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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 64-71

Severe acute respiratory syndrome-coronavirus-2 viral infection and orofacial clefts: A review on patient care during and after COVID-19 pandemic

1 Department of Orthodontics, Yogita Dental College, Ratnagiri, Maharashtra, India
2 Department of Orthodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College, Nagpur, Maharashtra, India

Date of Submission13-Oct-2020
Date of Decision26-May-2021
Date of Acceptance26-May-2021
Date of Web Publication04-Aug-2021

Correspondence Address:
Dr. Smarika Pravinprakash Jain
Department of Orthodontics, Yogita Dental College, Khed, Ratnagiri, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijor.ijor_42_20

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To summarize the details on severe acute respiratory syndrome-coronavirus-2 (SARS-Cov-2) viral infection and the effects of this infection on care of patients with orofacial clefts and provision of guidelines for orofacial cleft surgeries during Corona virus disease 2019 (COVID-19) by using recent available literature. PubMed and Google Scholar and current reports from major health bodies such as the Centers of Disease Control and Prevention, World Health Organization, National Institutes of Health, and major national associations of cleft lip and palate were searched for information which is relevant from orthodontic care for orofacial cleft point of view. Major priority is given to recent articles and peer-reviewed articles. Narration is done due to limitations in the quality of evidence and rapidly evolving information on the nature of COVID-19. Major relevance to the dental field is human-to human transmission of SARS-CoV-2. People who are infected mostly show mild symptoms, but patients with advanced age or any underlying disease or comorbidity may show severe multiorgan complications. During the COVID-19 pandemic, it is important to maintain social distancing and minimize direct contact. Most clinics and hospitals have determined that multidisciplinary visits, feeding, and speech-language evaluations are largely nonessential and can tolerate a delay. A specific plan with good foundation should be followed for emergency orthodontic care with effective communication and triage.

Keywords: COVID-19, orofacial cleft, pandemic, severe acute respiratory syndrome-coronavirus-2, transmission

How to cite this article:
Jain SP, Vibhute P, Patil C, Umale V, Kendre B, Akhare P. Severe acute respiratory syndrome-coronavirus-2 viral infection and orofacial clefts: A review on patient care during and after COVID-19 pandemic. Int J Orthod Rehabil 2021;12:64-71

How to cite this URL:
Jain SP, Vibhute P, Patil C, Umale V, Kendre B, Akhare P. Severe acute respiratory syndrome-coronavirus-2 viral infection and orofacial clefts: A review on patient care during and after COVID-19 pandemic. Int J Orthod Rehabil [serial online] 2021 [cited 2022 Aug 13];12:64-71. Available from: https://www.orthodrehab.org/text.asp?2021/12/2/64/323096

  Introduction Top

Corona virus disease 2019 (COVID-19) caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has been designated as a pandemic and Public Health Emergency of International Concern by World Health Organization (WHO). There is a huge amount of risk to the team that is performing the procedures as this infection is transmitted through droplets.

Furthermore, there is increased amount of risk in children and adolescents who are immunocompromised or having any underlying comorbidities and malnutrition.

The knowledge and understanding about this infection is constantly changing and updated through experiences and constant research. The aim of this article review was to provide a comprehensive summary of the implications of SARS-CoV-2 infection and COVID-19 on the care of patients with orofacial clefts and the provision of guidelines for orofacial cleft surgeries during COVID-19, using currently available data and literature.

  Materials and Methods Top

A wide selection of sources was searched and summarized to ensure that all relevant information regarding the rapidly evolving COVID-19 pandemic and any orthodontic implications for cleft patients were obtained. These sources included peer-reviewed literature publications from electronic databases such as PubMed and Google Scholar using the following search terms: “Coronavirus,” or “COVID-19,” or “SARS-CoV-2,” or “2019-novel coronavirus,” separately combined with “Orofacial cleft,” “cleft lip,” “cleft palate,” “structure,” “incubation,” “latency,” “transmission,” “symptoms,” “dentistry,” “infection control,” “treatment,” and “protocol.” Up-to-date reports and communications from major health bodies such as the Centers for Disease Control and Prevention (CDC), WHO, National Institutes of Health, and major national associations on cleft lip and palate and health professional regulatory bodies were also referenced.

