Fever, cough, sore throat – these are all symptoms we have come to know very well when it comes to COVID-19.  However, COVID tongue, among other oral manifestations, is gaining traction both scientifically and in the media. The relationship between our oral health, disease, and the immune system is well known across medical fields, yet many researchers and industry professionals are still contemplating how COVID shows up orally.

Let us take a closer look.

 

Changes or symptoms in the mouth can occur as a result of diseases affecting other organs. In fact, symptoms may show up in the mouth first before an individual suspects any other issues. This is what is referred to as oral manifestations, and research has found that over 90% of systemic diseases manifest orally in the form of ulcers, blisters, gum inflammation, and more.

 

In addition to systemic diseases, there is also a relationship between immune system diseases and oral manifestations, including inflammatory bowel disease (IBDs) and acquired immunodeficiency syndrome (AIDS). When the immune system is compromised, oral lesions and ulcers may occur. Several common oral manifestations include the following:

 

  • Thrush. Thrush is a type of yeast infection where a yeast-like fungus overgrows on the tongue.  It appears as bumpy white patches on the tongue.  It can also cause redness and pain. Several underlying systemic problems can cause thrush.

 

  • Burning mouth syndrome. As the name suggests, Burning Mouth results in a burning sensation on the tongue and in the mouth. Although the exact cause is unknown, research suggests it may be caused by nerve damage, allergies, nutritional deficiencies, or hormonal changes.

 

  • Black hairy tongue. Black hairy tongue appears as a dark coating of hair on the tongue when the tongue cannot shed dead cells, causing them to build up. This issue can develop after a course of antibiotics or a diet made up of soft foods that do not scrub the tongue’s surface to remove the cells.

 

  • Oral cancer. Oral cancer can present on the tongue in several ways. Tongue cancer symptoms may include pain or an ulcer that does not heal within two weeks.Alternatively, cancerous spots may be painless and can present in many forms, such as difficulty moving the tongue or white or red patches that do not heal.

 

  • Glossitis. Glossitis is swelling of the tongue and may be an independent issue or a symptom of another issue. Geographic tongue is an example of glossitis in which marks on the tongue’s surface look like a map.

 

Through our understanding of oral manifestations and the knowledge that COVID creates an immune response, I am confident that oral manifestations such as ulcers, redness, and pain may appear when an individual has COVID.

 

Early last year, the world became aware of the novel coronavirus quickly spreading across the globe. Initially, there was little understanding of the virus; however, nearly a year later, we now have a better understanding of how the virus is transmitted and how it affects the body. Although many health authorities have published lists of common symptoms, there are still several lesser common symptoms that should be addressed. These fewer common symptoms are still prevalent, with 1 in 5 COVID patients exhibiting symptoms that are not officially listed.

 

Research and numerous accounts from COVID patients have discovered oral manifestations resulting from COVID with symptoms affecting the tongue, gums, and teeth.

 

COVID Tongue

 

A recent article published on Dentistry online cited Tim Spector, King’s College London professor leading the UK’s ‘ZOE COVID Symptom Study’ app, and his reports on an increasing level of COVID tongue symptoms. According to Spector, there are additional symptoms that are not officially listed, which includes what he has called COVID tongue.

 

COVID tongue consists of ulcers and white patches in the mouth, specifically on the tongue. As this is a new phenomenon, there is no current medical definition and is instead being referred to as such. Researchers in Madrid dubbed the new term after conducting a field hospital study and discovering 25% of the 666 patients with mild to moderate cases of COVID presented bumps, ulcers, white coating, and inflammation of the tongue. They specified that the symptoms are not always consistent, and there are various forms of “COVID tongue.”

 

Another study, published in June 2020 in the Nature Journal Evidence-Based Dentistry, suggested a link between oral ulcers, blisters, and COVID. The researchers believe these symptoms have gone undetected due to a lack of intraoral examination. A similar study published in JAMA Dermatology in July 2020 expressed similar findings and believed oral manifestations go unnoticed as those with COVID concerns are not being examined.

 

Currently, no oral symptoms are listed by the World Health Organization (WHO), US Centers for Disease Control, or Public Health England (PHE), yet officials are “seeing increasing numbers of COVID tongues and strange mouth ulcers,” says Spector.

