Dental Care and Oral Health Assessments in Patients Admitted to an Intensive Care Unit with COVID-19 Infection: A Chart Review

Abstract

Background: This study aimed to investigate the provision of dental care to patients admitted to a public tertiary hospital due to SARS-CoV-2 infection. Methods: A chart review was conducted using medical records of patients admitted with a confirmed diagnosis of SARS-CoV-2 infection at a public tertiary hospital. Patients hospitalized for at least 10 days were included, and data were collected on demographic variables, comorbidities, oral health status, and hospitalization outcomes. Results: A total of 295 patients were included (mean age 60.8 ± 17.4 years). Comorbidities were common, with 29.8% of patients diagnosed with diabetes and 53.3% with hypertension. Only 47.5% of patients received an oral health assessment upon admission, and 58% received oral hygiene care during hospitalization. Oral health evaluations revealed that older adults exhibited significantly higher rates of total edentulism, received more oral hygiene care during hospitalization, and were more likely to undergo oral evaluation at admission. Regarding clinical outcomes, patients with altered mouth opening had significantly lower Glasgow Coma Scale scores (p < 0.001), and those with altered oral mucosa showed reduced oxygen saturation levels (p = 0.006). Conclusions: These study findings highlight the importance of dental care in critically ill COVID-19 patients, particularly in ICU settings. It emphasizes the need for improved dental documentation and integration of dental professionals into hospital-care teams to reduce complications and enhance both oral and systemic health outcomes.

1. Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the Coronaviridae family of RNA viruses, led to a global public health crisis known as the COVID-19 pandemic [1]. Countries, regions, and localities implemented a variety of response measures, with varying degrees of success, to control the transmission of the virus [2,3]. SARS-CoV-2 is primarily spread through respiratory droplets generated by coughing and sneezing, as well as via contact with contaminated surfaces followed by touching the mucous membranes of the nose, mouth, and eyes [4,5].

The oral cavity hosts a diverse microbial community, and many of these microbes have been implicated in the development of both oral and systemic diseases [6,7]. Data from a case series, supplemented by a literature review, have shown that the most common intensive care unit (ICU)-related oral complications in COVID-19 patients include perioral pressure ulcers, oral candidiasis, herpetic and hemorrhagic oral ulcers, and acute macroglossia [8]. In addition, microbiological testing conducted on both nasopharyngeal and lingual swabs from the case-series patients revealed the presence of opportunistic pathogens, including Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterococcus faecalis, indicating the possibility of co-infection [8]. These oral complications, combined with immune dysregulation, the effects of mechanical ventilation, prolonged prone positioning, and the use of broad-spectrum antibiotics, which can lead to secondary oral candidiasis, emphasize the importance of closely monitoring oral health in critically ill COVID-19 patients in the ICU.

Dental procedures, however, present a significant risk of viral transmission due to the high viral load in the upper respiratory tract and the generation of aerosols during dental interventions [9,10]. Despite these risks, it is essential for dental professionals to assess the oral health of critically ill patients, ideally within the first 24 h of ICU admission [11,12]. This includes addressing oral health factors such as loose or avulsed teeth, areas of infection, sharp dental appliances, and orthodontic devices that could potentially cause tissue damage [13,14]. Proper management of these factors can help prevent complications such as bacteremia and infections, as the oral cavity may serve as a source of systemic disease transmission [13].

The lack of proper oral hygiene in ICU patients is a significant risk factor for secondary infections, particularly ventilator-associated pneumonia (VAP), which often results from the aspiration of contaminated secretions from the upper airway [15]. Given the elevated transmission risk associated with SARS-CoV-2, national and international healthcare guidelines have recommended heightened infection-control protocols, including specific dental care measures in hospital settings [16,17,18]. In Brazilian hospital-based dental services, these measures included the use of specialized personal protective equipment (e.g., N95/PFF2 respirator masks; face shields), mouthwashes, careful patient triage, and enhanced sterilization and disinfection techniques [19].

This study aimed to investigate the provision of dental care to patients admitted to a public tertiary hospital in northeastern Brazil due to SARS-CoV-2 infection, focusing on clinical indicators that may be related to the oral health of hospitalized patients during the pandemic.

