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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 4  |  Page : 307-310

Oral lesions associated with Dengue fever


1 Department of Oral Medicine and Radiology, K.V.G Dental College and Hospital Sullia, Sullia, Karnataka, India
2 Department of Oral Medicine and Radiology, MAHE Institute of Dental Sciences and Hospital, Chalakkara, Palloor, Mahé, Kerala, India
3 Department of Oral Medicine and Radiology, Amritha School of Dentistry, Ernakulam, Kerala, India

Date of Submission09-Aug-2019
Date of Acceptance19-Nov-2019
Date of Web Publication03-Mar-2020

Correspondence Address:
Dr. Jayalakshmi Baipadavu
Department of Oral Medicine and Radiology, K.V.G Dental College and Hospital Sullia, Sullia - 574 327, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_141_19

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   Abstract 


Aims: Dengue is one of the most common arthropod-borne infection, which is of great public health importance. Literature presenting the specific and nonspecific general symptoms of dengue is available. However, descriptions of oral manifestations of dengue are not easily available. The aim of this study is to describe the uncommonly presented manifestations with importance to oral presentation. Methods and Materials: After obtaining institutional ethical clearance, 200 dengue cases were subjected to clinical and laboratory examinations. Dengue fever (DF) was diagnosed based on the World Health Organization (WHO) clinical criteria and serology. Informed consent was obtained from every patient. Results: The most common oral manifestations were lip crust and tongue coating. The occurrence of petechiae, erythema, gingival bleeding, and hemorrhagic plaque was associated with prolonged bleeding time, and it was a statistically significant association. There was also a statistically significant association between thrombocytopenia and tongue coating. Conclusions: Oral manifestations are an important finding in dengue patients. The timely identification of these symptoms can aid in the diagnosis and help the effective management of the disease.

Keywords: Dengue, erythema, gingival bleeding, hemorrhagic plaque, lip crusting, petechiae, thrombocytopenia, tongue coating


How to cite this article:
Anekar J, Baipadavu J, Chirakara RA, Nappalli D, Kumar KS, John IE. Oral lesions associated with Dengue fever. J Indian Acad Oral Med Radiol 2019;31:307-10

How to cite this URL:
Anekar J, Baipadavu J, Chirakara RA, Nappalli D, Kumar KS, John IE. Oral lesions associated with Dengue fever. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2020 Apr 4];31:307-10. Available from: http://www.jiaomr.in/text.asp?2019/31/4/307/279850




   Introduction Top


Dengue fever (DF) is a flu-like illness that affects all age groups. Although it is known to be endemic for centuries in India, only epidemics have been recognized and reported from various regions, such as Maharashtra,[1],[2] Gujarat,[3] Karnataka,[4] Kolkata,[5] and Rajasthan.[6] The World Health Organization (WHO) estimated about 50 million individuals infected with dengue virus (DENV) every year globally.[7],[8] India significantly shares 34% of the world's dengue population.[9]

A revised WHO Classification of DF [Table 1] was introduced in 2009, replacing the traditional (DF) and Dengue hemorrhagic fever(DHF)/Dengue shock syndrome(DSS) as dengue with or without warning signs and severe dengue,[9] which is frequently fatal.
Table 1: WHO suggested Dengue case classification and levels of severity[9]

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Consistent hematological findings, especially thrombocytopenia,[10] and unusual manifestations, such as cardiomyopathy, hepatic failure, and neurological disorders, have been reported in various studies.[11],[12],[13] However, there is a significant variation in the clinical presentation of dengue. Oral findings in dengue are secondary to the general manifestations. Oral lesions rarely occur and if present, are often mistaken for platelet disorders. In one of the study mucosal involvement is seen in about more than 15–20% of the patients, which most commonly involves conjunctiva and marginal gingiva, soft palate, lips, and tongue.[14] Gingival bleeding is the most common oral manifestation of dengue infection, however limited literature concerning the same exists on that.[15] This study emphasizes the significance of oral lesions as it may be the early indicator of DHF.

