The intention of this presentation is to share with colleagues the information circulating in international publications about the lesions that have been seen in the mouths of suspected and COVID-19 positive patients.
Going through the reliable search engines and focusing the search on this topic especially, we found different reports, all well-intentioned, but due to their research methodology, varied inclusion criteria and undefined conclusions, in our opinion, with some exceptions, could generate confusion. in patients and professionals.
Since the oral mucosa could be the first stage infected with SARS-CoV-2, it could be assumed that oral mucosal lesions could be the first signs of COVID-19 to appear. If this were confirmed, dentists would be the first to identify suspected SARS-CoV-2-positive patients and could direct them to appropriate testing and treatment. Two studies from Spain and France reported oral ulcerative lesions in patients with COVID-19.
The Spain 1 study included three patients. The first two cases (men) were suspected cases of COVID-19 as they were not tested. Intraorally, they had ulcers involving the hard palate unilaterally in the anatomical area innervated by a greater palatine nerve. The shape and pattern of the ulcers suggest a viral etiology.
The third case was a woman with a confirmed diagnosis of COVID-19, and typical manifestations of the disease. Her treatment consisted of immunosuppressants, antibiotics and antivirals. Approximately one week after recovery, she developed oral ulcers and “desquamative gingivitis” as described by the authors.
Some sources 2 question this presentation, since only one of the three cases was diagnosed with COVID 19. The other two cases were not diagnosed, nor did they have any of the recognized symptoms of the disease. Cohabiting with infected patients does not necessarily confirm infection or predict disease outcomes. Furthermore, the pattern and shape of the ulcers in the first two cases were very similar to the introral herpes infection that could be caused by the herpes family of viruses.
The unilateral distribution in both patients affecting a characteristic anatomic area implicates the varicella zoster virus, or at least probably one of the herpes simplex viruses. In the third case, oral ulcers affected the patient after recovery, and this occurred in association with skin lesions requiring antifungal therapy, suggesting that these skin lesions were fungal. The authors stated that "further studies need to be conducted to determine whether oral manifestations are common in patients affected by SARS-CoV-2 infection or whether the emotional distress of the situation itself could trigger such lesions."
The France 3 report warned of a tongue ulcer that manifested at the same time as erythematous skin lesions, in a middle-aged woman who tested positive for COVID-19. Unfortunately, this report did not provide a complete description of the patient’s medical condition and whether she had any other symptoms related to COVID-19. He also did not report whether the patient was taking any medication.
Other reports on COVID-19 cases report oral manifestations 4,5 6
Despite presentations reporting oral lesions in patients with COVID-19, the question remains unanswered as to whether such lesions are due to coronavirus infection or are secondary manifestations, resulting from the patient’s systemic condition.
Oral lesions could be due to many other factors, such as stress caused by restrictions on social life during the pandemic lockdown, lack of oral hygiene, work pressure 7 or the herpes simplex virus 8 .
Antiseptic rinses to reduce oral viral load, based on hydrogen peroxide 9, could also induce oral ulcers 10 . A complete history is essential to know the true etiology of the injury.
Some lesions may result from immunological deterioration, developing opportunistic infections, as well as adverse reactions to treatments. Therefore, the lesions that occur in the oral cavity during the course of COVID-19 infection justify broad and updated interest.
There is still no efficient and safe drug against infection, and the existing ones are related to several adverse reactions, including in the oral cavity 12.13
The indicated therapeutic measures could contribute to adverse outcomes related to oral health, leading to opportunistic infections, recurrences of oral herpes simplex (HSV-1), nonspecific oral ulcerations, drug hypersensitivity, dysgeusia, xerostomia related to decreased salivary flow. , ulcerations and gingivitis as a result of the impaired immune system and/or susceptible oral mucosa 14 .
In patients with COVID-19, we must consider the appearance of some oral signs and symptoms, such as dysgeusia, petechiae, candidiasis, traumatic ulcers, HSV-1 infection, geographic tongue, according to the Geographic Tongue Severity Index, new system Picciani clinical score 15 ulcers, thrush, among others. Therefore, the importance of clinical dental examination of patients with infectious diseases in the Intensive Care Unit should be emphasized, considering the need for support.
Although the SARS-CoV-2 genome was detected in the saliva in the majority of patients with this disease16 and in some cases, it was only detected in the saliva, without evidence of its presence in the nasopharynx 17 , we must be cautious when associate COVID-19 with oral ulcers, since there are many viruses that could affect the oral cavity with ulcers .
