Oral status of outpatients in Suining Central Hospital in post-epidemic era

doi:10.21203/rs.3.rs-3231031/v1

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Research Article

Oral status of outpatients in Suining Central Hospital in post-epidemic era

https://doi.org/10.21203/rs.3.rs-3231031/v1

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Background

To investigate the oral status of COVID-19 positive groups in Suining City under the comprehensive implementation of epidemic prevention and control, analyze the prognostic characteristics and related influencing factors, and understand the residual symptoms after recovery from COVID-19 infection in the post-epidemic era, so as to provide reference for the treatment of patients in the post-epidemic era.

Methods

Based on a 25-question online questionnaire survey, the oral status and prognosis of COVID-19 positive groups in Suining City were reviewed after the comprehensive implementation of epidemic prevention and control measures.

Results

1768 valid questionnaires were collected. The data showed that 363 people had oral problems after an infection with novel coronavirus. The oral problems after SARS-CoV‐2 infection mainly focused on gingiva swelling or bleeding (38.57%), toothache (37.74%), oral ulcer (30.30%), bad breath (27.55%), abnormal taste (24.24%) and some infected people had a variety of oral symptoms. A small number of infected people also showed dry mouth, herpes around the mouth, maxillofacial swelling, tongue pain and numbness, dry lip peeling, oral lichen planus, tongue coating black, tongue coating thick white oral symptoms. The incidence of oral symptoms was significantly correlated with sex, age, educational level, place of residence, smoking, basic diseases, long-term saline gargle and vaccination of COVID-19 vaccine. In addition, the age, place of residence, smoking history, basic diseases, and vaccination also showed significant differences in prognosis.

Conclusion

In the post-epidemic era, the most common oral problems are gingiva swelling or bleeding, toothache, bad breath, oral ulcer, and abnormal taste. And maintaining good living habits is the basis for promoting disease recovery and oral health.

SARS-CoV‐2 infection

Post-epidemic era

Oral health

Disease prognosis

At the end of 2019, unexplained pneumonia suddenly appeared in Wuhan, China, and spread rapidly, resulting in many people with fever, fatigue, cough, and even severe dyspnea and other clinical symptoms. Studies found that it was caused by β novel coronavirus infection.[1] At the beginning of the epidemic, about half of the patients will have dyspnea in the week after infection, and in severe cases, there will also be serious complications such as acute respiratory distress syndrome and septic shock. [2] At the end of 2022, China reached the peak of the epidemic, with the number of infected people everywhere surging. During the novel coronavirus epidemic, the Omicron-mutated strain was the most infected strain for most infected people in China. The virulence of this strain was significantly reduced, but infectivity increased. The main manifestations of infected persons are cough, fever, sore throat, general soreness, fatigue, etc. Only a small number of infected persons will progress to pneumonia.[3] After fully assessing the epidemic characteristics and evolution of the virus, China further optimized and adjusted the epidemic prevention policy, proposed to fully liberalize epidemic prevention and control measures in China, and implemented the optimization and adjustment of "Class B and B tube", marking a new stage of epidemic prevention and control. According to the public information on the epidemic situation, the infection rate in Suining City reached a peak on December 27, 2022, becoming the first epidemic peak after the opening of the epidemic prevention and control policy. In the new round of epidemic, the new variant strain has also produced higher and more lasting viral load in the mouth and nasal cavity, resulting in frequent oral problems. The most common symptoms of oral cavity are taste disorder, dry mouth and oral mucous membrane lesions.[4] As more and more research reports on the oral symptoms of COVID-19 patients reveal oral problems after infection, for example, periodontitis.[5–7] Salivary gland inflammation,[8] oral candidiasis,[9] oral ulcer,[10] oral herpes,[11] oral lichen planus,[12] "novel coronavirus tongue".[13] The oral tissues and microenvironment provide a good habitat for the novel coronavirus, and the production of oral secretions, aerosols and droplets accelerates the transmission of the virus.[14] Although the peak of the epidemic in China has passed by the end of 2022, a large number of secondary infections have been reported in major Chinese provinces since April 2023. Therefore, the harm of the epidemic and the disease still exists, and many infected people still have residual symptoms after recovery. At present, there is still a lack of research on the related factors affecting the oral performance of COVID-19 infected patients, and there is also a lack of prognosis analysis of infected people in the post-epidemic era. Therefore, to pay attention to the oral health and prognosis of positive infections, an online questionnaire survey was conducted in this study.

