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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 75-77

Should we tackle the oral cavity to stop the spread of COVID-19?

1 Independent Medical Researcher, K.J. Somaiya Hospital and Research Centre, Somaiya Ayurvihar Complex, Mumbai, Maharashtra, India
2 Department of Medicine, K.J. Somaiya Hospital and Research Centre, Somaiya Ayurvihar Complex, Mumbai, Maharashtra, India
3 Department of Ayurveda and Panchkarma, K.J. Somaiya Hospital and Research Centre, Somaiya Ayurvihar Complex, Mumbai, Maharashtra, India

Date of Submission30-Aug-2020
Date of Decision22-Jan-2021
Date of Acceptance19-Mar-2021
Date of Web Publication10-May-2021

Correspondence Address:
Dr. Manjusha Rajarshi
Independent Medical Researcher, Summit, 11/2, Amritvan, Yashodham, Goregaon, Mumbai - 400 063, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_25_20

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How to cite this article:
Rajarshi M, Gill N, Mestry P. Should we tackle the oral cavity to stop the spread of COVID-19?. J Patient Saf Infect Control 2020;8:75-7

How to cite this URL:
Rajarshi M, Gill N, Mestry P. Should we tackle the oral cavity to stop the spread of COVID-19?. J Patient Saf Infect Control [serial online] 2020 [cited 2023 Feb 9];8:75-7. Available from: https://www.jpsiconline.com/text.asp?2020/8/3/75/315742

The current pandemic situation of COVID-19 has stirred the importance of public health strategies for control and mitigation of contagious infections on priority. COVID-19 is new to humans that is rapidly evolving and researchers across the world are trying to explore all possible avenues that can help to contain the pandemic.

Its rapid spread by human-to-human contact has presented varied clinical features such as high-grade fever, non-productive cough, malaise, dyspnoea and pneumonia. Symptoms such as sputum production, haemoptysis, headache and gastrointestinal symptoms such as diarrhoea, nausea and vomiting along with olfactory disturbances are reported. Saliva is being considered as a convenient and non-invasive mode of diagnosis as well as an important reservoir of the virus playing an important role in the transmission of infection between contact through droplets.[1] The reports of the SARS-CoV, detection in saliva, almost in par with the levels found in nasopharyngeal specimens are already reported and among patients with COVID-19, there are reports of its detection even up to several days after hospitalisation [Table 1].[2]
Table 1: Comparison of 2019-nCoV and SARS-CoV in terms of saliva

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Coronaviruses are enveloped, single-stranded RNA viruses with high rates of mutation[3] and recombination. It is the spike surface protein that plays a crucial role in binding of the virus to the host cell receptors. In case of SARS-CoV-2, it has been confirmed that human angiotensin-converting enzyme 2 (ACE2) is the main receptor for viral entry into the host cell.[4] The entry of coronavirus into the host cell is a multi-step process using multiple distinct domains in the spike protein that facilitates attachment of the virus to the surface of the cell, engagement of the receptor, processing of proteases and membrane fusion. Receptor-binding domain (RBD) for the SARS_CoV-2 has been identified with its S-domain which enables it to bind to ACE2 and fuse into the membrane of epithelial cells. Researchers have demonstrated the SARS-CoV-2 RBD as a twisted 5-stranded antiparallel beta-sheet with short connecting helices and loops and contacting residues that are able to bind to ACE2.[5],[6]

Xu et al. have reported the abundantly expressed ACE2 in the epithelial cells of the oral mucosa, with higher expression in the tongue, in comparison to the buccal and gingival tissues. The typical point of entry for pathogens via droplet infection is the nasopharynx with complementary binding structures in the throat area with high susceptibility to COVID-19 infection in the oral cavity being already reported.[2],[7]

Highest salivary viral load in the oropharyngeal saliva swab sample during the 1st week of infections and in the nasopharynx is related to the severity of the disease is now known. Attempts to reduce the viral load in the body tissue at the initial stages of infection can influence the disease progression. The mRNA, protein levels of the cellular protease, furin, expression of TMPRSS2 have been found in the salivary glands. Thus, role of salivary gland cells in the initial entry, progress of the infection and as a source of the virus is being explored by several researchers.[8] The possibility of the salivary glands as a reservoir, harbouring latent infection, which may reactivate later, is one of the considerations that warrants further research.

