Review of oral ulcerative lesions in COVID-19 patients: A comprehensive study of 51 cases

Abstract

Numerous oral manifestations of COVID-19 have been reported in the literatures. Common oral lesions in COVID-19 patients included ulcerations, xerostomia, dysgeusia, gingival inflammation, and erythema. Among them, oral ulceration is the most frequent finding and is present as various but distinct patterns. Thus, we conducted a comprehensive review of 51 COVID-19 patients with oral ulcerative lesions to further analyze the various oral ulcerative lesions in COVID-19 patients. There were a median age of 41.4 years and a slight female predilection in these patients. Most oral lesions manifested as an aphtha-like ulceration but lack of an evidence of recurrent aphthous stomatitis. Some of them were present as herpetiform ulcerations without HSV infection. Widespread ulcerations accompanied with necrosis were observed in the more severe and immunosuppressed older patients. Although some reported patients were asymptomatic, most of them had systemic symptoms concurring or slightly preceding the oral ulcerative lesions and the latency from the onset of systemic symptoms to oral ulcerative lesions were under 10 days, suggesting that oral ulceration was one of the early symptoms of COVID-19. Therefore, the oral ulcerative lesions may be considered as oral markers for early diagnosis of the underlying COVID-19 infection in the asymptomatic patients.

Lack of direct association between oral mucosal lesions and SARS-CoV- 2 in a cohort of patients hospitalised with COVID-19

“…The oral symptoms of COVID-19 at the hospitalisation were limited to dysgeusia, which was observed in 17 patients (11%). During the period of hospitalisation, only two patients developed superficial ulcerative lesions covered with fibrinopurulent exudate surrounded by an erythematous halo, resembling aphthous-like ulcers [ 6–13 , 14 . One of these patients was HIV-positive, and as previously mentioned, also presented pseudomembranous candidiasis due to a marked decrease in the count of CD4 + T lymphocytes that relapsed after one week of hospitalisation when the ulcers also appeared.…”

“…Conversely, some studies investigated the presence of HSV-1 by using serology tests [ 6 ], immunohistochemistry [ 13 ], saliva PCR assay [ 7 , 14 ] or lesion swab [ 9 ]. Although some cases were positive for HSV-1 [ 7 , 14 ], they maintained the possibility of a direct relationship with SARS-CoV-2 infection.…”

“…As for the exclusion of the diagnosis of RAS, the majority of the studies investigated the previous history of ulcerative lesions in the oral mucosa during anamnesis [ 7 , 9 , 12 , 14 and found no such pattern.…”

“…A number of reports have been published on the possible oral manifestations of SARS-CoV-2 infection, such as intra-oral and labial aphthous-like ulcers suggestive of viral infection, petechiae and erythematous macules, blood blisters, depapillation on the tongue dorsum, reduction of the salivary flow resulting in xerostomia, and sensory disorders (e.g. dysgeusia, hyposmia and anosmia) [ 6–9 ; 10–13 , 14 . Dysgeusia and xerostomia are the main oral manifestations observed in COVID-19 patients [ 15 ].…”

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

“…In the present study, the ulcer was the lesion more commonly reported and tongue the main anatomical area described by authors. Previous review [34] found a slight predisposition to the appearance of ulcers in patients with COVID-19, suggesting as a potential pathognomonic sign for early diagnosis of the disease.…”