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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 215-221

Oral medicine practice during COVID-19: A scoping review

1 Department of Oral Medicine and Radiology, Amrita School of Dentistry, Kochi, Kerala, India
2 Department of Public Health Dentistry, Amrita School of Dentistry, Kochi, Kerala, India

Date of Submission06-Jan-2021
Date of Decision27-Apr-2021
Date of Acceptance15-May-2021
Date of Web Publication23-Jun-2021

Correspondence Address:
Dr. Krishna S Kumar
Department of Oral Medicine and Radiology, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, AIMS, Ponekkara PO, Kochi, Kerala - 682041
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_4_21

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Oral healthcare providers work near the face of the patients and are at an increased risk of being infected or transmitting the infection to the patients. Standard practice guidelines have to be modified to reorganize Oral Medicine care in the new normality of the COVID-19 pandemic to minimize the negative impacts of the infection on oral and systemic health. This scoping review aims to assess the guidelines for the safe practice of Oral Medicine during the COVID-19 pandemic. The literature search was done using Medline and Pubmed as the database and 23 articles were identified related to 8 domains. Utilization of teledentistry, efficient triaging of the patients with strict adherence to the infection control protocols, knowledge of the possible oral manifestations, and management of patients based on their presenting symptoms can help for the safe practice of Oral Medicine during the COVID-19 pandemic.

Keywords: COVID-19, infection control, oral lesions, Oral Medicine, practice guidelines

How to cite this article:
Kumar KS, Venkitachalam R, Varma B, Nair PK, Shanmugham AM, Jose R. Oral medicine practice during COVID-19: A scoping review. J Indian Acad Oral Med Radiol 2021;33:215-21

How to cite this URL:
Kumar KS, Venkitachalam R, Varma B, Nair PK, Shanmugham AM, Jose R. Oral medicine practice during COVID-19: A scoping review. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 Dec 1];33:215-21. Available from: http://www.jiaomr.in/text.asp?2021/33/2/215/319076

   Introduction Top

Coronavirus disease 19 (COVID-19) caused by the novel coronavirus (named SARS-CoV-2) has become a global pandemic and is considered as a public emergency of international concern.[1],[2] SARS-CoV-2 is a zoonotic virus similar to SARS-CoV and Middle East respiratory syndrome Corona Virus (MERS-CoV). The probable origin of this virus is from the Chinese horseshoe bats with pangolins as the intermediate host.[1] The mode of transmission of the virus is through the inhalation of respiratory droplets, exposure of the mucous membrane to infectious droplets, and via contaminated surfaces.[3] As on 29th December 2020, 80,155,187 confirmed cases have been recognized worldwide including 1,771,128 deaths.[4]

Healthcare personnel, especially those managing patients with disease of the aero-digestive tract are at an increased risk of contracting COVID-19 as compared to the general population.[5],[6] Airborne transmission can also occur through aerosols in medical procedures if the viral load in the aerosol is sufficiently high.[7]

Oral Medicine specialists manage chronic oral diseases including malignancies, orofacial pain, and play a major role in the management of patients with systemic diseases and comorbidities. Due to the COVID-19 crisis, there is a delay in routine dental care leading to serious consequences in the systemic health status of the individual due to exacerbation of diseases, self-medication, or interruption in pharmacotherapy, and deferred diagnosis of malignancies. Hence, prioritizing the emergencies with effective triaging of the patients along with ensuring maximum protection to the clinicians and the patients is necessary. Standard practice guidelines have to be modified to reorganize Oral Medicine care in the new normality of the COVID-19 pandemic to minimize the negative impacts of the infection on oral and systemic health.[6],[8] Oral manifestations due to COVID-19 infection has been reported[9] but whether these lesions are caused due to the viral infection itself or due to the deterioration in systemic health and side effect of medications is still unknown.[9]

The objective of this scoping review is to assess the guidelines of safe Oral Medicine practice in the COVID-19 pandemic situation including the efficient management of emergencies, a multidisciplinary approach for the management of oral mucosal lesions, and a brief discussion on the reported oral manifestations in patients with COVID-19 infection.

