Oral Manifestations of COVID-19: Early Studies Suggest Possible Systemic Link

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Information is updated often while we are still studying COVID-19 and its effects. Dental hygienists should be aware of even possible legitimate theories from scientists since this is a novel virus.

Recently, scientists have been making an oral health connection to COVID-19. In addition, patients often look to hygienists and other dental health professionals to have a dialogue about the virus and the latest findings.

COVID-19 and Periodontal Disease

It has recently been suggested that the presence of periodontal disease may cause a more severe infection of COVID-19.2,3 One article in Medical Hypotheses stated, “Since inflammatory and dysbiotic factors, as well as comorbidities, affect systemic health, it is possible that periodontal status indicates the risk of complication of COVID-19.”2

Another article from the same journal added, “Periodontitis may elevate the risk of invasion by bacterial pathogens, and potentially also viral pathogens such as SARS CoV-2.”3 The article continued, “The cytokine storm in severe COVID-19 infections has many components common with the cytokine expression profile of periodontitis suggesting a possible link between periodontitis and COVID-19 infection and complication.”3

COVID-19 and Oral Tissue

New research has also suggested that the virus, in rare cases, may contribute to oral lesions.

During the early outbreak of COVID-19, Carreras-Presas et al. published a study of two patients who confirmed positive and one patient who was a spouse (never tested).4 The Oral Diseases article summarized, “All three cases reported having had pain, oral ulcers, or blisters before seeking medical advice.”4

The first patient had lesions resembling recurrent herpetic stomatitis. However, it was the first time the patient had them.4 The second patient had multiple small ulcers on his palate and also did not have any previous history of herpetic infection.4 The third patient developed a large rash on her back and blisters on her internal lip mucosa as well as desquamative gingivitis.4

The article stated, “We suspect that intraoral lesions often are misdiagnosed due to the lack of intraoral examinations, considering the severity of other pathological processes that might concur with this viral infection.”4 The author suggests oral ulcers could be underreported since other symptoms might be more urgent to the patient.

A study published in July 2020 found an ulcerated lesion, multiple reddish macules of different sizes scattered along the hard palate, tongue, and lips on a 42-year-old patient.1 “Microscopically, the biopsied lesion presented the epithelium with severe vacuolization and occasional exocytosis.”1 From a histology point of view, this was an inflamed lesion with focal areas of necrosis and hemorrhage.1 Although severely inflamed ulcerated lesions appear to be rare, the authors conclude SARS-CoV-2 can cause oral lesions.1 They, therefore, suggest all patients positive for the virus should have a full mouth examination to better understand the pathobiology of these oral alterations.1

Another study published in the Journal of Oral Medicine and Oral Surgery observed a COVID-19 positive patient with a painful irregular ulcer on the dorsal side of the tongue.5 “Erythematous rash has been described and could also be explained by an inflammatory reaction.”5 The article concluded, “Thus, this irregular oral ulcer could be an inaugural symptom of COVID-19 which needs to be proven in larger cohorts of patients.”5


All in all, as oral health professionals, dental hygienists should keep up to date on the latest findings of COVID-19. Researchers suggest a link between periodontal disease and more severe COVID-19 infections.2,3 In addition, the virus has been suggested to cause lesions resembling herpetic blisters and ulcers.1,4,5

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  1. Soares, C.D., Andrade de Carvalho, R., Andrade de Carvalho, K., et al. Letter to Editor: Oral Lesions in a Patient with COVID-19. Medicina Oral Patologia Oral y Cirugia Bucal.2020; 25(4): e563-e564. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338069/
  2. Pitones-Rubio, V., Chavez-Cortez, E.G., Hurtado-Camarena, A., et al. Is Periodontal Disease a Risk Factor for Severe COVID-19 Illness? Medical Hypotheses. 2020; 144: 109969., Retrieved from https://doi.org/10.1016/j.mehy.2020.109969
  3. Räisänen, I.T., Umeizudike, K.A., Parnanen, P., et al. Periodontal Disease and Targeted Prevention Using aMMP-8 Point-of-care Oral Fluid Analytics in the COVID-19 Era. Medical Hypotheses. 2020; 144: 110276. Retrieved from https://doi.org/10.1016/j.mehy.2020.110276
  4. Carreras‐Presas, C.M., Carmen, J.A., Lopez-Sanchez, A.F., et al. Oral Vesiculobullous Lesions Associated with SARS‐CoV‐2 Infection. Oral Diseases. 2020; 27(S3): 710–712. Retrieved from https://doi.org/10.1111/odi.13382
  5. Abanoub, R., Marwa, G. Comment on: Oral Manifestation of Covid-19 as an Inaugural Symptom? Journal of Oral Medicine and Oral Surgery. 2020; 26(2): 19. Retrieved from https://doi.org/10.1051/mbcb/2020020