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| CASE REPORT |
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| Year : 2023 | Volume
: 13
| Issue : 1 | Page : 43-47 |
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Prosthetic rehabilitation of post-COVID mucormycosis
Ayana Shalimon, R Ravichandran, K Harsha Kumar, S Aneesh
Department of Prosthodontics, Government Dental College, Thiruvananthapuram, Kerala, India
| Date of Submission | 28-Dec-2022 |
| Date of Acceptance | 23-Feb-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Dr. Ayana Shalimon
Department of Prosthodontics, Government Dental College, Thiruvananthapuram - 695 011, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_32_22
 Abstract | | |
Mucormycosis is one of the most rapidly fulminating fatal mycotic infections in human beings leading to necrosis and destruction of the involved structures. Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2, has been associated with a wide range of opportunistic bacterial and fungal infections. Increasing case of mucormycosis has been seen in patients affected by COVID-19. This article includes a case report on diagnosis, pharmacological, surgical management, and prosthetic rehabilitation of post-COVID mucormycosis.
Keywords: Definitive obturator, maxillary defect, maxillectomy, obturator, post-COVID mucormycosis, prosthodontic rehabilitation
How to cite this article:
Shalimon A, Ravichandran R, Kumar K H, Aneesh S. Prosthetic rehabilitation of post-COVID mucormycosis. J Interdiscip Dentistry 2023;13:43-7 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
- Cases of mucormycosis are first addressed by the ear, nose, and throat specialist or by a dentist
- Specialist in oral medicine, oral surgeons, oral pathologist, and prosthodontist shares the responsibility of diagnosis, treatment planning, and management of oral mucormycosis
- Management of mucormycosis includes pharmacological approach, surgical approach, and finally prosthetic rehabilitation by consulting a prosthodontist.
| Introduction | | |
Mucormycosis, previously called zygomycosis, is a serious, rare fungal infection caused by a group of molds called mucormycetes which belong to the class phycomycetes. It is one of the most rapidly fulminating fatal mycotic infections in human beings leading to necrosis and destruction of the involved structures.[1] COVID-19 or coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus-2 which has been associated with a wide range of opportunistic bacterial and fungal infections.[2]
Diabetes mellitus, blood dyscrasias, neutropenia, organ transplants, long-term corticosteroid use, and patients under immunosuppressive therapy[1] predispose to the disease condition. The contact with the spores and weaker immune responses increase the widespread chance of the disease.[3] Mucormycosis is presented in various clinical forms; rhinocerebral, pulmonary, gastrointestinal, cutaneous, and disseminated.
Rhino-orbital-cerebral mucormycosis may present with periorbital or retro-orbital pain, double or blurred vision, and partial or complete loss of vision in one or both eyes might progress to blindness. The involvement of the brain can manifest with altered consciousness, unstable gait, and/or seizures.
The intraoral finding may be visualized as a erythematous lesion in the palate at the initial course of disease which will progress to black or gray areas of eschar as necrosis ensues. Eschar may be seen in the nasal septum, palate, eyelid, face, or orbital areas. Necrosis progresses to produce defects in palatal perforation resulting in oronasal communications.
The cases of mucormycosis can be diagnosed with history, examination, and laboratory investigations. All mucorales grow rapidly in 3–5 days on most fungal culture such as sabouraud agar and potato dextrose agar incubated at 25°C–30°C.