As many systemic and infectious diseases show their significant presence in the oral cavity, oral physicians must be able to differentiate between the varied presentations of such cases. The early identification of oral lesions of DF can help in its early diagnosis and effective management.


   Subjects and Methods Top


A cross-sectional observational study was done in four hospitals in Sullia, India during an outbreak of dengue between June and September 2016. The institutional ethics committee clearance was obtained before the study. DF was diagnosed based on the WHO clinical criteria and serology, and 200 subjects were studied after getting individual informed consent. Patients under anticoagulants, history of bleeding and clotting disorders, and mucocutaneous disorders were excluded. Detailed clinical and oral examinations were performed and relevant hematological investigations were documented in the proforma. The parameters taken were blood pressure (BP), oral lesions, such as lip crusting, petechiae, erythema, gingival bleeding, hemorrhagic plaque, tongue coating; and any other signs if present. Hematological parameters included hemoglobin (Hb), total white blood cell count (TC), hematocrit (HCT), platelet count (PCT), packed cell volume (PCV), red blood cell (RBC) count, and bleeding time (BT).

The data were entered in a Microsoft Office Excel 2007 sheet and statistical analysis was done using IBM's Statistical Analysis for the social sciences (SPSS) software, version 20.


   Results Top


A cross-sectional study among 200 dengue positive cases, admitted in four hospitals in Sullia, India, was conducted to analyze the oral manifestations of dengue among patients. Out of the 200 patients studied, 84% were aged between 21 and 60 years, with 6% and 10% of them in the age group of <20 years and >60 years, respectively [Table 2]. Among the studied patients, 59.5% were males and 40.5% were females. At the time of examination, 43% of the study population had a BP >120/80 [Table 2]. The mean systolic BP among the study population was 115.48 mmHg ± 14.41 and the mean diastolic BP was 73.83 mmHg ± 11.78.
Table 2: General characteristics of the patient

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The most common oral manifestations in the study subjects were lip crust and tongue coating, with at least 25% of the study population presenting with them. Petechiae were seen in 12.5% patients, gingival bleeding in 10.5%, erythema of oral mucosa in 6% and the least common manifestation was a hemorrhagic plaque that accounted only 2% [Table 3], [Figure 1].
Table 3: Oral manifestations in the study population

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Figure 1: Distribution of oral mucosal lesions in the study population

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Blood investigations such as Hb%, TC, packed cell volume (PCV), RBC count, platelets, and BT, were obtained for the study. The mean Hb was 13.26gms% ± 1.62, mean platelet count was 94890 cells/mm3 ± 49569.89. The mean TC was 5982.5 cells/mm3 ± 2334.82, mean PCV was 40.94% ± 4.56, and mean RBC count was 4.39 cells/mm3 ± 0.61 [Table 4].
Table 4: Lab parameters in the study population

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The relationship between oral manifestations, platelet count, and BT was studied. An association between thrombocytopenia and tongue coating with P < 0.05 was found[Table 5]. The occurrence of petechiae, erythema, gingival bleeding, and a hemorrhagic plaque was associated with prolonged BT with P < 0.05 [Table 6].
Table 5: Relationship of oral manifestations with platelet count

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Table 6: Relationship of oral manifestations with BT

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   Discussion Top


Dengue is one of the communicable, vector-borne, infectious disease, caused by DENV, belonging to genus flavivirus. Aedes aegypti mosquitoes transmit this virus, and DENV has four genetically related, but distinct serotypes (DENV 1-4).[16]

The major specific and nonspecific symptoms presented in DF are well-known and have been extensively described in the literature.[17] Mucosal involvement is seen in about 15-20% of the patients with DHF. The most commonly affected sites are the conjunctiva, sclera, soft palate, lips, and tongue. Stanford reported more than 50% of the cases in the soft palate.[18]

Oral manifestations of dengue infection have been described as gingival bleeding and included by WHO as the nonspecific finding of the disease.[17] Tongue and soft palate may also be affected by bleeding manifestations, such as erythema, petechiae, and ecchymosis.[19],[20]

