 22.2% vs. n = 5; 6.1%; p = 0.005) and halitosis (n = 7; 13.0% vs. n = 1; 1.2%; p = 0.007) were observed between the rRT-PCR-positive and -negative groups, respectively. Mouth ulcers, glossitis, tongue coating, and petechiae were reported in both groups without significant differences.

CONCLUSIONS

A high prevalence of oral manifestations was observed in symptomatic patients with suspected or confirmed COVID-19.

CLINICAL RELEVANCE

This study highlights the importance of routine oral examinations by dentists as part of the multidisciplinary care of COVID-19 patients.

The impact of periodontal disease on the clinical outcomes of COVID-19: A systematic review and meta-analysis

BACKGROUND

A possible relationship between periodontitis (PD) and COVID-19 and its adverse outcomes has been suggested. Hence, the present systematic review and meta-analysis aimed to investigate the available evidence regarding the potential association between periodontitis (PD) and COVID-19 and its adverse outcomes.

MATERIALS AND METHODS

PubMed, Scopus, Web of Science, and Google Scholar were searched for relevant studies published up to April 15th, 2023. Studies that evaluated the association between PD and COVID-19 were included. Risk of bias was evaluated by two reviewers, and meta-analyses were performed using RevMan 5.3 software.

RESULTS

A total of 22 studies involving 92,535 patients from USA, Europe, Asia, the Middle East and South America were included; of these, 12 were pooled into the meta-analysis. Most of the studies (19 studies) reported a significant association between PD and COVID-19. The pooled data found a significant association between PD and COVID-19 outcomes: more severe symptoms (OR = 6.95, P = 0.0008), ICU admissions (OR = 3.15, P = 0.0001), and mortality (OR = 1.92, P = 0.21). Additionally, compared to mild PD, severe PD was significantly associated with higher risks of severe COVID-19 outcomes: severe symptoms (P = 0.02); ICU admission (P = 0.0001); and higher mortality rates (P = 0.0001). The results also revealed 58% higher risk for COVID-19 infection in patients with PD (P = 0.00001).

CONCLUSIONS

The present findings suggest a possible association between poor periodontal health and the risk of poor COVID-19 outcomes. However, owing to the observed methodological heterogeneity across the included studies, further prospective cohort studies with standardized methodologies are warranted to further unravel the potential association between periodontal disease and COVID-19 and its adverse outcomes.

Prevalence of oral complications in the course of severe SARS-CoV-2 infection under mechanical non-invasive ventilation

BACKGROUND

The management of oral health during severe symptoms of Covid-19 is still a challenge, especially in intensive care units under invasive/noninvasive ventilation in hospital. Understanding the cause-and-effect relationships may allow for individual adjustment of oral care recommendations during Covid-19 disease. The study's objective was to assess Covid-19 patients' oral health status under hospital treatment due to pulmonary adverse Covid-19 outcomes.

MATERIAL AND METHODS

Covid-19 patients (mean age 74.4 ± 15.4; n = 120, male n = 50/female n = 70) were admitted to hospital in the acute phase of Covid-19 between January and March 2022 who required oxygen therapy due to pneumonia, rapid respiratory failure, low saturation. Blood and radiological tests were taken according to National Health Fund guidelines. The condition of teeth (Decayed, Missing, Filled teeth as DMFT index), dental hygiene (Plaque Control Record as PCR index), periodontal status (probing depth PD, clinical attachment CAL, bleeding on probing BOP) and oral mucosa (BRUSHED and Beck scores) were examined.

RESULTS

Charateristics of the teeth (dental caries 35.2%, DMFT Median 22), plaque retention (83.4%), advanced periodontitis (48.3%), xerostomia (74.2%), oral mucosa inflammation (80.8%), angular cheilitis (53.3%), hemorrhagic (21.7%) showed a high incidence of harmful oral conditions. BRUSHED model and Beck score indicated moderate oral dysfunction and need for oral care every 8 h. Spearman's analysis revealed a significant positive correlation between pneumonia and neutrophile, interleukin-6 IL-6, C-reactive protein CRP (p = 0.01, p < 0.001, p < 0.001), negative to lymphocyte count (p < 0.001). Multiple and logistic regressions selected the following risk predictors for pneumonia as IL-6, CRP, obesity and for severe COVID-19 symptoms D-dimer level and a lack of targeted vaccination (p < 0.001). Among oral predictors, the PCR index and Beck score were significant for both outcomes (respectively p < 0.001, p < 0.012). Patients who received oxygen therapy with face masks had more often angular heilitis and debris (p = 0.025, p = 0.035).

CONCLUSIONS

COVID-19 hospitalised patients with severe symptoms crossing with poor oral health-related conditions. This may exacerbate a response for COVID infection, and play a role in cytokine storm. For Covid-19 management, to inhibit extraoral/intraoral complications, it is recommended to adjust oral hygiene procedures, including antibacterial, protective, moisturising agents after individual oral health assessment.

Do Disinfectant Solutions during Gargling Reach the Pharynx?

INTRODUCTION

In times of COVID-19, gargling disinfectant is commonly used. Disinfectant solutions seem to decrease the infection's symptoms. For disinfection, several techniques are reported. So far, there are no data about the regions in the upper airways achieved by gargled fluid.

METHODS

Ten healthy volunteers without any dysphagia were investigated with a high-sensitivity flexible endoscopic evaluation of swallowing (hsFEES®) during and after gargling colored water. One volunteer repeated the gargling process in fast and real-time MRI.

RESULTS

In all cases, no color accumulation was detected on the posterior pharyngeal wall, epi- or hypopharynx during gargling. The MRI scans confirmed the results.

CONCLUSIONS

hsFEES® and fast MRI provide an insight into the gargling pattern. Data show that during gargling, the fluid covers the soft tissue in the oral cavity and the anterior part of the soft palate, but not the posterior pharyngeal wall nor the epi- and hypopharynx.

Nasal delivery as a strategy for the prevention and treatment of COVID-19

INTRODUCTION

The upper respiratory tract is a major route of infection for COVID-19 and other respiratory diseases. Thus, it appears logical to exploit the nose as administration site to prevent, fight, or minimize infectious spread and treat the disease. Numerous nasal products addressing these aspects have been considered and developed for COVID-19.

AREAS COVERED

This review gives a comprehensive overview of the different approaches involving nasal delivery, i.e., nasal vaccination, barrier products, and antiviral pharmacological treatments that have led to products on the market or under clinical evaluation, highlighting the peculiarities of the nose as application and absorption site and pointing at key aspects of nasal drug delivery.

EXPERT OPINION

From the analysis of nasal delivery strategies to prevent or fight COVID-19, it emerges that, especially for nasal immunization, formulations appear the same as originally designed for parenteral administration, leading to suboptimal results. On the other hand, mechanical barrier and antiviral products, designed to halt or treat the infection at early stage, have been proven effective but were rarely brought to the clinics. If supported by robust and targeted product development strategies, intranasal immunization and drug delivery can represent valid and sometimes superior alternatives to more conventional parenteral and oral medications.

