Role of Dentist in Diagnosis and Management of Mucormycosis in Association with COVID-19
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International Journal of Health Sciences and Research
DOI: https://doi.org/10.52403/ijhsr.20210722
Vol.11; Issue: 7; July 2021
Website: www.ijhsr.org
Review Article ISSN: 2249-9571
Role of Dentist in Diagnosis and Management of
Mucormycosis in Association with COVID-19
Piyush Dongre1, Tanya Bansal2
1
Post Graduate Trainee, Department of Prosthodontics and Crown & Bridge, DR R Ahmed Dental College and
Hospital, Kolkata-14
2
Post Graduate Trainee, Department of Conservative Dentistry, DR R Ahmed Dental College and Hospital,
Kolkata-14
Corresponding Author: Piyush Dongre
ABSTRACT
In surge of the novel corona virus, there is increase in the frequency of fungal infections.
Mucormycosis is one of the deep fungal infections which are increasing rapidly in this global
pandemic period. Thus the early diagnosis and management is of utmost importance to decline the
rate of this fatal infection. The clinical signs and symptoms and the culture reports are strictly
considered in the management of oral fungal infection. This review article focuses on the importance
of early diagnosis, prevention and management of mucormycosis and the role of the dentist in doing
so.
Keywords: Mucormycosis, diagnosis, management, dentist.
INTRODUCTION Rhizopus, Rhizomucor, Mucor, Saksenea,
Most of the fungal infections occur Cunninghamella are causative organisms for
due to opportunistic conditions depending mucormycosis. Most common type of
upon the resistance offered by the host. mucormycosis being rhino maxillary
Impairment of the host resistance may lead disease. [8] The black fungus has emerged as
to the initiation and later on progression of a new challenge for doctors. Mucormycosis
the pathogenic condition in the oral cavity has increased immensely after the surge in
through local colonization. As the incidence the viral infection, Covid-19. Post Covid
of the viral infections is increasing globally, mucormycosis cases are being reported
the frequency of the oral mycosis also massively. [18]
increasing rapidly. [1,2] Depending upon the This review focuses on the
severity, oral mycological conditions are diagnostic and therapeutic approaches to
divided into superficial and deep fungal mucormycosis of the oral cavity. Dictates
infections of the oral tissues. Slight oral the role of the dentist in the prevention and
discomfort, paraguesia, burning sensation management of this huge outbreak of fungal
are mostly seen in superficial fungal infection. All the data presented in this
infections while the deep fungal infections review was collected from available
are presented with ulcerations and also literature in PubMed and Google Scholar
perforations in the bony areas. [3,4] One of database.
the deep fungal infection which is rapidly
increasing in this time of covid-19 pandemic PATHOGENESIS
is Mucormycosis. Immunocompromised, poorly
Mucormycosis is also known as controlled diabetes, bone marrow transplant
‘black fungus’. Saprophytic fungi like and hematological malignancies individuals
International Journal of Health Sciences and Research (www.ijhsr.org) 159
Vol.11; Issue: 7; July 2021Piyush Dongre et.al. Role of dentist in diagnosis and management of mucormycosis in association with COVID-
19.
are primarily affected. [5] Mucormycosis is pain, ptosis, diplopia, fever, all of this are
commonly found on bread mold, decaying the red flags in mucormycosis.
vegetation and soil. Even the healthy person
may show this fungal infection when Transmission
cultures of swab are obtained from oral Transmission occurs through
cavity, nasal cavity, throat and stools. After inhalation, inoculation, or ingestion of
entering the host tissues, the fungi spores from the environment. Although,
germinate to form hyphae and these hyphae most cases are sporadic, healthcare-
bring about the start of the clinical associated outbreaks have been linked to
symptoms. Impaired phagocytic function adhesive bandages, wooden tongue
leads to ischemia, infarction and tissue depressors, hospital linens, negative
necrosis as there is an increase in the levels pressure rooms, water leaks, poor air
of hyphae. [6] Elevated levels of iron also filtration, non-sterile medical devices, and
promote the growth of mucormycosis. building construction.
Patients with elevated iron levels are at a
higher risk of getting mucormycosis. [7] DIAGNOSIS
Radiographic Diagnosis of mucormycosis
Risk Factors The earlier the mucormycosis is
AIDS, organ transplant, uncontrolled diagnosed, the better the infection can be
diabetes mellitus, cancers, prolonged use of treated. As this lethal disease requires
corticosteroids, cirrhosis, immunosuppr- prompt and aggressive treatment, early
essive therapy are the major risk factors for imaging is must in assessing the extent of
mucormycosis but some cases with no the involvement. [9] Gadolinium enhanced
predisposing risk factors have also been MRI is considered as the gold standard for
reported. [16] Patients with Covid-19 are radiographic diagnosis while CT-PNS with
usually treated with corticosteroids which contrast are the adjuvant imaging. [10]
are an immunosuppressant and it also
increases the levels of blood sugar in both Features on CT-PNS
diabetic and non diabetic patients which Mucosal thickening, inflammation of
may contribute to increase the risk for nasal turbinate, bony erosion, fluid filled
mucormycosis. [17,18] sinus, sequestered bone.