   Methodology Top

A thorough literature search was done using Medline/PubMed database as a search engine with standard MeSH terms like “Oral Medicine,” “COVID-19,” “Oral lesions,” SARS-CoV-2, and 2019-nCoV with a date range of December 2019 till 18th of September 2020. All full- text articles in the English language about the guidelines, management of oral mucosal lesions and emergencies, safe oral medicine practice during COVID-19 pandemic, and oral manifestations in COVID-19 patients were included in the review. Articles were also hand searched. The search strategy included was “Oral Medicine” and “COVID-19”. No restriction was placed on the type of study design. The following domains were identified to be extracted from the included articles.

  1. Management of patients in the Oral Medicine department/clinic
  2. Maintenance of patient records
  3. Infection control protocols to be followed during patient management
  4. Management of Oral Medicine emergencies
  5. Guidelines for the management of oral cancer and oral potentially malignant disorders
  6. Oral manifestations of COVID-19 infection
  7. Dental drug therapy during COVID-19
  8. Role of saliva as a diagnostic modality for COVID-19

A data extraction template was prepared and relevant data from the included articles were extracted.


Management of patients in the Oral Medicine department along with maintenance of patient records is of utmost importance during the COVID-19 pandemic as standard protective measures and protocols will not be sufficient enough for infection control. Definitive guidelines have to be followed for carrying out a procedure in the Oral Medicine clinic, which includes following specific protocols for the management of emergencies, oral cancer, and oral potentially malignant disorders. Oral manifestations have been reported in patients with confirmed COVID-19 infection. But it is still unclear whether this is caused due to the actual viral infection or is manifestations of systemic involvement. Salivary glands act as a potential receptor for COVID-19 infection due to the abundance of angiotensin- converting enzyme 2 (ACE2) and hence saliva may be a potential diagnostic tool for the detection of the COVID-19 virus. Drug therapy for the dental treatment and management of oral manifestations during the COVID-19 era requires special attention as there can be increased reliability on the use of analgesics and antibiotics for a longer period and also risk for drug interactions.

The obtained data were summarized descriptively based on the domains.

   Results Top

An electronic search from Medline retrieved 192 citations. Seven articles were obtained through hand search. After the removal of duplicates, 65 articles were included for screening. Title and abstract were screened of which 42 studies were excluded as they did not meet the study objectives. A total of 23 articles were included for synthesis [Figure 1].
Figure 1: Literature research search

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Retrieved articles comprised of 5 recommendations/guidelines, 5 letters to the editor, 4 review articles, 3 communications/perspectives, 3 medical imagery and hypothesis, and 1 case report, cohort, and cross-sectional study each.

Management of patients in oral medicine department/clinic

Six articles[3],[6],[10],[11],[12],[13] reported on information regarding the management of patients in the Oral Medicine department. They stressed the significance of specific guidelines which has to be followed in the dental setting to prevent nosocomial infection. Standard protective measures we use during dental practice may not be sufficient enough to prevent COVID-19 infection due to the high risk of transmission through aerosols and droplets. Patients who present to us may be in the incubation period, asymptomatic, or may even conceal their symptoms. The practice of proper hand hygiene, effective use of personal protective equipment (PPE), and thorough disinfection of the surfaces can help in reducing the risk in a significant manner.

Maintenance of patient records

One article stressed on the importance of mandatory implementation of pre check triages for all the patients. Details about the travel history and health status along with non-contact thermal screening of the patient has to be done during the triage. The home address and phone number of the patient and the bystander are also recorded initially so that future communications including tracing can be done if required. Installation of software-based programs for patient registration, which is approved by professional bodies, has to be made mandatory to encourage a paperless patient management system. COVID-19-specific declaration form explaining the risk of acquiring/transmitting COVID-19 infection in a dental setting has to be signed along with the routine consent form of the clinic/college.

