COVID-19 tongue

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—an RNA virus that is the cause of novel coronavirus (COVID-19)—has known symptoms including fever, loss of smell and taste, headache, sore throat, dyspnea, dry cough, abdominal pain, vomiting, and diarrhea.¹ The effects of the virus on various organs are due to the angiotensin-converting enzyme 2 (ACE2) receptor, the portal of cellular entry for SARS-CoV-2, found in the lung, colon, heart, liver, kidney, gastrointestinal (GI) region, and nervous system.²

The ACE2 receptor is also found in abundance in the oral cavity (figure 1)—including the salivary glands, tongue, tonsils, and floor of the mouth—which results in signs and symptoms of COVID-19 in the mouth.³ A recent article with eight case studies highlighted COVID-19–induced lesions on the tongue, alveolar mucosa, soft and hard palate, and buccal gingiva. This article will focus on COVID-19–associated pathology of the tongue, recently termed “COVID tongue” in news reports.⁴

Figure 2: White film that coats the tongue in a diagnosed COVID-19–positive patient — **Figure 2:** White film that coats the tongue in a diagnosed COVID-19–positive patient

A recent study evaluating 666 diagnosed COVID-19–positive patients manifesting mucocutaneous lesions found that 25% of those diagnosed were in the oral cavity. Of those that occurred in the oral cavity, 50% of the lesions affected the tongue.⁵ Typical presentation of tongue pathology dubbed “COVID tongue” includes loss or altered taste, burning, ulceration, inflammation, white/red “patches” of lesions, petechiae, and a whitish coating over the tongue (figures 2 and 3).

The proposed etiology of these lesions is thought to occur in two different ways and may be synergistic in fashion. The first suggested method is the result of viral binding to the oral epithelial cell’s ACE2 receptor and changes induced at the cellular level. The second proposed mechanism is allowing opportunistic infections brought about by other viruses, bacteria, and fungi in the oral cavity to cause disease due to COVID-19, stress, medications, and/or other related immunosuppressive factors compromising the immune system.

Figure 3: Lesion extending from the lateral border to the ventral tongue on a patient recently diagnosed with COVID-19 — **Figure 3:** Lesion extending from the lateral border to the ventral tongue on a patient recently diagnosed with COVID-19

Because of this etiology, the differential diagnosis for COVID-19 lesions would include aphthous stomatitis, herpetiform lesions, candidiasis, vasculitis, Kawasaki-like lesions, erythema migrans-like lesions, geographic tongue, mucositis, necrotizing periodontal disease, angina bullosa-like lesions, angular cheilitis, and burning mouth syndrome.⁶

Treatment of these lesions attributed to “COVID tongue” is best rendered with proper diagnosis via a biopsy and/or DNA analysis from swab or saliva. In general, the literature has reported success treating these lesions with ointments or rinses consisting of neomycin, nystatin, and triamcinolone acetonide (Kenacort) applied three times a day.⁵ Compounded rinses containing nystatin, metronidazole, and essential oils have also been used in treatment. In addition, because COVID-19 can affect salivary quantity and quality, rinses addressing oral dryness and inflammation, such as StellaLife Vega oral rinse, can alleviate symptoms and expedite recovery. As with any disease affecting the tongue, a full complement of vitamins, including vitamin B₃, vitamin B₆, vitamin B₉, vitamin B₁₂, vitamin D, vitamin C, and zinc, should be considered.

Editor’s note: This article originally appeared in Perio-Implant Advisory, a chairside resource for dentists and hygienists that focuses on periodontal- and implant-related issues. Perio-Implant Advisory is part of the Dental Economics and DentistryIQ network. To read more articles, visit perioimplantadvisory.com and subscribe at this link.

Related reading:

References

Symptoms of coronavirus. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Centers for Disease Control and Prevention. Updated December 22, 2020. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
Hamming I, Timens W, Bulthuis MLC, Lely AT, Navis GJ, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol. 2004;203(2):631-637. doi:10.1002/path.1570
Xu H, Zhong L, Deng J, et al. High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral Sci. 2020;12(1):8. doi:10.1038/s41368-020-0074-x
Miller K. What is COVID tongue, and is it a sign you’ve been infected with the virus? Health. January 27, 2021. https://www.health.com/condition/infectious-diseases/coronavirus/covid-tongue-swollen
Rodríguez MD, Romera AJ, Villarroel M. Oral manifestations associated with COVID-1. Oral Dis. 2020:10.1111/odi.13555. Published online: July 22, 2020. doi:10.1111/odi.13555
Iranmanesh B, Khalili M, Amiri R, Zartab H, Aflatoonian M. Oral manifestations of COVID-19 disease: a review article. Dermatol Ther. 2020:e14578. Published online November 25, 2020. doi:10.1111/dth.14578

Scott Froum, DDS, a graduate of the State University of New York, Stony Brook School of Dental Medicine, is a periodontist in private practice at 1110 2nd Avenue, Suite 305, New York City, New York. He is the editorial director of Perio-Implant Advisory and serves on the editorial advisory board of Dental Economics. Dr. Froum, a diplomate of the American Board of Periodontology, is a volunteer professor in the postgraduate periodontal program at SUNY Stony Brook School of Dental Medicine. Contact him through his website at drscottfroum.com or (212) 751-8530.