2. Materials and Methods

2.1. Study Design and Sample

This was a chart review that analyzed medical records to identify quality indicators for dental care. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The data were obtained from the medical records of a public tertiary hospital located in São Luís, Maranhão, Brazil. This study was reviewed and approved by the Research Ethics Committee of the Federal University of Maranhão (CAAE: 44397021.8.0000.5087).

The study sample included patients who had been admitted to the hospital with a confirmed diagnosis of SARS-CoV-2 infection, as confirmed with serological testing, between 1 January 2020, and 30 June 2021. Eligible patients were required to have been hospitalized for at least 10 days. A total of 295 patients met these inclusion criteria. A margin of error calculation was conducted using data from the final study, considering the total number of patients with a confirmed diagnosis of SARS-CoV-2 infection during the study period at the hospital (N = 6303) and a 95% confidence level. The margin of error was determined to be 5.57%.

2.2. Data Collection

Data for this study were extracted from the hospital’s admission forms and dental evolution forms, both of which are part of the medical records used by the hospital. The demographic variables collected included gender (male or female) and age (in years). The admission data provided information on the reason for hospitalization, symptoms upon admission (fever, dyspnea, fatigue, tonsillitis, conjunctivitis, diarrhea, loss of appetite, headache, anosmia, and ageusia), and patient comorbidities. These comorbidities included diabetes, hypertension, cardiovascular disease, end-stage renal disease, obesity, and chronic kidney disease. Smoking habits and current medications were also recorded, along with vital signs such as temperature (°C), systemic blood pressure (mmHg), SpO₂ (percentage), heart rate (bpm), respiratory rate (breaths/min), and neurological status.

Throughout the course of hospitalization, additional data were collected, including the length of stay (in days), hospitalization outcome (e.g., discharge, death, transfer to another hospital), and any hospital-acquired complications. Further details included the type of diet, the hospitalization unit (ward, ICU, isolation), and ongoing vital signs.

2.3. Oral Status Examination

The oral condition at admission was assessed using various parameters. A comprehensive bedside examination was performed by the dental team on hospitalized patients to evaluate the overall condition of the oral cavity and identify potential impairments related to oral health, swallowing, and other oral dysfunctions. The dental team, consisting of experienced and regularly trained professionals, conducted the examination with care, considering the patient’s overall health, mobility limitations, and the impact of any comorbidities. Data were collected using the standard dental form utilized at the hospital. During the study period, six dental surgeons were responsible for providing dental care at the hospital. The oral assessment was carried out systematically to ensure a thorough evaluation. Some parameters were assessed dichotomously, while others were classified into three levels: normal, moderate dysfunction, and severe dysfunction. Each examination item was recorded in detail, and patients were classified based on the severity of the observed signs (

Table A1. Description of the oral dysfunction evaluation.

