Oral lesions in COVID-19 infection: Is long-term follow-up important in the affected patients?

Oral lesions with immunohistochemical evidence of Sars-CoV-2 in swab-negative post-COVID syndrome

OBJECTIVES

Growing evidence exists about post-COVID condition/syndrome as sequelae of Sars-CoV-2 infection in healed patients, possibly involving the lungs, brain, kidney, cardiovascular and neuromuscular system, as well the persistency of taste dysfunction. Such symptoms develop during or after infection and continue for more than 12 weeks with pathogenesis related to virus persistency but variable by organs or systems.

MATERIALS AND METHODS

We recently observed six patients recovered from COVID-19 and with negative RT-PCR testing, showing oral mucosa lesions (mainly ulcers) overlapping those occurring in the acute phase, persisting up to 20 days and thus needing a biopsy with histological investigation and spike protein evaluation by immunohistochemistry.

RESULTS

We found epithelial ulceration, inflammatory infiltrate, vessels with increased diameter and flattened endothelium but no thrombi formation; also, we found a weak epithelial SARS-CoV-2 positivity limited to the basal/spinosum layers, progressively decreasing toward the periphery, and the intraepithelial lymphomonocytes, endothelium, and perivascular pericytes too.

CONCLUSIONS

Our findings provide evidence that SARS-CoV-2 can persist, as for other organs/systems, also in the oral epithelium/mucosa after the acute phase and can be responsible for lesions, although by a pathogenetic mechanism that should be better defined but certainly referable as the oral mucosa counterpart of post-COVID syndrome.

The Oral Lesion in the COVID-19 Patient: Is It True Oral Manifestation or Not?

Objective

Many previously reported publications mentioned that oral lesion in COVID-19 patients was varied. The term oral manifestations refer to pathognomonic features that are found consistently with a specific cause and effect. In this context, the oral manifestation of COVID-19 was inconclusive. This systematic review aimed to analyse previously reported publications related to oral lesions in COVID-19 patients to define as oral manifestations or not. The PRISMA guidelines were implemented in this review.

Methods

All umbrella reviews, systematic reviews, systematic reviews and meta-analyses, comprehensive reviews, and original and non-original studies were included. Twenty-one of systematic review, 32 original studies and 68 non-original studies reported the oral lesion in COVID-19 patients.

Results

Most of the publications mentioned that ulcers, macular, pseudomembranes and crusts were frequent oral lesions. The reported oral lesions in COVID-19 patients did not show any pathognomonic features and might be unrelated directly to COVID-19 infections, however, more likely due to gender, age, underlying diseases, and medication.

Conclusion

The oral lesions found in previous studies do not have pathognomonic features and are inconsistent. Therefore, the reported oral lesion, in present time, cannot be defined as an oral manifestation.

An update on oral clinical courses among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: A clinical follow-up (a prospective prevalent cohort) study

INTRODUCTION

Contemporary literature has revealed that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes acute sialadenitis and related symptoms, such as discomfort, pain, swelling, and secretory dysfunction in salivary glands. The secretory dysfunction is due to SARS-CoV-2 infection-induced xerostomia and other associated clinical courses such as sore tongue, mucosal ulcer, and gingivitis in the oral cavity. Furthermore, it has been reported that COVID-19 causes the development of other oral manifestations.

MATERIALS AND METHODS

A prospective clinical follow-up (a prevalent cohort) study was conducted to identify the possible oral manifestations of SARS-CoV-2 infection among patients admitted toat the Eka General Hospital COVID-19 treatment center. Furthermore, the study aimed to calculate the prevalence rate of oral clinical courses in the cohorts. The study consisted of two follow-up phases: Hospital and patient-home-based.

RESULTS

A total of 55 patients (36 males and 19 females) met the inclusion criteria and were followed for 7.5 weeks. The 3.5 weeks hospital-based prospective follow-up study documented an 18% (n = 10) prevalence rate of oral clinical courses among the cohorts. Twelve oral symptoms appeared in these ten patients. The manifested oral symptoms were oral mucosal lesions (n = 6), xerostomia (n = 5), and thickening of saliva (n = 1). The oral mucosal lesions per se consisted of aphthous lesions (n = 3), candidiasis (n = 1), geographic tongue (n = 1), and localized gingivitis (n = 1). The four weeks' home-based follow-up study disclosed four newly manifested oral symptoms: hemorrhagic crust, bulla, buccal mucositis, and petechiae. These manifestations appeared among six patients (four males and two females) who had not manifested any oral symptoms during the hospital-based follow-up. Accordingly, the overall prevalence of oral clinical courses among patients presented with SARS-CoV-2 is raised from 18% (n = 10) to 29% (n = 16). Similarly, the number of clinical courses increased from 12 to 16 after four additional weeks of follow-up.

