Oral Symptoms of COVID-19

Introduction:

The Coronavirus disease, named COVID‐19, is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). During the initiation of the COVID‐19 disease, it was believed that the absence of oral signs and symptoms was a distinct feature of COVID‐19. With SARS‐CoV‐2 identified in the saliva of COVID-19 patients, it is interesting to understand how this virus affects the oral mucosa.

What Are the Symptoms of COVID-19?

Frequent Clinical Symptoms- The frequent clinical symptoms are-

• Fever.

• Sore throat.

• Headache.

• Dyspnea.

• Dry cough.

• Vomiting.

• Abdominal pain.

• Diarrhea.

Dermatologic Manifestations- At present, the dermatologic manifestations of COVID‐19 disease are-

• Varicelliform lesions.

• Urticaria form.

• Erythema multiforme‐like lesions.

• Mottling.

• Maculopapular rash.

• Livedo reticularis‐like lesions.

• Petechiae and purpura.

Oral Lesions- Taste impairment is the most reported manifestation. However, other common oral symptoms include-

• Erythema.

• Lichen planus.

• Aphthous‐like lesions.

• Herpetiform lesions.

• Candidiasis.

• Oral lesions of Kawasaki‐like disease.

• White and erythematous plaques.

• Irregular ulcers.

• Small blisters.

• Petechiae.

• Desquamative gingivitis.

• Geographic tongue.

What Are the Oral Symptoms of COVID-19?

a) Dry Mouth:

Dry mouth is also called xerostomia. Dry mouth commonly occurs due to viral infections, autoimmune diseases, and currently also due to COVID-19. It produces serious adverse effects on the patient's quality of life, affecting dietary habits, nutritional status, speech, taste, tolerance to a dental prosthesis, and increased susceptibility to dental caries. A dry mouth has a hard time producing saliva. A dry mouth results in a sticky mouth and makes the saliva thicker. A lack of saliva can cause severe alterations in the mucous membrane, and the patient may have severe discomfort. The mucosa will appear dry and atrophic, sometimes inflamed, or, more often, pale and translucent. The tongue might get inflamed and look fissured and cracked. Soreness, burning, and pain in mucous membranes and the tongue common symptoms. Bad breath due to insufficient saliva to flush out bacteria a typical sign of dry mouth.

b) Angina Bullosa‐Like Lesions:

Angina bullosa-like lesions are characterized by blood-filled vesicles and bullae. They are a type of vesiculobullous-like lesions that commonly involve the mucosa of the patients. Intact bullae are rare in the mouth, and most commonly, patients have ill-defined, irregularly shaped gingival, buccal, or palatine erosions, which are painful and slow to heal. The erosions extend peripherally with the shedding of the epithelium. Erosions may be shattered and often extensive and may spread to involve the larynx with subsequent hoarseness. The patient is often unable to eat or drink adequately because the lesions cause discomfort. Angina bullosa‐like lesions do not cause spontaneous bleeding on the tongue and hard palate. It causes an asymptomatic reaction with erythematous‐purple blisters on the tongue and hard palate of a COVID‐19 individual.

c) Aphthous‐Like Lesions:

Aphthous-like lesions appear red and have yellowish-white membranes covering them. Usually, the lesions heal within 5 to 15 days. The major cause for its appearance in COVID-19 is stress and suppressed immune response after COVID-19 infection. When there is a reversal of oral symptoms, there is progress in the systemic diseases. Studies have shown the occurrence of oral lesions concurrent with systemic symptoms in some patients. Also, a favorable course of recurrent aphthous stomatitis (RAS) and polymerase chain reaction (PCR) for herpes simplex virus (HSV) were seen in some patients. One of the important reasons for aphthous-like lesions in COVID-19 patients is the increased level of tumor necrosis factor (TNF)‐α. This results in the chemotaxis of neutrophils in the oral cavity and the establishment of aphthous‐like lesions. In younger patients with mild infections, aphthous‐like lesions without necrosis, and immunosuppressive elderly patients with severe infection, aphthous‐like lesions with necrosis and hemorrhagic crusts were observed.

d) Erythema Multiforme‐Like Lesions:

Erythema multiforme (EM), also called Stevens-johnson syndrome and Herpes-associated erythema multiforme, is an acute self-limiting dermatitis characterized by a distinctive clinical eruption. It is of two types Erythema multiforme major and erythema multiforme minor. Erythema multiforme minor is characterized by mucosal erosions of raised atypical target lesions. They are usually located on the extremities or on the face. The characteristic findings of erythema multiforme major are mucosal erosions plus widespread distribution of atypical flat targets or purpuric macules. The oral mucous membrane lesions are not usually a significant feature of the disease except for the pain and discomfort they cause. The hyperemic macules, papules, or vesicles may become eroded or ulcerated and bleed freely. The tongue, palate, buccal mucosa, and gingiva are commonly diffusely involved. Occasionally mucous membrane lesions occur before the cutaneous manifestations. The onset of the lesion is after the onset of systemic diseases. The lesion is visible between seven to twenty-four days. Erythema multiforme(EM)‐like lesions that look like ulcers, painful blisters, and inflamed gums.

e) Herpetiform Lesions:

Herpetiform lesions start as multiple painful, small punctate, unilateral, pinhead-sized yellowish‐gray ulcers. They occur in both keratinized and nonkeratinized mucosa as recurrent episodes of minute ulcers affecting large areas of oral mucosa with an erythematous rim. They present with prodromal burning and itching sensation, and these lesions forgo and coincide with systemic symptoms. The most important cause for the occurrence of secondary herpetic gingivostomatitis is stress and immunosuppression related to COVID-19. Studies show up with the initiation of the geographic tongue after the revival from herpetiform lesions.

f) Ulcerative or Erosive Lesions:

Ulcerative or erosive lesions show up with irregular borders in the tongue and appear as painful lesions in the hard palate and labial mucosa. The important causes for the initiation of ulcerative or erosive lesions are-

• Drug eruption.