Item	Description	Categories
Swallowing	The patient’s ability to swallow was assessed, looking for signs of difficulty or pain while swallowing.	Normal: no difficulty swallowing. Moderate dysfunction: occasional difficulty or mild pain when swallowing. Severe dysfunction: inability to swallow or intense pain, particularly in intubated patients.
Lips	The condition of the lips was observed for dryness, cracks, or ulcers.	Normal: soft, normal-colored lips with no signs of lesions. Moderate dysfunction: dry or slightly cracked lips. Severe dysfunction: ulceration or bleeding of the lips.
Tongue	The tongue was examined for changes in color, moisture, and the presence of papillae.	Normal: normal-colored, moist tongue with visible papillae. Moderate dysfunction: loss of papillae or changes in color, such as redness or a shiny appearance. Severe dysfunction: swollen, cracked, or bleeding tongue.
Saliva	The quantity and consistency of saliva were assessed.	Normal: hydrated saliva with no significant clinical changes. Moderate dysfunction: thick or sticky saliva. Severe dysfunction: absence of saliva or extremely viscous saliva.
Oral mucosa	The oral mucosa was inspected for its color and the presence of lesions.	Normal: pink and moist mucosa with no lesions. Moderate dysfunction: reddened mucosa without ulcers. Severe dysfunction: presence of ulcers or bleeding.
Gums	The gums were examined for color, firmness, and signs of bleeding.	Normal: pink, firm gums with no signs of inflammation. Moderate dysfunction: gum edema with or without redness, possibly with mild bleeding. Severe dysfunction: gums that bleed easily or show intense signs of inflammation.
Teeth	The patient’s natural teeth were inspected.	Normal: sound or satisfactorily restored teeth. Moderate dysfunction: localized dental calculus, especially between the teeth. Severe dysfunction: generalized dental calculus or presence of dental cavities.
Oral odor	The presence of odor in the oral cavity was recorded.	Normal: no detectable odor. Moderate dysfunction: mild to moderate unpleasant odor. Severe dysfunction: strong, unpleasant odor.
Spontaneous gingival bleeding	This variable evaluates the presence of spontaneous bleeding from the gums, which can indicate gingival inflammation or periodontal disease.	No: no bleeding observed. Yes: bleeding observed without external provocation.
Dental calculus	Dental calculus, or tartar, is hardened plaque that forms on teeth and can lead to gum disease and cavities if left untreated.	No: no visible calculus present on the teeth. Yes: presence of dental calculus, localized or generalized, on the teeth.
Dental mobility	This refers to the movement or looseness of the teeth, often a sign of periodontal disease or trauma.	No: no mobility of teeth detected. Yes: mobility of one or more teeth observed.
Total edentulism	Total edentulism refers to the complete absence of teeth in either the upper or lower dental arch.	No: the patient has natural teeth or partial dentures. Yes: complete absence of teeth.
Tongue coating	Level of coating or buildup on the tongue, which can be associated with oral hygiene, diet, or underlying health conditions.	None: no coating present. Slight: mild coating on the tongue, usually in certain areas. Moderate: moderate coating present over a larger portion of the tongue. Moderate to severe: significant coating covering much of the tongue. Severe: severe coating, often dark or thick, covering the majority of the tongue. Very severe: extremely thick, dark, or odorous coating, often with underlying clinical concerns.
Salivary evaluation	The quantity and consistency of saliva, which plays a crucial role in oral health.	Xerostomia (dry mouth): a condition where there is a significant reduction in saliva production, leading to a dry mouth. Hyposalivation (reduced saliva): a reduction in the normal amount of saliva production, but not to the extent of xerostomia. Normal: normal salivation with no abnormalities in quantity or consistency. Sialorrhea (excessive saliva): an abnormal increase in saliva production.
Oral hygiene care performed during hospitalization	The patient received oral hygiene care during their hospitalization.	No: no oral hygiene care performed during the hospitalization period. Yes: oral hygiene care was performed during hospitalization.
Soft tissue injury	This variable assesses the condition of the oral soft tissues (such as the lips, cheeks, gums, and mucosa) to check for any injuries, cuts, bruises, or abrasions.	No: no injury to the soft tissues observed. Yes: presence of injury or trauma to the soft tissues (e.g., lacerations, abrasions, contusions).
Mouth opening	This variable evaluates the patient’s ability to open their mouth normally, which is crucial for oral examination, hygiene, and treatment procedures.	Normal: the patient is able to open the mouth fully without restriction. Maintains open: the patient can open the mouth but has difficulty keeping it open due to pain or muscular issues. Lockjaw: the patient is unable to open the mouth properly, typically due to muscle spasm, temporomandibular joint dysfunction, or other conditions causing severe restriction of jaw movement.
Salivary evaluation	Salivary function was assessed as part of the oral status examination.	Xerostomia (dry mouth): the patient’s perception of dry mouth and the presence of symptoms such as difficulty swallowing, speaking, or eating dry foods. Hyposalivation (reduced saliva): a measurable reduction in salivary secretion, typically assessed through clinical observation and examination of saliva quantity and consistency. Normal salivation: determined based on clinical inspection, with no noticeable symptoms of dry mouth or reduced salivary flow. Sialorrhea (excessive saliva): an abnormally high production of saliva, often resulting in drooling.

).

2.4. Statistical Analysis

The data were analyzed using GraphPad Prism version 10 (GraphPad Software Inc., San Diego, CA, USA) and SPSS version 29 (IBM, Chicago, IL, USA). Descriptive statistics were initially employed to summarize the data, including absolute and relative frequencies, mean values, and standard deviations. The results were presented in both tabular and graphical formats. The chi-square test and Fisher’s exact test were used to compare categorical variables.

