Index

1. INTRODUCTION

Chikungunya virus infection often results in severe fever, rash and debilitating poly-arthralgia lasting weeks to months [1 , 2 ]. While arthralgia, pain in joints is the most consistent and debilitating symptom of CHIKV-induced disease, most commonly effecting distal extremities as well as ankles and metatarsophalangeal joints [2 ]. Researchers have also investigated the involvement of temporomandibular joint in oral cavity; not much literature is available in this regard. Oral cavity may show features, as indicative in this research, which may uphill towards more specific diagnosis for CHIKV-induced disease.

CHIKV is considered a neglected tropical disease, because it circulates within the subtropical and tropical regions, but it has the potential to affect more than 1 billion people [3 ]. Since 2005, major breakouts of chikungunya virus have occurred in India, Indonesia, Maldives, Myanmar and Thailand have reported over 1.9 million cases. In Pakistan, it was first reported at Lahore in 2011 during dengue outbreak [4 ] chikungunya shares some common clinical symptoms with dengue and zika virus therefore requires greater expertise in diagnosis and treatment. Dated recently, the disease took a flare up in November, 2016 affecting 30 000 people in the metropolis of Karachi [5 ].

Joints being the commonest victim of Chikungunya Virus infection presents as poly-arthralgia, extent of pain vary from weeks, months to years [1 , 6 ]. Experiment and Research performed in 2015 by David W. Hawman hypothesized that increase in viral persistence, induction of autoimmune disease and exacerbation of pre-existing joint disease contributes to CHIKV-induced arthritis [7 ]. Like other body tissues, oral cavity appears to show some features such as bleeding gums, halitosis, difficulty in swallowing and mastication. A study evaluating the impact of CHIKV infection on oral health status conducted in India in year 2011 deduced that severe pain, bleeding gums and gingivitis along with discomfort in oral function was found in majority of cases affected by CHIKV [8 ]. The foremost concern is the involvement of musculoskeletal component of oral cavity; the temporomandibular joint is yet to be further experimented and researched. This study, based on observational survey, underscores the engrossment of TMJ and other oral features significant of CHIKV-induced infection.

2. MATERIAL AND METHOD

This study was aimed to evaluate the impact of CHIKV infection on oral cavity and temporomandibular joint via a survey conducted at different Hospitals and Health care centers, data was than collected from patients with due consent.

It was a cross sectional study, accompanied with a self-designed questionnaire run through a pilot study which encompassed clinical findings in oral cavity of patients with CHIKV and also its effect on temporomandibular joint. Patient’s demographics were collected, past hospital records of infection treated or active were also squared.

In Karachi, Baldia town and Malir town has been reported as endemic areas, where during course of this study 527 patients were found to be admitted with suspected infection. On lab investigations 204 patients were diagnosed with CHIKV infection, among which 135 were selected as participants for this study with their consensus. Study was undertaken at Civil hospital, Sindh Government Hospital Malir, RHC Baldia town and few private health care centers from January 2017 to October 2017.

Patients screened for active disease showing confirmatory lab diagnosis of CHIKV infection with no concomitant systemic disease or illness were included in this study. All those patients not detected with active CHIKV infection were not included in this study.

After Data Collection, Descriptive and Association tests were used for Statistical analysis using SPSS-16.0.

Clinically, the Gold standard Test for diagnosis of CHIKV infected person is viral culture [9 ] other includes Enzyme-linked immunosorbent assay (ELISA) and real-time PCR (RT-PCR) [10 , 11 ]. For the reason that endemic circumstances, small time window, lack of resources and funding’s for clinical diagnosis in adjunct with the hospital’s reports based on RT-PCR were also trusted and patients were considered positive based on reports confirmation.

3. RESULT

The study accompanied 135 patients diagnosed with CHIKV out of which 78 were male and 57 female. The age range from 13 to 61 years, patients of 15 to 30 years were mostly infected by virus as demonstrated in the pie graph (Figure, 1)

Figure-1. Patient’s age groups.