The treatment involves the control of any metabolic diseases, antifungal medications such as amphotericin B lipid complex, liposomal amphotericin B and posaconazole oral suspension, and surgical resection of affected tissues. Surgery majorly involves the radical resection of the infected area.[3]
The prognosis depends on the early diagnosis and treatment. The disease can rapidly spread in the midfacial and orbital region causing irreversible damages such as palatal defects, oralantral fistula, blindness, and associated craniofacial disfiguration.[4],[5],[6]
| Case Report | | |
A 47-year-old male patient reported to the Department of Prosthodontics, Government Dental College, Trivandrum, with a chief complaint of the presence of defect and missing teeth in the upper right region of the oral cavity [Figure 1]. History revealed that he had undergone limited maxillectomy of the right side for the management of rhino-orbital mucormycosis 1 year back, resulting in Cordeiro classification of maxillectomy defect Type 1 (resection of one or two walls of maxilla excluding the palate). The patient's consent was taken before the commencement of prosthodontic rehabilitation. The stability of the tissues was assessed, and a definitive prosthesis design was decided based on the functional requirements. | Figure 1: Intra-oral defect due to maxillectomy of right side for management of rhino-orbital mucormycosis
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The conventional impression procedures were utilised for making the primary impression; impression compound was used to record the defect and the remaining teeth and alveolar structure was recorded in alginate. Mouth preparation was done by preparing rest seats for cast partial metal framework. The cast partial obturator made of cobalt chromium was planned wherein maxillary left first premolar and molar tooth were prepared to receive a metal ceramic crown with rest seats incorporated as the teeth had undergone attrition, second molar was prepared to receive a distal rest of simple circlet clasp. Conventional designs and fabrication procedures were followed. Antero-posterior palatal strap major connector was planned.
Secondary impression of the defect was made over metal framework with admix material and lined with light body impression addition of silicon material and the master cast was obtained [Figure 2]. Jaw relation was done, followed by teeth arrangement [Figure 3]. Try-in was done to evaluate esthetics, phonetics, and function.
The obturator was then acrylized in conventional manner. Thermocol balls were incorporated during packing of acrylic in the defect area to reduce the weight of prosthesis [Figure 4] and [Figure 5]. The obturator prosthesis was finished and polished. Obturator was inserted and occlusion was verified [Figure 6] and [Figure 7]. At insertion, the pressure indicator paste was used to inspect for any pressure areas. The obturator prosthesis was inserted and postinsertion instructions were given to the patient in the care and use of obturator. This definitive cast metal obturator significantly improved the esthetics, phonetics, and function of the patient [Figure 8] and [Figure 9]. Patient was reviewed bimonthly for three months and then follow up visits were arranged to at three months interval.
| Discussion | | |
The collective effort of the ear, nose, and throat surgeon, maxillofacial surgeon, and prosthodontist has given physically and psychosocially incapacitated post-COVID mucormycosis-affected patients a greater level of social acceptance. Various prosthodontic treatment options are available but the selection of material and planning regarding the mode of retention is of utmost importance.[7]
Excellent biocompatibility and thermal stability made silicones gain more popularity and can be stained intrinsically and extrinsically. However, the use of silicone adjacent to the nasal defect area can be a source of infection due to the silicone porosity, so acrylics are preferred material in such cases.
The soft liners provide a cushioning effect between the prosthesis and the defect margins, thereby reduces pressure on defect areas also the flexibility of these materials allows for easier placement of the obturator into retentive undercuts.[8] There is higher risk of fungal contamination of soft liners compared to acrylic resins thus soft liners must be avoided in prosthesis that contacts the nasal mucosa.[9],[10] Maxillectomy defects are always prone to bacterial superinfection by oral and respiratory commensals even during rehabilitation procedures.[11],[12],[13]
