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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 150-153

Role of dentist in diagnosis and management of mucormycosis in association with COVID-19


1 Department of Prosthodontics and Crown and Bridge, Dr. R Ahmed Dental College and Hospital, Kolkata, West Bengal, India
2 Department of Conservative Dentistry, Dr. R Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Submission22-May-2021
Date of Decision19-Jun-2022
Date of Acceptance20-Jun-2022
Date of Web Publication01-Jul-2022

Correspondence Address:
Piyush Dongre
Department of Prosthodontics and Crown and Bridge, Dr. R Ahmed Dental College and Hospital, Kolkata - 700 014, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_36_21

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  Abstract 


The prevalence of fungal infection has skyrocketed in recent years. This is owing to the new corona virus's rapid spread. Mucormycosis is a deep fungal infection that has shown a rise in this worldwide pandemic period. Mucormycosis is a potentially fatal infection. To lower the rate of infection, it is critical to diagnose it as soon as possible and give appropriate treatment. The necessity of early diagnosis, prevention, and management of mucormycosis, as well as the role of the dentist in doing so, are discussed in this review article.

Keywords: Dentist, early diagnosis, management, mucormycosis


How to cite this article:
Dongre P, Bansal T. Role of dentist in diagnosis and management of mucormycosis in association with COVID-19. J Oral Res Rev 2022;14:150-3

How to cite this URL:
Dongre P, Bansal T. Role of dentist in diagnosis and management of mucormycosis in association with COVID-19. J Oral Res Rev [serial online] 2022 [cited 2022 Aug 16];14:150-3. Available from: https://www.jorr.org/text.asp?2022/14/2/150/349708




  Introduction Top


The majority of fungal infections are caused by opportunistic circumstances, which are dependent on the host's resistance. Through local colonisation, impaired host resistance may contribute to the development and later advancement of the pathogenic state in the oral cavity. As the incidence of the viral infections is increasing globally, the frequency of the oral mycosis also increasing rapidly.[1],[2] Depending upon the severity, oral mycological conditions are divided into superficial and deep fungal infections of the oral tissues. Slight oral discomfort, paraguesia, burning sensation are mostly seen in superficial fungal infections while the deep fungal infections are presented with ulcerations and also perforations in the bony areas.[3],[4] One of the deep fungal infection which is rapidly increasing in this time of COVID-19 pandemic is Mucormycosis.

Mucormycosis is also known as “black fungus.” Saprophytic fungi like Rhizopus, Rhizomucor, Mucor, Saksenea, Cunninghamella are causative organisms for mucormycosis. Most common type of mucormycosis being rhino maxillary disease.[5] This black fungus have created havoc for the doctors. With the increase in the viral infection, COVID-19 the cases of mucormycosis have increased immensely. It has emerged as a post COVID mucormycosis.[6]

This review focuses on the diagnosis and management of mucormycosis of the oral cavity. Dictates the role of the dentist in the prevention and management of this huge outbreak of fungal infection. All the data presented in this review was collected from available literature in PubMed and Google Scholar database.


  Pathogenesis Top


Immunocompromised, poorly controlled diabetes, bone marrow transplant and hematological malignancies individuals are primarily affected.[7] Mucormycosis is commonly found on bread mold, decaying vegetation and soil. Even the healthy person may show this fungal infection, when cultures of swab are obtained from oral cavity, nasal cavity, throat and stools. After entering the host tissues, the fungi germinates to form hyphae and this hyphae brings about the start of the clinical symptoms. Impaired phagocytic function leads to ischemia, infarction and tissue necrosis as there is an increase in the levels of hyphae.[8] Elevated levels of iron also promotes the growth of mucormycosis. Patients with elevated iron levels are at a higher risk of getting mucormycosis.[9]


