Dr Graham Lloyd-Jones
@DrGrahamLJ
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Consultant Radiologist. Medical educator. Director @RadMasterclass . Clinical anatomist. Linking poor #OralHealth to #ChronicDisease of the body. Views mine.
Salisbury, Wiltshire, UK
Joined November 2021
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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
...
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Just a reminder that we used to think peptic ulcers were ‘all in the mind’
We wasted 40 years by calling it stress related until it was shown to be caused by H.pylori (a bacterium)
#longCOVID
is
#notallinthemind
it is caused by
#SARSCoV2
(a virus)
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To all
#radiologists
.
Have you seen the typical
#COVID
pulmonary vasculopathy on CXR/CT in the last week?
We've not seen this since omicron became dominant Feb '22. I'm concerned we have a new variant which causes the same clotting in the lungs as delta/pre-delta.
Please retweet
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Please can all papers on
#COVID
stop referring to the lung disease as ‘pneumonia’. It is a pulmonary vasculopathy (disease of the lung blood vessels). Airways not inflamed. Distribution = vascular. Clots and abnormal blood vessels are primary, not a ‘complication’ of ‘pneumonia’.
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Friends often ask me for medical advice outside my usual work as a radiologist. I have started to notice a pattern.
Friend: My symptoms are…
Me: When did these start
Friend: X months ago
Me: Have you ever had
#COVID
Friend: Yes
Me: When
Friend: X months ago
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It's strange how every day doctors ask me (a radiologist) to explain diseases to them but when a global pandemic comes along nobody thinks a radiologist can offer any insight.
To anyone out there still using the term 'pneumonia' to refer to the lung disease in
#COVID
, it is not!
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The whole of medicine has been hoodwinked into thinking that the best medicine is therapeutic.
It is not.
The best medicine is preventative.
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It seems that people (including my medical friends) are not making the connection between new unexplained symptoms and onset at the time of having acute COVID.
These are not trivial symptoms.
#longCOVID
#silentCOVID
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#COVID
is a trimodal disease…
1/ Acute - Die v survive & recover
2/
#longCOVID
- Persistent symptoms following severe or mild acute disease
3/ Long term ⬆️risk of all cause morbidity/mortality (regardless of recovery from acute or long symptoms)
It’s all about clotting
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I’ll say it again
Dear medical colleagues who write about acute
#COVID
Stop calling the lung disease ‘pneumonia’
It is not!
It is a pulmonary vasculopathy, a disease of the lung blood vessels
Pneumonia causes airways inflammation
COVID is the opposite of pneumonia!
Thanks
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To all those with
#longCOVID
.
I want you to know that doctors have not given up and that some of us are still doing our hardest to understand this disease (acute & long).
We don’t know all the answers but hope remains.
To all doctors and scientists - it is time to
#collaborate
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Am I reading this right?
‘OHS [oral hygiene self care = regular toothbrushing & flossing] was associated with a 51% reduction in the risk of CVD mortality’ over a study period of 18.8 years.
If this study had been on an expensive drug it would be front page news.
#oralhealth
Make sure you read this paper on oral hygiene, mouthwash usage and cardiovascular mortality:
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Dear
#dentaltwitter
Many people are concerned about the risk of catching
#COVID
or other infections when going to the dentist.
It seems likely that the benefits outweigh the risks, but what measures do you have in place in your dental practice to reassure people?
Thanks
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Dear
#dentaltwitter
. Today a dentist friend told me she is seeing a lot more patients with ‘cracked teeth syndrome’ recently. She thinks this is something to do with
#COVID
but isn’t sure exactly why this would be the case.
Any thoughts on this would be welcome.
Thanks
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Dear
#medtwitter
, if you are looking for the missing link in medicine, the thing that explains everything that doesn’t make sense, it is gum disease.
I don’t even know where to begin to explain, there is so much evidence it is overwhelming.
Now attempting to write a book on this.
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Brain fog in
#LongCOVID
is not ‘all in the mind’.
It is in the brain.
It is caused by visible biological processes.
We can see it on MRI scans.
You know, by using our eyes 👀
👇👇👇
In long COVID patients with brain fog (brain scan at right), dye injected into the bloodstream tends to leak into the brain (see colored speckles) more so than in people without brain fog (left).