The remaining natural teeth provide retention, support, and stability for the planned prosthesis and have to be evaluated for endodontic and periodontal treatments to preserve them, as the success of the prosthesis largely depends upon these teeth. Wrought-wire clasps enhances retention of the immediate surgical obturator. The definitive prosthesis can be fabricated after 3–6 months of complete healing with cobalt chromium or titanium framework. Hollow obturator significantly reduces the weight, from 65.5% to 33.06%, depending on the size of the defect. The facial defects are rehabilitated with suitable prosthesis made of biomaterials such as polymethyl methacrylate, polyvinyl chloride, silicone, and polyurethane.[12],[14]
For mechanical retention of the prosthesis, tissue undercuts can be utilized or the prosthesis may be attached to the patient's eyeglasses, stabilized by an elastic band around the back of the head from one earpiece to the other or dentures.[11],[14] In addition, medical-grade adhesives, tapes, and implants provide retention.[5]
The open hollow bulb design is lighter in weight, improves suspension cantilever mechanics, prevents overstressing of the remaining supporting structures, and increases retention and produces better articulation.[14],[15]
Gaur et al. describe an implant-retained denture was used to assist with the retention, soft-tissue support, and stability of the definitive obturator.[16]
The use of pterygoid, zygomatic, and nasal implants in patients who have recovered from mucormycosis was also reported to be more effective than conventional implants in improving prosthesis retention and support.[17],[18],[19] Medically compromised conditions such as uncontrolled diabetes, immunodeficiency diseases, and irradiation limit the use of osseointegrated implants.[20],[21],[22]
Kaur et al. has suggested the use of a heat polymerized conformer substructure that makes use of the defect undercuts for retention in cases where implants are contraindicated. The conformer can be digitally fabricated and hollowed easily to reduce the overall weight of the prosthesis and facilitate hygiene procedures and minimize the tissue contact of silicone thereby minimizing the risk of tissue irritation and recurrence of infection.[17]
A direct contact of adhesive-retained silicone prosthesis is not recommended in orbital mucormycosis cases due to the risk of accelerated deterioration of the fit of the prosthesis and recurrence of infection.
Patients with orbital and maxillary defects with missing anatomic undercuts can be rehabilitated with orbital prosthesis attached to the obturator with a pin and socket of an electricity plug or magnetic buttons which are inexpensive and readily available that provide satisfactory retention, thereby preventing the use of adhesives or spectacles, provided patients must have manual dexterity to seat the prosthesis.[23] However, with time, their efficiency may be reduced due to corrosion or loss of magnetism.
Gowda et al. utilised a brass cylinder and housing method of retention in sino-orbital mucormycosis case which helps to reduce the movement of the extra-oral prosthesis when the obturator functions by providing a movable joint between both components.[24]
Dhiman et al. recommended the application of an antifungal medication, such as Nystatin cream, to the prosthesis surface coming in contact with the nasal or oral cavity. Patients should be scheduled for long-term follow-up appointments to check for any signs of possible candida or bacterial super infections. The most suitable disinfection procedure for the prosthesis is microwave exposure. Chlorhexidine has been shown as an excellent auxiliary method to cleanse facial prostheses, along with the use of hydrogen peroxide and isopropyl alcohol. Disinfection with sodium hypochlorite solution is not recommended.[5]
| Conclusion | | |