 

Taste Disorders

 

Further to these physical manifestations, oral manifestations are occurring with taste. According to a systematic review published in the British Dental Journal (BDJ), taste impairment was the most prevalent oral manifestation in COVID patients. More specifically, taste impairment is prevalent in 45% of patients. BDJ examined taste impairment further and found that not all impairments were the same. For those who experienced a gustatory impairment, 38% of patients experienced a bad taste in their mouth (dysgeusia), 35% had a limited ability to taste (hypogeusia), and 24% experienced losing a particular taste ability, such as tasting saltiness, sweetness, or bitterness (ageusia).

 

Centers for Disease Control and Prevention (CDC) reported the median duration for loss of taste was 8 days, and a smaller study conducted in Europe found loss of taste and loss of smell were strongly associated with one another and lasted an average of 8.9 days.

 

 

Gum Inflammation and Tooth Loss

 

In addition to COVID tongue and taste impairment, an increasing number of individuals have reported sudden tooth loss after recovering from COVID-19. These reports include blackened teeth, broken teeth, and teeth quickly falling out with no prior warning.

 

Dr. William W. Li, president of the Angiogenesis Foundation, told the New York Times that this sudden tooth loss could indicate that something is happening in the gum blood vessels that keep teeth alive. Dr. Li suggests that COVID-19 damages the vessels resulting in tooth loss with no pain. A prosthodontist in California believes the gum issues are a result of the COVID-induced hyper-inflammatory reactions.

Gingival inflammation has been seen in COVID patients, suggested to be a result of elevated cytokines and interleukin levels initiated by the virus. Further, severe COVID cases have been linked to immune dysregulation resulting in a cytokine storm. Knowing that periodontal disease increases levels of cytokines, researchers examined the relationship between periodontal disease (PD) and COVID. Their research found there to be sufficient evidence to believe that PD is a risk factor, as it indicates systemic health. It has not yet been closely studied, so it is impossible to determine the association at this point, but it is believed that the inflammatory response plays a role.

 

Although little formal research has looked at tooth loss, gum disease, and COVID, these anecdotal reports and scientific reviews are telling. COVID survivor support groups have formed where individuals can share their long-term effects following COVID. One of these groups is Survivor Corps, with over 145,000 members on Facebook, there are hundreds of personal stories of COVID survivors who have experienced similar tooth-related issues.

 

Oral Manifestations Of COVID: Causation Vs. Correlation

 

With so much still unknown, there are conflicting beliefs regarding oral manifestations and COVID. Many have posed the following: – Is COVID tongue, tooth loss, and gum inflammation directly caused by the virus, or are these symptoms a result of other factors such as increased stress, declining dental hygiene, and pre-existing dental issues, and inflammation?

 

The virus lives in the mouth, so it is no surprise that there are oral manifestations. It latches onto cells called ACE2 receptors, which are very prominent in our lungs and mouth. According to Eric Cioe-Oena, director of Global Health at Northwell Health, there is an intimate connection between our mouth and body, but when it comes to COVID, “We do not have enough data yet to know whether this is purely a temporal association or causation.”

 

Some of the issues could be a result of poor dental hygiene. Since the pandemic, research has shown that dental hygiene practices have decreased, creating further dental problems. According to a Utah-based periodontist Dr. David Okano, dental problems can be exacerbated when recovering from an acute infection. Alternatively, it could be triggered by extreme stress. A May 2020 
study described three COVID patients who exhibited oral ulcerative lesions and believed they might have been caused by the emotional distress associated with having COVID instead of the virus itself.

 

The review conducted by BDJ discovered that in mild COVID cases, oral lesions presented at the same time as respiratory symptoms. For more severe COVID cases resulting in hospitalisation, the lesions developed between 7 to 24 days following the onset of symptoms. Despite not being listed as a common symptom, enough research shows that oral manifestations of COVID are increasing.

Many of the researchers cited here stressed the importance of increasing intra-oral examinations in COVID patients. Dental professionals cannot assume that ulcers, blisters, and discoloration in the mouth result from COVID; however, the increasing prevalence of these oral manifestations highlights the importance of intraoral examination and the potential to identify the disease before definitive diagnosis.

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