Source: Self designed table generated by interpreting Data via SPSS 16.0

On analysis, more than 50% of patients’ complaint of pain and burning sensation in oral cavity along with discomfort in mouth opening and bleeding gums. Some also reported taste aversion and inability to chew food. Less than 50% of affected candidates listed discomfort in swallowing and bad breath. The major finding was tenderness over temporomandibular joint reported by 30.4% of CHIKV infected patients. Very few (<10%) indicated mouth sores, excessive salivation, discharge from gums, grating sound from TMJ and loosening of teeth as an associated symptom (Table 1 and 2).

Table-1. Impact of Chikungunya on Oral Cavity

  Source: Self designed table generated by interpreting Data via SPSS 16.0

Table-2. Impact of Chikungunya on Temporomandibular Joint

Source: Self designed table generated by interpreting Data via SPSS 16.0

Data collected was interpreted and evaluated on the basis of age and gender to signify the findings in oral cavity during CHIKV infection. On the basis of age group, statistically it was established that pain and burning sensation was mainly reported by younger patients (78%) while symptoms like discomfort in mouth opening (72%), bleeding gums (59%), inability to chew (72%) and halitosis (45%) were found to increase proportionally with escalation in age.

Figure-2. Severity of symptoms associated with age.

Source: Self designed chart generated by interpreting Data via SPSS 16.0

In the survey, 65.9% of Patients affected by chikungunya virus infection stated the significant symptoms associated with the  Temporomandibular Joint, irrespective of age and gender, in chikungunya virus infected patients are pain and discomfort in oral cavity during chewing, tenderness over temporomandibular joint (30.4%) and swelling over TMJ area (28.1%) (Table 2).

On gender basis, 79% female patients complaint of pain and burning sensation in oral cavity and 72% reported discomfort in mouth opening compared to 65% of male pupil. No other significant gender predilection was found for other symptoms under investigation (Table: 3.) (Figure, 3)

Table-3. Symptoms association with Gender

Source: Self designed table generated by interpreting Data via SPSS 16.0

Figure-3. Genders predilection chart

Source: Self designed chart generated by interpreting Data via SPSS 16.0

4. DISCUSSION

Research and studies [1 , 12-15 ] done in this regard mainly focused on joint infection and extremities involved in chikungunya virus infection, based on systemic, arthrological and classical signs and symptoms of chikungunya virus infection. Very few literatures were exclusively focused on impacts of CHIKV infection on oral health and temporomandibular joint [8 ]. 

This study aimed to correlate the oral findings and effects on temporomandibular joint with chikungunya virus infection so as to help understanding the nature of CHIKV Infection and for better diagnosis of disease even in Dental outpatient department. Actively diseased patients were identified and approached in Health care centers of major endemic areas and randomly chosen for data collection.

During the study, it was found that CHIKV infection affects a vast group of population from teens to adults ranging 13 to 61 years. However, around 47% of the patients fall in age range 15 to 30 years thus a leading population in mid-teens and young adults is infected. Other research articles [16 , 17 ] also highlighted that pupil of 20 to 40 years or > 45 years [18 ] were also found to be infected.

On statistical analysis, a male female ratio was 1.3:1. In similar studies, the ratio was 2.3:1 [11 ] and 2.4:1 [18 ] showing male dominance. Contrary to this, other studies show female domination with ratio 0.9:1 [2 , 8 ]. This difference in gender predominance can be due to socio-cultural diversity and difference in exposure indexes.

In this study, most prevailing intra oral symptom found in 71.1% of affected patients was pain and burning sensation along with less established ulceration of gums reported by 15.5% of patients indicating gingivitis. The laboratory findings show that patients with CHIKV viral fever have Lymphopenia (lymphocyte count, <1000 cells/mm3), a very common finding, which can account for hemorrhagic findings [1 , 18 , 19 ].