Effect of phthalocyanine oral and nasal antiseptic solutions on the infectivity of SARS-CoV-2 in patients with COVID-19: a randomized controlled trial

Background

In individuals with coronavirus disease (COVID-19), the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load (VL) plays an important role in infectivity.

Objectives

This study aimed to evaluate the reduction in the VL and infectivity induced by phthalocyanine mouthwash and nasal spray in patients with COVID-19.

Methods

Patients with mild COVID-19 were recruited to participate in a triple-blinded randomized controlled trial. Participants were assigned to one of three groups: Group 1, non-active mouthwash and saline nasal spray (SNS); Group 2, phthalocyanine mouthwash and SNS; and Group 3 phthalocyanine mouthwash and phthalocyanine nasal spray. VL was assessed in nasopharyngeal and oropharyngeal swabs collected at the time of clinical diagnosis at baseline as well as 24 and 72 hours after starting the rinsing protocols.

Findings

Forty-six participants were included in the analysis: 15, 16, and 15 in Groups 1, 2, and 3, respectively. After 72 hours, the reduction in VL was significantly higher in Group 3 (mean cycle threshold (Ct) decrease: 11.21) than in Group 1 (mean Ct decrease: 5.53). Additionally, only the mean VL in Group 3 was reduced to a non-contagious level after 72 hours.

Main conclusions

Use of phthalocyanine mouthwash and nasal spray is effective at reducing SARS-CoV-2 infectivity.

Preprocedural mouthwashes for infection control in dentistry-an update

OBJECTIVES

Aerosols and splatter are routinely generated in dental practice and can be contaminated by potentially harmful bacteria or viruses such as SARS-CoV-2. Therefore, preprocedural mouthwashes containing antiseptic agents have been proposed as a potential measure for infection control in dental practice. This review article aims to summarize the clinical (and, if insufficient, preclinical) evidence on preprocedural mouthwashes containing antiseptic agents and to draw conclusions for dental practitioners.

METHODS

Literature on preprocedural mouthwashes for reduction of bacterial or viral load in dental aerosols was searched and summarized.

RESULTS

Preprocedural mouthwashes, particularly those containing chlorhexidine digluconate (CHX), cetylpyridinium chloride (CPC), or essential oils (EO), can significantly reduce the bacterial load in dental aerosols. With respect to viruses such as HSV-1, there are too little clinical data to draw any clear recommendations. On the other hand, clinical data is consolidating that CPC-containing mouthwashes can temporarily reduce the intraoral viral load and infectivity in SARS-CoV-2 positive individuals. Nevertheless, potential risks and side effects due to regular antiseptic use such as ecological effects or adaptation of bacteria need to be considered.

CONCLUSIONS

The use of preprocedural mouthwashes containing antiseptics can be recommended according to currently available data, but further studies are needed, particularly on the effects on other viruses besides SARS-CoV-2. When selecting a specific antiseptic, the biggest data basis currently exists for CHX, CPC, EO, or combinations thereof.

CLINICAL RELEVANCE

Preprocedural mouthwashes containing antiseptics can serve as part of a bundle of measures for protection of dental personnel despite some remaining ambiguities and in view of potential risks and side effects.

Oral and systemic health: is there a "new" link with COVID-19?

OBJECTIVES

The objective of the present narrative review was to evaluate the evidence of a possible association between periodontitis and COVID-19, and its biological plausibility, using as models the potential associations with cardiovascular diseases, diabetes, and some respiratory diseases.

METHODS

A recent systematic review was used as main reference to explore the associations of periodontitis with different respiratory diseases, including COVID-19, following two focussed questions: a PECOS question, aimed to explore epidemiological evidence, and a PICOS question, designed to explore the evidence derived from intervention studies. In addition to that evidence, other relevant scientific documents, including consensus papers, were carefully selected and appraised.

FINDINGS

Convincing evidence was found to support the association of periodontitis and cardiovascular diseases, diabetes, and some respiratory diseases. The biological plausibility behind those associations is based on four factors: (1) bacteraemia of oral bacteria and periodontal pathogens, (2) increased systemic inflammation, (3) common genetic factors, and (4) common environmental risk factors. Limited initial evidence is available to support an association between periodontitis and COVID-19 complications. Among the proposed factors to explain the suggested association, a combination of the previously mentioned factors, plus additional factors related with SARS-CoV-2 characteristics and pathogenicity, has been suggested.

CONCLUSIONS

Initial evidence suggests that periodontitis may be associated with a more severe COVID-19 and with a higher risk of death due to COVID-19.

CLINICAL RELEVANCE

Due to the possible association between periodontitis and an increased severity for COVID-19, additional efforts should be made to improve oral and periodontal health, including the promotion of oral healthy habits, such as oral hygiene.

Reduction of SARS-CoV-2 salivary viral load with pre-procedural mouth rinses: a randomised, controlled, clinical trial

Introduction The purpose of this study was to test the short-term efficacy of four commercial mouthwashes versus water in reducing SARS-CoV-2 viral load in the oral cavity over clinically relevant time points.Methods In total, 32 subjects that were proven SARS-CoV-2-positive via polymerase chain reaction (PCR)-based diagnostic test were recruited and randomised into five parallel arms. Cycle threshold (Ct) values were compared in saliva samples between the groups, as well as within the groups at baseline (pre-rinse), zero hours, one hour and two hours post-rinse, using SARS-CoV-2 reverse transcription-PCR analysis.Results We observed a significant increase in Ct values in saliva samples collected immediately after rinsing with all the four mouthwashes - 0.12% chlorhexidine gluconate, 1.5% hydrogen peroxide, 1% povidone iodine, or Listerine - compared to water. A sustained increase in Ct values for up to two hours was only observed in the Listerine and chlorohexidine gluconate groups. We were not able to sufficiently power this clinical trial, so the results remain notional but encouraging and supportive of findings in other emerging mouthwash studies on COVID-19, warranting additional investigations.Conclusions Our evidence suggests that in a clinical setting, prophylactic rinses with Listerine or chlorhexidine gluconate can potentially reduce SARS-CoV-2 viral load in the oral cavity for up to two hours. While limited in statistical power due to the difficulty in obtaining this data, we advocate for pre-procedural mouthwashing, like handwashing, as an economical and safe additional precaution to help mitigate the transmission of SARS-CoV-2 from a potentially infected patient to providers.

