COVID-19-Related Oral Manifestations: Early Disease Features?

Dear Editor,

The outbreak of novel communicable diseases urges epidemiologic and clinical researchers to establish highly sensitive case definitions to track all true‐positive cases; therefore, there is emerging evidence on the oral lesions that may be indicative of the coronavirus disease (COVID‐19).(European Centre for Disease Prevention and Control (ECDC), 2014) While specific respiratory symptoms of COVID‐19 are lacking, dental facilities are preparing for reopening amid a pandemic with anticipated outbreaks. Therefore, we aim to scrutinize the epidemiologic significance of the potential COVID‐19 oral manifestations.

Heretofore, eight cases were reported to have had oral lesions adjacent to SARS‐CoV‐2 infection (Table 1 ).(Ansari, Gheitani, Heidari, & Heidari, 2020; Chaux‐Bodard, Deneuve, & Desoutter, 2020; Martín Carreras‐Presas et al., 2020; Patel & Woolley, 2020; Sakaida, Isao, Matsubara, Nakamura, & Morita, 2020) All reports were published as correspondence articles (short communication or letter to the editor), thus imposing editorial limitations per se that minimize reporting comprehensibility. Manifestations were equally distributed among females and males. The mean age was 55.3 ± 11.3 years old, with seven cases (88%) were above 45 years old. While five cases (62%) were laboratory‐confirmed, three cases (38%) were suspected based on clinical manifestations.

Table 1

Characteristics of COVID‐19‐Related Oral Manifestations

Study, Location	Gender	Age	Lab	Medical History	Systemic Manifestations	Oral Manifestations	Onset	Suggested Etiology
Sakaida et al., 2020, Inazawa (Japan)	Female	52	Confirmed	N/A	No flu symptoms nor fever. Received dental treatment three days prior and given antibiotics and NSAID.	Erythematous lesions and erosions on lips and buccal mucosa.	2 days after dental drugs administered.	Drug eruption.
Chaux‐Bodard et al., 2020, Lyon (France)	Female	45	Confirmed	N/A	Mild asthenia with a painful erythematous plane lesion on the big toe.	Irregular asymptomatic ulcer on the dorsal side of the tongue.	8 days before laboratory testing.	Vasculitis.
Martín Carreras‐Presas et al., 2020, Madrid (Spain)	Male	56	Suspicious	Healthy	Fever, asthenia, hyposmia, dysgeusia, and enlarged lymph nodes.	Painful herpetic recurrent stomatitis on palate accompanied by sore throat.	N/A	Viral exanthem.
Martín Carreras‐Presas et al., 2020, Madrid (Spain)	Male	58	Suspicious	Diabetes. Hypertension.	N/A	Multiple small painful ulcers on palate with unilateral affection.	N/A	Viral exanthem.
Martín Carreras‐Presas et al., 2020, Madrid (Spain)	Female	65	Confirmed	Obesity. Hypertension	Fever, diarrhea, and multiple rashes on breasts, back and genital area.	Blisters on internal labial mucosa with desquamative gingivitis and pain on tongue.	11 days after hospital discharge.	Viral exanthem.
Ansari et al., 2020, Tehran (Iran)	Female	56	Confirmed	Diabetes.	Fever and shortness of breath.	Multiple small painful ulcers with irregular margins on hard palate.	5 days after respiratory symptoms.	Stress‐related lesion. Viral exanthem.
Ansari et al., 2020, Tehran (Iran)	Male	75	Confirmed	Hypertension.	Hypoxia. Dysphasia one week after his hospitalization.	Multiple small painful ulcers with irregular margins on tongue.	7 days after respiratory symptoms.	Stress‐related lesion. Viral exanthem.
Patel et al. 2020, London (UK)	Female	35	Suspicious	N/A	Fever.	Severe halitosis with generalized erythematous and edematous gingivae. Necrotic interdental papillae with unprovoked gingival bleeding.	3 days after fever.	Bacterial co‐infection.

Abbreviation: N/A, not reported

The masticatory mucosa was affected in 75% of the cases (2 tongue dorsum, 3 hard palate, 1 gingival mucosa), whereas 25% of manifestations were in the lining mucosa (1 labial mucosa, 1 buccal mucosa). Three cases (38%) experienced erythematous lesions, four cases (50%) had ulcers, and one case (12%) had blisters.

As for the etiology, the authors suggested various underlying causes and pathophysiologic courses. Oral manifestations were suggested by Sakaida et al. to be a possible drug reaction that may develop during the latency period.(Sakaida et al., 2020) Viral exanthem was also suggested, and it may impose additional challenges to differential diagnosis in dental practice because of the wide array of viral agents that cause oral exanthems.(Ansari et al., 2020; Martín Carreras‐Presas et al., 2020; Rocha et al., 2020) The psychosocial burden of the pandemic outbreak and the physical distancing policies should not be overlooked while evaluating oral ulcers.(Ansari et al., 2020) Oral symptoms may occur due to co‐infection with SARS‐CoV‐2 and another bacterial infection enhancing the COVID‐19 severity.(Patel & Woolley, 2020) In consistence with the dermatologic observations, Chaux‐Bodard et al. hypothesized that oral lesions may arise as an inflammatory reaction that induces vascular inflammation.(Chaux‐Bodard et al., 2020) The inflammatory hypothesis is supported by the surging number of the pediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2 (PIMS‐TS) cases reported in Italy and the United Kingdom.(Viner & Whittaker, 2020).

The onset of the oral manifestations varied considerably among the cases due to lack of reference time points. The days of laboratory testing, drug administration, admission to the hospital, discharge from the hospital, and respiratory and systemic manifestations were used as reference time points to describe the onset of oral symptoms. It is worthy to note that no case was reported yet to have oral symptoms prior to respiratory symptoms; this may be attributed to the methodological flaws.

To conclude, dentists may have a life‐saving role in intervening with the pandemic severity among children by early detection of the mucosal symptoms of PIMS‐TS. The epidemiologic significance of the oral manifestations remains unclear, thus necessitating larger observational studies to reveal the prevalence and the onset of these symptoms while maintaining the methodological quality by following the CARE and STROBE guidelines.(Von Elm et al., 2009; Gagnier et al., 2013).

CONFLICT OF INTEREST

None to declare.

AUTHOR CONTRIBUTION

Abanoub Riad: Conceptualization; Writing‐original draft. Miloslav Klugar: Methodology; Writing‐review & editing. Martin KRSEK: Supervision.