2.1 Study design and survey subjects

This study adopts retrospective investigation and analysis, taking the outpatients in Suining Central Hospital of Sichuan Province as the research objects. The subjects were positive patients who had recovered from SARS-CoV-2 infection or were in the stage of infection. The subjects included permanent residents in the central urban area, suburbs, and rural areas of Suining city. Random sampling was conducted among people of different genders, ages, places of residence, degrees of education and occupations. Using WeChat scanning QR code, following the principle of voluntary participation, obtaining the consent of the respondents, and telling the questionnaire to fill in the anonymous way.

2.2 Questionnaire construction and collection

The questionnaire consisted of 25 questions, which were divided into three parts: (1) general information (including gender, age, education level, occupation category, residence, and basic diseases) (2) living habits (including smoking history, drinking history, oral habits, etc.) (3) vaccination information, infection symptoms, measures, and prognosis after infection. The questionnaire was collected by scanning the two-dimensional code of "WeChat". The survey was conducted from 4 January 2023 to 24 January 2023 and a total of 1768 valid questionnaires were collected.

2.3 Statistical Processing

SPSS20.0 statistical software is used to analyze the data. Chi-square test was used to analyze the prevalence, healing rate and residual symptom prevalence rate of oral symptoms in COVID-19 "positive" infected people under different demography and habits. When p＜0.05, there was statistical difference.

Among the 1768 questionnaires collected, 40.50% were males and 59.50% were females. The main age stages were 20 to 40 years of age (60.35%), 40 to 60 years of age (18.38%) and 14 to 20 years of age (11.71%). Educational level concentrated on bachelor's degree or above (48.81%). Occupations involve students (30.37%), individual private business (13.24%), (13.24%), enterprises and institutions (11.93%), medical workers (11.71%). Residential areas were concentrated in cities and towns (73.93%). Among the participants, 344 (19.46%) had a history of smoking and 489 (27.66%) had a history of drinking. A total of 1080 people (61.09%) had been fully vaccinated against COVID-19 before becoming infected.

3.1 Non-oral symptoms of COVID-19 's "positive" population

In this survey, the infection time of positive patients living in rural areas was significantly later than that in urban areas (p < 0.05). Figure 1 shows the first symptoms of "positive" COVID-19 patients, mainly manifested as body soreness (26.02%), fever (25.45%) and sore throat (22.62%). The number of male patients with fever, cough and expectoration during infection was significantly higher than that of female patients, the number of women with sore throat was higher than that of men (p < 0.05). There was no substantial difference in other first symptoms.

3.2 Oral symptoms of COVID-19 positive groups

The results of this study showed that 363 people had oral problems after infection with novel coronavirus, accounting for 20.53% of the total number of people surveyed.

The oral problems after COVID-19 infection mainly focused on gingiva swelling or bleeding (38.57%), toothache (37.74%), bad breath (27.55%), oral ulcer (30.30%) and abnormal taste (24.24%). A small number of infected people also had other oral problems. Such as dry mouth, herpes around the mouth, maxillofacial swelling, tongue pain and numbness, dry and peeling lips, oral lichen planus, black tongue coating, thick and white tongue coating, and other problems.

The results of this survey showed that the prevalence of oral symptoms of COVID-19 was significantly correlated with different genders, different ages, different educational levels, different places of residence, whether there was a history of smoking, whether there was a history of drinking alcohol, whether there were basic diseases, whether there was a long-term gargle habit of salt water and COVID-19 vaccination status (p＜0.05).Table 1 shows the oral prevalence of COVID-19 with different demographic characteristics and living habits. Men are more likely to have oral problems than women; COVID-19 patients aged 60 years or older were more likely to have oral problems, and among different age groups, except the 14–20 years old group, the oral prevalence was higher than the 20–40 years old group. Those with junior high school education below junior high school are more likely to have oral problems than those with college or above, and with the increase of academic qualifications, the number of oral problems showed a decreasing trend. People infected with COVID-19 in rural areas are more likely to show oral symptoms than those in urban areas; people who had underlying medical conditions before infection were more likely to have oral problems than other cases; under different living habits, the prevalence of oral problems in smoking and drinking cases was higher than those in non-smoking and non-drinking cases, and the prevalence of oral problems in those who used salt water gargling before infection was also significantly higher than those who did not. From the vaccination situation, it is shown that the incidence of oral symptoms is higher in the cases of unvaccinated and not fully vaccinated than in the complete vaccination cases.