In addition, the emotional stress associated with home quarantine, confinement and infection of loved friends and family also endangers health and complicates the picture.
| SARS-Cov- 2 can cause acute sialadenitis 18 |
Acute sialadenitis can manifest after SARS-Cov 2 binds to ACE2 receptors in the epithelium of the salivary glands. It fuses with them, replicates and lyses the cells to induce symptoms and signs such as discomfort, swelling and pain in the major salivary glands (parotid and submandibular glands).
When acinar cells are lysed by the cytolytic effect of the virus, salivary amylase is released into the peripheral blood. Therefore, we infer that amylase increases in the peripheral blood in the early phase of infection. Symptoms such as discomfort, pain, swelling and secretory dysfunction in the salivary glands may occur in some patients. As the immunoreaction subsides, the inflammatory damage will be repaired through granulation and fibrogenesis.
| SARS-Cov-2 can cause chronic sialadenitis |
As a result of the conventional repair mechanism of acute inflammatory damage 15,16,17 , it is speculated that the inflammatory destruction of the salivary glands will be repaired through the proliferation of fibroblasts and the formation of fibrous connective tissue, leading to a condition of hyposecretion of the glands. salivary glands.
Ductal stenosis produced together with episodes of sialolithiasis would lead to chronic obstructive sialadenitis caused by COVID -19
> A report to take into account
Ciro Dantes Soares, et al 19 present the clinical and microscopic characteristics of the oral and reddish oral lesions that occurred in a 42-year-old male patient positive for SARS-Cov-2 confirmed by polymerase chain reaction (PCR).
They comment that the patient complained of a painful ulceration in the oral mucosa that was biopsied. The oral examination showed, in addition to the ulcerated lesion, multiple reddish macules of different sizes scattered along the hard palate, tongue and lips. After 3 weeks of follow-up, the lesions showed complete remission.
They describe the microscopic characteristics of oral lesions: epitheliumwhich demonstrates vacuolization and hemorrhage in the superficial portion of the lamina propria, with hyperemic vessels. Lymphocytic infiltration into the connective tissue and thrombi of different sizes. Positive expression of CD34 in small vessel thrombi. Larger thrombi with a variable amount of fibrin and CD34-positive endothelial cells.
In the lamina propria, a diffuse chronic inflammatory infiltrate was associated with focal areas of necrosis and hemorrhage. The visible small superficial and deep vessels were obliterated by obvious thrombi.
The small thrombi appeared to be composed primarily of endothelial cells, while the larger ones were composed of fibrin and endothelial cells.
The adjacent minor salivary glands exhibited intense lymphocytic infiltration, mainly positive for CD3, and some of these cells were also found in the basal layer of the epithelium. Immunohistochemical reactions against HHV-1, HHV-2, CMV, treponema pallidum, and EBV by in situ hybridization were negative. Taking into account the clinical and microscopic characteristics, it was suggested that the patient had lesions that could be associated with Covid-19 disease.
Diffuse thrombotic disease in the lung of patients with COVID-19 has been previously reported and appears to be common. Therefore, oral involvement appears to be very rare . The authors acknowledge that the oral lesions observed in a COVID-19 positive patient, who exhibited microscopic areas of hemorrhage and small thrombotic vessels would be the first time reported in a COVID-19 positive patient that includes the clinical and microscopic features of oral lesions .
They state that these injuries must be better understood and characterized, considering the possible mechanisms involved. These microscopic alterations could suggest a primary reaction to SARS-CoV-2, since their patient had not undergone intubation or any other traumatic event.
| Conclusion |
As can be seen, until now, there is no evidence of the presence of specific and pathognomonic oral lesions related to Sars-Cov-2.
However, the work of Ciro Dante Soares and collaborators is not without importance, reporting on thrombotic symptoms in the pathological anatomy of a mouth ulcer, not related to any known etiology, and also the description of the pathologies of the salivary glands described, associated directly with the cytolytic action of the virus.
Five months later, we still do not know if we are at the end of the beginning or the beginning of the end of this unexpected pandemic.
What is clear is that the dental profession continues to be attentive and rise to the occasion alongside the multidisciplinary teams that fight the disease.
- The author: Dr. Eduardo L. Ceccotti
- Numerary Member of the National Academy of Dentistry
- Former Head Professor of Stomatology Clinic. University of Salvador.AOA
- Former Head of Oral Pathology Section. Institute of Oncological Studies. Maissa Foundation National Academy of Medicine
- Author of four books on the Specialty
