Dental and Oral Manifestations of COVID-19 Related Mucormycosis: Diagnoses, Management Strategies and Outcomes

Abstract

It has been nearly two years since the pandemic caused by the novel coronavirus disease (COVID-19) has affected the world. Several innovations and discoveries related to COVID-19 are surfacing every day and new problems associated with the COVID-19 virus are also coming to light. A similar situation is with the emergence of deep invasive fungal infections associated with severe acute respiratory syndrome 2 (SARS-CoV-2). Recent literature reported the cases of pulmonary and rhino-cerebral fungal infections appearing in patients previously infected by COVID-19. Histopathological analysis of these cases has shown that most of such infections are diagnosed as mucormycosis or aspergillosis. Rhino-orbital-cerebral mucormycosis usually affects the maxillary sinus with involvement of maxillary teeth, orbits, and ethmoidal sinuses. Diabetes mellitus is an independent risk factor for both COVID-19 as well as mucormycosis. At this point, there is scanty data on the subject and most of the published literature comprises of either case reports or case series with no long-term data available. The aim of this review paper is to present the characteristics of COVID-19 related mucormycosis and associated clinical features, outcome, diagnostic and management strategies. A prompt diagnosis and aggressive treatment planning can surely benefit these patients.

Keywords: SARS-CoV-2; aspergillosis; fungal infection; mucormycosis; oral mucormycosis.

Figure 1

Pathogenesis of mucormycosis. $\mathsf{\beta }$-hydroxybutyrate (BHB); Glucose regulator protein (GPR78); Spore-coating protein family (CotH).

Figure 2

Association of diabetes, corticosteroid, and COVID-19 with mucormycosis. Reprinted with permission from ref. [67]. Copyright Year (2021) Copyright Owner’s Name (Elsevier). Glucose regulator protein (GPR78); Spore-coating protein family (CotH).

Figure 3

Coronal slices of CT scan with sinus opacification and sequestrum formation (A) and (B). Axial slices of the contrast enhanced CT scan and show involvement of maxillary sinuses and nasal turbinates (C) and (D). An axial slice of HRCT of chest showing post-COVID fibrosis (E). A clinical picture showing non-healing extraction sockets and necrotic bone in the maxilla, the rest of the teeth present were grade I mobile (F). OPG of the same patient showing sinus involvement, thickening of the lamina dura of the extraction sockets in the anterior maxilla (G).

Figure 4

Picture A, showing exposed necrotic bone in the left posterior maxilla (A). The axial (B) and coronal (C) slices of contrast enhanced CT scan showing bone destruction, sequestrum formation, sinus opacification, and involvement of the nasal turbinates.

Figure 5

An edentulous maxilla with an exposed necrotic bone in the palate and draining sinus in the right canine region (A). The axial (B) and coronal (C) slices of contrast enhanced CT scans of the maxilla respectively showing bone destruction, sequestrum formation, involvement of the right turbinate and sinus opacification. Histopathological slides (H&E staining) showing non-septate fungal hyphae consistent with diagnosis of mucormycosis (D,E).