Pilot study of aerosols visualized and evaluated in a radiotherapy room

Health care institutions provide prevention strategies for coronavirus disease 2019 and non-infectious disease care. We investigated the characteristics of patient contamination in a radiotherapy room by examining the trajectory and number of airborne particles in the air when talking and coughing occurred and clarified the actual state of contamination in this closed space. Aerosols were visualized and evaluated in the vertical height and head-to-tail width directions when the participant was lying on the radiotherapy tabletop. Aerosol reach was significantly greater for loud voice and coughing both at vertical height and the head-to-tail width direction. The size and number of particles around the radiotherapy tabletop were also visualized and evaluated in the radiotherapy room. The radiotherapy staff who were in the presence of the participant sometimes had many particles adhering to their facial area; particle adhesion to the staff was dominated by small size particles. Particle adherence to the irradiation device surface near the ceiling had particles larger than 1 mm. Tabletop particles tended to have a wider size range, including bigger sizes and a larger count compared to the surrounding floor. The 0.7-m radius distance from the participant's mouth tended to be highly contaminated, and the smaller the particle size, the farther it reached. The capacity to estimate areas prone to contamination can be used to predict infection of other patients and medical staff in a radiotherapy room.

Efficacy of a Mouthwash Containing CHX and CPC in SARS-CoV-2-Positive Patients: A Randomized Controlled Clinical Trial

Soon after the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, preprocedural mouthwashes were recommended for temporarily reducing intraoral viral load and infectivity of individuals potentially infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to protect medical personnel. Particularly, the antiseptic cetylpyridinium chloride (CPC) has shown virucidal effects against SARS-CoV-2 in vitro. Therefore, the aim of this randomized controlled clinical trial was to investigate the efficacy of a commercially available mouthwash containing CPC and chlorhexidine digluconate (CHX) at 0.05% each in SARS-CoV-2-positive patients as compared to a placebo mouthwash. Sixty-one patients who tested positive for SARS-CoV-2 with onset of symptoms within the last 72 h were included in this study. Oropharyngeal specimens were taken at baseline, whereupon patients had to gargle mouth and throat with 20 mL test or placebo (0.9% NaCl) mouthwash for 60 s. After 30 min, further oropharyngeal specimens were collected. Viral load was analyzed by quantitative reverse transcriptase polymerase chain reaction, and infectivity of oropharyngeal specimens was analyzed by virus rescue in cell culture and quantified via determination of tissue culture infectious doses 50% (TCID₅₀). Data were analyzed nonparametrically (α = 0.05). Viral load slightly but significantly decreased upon gargling in the test group (P = 0.0435) but not in the placebo group. Viral infectivity as measured by TCID₅₀ also significantly decreased in the test group (P = 0.0313), whereas there was no significant effect but a trend in the placebo group. Furthermore, it was found that the specimens from patients with a vaccine booster exhibited significantly lower infectivity at baseline as compared to those without vaccine booster (P = 0.0231). This study indicates that a preprocedural mouthwash containing CPC and CHX could slightly but significantly reduce the viral load and infectivity in SARS-CoV-2-positive patients. Further studies are needed to corroborate these results and investigate whether the observed reductions in viral load and infectivity could translate into clinically useful effects in reducing COVID-19 transmission (German Clinical Trials Register DRKS00027812).

The SARS-CoV-2 Virus could Downregulate Dual Specificity Phosphatase-1 Expression in Oral Cancer: A Plausible Hypothesis that could Explain Oral Cancer Progression in the COVID-19 Pandemic and Post-pandemic Situation

This study explores the downregulation of Dual Specificity Phosphatase-1 (DUSP-1) expression in oral cancer progression during the pandemic and post-pandemic situations. Keywords: COVID-19, Dual specificity phosphatase-1, Oral cancer, SARS-CoV-2.

Angina Bullosa Haemorrhagica in COVID 19: A Diagnostic Conundrum. Case Report and Review of Literature

Oral manifestations of COVID-19 are amongst the most obscure and ill-reported. Of these, angina bullosa haemorrhagica is amongst the rarest. Only 2 cases of angina bullosa haemorrhagica in COVID-19 patients have been reported in literature. Angina bullosa haemorrhagica (ABH) is an enigmatic, abstruse condition represented by sudden onset of painful subepithelial, mucosal blood-filled vesicles and bullae in the oral cavity. It is not attributed to any systemic conditions, blood dyscracias or other well-known dermatological pathologies. The occurrence of these lesions in patients of COVID-19 suggests that the underlying pathology of the latter may predispose to ABH and thus help in shedding some light onto the pathogenesis of this obscure disease. Herein we present 2 cases of ABH in patients of COVID-19 within a few weeks of the resolution of the latter. Both patients reported that they had never had this condition before and that this was the first presentation of the symptom. A review of literature shows that the etiopathogenesis of ABH is ambiguous at best and that the pathology underlying the oral manifestation of COVID-19 may well be applicable to ABH as well. Various mechanisms have been proposed to cause oral manifestations in COVID-19 patients. These include imbalance in the RAS pathway causing mucosal disruption, immune dysregulation, deranged cellular immune mechanism and disruption of local immune mechanisms. Since ABH has been reported in COVID 19, it is plausible that some of the mechanisms underlying the pathogenesis of oral manifestations may explain the pathogenesis of ABH.

Detection of SARS-CoV-2 IgG antibodies and inflammatory cytokines in saliva-a pilot study

Objective

The pandemic caused by SARS-CoV-2 virus continues to have a profound effect worldwide. However, COVID-19 induced oral facial manifestations have not been fully described. We conducted a prospective study to demonstrate feasibility of anti-SARS-CoV-2 IgG and inflammatory cytokine detection in saliva. Our primary objective was to determine whether COVID-19 PCR positive patients with xerostomia or loss of taste had altered serum or saliva cytokine levels compared to COVID-19 PCR positive patients without those oral symptoms. Our secondary objective was to determine the correlation between serum and saliva COVID-19 antibody levels.

Materials and methods

For cytokine analysis, saliva and serum were obtained from 17 participants with PCR-confirmed COVID-19 infection at three sequential time points, yielding 48 saliva samples and 19 paired saliva-serum samples from 14 of the 17 patients. For COVID-19 antibody analyses, an additional 27 paired saliva-serum samples from 22 patients were purchased.

Results

The saliva antibody assay had 88.64% sensitivity [95% Confidence Interval (CI) 75.44%, 96.21%] to detect SARS-CoV-2 IgG antibodies compared to serum antibody. Among the inflammatory cytokines assessed - IL-6, TNF-α, IFN-γ, IL-10, IL-12p70, IL-1β, IL-8, IL-13, IL-2, IL-5, IL-7 and IL-17A, xerostomia correlated with lower levels of saliva IL-2 and TNF-α, and elevated levels of serum IL-12p70 and IL-10 (p < 0.05). Loss of taste was observed in patients with elevated serum IL-8 (p < 0.05).

Conclusions

Further studies are needed to construct a robust saliva-based COVID-19 assay to assess antibody and inflammatory cytokine response, which has potential utility as a non-invasive monitoring modality during COVID-19 convalescence.

