SARS-CoV-2 oral-associated lesions: Discussion of elicited response

Oral Manifestations Associated with COVID-19 Infection: A Cross-Sectional Study of Recovered Iraqi Patients

Aims

The aim of this study was to determine prevalence of oral manifestations related to COVID-19 infection among a sample of recovered patients in the Basrah province of Iraq. Methodology. This cross-sectional study included a total of 574 individuals from Basrah city, Iraq (196 males and 378 females), who had been previously infected with COVID-19. A questionnaire was developed and used to record the demographic data, medical history, severity of respiratory infection followed by hospitalization along with oral signs and symptoms that occurred during the COVID-19 infection and their persistence after recovery.

Results

Oral manifestations were reported in 88.3% of the studied sample. The most common oral manifestation was ageusia (66.8%), followed by dry mouth (59%), gustatory changes (46%), dysphagia (40.5%), burning sensation (20.8%), oral ulceration (14.5%), and gingival bleeding (3.3%). The findings suggested that ageusia was the only symptom that persisted following recovery from the COVID-19 infection. The results showed a significant statistical correlation between the incidence of oral manifestations and the severity of COVID-19 infection followed by hospitalization. A significant correlation was also found between the age groups and COVID-19 oral manifestations, whereas no significant statistical relationship was observed between gender, smoking, and systemic diseases.

Conclusions

COVID-19 infection has considerable impacts on the oral cavity and salivary glands and after recovery from the infection, some patients continue to complain of ageusia for several months. There is a positive correlation between the incidence of oral signs and symptoms associated with COVID-19 infection and the severity of the infection.

Characteristics of Oral Manifestations in Symptomatic Non-Hospitalized COVID-19 Patients: A Cross-Sectional Study on a Sample of the Saudi Population

Purpose

Few case reports and letters to the editor have been published regarding oral signs and symptoms in COVID-19 patients. The aim of the study therefore is to investigate different types of oral manifestations in COVID-19 patients as well as their prevalence.

Patients and Methods

The study is a cross-sectional study from a single medical center. A convenience sample was taken from all patients who were COVID-19 confirmed, symptomatic, and non-hospitalized. Demographic information, medical and travel history, general symptoms, and clinical examination results of the oral cavity were collected.

Results

This study included a total of 109 patients. Loss of taste was the most common oral manifestation of COVID-19 (43.4%), followed by erythema/desquamated gingivitis and coated tongue (7.3% each) and ulcers/blisters (6.4%). Loss of taste was the only symptom persisting for 10 days. Oral manifestations appeared as a single symptom (79.3%), and dorsum of tongue was the most common oral location (72.4%).

Conclusion

Loss of taste was the most prevalent specific reported oral manifestation. Other nonspecific oral lesions/symptoms are controversial. It has been suggested that oral examinations of COVID-19 patients should be conducted as part of routine examinations to investigate any possible correlation between the disease and the oral cavity.

Covid-19 and oral diseases: Crosstalk, synergy or association?

The coronavirus disease 2019 (Covid-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that clinically affects multiple organs of the human body. Cells in the oral cavity express viral entry receptor angiotensin-converting enzyme 2 that allows viral replication and may cause tissue inflammation and destruction. Recent studies have reported that Covid-19 patients present oral manifestations with multiple clinical aspects. In this review, we aim to summarise main signs and symptoms of Covid-19 in the oral cavity, its possible association with oral diseases, and the plausible underlying mechanisms of hyperinflammation reflecting crosstalk between Covid-19 and oral diseases. Ulcers, blisters, necrotising gingivitis, opportunistic coinfections, salivary gland alterations, white and erythematous plaques and gustatory dysfunction were the most reported clinical oral manifestations in patients with Covid-19. In general, the lesions appear concomitant with the loss of smell and taste. Multiple reports show evidences of necrotic/ulcerative gingiva, oral blisters and hypergrowth of opportunistic oral pathogens. SARS-CoV-2 exhibits tropism for endothelial cells and Covid-19-mediated endotheliitis can not only promote inflammation in oral tissues but can also facilitate virus spread. In addition, elevated levels of proinflammatory mediators in patients with Covid-19 and oral infectious disease can impair tissue homeostasis and cause delayed disease resolution. This suggests potential crosstalk of immune-mediated pathways underlying pathogenesis. Interestingly, few reports suggest recurrent herpetic lesions and higher bacterial growth in Covid-19 subjects, indicating SARS-CoV-2 and oral virus/bacteria interaction. Larger cohort studies comparing SARS-CoV-2 negative and positive subjects will reveal oral manifestation of the virus on oral health and its role in exacerbating oral infection.

