Oral Manifestations of Coronavirus Disease 2019 (COVID-19)

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents rapid transmission and significant mortality worldwide. It is responsible for coronavirus disease 2019 . The disease presents diverse clinical symptoms, including fever, cough, dyspnea, and pneumonia. However, other manifestations associated with COVID-19 need to be clarified, leading specialists to an early diagnosis and better prognosis. We describe the spectrum of clinicopathologic COV-ID-19-related oral lesions that can be the first and/or the unique manifestation of the disease. Fourteen patients with a mean age of 58 years (range: 23 to 88 y) with oral lesions were included. All patients were confirmed to be infected with SARS-CoV-2 by reverse transcription polymerase chain reaction testing. Patients demonstrated mild symptoms, including dysgeusia, anosmia, fever, and headache. The lesions were recognized and classified into 2 groups: (1) lesions caused by ischemia and/or hemorrhage and (2) lesions secondary to inflammatory events associated with viral load. The palate was most affected (n = 8), followed by the tongue (n = 4), and both the lip and palate (n = 2). Histologic analysis demonstrated thrombosis of small arteries and capillaries, associated with areas of hemorrhage and chronic inflammatory infiltrate. Immunohistochemistry showed positive staining for spike protein (SARS-CoV and SARS-CoV-2) and angiotensin-converting enzyme 2 in the surface epithelium, salivary glands, inflammatory cells, and endothelial cells. Although the incidence of oral lesions among patients infected with SARS-CoV-2 appears to be uncommon, these findings suggest that the oral mucosa can also be a target organ for SARS-CoV-2.

Symptomatic subgemmal neurogenous plaque in patients with COVID‐19: Is there an association?

“…COVID-19 manifestations in the oral cavity can be the first signs of the disease. [10][11][12][13] The most frequently reported signs include areas of ecchymosis, petechiae, ulcers, and vesiculobullous lesions. [11][12][13] However, under clinical practice, other significant anatomical modifications have been observed, such as parotid and lingual tonsil enlargement.…”

“…[10][11][12][13] The most frequently reported signs include areas of ecchymosis, petechiae, ulcers, and vesiculobullous lesions. [11][12][13] However, under clinical practice, other significant anatomical modifications have been observed, such as parotid and lingual tonsil enlargement. 14 Subgemmal neurogenous plaques (SNP) represent neural structures found in the posterolateral region of the tongue, and may present a variety of signs and symptoms, including burning sensation, erythema, ulcers, white patches and hyperplastic nodules, that may lead on decreasing of taste sensation in the posterior region of the tongue.…”

“…COVID‐19 manifestations in the oral cavity can be the first signs of the disease 10–13 . The most frequently reported signs include areas of ecchymosis, petechiae, ulcers, and vesiculobullous lesions 11–13 .…”

Oral expression following COVID-19: A systematic review

“…proposed an etiologic classification of oral manifestations divided into two groups: ischemia or hemorrhage and inflammation secondary to viral load (4).…”

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

“…Immunohistochemical characterizations of the inflammatory infiltrate consisting of CD3-positive T-lymphocytes (on the left -Immunohistochemistry anti-CD3, 10×), CD20-positive B-lymphocytes (in the middle -Immunohistochemistry anti-CD20, 40×), and CD68positive monocytes/macrophages (on the right -Immunohistochemistry anti-CD68, 20×). F I G U R E 7 The placenta of a COVID-19-positive patient used as immunohistochemical positive control (immunohistochemistry anti-SARS-CoV-2, 20×).Such data reported that spike protein-positive cells of the oral epithelium in COVID-19 patients are detectable in all the epithelial layers, including the vacuolated cells of the superficial layers, thus resembling related to direct viral effects(Soares et al, 2021(Soares et al, , 2022; also,Marques et al (2022) recently demonstrated by a cytological study such positivity also in desquamated epithelial cells from the dorsum of the tongue of 10 out of 14 COVID-19-positive patients and in absence of oral lesions.In the PCS oral lesions we studied, the histological investiga-tions showed that the epithelial cells of the basal and spinosum layers showed a weak SARS-CoV-2 positivity progressively decreasing or absent in the uppers as well as from the lesion towards the periphery until completely disappearing, thus supporting the Sars-CoV-2-related aetiopathogenesis of the oral mucosa lesions herein described. Additionally, the inflammatory infiltrate was mainly composed of lymphocytes in COVID-19-related oral lesions, which are strongly reduced (almost absent) in post-COVID-19 related ones and replaced by CD68-and CD163-positive cells, including phagocytic neutrophils, macrophages, dendritic cells, natural killer cells, and mast cells; such immune cells potentially form an integrated defensive system against pathogens or induce adaptive mucosal immunity, as widely discussed in the literature for several years now (Gutierrez-Camacho et al, 2022; Holmgren & Czerkinsky, 2005; Yuan & Walker, 2004).Overall, our data provide consistent evidence that SARS-CoV-2 can potentially persist in the oral mucosa after the acute phase and can be responsible for lesions too.…”