The oral manifestations and related mechanisms of COVID-19 caused by SARS-CoV-2 infection

Coronavirus disease 2019 (COVID-19) was reported to be associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, and patients present mostly with respiratory symptoms. There have been an increasing number of reports on oral manifestations, and some of these signs are informative in terms of identifying SARS-CoV-2 infection. The goal of present study was to review and synthesize the clinical characteristics and underlying mechanisms of COVID-19 oral manifestations, as well as to evaluate the factors influencing SARS-CoV-2 infectivity, in order to conduct further in-depth investigations and help clinicians diagnose COVID-19 patients exhibiting oral symptoms.

Role of antiseptics in the prevention and treatment of infections in nursing homes

Inadequate infection control, wound care, and oral hygiene protocols in nursing homes pose challenges to residents' quality of life. Based on the outcomes from a focus group meeting and a literature search, this narrative review evaluates the current and potential roles of antiseptics within nursing home infection management procedures. We examine contemporary strategies and concerns within the management of meticillin-resistant Staphylococcus aureus (MRSA; including decolonization regimes), chronic wound care, and oral hygiene, and review the available data for the use of antiseptics, with a focus on povidone-iodine. Compared with chlorhexidine, polyhexanide, and silver, povidone-iodine has a broader spectrum of antimicrobial activity, with rapid and potent activity against MRSA and other microbes found in chronic wounds, including biofilms. As no reports of bacterial resistance or cross-resistance following exposure to povidone-iodine exist, it may be preferable for MRSA decolonization compared with mupirocin and chlorhexidine, which can lead to resistant MRSA strains. Povidone-iodine oral products have greater efficacy against oral pathogens compared with other antiseptics such as chlorhexidine mouthwash, highlighting the clinical benefit of povidone-iodine in oral care. Additionally, povidone-iodine-based products, including mouthwash, have demonstrated rapid in-vitro virucidal activity against SARS-CoV-2 and may help reduce its transmission if incorporated into nursing home coronavirus 2019 control protocols. Importantly, povidone-iodine activity is not adversely affected by organic material, such as that found in chronic wounds and the oral cavity. Povidone-iodine is a promising antiseptic agent for the management of infections in the nursing home setting, including MRSA decolonization procedures, chronic wound management, and oral care.

Mouth rinses efficacy on salivary SARS-CoV-2 viral load: A randomized clinical trial

Considering the global trend to confine the COVID-19 pandemic by applying various preventive health measures, preprocedural mouth rinsing has been proposed to mitigate the transmission risk of SARS-CoV-2 in dental clinics. The study aimed to investigate the effect of different mouth rinses on salivary viral load in COVID-19 patients. This study was a single-center, randomized, double-blind, six-parallel-group, placebo-controlled clinical trial that investigated the effect of four mouth rinses (1% povidone-iodine, 1.5% hydrogen peroxide, 0.075% cetylpyridinium chloride, and 80 ppm hypochlorous acid) on salivary SARS-CoV-2 viral load relative to the distilled water and no-rinse control groups. The viral load was measured by quantitative reverse transcription PCR (RT-qPCR) at baseline and 5, 30, and 60 min post rinsing. The viral load pattern within each mouth rinse group showed a reduction overtime; however, this reduction was only statistically significant in the hydrogen peroxide group. Further, a significant reduction in the viral load was observed between povidone-iodine, hydrogen peroxide, and cetylpyridinium chloride compared to the no-rinse group at 60 min, indicating their late antiviral potential. Interestingly, a similar statistically significant reduction was also observed in the distilled water control group compared to the no-rinse group at 60 min, proposing mechanical washing of the viral particles through the rinsing procedure. Therefore, results suggest using preprocedural mouth rinses, particularly hydrogen peroxide, as a risk-mitigation step before dental procedures, along with strict adherence to other infection control measures.

Associations between Periodontitis, COVID-19, and Cardiometabolic Complications: Molecular Mechanisms and Clinical Evidence

Periodontitis is a microbially driven, host-mediated disease that leads to loss of periodontal attachment and resorption of bone. It is associated with the elevation of systemic inflammatory markers and with the presence of systemic comorbidities. Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although the majority of patients have mild symptoms, others experience important complications that can lead to death. After the spread of the COVID-19 pandemic, several investigations demonstrating the possible relationship between periodontitis and COVID-19 have been reported. In addition, both periodontal disease and COVID-19 seem to provoke and/or impair several cardiometabolic complications such as cardiovascular disease, type 2 diabetes, metabolic syndrome, dyslipidemia, insulin resistance, obesity, non-alcoholic fatty liver disease, and neurological and neuropsychiatric complications. Therefore, due to the increasing number of investigations focusing on the periodontitis-COVID-19 relationship and considering the severe complications that such an association might cause, this review aims to summarize all existing emerging evidence regarding the link between the periodontitis-COVID-19 axis and consequent cardiometabolic impairments.

Randomized clinical trial to assess the impact of oral intervention with cetylpyridinium chloride to reduce salivary SARS-CoV-2 viral load

AIM

Aerosols released from the oral cavity help spread the SARS-CoV-2 virus. The use of a mouthwash formulated with an antiviral agent could reduce the viral load in saliva, helping to lower the spread of the virus. The aim of this study was to assess the efficacy of a mouthwash with 0.07% cetylpyridinium chloride (CPC) to reduce the viral load in the saliva of Coronavirus disease 2019 (COVID-19) patients.

MATERIALS AND METHODS

In this multi-centre, single-blind, randomized, parallel group clinical trial, 80 COVID-19 patients were enrolled and randomized to two groups, namely test (n = 40) and placebo (n = 40). Saliva samples were collected at baseline and 2 h after rinsing. The samples were analysed by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and an enzyme-linked immunosorbent assay test specific for the nucleocapsid (N) protein of SARS-CoV-2.

RESULTS

With RT-qPCR, no significant differences were observed between the placebo group and the test group. However, 2 h after a single rinse, N protein concentration in saliva was significantly higher in the test group, indicating an increase in lysed virus.

CONCLUSIONS

The use of 0.07% CPC mouthwash induced a significant increase in N protein detection in the saliva of COVID-19 patients. Lysis of the virus in the mouth could help reduce the transmission of SARS-CoV-2. However, more studies are required to prove this.

Virucidal activity and mechanism of action of cetylpyridinium chloride against SARS-CoV-2

Objective

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen causing the coronavirus disease 2019 (COVID-19) global pandemic. Recent studies have shown the importance of the throat and salivary glands as sites of virus replication and transmission. The viral host receptor, angiotensin-converting enzyme 2 (ACE2), is broadly enriched in epithelial cells of the salivary glands and oral mucosae. Oral care products containing cetylpyridinium chloride (CPC) as a bactericidal ingredient are known to exhibit antiviral activity against SARS-CoV-2 in vitro. However, the exact mechanism of action remains unknown.

Methods

This study examined the antiviral activity of CPC against SARS-CoV-2 and its inhibitory effect on the interaction between the viral spike (S) protein and ACE2 using an enzyme-linked immunosorbent assay.

Results

CPC (0.05%, 0.1% and 0.3%) effectively inactivated SARS-CoV-2 within the contact times (20 and 60 s) in directions for use of oral care products in vitro. The binding ability of both the S protein and ACE2 were reduced by CPC.