• Vasculitis.

• Thrombotic vasculopathy, secondary to COVID‐19 infection.

The ulcerative and erosive lesions could be seen after a week delay. A recent study showed up with lesions two to three days prior to the initiation of systemic symptoms. It becomes normal after a gap of three weeks.

g) Nonspecific Lesions (Mucositis):

It results in discomfort and pain with observed visual changes. Initially, areas of redness are seen, which is called erythema, and progress into painful ulcerations. They appear as round yellow plaques. Small ulcerations usually do not cause any pain, but extensive ulcerations interrupt eating and drinking liquids and affect the integrity of oral mucosa. Erythematous‐violaceous macules, papules, and plaques appear on the sides and underside of the tongue, lip, inside the cheeks, hard palate, and oropharynx.

h) COVID-19 Tongue:

The British Journal of Dermatology says that a considerable amount of COVID-19 patients have bumps in the tongue, along with swelling and inflammation on the surface of the tongue. In contrast to the regular healthy pink tongue, unique redness, white patches, or dark-colored tongue are identified when affected by the infectious virus. The exact cause for the COVID-19 tongue is not known. . COVID-19 also influences oral cavities by changing the color and texture of the tongue. General physicians accept the link between the COVID tongue and skin rashes that have developed an association with COVID-19. COVID-19 tongue results with:

• Plenty of discomforts.

• Mouth irritation.

• Change in color of the tongue.

• Tingled lips.

• Irritated tongue

• Tingly tongue.

i) White and Red Plaques:

Normally oral mucosa appears pink in color. This is because of the translucent superficial mucosa striking the capillary bed. They are classified as keratotic and non-keratotic lesions and red and white plaques with defined precancerous potential. Whenever a patient presents with a white or red plaque, it should be first determined whether the lesion can be removed or dislodged by gentle rubbing. The plaques or lesions which can be scraped off are generally without hyperkeratosis like pseudomembranous candidiasis lesions. The lesions or plaques which cannot be scraped off or dislodged are hyperkeratotic like leukoplakia and lichen planus. The common site of occurrence of white and red plaques in patients with confirmed or assumed COVID-19 are:

• Dorsum of the tongue.

• Gingiva.

• Palate.

j) Kawasaki‐Like Disease:

It is commonly seen in children <5 years of age. It is very rarely seen in adults. It most commonly occurs in immunocompromised individuals. COVID‐19 patients with Kawasaki‐like disease (Kawa‐COVID) showed up with oral lesions such as,

• Cheilitis.

• Glossitis.

• Erythematous.

• Swollen tongue.

k) Necrotizing Periodontal Disease:

Necrotizing periodontal disease deals with the inflammation of the gums, which results from the unusual bacteria. This condition affects the oral cavity with tissue death known as necrosis, and ulceration of the mucosa is also a common feature. A 35‐year‐old woman suspected of COVID‐19 had oral lesions along with her systemic symptoms. Oral lesions were painful with diffuse erythematous and edematous gingiva. She also presented with necrosis of the inter‐papillary areas, and it was diagnosed as a necrotizing periodontal disease along with COVID‐19.

l) Vesicles and Pustules:

Studies showed that oral lesions were seen in a COVID-19 case along with regular COVID-19 symptoms. The oral lesions are-

• Vesicular eruptions.

• Oral erythematous papular exanthem.

• Erosions on the tongue.

• Erosions on the buccal mucosa.

The COVID-19 symptoms and the lesions get cured within a week. Another study reported erythema on the hard palate, and oropharynx with petechiae, and which was diagnosed as a lesion called was enanthem due to COVID‐19. These lesions were cured within a few days.

m) Petechiae:

Petechiae are tiny red spots, which are circular, non-raised lesions and appear on the skin and mucous membrane. Petechiae results when bleeding in the capillaries where the blood leaks into the skin. Thrombocytopenia (low platelet count) as a result of COVID‐19 infection or due to any prescribed COVID-19 drugs is the most important cause of petechiae. The common sites of occurrence are-

• Lower lip.

• Palate (hard and soft palate).

• Oropharynx mucosa.

What Are the Oral Symptoms in Patients With Mechanical Ventilation?

Severe COVID-19 patients that require long-term mechanical ventilation, and oxygen supply, suffer from a large number of oral complications like bad breath, mucosal damage, retention of secretions in the mouth, etc. Long-term intubation can lead to oral and laryngeal muscle injury, resulting in dysphonia (voice disorders) and dysphagia (difficulty in swallowing) after the extubation.

Conclusion:

Awareness regarding the early symptoms of COVID-19 is essential. General physicians and dental surgeons need to be conscious of the various oral signs and symptoms of COVID-19. They are at high risk as they are in close proximity to the patient's saliva and blood during treatment. Safety measures should be followed in the dental clinics as cross-infections are common occurrences. So wearing masks, avoiding touching your face and eyes, following general hygiene habits, are the major steps to be followed during the pandemic. The major susceptibility factors for initiating oral lesions in COVID‐19 patients are poor oral hygiene, stress, diabetes mellitus, trauma, opportunistic infections, immunosuppression, vascular compromise, and high inflammatory response. So it is necessary for elderly people and immunocompromised people to stay indoors and stay healthy to prevent themselves from this infectious disease.