{"id":5922,"date":"2024-01-25T06:00:00","date_gmt":"2024-01-25T11:00:00","guid":{"rendered":"http:\/\/wp.cov19longhaulfoundation.org\/?p=5922"},"modified":"2024-01-16T11:32:04","modified_gmt":"2024-01-16T16:32:04","slug":"oral-manifestations-of-covid%e2%80%9019-disease-a-review-article","status":"publish","type":"post","link":"https:\/\/cov19longhaulfoundation.org\/?p=5922","title":{"rendered":"Oral manifestations of COVID\u201019 disease: A review article"},"content":{"rendered":"\n

Authors: Behzad Iranmanesh<\/a>,\u00a0<\/sup>Maryam Khalili<\/a>,\u00a0<\/sup> et. al. Dermatol Ther.<\/a>\u00a02021 Jan-Feb; 34(1): e14578.\u00a0Published online 2020 Dec 13.\u00a0doi:\u00a010.1111\/dth.14578<\/a>PMCID:\u00a0PMC7744903PMID:\u00a033236823<\/a><\/p>\n\n\n\n

Abstract<\/h2>\n\n\n\n

Dysgeusia is the first recognized oral symptom of novel coronavirus disease (COVID\u201019). In this review article, we described oral lesions of COVID\u201019 patients. We searched PubMed library and Google Scholar for published literature since December 2019 until September 2020. Finally, we selected 35 articles including case reports, case series and letters to editor. Oral manifestations included ulcer, erosion, bulla, vesicle, pustule, fissured or depapillated tongue, macule, papule, plaque, pigmentation, halitosis, whitish areas, hemorrhagic crust, necrosis, petechiae, swelling, erythema, and spontaneous bleeding. The most common sites of involvement in descending order were tongue (38%), labial mucosa (26%), and palate (22%). Suggested diagnoses of the lesions were aphthous stomatitis, herpetiform lesions, candidiasis, vasculitis, Kawasaki\u2010like, EM\u2010like, mucositis, drug eruption, necrotizing periodontal disease, angina bullosa\u2010like, angular cheilitis, atypical Sweet syndrome, and Melkerson\u2010Rosenthal syndrome. Oral lesions were symptomatic in 68% of the cases. Oral lesions were nearly equal in both genders (49% female and 51% male). Patients with older age and higher severity of COVID\u201019 disease had more widespread and sever oral lesions. Lack of oral hygiene, opportunistic infections, stress, immunosuppression, vasculitis, and hyper\u2010inflammatory response secondary to COVID\u201019 are the most important predisposing factors for onset of oral lesions in COVID\u201019 patients.<\/p>\n\n\n\n

1.\u2003INTRODUCTION<\/h2>\n\n\n\n

Severe acute respiratory syndrome coronavirus 2 (SARS\u2010CoV\u20102) is a single\u2010chain RNA virus that is the cause of novel coronavirus disease known as COVID\u201019. The most common clinical symptoms are fever, headache, sore throat, dyspnea, dry cough, abdominal pain, vomiting, and diarrhea. Angiotensin converting enzyme 2 (ACE 2) receptor is a known receptor for SARS\u2010CoV\u20102 that is found in the lung, liver, kidney, gastrointestinal (GI) and even on the epithelial surfaces of sweet glands and on the endothelia of dermal papillary vessels. Todate, various cutaneous manifestations of COVID\u201019 disease have been described including varicelliform lesions, pseudochilblain, erythema multiforme (EM)\u2010liker lesions, urticaria form, maculopapular, petechiae and purpura, mottling, and livedo reticularis\u2010like lesions. 1 <\/a>, 2<\/a><\/p>\n\n\n\n

At the beginning of COVID\u201019 pandemic, it was assumed that lack of oral involvement is a differentiating feature of COVID\u201019 exanthema relative to other viral exanthemas. Recently, SARS\u2010CoV\u20102 has been detected from saliva of the patients and it has been demonstrated that reverse transcriptase\u2010polymerase chain reaction (RT\u2010PCR) from saliva can even be a more sensitive test in comparison with nasopharyngeal test. Furthermore, ACE2 has been found in oral mucosa, especially with more density on dorsum of tongue and salivary glands relative to buccal mucosa or palates. To date, there is only one systematic review that described oral manifestations of COVID\u201019 disease; however, it mostly focused on impairment of taste. Dysgeusia is the first recognized oral symptom of COVID\u201019 reported in 38% of patients, mostly in North Americans and Europeans, females, and patients with mild\u2010moderate disease severity.\u00a01\u00a0<\/a>In this review article, we described oral lesions of COVID\u201019 patients.<\/p>\n\n\n\n