Prevalence of bleeding gums was recorded to be 53.3% in this study, similar results were found in other studies [8 , 18 ]. Mild thrombocytopenia during chikungunya virus infection can be a decent justification for bleeding gums [1 , 18 , 19 ].

Another noteworthy finding recorded during this study was taste aversion in 50.3% patients indicates strong association with chikungunya virus infection.

Discomfort in mouth opening in 59.9% patients, inability to chew food 48.1% and pain or tenderness over TMJ area were the major complaints involving oral cavity in the chikungunya virus infection related with TMJ arthralgia and myalgia. These symptoms signifies the arthralgic nature of CHKV affecting TMJ along with other joints of the body [20 ].

Halitosis was also an underlined complaint recorded in 34.8% of CHIKV affected group. This may be attributed to inability of patients to maintain oral hygiene when combatting infectious disease which then leads to debilitated gingival status thus bad breath [8 ].

Overall prevalence of inquired symptoms among diseased males and females was 50.1% Average-positivity rate in Males and 52% Average-positivity rate in females. While excruciating symptoms like intra-oral pain and burning sensations, pain or discomfort in mouth opening and food swallowing were found to be greater in females (79%, 72%, 40%) as compared to males (65%, 61%, 32%).

The Gold standard Test for diagnosis of CHIKV infected person is viral culture [9 ] but for this study because of endemic circumstances, small time window and lack of resources and funding’s clinical diagnosis in adjunct with the hospital’s reports based on RT-PCR were also trusted and patients were considered positive based on such reports confirmation.

5. CONCLUSION

Chikungunya virus infection has affected almost every continent of the world and is still dynamically involving and infecting millions of lives. The impact of chikungunya virus on patient’s health is acutely painful and tremendously debilitating. Agony is that chikungunya virus infection is still medically unpreventable although the disease itself is self-limiting. Together with fever and joints pain in extremities it significantly involves Oral cavity and temporomandibular joint. Its impact on Oral health and TMJ is found to be quite painful and uncomfortable to bear causing burning gums, limiting speech, decreased chewing ability, altering taste perception, TM-joint and muscles tenderness and difficulty in food swallowing. Unfortunately very few exclusive studies have been done on chikungunya virus impact on oral health and Temporomandibular joint hence literature needs extensive studies and researches to help in understanding the pathological processes, pacifying the distresses and enhancing the treatment options.      

REFRENCES

[1]         B. A. Goupil and C. N. Mores, "A review of Chikungunya virus-induced Arthralgia: Clinical manifestations, therapeutics, and pathogenesis," Open Rheumatology Journal, vol. 10, pp. 129-140, 2016. View at Google Scholar 

[2]         L. H. Calabrese, "Emerging viral infections and arthritis: The role of the rheumatologist," Nature Clinical Practice Rheumatology, vol. 4, pp. 2–3, 2008. View at Google Scholar | View at Publisher

[3]         W.H.O. Neglected Tropical Diseases, "Retrieved: http://www.who.int/ neglected_diseases/diseases/en/. [Accessed March 2016]," 2016.

[4]         M. F. Afzal, S. Q. Naqvi, M. A. Sultan, and A. Hanif, "Chikungunya fever among children presenting with nonspecific febrile illness during an epidemic of dengue fever in Lahore, Pakistan," Merit Research Journal of Medicine and Medical Sciences, vol. 3, pp. 69–73, 2015. View at Google Scholar 

[5]         M. Rauf, "Outbreak of chikungunya in Pakistan," Lancet Infectious Diseases, vol. 17, p. 258, 2017. View at Google Scholar 

[6]         C. Angela, H. Zhisheng, K. S. O. Edward, C. Jin-miao, D. Frederico, J. C. K. Dyan, B. Timothy, Y. Henry, R. Laurent, and L. Yee-Sin, "Ng; Persistent Arthralgia induced by Chikungunya virus infection is associated with interleukin-6 and granulocyte macrophage colony-stimulating factor," Journal of Infectious Diseases, vol. 203, pp. 149-157, 2011. View at Google Scholar | View at Publisher