Conclusions

Our results suggest that CPC inhibits the interaction between S protein and ACE2, and thus, reduces infectivity of SARS-CoV-2 and suppresses viral adsorption.

Infection of the oral cavity with SARS-CoV-2 variants: Scope of salivary diagnostics

Coronaviruses, including SARS-CoV-2, have caused pandemics in the past two decades. The most prevalent SARS-CoV-2 variants of concern can re-infect individuals who have been previously infected with other variants or had protection from vaccines targeting the original SARS-CoV-2 variant. Given the high risk of transmission of coronavirus via aerosols produced during dental procedures, it is important to understand the future risk of coronavirus infection for oral health professionals and to diagnose quickly early stages of outbreaks. Testing of saliva for coronavirus may be the least invasive and most convenient method for following the outbreak at the individual and community level. This review will describe strategies for diagnosis of coronavirus in saliva.

Reduction of SARS-CoV-2 viral load in exhaled air by antiseptic chewing gum: a pilot trial

PURPOSE

The dominant route of transmission of SARS-CoV-2 is airborne, through respiratory transmission by aerosols or droplets which can be measured by viral load in exhaled air. Several natural substances have shown antiviral activity. The aim of this pilot study was to investigate the effect of a chewing gum containing natural antiseptic ingredients (cinnamon-, peppermint- and lemon-oil, quercetin, spermidine, ginger and ginseng) on viral load in exhalative air in patients infected with SARS-CoV-2.

METHODS

Nine patients infected with SARS-CoV-2 were enrolled and exhaled forcefully into a special mouthpiece at different time points before and after chewing the antiseptic gum. The mouthpiece contained a filter paper serving for extraction of coronaviruses following real-time PCR to quantify the viral load.

RESULTS AND CONCLUSION

Cycle threshold (Ct) values of all patients increased after chewing the gum. The mean difference between the Ct values at baseline (before chewing the antiseptic gum) and time point 30 min (15 min after chewing) was 3.8 ± 2.6; (93% viral load reduction; p = 0.002). Time point 15 min (2.7 ± 1.7 (83% viral load reduction; p = 0.003)), 60 min (3.0 ± 3.4 (88% viral load reduction; p = 0.028)), 90 min (3.7 ± 1.8 (92% viral load reduction; p = 0.004)) and 120 min (3.0 ± 3.7 (91% viral load reduction; p = 0.05)) showed similar results. The antiseptic chewing gum demonstrated a significant potential to reduce SARS-CoV-2 viral load in exhalative air and, in this way, reduce further spread and infection risk. Larger placebo-controlled clinical trials are required to confirm these findings further.

Your health is in your mouth: A comprehensive view to promote general wellness

Background

Even though various studies recognize the importance of the oral cavity to have general health, in multidisciplinary professional practice it is almost always excluded and on an individual basis, very commonly neglected. Oral diseases are preventable, still, they are highly prevalent. Although some studies consider oral health within integral health, currently, there is no model in which the mouth is integrated within other levels for the achievement of well-being. The objective of this article was to review the importance of oral health and its connection with well-being and, based on these findings, propose a complex and comprehensive perspective for approach and care.

Methods

The databases MEDLINE, PubMed, and Google Scholar were revised for randomized controlled trials and reviews that included search terms related to oral health and its relationship with the general health in its different levels (physical, psychological, social and environmental).

Results

The review shows that oral health is critical, as the teeth and mouth are not only an integral part of the body, but also, they also support and enable essential human functions. That is, oral health has a multidimensional nature, as it includes the physical, psychological, social, and environmental domains that are essential for overall health and well-being. Likewise, the mouth is the psychological seat of the first physiological needs and emotional gratifications, with it we take a taste of the world around us. Thus, the mouth plays an important role in the feeling of unity and in the constitution of the self. Based on these results we propose an integrative model in which the mouth is the first step for well-being and from this integrative model we build a multidisciplinary approach which could be used in the clinical practice for the promotion of oral care and general health.

Conclusion

The effort on the part of oral health professionals is essential for people's well-being and must be integrated as part of health promotion. Dental treatments alone cannot solve this problem, it requires a comprehensive and approach in which the bio-psychological, behavioral, and socio-environmental determinants are included to face this global oral health challenge. That is, without a comprehensive and multidisciplinary approach to medical science that includes dental and oral health, our public policies cannot provide the best answers to health promotion, disease prevention, early detection, and treatment.

Oral Lesions Associated with COVID-19 and the Participation of the Buccal Cavity as a Key Player for Establishment of Immunity against SARS-CoV-2

BACKGROUND

Some oral lesions have been described in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); the possibility has been raised that the buccal lesions observed in patients with the coronavirus disease 2019 (COVID-19) are due to this virus and the patient's systemic condition. The aim of this review was to integrate the knowledge related to the oral lesions associated with COVID-19 and the participation of the buccal cavity in the establishment of immunity against SARS-CoV-2.

METHODS

A literature search on the manifestations of buccal lesions from the beginning of the pandemic until October 2021 was carried out by using the PubMed database. A total of 157 scientific articles were selected from the library, which included case reports and reports of lesions appearing in patients with COVID-19.

RESULTS

Oral lesions included erosions, ulcers, vesicles, pustules, plaques, depapillated tongue, and pigmentations, among others. The oral cavity is a conducive environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, immunodeficiencies, and autoimmunity primarily.

CONCLUSIONS

The oral cavity is an accessible and privileged environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; the direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, in particular those related to immunodeficiencies and autoimmunity.

Decrease in Angiotensin-Converting Enzyme activity but not concentration in plasma/lungs in COVID-19 patients offers clues for diagnosis/treatment

Although several therapeutics are used to treat coronavirus disease 2019 (COVID-19) patients, there is still no definitive metabolic marker to evaluate disease severity and recovery or a quantitative test to end quarantine. Because severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infects human cells via the angiotensin-converting-enzyme 2 (ACE2) receptor and COVID-19 is associated with renin-angiotensin system dysregulation, we evaluated soluble ACE2 (sACE2) activity in the plasma/saliva of 80 hospitalized COVID-19 patients and 27 non-COVID-19 volunteers, and levels of ACE2/Ang (1-7) in plasma or membrane (mACE2) in lung autopsy samples. sACE2 activity was markedly reduced (p < 0.0001) in COVID-19 plasma (n = 59) compared with controls (n = 27). Nadir sACE2 activity in early hospitalization was restored during disease recovery, irrespective of patient age, demographic variations, or comorbidity; in convalescent plasma-administered patients (n = 45), restoration was statistically higher than matched controls (n = 22, p = 0.0021). ACE2 activity was also substantially reduced in the saliva of COVID-19 patients compared with controls (p = 0.0065). There is a strong inverse correlation between sACE2 concentration and sACE2 activity and Ang (1-7) levels in participant plasmas. However, there were no difference in membrane ACE2 levels in lungs of autopsy tissues of COVID-19 (n = 800) versus other conditions (n = 300). These clinical observations suggest sACE2 activity as a potential biomarker and therapeutic target for COVID-19.