DISCUSSION

The study's findings suggest the importance of initiating oral health care for patients with COVID-19. Therefore, multidisciplinary healthcare approaches should be delivered to assure optimal health outcomes. Accordingly, oral health professionals must be a substantial part of the interdisciplinary approach in caring for patients with COVID-19.

Oral mucosa lesions in confirmed and non-vaccinated cases for COVID-19: A systematic review

This systematic review purposed to investigate reports of oral lesions in confirmed COVID-19 patients summarizing clinical characteristics, histological findings, treatment and correlation of oral lesions and COVID-19 severity. Electronic search was conducted on November 2021 using seven databases to identify case reports/series describing lesions in oral mucosa in COVID-19 confirmed cases. A total of 5,179 studies were found, being 39 eligible from 19 countries, totalling 116 cases. It was observed only COVID-19 non-vaccinated cases and no sex or age predilection. The oral lesions presentation was mostly single location (69.8%), commonly in the tongue, lips, and palate, being ulcer the main clinical presentation. According to severity index for COVID-19, the reports were more frequent in patients with mild and moderate symptoms, being 75.8% in acute phase. The oral lesion appearance in post-acute COVID-19 were described after 14 to two months after patient recovery. Histologically, keratinocytes with perinuclear vacuolization, thrombosis and mononuclear inflammatory infiltrate were also described with the presence of the virus in keratinocytes, endothelial cells, and minor salivary glands. In conclusion, health care professionals should consider COVID-19 association when patient present ulcerated oral lesions and mild to moderate symptoms for COVID-19 or had acute-COVID-19.

Oral manifestations associated with COVID-19 disease: An observational cross sectional study

Objectives

The aim of present study was to investigate oral manifestations associated with COVID-19 disease.

Materials and methods

This cross-sectional study comprised 367 suspects with mild/moderate COVID-19 symptoms who reported to a tertiary care hospital's screening OPD. An in-depth case history was taken, and an oral cavity examination was performed to detect any oral findings. All participants were tested for SARS-CoV-2 using a naso-pharyngeal swab and reverse transcription polymerase chain reaction.

Oral manifestations and the results of RT-PCR testing were correlated. Statistical analyses were performed using Epi Info and R software. To estimate the prevalence of oral symptoms, the Pearson chi-square test was used.

Results

Oral manifestations were found in 58% of the study population. The difference in the prevalence of oral manifestations between RT-PCR positive COVID-19 patients versus RT-PCR negative suspects was statistically significant (p = 0.007) with xerostomia and dysgeusia being significantly higher in positive patients (p = 0.036 and p = 0.044 respectively) while the prevalence of stomatopyrosis and other intraoral signs was insignificant.

Conclusion

Xerostomia and dysgeusia are the common oral manifestations of COVID-19.

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First cross sectional study on oral manifestations of COVID-19 disease.

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Xerostomia and dysgeusia are the most common oral manifestations of COVID-19 disease.

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Oral ulcers and lesions present in COVID-19 patients are non-specific and not related to COVID-19 disease.

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Xerostomia and dysgeusia along with any systemic symptom like fever have more probability of suffering from COVID-19.

Long COVID Oral Cavity Symptoms Based on Selected Clinical Cases

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is characterized by variable clinical features, different durations, and several previously unheard-of late complications. Knowledge about this infection is constantly evolving.

The aim of the study is to present selected cases of the most common symptoms of long COVID in the oral cavity.

Among the 1,256 studied patients, 32% of them had discoloration, ulceration, and hemorrhagic changes on the oral mucosa, 29.69% had mycosis located on the tongue, 25.79% of patients had aphthous-like lesions on the hard palate, and in 12.5% atrophic cheilitis was observed. During the anamnesis, approximately 60% of patients reported salivary secretory disorders in the initial period of infection, which is 6.68% prolonged up to 4 months after systemic symptoms disappeared. In an extreme case, an aphthous-like lesion was located on the hard palate, which persisted for 6 months. Approximately 36% of patients did not agree to the proposed treatment. As a result, they only received recommendations on the use of oral hygiene products and received weekly check-ups. In this group of patients, most pathological changes spontaneously cleared after 3 weeks. The elderly with coexisting diseases, persons with a more severe SARS-CoV-2, and hospitalized patients had more extensive and severe lesions in the oral cavity that persisted for a long time after infection.