The normality of the distribution of continuous variables was assessed using the Shapiro–Wilk test. Following this assessment, the Mann–Whitney U test was applied to compare the length of hospitalization, oxygen saturation levels, and Glasgow Coma Scale scores between groups. For these variables, the median and interquartile range (IQR) were reported as summary measures. A significance level of 5% was adopted for all statistical tests.

To address missing data, a complete case-analysis strategy was employed. Patients with incomplete or missing data were excluded from specific analyses. No imputation methods were used. This methodological decision aimed to ensure consistency in the dataset and minimize the risk of introducing bias through data imputation. Although this approach reduced the sample size for some variables, it preserved the integrity of the analysis by relying solely on complete cases. Statistical tests were performed on the available data, and the results were interpreted within the context of these limitations.

3. Results

A total of 295 patients (172 males and 123 females), with an average age of 60.8 ± 17.4 years, were included in this study. Notably, a significant portion of the study sample had underlying health conditions: 29.8% of patients were diagnosed with diabetes, and 53.3% with hypertension. The majority of patients (80.7%) were admitted to the general ward, while a smaller proportion (18.3%) were admitted to the intensive care unit (ICU). Among the patients admitted to the ICU, a notable proportion (49.8%) was placed in isolation, while the remaining 51.2% was not. It is important to highlight the type of ventilation used for these patients. Of the total sample, 43.1% were breathing without mechanical assistance, 22.9% were intubated orotracheally, 20.7% were using nasal cannulas, 9.5% were using a Venturi mask, and 3.1% were tracheostomized (

Table 1. The distribution of the general characterization variables of the sample.

Variables	Mean	±SD	n	%
Gender
Male			172	58.3%
Female			123	41.7%
Age (years)	60.8	±17.4
Comorbidities (% of total sample)
Diabetes			88	29.8%
Hypertension			157	53.2%
Chronic kidney disease			27	9.2%
Heart disease			48	16.3%
Neuropathy			31	10.5%
Hospitalization unit
ICU (intensive care unit)			54	18.3%
Ward (general hospital room)			238	80.7%
No information			3	1.0%
Isolation due to COVID-19
Yes			147	49.8%
No			148	51.2%
Glasgow coma scale	13.6	±3.2
Systolic blood pressure (mmHg)	122.0	25.1
Diastolic blood pressure (mmHg)	71.8	43.0
Oxygen saturation (%)	93.1	9.7
Heart rate (bpm)	89.3	24.0
Respiratory rate (mov/min)	22.8	10.9
Days of hospitalization	19.9	10.3
Ventilation
Room air			127	43.1%
Catheter			61	20.7%
Venturi			28	9.5%
Orotracheal			68	22.9%
Tracheostomy			9	3.1%
No information			2	0.7%
Head of bed elevation
No			15	5.1%
Yes			253	86.1%
No information			26	8.8%
Ventilator-associated pneumonia (VAP)
No			34	11.6%
Yes			7	2.4%
No information			254	86.1%

±SD = standard deviation. VAP = ventilator-associated pneumonia.

).

Figure 1 presents a comparative analysis of comorbidities by gender and age group. There were no statistically significant differences in the frequency of comorbidities between males and females. However, individuals aged ≥60 years showed a higher prevalence of diabetes (38.3% vs. 22.5%, p = 0.004), hypertension (70.5% vs. 36.4%, p < 0.001), heart disease (23.9% vs. 11.4%, p = 0.008), and neuropathy (17.6% vs. 5.6%, p = 0.002) compared to those under 60 years of age.

Table 2. The distribution of variables from the oral evaluation conducted during hospitalization, categorized by gender and age.