CLINICAL FEATURES Features on MRI
Mucormycosis are of five types Perisinusal spread on T2 weighted
mainly Mucormycosis of the sinuses and images, black turbinate sign which is the
brain, Mucormycosis of the lung, first sign, high intensity signal in fat
Mucormycosis of the digestive tract, suppressed T2 image in pterygoid bone,
Mucormycosis of the skin and Disseminated osseous erosion as T2 weighted hypointense
Mucormycosis. [8] A classic clinical sign of signal and mucosal thickening.
mucormycosis is the rapid onset of tissue
necrosis with or without fever. Various Lab Investigations for diagnosis of
signs and symptoms include: Mobile teeth, Mucormycosis
halitosis, dental pain, palatal ulceration, Deep nasal swab for KOH smear and
intra oral draining sinuses, nasal stuffiness, fungal culture, CRP level, negative
nasal discharge with epistaxis, black galatomannan and beta glucan test, biopsy
purulent discharge, erythema of nasal (50% tissue in saline for fungal culture, 50%
mucosa, one sided facial swelling, facial tissue in 10% formalin for histopathology)
[11,12]
erythema, black discoloration of skin,
periorbital erythema and edema, orbital
International Journal of Health Sciences and Research (www.ijhsr.org) 160
Vol.11; Issue: 7; July 2021Piyush Dongre et.al. Role of dentist in diagnosis and management of mucormycosis in association with COVID-
19.
Protocol for Prevention of Mucormycosis Surgical Management
in a Covid -19 patient It includes Aggressive clearance of
1. Diagnosis of glycemic control on pathologic tissue to make healthy tissue bed
admission using glycated hemoglobin for perfusion of anti-fungal therapy. Role of
(Hba1c) maxillofacial surgeon in clearance of
2. Judicious use of Steroid and pathologic tissue while the role of
Tocilizumab prosthodontists for reconstruction and
3. Blood Sugar level monitoring and rehabilitation post mucormycosis surgery.
maintenance (110-180 mg/dl) Resection of involved jaw bone by
4. Hygiene maintenance of O2 delivery Maxillectomy, Mandibulectomy, Caldwell-
system and use of distilled water in Luc operation for maxillary sinus
Humidifiers debridement, resection of zygomatic bone.
5. ENT/OMFS evaluation of patient on day Use of free vascular grafts/regional soft
3, day 7 and before hospital discharge tissue flaps for reconstruction and use of
(Nasal endoscopy, Biopsy, Deep nasal zygomatic implants for dental rehabilitation
swab for fungal culture can be done in in indicated cases.
suspected cases)
6. Nasal Saline Spray twice daily ROLE OF DENTIST IN PREVENTION
7. Application of Amphotericin B gel AND MANAGEMENT OF
intranasally for high risk patients MUCORMYCOSIS
1. Note down patient’s chief complaint and
Protocol for Prevention of Mucormycosis ask for symptoms related to nasal cavity,
in post-Covid patient:- paranasal sinuses, nasal discharge,
1. Maintenance of Oral hygiene and Use of ophthalmic pain or vision disturbance.
2% povidone Iodine Gargles. 2. Take History of Covid-19 infection,
2. Steam inhalation to improve ciliary requirement of admission, steroid use.
function and sinus health. 3. Evaluate patient’s discharge file for
3. Use of 0.5% Betadine Nasal Irrigation deranged blood markers like ferritin and
4. Patient education regarding early signs CRP and raised blood sugar levels
and symptoms of mucormycosis leading 4. Evaluate patient’s oral cavity for red
to early reporting. flags.
5. Strict Glycemic control 5. Draining sinus should be suspected as
6. Defer non-emergency invasive oral or mucormycosis in Covid-19 recovered
dental procedure for 3 months after patient.
Covid 19 infection. 6. Avoid rushing into extraction of mobile
7. Use of Tablet Vitamin E 1000IU Tablet teeth in Covid-19 recovered patient
[13]
Vitamin A 6000IU [14], B-complex without complete evaluation.
tablets and high protein low sugar diet. 7. If intraoral draining sinus is present then
send pus for KOH mount and fungal
MANAGEMENT culture.
Medical Management:- 8. Keep low threshold of diagnosis for
First Line Antifungal Therapy- mucormycosis.
Amphotericin B Therapy (Inj.Liposomal 9. Take immediate OMFS/ENT opinion for
Amphotericin B,Inj. Amphotericin B lipid suspected cases.
complex,Inj Amphotericin B Deoxycholate) 10. No prophylactic anti-fungal therapy is
Second Line Antifungal Therapy- 1. required as per ICMR guidelines. [15]
Isavuconazole (Injection/Tablet) 2. 11. Mucormycosis patients require a team
Posaconazole (Tablet) approach of ENT, OMFS and
Ophthalmologist with in-patient hospital
care.
International Journal of Health Sciences and Research (www.ijhsr.org) 161
Vol.11; Issue: 7; July 2021Piyush Dongre et.al. Role of dentist in diagnosis and management of mucormycosis in association with COVID-
19.
12. Do not delay specialist’s opinion and mucormycosis. Clinical Infectious Diseases.
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CONCLUSION 8. Prakash H, Chakrabarti A. Global
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Conflict of Interest: None https://www.indianjotol.org/article.asp?issn
=0971-
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215;epage=218;aulast=Lone
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