Table 1

Incidence of oral symptoms after novel coronavirus infection
	Incidence of oral symptoms (%)
	Have oral symptoms	No oral symptoms		P
Sex			p＜0.05
Male	26.54	73.46
Female	16.44	83.56
Age			p＜0.05
Age < 14	31.58*	68.42
14 ≥ Age < 20	16.91*	83.09
20 ≥ Age < 40	15.93	84.07
40 ≥ age < 60	26.46*	73.54
Age ≥ 60	56.76*	43.25
Different cultural stages			p＜0.05
College degree and below	29.01*	70.99
College degree or above	23.24*	76.76
Bachelor degree or above	15.06	84.94
Different places of residence			p＜0.05
countryside	29.72	70.28
cities and towns	17.29	82.71
Smoking			p＜0.05
Yes	38.66	61.34
No	16.15	83.85
Alcohol			p＜0.05
Yes	26.38	73.62
No	18.30	81.70
COVID-19 vaccination status			p＜0.05
Nonvaccinated	28.95*	71.05
Not fully vaccinated	31.38*	68.62
Complete vaccination	13.70	86.30
Underlying disease or not			p＜0.05
Yes	31.75	68.25
No	18.51	81.49
Gargle with salt			p＜0.05
Yes	49.42	50.58
No	15.62	84.38

(In different age groups, each group was compared with the age group of "20 ≥ age < 40 ",p＜0.05 was represented by "*"; In different cultural stage groups, each group was compared with the "undergraduate and above" group, p＜0.05 was represented by "*"; In the vaccination situation group, the comparison between each group and the "complete vaccination" group was conducted, and p＜0.05 was represented by "*")

3.3 Analysis of prognosis and related influencing factors of "positive" infection group

By the end of the investigation, 75.11% of the subjects had been recoveryed, but some patients still had cough and expectoration (10.07%), dry cough and no sputum (11.37%), fatigue and weakness (9.11%), decreased taste and smell (7.64%), and decreased hearing (4.41%), headache (3.28%) and other related symptoms (2.88%). The prognosis of infection cases was related to age, place of residence, smoking history, underlying diseases, and vaccination status of the subjects (p < 0.05). There was no significant correlation between the prognosis of the subjects and their occupation, gender, drinking history, cultural level, initial symptoms, and post-infection coping measures. As shown in Table 2: Among different age groups, the recovery rate of infected persons between 20 and 40 years old is the best, followed by those between 40 and 60 years old, and the recovery rate of elderly infected persons over 60 years old is the lowest. In different places of residence, the recovery rate of rural infected persons was lower than that of urban residents. From the healing rate of yes and no smoking, it is obvious that the healing rate of infected people with bad smoking habits is lower than that of non-smoking group. In addition, the cases with a history of smoking after the recovery of infection are more likely to continue to develop cough and sputum, dry cough without sputum, fatigue, taste, and smell loss residual symptoms. According to the analysis of prognosis results of whether the subjects had underlying diseases and infection, the healing rate of the subjects who had underlying diseases such as diabetes, hypertension and heart disease before infection was lower than that of those without underlying diseases, and the incidence of residual symptoms after recovery was about twice as high as that of those without underlying diseases. The results related to the prognosis of the study subjects and the situation of COVID-19 vaccination showed that the recovery rate of those who completed the full course of vaccination was 15% higher than that of those who did not receive the vaccine, and the rate of residual symptoms after recovery of those who completed the full course of vaccination was lower than that of those who did not receive the vaccine.

Table 2

The healing rate of COVID-19 patients with different demographic characteristics and different living habits
		The healing rate(%)
	Total number of persons	Complete recovery from illness	There are still residual symptoms	P
Different age groups				P＜0.05
Age < 14	95	53.68*	46.32
14 ≥ Age < 20	207	59.90*	40.10*
20 ≥ Age < 40	1067	82.29	17.71
40 ≥ age < 60	325	73.23*	26.77
Age ≥ 60	S74	50.00*	50.00
Different places of residence				P＜0.05
Countryside	461	67.03	32.97
Cities and towns	1307	77.96	22.04
Smoking				P＜0.05
Yes	344	67.73	32.27
No	1424	76.90	23.10
Underlying disease or not				P＜0.05
Yes	126	58.73	41.27
No	1561	77.90	22.10
COVID-19 vaccination status				P＜0.05
Nonvaccinated	38	63.16*	36.84
Not fully vaccinated	650	68.46*	31.54
Complete vaccination	1080	79.54	20.46

(In different age groups, each group was compared with the age group of "20 ≥ age < 40 ", p＜0.05 was represented by "*"; In the vaccination situation group, the comparison between each group and the "complete vaccination" group was conducted, p＜0.05 was represented by "*")