Impact of COVID-19 disease and its treatment on the development of maxillofacial complications

The novel coronavirus spread worldwide in 2020, causing millions of deaths and disabilities. Even though the virus was considered a respiratory virus, its adverse effects can be detected in several body systems. The article describes COVID-19 disease and its complications in the maxillofacial area. Several complications develop either in response to therapeutic modalities used to treat the underlying disease, or due to overuse of particular medications namely glucocorticoids, antirheumatic agents, interleukin 6-inhibitors, and antibiotics. This article will describe a number of complications ranging from mild complications to severe ones such as osteonecrosis of the upper jaw and facial bones, ophthalmologic and neurological complications. It will also summarize recommendations that will help prevent or minimize these complications.

The psychobiological links between chronic stress-related diseases, periodontal/peri-implant diseases, and wound healing

Chronic stress is a relevant disease to periodontal practice, encompassing 25%-28% of the US population (American Psychological Association 2015). While it is well established that chronic psychologic stress can have significant deleterious systemic effects, only in recent decades have we begun to explore the biochemical, microbial, and physiologic impacts of chronic stress diseases on oral tissues. Currently, chronic stress is classified as a "risk indicator" for periodontal disease. However, as the evidence in this field matures with additional clinically controlled trials, more homogeneous data collection methods, and a better grasp of the biologic underpinnings of stress-mediated dysbiosis, emerging evidence suggests that chronic stress and related diseases (depression, anxiety) may be significant contributing factors in periodontal/peri-implant disease progression and inconsistent wound healing following periodontal-related therapeutics. Ideal solutions for these patients include classification of the disease process and de-escalation of chronic stress conditions through coping strategies. This paper also summarizes periodontal/implant-related therapeutic approaches to ensure predictable results for this specific patient subpopulation.

Complications of COVID-19 in the maxillo-facial region: Clinical case and review of the literature

COVID-19 is currently causing a pandemic around the world. With the increase in the number of patients, there was a slight increase in the incidence of various complications. In particular, infectious and inflammatory diseases of the face and jaw are observed in patients with COVID-19 in the early infectious stages of the disease, as well as in the late stages. In the previous literature, as a sign or complication of COVID-19 were mentioned cases of changes in the oral cavity - ulcers, rashes, and inflammation of salivary glands. The conditions presented in this article are a serious complication of COVID-19, radically different from the usual course of osteomyelitis, in which the patient has a course with a predominance of long-term, chronic-progressive, atrophic processes. Treatment was somewhat ineffective due to local chronic inflammation (pansinusitis), metabolic, microcirculatory, immune, and coagulation disorders in patients.

Could the oral cavity be a target organ in SARS-CoV-2 infection?

Data sources A series of eight patients with active COVID-19 who also presented with associated oral lesions seen at a hospital in Sao Paulo, Brazil provided the information in this report.

Study selection The authors reported a case series with eight COVID-19 patients.

Data extraction and synthesis Demographic information, hospitalisation details including signs, symptoms and severity of COVID-19, along with presence of anosmia, dysgeusia, ageusia and oral lesions from all eight patients were documented and reported by the authors.

Results All eight patients in this report presented for medical care with well-established respiratory symptoms of COVID-19. These patients also presented with oral ulcers that resembled aphthous ulcers, of which some also had necrosis and haemorrhagic ulcerations. The time to onset ranged between two to ten days and duration lasted between 5-15 days. The painful ulcers were empirically managed using daily photobiomodulation (PBMT) therapy using a PBMT device (Twin Flex, MMOptics, Sao Carlos, Brazil).

Conclusions Oral lesions may precede COVID-19 and progressively worse oral lesions are seen in severe COVID-19 patients. Some of these oral lesions also tend to occur early along with loss of taste and smell in some patients. Taken together, these oral manifestations could serve as early indication of COVID-19 and prompt referral for further testing is recommended.