  Risk Factors Top


Acquired immunodeficiency syndrome, organ transplant, uncontrolled diabetes mellitus, cancers, prolonged use of corticosteroids, cirrhosis, immunosuppressive therapy are the major risk factors for mucormycosis but some cases with no predisposing risk factors have also been reported.[10] Patients with COVID-19 are usually treated with corticosteroids which is an immunosuppressant and it also increases the levels of blood sugar in both diabetic and nondiabetic patients which may contribute to increase the risk for mucormycosis.[11]


  Clinical Features Top


Mucormycosis is divided into five types: sinus and brain mucormycosis, lung mucormycosis, digestive mucormycosis, skin mucormycosis, and disseminated mucormycosis.[5] The quick onset of tissue necrosis with or without fever is a hallmark clinical indication of mucormycosis. Mobile teeth, halitosis, dental pain, palatal ulceration, intraoral draining sinuses, nasal stuffiness, nasal discharge with epitaxis, black purulent discharge, erythema of nasal mucosa, one-sided facial swelling, facial erythema, black discoloration of skin, periorbital erythema and edoema, orbital pain, ptosis, diplopia, fever, and all of these are signs and symptoms of mucormycosis.[3]

Transmission

Inhalation, inoculation, or ingestion of spores from the environment are the most common methods of transmission. The majority of cases are sporadic. Adhesive bandages, wooden tongue depressors, hospital linens, negative pressure rooms, water leaks, inadequate air filtering, nonsterile medical devices, and building construction have all been connected to healthcare-related outbreaks.


  Diagnosis Top


Radiographic diagnosis of mucormycosis

The earlier mucormycosis is detected, the more effectively it can be treated. Because this life-threatening disease necessitates rapid and aggressive treatment, early imaging is essential for determining the amount of the disease's involvement.[12] The gold standard for radiographic diagnosis is gadolinium enhanced magnetic resonance imaging, with computed tomography-paranasal sinuses (PNS) with contrast serving as adjuvant imaging.[13]

Features on computed tomography-paranasal sinuses

Mucosal thickening, inflammation of nasal turbinate, bony erosion, fluid filled sinus, sequestered bone.

Features on magnetic resonance imaging

On T2 weighted images, there is a perisinusal spread, a black turbinate sign, a high intensity signal in a fat suppressed T2 picture in the pterygoid bone, osseous erosion as a T2 weighted hypointense signal, and mucosal thickening. Marrow edoema and fat plane augmentation around the maxillary antrum, as well as soft tissue enlargement around the orbital apex and pterygopalatine fossa. With peripheral enhancement, meningeal enhancement and cerebral parenchymal signal change.

Lab investigations for diagnosis of mucormycosis

C-reactive protein (CRp) level, negative galatomannan and beta glucan test, biopsy (50% tissue in saline for fungal culture, 50% tissue in 10% formalin for histopathology).[14],[15] H and E (hematoxyline), periodic acid–schiff (per iodic schiff), and Grocott's methanamine silver (GMS) were used to perform histopathology. GMS staining reveals if the hyphae are septate (or) nonseptate. Histological sections were used to identify hyphae, but only culturing was used to determine the actual species.

Protocol for prevention of mucormycosis in a COVID-19 patient

  1. Diagnosis of glycemic control on admission using glycated hemoglobin
  2. Judicious use of Steroid and Toclizumab
  3. Blood Sugar level monitoring and maintenance (110–180 mg/dl)
  4. Hygiene maintenance of O2 delivery system and use of distilled water in Humidifiers
  5. Ear, nose and throat/oral and maxillofacial surgery ENT/OMFS evaluation of patient on day 3, day 7 and before hospital discharge (nasal endoscopy, biopsy, deep nasal swab for fungal culture can be done in suspected cases)
  6. Nasal saline spray twice daily
  7. Application of Amphotericin B gel intranasally for high risk patients.