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Use of a nasal spray makes sense when you know that the ACE2 receptor (cellular receptor for the
#SARS2
virus) is expressed in the nose 200-700 times more intensely than in the airways of the lungs.
See this -
👃🏽💦 Nasal sprays are an under-used but highly effective layer to include in your covid-safety strategy! 👃🏿 Here's a thread on 4 really effective ones:
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Please can all
#radiologists
stop calling the vascular phenomena of acute
#COVID
lung disease ‘complications’. They are not complications they are the disease itself.
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Summary thread of the oral-vascular-pulmonary model of
#COVID
-19 lung disease, why this is important and what to do about it.
Also potentially relevant in
#LongCOVID
@SpringerNature
review -
1/21
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A reminder that
#COVID
is not a common cold. It is a nasty vascular disease which kills, leads to long term symptoms and/or increases risk of cardiovascular death in the months after infection.
See the Lancet report about excess deaths following COVID.
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Based on imaging of the lung disease post acute
#COVID
/
#longCOVID
there might be 2 things going on
1- fibrosis due to the acute phase lung injury
2 - endothelial damage - not related to the acute disease
The literature doesn't yet reflect the complexity but getting there ...
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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👇
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The biggest silo gap in healthcare is medicine v dentistry.
Doctors, we need to learn about the mouth. It turns out good oral health is massively important for body health.
I don’t mean smiles - I mean Alzheimer’s, heart disease, rheumatoid, cancer…
#takegumdiseaseseriously
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CPC mouthwash v
#SARS2
systematic review now published.
👇 👇 👇 👇 👇
With thanks to my Italian friends.
@DrFDamico
@MMarmiere
et al
#COVID
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@ITVNewsPolitics
Dear
@RishiSunak
Please can I check you know
#COVID
isn't like influenza. It's a disease of blood vessels (including the lung disease).
#COVID
causes lasting damage to blood vessels all over the body.
The reason for long term sickness becomes obvious, no?
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@OGdukeneurosurg
The endothelium is bigger than the skin. This is the inner lining of our blood vessels which supplies every part of our body
The endothelium is rarely thought of as an organ and we don’t have endothelium doctors
Which is why humans have failed to understand
#COVID
/
#LongCOVID
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If we consider the endothelium* as a distinct organ of the body it becomes easy to see why
#COIVD
/
#longCOVID
causes systemic symptoms.
I wonder, should 'endotheliology' become a medical specialty?
(*Endothelium = inner lining of blood vessels)
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@MellilianFlyer
The point I’m making is that not even the lower respiratory disease is respiratory, it is vascular.
Yes the upper respiratory tract is involved and transmission is respiratory, but the lung disease (thankfully now rare) was never a respiratory ‘pneumonia’
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You go to the doctor with symptoms.
You get treated.
You get better.
The doctor says - I made the right diagnosis.
You go another time.
You get treated.
You don’t get better.
The doctor says - it’s all in your mind.
Success or failure of treatment does not define disease!
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History of medicine:
Patient: Doc, I have symptom X.
Doctor: I can’t find a cause for symptom X. Symptom X is psychological.
Some time later…
Cause of symptom X is discovered.
Patient: Doc, I have symptom X.
Doctor: Symptom X is medical - here is a pill.
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Please can I add a different view on the
#COVIDinquiry
, something which the inquiry will ignore.
#COVID
-19 is a disease!
The COVID-19 pandemic is caused by COVID-19!
Pandemics and the diseases which cause them are not the same thing!
A thread ...
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People are still dying from AND with
#COVID
. This has has always been the case, but Omicron 'mode of death' (MoD) is different from Delta etc - very few go to ITU and die of respiratory failure. Something else is going on which we need to study.
Does anyone have MoD data please?
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Just finished a first draft chapter on how a harmful biofilm forms in your mouth.
It needs some work but here is a summary…
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Important news about XXB1.5 pointing out that infection is more via the ACE2 receptor than previous Omicron variants.
But … the mouth is not mentioned as an important site of infection….
A thread … 1/
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Many viruses persist in the mouth.
I think a persistent
#SARS2
oral reservoir - along with oral dysbiosis associated with
#COVID
- would provide answers in understanding
#longCOVID
development. (The mouth is upstream of everything!)