Variables	Total		Gender		p Value	Age Group		p Value
			Male	Female		<60 yo	≥60 yo
	n	%	%	%		%	%
Soft-tissue injury					1.000			1.000
No	44	14.9%	81.8%	81.0%		81.0%	81.8%
Yes	10	3.4%	18.2%	19.0%		19.0%	18.2%
No information	241	81.7%
Mouth opening					0.814			0.259
Normal	112	38.0%	88.0%	92.0%		92.5%	86.2%
Maintains open	8	2.7%	8.0%	4.0%		3.0%	10.3%
Lockjaw	5	1.7%	4.0%	4.0%		4.5%	3.4%
No information	170	57.6%
Swallowing alteration					0.783			0.236
Normal	73	24.7%	89.6%	96.8%		95.8%	87.1%
Moderate	5	1.7%	8.3%	3.2%		4.2%	9.7%
Severe	1	0.3%	2.1%	0		0	3.2%
No information	216	73.2%
Lip alteration					0.657			0.214
Normal	20	6.8%	52.4%	56.3%		53.3%	54.5%
Moderate	15	5.1%	38.1%	43.7%		33.3%	45.5%
Severe	2	0.7%	9.5%	0		13.3%	0
No information	158	87.5%
Tongue alteration					0.813			1.000
Normal	11	3.7%	38.5%	60.0%		45.5%	50.0%
Moderate	11	3.7%	53.8%	40.0%		45.5%	50.0%
Severe	1	0.3%	7.7%	0		9.0%	0
No information	272	92.2%
Saliva alteration					0.802			0.520
Normal	13	4.4%	50.0%	66.7%		45.5%	66.7%
Moderate	9	3.1%	42.9%	33.3%		45.5%	33.3%
Severe	1	0.3%	7.1%	0		9.0%	0
No information	272	92.2%
Oral mucosa alteration					0.153			0.245
Normal	16	5.4%	53.4%	88.9%		58.3%	75.0%
Moderate	5	1.7%	33.3%	0		16.7%	25.0%
Severe	3	1.0%	13.3%	11.1%		25.0%	0
No information	271	91.9%
Gum alteration					0.769			1.000
Normal	19	6.5%	73.4%	88.9%		75.0%	83.4%
Moderate	3	1.0%	13.3%	11.1%		16.7%	8.3%
Severe	2	0.7%	13.3%	0		8.3%	8.3%
No information	270	91.8%
Tooth alteration					0.335			0.407
Normal	11	3.7%	53.8%	50.0%		36.4%	70.0%
Moderate	7	2.4%	23.1%	50.0%		45.5%	20.0%
Severe	3	1.0%	23.1%	0		18.2%	10.0%
No information	274	92.9%
Odor alteration					0.735			0.545
Normal	7	2.4%	42.9%	80.0%		50.0%	66.6%
Moderate	4	1.4%	42.9%	20.0%		50.0%	16.7%
Severe	0	0.0%	14.2%	0		0	16.7%
No information	284	96.2%
Spontaneous gingival bleeding					1.000			1.000
No	18	6.1%	88.9%	88.9%		83.3%	88.9%
Yes	3	1.0%	11.1%	11.1%		16.7%	11.1%
No information	274	92.9%
Dental calculus					0.673			1.000
No	16	5.4%	71.4%	60.0%		63.6%	69.2%
Yes	8	2.7%	28.6%	40.0%		36.4%	30.8%
No information	271	91.9%
Dental mobility					0.495			1.000
No	18	6.1%	83.3%	100%		90.0%	90.0%
Yes	2	0.7%	16.7%	0		10.0%	10.0%
No information	275	93.2%
Total edentulism					0.341			0.016 *
No	32	10.8%	76.9%	63.2%		93.8%	58.6%
Yes	13	4.4%	23.1%	36.8%		6.3%	41.4%
No information	250	84.7%
Tongue coating					0.017 *			0.111
0 (none)	12	4.1%	10.7%	42.9%		16.7%	29.0%
1 (slight)	21	7.1%	42.9%	42.9%		33.3%	48.4%
2 (moderate)	12	4.1%	35.7%	9.5%		38.9%	16.1%
3 (moderate to severe)	1	0.3%	0	4.8%		5.6%	0
4 (severe)	2	0.7%	7.1%	0		0	6.5%
5 (very severe)	1	0.3%	3.6%	0		5.6%	0
No information	246	83.4%
Salivary evaluation					0.779			0.118
Xerostomia (dry mouth)	4	1.4%	7.1%	9.5%		16.7%	3.2%
Hyposalivation (reduced saliva)	19	6.4%	39.3%	38.1%		27.8%	45.2%
Normal	25	8.5%	53.6%	47.6%		50.0%	51.6%
Sialorrhea (excessive saliva)	1	0.3%	0	4.8%		5.6%	0
No information	246	83.4%
Oral hygiene care performed during hospitalization					0.968			0.046 *
No	80	27.1%	32.0%	31.7%		38.3%	26.5%
Yes	171	58.0%	68.0%	68.3%		61.7%	73.5%
No information	44	14.9%
Any oral evaluation at admission					0.425			0.021 *
Yes	140	47.5%	50.6%	55.3%		45.1%	58.6%
No	155	52.5%	49.4%	44.7%		54.9%	41.4%