In the present study, out of 200 study subjects, 114 (57%) had at least one form of mucosal or cutaneous manifestations. Patients who were examined had either lip crusting, tongue coating gingival bleeding, petechiae, erythema, or hemorrhagic plaque. Although 50.5% presented with at least one type of oral manifestation, they are nonspecific to DF. In a study conducted by Thomas et al.[21] in Punjab, 30% of the patients with dengue viral infections presented with oral mucosal involvement. The manifestations were seen more in patients with DHF than in DF cases. The conjunctiva (21%) was the most common site of mucosal involvement, followed by the lips (4.8%), palate (2.4%), and tongue (1.6%). The lips showed hemorrhagic crusting, whereas the tongue showed erythema with coating. The palate showed vesicles, mainly, on the soft palate. Two of the four subjects who presented with DSS had extensive ecchymotic lesions on the trunk and extremities. Further, it was shown that cutaneous manifestations did not reflect the severity of the disease. In the present study, only four patients presented with a hemorrhagic plaque.

There are some studies that have shown the presence of small vesicles on the soft palate.[22] but in the present study, such vesicles were not found. Byatnal et al. have shown the occurrence of numerous hemorrhagic bullae on the left sublingual mucosal membrane, as well as on the left lateral surface of the tongue and floor of the mouth.[23] It was also reported by the same authors that there were cases with the presence of brown color plaques with a rough surface on the buccal mucosa, which bled on touch, along with spontaneous bleeding from gingiva and tongue.[23] Mitra et al. have reported inflammation of bilateral tonsils along with manifestations, such as gingival bleeding and hemorrhagic plaque.[18] Xerostomia and tongue coating have also been reported by the same authors.[18] Whereas, tonsillar inflammation and xerostomia were not found in our study.

The most common manifestation in the present study was tongue coating followed by a lip crust. This is different from a study done by Sirotheau et al., where gingival bleeding was shown to be the most common manifestation.[15] A statistically significant association between thrombocytopenia and tongue coating was found in the present study, which is nonspecific in DF. Detailed further studies may be required in this aspect. The occurrence of petechiae, erythema, gingival bleeding, and a hemorrhagic plaque were associated with prolonged BT, and it was statistically significant.


   Conclusion Top


In this study, 50.5% of the patients presented with oral manifestations. The most common manifestation was tongue coating followed by lip crust, which is nonspecific to DF. Oral bleeding is one of the common manifestations in dengue other than the nonspecific symptoms like lip crusting and tongue coating. Physicians and dental surgeons must always remember that oral manifestations in DF are not uncommon and have to be carefully evaluated, as it is an indication for the diagnosis and may help in minimizing complications. We recommend further studies to find the possible reasons for the association of oral lesions in DF for the early diagnosis and its effective management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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WHO/TDR. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control. New ed. Geneva: World Health Organization; 2009.  Back to cited text no. 9
    
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Parkash O, Almas A, Jafri SW, Hamid S, Akhtar J, Alishah H. Severity of acute hepatitis and its outcome in patients with dengue fever in a tertiary care hospital Karachi, Pakistan (South Asia). BMC Gastroenterol 2010;10:43.  Back to cited text no. 13
    
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Thomas EA, John M, Kanish B. Mucocutaneous manifestations of dengue fever. Indian J Dermatol 2010;55:79-85.  Back to cited text no. 14
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Pontes FS, Frances LT, Carvalho MDEV, Fonseca FP, Neto NC, do Nascimento LS, et al. Severe oral manifestations of dengue infection: A rare clinical description. Quintessence Int 2014;45:151-6.  Back to cited text no. 15
    
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Byatnal A, Mahajan N, Koppal S, Ravikiran A, Thriveni R, Parvathi Devi MK. Unusual yet isolated oral manifestations of persistent thrombocytopenia – A rare case report. Braz J Oral Sci 2013;12:233-6.  Back to cited text no. 23
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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