key: cord-0767530-cvk1uyuu
authors: Díaz Rodríguez, Milagros; Jimenez Romera, Amelia; Villarroel, Mariana
title: Oral manifestations associated to Covid‐19
date: 2020-07-22
journal: Oral Dis
DOI: 10.1111/odi.13555
sha: a0aaa9ac6dbdf2be9944ede5d55afa430039b2ab
doc_id: 767530
cord_uid: cvk1uyuu

The appearance in December of a new coronavirus has caused an unprecedented pandemic in the modern era. Undoubtedly, the disease produced by the novel Coronavirus and its consequences have posed a challenge for health authorities worldwide. The way of contagion through direct contact, through saliva in the form of small drops and the production of aerosols have facilitated the rapid spread worldwide. In Spain the authorities declared the confinement for the majority of population in March 14th , therefore most of dental clinics were closed except for emergencies. Dentists were considered at high risk due to two factors: all procedures are obviously performed in the mouth with direct contact with saliva and the exposure to aerosols produced by rotatory instruments. Many articles have been published regarding to the spread of the virus and the role that saliva plays in its transmission and diagnosis. (Li et al.,2020) (Sabino-Silva, R.,2020) (Xu et al., 2020) (Zhong et al.,2020) (Chen et al., 2020).

The appearance in December of a new coronavirus has caused an unprecedented pandemic in the modern era. Undoubtedly, the disease produced by the novel Coronavirus and its consequences have posed a challenge for health authorities worldwide. The way of contagion through direct contact, through saliva in the form of small drops and the production of aerosols have facilitated the rapid spread worldwide. In Spain the authorities declared the confinement for the majority of population in March 14 th , therefore most of dental clinics were closed except for emergencies. Dentists were considered at high risk due to two factors: all procedures are obviously performed in the mouth with direct contact with saliva and the exposure to aerosols produced by rotatory instruments. Many articles have been published regarding to the spread of the virus and the role that saliva plays in its transmission and diagnosis. (Sabino-Silva, R.,2020) (Zhong et al.,2020 ) (Chen et al., 2020 . In relationship to extrapulmonary manifestations, several authors have reported cases with cutaneous manifestations in which maculo-papular, acral, urticariform, vesicular and vascular obstruction-type manifestations are the most common. (Recalcati et al., 2020) (Estebanez et al., 2020 ) (Galvan et al., 2020 (Landa et al., 2020) . During this period, despite the implications of saliva for virus transmission and the possibility of salivary glands as a reservoir, few oral manifestations have been reported. Oral dryness, vesiculobullous lesions, aphthous-like lesions, dysgeusia and anosmia are the most common oral signs reported. (Martín Carreras-Presas et al., 2020) .

In this paper we present 3 cases in which we have a confirmation for SARS-Cov-2 with oral manifestations. 43-year-old woman, tested positive for SARS-Cov-2 for 56 days, period in which several PCR were performed. Patient developed fever, malaise, dysgeusia and anosmia, diarrhea, pneumonia and blood laboratories suggested risk of thrombosis. She was isolated and remained in quarantine during this period with regular follow-ups by doctors over the phone. In the last two weeks, she reported aphthous-like lesions, burning sensation and tongue depapillation that progressed as observed in figure 1. Image was sent through SMS-message with informed consent and data protection for sending images. In this case

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ODI.13555 This article is protected by copyright. All rights reserved we prescribed rinses with a solution containing triamcinolone acetonide 0,05% , 3 times a day for a 10 day period. After treatment, lingual depapillation persisted but ulcers and burning sensation disappeared.

Male 53 years old, tested positive for SARS-Cov-2, with hospital admission in the first week of April. A few days after hospital discharged, patient scheduled an appointment at the dental clinic for consultation. He referred burning mouth sensation and also unilateral commissural fissures (figure 2). Complaining for anosmia and dysgeusia were recorded. Lesions were diagnosed as commissural cheilitis. In this case we prescribed ointment containing neomycin, nystatin, and triamcinolone acetonide for application 3 times a day. Avoid self-licking the area, as well as shaving were recommended in order to diminish trauma. Hygiene of the area using a gauze with clorhexidine between ointment application was also indicated. Commissural lesions disappeared completely after treatment, but anosmia and dysgeusia were still present. 78-year-old woman, tested positive for SARS-Cov-2, with hospital admission in the first days of April. Since hospitalization, she reported very intense sensation of dry mouth that she did not have previously. During dental consultation, lesions on the tongue, palate and commissure compatible with pseudomembranous candidiasis and angular cheilitis were observed (figure 3). In this case we prescribed solutions and gels to improve salivary dryness. Nystatin solution rinses 4 times a day were prescribed for the intraoral lesions for 15 days. Angular cheilitis was treated using ointment containing neomycin, nystatin, and triamcinolone acetonide. After treatment pseudomembranous lesions disappeared as well as comisural fissures. Moreover, salivary flow and dry mouth sensation improved. In relation to the cases reported, it should be noted that all of them are related to a certain state of immunosuppression. Stress might play an important role in the appearance of these oral conditions. Cause-effect relationship between Coronavirus infection and the appearance of oral lesions cannot be established, however, as in HIV infection, COVID patients develop oral lesions related to immunosuppression more frequently.

The reasons for absence of sufficient scientific evidence reporting oral lesions may be due to the confinement situation, lack of access to test therefore diagnosis confirmation, and the fact that most dentists, as a result of the high risk contagion, have been out of the health system. Nevertheless, telemedicine has been a useful tool to establish triage and primary diagnosis avoiding personal attendance during the peak of infection.

It is important to consider that an exhaustive intraoral examination should be performed in patients that were diagnosed with COVID-19 in order to find any oral manifestation that might be related. For instance, appearance of temporal oral pigmented lesions is expected as chloroquine has been used as part of the treatment in patients with COVID-19. Also dentist should improve the examination of salivary glands and saliva flow in order to perform early diagnoses related to changes in the glandular parenchyma that might be affected by the virus. Figure 2 : Commissural cheilitis. Notice the fissure and bleeding located in the commissure. Figure 3 : Atrophy of the surface of the tongue including white fungal patches,distributed mainly in the left lateral side, and a red plate located in the hard and soft palate. Notice also the fissures located in the dorsum of the tongue. This article is protected by copyright. All rights reserved Accepted Article

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