Protocol for prevention of mucormycosis in post-COVID patient

  1. Maintenance of oral hygiene and use of 2% povidone Iodine Gargles
  2. Steam inhalation to improve ciliary function and sinus health.
  3. Use of 0.5% Betadine nasal irrigation
  4. Patient education regarding early signs and symptoms of mucormycosis leading to early reporting
  5. Strict Glycemic control
  6. All nonemergency dental operations should be avoided for the first 3 months following COVID 19 infection.
  7. Use of Vitamin E 1000 IU tablets,[16] Vitamin A 6000 IU tablets,[17] B-complex tablets, and a high-protein, low-sugar diet.



  Management Top


Medical management

First line antifungal therapy

Amphotericin B therapy (Injection Liposomal Amphotericin B, Injection Amphotericin B lipid complex, Injection Amphotericin B Deoxycholate). The usual startind dose is 5 mg/kg of Injection Liposomal Amphotericin B, Injection or Amphotericin B lipid complex.

Second line antifungal therapy-1

Isavuconazole (Injection/Tablet) loading doses of 200 mg are necessary for the first 48 h for every 8 h for 6 doses followed by 200 mg once daily after the last loading dose 2. Posaconazole (tablet) 300 mg every 12 h on 1st day then 300 mg once daily.

Surgical management

It includes aggressive clearance of pathologic tissue to make healthy tissue bed for perfusion of anti-fungal therapy. Role of maxillofacial surgeon in clearance of pathologic tissue while the role of prosthodontist for reconstruction and rehabilitation post mucormycosis surgery. Resection of involved jaw bone by Maxillectomy, Mandibulectomy, Caldwell-Luc operation for maxillary sinus debridement, resection of zygomatic bone. Use of free vascular grafts/regional soft tissue flaps for reconstruction and use of zygomatic implants for dental rehabilitation in indicated cases.


  Role of Dentist in Prevention And Management of Mucormycosis Top


  1. Note down patient's chief complaint and ask for symptoms related to nasal cavity, PNS, nasal discharge, ophthalmic pain or vision disturbance
  2. Take History of COVID-19 infection, requirement of admission, steroid use
  3. Evaluate patient's discharge file for deranged blood markers like ferritin and CRP and raised blood sugar levels
  4. Evaluate patient's oral cavity for red flags
  5. Draining sinus should be suspected as mucormycosis in COVID-19 recovered patient
  6. Avoid rushing into extraction of mobile teeth in COVID-19 recovered patient without complete evaluation
  7. If intraoral draining sinus is present then send pus for KOH mount and fungal culture
  8. Keep low threshold of diagnosis for mucormycosis
  9. Take immediate OMFS/ENT opinion for suspected cases
  10. No prophylactic anti-fungal therapy is required as per ICMR guidelines[18]
  11. Mucormycosis patient's require a team approach of ENT, OMFS and ophthalmologist with in-patient hospital care
  12. Do not delay specialist's opinion and treat patients with facial or jaw related pain with antibiotics and analgesic therapy as this is a fast spreading disease and time is of utmost importance.



  Conclusion Top


To cease the rise of mucormycosis, early diagnosis and management becomes the crucial step in this time of COVID-19 pandemic. Dentist plays a huge role in the management of the outbreak of this fungal infection and acts as an important lethal weapon in making the early diagnosis possible. This fatal fungal infection can be managed with minimum morbidity and mortality with help of early diagnosis and the preventive measures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Richardson M, Lass-Flörl C. Changing epidemiology of systemic fungal infections. Clin Microbiol Infect 2008;14 Suppl 4:5-24.  Back to cited text no. 1
    
2.
Nagy E. Changing epidemiology of systemic fungal infections and the possibilities of laboratory diagnostics. Acta Microbiol Immunol Hung 1999;46:227-31.  Back to cited text no. 2
    
3.
Samaranayake LP, Leung WK, Jin L. Oral mucosal fungal infections. Periodontol 2000 2009;49:39-59.  Back to cited text no. 3
    