SARS-CoV-2 has demonstrated the characteristic of initial throat tropism. Thus, throat gargling, an ancient therapeutic method as well as chemical inactivation by use of antiseptic agents such as chlorhexidine and povidone-iodine could be useful in controlling the COVID-19 pandemic which is reported by researchers.[9],[10] Pharmaceutical preparations such as mouthwash, locally acting lozenges and mouth paints form films or coats on the oral mucosa acting as a barrier and reduce the adhesion of the pathogen, thereby reducing immediate exposure in the host. Such interventions additionally can offer their potential use in breaking the chain of transmission at the portal of entry. Hensel et al. have proposed a prophylactic method such as sucking a lozenge, or the gargle solution is kept in the mouth for short-term protection to reduce the pathogen load in the oral cavity as a preventive measure.[11]

Although influenza and other respiratory viral infections are the most common type of acute respiratory infection, they carry a lot of morbidity–mortality due to secondary bacterial infections, leading to the severe clinical course due to complex multifactorial processes consisting of interactions between viruses, bacteria and the host immune system. Clinical studies have detected a cytokine storm in critical patients with COVID-19 which is an exaggerated response of the immune system. It is primarily our immune system that protects us from viral infections. The COVID-19 pandemic has focused on the weakened immunity of the population and activating our immune system is as important. Anything that weakens the immune system makes us more susceptible and reduces our ability to fight infections and increases susceptibility. In a quest to combat emerging pandemic situations in future, two-way strategies can potentially help find a preventive as well as treatment solution. Use of orally acting antiseptics/germicides can arrest the growth of the pathogen at the port of entry and use of adaptogens can sharpen immunity axis.[12],[13] Innate immunity and mucosal immunity responses are extremely important as it harnesses and triggers the further steps of protection. Coronavirus attaches itself to the epithelial cells of the oral cavity and replicates very rapidly by adhering to the epithelial tissues.[1],[14] Introducing a barrier to this adhesion can help prevent its entry and subsequent replication; additionally, it also gives time from the mucosal immunity to activate itself for destruction of the antigen.

Several natural plant-based substances possess germicide and immunomodulatory properties. They are natural compounds with intricate molecular structures and the ability to interact with proteins to assume a certain degree of protection is possible through a topical treatment of the oral mucosa.[11],[15] All these natural plant-based compounds are high proanthocyanidin and polyphenols and have the ability to exercise antimicrobial activities. To make a universally acceptable intervention, we need to take key lessons from the nature and the traditional knowledge present. An ingredient from the food chain provides a wide margin of safety with its historical use. The natural agents that are rich in flavonoids, polyphenols and proanthocyanidin are desirable. Curcuma longa, Glycyrrhiza glabra, quercetin and Tinospora cordifolia are few such natural plant-based ingredients with pharmacological activities.[15]

Investigations studies are necessary for interventions that can act in the saliva for reducing the bioburden and adaptogens that can activate the immune system. Emergence of novel pathogens is anticipated,[16] and we are likely to face a situation like COVID-19 in the near future. We have an along way to go for finding an effective solution to COVID-19; however, breaking the chain of infection is the priority and emphasis on breaking the chain at the portal of entry (oral cavity) should be considered. This perspective that is cited certainly needs further research.