Oral microbial taxa associated with risk for SARS-CoV-2 infection

Hypothesis and objective

The oral and digestive tract microbial ecosystem has sparked interest because of its impact on various systemic diseases and conditions. The oral cavity serves not only as a reservoir for many potentially virulent microbiota but also as an important entry point and portal to the human body system. This is especially significant in the transmissibility of the virulent current pandemic virus SARS-CoV-2. The oral and digestive microbiome influences the inflammatory burden and effectiveness of the immune system and serves as a marker of activity of these host processes. The host immune response plays a role in infection susceptibility, including SARS-CoV-2. The purpose of this study is to investigate the role of specific salivary oral microbiome in susceptibility to SARS-CoV-2 infection.

Methods and results

One hundred six subjects of known medical and dental history who consented to provide saliva samples between January 2017 and December 2019 were included in this study. Sixteen had become COVID-19 positive based on the PCR test by 3/01/2021. A comparison of oral microbiome bacteria taxa profiles based on 16S rRNA sequencing revealed differences between the two groups in this pilot study.

Conclusions

These bacteria taxa may be markers of increased susceptibility to SARS-CoV-2 infection in the unvaccinated population.

Debulking different Corona (SARS-CoV-2 delta, omicron, OC43) and Influenza (H1N1, H3N2) virus strains by plant viral trap proteins in chewing gums to decrease infection and transmission

Because oral transmission of SARS-CoV-2 is 3-5 orders of magnitude higher than nasal transmission, we investigated debulking of oral viruses using viral trap proteins (CTB-ACE2, FRIL) expressed in plant cells, delivered through the chewing gum. In omicron nasopharyngeal (NP) samples, the microbubble count (based on N-antigen) was significantly reduced by 20 μg of FRIL (p < 0.0001) and 0.925 μg of CTB-ACE2 (p = 0.0001). Among 20 delta or omicron NP samples, 17 had virus load reduced below the detection level of spike protein in the RAPID assay, after incubation with the CTB-ACE2 gum powder. A dose-dependent 50% plaque reduction with 50-100 ng FRIL or 600-800 μg FRIL gum against Influenza strains H1N1, H3N2, and Coronavirus HCoV-OC43 was observed with both purified FRIL, lablab bean powder or gum. In electron micrographs, large/densely packed clumps of overlapping influenza particles and FRIL protein were observed. Chewing simulator studies revealed that CTB-ACE2 release was time/dose-dependent and release was linear up to 20 min chewing. Phase I/II placebo-controlled, double-blinded clinical trial (IND 154897) is in progress to evaluate viral load in saliva before or after chewing CTB-ACE2/placebo gum. Collectively, this study advances the concept of chewing gum to deliver proteins to debulk oral viruses and decrease infection/transmission.

Oral dysbiosis and its linkage with SARS-CoV-2 infection

The human oral cavity harbours complex microbial communities with various commensal microorganisms that play pivotal roles in maintaining host health and immunity but can elicit local and systemic diseases. The role of commensal microorganisms in SARS-CoV-2 infection and disease susceptibility and enrichment of opportunistic pathobionts in the oral cavity is poorly understood. The present study aims to understand the altered landscape of the oral microbiome and mycobiome in SARS-CoV-2 infected patients (n = 30) and its correlation with risk factors compared to non-infected individuals (n = 24) using targeted amplicon sequencing. Diminution of species richness, an elevated abundance of opportunistic pathogens (Veillonella, Acinetobacter, Klebsiella, Prevotella, Gemella, and Streptococcus) and impaired metabolic pathways were observed in the COVID-19 patients. Similarly, altered oral mycobiome with enrichment of known respiratory disease causing pathogenic fungi were observed in the infected individuals. The data further suggested that reduction in immunomodulatory microorganisms lowers the protection of individuals from SARS-CoV-2. Linear discriminant analysis identified several differentially abundant taxa associated with risk factors (ageing and co-morbidities). We also observed distinct bacterial and fungal community structures of elderly infected patients compared to the younger age group members making them highly vulnerable to SARS-CoV-2 infection and disease severity. Furthermore, we also assessed the dynamics of the oral microbiome and mycobiome in symptomatic and asymptomatic patients, host types, co-morbidities, and viral load in the augmentation of specific pathobionts. Overall, the present study demonstrates the microbiome and mycobiome profiling of the COVID-19 infected individuals, the data further suggests that the SARS-CoV-2 infection triggers the prevalence of specific pathobiont.

Melatonin: Regulation of Viral Phase Separation and Epitranscriptomics in Post-Acute Sequelae of COVID-19

The relentless, protracted evolution of the SARS-CoV-2 virus imposes tremendous pressure on herd immunity and demands versatile adaptations by the human host genome to counter transcriptomic and epitranscriptomic alterations associated with a wide range of short- and long-term manifestations during acute infection and post-acute recovery, respectively. To promote viral replication during active infection and viral persistence, the SARS-CoV-2 envelope protein regulates host cell microenvironment including pH and ion concentrations to maintain a high oxidative environment that supports template switching, causing extensive mitochondrial damage and activation of pro-inflammatory cytokine signaling cascades. Oxidative stress and mitochondrial distress induce dynamic changes to both the host and viral RNA m6A methylome, and can trigger the derepression of long interspersed nuclear element 1 (LINE1), resulting in global hypomethylation, epigenetic changes, and genomic instability. The timely application of melatonin during early infection enhances host innate antiviral immune responses by preventing the formation of "viral factories" by nucleocapsid liquid-liquid phase separation that effectively blockades viral genome transcription and packaging, the disassembly of stress granules, and the sequestration of DEAD-box RNA helicases, including DDX3X, vital to immune signaling. Melatonin prevents membrane depolarization and protects cristae morphology to suppress glycolysis via antioxidant-dependent and -independent mechanisms. By restraining the derepression of LINE1 via multifaceted strategies, and maintaining the balance in m6A RNA modifications, melatonin could be the quintessential ancient molecule that significantly influences the outcome of the constant struggle between virus and host to gain transcriptomic and epitranscriptomic dominance over the host genome during acute infection and PASC.

Oral Antiseptics against SARS-CoV-2: A Literature Review

Dentists are health care workers with the highest risk of exposure to COVID-19, because the oral cavity is considered to be a reservoir for SARS-CoV-2 transmission. The identification of SARS-CoV-2 in saliva, the generation of aerosols, and the proximity to patients during dental procedures are conditions that have led to these health care workers implementing additional disinfection strategies for their protection. Oral antiseptics are widely used chemical substances due to their ability to reduce the number of microorganisms. Although there is still no evidence that they can prevent the transmission of SARS-CoV-2, some preoperative oral antiseptics have been recommended as control measures, by different health institutions worldwide, to reduce the number of microorganisms in aerosols and droplets during dental procedures. Therefore, this review presents the current recommendations for the use of oral antiseptics against SARS-CoV-2 and analyzes the different oral antiseptic options used in dentistry.