yo = years old. * Statistically significant differences between categories (p < 0.05) by chi-square or Fisher’s exact test.

presents data from the oral health evaluation during hospitalization, categorized by gender and age group. Statistically significant differences were identified in several key variables. A significant difference was observed between age groups (p = 0.016), with a higher percentage of patients aged ≥ 60 years exhibiting total edentulism (41.4%) compared to those aged < 60 years (6.3%). Males exhibited higher levels of tongue coating, particularly in the moderate to severe categories, compared to females (p = 0.017). Additionally, a higher proportion of patients aged ≥ 60 years (73.5%) received oral hygiene care compared to those aged < 60 years (61.7%) (p = 0.046). Furthermore, a higher proportion of patients aged ≥ 60 years (58.6%) underwent an oral evaluation at admission compared to those aged < 60 years (45.1%) (p = 0.021). Other variables did not show statistically significant differences between gender or age groups.

Table 3. Distribution of length of hospitalization, oxygen saturation level, and Glasgow Coma Scale based on oral evaluation.

Variables	Length of Hospitalization		p Value	SpO2		p Value	Glasgow Coma Scale		p Value
	Median	IQR		Median	IQR		Median	IQR
Oral hygiene care performed			0.693			0.269			0.774
No	17.0	10.0		0.96	0.05		15.0	1.0
Yes	17.0	11.5		0.96	0.05		15.0	0.0
Mouth opening			0.542			0.061			<0.001 *
Normal	16.0	13.0		0.96	0.03		15.0	0.0
Altered	19.0	7.0		0.93	0.16		4.5	7.0
Swallowing alteration			0.925			0.126			0.347
Normal	16.0	9.0		0.96	0.03		15.0	0.0
Altered	21.5	20.0		0.96	0.02		15.0	3.0
Lip alteration			0.216			0.621			0.820
Normal	27.0	15.0		0.96	0.03		15.0	1.0
Altered	20.0	10.0		0.94	0.05		15.0	5.0
Tongue alteration			1.000			0.131			0.871
Normal	21.5	15.0		0.96	0.01		15.0	2.0
Altered	19.0	13.0		0.93	0.13		15.0	4.5
Saliva alteration			0.563			0.154			0.895
Normal	17.5	15.0		0.96	0.02		15.0	9.0
Altered	25.0	5.5		0.93	0.12		15.0	12.0
Oral mucosa alteration			0.245			0.006 *			0.287
Normal	27.0	16.5		0.96	0.02		15.0	0.0
Altered	17.0	9.5		0.82	0.24		9.0	6.0
Gum alteration			0.859			0.368			0.628
Normal	24.0	16.5		0.96	0.04		15.0	6.0
Altered	24.0	2.5		0.93	0.11		9.0	6.0
Tooth alteration			0.862			0.784			0.653
Normal	26.0	7.5		0.96	0.01		15.0	8.0
Altered	23.0	15.5		0.95	0.05		15.0	3.0
Gingival bleeding			0.828			0.828			0.819
Normal	27.0	19.5		0.96	0.03		15.0	2.0
Altered	23.0	6.5		0.94	0.07		12.0	3.0
Dental calculus			0.213			0.511			0.293
No	16.0	12.5		0.96	0.02		15.0	9.0
Yes	20.0	16.0		0.93	0.05		15.0	0.0