It is very necessary to focus on strengthening the immune axis as part of general health strategies with the importance of hand hygiene, nasal hygiene and oral hygiene as a daily routine. Effective implementation of water, sanitation and hygiene programme[17] as public health policies must be considered seriously by all governments with public health education and awareness programmes to reach every component of the community.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Han P, Ivanovski S. Saliva-Friend and Foe in the COVID-19 Outbreak. Diagnostics (Basel) 2020;10:290.  Back to cited text no. 1
Xu R, Cui B, Duan X, Zhang P, Zhou X, Yuan Q. Saliva: Potential diagnostic value and transmission of 2019-nCoV. Int J Oral Sci 2020;12:11.  Back to cited text no. 2
Mercatelli D, Giorgi FM. Geographic and Genomic Distribution of SARS-CoV-2 Mutations. Front. Microbiol 2020;11:1800.  Back to cited text no. 3
Liu L, Wei Q, Alvarez X, Wang H, Du Y, Zhu H, et al. Epithelial cells lining salivary gland ducts are early target cells of severe acute respiratory syndrome coronavirus infection in the upper respiratory tracts of rhesus macaques. J Virol 2011;85:4025-30.  Back to cited text no. 4
Tai W, He L, Zhang X, Pu J, Voronin D, Jiang S, et al. Characterization of the receptor-binding domain (RBD) of 2019 novel coronavirus: Implication for development of RBD protein as a viral attachment inhibitor and vaccine. Cell Mol Immunol 2020;17:613-20.  Back to cited text no. 5
Chakraborti S, Prabakaran P, Xiao X, Dimitrov DS. The SARS coronavirus S glycoprotein receptor binding domain: Fine mapping and functional characterization. Virol J 2005;2:73.  Back to cited text no. 6
Henrique Braz-Silva P, Pallos D, Giannecchini S, To KK. SARS-CoV-2: What can saliva tell us? Oral Dis 2021;27:746-7.  Back to cited text no. 7
Coutard B, Valle C, de Lamballerie X, Canard B, Seidah NG, Decroly E. The spike glycoprotein of the new coronavirus 2019-nCoV contains a furin-like cleavage site absent in CoV of the same clade. Antiviral Res 2020;176:104742.  Back to cited text no. 8
Tsai CL, Wu PC. Possible beneficial role of throat gargling in the coronavirus disease pandemic. Public Health 2020;185:45-6.  Back to cited text no. 9
Yoon JG, Yoon J, Song JY, Yoon SY, Lim CS, Seong H, et al. Clinical Significance of a High SARS-CoV-2 Viral Load in the Saliva. J Korean Med Sci 2020;35:e195.  Back to cited text no. 10
Hensel A, Bauer R, Heinrich M, Spiegler V, Kayser O, Hempel G, et al. Challenges at the time of COVID-19: Opportunities and innovations in antivirals from nature. Planta Med 2020;86:659-64.  Back to cited text no. 11
Wagner H, Nörr H, Winterhoff H. Plant adaptogens. Phy Med 1994;1:63-76.  Back to cited text no. 12
Rege NN, Thatte UM, Dahanukar SA. Adaptogenic properties of six rasayana herbs used in Ayurvedic medicine. Phytother Res 1999;13:275-91.  Back to cited text no. 13
Baghizadeh Fini M. Oral saliva and COVID-19. Oral Oncol 2020;108:104821.  Back to cited text no. 14
Alschuler L, Weil A, Horwitz R, Stamets P, Chiasson AM, Crocker R, et al. Integrative considerations during the COVID-19 pandemic. Explore (NY) 2020;16:354-6.  Back to cited text no. 15
Brownlie J, Peckham C, Waage J, Woolhouse M, Lyall C, Meagher L, et al. Foresight Infectious Diseases: Preparing for the Future Threats. London: Office of Science and Innovation; 2006.  Back to cited text no. 16
Dery F, Bisung E, Dickin S, Dyer M. Understanding empowerment in water, sanitation, and hygiene (WASH): a scoping review. Journal of Water, Sanitation and Hygiene for Development 202010:5-15.\  Back to cited text no. 17


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