2.\u2003METHODS<\/h2>\n\n\n\n

We searched PubMed library and Google Scholar for published literature using keywords \u201cCOVID\u201019\u201d or \u201cSARS\u2010CoV\u20102\u201d or \u201ccoronavirus disease 2019\u201d AND \u201coral\u201d OR \u201cbuccal mucosa\u201d in the abstract or title since December 2019 until September 2020. We also searched related articles in the reference lists of the found articles. Finally, we selected 35 articles after deletion of non\u2010English literature and opinion articles.<\/p>\n\n\n\n

3.\u2003RESULTS<\/h2>\n\n\n\n

Oral manifestations included ulcer, erosion, bulla, vesicle, pustule, fissured or depapillated tongue, macule, papule, plaque, pigmentation, halitosis, whitish areas, hemorrhagic crust, necrosis, petechiae, swelling, erythema, and spontaneous bleeding. The most common sites of involvement in descending order were tongue (38%), labial mucosa (26%), palate (22%), gingiva (8%), buccal mucosa (5%), oropharynx (4%), and tonsil (1%). Suggested diagnoses of the lesions were aphthous stomatitis, herpetiform lesions, candidiasis, vasculitis, Kawasaki\u2010like, EM\u2010like, mucositis, drug eruption, necrotizing periodontal disease, angina bullosa\u2010like, angular cheilitis, atypical Sweet syndrome, and Melkerson\u2010Rosenthal syndrome. Oral lesions were symptomatic (painful, burning sensation, or pruritus) in 68% of the cases. Oral lesions were nearly equal in both genders (49% female, 51% male). Latency time between appearance of systemic symptoms and oral lesions was between 4\u2009days before up to 12\u2009weeks after onset of systemic symptoms. In three cases, oral lesions preceded systemic symptoms and in four cases oral and systemic symptoms appeared simultaneously. The longest latency period belonged to Kawasaki\u2010like lesions. Oral lesions healed between 3 and 28\u2009days after appearance. Different types of therapies including chlorhexine mouthwash, nystatin, oral fluconazole, topical or systemic corticosteroids, systemic antibiotics, systemic acyclovir, artificial saliva, and photobiomodulation therapy (PBMT) were prescribed for oral lesions depends on the etiology 3 <\/a>, 4 <\/a>, 5 <\/a>, 6 <\/a>, 7 <\/a>, 8 <\/a>, 9 <\/a>, 10 <\/a>, 11 <\/a>, 12 <\/a>, 13 <\/a>, 14 <\/a>, 15 <\/a>, 16 <\/a>, 17 <\/a>, 18 <\/a>, 19 <\/a>, 20 <\/a>, 21 <\/a>, 22 <\/a>, 23 <\/a>, 24 <\/a>, 25 <\/a>, 26 <\/a>, 27 <\/a>, 28 <\/a>, 29 <\/a>, 30 <\/a>, 31 <\/a>, 32 <\/a>, 33 <\/a>, 34 <\/a>, 35 <\/a>, 36 <\/a>, 37 <\/a>. The results of literature are summarized in Table \u200bTable11<\/a>.<\/p>\n\n\n\n

TABLE 1<\/h3>\n\n\n\n

Clinical and laboratory characteristics of patients with oral manifestations<\/p>\n\n\n\n

