Knowledge and perception regarding oral manifestations of COVID-19 among the undergraduate and postgraduate students of Vishnu Dental College—a questionnaire based study

Introduction

Coronavirus disease can be asymptomatic or cause respiratory distress, multi-organ failure, ocular symptoms, dermatological symptoms, and oral signs. The most common symptoms of coronavirus disease-19 (COVID-19) infection include a headache, sore throat, diarrhoea, loss of taste, smell, and shortness of breath. Some works report manifestations in the oral cavity, in addition to dermatological manifestations (1,2).

COVID-19 infection has atypical oral manifestations that are typically ignored by undergraduate and graduate students because many systemic diseases have some oral presentations similar. But the oral manifestations that are characteristic in COVID-19 have to be identified at the early. If dental practitioners conduct extensive examinations for atypical oral manifestations in COVID-19 patients, they will be able to identify the severity of COVID-19 infection and make recommendations to patients for appropriate medical treatment (3,4).

Dry mouth is the most common oral manifestation in COVID-19 patients, followed by gustatory dysfunction such as loss of salt sensation, loss of sweet sensation, altered food taste, pain or swelling in the salivary gland or cheek, pain or swelling below mandible, oral mucosal changes such as burning mouth sensation, oral ulcerations, mouth and lip spots, tongue redness, and gingival bleeding. These are the oral manifestations observed during COVID-19 infection even at the early stages. Thus identifying these manifestations at the earliest is important to diagnose and prevent the disease (5).

COVID-19 infection is extremely infectious and contagious; hence more research is needed to confirm the link between oral indicators and manifestations. Dental professionals must be aware of early oral manifestations in COVID-19 patients and provide assistance on how to overcome or follow the right treatment protocol to avoid and control the COVID-19 (6,7).

The objective of this study was to assess Indian dental school undergraduate and postgraduate students’ knowledge and perception of the oral symptoms present in COVID-19 patients. We present the following article in accordance with the SURGE reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-22-24/rc).

Methods

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by Institutional Ethics Committee-Vishnu Dental College (No. VDC/IEC/2022/F/PI/IVV/53) and informed consent was taken from all the patients. Two experts designed this questionnaire and subjected to validation in 50 participants after reviewing similar questionnaires. The content validity score was 3.8 and above for all the questions included in this study. An online questionnaire was created to measure dentistry students’ knowledge and perception of the existence of oral manifestations in COVID-19 infected people. A total of 380 Vishnu dental college students with at least 6 months of clinical experience in detecting and diagnosing oral diseases have been recruited. Each participant gets a WhatsApp message containing a link to a shareable Google Drive. A digital agreement to participate in this study was obtained before to finishing the questionnaire.

Sample size in each group

A total of 380 students took part in the research. Based on their academic year, 99 students from the 3rd Bachelor of Dental surgery (BDS), 77 from the 4th BDS, 82 from Interns, 43 from the 1st Master of Dental Surgery (MDS), 42 from the 2nd MDS, and 38 from the 3rd MDS participated.

Participants must meet the following criteria: (I) be undergraduate or postgraduate students from the same dentistry school; and (II) have a minimum of 6 months of clinical experience. Students who are not from the same dental school and who have not had at least 6 months of clinical experience are also excluded.

Questionnaire tool

The questionnaire was broken into three parts and comprised 12 questions about oral manifestations in COVID-19 patients’ knowledge and perception. The first section dealt with questions about knowledge, while the second dealt with questions about perception. The third segment comprised questions about undergraduate and postgraduate students’ perceptions of the prevalence and severity of oral manifestations in COVID-19 infected patients.

Assessment of the knowledge and perception regarding oral manifestations

The participants’ knowledge and perception were assessed by the principal investigator based on their responses to the first and second portions of the questionnaire, which indicated the most prevalent oral manifestations of COVID-19 infection. The final component of the questionnaire revealed the frequency and severity of COVID-19 infected patients’ oral manifestations.

Statistical analysis

The statistical package IBM SPSS Statistics for Windows, v. 22.0, was used to gather and enter data (IBM Corp., Armonk, USA). The frequency and percentage of categorical variables were calculated. The Pearson Chi-Square test was used to make comparisons between the groups in terms of the incidence of the researched parameters. Statistical significance was defined as a P value of less than 0.005.

