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    1. Periodontics
    2. Oral Pathology

    Oral manifestations in COVID-19–positive patients: 8 case reports

    Feb. 3, 2021
    Dr. Aravindhan Karunakaran describes eight cases of oral manifestations seen in COVID-19–positive patients and highlights their management.
    21 Feb11 Pi Akarunakaran08

    The coronavirus disease 2019 (COVID-19) presents with flulike symptoms—fever, cough, loss of smell and taste, and body aches, to name a few.1,2 In immunocompromised patients, COVID-19 can lead to lethal respiratory distress.3 SARS-CoV-2 binds to the angiotensin-converting enzyme 2 (ACE2) receptor, which is detected in the cell membrane of numerous human organs and tissues, including the lungs, kidneys, liver, epithelial cells of the tongue and salivary glands, upper respiratory tract, nervous system, and skeletal muscle, among others.4

    Many studies suggest that the cells expressing ACE2 enzymes are considered to be host cells for the COVID-19 virus. The ACE2 enzyme is highly expressed in type II alveolar cells of the lungs as well as on the epithelial cells of the tongue.5 The saliva is a medium for transmission of various microorganisms, including herpes simplex virus, Epstein-Barr virus, and MRSA bacteria. Oral manifestations seen in patients with COVID-19 can be due to virus itself and/or the decreased immunity in these individuals. Many studies have reported that the rashlike lesion that occurs is due to proliferation of SARS-CoV-2 in the oral cavity, which is caused by decreased immunity. The epithelial cells on the tongue are rich in ACE2 enzymes, which aid in the multiplication of SARS-CoV-2.

    The oral lesions observed in COVID-19–positive patients may be due to the virus breeding in saliva, decreased immunity, or a reaction to antiviral medications.6 There have been reports that oral manifestations precede typical respiratory symptoms seen with COVID-19. Symptoms such as anosmia (lack of smell) and dysgeusia (lack of taste) were also reported in many COVID-19 studies.7 These manifestations suggest that SARS-CoV-2 virus might have the ability to target the oral mucous membrane.

    This article describes eight different cases of oral manifestations seen in patients testing positive for COVID-19. Moreover, the article highlights the management of such cases.

    Case no. 1

    Figure 1: Hard palate showing erosive lesion in a COVID-19–positive female
    Figure 1: Hard palate showing erosive lesion in a COVID-19–positive female
    A 40-year-old female tested positive for COVID-19 on December 10, 2020 (RT-PCR test). The patient did not show any classical symptoms of COVID-19 and had only intermittent cough and headache. She presented with severe palatal and oropharyngeal pain, profuse salivation, and paresthesia near the lesions. The oral findings included erosive lesions involving the hard palate and gingiva (figure 1). Multiple petechial spots were noted on the palate and oropharynx, and the lesions were sore and painful. The palatal areas of the lesions felt numb. Irregular areas of blanching were noted on the palate as was sialorrhea.

    The provisional diagnosis was COVID-19–related oral lesions. The case was managed using topical triamcinolone acetonide (Kenacort) 0.1% paste, doxycycline and benzalkonium chloride mouthrinse, and topical lignocaine 2% gel three times per day.

    Case no. 2

    Figure 2: Generalized erythema, petechiae, and erosive lesions in a COVID-19–positive male
    Figure 2: Generalized erythema, petechiae, and erosive lesions in a COVID-19–positive male
    A 67-year-old male tested positive for COVID-19 (rapid test) on December 4, 2020. The patient did not have any classical symptoms of COVID-19 except intermittent cough, and he tested positive for the COVID-19 virus based on his travel history and oropharyngeal lesions and symptoms. The symptoms observed were severe oropharyngeal pain, profuse salivation, partial dysgeusia, and paresthesia surrounding the lesions. Oral findings included generalized erythema, petechial spots, and erosive lesions on the hard and soft palate, fauces, and adjoining buccal mucosa (figure 2). The lesions were excruciatingly painful. The surrounding areas of the lesions felt numb. Severe sialorrhea was noted. The patient’s taste sensation was altered. He reported having severe pain during mastication as well as suffering from dysphagia.

    The provisional diagnosis was COVID-19–related oral lesions. The case was managed with topical triamcinolone acetonide (Kenacort) 0.1% paste, doxycycline and benzalkonium chloride mouthrinses, and topical benzocaine 5% gel.

    Case no. 3

    Figure 3: Petechial spots on the hard palate of a COVID-19–positive patient
    Figure 3: Petechial spots on the hard palate of a COVID-19–positive patient
    A 51-year-old male tested positive for COVID-19 on December 6, 2020 (RT-PCR test). The patient did not have any classical symptoms of COVID-19 and was tested after COVID-19–related oropharyngeal lesions were noticed. He presented with severe oropharyngeal pain, profuse salivation, ageusia, anosmia, and partial paresthesia near the lesions. Petechial spots were noticed on the hard and soft palate as well as the oropharynx (figure 3). The lesions were extremely painful, and the areas adjacent to the lesions felt numb. Sialorrhea was noted. Additionally, the patient complained of severe pain while eating, and he suffered from dysphagia.