Current status and future of delivery systems for prevention and treatment of infections in the oral cavity

Oral health reflects the general health, and it is fundamental to well-being and quality of life. An infection in the oral cavity can be associated with serious complications in human health. Local therapy of these infections offers many advantages over systemic drug administration, targeting directly to the diseased area while minimizing systemic side effects. Specialized drug delivery systems into the oral cavity have to be designed in such a fashion that they resist to the aqueous environment that is constantly bathed in saliva and subject to mechanical forces. Additionally, a prolonged release of drug should also be provided, which would enhance the efficacy and also decrease the repeated dosing. This review is aimed to summarize the current most relevant findings related to local drug delivery of various drug groups for prevention and treatment of infections (viral, bacterial, fungal) and infection-related manifestations in the oral cavity. Current therapeutic challenges in regard to effective local drug delivery systems will be discussed, and the recent approaches to overcome these obstacles will be reviewed. Finally, future prospects will be overviewed to promote novel strategies that can be implemented in clinical management for prevention and treatment of oral infections.

Oral manifestations of COVID-19 disease: A review article

Dysgeusia is the first recognized oral symptom of novel coronavirus disease (COVID‐19). In this review article, we described oral lesions of COVID‐19 patients. We searched PubMed library and Google Scholar for published literature since December 2019 until September 2020. Finally, we selected 35 articles including case reports, case series and letters to editor. Oral manifestations included ulcer, erosion, bulla, vesicle, pustule, fissured or depapillated tongue, macule, papule, plaque, pigmentation, halitosis, whitish areas, hemorrhagic crust, necrosis, petechiae, swelling, erythema, and spontaneous bleeding. The most common sites of involvement in descending order were tongue (38%), labial mucosa (26%), and palate (22%). Suggested diagnoses of the lesions were aphthous stomatitis, herpetiform lesions, candidiasis, vasculitis, Kawasaki‐like, EM‐like, mucositis, drug eruption, necrotizing periodontal disease, angina bullosa‐like, angular cheilitis, atypical Sweet syndrome, and Melkerson‐Rosenthal syndrome. Oral lesions were symptomatic in 68% of the cases. Oral lesions were nearly equal in both genders (49% female and 51% male). Patients with older age and higher severity of COVID‐19 disease had more widespread and sever oral lesions. Lack of oral hygiene, opportunistic infections, stress, immunosuppression, vasculitis, and hyper‐inflammatory response secondary to COVID‐19 are the most important predisposing factors for onset of oral lesions in COVID‐19 patients.

COVID-19 and cutaneous manifestations: a systematic review

The cutaneous manifestations of COVID-19 patients have been increasingly reported, but not summarized, and the potential mechanisms remain to be investigated. Herein, we performed a comprehensive review of literatures (from inception to 30 May 2020) using PubMed, CNKI, medRxiv and bioRxiv with the terms "((novel coronavirus) OR (2019 novel coronavirus) OR (2019-nCoV) OR (Coronavirus disease 2019) OR (COVID-19) OR (SARS-CoV-2)) AND ((Dermatology) OR (skin) OR (rash) OR (cutaneous))" and "((ACE2) OR (Angiotensin-converting enzyme)) AND ((skin) OR (epidermis) OR (dermis))." Totally, 44 articles met the inclusion criteria. A total of 507 patients with cutaneous manifestations were summarized, and 96.25% patients were from Europe. The average age of the patients was 49.03 (range: 5-91) with a female ratio of 60.44%. The skin lesions were polymorphic, and erythema, chilblain-like and urticarial lesions were most common, occurring on an average of 9.92 days (range: 1-30) after the onset of systemic symptoms. The receptor of SARS-CoV-2, ACE2, was found to be expressed on skin, mainly on keratinocytes. Our review systematically presented the clinical characteristics of 507 patients and showed that skin might be the potential target of the infection according to ACE2 expression. More work should be done to better understand the underlying pathogenesis.