Working on proving it.
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The lungs are a vascular immune filter - not just organs of gas exchange
Overwhelming the immune filter system due to immunothrombosis (inflammatory clotting) was the cause of
#COVID
lung disease, not airways inflammation
The lungs are trying to protect the rest of the body
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A lesson from history ...
When doctors do not understand a disease we repeatedly dismiss patients as fabricators of symptoms or as mentally unwell.
Dear medical colleagues, please let’s not make the same mistake when it comes to
#LongCOVID
.
History will judge us.
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@KashPrime
@lisa_iannattone
Please do not call
#COVID
lung disease a ‘pneumonia’. This does not accurately reflect what is going on. The lung shadowing represents areas of vascular congestion due to immunothrombosis (inflammatory mediated clotting). It is more accurately termed a ‘pulmonary vasculopathy’.
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@1goodtern
That the acute lung disease of
#COVID
-19 is not a conventional pneumonia of the lung airways but a pulmonary vasculopathy - a disease of the lung blood vessels which is mediated by in situ clotting, vascular congestion and endothelial damage.
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@DrEricDing
An MRI scanner magnetic field is always on, so magnetic objects should never be taken into the scanner room.
(In the UK is is also considered unnecessary to take a gun to a hospital)
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A nice summary of the science relating to
#LongCOVID
from Prof David Putrino
@PutrinoLab
.
Well worth the 7 minute watch and worth sending to medics who are sceptical about the physical nature of the disease.
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@loscharlos
Please take a look at this presentation I gave at the
@SalisburyNHS
symposium - March 2022. It summarises the imaging evidence for the vascular nature of
#COVID
lung disease. It also explains why oral health is important for understanding disease severity.
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#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
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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)
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@theAliceRoberts
Dear Alice, please take a look at the mouth care guidance we are offering our
#COVID
-19 patients
@SalisburyNHS
hospital -
and here’s why
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I am convinced the biggest missing link in understanding development of diseases in the body is …
GUM DISEASE!
(And oral dysbiosis - an imbalance of bad v good bacteria in the oral microbiome)
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Can all doctors who don’t think
#longCOVID
is a real disease please step forward.
Ok to say we don’t understand it.
Not ok to deny it exists.
In those with respiratory symptoms at 3 months, Dual Energy CT shows persistent clots & perfusion defects.
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Please can all papers relating to
#COVID
stop saying the lungs are the primary site of infection. This is not the case.
The upper respiratory tract (nasal airways and mouth) are the first site of infection.
The ACE2 receptor is not expressed intensely in lung airways.
Thank you
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Dear colleague doctor. This is the mouth, also know as the gaping hole on our knowledge of the body. This year I challenge you to read about the causative links between pour oral health and the development of disease in your area of interest. It turns out that
#mouthcarematters
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Radiologically (my specialty) the acute lung disease of
#COVID
-19 is a pulmonary vasculopathy – a disease of the lung blood vessels.
The airways of the lungs are not inflamed as in other pneumonias such as influenza
(I will keep saying this until the day I die)
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Most doctors are blissfully unaware of the importance of poor oral health and the oral microbiome in determining which diseases you get, how badly you get them and how long you live.
If you have gum disease you have an open wound in the mouth.
#takegumdiseaseseriously
#oralhealth
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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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All disease has a psychological element, but no,
#LongCOVID
is not psychosomatic. Anyone who says so, please direct them here.
#LongCOVID
is not just physical, in some people it is visible!
@long_covid
@IndependentSage
#TeamClots
@BinitaKane
@dbkell
@resiapretorius
@Sunny_Rae1
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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.
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Just off to see my 90-yr-old dad in his care home
Check list
-neg LF✅
-wash hands✅
-wear mask✅
-before setting out use a CPC mouthwash which has been shown to completely eradicate
#SARSCoV2
in the test tube and make it undetectable in the mouth for a prolonged period✅
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@EricTopol
@LancetRespirMed
This is nonsense! We can see physical damage in the lungs and blood abnormalities in
#LongCOVID
.
Remember, if you break a bone it makes you miserable. It isn’t the misery which caused the break in the bone, it is the pain (a symptom of the broken bone) which causes the misery.