    The provisional diagnosis was COVID-19–related oral lesions. Topical triamcinolone acetonide (Kenacort) 0.1% paste, doxycycline and benzalkonium chloride mouthrinses, and topical benzocaine 5% gel were prescribed three times per day.

    Case no. 4

    Figure 4: Erosive lesion on mandibular posterior gingival area
    Figure 4: Erosive lesion on mandibular posterior gingival area
    A 44-year-old female tested positive for COVID-19 on November 8, 2020. The patient did not exhibit any classical symptoms of COVID-19 and was tested due to known contact with a virus-positive person. Multiple painful ulcers and erosive lesions were noted on the right side of the mandibular posterior gingival tissues, alveolar mucosa, and the adjoining buccal mucosa (figure 4). Additionally, the patient complained of profuse salivation.

    The tentative diagnosis noted was COVID-19–related oral lesions. The lesions were addressed with topical triamcinolone acetonide (Kenacort) 0.1% paste, doxycycline and benzalkonium chloride mouthrinses, and topical benzocaine 5% gel, thrice daily.

    Case no. 5

    Figure 5: Diffuse reddish lesions on the hard palate of a 52-year-old COVID-19–positive patient
    Figure 5: Diffuse reddish lesions on the hard palate of a 52-year-old COVID-19–positive patient
    A 52-year-old male tested positive for COVID-19 after being referred for testing because COVID-19–related oral lesions were noticed. Diffused reddish lesions were seen throughout hard palate (figure 5). The lesions were painful and erythematous. The patient was experiencing soreness and dysgeusia.

    The provisional diagnosis was COVID-19–related oral lesions. The case was managed with topical triamcinolone acetonide (Kenacort) 0.1% paste, and doxycycline and benzalkonium chloride mouthrinses.

    Case no. 6

    Figure 6: Reddish lesion on the right side of the hard and soft palate that crosses the midline in a COVID-19–positive patient
    Figure 6: Reddish lesion on the right side of the hard and soft palate that crosses the midline in a COVID-19–positive patient
    A 45-year-old male tested positive for COVID-19 viral disease on September 10, 2020. The patient complained of a palatal lesion 30 days after he was tested. He was tested for Candida albicans with a culture test that came out negative. Initially, the lesion was mildly painful. After a few days, it became extremely painful. The surrounding areas of the palate felt numb. The patient also complained of profuse salivation and dsyphagia. The lesion was around 2x2 cm, located predominantly on the right side of the hard and soft palate, crossing the midline, with elevated erythematous, edematous patches with ill-defined borders. A few petechial spots were noted within the lesion (figure 6). Chemical burns, traumatic injuries, and contact stomatitis were ruled out.

    The tentative diagnosis was COVID-19–related oral lesions. The lesions were addressed with topical triamcinolone acetonide (Kenacort) 0.1% paste, doxycycline and benzalkonium chloride mouthrinses, and topical lidocaine 2% gel three times per day.

    Case no. 7

    Figure 7: Large ulcer on the left lateral aspect of the tongue in an active COVID-19–positive patient
    Figure 7: Large ulcer on the left lateral aspect of the tongue in an active COVID-19–positive patient
    A 50-year-old COVID-19–positive male complained of painful oral ulcers on the fifth day after testing. Large, painful oral ulcers with a burning sensation were noticed in the patient with active COVID-19 (figure 7). The ulcers were located on the left lateral aspect of the tongue and were sore in nature.

    The case was managed with doxycycline mouthrinses, topical benzocaine gel 5%, and polyvitamin supplements thrice daily for 14 days.

    Case no. 8

    Figure 8: Ulcers and petechiae spots on multiple areas of the oral cavity
    Figure 8: Ulcers and petechiae spots on multiple areas of the oral cavity
    A 21-year-old female tested positive for the COVID-19 viral infection on October 7, 2020. The oral lesions were first noted on October 13. Multiple, painful oral ulcers accompanied by a burning sensation were noted in the active–COVID-19 patient (figures 8–10).

    The case was managed with doxycycline mouthrinses, topical benzocaine gel 5%, and polyvitamin supplements thrice daily for 14 days.