Orofacial manifestations of COVID-19: a brief review of the published literature

Coronavirus disease 2019 (COVID-19) has spread exponentially across the world. The typical manifestations of COVID-19 include fever, dry cough, headache and fatigue. However, atypical presentations of COVID-19 are being increasingly reported. Recently, a number of studies have recognized various mucocutaneous manifestations associated with COVID-19. This study sought to summarize the available literature and provide an overview of the potential orofacial manifestations of COVID-19. An online literature search in the PubMed and Scopus databases was conducted to retrieve the relevant studies published up to July 2020. Original studies published in English that reported orofacial manifestations in patients with laboratory-confirmed COVID-19 were included; this yielded 16 articles involving 25 COVID-19-positive patients. The results showed a marked heterogeneity in COVID-19-associated orofacial manifestations. The most common orofacial manifestations were ulcerative lesions, vesiculobullous/macular lesions, and acute sialadentitis of the parotid gland (parotitis). In four cases, oral manifestations were the first signs of COVID-19. In summary, COVID-19 may cause orofacial manifestations that might be the initial features in several cases. However, the occurrence of orofacial manifestations in COVID-19 seems to be underreported, mainly due to the lack of oral examination of patients with suspected and/or confirmed COVID-19. Oral examination of all suspected and confirmed COVID-19 cases is crucial for better understanding and documenting COVID-19-associated orofacial manifestations.

The trend of cutaneous lesions during COVID-19 pandemic: lessons from a meta-analysis and systematic review

BACKGROUND

Besides predominant respiratory and gastrointestinal manifestations, reports on cutaneous manifestations in COVID-19 patients are being noted increasingly.

OBJECTIVES

To estimate the prevalence of cutaneous manifestations in COVID-19 patients.

METHODS

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. A detailed literature search was done in PubMed and Embase from December 1, 2019, till May 1, 2020. Studies reporting cutaneous manifestations in COVID-19 patients were included. Irrespective of the heterogeneity of data, a random effects model with inverse-variance approach was used for pooling the prevalence using meta package in R version 3.6.2.

RESULTS

Out of 15,143 articles, 2086 articles were selected for full-text read. Forty-three articles were selected for qualitative analysis, of which 10 articles (N = 1682) were included for meta-analysis. The pooled prevalence of overall cutaneous lesions was 5.69 (95% confidence interval [CI]: 1.87-15.98; I² 88%). The pooled prevalence of other outcome parameters were as follows: viral exanthem-like presentation 4.15 (95% CI: 1.33-12.23; I² 88%), maculopapular rash 3.81 (95% CI: 1.02-13.18; I² 87%), vesiculobullous lesions 1.67 (95% CI: 0.70-3.96; I² 0%).

CONCLUSION

The estimated prevalence of cutaneous manifestations in COVID-19 was 5.69%. Other manifestations were urticaria, chilblain-like lesions, livedo reticularis, and finger/toe gangrene. Although it is premature to conclude the prevalence of the cutaneous manifestations during this ongoing pandemic, our report may be a stimulating factor for the physicians to perform further vigilant streamlined reporting of cutaneous manifestations in COVID-19 patients to estimate the final prevalence.

Oral mucosal lesions in patients with SARS-CoV-2 infection. Report of four cases. Are they a true sign of COVID-19 disease?

BACKGROUND

Vesiculobullous and macular lesions in the oral mucosa have been reported in patients positive for SARS-CoV-2 infection. Nonetheless, the significance and physiopathology of oral manifestations have not been clearly established in the clinical progression or outcome of the infection.

AIM

To describe the clinico-pathological oral mucosal lesions in four patients with confirmed SARS-CoV-2 infection.

METHODS AND RESULTS

Four patients with COVID-19 disease and confirmed by polymerase chain reaction (PCR) presented angina bullosa hemorragica-like lesion, vascular disorder, and nonspecific stomatitis, one patient with histological analysis demonstrated perivascular reactive lymphocitic infliltrate, focal capillary thrombosis, and hemorrhage. According to the discrimination of other local and systemic conditions and the synchronous onset of oral and systemic symptoms, the diagnosis of oral lesions probably associated with COVID-19 was established.

CONCLUSION

Infection with SARS-CoV-2 may result in oral manifestations with various clinical presentations, which presumably support the hypothesis of thrombi formation and vasculitis; nevertheless, these findings need more evidence and a long-term follow up of patients to accurately establish the significance of the oral mucosa affection in the COVID-19 disease.