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A big lesson we must learn as we continue to study
#COVID
is that the world of medicine suffers terribly from siloed thinking
Lack of a funded organisation to formally collaborate across different medical specialties has resulted in failure to share & moderate important lessons
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If we fail to understand that the lung disease of acute
#COVID
-19 is primarily a vascular disease, and not an airways pneumonia, then we will likely also fail to understand the pathology of
#LongCOVID
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Summary - in both acute & long
#COVID
the lung disease is about damage to blood vessels in the lungs, not the airways.
Likely there are similar processes going on elsewhere in the body in
#longCOVID
involving damaged endothelium (inner lining of blood vessels) & persistent clots.
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It is vascular inflammation and blood clotting within the pulmonary blood vessels themselves which causes the lung disease of acute COVID-19. This results in perfusion defects and failure of gas transfer.
The failure is in the vascular compartment not in the airways.
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Please support
#LongCovidAwarenessDay
For anyone with
#LongCOVID
please see resources
@Long_Covid
Support 👇👇👇
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Thank you to all those who have shared personal stories of
#longCOVID
today. These stories have not gone unnoticed and they are a great motivator to all involved in researching the disease.
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Our Springer Nature review, published today.
‘The Oral-Vascular-Pulmonary Infection Route: a Pathogenic Mechanism Linking Oral Health Status to Acute and Post-Acute COVID-19’
👇👇👇👇👇
#COVID
-19
#SARS2
#OralHealth
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@Seafoam_Dream
It depends on the symptoms and the stage of disease (acute or long COVID). The important thing to know is that even if imaging tests are negative this does not mean there is nothing going on. This is true in almost every clinical scenario.
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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.
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Dear Santa
Please can we have a new government for Christmas.
It isn’t the policies.
It’s the lack of humanity.
Thanks
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We do not yet know the best way to treat diseases of the endothelium like
#LongCOVID
and
#MECFS
but this does not mean people cannot be helped.
The first step is for the medical community to understand that these patients must be taken seriously.
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Spent the day writing a response letter to a radiological review on
#COVID
'pneumonia'.
Having to do this is becoming annoying.
In summary ...
COVID-19 is not pneumonia (even the lung disease)
COVID-19 lung disease is a pulmonary vasculopathy (disease of the lung blood vessels)
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The mouth is a powerful immune organ. If you don’t look after it then your whole body suffers.
If you have gum disease (e.g bleeding gums, wobbly teeth) please seek help from a dentist.
#notjustacakehole
#oralhealth
#mouthcarematters
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@EricTopol
Please can we stop calling the endothelial/vascular phenomena ‘complications’. They are not complications they are the disease itself.
All the damage done in the lungs is vascular. On CT scans the visible airways are not inflamed.
See this from 2020
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Published 2 years ago...
The COVID-19 Pathway: A Proposed Oral-Vascular-Pulmonary Route Of SARS-CoV-2 Infection And The Importance Of Oral Healthcare Measures
What has changed since then?
Please see this thread ...
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@martinmckee
The biggest mistake has been not listening to radiologists. COVID-19 does not cause macroscopic airways inflammation. It is a primary pulmonary vasculopathy. The lung damage is mediated by immunothrombosis and vascular congestion. Vascular events are primary not secondary.
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Today I put pen to paper.
I am writing a non-fiction science book about the connections between poor oral health and diseases of the body.
I promise you, you will want to read it.
Wish me luck.
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@lisa_iannattone
Thanks for your interest.
Not a thread (will do this) but here is a 20 min talk which introduces the concept. My understanding of the importance of oral health has been transformed by gaining understanding of lung disease development in
#COVID
.
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Acute
#COVID
-19 is neither a pneumonia nor solely a lung disease. Both acute and
#LongCOVID
are dominantly diseases of the endothelium. This is why both diseases are systemic. This is also why they can be seen as different phases of the same disease - a pathological continuum.
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@EnemyInAState
The concept that
#longCOVID
could be infectious is potentially possible, given that we know there is viral persistence in saliva for a lot longer than most are aware. At least 2 months according to this paper.