Periodontitis and COVID-19: Biological Mechanisms and Meta-analyses of Epidemiological Evidence

Since the beginning of 2020, the entire global health care system has been severely challenged by the outbreak of coronavirus 2019 disease (COVID-19). Robust evidence has demonstrated a more severe course of COVID-19 in the presence of several comorbidities, such as cardiovascular diseases, diabetes mellitus, and obesity. Here, we critically appraise the recent research discoveries linking periodontitis to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to severe COVID-19, with a special focus on the associated biological mechanisms and the available epidemiological evidence. SARS-CoV-2 main receptors and coreceptors (ACE2, TMPRSS2, furin, CD147) are overexpressed in periodontal tissues of periodontitis patients, with inflammation, periodontal pathogens, and damage-induced pyroptosis triggering a positive feedback loop. However, meta-analyses of epidemiological studies only indicated a nonstatistically significant tendency for an increased risk of SARS-CoV-2 infection in subjects with periodontitis (odds ratio [OR] = 1.69; 95% CI, 0.91-3.13, P = 0.09). Furthermore, periodontitis may worsen clinical COVID-19 courses through multiple direct and indirect pathways, including damage to lower airways due to aspiration of periodontal pathogens, exacerbation of the cytokine storm via the low-grade chronic systemic inflammation, and SARS-CoV-2 dissemination through the ulcerated gingival epithelium with consequent induced pulmonary vessels vasculopathy. Indeed, meta-analyses of epidemiological studies indicated that periodontitis subjects are more likely to experience a more severe course of COVID-19. Specifically, periodontitis was associated with a 4-fold increased odds of hospitalization (OR = 4.72; 95% CI, 1.11-20.03, P = 0.04), 6-fold of requiring assisted ventilation (OR = 6.24; 95% CI, 2.78-14.02, P = 0.00), and more than 7-fold of death due to COVID-19 complications (OR = 7.51; 95% CI, 2.16-26.10, P = 0.00). The breakthrough analyzed here emphasizes the relevance of the mouth-systemic connection as a target to mitigate the current COVID-19 emergency and the future predicted coronavirus pandemics.

Relationship between Oral Health Knowledge and Maternal Oral Health with Obstetric Risk and Breastfeeding

The relationship between maternal gingival health status and low birth weight or preterm delivery is controversial. The aim of this study was to analyze the association between maternal oral knowledge and the level of oral health during pregnancy with the risk of obstetric complications and breastfeeding. A descriptive cross-sectional study was conducted after an oral health educational intervention in a consecutive sample of 97 pregnant women. Data collection consisted of a validated questionnaire, oral examination, the Caries Index (CAOD) and the Simplified Oral Hygiene Index (IHOS). The participants had a mean age of 32.5 ± 5.19 years and a predominantly university education (57.1%). The level of knowledge regarding oral health was fair (12.5 ± 3.56 correct answers). Older pregnant women (33.0 ± 4.80 years) practiced breastfeeding and had a higher number of correct answers to the questionnaire. Adequate IHOS was associated with higher birth-weight newborns (3333 ± 0.3), whereas poor oral hygiene control was associated with lower birth-weight newborns (2960 ± 0.1) (p < 0.05). A lower level of academic education was associated with worse oral hygiene (p < 0.05). In addition, the greater the number of children, the higher the CAOD. Finally, among non-smoking women, the weight of infants was 437 mg higher. Maternal oral hygiene and the week of delivery were associated with newborn weight (p < 0.05) in a multiple linear regression model. Smoking was also related to low birth weight (p < 0.05). Educational interventions in pregnancy are necessary to decrease the incidence of obstetric adverse effects and improve the oral health of mothers and their children.

Cetylpyridinium Chloride Mouthwash to Reduce Shedding of Infectious SARS-CoV-2: A Double-Blind Randomized Clinical Trial

The airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via respiratory fluids and droplets suggests that mouthwashes containing substances with virucidal activity can help reduce viral spread. We conducted a multicenter, double-blind, placebo-controlled, randomized trial to assess the virucidal activity of cetylpyridinium chloride (CPC) mouthwashes. Outpatients who tested positive for SARS-CoV-2 infection with or without symptoms were randomized to perform washes and gargles for 1 min with 15 mL of either colored distilled water or 0.07% CPC (Vitis CPC Protect) mouthwash. The study outcomes were the SARS-CoV-2 log₁₀ viral RNA load and the nucleocapsid protein levels, both in saliva at 1 and 3 h after the intervention. In total, 118 patients were enrolled and randomized (mean [SD], age 46 [14] y). Thirteen of 118 participants (11%) did not complete follow-up or had insufficient sample volume for testing and were excluded from the analysis. The assessment of the viral load showed no significant differences between groups at any of the investigated points. However, the levels of SARS-CoV-2 nucleocapsid protein of lysed viruses were significantly higher in the CPC group compared with the control group at 1 h (adjusted difference 269.3 pg/mL; 95% confidence interval [CI], 97.1-441.5) and at 3 h postintervention (561.1 pg/mL; 95% CI, 380.0-742.2). In nonhospitalized patients with asymptomatic or mild symptomatic SARS-CoV-2 infection, a 0.07% CPC mouthwash, compared to placebo, was associated with a significant increase of nucleocapsid protein levels in saliva, indicating enhanced disruption of viral particles.

Poor oral health status and adverse COVID-19 outcomes: A preliminary study in hospitalized patients

BACKGROUND

Most of the common risk factors for severe outcomes of coronavirus disease 2019 (COVID-19) are correlated with poor oral health, tooth loss, and periodontitis. This has pointed to a possible relationship between oral and systemic health in COVID-19 patients. Hence, this study aimed to assess the dental and periodontal status of hospitalized COVID-19 patients and their associations with the incidence of adverse COVID-19 outcomes.

METHODS

We included 128 hospital patients aged between 20 and 97 years and with diagnoses of COVID-19 in this prospective observational study. Dental and periodontal status was assessed using in-hospital clinical examinations, including the Decayed, Missing, and Filled Teeth index, periodontal status, and tooth loss patterns (Eichner index). Associations between oral health measures, the severity of COVID-19 symptoms, and hospitalization endpoints were tested using chi-square test and incidence rate ratio (IRR) estimation using a generalized linear model with log-Poisson regression. The regression models used a block-wise selection of predictors for oral health-related variables, comorbidities, and patients' ages.

RESULTS

Overall, poor oral health conditions were highly prevalent and associated with critical COVID-19 symptoms, higher risk for admission in the intensive care unit (ICU), and death. Periodontitis was significantly associated with ICU admission (IRR = 1.44; 95% confidence interval [95%CI] = 1.07-1.95; P = 0.017), critical symptoms (IRR = 2.56; 95%CI = 1.44-4.55; P = 0.001), and risk of death (IRR = 2.05; 95%CI = 1.12-3.76; P = 0.020) when adjusted for age and comorbidities. The Eichner index (classes B and C) was associated with ICU admission.

