Oral ulceration and blistering in patients with COVID-19.

Design Case series.Introduction The most common signs and symptoms of SARS-CoV-2 infection include headache, sore throat, hyposmia, hypogeusia, diarrhoea, dyspnoea and pneumonia. Dermatological manifestations have also been reported but few authors have documented oral signs and symptoms. Methods Three cases are reported where oral ulceration or blistering is found in patients with confirmed or suspected COVID-19.Results One patient had serologically confirmed COVID-19, whilst the remaining two cases were only suspected. Two patients reported pain from the palate, whilst the third reported in the tongue. The first two patients had lesions affecting keratinised tissue consistent with herpes simplex lesions but with no history of herpetic infection. The third patient had lesions compatible with erythema multiforme.Conclusions The authors suggest a link between COVID-19 and oral ulceration and blistering, but acknowledge these signs may often go undetected due to a lack of intraoral examination during hospital admission.

A commentary on

Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez A F, Jané-Salas E, Somacarrera Pérez M L.

Oral vesiculobullous lesions associated with SARS-CoV-2 infection.

Oral Dis 2020; DOI:10.1111/odi.13382.

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Commentary

Multiple manifestations of SARS-CoV-2 infection have been described in the literature to date. The most common signs and symptoms are headache, sore throat, hyposmia, hypogeusia, diarrhoea, dyspnea, and pneumonia.[1] Authors have also described cases with dermatological manifestations.[2]

This case series describes three patients presenting with oral manifestations.[3] One of these patients had confirmed COVID-19 infection, and two patients were awaiting serological testing to confirm this. All three patients were examined by video consultation, and all cases presented with ulceration or blistering in the oral cavity.

The first reported case is a 56-year-old otherwise healthy male with suspected COVID-19. Alongside systemic signs and symptoms the patient reported pain in his palate and a sore throat. A photograph sent by the patient revealed lesions resembling herpetic recurrent stomatitis. The patient was prescribed Valaciclovir and topical antiseptics (chlorhexidine and hyaluronic acid). The oral lesions resolved after ten days.

The second case is a 58-year-old male with underlying diabetes and hypertension, also reporting pain on the palate. His wife had confirmed COVID-19 and as a result the pair were self-isolating. A photograph sent by the patient revealed unilateral palatal ulceration with no history of previous herpetic infection. With the use of topical antiseptic mouthwash, the lesions resolved within one week.

The final case in the series is a 65-year-old female with underlying health conditions: obesity and hypertension. The patient developed severe symptoms and was hospitalised with bilateral pneumonia due to SARS CoV-2 infection. Since the onset of symptoms, the patient reported pain in her tongue, but this was not examined during her hospital stay. She went on to develop dermatological symptoms and blisters of the labial mucosa and desquamative gingivitis. This was again treated with topical antiseptics.

The lesions in the first two cases affected keratinised tissue as seen in herpes simplex lesions. For the last case, the authors describe lesions more consistent with erythema multiforme, presenting on both keratinised and non-keratinised tissue. The authors state that it seems possible that the novel coronavirus may provoke oral lesions which are commonly missed due to a lack of intraoral examination in these patients.

It is important to remember the limited strength of evidence in this case series: only one of the three reported cases had confirmed COVID-19 and an observed association between the coronavirus and oral manifestations is discusse as just possibly being meaningful. Nevertheless, given the relatively early stages of research in this field, this case series provides dental professionals with useful information regarding possible oral signs of COVID-19. The authors conclude by emphasising the importance of intraoral examinations for patients affected by SARS-CoV-2.

• Intraoral symptoms in COVID patients is, as yet, just a possibility, but dental professionals should be alert for them, particularly in the presence of other possibly COVID-related symptoms.