Infection control protocols to be followed during patient management

Six articles[1],[5],[6],[7],[10],[11] reported on the specific protocols to be followed before the treatment and during the treatment in the dental clinic. Standard hand hygiene protocol and use of PPE have to be followed by the operator and the patient. PPE to be used while doing an invasive procedure differs from that which is used while carrying out an examination. Invasive procedures should be carried out in a designated room that is separated from the main clinic area.[10] Saliva can be a major source of the virus as salivary epithelial cells can potentially be infected with SARS-CoV-2. It has been reported that virus strains can be present in saliva for 29 days. Hence patients in the convalescent stage can also be potentially contagious along with active cases and asymptomatic carriers.[11] Hence, all the patients should be advised to take a teleconsultation before the visit to the department. This helps in effective triaging of the patient and also helps maintain the social distancing norms inside the department. After the initial screening, patients can be divided into various groups based on their medical history and presenting complaint which will help us provide treatment following the infection control protocols.[1]

Management of oral medicine emergencies

Five articles[3],[6],[8],[12],[13] reported on the management of Oral Medicine emergencies during the COVID-19 pandemic. They stressed the practice of teledentistry utilizing videoconferencing software and telephone consultations. It can help in providing interim management of chronic conditions, self-advice care, and reassurance to the patients.[12] After the initial triaging, Oral Medicine cases should be divided into high-priority cases that require urgent care and low-priority conditions that do not require urgent intervention and can be managed accordingly.[6]

Guidelines for the management of oral cancer and oral potentially malignant disorders

Three articles[13],[14],[15] provided guidelines on the diagnosis and management of oral cancer and oral potentially malignant disorders (OPMDs) in the COVID era. Early diagnosis is important to reduce the adverse outcomes as there is an increased risk of progression of the lesions and detriments of these diseases, which patients have to incur in long term. Tobacco use in the smoked and smokeless form along with alcohol use and betel quid chewing is the major etiological factor in the development of oral cancer and OPMDs. Patients who chew tobacco/betel nut have a habit of spitting in public spaces which can lead to increased spread of the COVID-19 virus. Also, the use of long-term corticosteroids and immunosuppressive agents used for the treatment of diseases like oral lichen planus can affect the immune status of the individual, which makes the patient more susceptible to serious effects from COVID-19 infection. As there is a disruption in the regular screening process due to the pandemic situation, teledentistry consultations can be utilized efficiently for initial evaluation, reviews, and habit cessation counseling.

Oral manifestations of COVID-19 infection

Seven articles[9],[16],[17],[18],[19],[20],[21] have mentioned the possible oral manifestations of COVID-19 infection. It is still doubtful whether this is caused due to primary viral infection, which may result in vasculitis and microvascular thrombosis, or secondary due to systemic vascular-hematologic damage and adverse treatment outcomes/medications used for the treatment.[9],[19] Gustatory disorders, sialadenitis, aphthous-like ulcerations, and erosive macules of the oral mucosa are the commonly reported oral manifestations.[18],[20]

Dental drug therapy during COVID-19

Three[21], [22,[23] articles provided guidelines on the prescription of drugs during the COVID-19 pandemic. As most of the professional regulatory bodies have advised for the provision of dental services only for emergency cases, most of the patients rely on the use of analgesics and non-steroidal anti-inflammatory agents (NSAIDs) for pain relief. Oral Medicine physicians may have to provide higher doses of drugs for prolonged periods. Our aim should be to provide the lowest effective dose for a short duration. Oral Medicine physicians should remain updated regarding the latest information about the drug therapy and prescribe analgesics after weighing benefit against harm. Prescription of medications should be done after considering the medical history of the patient and consultation with the patient's physician whenever required.[22] Hydroxychloroquine has gained popularity during the COVID-19 pandemic due to its antiviral properties and is widely used worldwide for the treatment of SARS-CoV-2 infection. Hence, there may be an acute shortage of the drug and alternative therapy may be required for the management of oral manifestations of patients with Sjogren's syndrome or systemic lupus erythematosus who are on hydroxychloroquine therapy.[21],[23]

Role of saliva as a diagnostic modality for COVID-19

Two articles[24],[25] have provided information on the utilization of saliva as a reliable diagnostic tool to detect SARS-CoV-2 infection. Salivary droplets are the main source of transmission of the virus. Using saliva to detect COVID has many advantages that include reduced discomfort to the patient, ease in the collection of the sample, and also trained healthcare professionals are not required for sample collection. Hence, it can be easily utilized for mass screening programs.