CONCLUSION

There was a positive association between deleterious oral health-related conditions, especially periodontitis, and severe COVID-19 outcomes in hospitalized COVID-19 patients.

Periodontitis and coronavirus disease 2019

The coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 is usually a mild condition; however, in some cases it can result in severe sickness and even death. Thus, understanding the reasons behind these grave outcomes is of great importance. Coronavirus disease 2019 and periodontitis share some intriguing characteristics. They can both lead to systemic inflammation and alterations of coagulation pathways, and both share confounding factors, such as diabetes, hypertension, and obesity. Accordingly, a possible association between these conditions has been hypothesized in the literature. The objective of this review was to evaluate the scientific evidence linking these diseases and the possible underlying mechanisms. Evidence has shown that coronavirus disease 2019 presents oral manifestations and can even affect periodontal tissues. Moreover, some studies have shown a possible association between coronavirus disease 2019 severity and the presence of periodontitis. Current evidence suggests that this association could be explained through the direct role of periodontal bacteria in aggravating lung infections, as well as through the indirect effect of periodontitis in inducing systemic inflammation and priming of the immune system to an exacerbated reaction to severe acute respiratory syndrome coronavirus 2 infection. Future research is needed to confirm these observations and explore the possible role that periodontal care might play in the coronavirus disease 2019 pandemic.

Evaluation of the Effect of Anti-COVID-19 Mouthwashes on Shear Bond Strength of Composite Resin Restorations to Dentin and Enamel: An “In Vitro Study”

Objectives

Given the high prevalence of the coronavirus and the high risk of virus transfer to dentists, the use of mouthwashes, which can potentially eliminate this virus, is suggested before dental procedures. Since these mouthwashes may affect the bond strength of composite resin restorations to teeth, this study was conducted to investigate the effect of recommended mouthwashes on the shear bond strength of composite resin restorations to dentin and enamel in selective etch and rinse and two-step self-etch bonding systems.

Methods

Five groups of posterior teeth (n = 15) were selected for five groups of cetylpyridinium chloride 0.07%, povidone-iodine 1%, hydrogen peroxide 1%, and chlorhexidine 0.2% as mouthwash and distilled water as the control group. The buccal enamel and lingual dentin of each tooth were rinsed after immersion in a mouthwash. After 20 seconds of enamel acid-etching and 15 seconds of dentin priming, they were impregnated with an adhesive, and composite cylinders were placed on the dentin and enamel surfaces of the tooth. The shear bond strength test was performed after 24 hours, and results were analyzed by ANOVA and paired t-test (α = 0.05).

Results

The mean shear bond strength of enamel to composite was significantly (p < 0.05) higher than that of dentin to composite in each study group, but no significant difference was found between the mean shear bond strength of composite to enamel (p = 0.199) and to dentin (p = 0.335) after the use of mouthwashes and that of the control group.

Conclusion

The use of mouthwashes used in this study did not have negative effects on the shear bond strength of composite to enamel and dentin.

Top 50 covid and oral health articles: A 2021 altmetric analysis

Objectives

There is a world of information at our disposal, and it is increasingly difficult to transform this dull amount of data into knowledge. How to be constantly actualized? This study aims to create an altmetric list of the top 50 articles related to COVID-19 and oral health.

Methods

Research of terms COVID-19 and oral health was done using Dimensions app. Results were ranked in altmetric citations and analyzed through Microsoft Excel. Some tables and graphics were created. Graphical illustration of keywords was created using VOSviewer.

Results

Some interesting facts can be seen, like growing interest in dental aerosols, perspectives, and virucidal activity of some mouthwashes.

Conclusions

Altmetric analysis is a helpful manner to scientific updates, supplementing bibliometric analysis. A terrific manner to see trends. The scientific community goes to great lengths to solve problems with dental aerosols, particularly to reduce contamination. Some adjustments to dental office and the use of barriers are recommended.

Mouthrinses against SARS-CoV-2 – high antiviral effectivity by membrane disruption in vitro translates to mild effects in a randomized placebo-controlled clinical trial

The emergence of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) represents an unprecedented threat for the human population, necessitating rapid and effective intervention measures. Given the main infection route by airborne transmission, significant attention has been bestowed upon the use of antiseptic mouthrinses as a way to possibly reduce infectious viral titers. However, clinical evaluations are still sparse. Thus, we evaluated a wide variety of antiseptic agents that can be used as mouthrinses for their antiviral effects in vitro and their respective mode of action. One of the most promising antiseptic agents (benzalkoniumchloride, BAC) was used in a randomized placebo-controlled clinical trial with subsequent analysis of viral loads by RT-qPCR and virus rescue in cell culture. Mechanistic analysis revealed that treatment with BAC and other antiseptic agents efficiently inactivated SARS-CoV-2 in vitro by primarily disrupting the viral envelope, without affecting viral RNA integrity. However, the clinical application only resulted in a mild reduction of viral loads in the oral cavity. These results indicate that gargling with mouthrinses comprising single antiseptic agents may play a minor role towards a potential reduction of transmission rates and thus, these findings are of utmost importance when considering alternative COVID-19 prevention strategies.

In vitro virucidal activity of mouthwashes on SARS‐CoV‐2

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Drug-Free Nasal Spray as a Barrier against SARS-CoV-2 and Its Delta Variant: In Vitro Study of Safety and Efficacy in Human Nasal Airway Epithelia

The nasal epithelium is a key portal for infection by respiratory viruses such as SARS-CoV-2 and represents an important target for prophylactic and therapeutic interventions. In the present study, we test the safety and efficacy of a newly developed nasal spray (AM-301, marketed as Bentrio) against infection by SARS-CoV-2 and its Delta variant on an in vitro 3D-model of the primary human nasal airway epithelium. Safety was assessed in assays for tight junction integrity, cytotoxicity and cilia beating frequency. Efficacy against SARS-CoV-2 infection was evaluated in pre-viral load and post-viral load application on airway epithelium. No toxic effects of AM-301 on the nasal epithelium were found. Prophylactic treatment with AM-301 significantly reduced viral titer vs. controls over 4 days, reaching a maximum reduction of 99% in case of infection from the wild-type SARS-CoV-2 variant and more than 83% in case of the Delta variant. When AM-301 administration was started 24 h after infection, viral titer was reduced by about 12-folds and 3-folds on Day 4. The results suggest that AM-301 is safe and significantly decelerates SARS-CoV-2 replication in cell culture inhibition assays of prophylaxis (pre-viral load application) and mitigation (post-viral load application). Its physical (non-pharmaceutical) mechanism of action, safety and efficacy warrant additional investigations both in vitro and in vivo for safety and efficacy against a broad spectrum of airborne viruses and allergens.