    Summary

    Figure 9: Ulcers and petechiae spots on multiple areas of the oral cavity
    Figure 9: Ulcers and petechiae spots on multiple areas of the oral cavity
    COVID-19 infections have numerous oral manifestations. Sometimes these oral manifestations precede the active infectious stage.8 The most common oral manifestations in these eight cases were ulcers and petechial areas. Additionally, excessive salivation and dysgeusia were also reported. Wadia R. reported gustatory impairment prevalence as 45% in COVID-19–positive patients.9
    Figure 10: Ulcers and petechiae spots on multiple areas of the oral cavity
    Figure 10: Ulcers and petechiae spots on multiple areas of the oral cavity
    Triamcinolone acetonide (Kenacort) 0.1% paste was recommended for treating the patient’s sore throat. This paste is a synthetic corticosteroid cream with anti-inflammatory effects via inhibiting macrophage and leukocyte migration to the affected site through reversal of vascular dilation and permeability. These actions lead to reduced edema and erythema, which is commonly seen in ulcers.10 Doxycycline monthrinse is a tetracycline-based product that inhibits the growth of bacteria. It is contraindicated in pregnant women and children under age 12 due to its interference with the development of teeth and staining.11 Topical anesthetics were recommended to relieve the pain caused by petechiae and ulcers. The anesthetic works by stopping nerves from sending pain signals to the brain.12 Additionally, multivitamins were recommended during the active COVID-19 phase to boost immunity. Studies show that vitamin D–deficient patients are more prone to acquire COVID-19. Thus, the body’s immune response plays a very important role in recovery time from COVID-19 infection.

    Conclusion

    The COVID-19–positive patient presents with a variety of oral lesions, which include:

    • Multiple palatal and oropharyngeal petechial lesions
    • Dysgeusia
    • Palatal and oropharyngeal erosions and ulcerative lesions
    • Excessive salivation
    • Severe pain over the lesion area
    • Partial paresthesia surrounding the lesions
    • Irregular areas of blanching involving the palate
    • Burning sensation of palate and oropharynx, and dysphagia
    • Palatal and oropharyngeal tenderness and soreness
    • Necrotic pseudomembranes covering the erosive/ulcerative lesions

    Management protocol A management protocol for COVID-19–positive patients is as follows:

    1. Topical triamcinolone acetonide (Kenacort) 0.1% paste (applied by the patient three times daily)
    2. Doxycycline and benzalkonium chloride mouthrinses (applied by the patient three times daily)
    3. Topical benzocaine 5% gel (applied by the patient three times daily)

    All photos courtesy of the author

    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.

    References

    1. Singhal T. A review of coronavirus disease–2019 (COVID-19). Indian J Pediatr. 2020;87(4):281-286. doi:10.1007/s12098-020-03263-6
    2. Lo Giudice R. The severe acute respiratory syndrome coronavirus–2 (SARS CoV-2) in dentistry. Management of biological risk in dental practice. Int J Environ Res Public Health. 2020;17(9):3067. doi:10.3390/ijerph17093067
    3. Yi Y, Lagniton PNP, Ye S, Li E, Xu RH. COVID-19: what has been learned and to be learned about the novel coronavirus disease. Int J Biol Sci. 2020;16(10):1753-1766. doi:10.7150/ijbs.45134
    4. Salamanna F, Maglio M, Landini MP, Fini M. Body localization of ACE-2: on the trail of the keyhole of SARS-CoV-2. Front Med (Lausanne). 2020;7:594495. doi:10.3389/fmed.2020.594495
    5. Fini MB. Oral saliva and COVID-19. Oral Oncol. 2020;108:104821. doi:10.1016/j.oraloncology.2020.104821
    6. 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
    7. Carrillo-Larco RM, Altez-Fernandez C. Anosmia and dysgeusia in COVID-19: a systematic review. Wellcome Open Res. 2020;5:94. doi:10.12688/wellcomeopenres.15917.1
    8. Rodríguez MD, Romera AJ, Villarroel M. Oral manifestations associated with COVID-19. Oral Dis. 2020;10.1111/odi.13555. doi:10.1111/odi.13555
    9. Wadia R. COVID-19 – oral manifestations. Br Dent J. 2020;229(10):669. doi:10.1038/s41415-020-2411-z
    10. Hamishehkar H, Nokhodchi A, Ghanbarzadeh S, Kouhsoltani M. Triamcinolone acetonide oromucoadhesive paste for treatment of aphthous stomatitis. Adv Pharm Bull. 2015;5(2):277-282. doi:10.15171/apb.2015.038
    11. Lewis MAO, Wilson NHF. Oral ulceration: causes and management. The Pharmaceutical Journal. March 19, 2019. https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/oral-ulceration-causes-and-management/20205786.article
    12. Altenburg A, El-Haj N, Micheli C, Puttkammer M, Abdel-Naser MB, Zouboulis CC. The treatment of chronic recurrent oral aphthous ulcers. Dtsch Arztebl Int. 2014;111(40):665-673. doi:10.3238/arztebl.2014.0665

    Dr. Aravindhan Karunakaran is an associate professor and head of the department of oral medicine and radiology at Konaseema Institute of Medical Sciences Dental College in India.