   Discussion Top

Routine non-essential dental care can be delayed until there is a reduction in the transmission rate of the COVID-19 infection. Urgent/emergency care should be provided which includes management of acute oral infections and swelling, severe pain, systemic infection, prolonged/severe bleeding, or any condition which is vital for the patient's normal oral functioning and maintenance of the quality of life. Performing emergency care in patients with suspected/confirmed COVID-19 infection should only be done with appropriate measures and should be separated from other patients.[3] All the patients requesting oral medicine care should undergo triaging through telephone. It helps to determine the urgency of the condition and also to understand the COVID-19 risk status of the patient.[6] Teledentistry can be utilized through which patients can provide images and videos of the oral problem which can help the clinician to arrive at a provisional diagnosis. In this way, initial triaging of the patients and appointment for face- to- face assessment or referral can be done.[13]

The seating area of the clinic including the triage area should follow the social distancing norms of the 6-feet gap between individuals. Rooms with a wide entrance and exit areas with good ventilation should be used for providing oral care.[10] Negative pressure or mechanically ventilated rooms with 6–12 air exchanges/hour can be used. The use of exhaust fans and high-efficiency particulate air filters can be used instead of recirculation devices like split air conditioning. Posters and flyers have to be put up in the clinic to educate the patient regarding the importance of maintaining social distancing norms, hand hygiene, use of elbow or tissues while sneezing/coughing with its correct disposal, etc.[3]

After initial triaging Oral Medicine cases should be divided into high-priority cases that require urgent care and low-priority conditions that do not require urgent intervention and can be managed accordingly. Following conditions should be considered as high-priority Oral Medicine cases and should be provided with urgent care.

  • Solitary ulceration of the oral mucosa that has persisted for more than 2 weeks and is unlikely to be caused by local trauma or infection
  • Persistent swelling of the oral mucosa or jawbones for more than 2 weeks and is unlikely to be caused by local trauma or infection
  • Paraesthesia/anesthesia in the area supplied by trigeminal nerve without any identifiable local cause
  • Acute swelling or exacerbation of chronic swelling of the major salivary glands
  • Acute lymphadenopathy or progression of chronic lymphadenopathy of the head and neck region
  • Severe orofacial pain which is not resolving with over-the-counter medications
  • Persistent/widespread gingival ulceration or blistering lasting for more than 2 weeks

Low-priority Oral Medicine conditions that do not require urgent intervention include

  • Ulceration of oral mucosa/swelling of the jawbones/ acute lymphadenopathy caused by trauma or odontogenic infection with a duration of less than 2 weeks that can be managed by extraction of teeth/incision and drainage.

    • Self-resolving gingival blisters
    • Acute infections of the major salivary gland that can be managed by antibiotics and analgesics
    • Pre-existing and persistent burning mouth sensation[6]

    Even though the majority of Oral Medicine procedures are non-aerosol generating, enhanced safety measures have to be undertaken as saliva and the oropharyngeal area is a potential reservoir of SARS-CoV-2. Rapid real- time-quantitative polymerase chain reaction screening has to be done for all the patients visiting the Oral Medicine clinic for urgent invasive care as this can reduce the staff exposure.[13]

    Before the initiation of the dental treatment, the patient should be instructed to wear a disposable head cap, full coverage disposable patient gown, plastic utility gloves, and disposable shoe covers. The patient should be asked to rinse his/her mouth with 1% hydrogen peroxide or 0.2% povidone- iodine oral rinse. This is done to reduce the microbial load of the oral cavity. Use of spittoon has to be avoided, high-speed suction or disposable cup can be used instead. The instruments and materials which are necessarily required should be set for the procedure.

    All healthcare professionals should wear personal protective equipment (PPE) as appropriate for the procedure.[10] All healthcare professionals involved in the procedure should perform hand hygiene using an alcohol-based hand rub (ABHR) which contains 60–80% alcohol if hands are not visibly dirty. If hands are visibly dirty, they should be washed with soap and water. Hand hygiene should be performed fulfilling the 5-moment recommendation by WHO. It includes “before patient contact,” “before aseptic task,” “after body fluid exposure risk,” “after patient contact,” and “after contact with patient surroundings.” Hands should be dried with disposable paper towels.