[7]         D. Hawman, K. Stoermer, S. Montgomery, P. Pal, L. Oko, M. Diamond, and T. Morrison, "Chronic joint disease caused by persistent Chikungunya virus infection is controlled by the adaptive immune response," Journal of Virology, vol. 87, pp. 13878-13888, 2013. View at Google Scholar | View at Publisher

[8]         R. Katti, P. R. Shahapur, and K. L. Udapudi, "Impact of Chikungunya virus infection on oral health status: An observational study," Indian Journal of Dental Research, vol. 22, p. 613, 2011. View at Google Scholar | View at Publisher

[9]         D. Mourya and P. Yadav, "Vector biology of dengue and chikungunya viruses," Indian Journal of Medical Research, vol. 124, pp. 475-480, 2006. View at Google Scholar 

[10]       I. Sam, B. Kümmerer, Y. Chan, P. Roques, C. Drosten, and B. S. Abu, "Updates on Chikungunya epidemiology, clinical disease, and diagnostics," Vector-Borne and Zoonotic Diseases, vol. 15, pp. 223-230, 2015. View at Google Scholar | View at Publisher

[11]       F. Burt, M. Rolph, N. Rulli, and S. Mahalingam, "Chikungunya: a re-emerging virus," Lancet, vol. 379, pp. 662-71, 2012.View at Google Scholar | View at Publisher

[12]       M. Robinson, "An epidemic of virus disease in southern province, Tanganyika territory in 1952, 53. Clinical features," Transactions of The Royal Society of Tropical Medicine and Hygiene, vol. 49, pp. 28-32, 1955. View at Google Scholar | View at Publisher

[13]       M. Jadhav, M. Namboodripad, R. Carman, D. Carey, and R. Myers, "Chikungunya disease in infants and children in vellore: A report of clinical and haematological features of virologically proved cases," Indian Journal of Medical Research, vol. 53, pp. 764-776, 1965. View at Google Scholar 

[14]       K. Thiruvengadam, V. Kalyansundaram, and J. Rajgopal, "Clinical and pathological studies on chikungunya fever in madras city," Indian Journal of Medical Research, vol. 53, pp. 729-744, 1965. View at Google Scholar 

[15]       F. Rodrigues, M. Patankar, K. Banarjee, P. Bhatt, M. Goverdhn, and K. Pavri, "Etiology of the 1965 epidemic of febrile illness in Nagpur city, Maharashtra State, India," Bulletin of the World Health Organization, vol. 46, pp. 173-179, 1972. View at Google Scholar 

[16]       P. Kaur, M. Ponniah, M. Murhekar, V. Ramachandran, R. Ramachandran, and H. Raju, "Chikungunya outbreak, South India, 2006," Emerging Infectious Diseases, vol. 14, pp. 1623-1625, 2008. View at Google Scholar | View at Publisher

[17]       S. Suryawanshi, A. Dube, R. Khadse, S. Jalgaonkar, P. Sathe, and S. Zawar, "Clinical profile of chikungunya fever in patients in a tertiary care centre in Maharashtra, India," Indian Journal of Medical Research, vol. 129, pp. 438-441, 2009. View at Google Scholar 

[18]       G. Borgherini, P. Poubeau, F. Staikowsky, M. Lory, N. Moullec, and J. Becquart, "Outbreak of chikungunya on reunion Island: Early clinical and laboratory features in 157 adult patients," Clinical Infectious Diseases, vol. 44, pp. 1401-1407, 2007. View at Google Scholar | View at Publisher

[19]       A. O. A. Sanae and C. Bernard, "Arthritis after infection with Chikungunya virus," Best Practice & Research Clinical Rheumatology, vol. 25, pp. 337-346, 2011. View at Google Scholar | View at Publisher

[20]       A. Kennedy, J. Fleming, and L. Soloman, "Chikungunya viral arthropathy: A clinical description," Journal of Rheumatology, vol. 7, pp. 231–236, 1980. View at Google Scholar