  Results Top

Due to the rapidly evolving nature of the disease and the need for scientific evidence to be available quickly, most of the studies were descriptive, small investigational studies, narrative reviews, and expert opinions [Table 1]. More recent studies and peer-reviewed studies were preferred when available. As the evidence is still new and limited in quality, a narrative synthesis was undertaken to provide a broad review of key aspects relevant to orthodontists during the current pandemic.
Table 1: Sources of information and literature included in this review article, with levels of evidence*

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  Discussion Top

Structure of the virus

SARS-CoV-2 is a single-stranded RNA virus. Electron microscopy revealed the coronavirus-specific morphology of SARS-CoV-2 with virus particle sizes ranging from 70 nm to 90 nm.[1],[2],[3] A surface viral protein named spike glycoprotein is present on virus which interacts with cell surface having angiotensin-converting enzyme 2 (ACE2) receptor. The viral membrane glycoprotein (M) and envelope (E) of SARS-CoV-2 are embedded in host membrane-derived lipid bilayer encapsulating the helical nucleocapsid comprising viral RNA [Figure 1].[4],[5]
Figure 1: Structure of severe acute respiratory syndrome-coronavirus-2

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The genome of SARS-CoV-2 is similar to other coronaviruses that comprise of ten open reading frames (ORFs). The first ORFs (ORF1a/b), about two-thirds of viral RNA, are translated into two large polyproteins pp1a and pp1ab, which processed into nonstructural proteins (nsp1nsp16).[20],[21] The genome of SARS-CoV-2 encodes for four structural proteins similar to other coronaviruses. These proteins are S (spike), E (envelope), M (membrane), and N (nucleocapsid) protein which are required to make complete virus particles [Figure 2].
Figure 2: Typical symptoms of COVID-19

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S protein is responsible for the attachment and entry of SARS-CoV-2 to the host target cell receptor, probably ACE2 mainly expressed on Alveolar epithelial cell type II (AECII) cells, including extrapulmonary tissues such as heart, kidney, endothelium, and intestine [Figure 3].[22]
Figure 3: Binding of severe acute respiratory syndrome-coronavirus-2 to cell membrane

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Symptoms and progression of disease

As we have seen children and adolescents have lower death rates still they can be a potential transmitter of infection. Children infected with coronavirus often present with fever, cough, and breathing difficulties [Figure 4].
Figure 4: Severe acute respiratory syndrome-coronavirus-2 has been shown to exhibit novel glycosylation sites in the spike glycoprotein of 2019-novel coronavirus, suggesting that the virus may utilize different glycosylation sites to interact with its receptors. Studies have demonstrated that severe acute respiratory syndrome-coronavirus-2 spike protein has higher af?nity to the angiotensin-converting enzyme 2 receptor as compared with severe acute respiratory syndrome[23]

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Many children also report vomiting, diarrhea and a fore mentioned symptom. Children born from infected mothers have higher risk of contracting the infection from the mother.[6] There is also very close resemblance of the symptoms with coronavirus and viral pneumonia. It has been reported that children often have milder symptoms than adults and the elderly.[7],[8],[9],[10]


A report mentions that even an apparently healthy infant had heavy viral load which indicates that children can even transmit infection without manifesting the illness [Figure 5].[11],[12],[13],[14],[15],[16],[17],[18],[19]
Figure 5: How aerosols transmitted in air[20]

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Phases of severe acute respiratory syndrome-coronavirus-2 infections

Based on current epidemiological investigation, the incubation period is 1–14 days, mostly 4–7 days. And the COVID-19 is contagious during the latency period [Figure 6].[23],[24]
Figure 6: Six phases of severe acute respiratory syndrome-coronavirus-2 infections[24]

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COVID-19 and orofacial cleft

Many syndromes have cleft as a part of it which could increase the risk of infection. However, an unrepaired cleft without syndrome doesn't make someone more likely to catch the virus. The two most common syndromes where a cleft (usually cleft palate) is a symptom are pierre robin sequence and sticklers syndrome.

Delaying cleft lip and/or palate repair surgery

Careful priority should be given to the backlog surgeries of cleft which was scheduled [Table 2].
Table 2: Recommended protocol for Cleft lip and palate patient care during and after COVID-19 pandemic

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Speech is mainly affected by cleft palate repair which makes it more time-sensitive. However, research is ongoing to work out when the best time to operate is, as there's no clear evidence that 6 months is better than 12 months.

For alveolar bone graft surgery, there is a reasonably long “window of opportunity” during which this can be performed, so the most important thing at this time is keeping up the care of any orthodontic appliances.

Most orthodontic appliances can be left as they are for some months without issues as long as the usual aftercare instructions are followed.

  1. Maintaining excellent oral hygiene: Brush three times a day with a standard toothbrush, followed by an interdental brush. Use a fluoride mouthwash once a day
  2. Low sugar diet: Where possible, avoid all snacking on sugars and drinks with added sugar. Avoid fizzy drinks in particular
  3. Avoid hard or sticky food: that could break the brace wire or brackets off a tooth.

  Conclusions Top

  • Despite low mortality and low infection rate among children and adolescents, they play a crucial role in the spread of infection in this ongoing pandemic of coronavirus disease
  • Adequate prevention measures, early identification, and isolation will be helpful in altering the course of this pandemic
  • Telehealth or phone conversations with parents may be sufficient
  • It is also imperative that care teams proactively establish a re-entry plan and prioritize patients for future evaluation and treatment
  • Guidelines and practice advisories issued by federal, state/provincial, and local health and regulatory authorities should be followed[44].


The author would like to thank Dr. Pavankumar Vibhute for their guidance and support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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