    Only the patient should be allowed to enter the working area and 5–6 chairs alone should be used for examination. Chairs should be kept at least a 2-meter distance from one another and only the clinician with 1 assistant should be present along with the patient to ensure that there is no crowding. Change over time of 15–20 minutes can be provided in between every patient to ensure that sufficient time is allotted to perform hygiene measures.[10]

    Teledentistry can be utilized for the evaluation of lesions of the lip, anterior gingiva, and the tip of the tongue.[12] Clinical diagnosis, strengthened by non-invasive chair side investigations can be used in the initial stages and microbiological examinations including smear, culture, and biopsy can be carried out at a later stage when the outbreak is controlled. For acute infectious disorders, systemic therapy along with topical therapy can be advocated. For allergic diseases including allergic stomatitis and erythema multiformae antihistamines and low dose glucocorticoid therapy (0.5–1.0 mg/kg × d) can be used along with topical drug therapy. For ulcerative bullous and erosive lesions, low to medium dose glucocorticoid therapy, immunosuppressant drugs, and topical drug therapy can be given. The use of anti-inflammatory mouth rinses and ointments can help to reduce pain and accentuate the healing process. Patients with severe oral presentations along with dermatological manifestations may be sent to the dermatology department as they might require intravenous therapy.[13] Management of Steven-Johnson syndrome and toxic epidermal necrolysis has to be done similar to major burns and immediate hospital admission is required. Oral mucositis in patients undergoing chemotherapy/radiation may present as acute widespread ulcers with extensive erythema. In such cases, the patient finds it difficult to consume food. Consultation with the oncologist as well as hospital administration may be required in such cases.[8]

    For the management of orofacial pain, a good history is very important as it can help us to differentiate between various conditions. Temporomandibular dysfunction is usually a significant proportion of patients complaining of chronic orofacial pain. Stress and anxiety, especially during such pandemic situations, can aggravate these conditions. Hence, proper reassurance is essential and neuropathic medications can be given if required. Special caution has to be made if the patient presents with symptoms of giant cell arteritis, as it is associated with progressive and irreversible ophthalmic damage. Such patients have to be referred to a hospital immediately or prescribed high-dose glucocorticoids to avoid complications.[8]

    About the effect of pandemics on patients with early-stage oral cancer and OPMDs, there is a paucity of literature. Patients who present with OPMDs usually have a history of chronic diseases like diabetes, hypertension, or pulmonary diseases like asthma.

    Among the OPMDs erythroplakia and erythroleukoplakia presenting in heterogenous/ulcerated form with a size greater than 200 mm2 on the tongue and floor of the mouth are considered to have high risk for immediate malignant transformation or for harboring oral cancer. Such presentations demand immediate in-office evaluation and management under COVID-19 protocol. Low-risk lesions include homogenous leukoplakia, oral submucous fibrosis (OSMF), oral lichen planus, discoid lupus erythematosus, chronic candidiasis, syphilitic glossitis, and palatal changes associated with reverse smoking.[14] In patients with oral submucous fibrosis, there is a downregulation of ACE2. So, it can be speculated that in patients with OSMF there is reduced availability of ACE2, which makes the binding of SARS-CoV-2 difficult. In patients with OSMF who gets infected with SARS-CoV-2, there will be further exhaustion of ACE2 that results in the progression of the disease.[16] For low-risk lesions, in-office treatment can be deferred up to less than 3 months but has to be evaluated with monthly teledentistry consultations through photographs and videos.[13],[17]

    Salivary glands may be a potential target for SARS-CoV-2. SARS-CoV and SARS-CoV-2belong to the beta type of coronavirus that can infect humans. The receptor- binding domain (RBD) of the spike protein present in the envelope of SARS-CoV binds to the host receptor, ACE2 which gets adsorbed into the host cells. Host cells then produce neutralizing antibodies which mediate the cellular immune response. RBD sequence of the SARS-CoV and SARS-CoV-2 are similar and hence it may be postulated that their invasion mechanism will be also similar. The epithelial cells of salivary glands have receptors for ACE2 and serve as the targets for SARS-CoV infection. Replication of the virus can occur within the epithelial cells which will be then released into the saliva, and related studies have shown that the virus may be isolated from the saliva which is confirmed using polymerase chain reaction.