IQR = interquartile range. SpO₂ = oxygen saturation level. * Statistically significant differences between categories (p < 0.05) by Mann–Whitney test.

shows the relationship between oral health variables and clinical outcomes, including the length of hospitalization, oxygen saturation levels (SpO₂), and the Glasgow Coma Scale (GCS) score. Patients with altered mouth opening had a significantly lower median GCS score compared to those with normal mouth opening (4.5 vs. 15.0, p < 0.001). In addition, patients with altered oral mucosa had a lower median oxygen saturation level (0.82) compared to those with normal oral mucosa (0.96), indicating that oral mucosal changes may be associated with reduced oxygen saturation (p = 0.006).

4. Discussion

This study analyzed the oral health status and clinical characteristics of hospitalized patients with confirmed SARS-CoV-2 infection in a public tertiary hospital in northeastern Brazil. The main findings suggest that certain oral health conditions observed in this population may be associated with clinical outcomes, including length of hospitalization, oxygen saturation levels, and neurological status as measured by the Glasgow Coma Scale.

Descriptive results revealed a high prevalence of comorbidities, particularly hypertension and diabetes, which is consistent with previous studies identifying these conditions as risk factors for severe COVID-19 outcomes [20]. Older adults (≥60 years) exhibited a significantly higher prevalence of these comorbidities, highlighting their increased vulnerability to both systemic and oral health complications during hospitalization. As the population ages, such systemic conditions become more common, placing elderly individuals at greater risk of developing severe infections and associated complications.

Moreover, in the present study, older patients were more likely to exhibit some oral health issues, particularly total edentulism, and received more oral hygiene care during hospitalization. These findings may reflect age-related oral health decline, as tooth loss becomes more common due to factors such as dental caries, endodontic issues, periodontal disease, and a lack of dental care over time [21,22]. Additionally, older adults, especially those with multiple comorbidities, may be at higher risk for oral complications [23,24], leading to increased attention to their oral hygiene needs during hospitalization. These results underscore the importance of age-specific oral health interventions in the hospital setting. For older patients, particularly those with multiple comorbidities, maintaining oral health is not only critical for preventing oral disease but also for improving overall clinical outcomes.

The study finding that males exhibited more severe tongue coating than females may suggest a gender-specific difference in oral health, potentially related to factors such as differences in diet, oral hygiene habits, smoking status, or underlying health conditions [25,26,27,28]. However, the present results indicate that gender may play a less prominent role in the overall oral health profile of hospitalized patients compared to age. Tongue coating has been associated with increased bacterial load and systemic inflammation, which could further complicate recovery in hospitalized patients [6].

The present study identified associations between impaired mouth opening and Glasgow Coma Scale (GCS) scores, suggesting a potential association between impaired mouth opening and worse neurological status [29], as well as between alterations in oral mucosa and oxygen saturation levels. These findings suggest that some oral health conditions, such as limited mouth opening and changes in oral mucosa, may impact key clinical parameters, particularly neurological and respiratory function, during hospitalization. These results underscore the critical role of dental care in the hospital setting. Incorporating routine dental assessments and interventions could not only help manage oral health but also contribute to improvements in overall clinical outcomes [30,31], particularly for patients with compromised neurological and respiratory conditions. This relationship may reflect the overall decline in general health among critically ill patients, in which oral dysfunction serves as both a consequence and a clinical marker of disease severity.

One important finding of this study was that patients with oral mucosal changes had significantly lower oxygen saturation levels compared to those with normal mucosa. This suggests that oral mucosal changes may serve as an indicator of respiratory failure in COVID-19 patients, who often require intubation and mechanical ventilation. Such interventions can cause trauma to the oral mucosa, leading to lesions that may further impair oxygen saturation and overall health. Proper oral care, including the use of oral protectors and therapeutic interventions such as laser therapy, hydration, and corticosteroids, can help mitigate these complications [32].

The present study also highlighted the significant gap in dental documentation in the electronic health records, both at admission and throughout hospitalization. This suggests that dental professionals were either not included in the hospital care team or did not properly document patient information. In February 2010, ANVISA (Brazilian Health Regulatory Agency) issued Resolution RDC-07, which outlines the basic requirements for ICU operations, including bedside dental care [33]. This regulation implicitly recognizes dentists as members of the multidisciplinary healthcare team [34]. However, the resolution does not specify the minimum working hours required for dental professionals. Unfortunately, this is not the reality in all ICUs across the country.

