Dr Graham Lloyd-Jones Profile picture
Oct 11, 2022 17 tweets 6 min read Read on X
1/
A thread to explain the reasons why it is important to care for the mouth if you have #COVID.

If you don't have time to read is all, here is the mouth care guidance (patient information sheet) we are providing our patients @SalisburyNHS ...

salisbury.nhs.uk/coronavirus/co…
Image
2/
... and this is a presentation giving more detail.

Highlights in thread below.

3/
Here goes ...

The lung disease of COVID-19 is not a conventional respiratory 'pneumonia'. It is a 'pulmonary vasculopathy' - a disease of the lung blood vessels.

4/
This raises the question - 'How does the virus (or viral elements) reach the lung blood vessels?'
5/
Yes, the virus is inhaled but it doesn't cause disease in the visible airways on CT scans.

Blood vessels are dominantly affected.

Areas of the lungs damaged are the least accessible to the airways (bottom, back, and sides of the lungs)

It is not flu! pubmed.ncbi.nlm.nih.gov/33634067/
6/
All the medical imaging characteristics of the lung disease are vascular - clotting, dilated blood vessels, perfusion defects (reduced blood flow) - dominantly in a vascular, gravity-dependent distribution. Image
7/
Could #SARS2 be arriving in the lungs via the bloodstream?

If so, what is the route?

The upper respiratory tract is the first site of infection, not the lungs. The ACE2 receptor is expressed x200-700 more intensely in the nose than in the lung airways
erj.ersjournals.com/content/56/3/2…
8/
The airways of the lungs do not express the ACE2 receptor with high intensity -
'ACE2 expression in the respiratory tract is limited, with none or low levels of ACE2 expression in lung and respiratory epithelia' - Hikmet et al
embopress.org/doi/full/10.15…
9/
We know that multiple epithelial cell types in the mouth are highly susceptible to infection and replication (copying) of the virus.

nature.com/articles/s4159…
10/
The mouth is a viral 'factory' with levels of the virus in saliva reaching 100 million per ml. That's half a billion in a 5 ml teaspoon.

ncbi.nlm.nih.gov/pmc/articles/P…
11/
Also reported is a link between high viral load (concentration) in saliva and disease severity. High viral load in saliva is a better predictor of death than patient age. (This is independent of nasopharyngeal load).

(Preprint from Yale University.)
medrxiv.org/content/10.110…
12/
A study showed that gum disease is linked to poor outcome in COVID-19 with an odds ratio for death of 8.81.

doi.org/10.1111/jcpe.1…
13/
Hypothesis that the virus could escape the mouth - for example across bleeding gums - with direct delivery to the lungs via the bloodstream. The alveolar capillaries (small blood vessels in the lungs) is the first place the virus would reach.

bit.ly/36uEwar
Image
14/
The mouth is the most accessible place we can kill #SARS2.
How? By caring for our mouth with simple oral hygiene measures - such as toothbrushing and ...
15/
A study showing mouthwashes containing cetylpyridinium chloride (CPC) and ethyl lauryl arginate (ELA or LAE) completely eradicate the virus in the test tube and reduce viral load in saliva in the mouth.
(Other mouthwashes may have some affect also)
pubmed.ncbi.nlm.nih.gov/35436499/
16/
Using a mouthwash which reduces viral load in the mouth, as a single measure in addition to standard care, reduces average COVID-19 length of hospital stay from 7 days to 4 days.
nature.com/articles/s4159…
17/
In summary, the mouth plays an important role in COVID-19 and there is something we can do about it.
There is good reason to suggest the mouth also plays a role in #longCOVID which is what I hope to investigate next.

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More from @DrGrahamLJ

May 17
I've previously highlighted the importance of correct nomenclature relating to #COVID.

Here's a response letter I wrote to 'Clinical Radiology' explaining why terms such as 'pneumonia' are inappropriate.



And a thread for public interest...
👇👇👇
1/18 authors.elsevier.com/a/1j2TT2GSL8dc2
Image
I wrote this letter with colleagues - Dr Rob Alcock & Professor Matthijs Oudkerk - in response to a review of the medical imaging appearances of the lung disease of #COVID. It was a good review but like most journal articles it did not accurately describe the lung disease.
2/18
The lung disease of acute #COVID-19 has been incorrectly described as a 'pneumonia' by almost all researchers and doctors since the beginning of the pandemic.

This was a big mistake!

3/18
Read 18 tweets
Apr 5
#RheumatoidArthritis is triggered by immune responses to oral bacteria circulating in the blood in people with #GumDisease.

A thread to attempt to unpick this complicated but fascinating study from 2023👇👇👇

1/19
ncbi.nlm.nih.gov/pmc/articles/P…
Oral bacteria frequently pass across our gum tissue and enters our bloodstream. This occurs to a greater extent in people with #gumdisease which makes the gums more leaky.
2/19
The actions of immune cells (neutrophils) in the mouth alter the protein structures of oral bacteria by a process called citrullination.
Oral bacteria with altered proteins (citrullinated proteins) are detected by cells of the immune system.
3/19
Read 19 tweets
Apr 2
#PoorOralhealth / #OralDysbiosis / #GumDisease causes systemic diseases 101 ...

The bacterium Porphyromonas gingivalis causes #InsulinResitence (#Type2Diabetes)

A long thread to unpack this review paper
👇👇👇👇👇

1/25 frontiersin.org/articles/10.33…
Image
The bacterium Porphyromonas gingivalis (#Pgingivalis/Pg) is the main causative agent of periodontitis (gum disease).
P.gingivalis is also directly implicated in the development of multiple important systemic diseases, including #Type2Diabetes.
2/25
P.gingivalis expresses virulence factors leading to disruption of the innate and adaptive immune systems allowing it to survive in the mouth and cause an inflammatory process which destroys gum tissue.
3/25
Read 25 tweets
Mar 15
Dear #MedTwitter
To help understand #LongCOVID I believe there are important lessons we first need to learn about the acute phase of #COVID-19. This is because (as I see it) they are different phases of the same disease.
#LongCovidAwarenessDay
A thread👇
The human body has 60,000 miles of blood vessels. The inner lining of these blood vessels – the endothelium – should be considered as an organ of the body. It is an organ which determines overall body physiological health.
It is this organ – the endothelium – which is damaged in all phases of #COVID.
Read 17 tweets
Dec 10, 2023
Thanks to all who answered this quiz question.
Well done to those who noticed the question is ambiguous. It could mean...
Which pathogen-
-causes disease in the most people?
-has killed most people?
-is most lethal?

In answer to the first two, I think it’s this one👇
A thread …
Image
Malaria, TB, Y.pestis have certainly killed many people.

Ebola has high lethality, but rabies wins this one.

In terms of which pathogen causes most disease AND killed most people, I now believe the answer is the oral microbiome bacteria - Porphyromonas gingivalis Image
Well done to those who mentioned P.gingivalis

Why do I think it is the most pathological? Image
Read 13 tweets
Dec 1, 2023
Thanks for sharing this Robert. I share your concern regarding routine use of mouthwash.
Please can I pick apart this study a little because there are important points to make…
1/
2/
Firstly, this is not an interventional study. It is an observational study. It acknowledges that causation cannot be inferred (which is good).
The study simply asked a population of overweight people if they used mouthwash. Then waited to see if they developed hypertension.
3/
But the study missed reference to a large potential confounder…
Gum disease!
Periodontitis (severe gum disease) is increasingly linked to the onset and worsening of hypertension and diabetes.
Read 17 tweets

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