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I am pleased to be working with
@resiapretorius
@dbkell
@DavidJoffe64
@PutrinoLab
@doctorasadkhan
, Arneaux Kruger and Jaco Laubscher to draw together evidence highlighting the role the vascular endothelium plays in
#LongCOVID
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In those with respiratory symptoms at 3 months - on Dual Energy CT scans
- 5% have visible clots in lung arteries
- 65% have microangiopathy (disease of small blood vessels of the lungs)
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Why is a radiologist interested in oral health?
Because diseases of the body I diagnose on a daily basis are evidently caused by oral organisms which escape the mouth (via diseased gums) pass into the bloodstream and cause disease elsewhere in the body.
The word is ‘cause’.
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Importantly, the same pulmonary vascular processes visible radiologically in acute COVID are also visible radiologically in people with
#LongCOVID
. Clots and/or perfusion defects are visible in 87% of patients with persistent respiratory symptoms six months after infection.
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You may have thought that the lung disease in the acute phase of
#COVID
-19 is a bit like influenza or other respiratory infections. It is not!
Anatomically and pathologically the lung disease of COVID-19 is the opposite of influenza.
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Why oral health and caring for the mouth is important for understanding
#COVID
-19 severity.
A radiological perspective.
Highlighting oral care project
@SalisburyNHS
.
Presentation at national IPC conf. Birmingham UK 27 April
Thanks to
@KnowlexUK
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Dear humans, please can we all learn that when a new disease comes along we need a systematic and collaborative multidisciplinary approach to understanding that new disease. Not just the pandemic caused by spread of the disease, the disease itself. They are different things.
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#COVID
-19 is a complex disease. Humanity has failed to understand it because the focus is on bean counting pandemic data.
To understand a pandemic, first we need to understand the disease which causes it, collaborating across all medical disciplines with scientists and patients.
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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.
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If you plan to go to a cinema, church, pub or other crowded space this weekend, please stay at home if you have cold symptoms.
This applies even if you’re vaccinated, think you only have a cold, or have a negative lateral flow.
#COVID
Sorry but
#itsnotover
Symptoms = stay at home
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This is not at all a surprise to someone who has hypothesised that the lung disease is caused by viral transfer from the mouth via the bloodstream to the lung blood vessels.
(It is not a pneumonia! The airways are normal!)
Read more hear👇
"Our case proves that replication-competent
#SARSCoV2
can traffic in blood during COVID-19 and seed tissues throughout the body."
@AnnalsofIM
@icelight
@NIAIDNews
@NIH
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Play a little anatomy game (with a purpose to be revealed later)
Without checking the comments of others -
Name 5 organs of the body
Any 5 organs
Go!
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Dear doctor colleagues
This is the mouth
It’s your biggest knowledge gap!
Please tell your patients that if they do not have good oral health they cannot expect to be healthy and live a full life
Please campaign for free/affordable preventative dentistry
Thanks
#medtwitter
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@KunstJonas
Not a surprise. Acute COVID-19 is ALL about the blood vessels. The radiology shows the lung disease is a pulmonary vasculopathy. Airways are NOT inflamed. Blood vessels are congested.
#longcovid
is also characterised by vascular damage in the lungs in those with chest symptoms.
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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.)
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The clotting is not due to embolic events as in conventional DVT-driven emboli. The clotting occurs in situ.
Clotting in lung capillaries is found universally in autopsy studies of those who have died of
#COVID
.
Superinfection does not play a major role as in influenza.
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Well said
@Helen_Oakleigh
(most articulate person in the room)
No response from the panel because of total ignorance of
#LongCOVID
.
Yes we need a ‘multidisciplinary’ approach. There is no multidisciplinary team without a radiologist. Now you have one…
@bbcquestiontime
Thanks to
@Helen_Oakleigh
we know the effort it took to represent our
#LongCovid
community on
#bbcqt
UK has over half a million
#pwLC
like Helen
#DisabledByLongCovid
since 2020.
What % of our population need to become economically inactive before action is taken?
#LongCovidWork
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@TheBDA
@PaddyMcGuinness
@38degrees
@DailyMirror
Extraordinary!
@PaddyMcGuinness
shows more insight into
#NHSDentistry
than the health minister
#VictoriaAtkins
And more humanity
And more humility
And more coherence
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