COVID-19 Long-Haulers and Dentistry

When the coronavirus 2019 disease (COVID-19)affects you personally, it strikes an unexpected emotional cord. Social media allows me to communicate with high school and college classmates on a regular basis. For instance, I recently reconnected with a classmate and great friend who was diagnosed with COVID-19.

She’s an RN who probably became infected at work. SARS CoV-2 hit her very hard and although she avoided hospital admission, she was worried she would become what’s called a COVID-19 long-hauler (also referred to as long COVID). After 4 weeks, this RN was still experiencing extreme fatigue, anxiety and depression so she joined a support group and started taking a homeopathic sleep aid to help her tackle insomnia.

The term “long COVID” refers to illness in people who continue to have lasting effects after infection.¹ In dentistry, some of these patients will undoubtedly be walking in the door and seeking care with an array of symptoms, long after quarantine or negative test results.

Eighty-one percent of COVID-19 cases are reportedly on the mild end of the spectrum.¹ In one Geneva, Switzerland study that described symptoms and persistence of COVID-19 from day 1-45 after diagnosis, a third of ambulatory patients 30-45 days after diagnosis showed persistence of symptoms. Fatigue, dyspnea, and loss of taste or smell were the main persistent symptoms.¹

Influenza pandemic of 1889-92

The lingering after-effects of past pandemics like Russian influenza did not mean the end of sickness but was instead the prelude to a “longue durée” of mysterious sequelae of chronic illnesses with some convalescents too debilitated to return to work and daily routines for a long time to come.² Similarly, patients with severe acute respiratory syndrome coronavirus have created a new category of patients who may not have been critically ill but report an array of symptoms including extreme fatigue, hallucinations, “brain fog”, delirium, memory loss, tachycardia, numbness, tingling, and shortness of breath.² Colleagues of mine with COVID-19 have reported anxiety and depression and some have joined social media or in-person support groups and research forums. #LongCovid threads on Twitter seem to resemble earlier influenza victims and they assist each other in trying to navigate puzzling debility, recurrence, and overall dread of a new disease with so many unknowns.²

COVID-19 long-haulers report having their experience of psysiological suffering to be disbelieved by medical practitioners

and even worse, COVID-19 interacts with other social and biological phenomena like non-communicable diseases, health resource strain, socioeconomic disparities, unequal housing, and racism and this new clustering is called SYNDEMIC.²

There are encouraging signs that post-COVID-19 data on long-haulers is being taken seriously. Post-COVID-19 rehabilitation and outpatient care are being introduced in India, Italy, and the U.S., and the WHO is collecting data about the long-term effects of COVID-19 and sharing rehabilitation advice.² Initial data has already shown that those individuals who are self-reporting indicate that 10 percent have had symptoms for 30 days and 1.5 to 2 percent for 90 days.² Women are about twice as common as men to have long-COVID-19 symptoms but sampling bias is possible and it’s probably too early to jump to any conclusions about long-hauler characteristics. COVID-19, in one form or another, is probably here to stay and the pandemic, like previous ones, tends to linger not only in our bodies but also in our minds, culture, and communities.²

Types of long-haulers and conditions they may develop

COVID-19 is a relatively new disease that began in China in December 2019. Researchers are beginning to collect data on long-term recovery rates but it is still premature to expect much. We can’t even predict who will become a long-hauler.³ Continued symptoms are more likely to continue in patients over age 50, those with severe COVID-19, and those with two-three chronic illnesses.³

Long haulers include two types of people:

1. those individuals with permanent damage to organs like lungs, brain, heart, or kidneys that may affect their ability to function
2. those individuals who experience debilitating symptoms without detectable damage to organs3

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease at the National Institute of Health, reports the possibility of those in the second, debilitating group to develop a condition called myalgic encephalomyelitis/chronic disease syndrome, also known as ME or CFS. ME/CFS is not the symptom of long-term fatigue but a chronic disease with symptoms in every body system. SARS CoV-2 is not the only coronavirus to result in this ME/CFS syndrome. One study showed that 27 percent of those individuals who survived SARS showed symptoms of CFS years after developing SARS.⁴ In fact, chronic post-SARS (another coronavirus outbreak in 2003) is characterized by persistent fatigue, diffuse myalgia, weakness, depression and non-restorative sleep with associated sleep disorders like CFS.⁵ Longer term, large scale studies will be needed post-COVID-19 to investigate COVID-19 long-hauler conditions.

Dental considerations for COVID-19 long-haulers

Studies and guidance for COVID-19 long-haulers will emerge in dentistry, albeit gradually as data is collected and patients continue to return for care in dental practices. These patients should be encouraged to return but you will need to be prepared to ask appropriate questions, especially those pertaining to lingering symptoms.

Many COVID-19 long-haulers have turned to patient-centered and online forums for support and validation and they may already be prepared to ask pointed questions about their oral health. For example, if a COVID-19 long hauler presents with mild chronic fatigue syndrome, what preventive measures would a dental practitioner recommend? Some ME/CFS patients are bedbound and/or homebound but for those who can visit a dental practice, many report dental pain.⁶

Effective communication is essential to the maintenance of oral health in these patients and should be a significant component in the overall care plan.⁶ Dental practitioners should be aware of their role as members of an interdisciplinary healthcare team and their input should be included in the broader healthcare community involved in the care of these patients.⁶ Read all you can about treating the patient’s disabling fatigue and muscle pain that will affect every aspect of the patient’s care including the length of appointment to keeping an appointment.

I read a recent online article about a dental hygienist and therapist in London, England who’s a COVID-19 long-hauler.⁷ She’s created a Facebook page for colleagues with long haul COVID symptoms which gives this dental hygienist and colleagues the lifeline they need.⁷ She mentions in her article that her experience has driven her to improve her diet by removing caffeine and reducing sugar intake and she believes that her symptoms would have been worse if she had not changed her diet.

Debilitating after-effects plague many COVID-19 long-haulers and we must be prepared to manage this complex population group. The patient’s chief complaint always comes first followed by a thorough review of the patient’s medical history, including long-haul symptoms. Many long-haulers complain of “brain fog” and in those patients with ME/CFS, about 85 percent experienced some degree of cognitive impairment.⁶

I’ve learned from friends and colleagues who have been infected with COVID-19 that simple acts of reassurance help the most when suffering from unexpected conditions like anxiety and depression that can sometimes accompany COVID-19. Something as basic as hearing from loved ones regularly or being given a recommendation for a homeopathic sleep aid or a beverage that boosts the immune system works wonders. Just knowing that you’re not alone and that in time you’ll be back to your old routine is extremely helpful. Use your magical communication skills to wow this subset of patients and remember that every kind gesture helps.

References

1. https://www.acpjournals.org/doi/10.7326/M20-5926 Accessed December 14, 2020
2. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32134-6/fulltext Accessed December 14, 2020
3. https://www.health.harvard.edu/blog/the-tragedy-of-the-post-covid-long-haulers-2020101521173 Accessed December 14, 2020
4. https://www.meaction.net/long-covid-me-understanding-the-connection/ Accessed December 14, 2020
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071317/ Accessed December 14, 2020
6. https://www.preprints.org/manuscript/202007.0754/v1/download Accessed December 14, 2020
7. https://www.dentistry.co.uk/2020/09/29/supporting-dental-colleagues-long-haul-covid-symptoms/ Accessed December 14, 2020