    After the initial process of replication in the salivary duct cells, there is an excessive immune reaction and inflammatory response that induces severe tissue damage. It may present as swelling, pain, and discomfort of the major salivary glands. The virus may be detected in the saliva along with the elevation of salivary amylase in the peripheral blood. This is considered to be the stage of acute sialadenitis. Following this, due to the exaggerated immune response, there may be damage to the salivary gland tissue, which is followed by granulation and fibrogenesis. As a result, there will be reduced secretion of saliva, which can, in turn, result in retrograde infection of the ductal orifices and formation of sialoliths. Ductal stenosis and ductal dilatation can also occur due to the formation of hyperplastic fibrous scars which may result in the formation of mucous plugs. All these processes can contribute to chronic obstructive sialadenitis caused by SARS-CoV-2. Ultrasound examination along with analysis of amylase level in the peripheral blood can be used for the diagnosis of acute sialadenitis. Sialography, ultrasound, measurement of salivary flow, magnetic resonance imaging, etc., can be done for the assessment of chronic sialadenitis. Artificial saliva may be used for the treatment of xerostomia and follow-up care should be provided to evaluate the salivary gland status.[17]

    Many studies have reported the presence of gustatory disorders in laboratory- proven COVID-19 patients. The SARS-CoV-2 virus can cause direct damage to the ACE2 receptors present in the epithelium of the taste buds and peripheral taste neurosensory chemoreceptors. It can also cause damage to the cranial nerve VII, IX, and X, which are responsible for gustation. Dysgeusia or altered taste sensation can also occur due to the involvement of the chorda tympani nerve as the virus can enter the middle ear through the eustachian tube from the nasopharynx and cause subsequent damage to the nerve. Tissue hypoxia and anemia are also thought to cause dysgeusia in patients with COVID-19 infection. Another hypothesis proposed for gustatory disturbances in patients with COVID-19 infection is the inflammatory response pathway. SARS-CoV-2 virus binding to the ACE2 receptors presenting in the oral mucosa can trigger an inflammatory reaction resulting in cellular and genetic changes which can, in turn, cause altered taste sensation. The inflammatory mediators can cause abnormal turnover/net loss of taste bud cells, which can lead to taste dysfunction. Inflammatory process can also result in zinc chelation and change in its homeostasis inside the oral gustatory cells. Zinc insufficiency may be seen as a result of these changes which can cause taste disturbances. Zinc plays a significant role in the inhibition of coronavirus RNA polymerase activity and also can decrease the duration of common cold symptoms in healthy patients. Hence, zinc supplementation of 75 milligram/day or greater is found to be effective in COVID-19 patients as it can reduce the rate of viral replication in the oral mucosa.[18]

    Aphthous-like ulcerations, erosive macules of the oral mucosa, recurrent herpetic oral lesions, candidiasis, fixed drug eruptions, angina bullosa hemorrahagica like lesions, gingivitis, and xerostomia may be seen in patients with COVID-19 infection that may be a result of the impaired immune system or susceptible oral mucosa. Concomitant skin lesions may be also present. Most of the lesions may be present in the tongue and hard palate followed by lips, buccal mucosa, and gingiva. Oral lesions can be self-limiting and may resolve in 10 days. Treatment needs are provided only if the patient is symptomatic.[9],[19],[20]

    Dental drug therapy during COVID-19 infection is an area of concern due to the dependence on the use of analgesics and non-steroidal anti-inflammatory agents (NSAIDs) for pain relief. Paracetamol can be used as the first- line analgesic and if in case it is not effective, then other NSAIDs can be prescribed, unless there is a contraindication. The use of ibuprofen in patients with COVID-19 remains controversial as it is said to increase the expression of ACE2 receptors, which is the binding receptor of the Sars-CoV-2 virus.[21]

