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

Abstract

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. Irregular asymptomatic ulcer on the dorsal side of the tongue. Diabetes. Hypertension. Obesity. Hypertension Stress-related lesion. Viral exanthem. Hypoxia. Dysphasia one week after his hospitalization. Stress-related lesion. Viral exanthem. 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). None to declare. Abanoub Riad: Conceptualization; Writing-original draft. Miloslav Klugar: Methodology; Writing-review & editing. Martin KRSEK: Supervision.

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