According to the data analysis of the respondents in this survey, most of the COVID-19 positive patients showed various systemic symptoms, including fever, abnormal taste, body aches, cough, and sore throat, and only 4.8% of the cases had no obvious symptoms. Among the first symptoms, the gender difference in fever and cough and expectoration may be due to the difference in life between men and women. Among the participants, the number of men with a smoking history was about 2.8 times that of women. A large number of studies have shown that smoking is a risk factor for many respiratory diseases.[15, 16] Long-term stimulation of nicotine and smoke can lead to inflammation of respiratory mucosal cells and affect their phagocytosis ability. Reduced ciliated movement in the respiratory tract leads to a decrease in immune capacity, thus increasing the risk of inflammation in the upper respiratory tract.[17] The results of this study showed that smoking not only affected the first symptoms of "positive" infected people, but also increased the prevalence rate of oral problems. In addition, the cases with a history of smoking after the recovery of infection are more likely to continue to develop cough and sputum, dry cough without sputum, fatigue, taste, and smell loss residual symptoms.

In this study, the common oral problems in cases infected with SARS-CoV‐2 were similar to the results of Lin et al[4] The oral symptoms of "positive" infected persons are mainly concentrated in abnormal taste, gingiva red swelling or bleeding, toothache and bad breath. The development of their oral symptoms is significantly related to the different demographic characteristics and different living habits of the population. Tomo also showed that a history of smoking, poor oral hygiene and oral diseases can affect the oral status of patients infected with COVID-19.[18]

Sakaguchi et al[19]showed that the tongue and taste buds are not only the targets for SARS-CoV-2, but also the repository. Therefore, SARS-CoV-2 can act on human taste buds, which can lead to local inflammation and edema of the tongue, and damage the normal function of taste buds.[20] Some scholars have also suggested that the abnormal taste after infection with the novel coronavirus may be related to peripheral nerve tropism and direct toxicity of the virus to olfactory epithelium.[21] In this study, most of the abnormal tastes lasted for more than seven days. 24.77% of the infected people said that they felt the taste was too weak when they ate food, and even 23.08% of the infected people felt that there was no taste. Some of them also felt bitter, salty, and other taste changes when eating. According to the analysis of different demographic characteristics and living habits, the change of taste has no substantial correlation with the age, gender, and occupation of "positive" infected persons. The study of EI Kady et al[22]also shows that there is no significant correlation. However, the proportion of abnormal taste of infected people living in rural areas is much higher than that of urban residents, and the main taste abnormalities are bitter, bland taste when eating. This may be related to dietary differences, rural residents ' long-term use of a large amount of salt and condiments pickled food, such as cured meat, preserved vegetables and so on.[23] Those infected with smoking and drinking were more likely to have abnormal taste than those without smoking and drinking. Most of the infected men had bad living habits such as smoking and drinking, which is the main reason why men had more oral problems than women in this study. Agarwal et al[24]research results showed that long-term smoking, drinking and other adverse factors stimulate the taste buds for a long time, which will make our taste function insensitive. The results of this study are consistent with that. More than half of the infected people who smoke and drink alcohol said that the taste of food was weak or even had no taste. In addition, in the long-term use of saline gargling habit of infected people, 80 percent of cases developed abnormal taste.

According to the research results of Fernandes, it showed that periodontal tissue SARS-CoV-2 can be detected in death cases of SARS-CoV‐2 infection.[25] Yatsenko et al[26] also indicated that abundant molecules necessary for SARS‐CoV‐2 infection were expressed in the oral cavity, such as angiotensin-convert enzyme 2(ACE2), and were highly expressed in gums and salivary glands. As the host receptor of SARS-CoV-2, ACE2 binds with corresponding proteins to promote the entry of novel coronavirus into host cells and accelerate the release of viral pro-inflammatory cytokines, thus accelerating gingiva and periodontal infection.[27] Among the subjects in this survey, the duration of toothache, periodontal and gum problems was mostly 1–3 days, and there was no significant difference in duration and incidence among people with different genders, ages, occupations, alcohol consumption and underlying diseases. However, in the study of Campisi et al,[7] the pathogenesis of periodontal diseases is related to gender, and the incidence of periodontal diseases is more in males than in females, and those with underlying diseases are more likely to have periodontal infections. The results of this study showed that compared with those without smoking history, those with smoking history were more likely to suffer from gingiva swelling, bleeding, toothache and other symptoms (p = 0.015), which was consistent with the study of Gupta et al.[5]