These findings reinforce the importance of early and consistent dental care during hospitalization. Although a substantial proportion of patients received oral hygiene care and initial evaluations, a documentation gap, especially among younger patients, remains evident. This underscores the need to standardize oral health assessments as part of routine hospital care, regardless of age or initial oral health status.

Healthcare organizations use regulatory tools to achieve efficiency, equity, and a balance between supply, demand, and public funding in health systems [35]. However, this process must be improved to ensure high-quality care and efficient resource allocation within Brazil’s unified health system (SUS). Previous findings have highlighted that disorganization in patient flow is a significant issue faced by SUS. Complaints about limited access, poor quality, and gaps in the provision of medium- and high-complexity health services have been increasing [36].

The findings suggest that the frequency of dental evaluations upon admission should be increased, and that documentation should be more thorough in hospital records to improve oral and systemic health indicators during hospitalization. The presence of a dentist in the hospital setting, particularly in ICUs, would contribute to providing comprehensive care for patients, preventing complications related to the stomatognathic system [37,38,39]. This could lead to reduced hospitalization time, decreased public healthcare costs, and improved patient quality of life.

One limitation of this study was the reliance on retrospective data from medical records, which were incomplete in some instances, particularly regarding oral health assessments. This limited the ability to perform more comprehensive analyses and potentially influenced the generalizability of the findings. Additionally, the study design does not allow for cause and effect analysis. Furthermore, due to the retrospective design, the authors of this study could not control for all potential confounders, such as the severity of COVID-19 or other patient-specific factors that might have influenced the provision of dental care.

Another limitation was the incomplete data available regarding the oral health status of patients, with some oral assessments being infrequently documented. The lack of comprehensive data for some variables may have compromised the accuracy and integrity of a multivariate regression analysis. As a result, we decided not to pursue this analysis, to avoid potential biases or misleading conclusions. This data gap highlights a broader challenge in integrating comprehensive oral health assessments into the routine care of critically ill patients, particularly in an ICU setting. In the hospital setting, the dental team was more often involved in direct interventions, such as dental pain management or infection control, than in thorough oral assessments. This highlights the importance of implementing standardized protocols for complete oral health assessments in ICU patients, including routine documentation of key parameters such as swallowing ability, salivation levels, and oral mucosal condition. In addition, increased collaboration between dental teams and ICU staff could help ensure that oral health assessments are prioritized, even for critically ill patients. Improving the completeness and consistency of oral health data collection would provide a more complete understanding of the role of oral health in ICU patient outcomes. Finally, the qualitative nature of the oral health parameters assessed introduces the potential for subjectivity in the evaluations. Future studies may benefit from incorporating more objective assessment methods to complement these qualitative evaluations.

Strengths of the Study

It is important to emphasize that a major strength of this study was the integration of detailed clinical and demographic data, which allowed for a comprehensive assessment of various factors, such as comorbidities and oral health status, and their potential impact on patient outcomes. The use of medical records as the primary data source allowed for the examination of real-world practices in the provision of dental care in a hospital setting, shedding light on gaps and opportunities for improvement in oral health management during hospitalization. In addition, the study provides valuable insights into the critical role of dental care in the management of critically ill patients, particularly those in intensive care units, and highlights the importance of integrating dental professionals into multidisciplinary healthcare teams to improve both oral and systemic health outcomes.

5. Conclusions

This chart review highlights the importance of oral health assessments and dental care interventions among hospitalized patients with COVID-19, particularly those admitted to intensive care units. The analysis of medical records is a crucial method for assessing the impact of COVID-19 on the provision of dental services and understanding how healthcare quality indicators responded during the pandemic. Moreover, associations between oral health variables and clinical outcomes, including lower Glasgow Coma Scale scores and oxygen saturation levels, underscore the potential impact of oral conditions on the overall health status of critically ill patients. These findings emphasize the need for greater attention to the role of dental professionals in accurately documenting oral health conditions, especially in ICU settings.