    Patients taking NSAIDs regularly for other conditions like arthritis should not be given ibuprofen or diclofenac for routine analgesia. Patients on low-dose aspirin (75 mg/day) for cardiovascular conditions can be given other NSAIDs for analgesia unless there are no other contraindications. But if possible, ibuprofen has to be avoided as there is evidence that it can minimize the antiplatelet effect of aspirin. Patients who are on warfarin therapy should not be prescribed other NSAIDs as it can have drug interactions. Physician consultation and the international normalized ratio have to be monitored if required. Asthma can be exacerbated with the use of NSAIDs, hence it has to be used with caution. In pregnant patients, paracetamol is the safest analgesic that can be used, but prolonged high doses in the 2nd trimester are associated with the development of childhood asthma. There is no absolute contraindication for the use of NSAIDs till the 30th week of gestation, but it will be ideal if we can get the opinion of the patient's gynecologist before the prescription of analgesics to pregnant patients. NSAIDs can be prescribed for lactating mothers but not in high doses and paracetamol is the preferred choice of analgesic.

    In patients who are taking proton pump inhibitors (PPIs) for peptic ulcer disease, NSAIDs can be prescribed for up to 2 weeks, as the PPIs will protect the gastric mucosa from irritation. If NSAIDs have to be prescribed for a longer duration or the patient is at risk of gastrointestinal adverse events due to other comorbidities, physician consultation has to be obtained for the prescription of PPIs.[22]

    Chloroquine is an antiparasitic drug that is mainly used as an antimalarial drug. Hydroxychloroquine is the derivative of chloroquine with less toxicity and has side effects. It is also used for the treatment of autoimmune diseases like systemic lupus erythematosus, chronic ulcerative stomatitis, and Sjogren's syndrome as it can prevent the release of proinflammatory cytokines and prevents autophagy. Due to its antiviral properties, it has been widely used for COVID-19. It is contraindicated during pregnancy and is associated with toxicity and serious side effects when taken in high doses. Oral physicians should be also aware of the drug-induced lichenoid reactions and macular pigmentations, which can be seen in the oral mucosa of patients taking chloroquine/hydroxychloroquine. Azithromycin is one of the most commonly prescribed antibiotics in the dental setting especially in cases with penicillin allergy. The efficacy of using azithromycin and hydroxychloroquine combination for the treatment of COVID-19 is yet to be proved. It is associated with increased incidence of QT prolongation on electrocardiogram. It is associated with increased incidence of QT prolongation on electrocardiogram and ventricular arrhythmias in patients with other cofactors like advanced age, cardiac disease and use of other QT prolongation drugs.[21],[23]

    Saliva can be utilized as a diagnostic modality due to its various advantages. A study was done by Azzi L et al.[24] showed positive rRT-PCR results for all the saliva samples of patients affected with severe COVID-19 infection. It also showed positive results for the saliva samples of two patients on the same day when the nasopharyngeal swab tested negative. There have been reports of SARS-CoV-2 detection in the saliva of COVID-19 confirmed patients on the 11th day after hospitalization. This signifies the importance of the risk of transmission of the virus through saliva even when the patient is completely asymptomatic and also the utility of saliva in the detection of SARS-CoV-2.[25]

    One of the limitations of this review was the limited number of studies on this topic and the type of articles mainly belonging to review, opinion, and short communications. Hence, the quality of evidence is comparatively low.

       Conclusion Top

    Dental professionals belong to the high-risk category of contracting COVID-19. Among the dental professionals also there is the categorization of risk depending on the use of aerosols. But with the increasing evidence of saliva being a reservoir for the virus the risk for all dental personals may be considered almost equal. Oral physicians need to be alert regarding the increased possibility of adverse drug reactions, drug interactions, side effects, etc., in the COVID-19 era. One has to have a thorough knowledge of the medications used, availability of alternate medications in case of scarcity, and the protocol to be followed while treating patients. Remote consultations and digital images can be used but with caution, as the clarity and authenticity also have to be taken into consideration. Triaging and other protocols have to be strictly implemented.

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    Conflicts of interest

    There are no conflicts of interest.

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