4.
Carmello JC, Alves F, G Basso F, de Souza Costa CA, Bagnato VS, Mima EG, et al. Treatment of oral candidiasis using Photodithazine®-mediated photodynamic therapy in vivo. PLoS One 2016;11:e0156947.  Back to cited text no. 4
    
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Prakash H, Chakrabarti A. Global epidemiology of mucormycosis. J Fungi (Basel) 2019;5:26.  Back to cited text no. 5
    
6.
Garg D, Muthu V, Sehgal IS, Ramachandran R, Kaur H, Bhalla A, et al. Coronavirus disease (Covid-19) associated mucormycosis (CAM): Case report and systematic review of literature. Mycopathologia 2021;186:289-98.  Back to cited text no. 6
    
7.
Vučićević Boras V, Jurlina M, Brailo V, Đurić Vuković K, Rončević P, Bašić Kinda S, et al. Oral mucormycosis and aspergillosis in the patient with acute leukemia. Acta Stomatol Croat 2019;53:274-7.  Back to cited text no. 7
    
8.
Ibrahim AS, Spellberg B, Walsh TJ, Kontoyiannis DP. Pathogenesis of mucormycosis. Clin Infect Dis 2012;54 Suppl 1:S16-22.  Back to cited text no. 8
    
9.
Hingad N, Kumar G, Deshmukh R. Oral mucormycosis causing necrotizing lesion in a diabetic patient: A case report. Int J Oral Maxillofac Pathol 2012;3:8-13.  Back to cited text no. 9
    
10.
Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis 2005;41:634-53.  Back to cited text no. 10
    
11.
Koehler P, Bassetti M, Chakrabarti A, Chen SC, Colombo AL, Hoenigl M, et al. Defining and managing COVID-19-associated pulmonary aspergillosis: The 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2021;21:e149-62.  Back to cited text no. 11
    
12.
Therakathu J, Prabhu S, Irodi A, Sudhakar SV, Yadav VK, Rupa V. Imaging features of rhinocerebral mucormycosis: A study of 43 patients. Egypt J Radiol Nucl Med 2018;49:447-52.  Back to cited text no. 12
    
13.
Lone PA, Wani NA, Jehangir M. Rhino-orbito-cerebral mucormycosis: Magnetic resonance imaging. Indian J Otol 2015;21:215.  Back to cited text no. 13
  [Full text]  
14.
Chander J, Kaur M, Singla N, Punia RP, Singhal SK, Attri AK, et al. Mucormycosis: Battle with the deadly enemy over a five-year period in India. J Fungi (Basel) 2018;4:46.  Back to cited text no. 14
    
15.
Lamoth F. Galactomannan and 1, 3-β-d-Glucan testing for the diagnosis of invasive aspergillosis. J Fungi 2016;2:22.  Back to cited text no. 15
    
16.
Rizvi S, Raza ST, Ahmed F, Ahmad A, Abbas S, Mahdi F. The role of vitamin e in human health and some diseases. Sultan Qaboos Univ Med J 2014;14:e157-65.  Back to cited text no. 16
    
17.
Natarajan S, Anbarasi C, Sathiyarajeswaran P, Manickam P, Geetha S, Kathiravan R, et al. Kabasura Kudineer (KSK), a poly-herbal Siddha medicine, reduced SARS-CoV-2 viral load in asymptomatic COVID-19 individuals as compared to vitamin C and zinc supplementation: Findings from a prospective, exploratory, open-labeled, comparative, randomized controlled trial, Tamil Nadu, India. Trials 2021;22:623.  Back to cited text no. 17
    
18.
Aranjani JM, Manuel A, Abdul Razack HI, Mathew ST. COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India. PLoS Negl Trop Dis 2021;15:e0009921.  Back to cited text no. 18
    




 

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  In this article
Abstract
Introduction
Pathogenesis
Risk Factors
Clinical Features
Diagnosis
Management
Role of Dentist ...
Conclusion
References

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