In patients after the SARS-CoV-2 infection and suspected of this infection, a detailed intraoral examination should be performed, and the patient must be obligatorily monitored for a minimum period of 6 months. Depending on the patient's clinical condition, changes in the oral cavity require observation, basic or specialist treatment. In the case of changes in the cavity without pain symptoms, observation should be made for approximately 4 weeks and wait for the spontaneous regression of the changes. However, when pain occurs, a good solution is to use laser biostimulation. In the case of complex pathological changes occurring in the oral cavity, the patient should be directed for specialist treatment.

COVID-19 and Its Repercussions on Oral Health: A Review

In 2019, a new type of coronavirus, SARS-CoV-2, the causing agent of COVID-19, was first detected in Wuhan, China. On 11 March 2020, the World Health Organization declared a pandemic. The manifestations of COVID-19 are mostly age-dependent and potentially more severe in cases with involved co-morbidities. The gravity of the symptoms depends on the clinical stage of the infection. The most common symptoms include runny nose and nasal congestion, anosmia, dysgeusia or hypogeusia, diarrhea, nausea/vomiting, respiratory distress, fatigue, ocular symptoms, diarrhea, vomiting, and abdominal pain. These systemic conditions are often accompanied by skin and mucosal lesions. Oral lesions reported in patients with COVID-19 include: herpex simplex, candidiasis, geographic tongue, aphthous-like ulcers, hemorrhagic ulcerations, necrotic ulcerations, white hairy tongue, reddish macules, erythematous surfaces, petechiae, and pustular enanthema. It is still unclear if these manifestations are a direct result of the viral infection, a consequence of systemic deterioration, or adverse reactions to treatments. Poor oral hygiene in hospitalized or quarantined COVID-19 patients should also be considered as an aggravating condition. This narrative review is focused on presenting the most relevant data from the literature regarding oral manifestations related to SARS-CoV-2, as well as the challenges faced by the dental system during this pandemic. A routine intraoral examination is recommended in COVID-19 patients, either suspected or confirmed, as, in certain cases, oral manifestations represent a sign of severe infection or even of a life-threatening condition. It is our belief that extensive knowledge of all possible manifestations, including oral lesions, in cases of COVID-19 is of great importance in the present uncertain context, including new, currently emerging viral variants with unknown future impact.

An integrative review of oral manifestations in patients with COVID-19: signs directly related to SARS-CoV-2 infection or secondary findings?

We conducted an integrative review on oral manifestations in patients with COVID‐19 based on the current available literature evidence. A bibliographic search was carried out on March 11, 2021, among published studies in the years 2019–2021 in the PubMed database and based on the search strategy (“COVID‐19” AND “oral lesions” OR “oral mucositis” OR “oral manifestation”). After applying the inclusion and exclusion criteria, 29 articles were considered suitable for this review. A total of 110 cases of patients with COVID‐19 who had oral manifestations were reported. The presence of ulcerated lesions was the most common finding, having a herpetiform and aphthous clinical pattern observed in most cases. Macules, petechiae, hemorrhagic blisters, pustular enanthem, mucositis, and halitosis were also among the most frequently described oral manifestations. The tongue was the most commonly affected site, followed by the palate and lip. Most of the reported cases were diagnosed only by the clinical aspect of the lesion associated with a positive SARS‐CoV‐2 test or the presence of other COVID‐19 symptoms. Current scientific evidence still could not affirm that most of the oral lesions observed in patients with COVID‐19 are related to the virus's direct or indirect action on the oral mucosa. To confirm this association, prospective and longitudinal studies are further needed, together with a larger number of patients, complemented by histopathological examination of these lesions. Additionally, molecular techniques, such as immunohistochemistry and in situ hybridization, may be necessary to perform the differential diagnosis with other oral lesions.

