E2 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 1/2021 “COVID tongue”—dentists urged to remain alert to symptoms in the oral cavity By Jeremy Booth, Dental Tribune In- ternational LEIPZIG, Germany: New discoveries about COVID-19 are outpacing the nomenclature. Research is emerg- ing that suggests that a large num- ber of COVID-19 patients experience symptoms in the oral cavity that are not yet recognised as typical signs of the disease. Geographic tongue— which is being referred to as “COVID tongue”—has been observed in those with COVID-19, as have her- petic lesions and oral aphthous ul- ceration. Guidance from the World Health Organization lists the three most common symptoms of COVID-19 as being fever, a dry cough and tired- ness. The oral cavity is implicated in some of the additional symptoms that the public health agency ad- vises to watch for—such as loss of taste or smell—but it currently does not mention further oral manifesta- tions. Dr Tim Spector, professor of genetic epidemiology at King’s College Lon- don, has been drawing attention to symptoms of COVID-19 that present in the mouth, such as geographic tongue. He says that those suffer- ing from “strange symptoms” like COVID tongue should stay home, even if the symptoms are not in- cluded in official lists provided by health authorities. Spector tweeted in January: “One in five people with COVID still present with less com- mon symptoms that don’t get on the official [Public Health England] list—such as skin rashes.” He said he was seeing an increasing number of examples of COVID tongue and other strange mouth ulcers. “If you have a strange symptom or even just headache and fatigue stay at home,” he emphasised. In January, Spector’s Twitter feed featured numerous images of sus- pected COVID tongue submitted by the public. On 27 January, he shared an image of the tongue of a 32-year- old with long-term COVID-19 effects. The tongue exhibited macroglos- sia and scalloping at the edges, and Spector noted that specialists could not determine the cause. Dr Lucy Davenport-Jones, a consultant or- thodontist from London, replied to Spector’s tweet, confirming that oral aphthous ulceration was emerging as a common complaint. Researchers in Iran and Spain have found that COVID-19 patients develop a range of oral manifestations, including xerostomia, dysgeusia, candidiasis and geographic tongue. k c o t s r e t t u h S / k l i u r s © According to Spector—the princi- pal investigator behind the COVID Symptom Study mobile application, which allows its (now more than four million) users to contribute data about the virus—at least 20 symptoms of COVID-19 are not be- ing commonly considered. He says that 35% of people have non-classic symptoms in the first three days, when they are most infectious. COVID-19 from the perspective of a dentist Researchers in Iran examined the ef- fects of the disease on the oral cavity in a review of 17 studies. They found that 170 patients, ranging in age from 9 to 90 years, had developed oral manifestations. The most com- mon was xerostomia (reported in 75 cases), followed by dysgeusia (71 cases) and candidiasis (67 cases). Of the 67 cases in which candidiasis was identified, specimens taken from 55 of the patients confirmed fungal infection. A change in tongue sensa- tion was reported by 48 patients, of which 28 experienced painful ulcers in the area. Muscle pain during mas- tication was reported by 15 patients, and ten patients experienced swell- ing in the oral cavity. According to the study, a change in tongue sensa- tion correlated strongly with swollen palate and changes in the candidi- asis. The authors identified six cases of re- current herpes simplex virus—two on the tongue and four on the hard palate. “Four patients developed ery- thema multiforme-like eruptions, three of whom had palatal macules and petechiae and one of whom showed three blisters in the inner lip mucosa. Erosions, erythema, ulcers, necrotising ulcerative periodontitis, and aphthous-like lesions were also observed in single cases,” the study read. The onset of the oral manifestations was detailed in 95 of the total 170 cases, and the researchers found a mean of 7.21 days between the onset of systemic symptoms and that of oral manifestations. The onset of the latter varied from ten to 42 days after systemic symptoms. The authors concluded: “The oral symptoms often appeared after general symptoms such as fever and asthenia, but can still be the initial or only sign of COVID-19. Thus, a careful i y a b a x P / n n a m t l A d r e G © clinical intra-oral examination must be performed on COVID-19-positive patients and equally on any patients who need dental care thoroughly and systematically to ensure that no parts are missing and to obtain fur- ther clinical data, which could pave the way for further studies.” Corresponding author Dr Pegah Hos- seinzadeh, postgraduate resident of orthodontics at the Faculty of Den- tistry at Guilan University of Medical Sciences in Iran, told Dental Tribune International that it was important for dentists to check for COVID-19 symptoms in the oral cavity. She explained: “Certainly, awareness of the symptoms, especially oral manifestations, is important to iden- tify and manage COVID-19 patients, but also to protect the dentist and other dental patients. For this reason, dentists must stay up to date with the latest research and knowledge of mucosal COVID-19 symptoms. A careful clinical intraoral examina- tion must be performed prior to any other dental treatment in every visit.” Hosseinzadeh said that the study showed that COVID-19 symptoms in the oral cavity were multifacto- rial. She added, however, that it was certain that the immune system was playing a significant role. “Medicine, stress, opportunistic infections like candida albicans and herpes sim- plex, and the virus, could be consid- ered as possible factors,” she said. “It is worth mentioning that these oral manifestations could be the only signs of COVID-19, and that they are also likely to manifest before general symptoms.” The findings were presented in a re- view article, titled “COVID-19 from the perspective of dentists: A case report and brief review of more than 170 cases”, published online on 26 December 2020 in Dermatologic Therapy, ahead of inclusion in an is- sue. Spanish study finds a quarter of COVID-19 patients had oral symptoms A cross-sectional study conducted by dermatologists in Spain in April 2020 found that a quarter of pa- tients had one or more symptoms in the oral cavity. The study was undertaken at a temporary field hospital established to treat mild to moderate cases of COVID-19-associ- ated pneumonia during the peak of SARS-CoV-2 infections in Madrid. It included 666 patients who had ei- ther a positive reverse transcription- polymerase chain reaction test or bilateral pneumonia. According to the study, symptoms in the oral cavity were present in 78 cases (25.7%), and the authors listed these as follows: transient lingual papillitis (11.5%), glossitis with lateral indentations (6.6%), aphthous sto- matitis (6.9%), glossitis with patchy depapillation (3.9%), and mucositis (3.9%). A burning sensation in the oral cavity was reported by 5.3% of participants and was found to be commonly associated with dysgeu- sia. The study, presented in a research letter published online in the Brit- ish Journal of Dermatology, stated that symptoms in the oral cavity such as glossitis or papillitis had not previously been associated with COVID-19, but hypothesised that the contagion risk of examining the oral cavity may have prevented a thor- ough examination of the oral cavity of COVID-19 patients. The authors acknowledged the study limitations that all study partici- pants were adults with only mild to moderate COVID-19 pneumonia and that the study was conducted during a two-week period; thus, the researchers may have missed previ- ous or later symptoms of the dis- ease. Despite these limitations, the authors stated: “The oral cavity was frequently involved and deserves specific examination under appro- priate circumstances to avoid conta- gion risk.”