Results

Demographic data

The questionnaire survey drew 380 students from Indian dental school. Participants were separated into two groups based on their age (range, 19–24 and 25–30 years). There were 291 females and 89 males among the participants. Participants were divided into four categories based on their academic level: 3rd BDS (n=99), 4th BDS (n=74), Interns (n=81), and postgraduate students (n=126).

Assessment of knowledge and perception regarding oral manifestations in COVID-19

Responses according to the academic year

In this study, we mainly included participants with a minimum of 6 months of clinical experience, so that they know in identifying and diagnosing oral diseases. As reported in Table 1, the percentage and number of the respondents who observed oral manifestations in COVID-19 patients in their clinical experience were: Halitosis was about 50.7% [193], Xerostomia—67.4% [256], overgrowth on the tongue, ulcers and burning sensation—54.8% [208], oral ulcerations—51.9% [197], oral or dental pain—38.2% [145], Pain in jaw bones or joint—42.3% [160], vesicles and erosions on the lips, anterior tongue, and buccal mucosa—40.9% [155].

When it comes to the perception-related analysis 89% [338] agreed that oral manifestations are ignored just due to their less prevalence and less severity and 81.1% [308]agreed that nearly half of COVID-19 patients suffer from oral manifestations during infection (Table 1, Figure 1).

Figure 1 The percentages of oral manifestations observed in COVID-19 infected patients by undergraduate and postgraduate students of Vishnu Dental College in India. COVID-19, coronavirus disease-19.

Responses according to the age

In this study, we mainly included participants with age ranges of 19–24 and 25–30 years. The knowledge and perception regarding oral manifestations according to the age were reported in Table 2, and the percentage and number of the respondents who observed oral manifestations in COVID-19 patients in their clinical experience were: Halitosis was about 57.6% [191], Xerostomia—67.3% [254], overgrowth on tongue, ulcers and burning sensation—54.8% [207], oral ulcerations—52.1% [196], oral or dental pain—38.2% [144], pain in jaw bones or joint—42.6% [160], vesicles and erosions on the lips, anterior tongue, and buccal mucosa—40.7% [153].

When it comes to the perception-related analysis 88.9% [335] agreed that oral manifestations are ignored just due to their less prevalence and less severity and 80.9% [305]agreed that nearly half of COVID-19 patients suffer from oral manifestations during infection (Table 2, Figure 1).

Responses according to the gender

In this study, out of 381 individuals, 291 were females and 89 were males. The knowledge and perception regarding oral manifestations according to the gender were reported in Table 3, and the percentage and number of the respondents who observed oral manifestations in COVID-19 patients in their clinical experience were: Halitosis was about 51% [193], Xerostomia—68.1% [260], overgrowth on tongue, ulcers and burning sensation—55.9% [213], oral ulcerations—53.0% [202], oral or dental pain—39.3% [151], pain in jaw bones or joint—43.2% [166], vesicles and erosions on the lips, anterior tongue, and buccal mucosa—41.7% [149].

When it comes to the perception-related analysis 89.0% [339] agreed that oral manifestations are ignored just due to their less prevalence and less severity and 81.8% [312]agreed that nearly half of COVID-19 patients suffer from oral manifestations during infection (Table 3, Figure 1).

Discussion

The oral mucosa is a key site of infection for SARS-CoV-2 and is thought to be at a high risk of COVID-19 infection (8,9). However, it is still unclear whether oral manifestations are caused by COVID-19 infection, underlying systemic disease, or impaired immune function. The current study aimed to assess Indian dental school undergraduate and postgraduate students’ knowledge and perception of the oral symptoms present in COVID-19 patients (10,11).