Patients with post-covid mucormycosis with involvement of oral tissues, requires a multidisciplinary approach ranging from medical management, surgical approach and finally prosthodontic rehabilitation. Post-surgical prosthodontic management of intraoral and facial defects by means of obturator prosthesis can improve the form, function and appearance of patients and thus enhancing the patients with a psychological benefit as it vanishes the social stigma. Long term follow up will provide better treatment outcome for patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Mane RS, Watve JK, Mohite AA, Patil BC. Rhinocerebral mucormycosis: A deadly disease on the rise. Indian J Otolaryngol Head Neck Surg 2007;59:112-5.  |
| 2. | Singh AK, Singh R, Joshi SR, Misra A. Mucormycosis in COVID-19: A systematic review of cases reported worldwide and in India. Diabetes Metab Syndr 2021;15:102146. |
| 3. | Sykes LM, Coogan MM. Yeast counts as a measure of host resistance in dental patients. J Dent Assoc S Afr 1997;52:19-23. |
| 4. | Spellberg B, Ibrahim AS. Recent advances in the treatment of mucormycosis. Curr Infect Dis Rep 2010;12:423-9. |
| 5. | Dhiman R, Arora V, Kotwal N. Rehabilitation of a rhinocerebral mucormycosis patient. J Indian Prosthodont Soc 2007;7:88. [Full text] |
| 6. | Brunet K, Rammaert B. Mucormycosis treatment: Recommendations, latest advances, and perspectives. J Mycol Med 2020;30:101007. |
| 7. | Shah RJ, Katyayan MK, Katyayan PA, Chauhan V. Prosthetic rehabilitation of acquired maxillary defects secondary to mucormycosis: Clinical cases. J Contemp Dent Pract 2014;15:242-9. |
| 8. | Gaur V, Patel K, Palka L. An implant-supported prosthetic rehabilitation of a patient with a bilateral subtotal maxillectomy defect secondary to rhino-orbital-cerebral mucormycosis: A clinical report of a graftless approach. J Prosthet Dent 2022;128:101-6. |
| 9. | Kovács AF. A follow-up study of orbital prostheses supported by dental implants. J Oral Maxillofac Surg 2000;58:19-23. |
| 10. | Toljanic JA, Eckert SE, Roumanas E, Beumer J, Huryn JM, Zlotolow IM, et al. Osseointegrated craniofacial implants in the rehabilitation of orbital defects: an update of a retrospective experience in the United States. J Prosthet Dent 2005;94:177-82. |
| 11. | Diz P, Scully C, Sanz M. Dental implants in the medically compromised patient. J Dent 2013;41:195-206. |
| 12. | Al-Mendalawi MD. Refractory mucormycosis: A possible cause for maxillary necrosis. J Interdiscip Dentistry 2018;8:41. [Full text] |
| 13. | Arora A, Patil BA, Adepu A, Reynold R. Refractory mucormycosis: A possible cause for maxillary necrosis. J Interdiscip Dentistry 2017;7:65-8. [Full text] |
| 14. | Jain RA, Verma M, Gupta R, Gill S, Ghosh M. Fabrication of a bicomponent hybrid orbital prosthesis. J Prosthet Dent 2019;122:568-72. |
| 15. | Hahn GW. A comfortable silicone bulb obturator with or without dentures. J Prosthet Dent 1972;28:313-7. |
| 16. | Veerareddy C, Nair KC, Reddy GR. Simplified technique for orbital prosthesis fabrication: A clinical report. J Prosthodont 2012;21:561-8. |
| 17. | Kaur H, Nanda A, Verma M, Mutneja P, Koli D, Bhardwaj S. Prosthetic rehabilitation of resected orbit in a case of mucormycosis. J Indian Prosthodont Soc 2018;18:364-9. [Full text] |
| 18. | Ahmed ZU, Flynn J, Riedel ER, Huryn JM, Rosen EB. Definitive maxillary obturator prosthesis: Timelines for fabrication and follow-up. Spec Care Dentist 2020;40:315-9. |
| 19. | Arora A, Patil BA, Adepu A, Reynold R. Refractory mucormycosis: A possible cause for maxillary necrosis. J Interdiscip Dentistry 2017;7:65-8. [Full text] |
| 20. | Jilta CF, Sreeraj RS, Ravichandran R, Kumar KH. Rehabilitating a maxillectomy patient by interdisciplinary alveolar bone preservation technique using submergence of teeth roots. J Interdiscip Dentistry 2020;10:126-31. [Full text] |
| 21. | Ali IE, Chugh A, Cheewin T, Hattori M, Sumita YI. The rising challenge of mucormycosis for maxillofacial prosthodontists in the Covid-19 pandemic: A literature review. J Prosthodont Res 2022;66:395-401. |
| 22. | Kar S, Tripathi A. Delayed obturator for irradiated maxillectomy patients: Case report of two patients. J Interdiscip Dentistry 2015;5:136-9. [Full text] |
| 23. | Mani UM, Mohamed K, Krishna Kumar A, Inbarajan A. A modified technique to fabricate a complete hollow obturator for bilateral maxillectomy in a patient with mucormycosis-A technical case report. Spec Care Dentist 2019;39:610-6. |
| 24. | Gowda M, Shashidhar MP, Prakash P, Sahoo NK. Rehabilitation of a defect secondary to sino-orbital mucormycosis- A prosthodontic challenge. IP Ann Prosthodont Restor Dent 2021;7:41-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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