Most infected people have bad breath for 1–3 days. There was a significant correlation between different places of residence(p = 0.025), vaccination status (p = 0.028), long-term saltwater gargle habits(p = 0.038) and bad breath. Infected people living in rural areas are more likely to develop bad breath after infection with COVID-19, which may be related to poor oral "knowledge, belief and practice" ability of rural residents, poor oral health care awareness, and poor oral hygiene. Recent studies have shown that rural families have weak oral health awareness and poor oral health status.[28] From the analysis of vaccination situation, it is found that people who are not vaccinated are more likely to have halitosis than those who have been vaccinated, but it has no significant correlation with whether or not to complete the whole vaccination. Those who gargled with salt water were significantly more likely to develop bad breath after infection than those who did not. Some scholars have shown that although gargling with salt water can clean the mouth, it can change the PH value of the oral cavity for a long time and affect the secretion of saliva in the oral cavity, thus affecting the scouring ability of oral cavity to viruses.[29]

As for the difference in prognosis of SARS-CoV‐2 infection, the healing rate of those aged between 20 and 40 was the highest among different age groups. Young and middle-aged people have various positive factors conducive to the recovery of the disease, the body's strong immune ability and high vaccination rate, so that they have a strong ability to resist the virus invasion. From the analysis of the recovery of infection cases in rural and urban areas, it is speculated that the lower recovery rate in rural areas may be related to the fact that the rural population is infected later than the urban population and the rural vaccination rate is lower than the urban population. According to the analysis of infection cases with basic diseases, it is concluded that the recovery cycle of such patients is relatively long, which may be associated with the long-term existence of basic diseases to damage the autoimmune system. From the situation of SARS‐CoV‐2 infection, we know that COVID-19 vaccine can not only promote the recovery after infection, but also reduce the probability of residual symptoms after SARS‐CoV‐2 infection rehabilitation. This may be related to the ability of binding antibodies and neutralizing antibodies produced by infected people after vaccination, which further indicates that vaccination has a high protective rate.[30]

According to the results of this study, it can be seen that bad habits such as smoking and drinking in "positive" infected people can affect the prevalence of oral symptoms and prognosis, and maintaining good living habits is the basis for promoting disease recovery and promoting oral health. The differences of oral symptoms and prognosis in different places of residence also suggest that we should pay attention to the disease of rural population and the lack of knowledge of oral health care. However, this study area is limited to a single province, thus limiting the scope of the study. With different strains of infection in different regions, there may be deviations in prognosis, so the difference between different provinces is not known. In addition, there may be differences in living habits among "positive" infected people in different regions. The bad living habits involved in this study are limited to smoking, drinking and saltwater gargling, and the effects of more detailed habits on the prognosis and oral cavity of COVID-19 have not been collected.

Acknowledgements

The authors would like to thank the participants who took part in this study.

Ethics approval and consent to participate

The questionnaire of this subject follows the principle of voluntary participation and is filled in voluntarily after obtaining the consent of the respondents. No ethical approval was required.

Consent for publication

The content of the manuscript has been reviewed and approved by all authors, and has been consented to the publication of the study in your journal.

Availability of data and materials

The dataset supporting the conclusions of this article is included within the article , and data sets used and analyzed in this study may also be reasonably requested from corresponding authors.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Funding information

Science and Technology Project of Sichuan Provincial Health Commission (Appropriate Technology Base), Grant/Award Numbers: 2022JDXM021; The Primary Health Development Research Center of Sichuan Province Program, Grant/Award Numbers: SWFZ20-C-086; Provincial Science and Technology Plan Project of Sichuan Science and Technology Department, Grant/Award Numbers:2022SNZY001

Authors' contributions

Tengmin Gao was mainly involved in questionnaire design, questionnaire data collection and analysis, and writing original draft. Yigui Wang participated in the questionnaire collection and data analysis. Two professors, including Lijuan Guo and Sen Yang, supervised the writing process of this article and revised the original manuscript.

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No competing interests reported.

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Oral status of outpatients in Suining Central Hospital in post-epidemic era

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Abstract

Figures

1. Background

2. Methods

2.1 Study design and survey subjects

2.2 Questionnaire construction and collection

2.3 Statistical Processing

3. Results

3.1 Non-oral symptoms of COVID-19 's "positive" population

3.2 Oral symptoms of COVID-19 positive groups

3.3 Analysis of prognosis and related influencing factors of "positive" infection group

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

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