Oral Manifestations of COVID-19: Updated Systematic Review With Meta-Analysis

There is increasing evidence for oral lesions and manifestations of COVID-19. The aim of this meta-analysis was to investigate the types of oral manifestations of COVID-19 and their prevalence. PubMed/Medline, Scopus, Web of Science, and Google Scholar databases were used to search for publications on oral manifestations in patients with PCR-confirmed COVID-19. A total of 310 records were selected, and 74 were included. Oral lesions in COVID-19 were classified according to their etiologies, including iatrogenic lesions caused by intubation and opportunistic infections. Of the included studies, 35 reported oral lesions probably caused by severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) infection. Meta-analysis of prevalence data on oral manifestations and aphthous lesions indicated high heterogeneity, while meta-analysis of xerostomia prevalence data revealed a pooled prevalence, with considerable heterogeneity. In conclusion, the meta-analysis yielded high heterogeneity between studies: oral lesions yielded a prevalence of 0.33 (95% CI 0.11-0.60), xerostomia lesions a prevalence of 0.44 (95% CI 0.36-0.52) and aphthous lesions 0.10 (95% CI 0.01-0.24). In addition, a gap in the evidence regarding the prevalence of oral lesions in COVID-19 was identified and the need for further observational studies focusing on this issue and on the causal relationships between oral lesions and COVID-19 was highlighted.

Oral Complications of ICU Patients with COVID-19: Case-Series and Review of Two Hundred Ten Cases

BACKGROUND

The critically ill patients suffering from coronavirus disease (COVID-19) and admitted to the intensive care units (ICUs) are susceptible to a wide array of complications that can be life-threatening or impose them to long-term complications. The COVID-19 oral mucocutaneous complications require multidisciplinary management and research for their pathophysiological course and epidemiological significance; therefore, the objective of this study was to evaluate the prevalence and characteristics of the critically ill COVID-19 patients with oral complications.

METHODS

We described the clinical and microbiological characteristics of the critically ill COVID-19 patients in our ICU department (Banska Bystrica, Slovakia). In addition, we reviewed the current body of evidence in Ovid MEDLINE®, Embase, Cochrane Library, and Google Scholar for the oral mucocutaneous complications of ICU patients with COVID-19.

RESULTS

Three out of nine critically ill patients (33.3%) in our ICU department presented with oral complications including haemorrhagic ulcers and necrotic ulcers affecting the lips and tongue. The microbiological assessment revealed the presence of opportunistic pathogens, confirming the possibility of co-infection. On reviewing the current literature, two hundred ten critically ill patients were reported to have oral complications due to their stay in the ICU setting. Perioral pressure ulcers were the most common complication, followed by oral candidiasis, herpetic and haemorrhagic ulcers, and acute onset macroglossia. The prolonged prone positioning and mechanical ventilation devices were the primary risk factors for those oral complications, in addition to the immunosuppressive drugs.

CONCLUSIONS

The multidisciplinary approach is strongly advocated for monitoring and management of COVID-19 patients, thus implying that dermatology and oral healthcare specialists and nurses should be integrated within the ICU teams.

Association of Viral Infections With Oral Cavity Lesions: Role of SARS-CoV-2 Infection

Different viral agents, such as herpesviruses, human papillomavirus, and Coxsackie virus, are responsible for primary oral lesions, while other viruses, such as human immunodeficiency virus, affect the oral cavity due to immune system weakness. Interestingly, it has been reported that coronavirus disease 2019 (COVID-19) patients can show cutaneous manifestations, including the oral cavity. However, the association between oral injuries and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still unclear. This narrative review aimed to summarize the available literature and provide an overview of oral lesions associated with COVID-19. An online literature search was conducted to select relevant studies published up to November 2020. The results of 17 studies showed variability in oral lesions associated with COVID-19, including ulcerations, aphthous-like lesions, and macules. The tongue, lips, and palate were the most frequent anatomical locations. According to current knowledge, the etiopathogenesis of multiple COVID-19-associated lesions seems to be multifactorial. The appearance of such lesions could be related to the direct or indirect action of SARS-CoV-2 over the oral mucosa cells, coinfections, immunity impairment, and adverse drug reactions. Nevertheless, COVID-19-associated oral lesions may be underreported, mainly due to lockdown periods and the lack of mandatory dispositive protection. Consequently, further research is necessary to determine the diagnostic and pathological significance of oral manifestations of COVID-19. All medical doctors, dentists, and dermatologists are encouraged to perform an accurate and thorough oral examination of all suspected and confirmed COVID-19 cases to recognize the disease's possible early manifestations.