The oral cavity is well-known for acting as a mirror that reflects the underlying health situation. Because various oral symptoms can be linked with underlying systemic illness and COVID-19 infection, and studies have regarded oral transmission to be one of the major routes of COVID-19 transmission, careful evaluation of the oral cavity will aid in early identification and treatment. The only difficulty in establishing a link between diagnosis and oral manifestations in COVID-19 patients is that similar manifestations can be seen in a variety of systemic diseases, making it difficult to determine whether these manifestations are the result of systemic disease or COVID-19 infection. Longitudinal research will fill the information gap about COVID-19 oral manifestations and their influence on the oral cavity (12).

According to a study by Huang et al., [2021] the oral manifestations observed roughly in half of COVID-19 patients during the infection. Because only the classic indicators are visible, most undergraduate and postgraduate students have difficulty recognizing the mild to moderate oral manifestations, which can appear much earlier than the classic signs. As a result, greater study into COVID-19 oral manifestations is needed to determine the link between oral manifestations and COVID-19 infection. Many research investigations have looked into halitosis, xerostomia, COVID-19 tongue, oral ulcerations, oral or dental discomfort, pain in jaw bones or joints, vesicles, and erosions in the oral cavity, in addition to taste loss (13).

Coronavirus targets human cells via angiotensin-converting enzyme 2 (ACE2) receptors, as evidenced by the fact that ACE2 is the predominant host cell receptor for severe acute respiratory syndrome coronavirus 2. As a result, organs with high ACE2 expression (for example, the lung) might become target cells during SARS-CoV-2 infection, causing inflammatory responses in other organs and tissues (5). The entry of the virus into our bloodstream via receptors called ACE2 found in oral cavity, tongue, and gums is one proposed explanation of coronavirus influencing oral health. As a result, people with poor dental health have more ACE2 receptors. According to studies, those with poor dental health are more likely to get severe COVID-19 (13).

According to the National Institute of Health [2021], the oral manifestations can even be detected in silent or mild instances of COVID-19 where no other indicators of infection are present. The presence of the virus in oral cavity tissues demonstrated that the oral cavity is the primary site of COVID-19 transmission (13).

Halitosis was identified as one of the oral manifestations in COVID-19 infected patients by 50.7% of participants in this survey. This research builds on prior research by Scully et al. [2005], and Zürcher et al. [2012], which shown that halitosis is one of the oral manifestations linked to communicable diseases (14,15).

When asked about patients’ complaints of pain during COVID-19 infection, 38.2% of dental students said they had pain in their mouths or teeth, and 42% said they had pain in their jaw bones and joints. This is in line with a study published by Fukuda et al. [2016] which found a link between mouth pain and communicable infections (16).

Oral ulcerations are also regularly identified manifestations in COVID-19 patients, according to 51.9% of students. This is in line with the findings of a recent study by Amorim Dos Santos et al. [2020] who demonstrated that oral ulcerations are a prevalent sign of COVID-19 infection (17).

COVID-19 infected people have oral symptoms like dry mouth, loss of salt sensation, loss of sweet sensation, altered food taste, oral ulcerations in common even at early stages of COVID-19 infection. By identifying these manifestations at the early stages by the dental practitioners, and relating to the severity of COVID-19 infection, one can preserve the oral and overall health of patients.

The statistical analysis revealed substantial differences in the knowledge and perception levels of oral manifestations found in COVID-19 infected persons based on their mean age and educational level. The scientists also demonstrated a link between high bacterial loads in the mouth and post-viral problems, as well as how better oral hygiene could reduce the likelihood of COVID-19 sequelae. Small sample size and the research done at one dental school are the limitations of the study. Longitudinal research will fill the information gap about COVID-19 oral manifestations and their influence on the oral cavity.

Conclusions

The study demonstrated that dental students have sufficient knowledge to identify the oral manifestations of COVID-19 infected individuals. It also demonstrated the importance of every dental student in identifying oral manifestations and relating these manifestations to the severity of COVID-19 infection, which aids in educating and advising patients on how to follow the proper treatment plan.

Acknowledgments

We would like to thank Professor Deepthi, MA in English from Kendriya Vidyalaya, Hyderabad, Telangana, India for polishing our paper.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-22-24/rc

Data Sharing Statement: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-22-24/dss

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-22-24/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by Institutional Ethics Committee - Vishnu Dental College (No. VDC/IEC/2022/F/PI/IVV/53) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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