First name author<\/th>Age<\/th>Sex<\/th>Underlying disease<\/th>Cutaneous<\/th>Oral<\/th>Oral Symptom<\/th>Site<\/th>Duration (days)<\/th>Systemic manifestations<\/th>Latency (days)<\/th>COVID\u201019<\/th>Suggested etiology<\/th>Treatment<\/th>Lab tests<\/th><\/tr><\/thead>
Verdoni 28<\/a><\/td>7\/5(2\/9\u201016)Y<\/td>M = 7F = 3<\/td>\u2013<\/td>MPAcral swelling<\/td>NA<\/td>\u2013<\/td>LipOral cavity(80%)<\/td>\u2013<\/td>FeverDiarrheaConjunctivitisMeningeal signlymphadenopathy<\/td><\/td>20%+(PCR)80%(IgG)30%(IgM)<\/td>Kawasaki\u2010like<\/td>\u2013<\/td>\u2013<\/td><\/tr>
Jones 29<\/a><\/td>6 M<\/td>F<\/td>\u2013<\/td>MPAcral swelling<\/td>Cracked lipProminent papilla in tongue<\/td>\u2013<\/td>LipTongue<\/td>\u2013<\/td>FeverConjunctivitisTachypnea<\/td>2<\/td>+(PCR)<\/td>Kawasaki\u2010like<\/td>IVIGASA<\/td>Increased levels of CRP, ESRHypoalbuminemia<\/td><\/tr>
Pouletty 30<\/a><\/td>10(4\/7\u201012\/5)Y<\/td>M = 8F = 8<\/td>Over weightAsthma<\/td>Rash<\/td>Cracked lip (87%)<\/td>\u2013<\/td>Lip<\/td>\u2013<\/td>FeverRespiratory &GI symptomAnosmia<\/td>\u2013<\/td>69%+(PCR)<\/td>Kawasaki\u2010like<\/td>IVIGCSANTI IL1, IL6HCH<\/td>Increased levels of cardiac markersIncreased levels of CRP, ESRLymphocytopenia<\/td><\/tr>
Singh 19<\/a><\/td>44Y<\/td>M<\/td>DMHTN<\/td>Non blanch able erythema Necrosis<\/td>Extensive mucosal damage<\/td>\u2013<\/td>LipTongue<\/td>\u2013<\/td>MalaiseDyspnea<\/td>4<\/td><\/td>Vascular inflammation Ischemic reperfusion injury<\/td><\/td><\/td><\/tr>
Chiotos 31<\/a><\/td>5Y<\/td>F<\/td>\u2013<\/td><\/td>Fissured lip<\/td>\u2013<\/td>Lip<\/td>\u2013<\/td>FeverDiarrheaConjunctivitis<\/td>\u2013<\/td><\/td>Kawasaki\u2010like<\/td>IVIG<\/td>ThrombocytopeniaIncreased levels of cardiac marker<\/td><\/tr>
Chiotos 31<\/a><\/td>9Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Fissured lipStraw berry tongue<\/td>\u2013<\/td>LipTongue<\/td>\u2013<\/td>FeverDiarrheaConjunctivitis<\/td>\u2013<\/td>+(PCR)<\/td>Kawasaki\u2010like<\/td>IVIGASACS<\/td>Increased levels of CRP, ESR<\/td><\/tr>
Chiotos 31<\/a><\/td>12Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Fissured lip<\/td>\u2013<\/td>Lip<\/td>\u2013<\/td>FeverAbdominal painDiarrhea<\/td>\u2013<\/td>(\u2212)(PCR)<\/td>Kawasaki like<\/td>IVIGMilrinone<\/td>Increased levels of Cardiac markerIncreased levels of CRP, ESR<\/td><\/tr>
Chiu 32<\/a><\/td>10Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Cracked lipErythema<\/td>\u2013<\/td>LipOropharynx<\/td>\u2013<\/td>FeverCoughDiarrheaConjunctivitis<\/td>\u2013<\/td>+(PCR)<\/td>Kawasaki\u2010like<\/td>Dopamine<\/td>LeukocytosisLymphocytopeniaIncreased levels of CRP, ESR, D\u2010dimer, ProcalcitoninIncreased levels of Cardiac markers<\/td><\/tr>
Mazzotta 26<\/a><\/td>9Y<\/td>M<\/td>\u2013<\/td>UrticariaAngioedemaAcral edema<\/td>GlossitisCheilitis<\/td>Painful<\/td>\u2013<\/td>\u2013<\/td>FeverCoughDiarrheaConjunctivitis<\/td>28\u201084<\/td>+(Ig G)<\/td>Kawasaki\u2010like<\/td>CS<\/td>\u2013<\/td><\/tr>
Indu 13<\/a><\/td>NS<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Ulcer<\/td>BurningItchingPainful<\/td>LipTongue<\/td>10<\/td>Fever<\/td>\u22124<\/td>+(PCR)<\/td>Zosteriform<\/td>\u2013<\/td>\u2013<\/td><\/tr>
Ta\u015fk\u0131n 25<\/a><\/td>61Y<\/td>F<\/td>\u2013<\/td>Nodules<\/td>Minor aphthous ulcer<\/td>\u2013<\/td>Hard palateBuccal<\/td>\u2013<\/td>FeverFatigueMyalgiaArthralgia<\/td>\u2013<\/td>+(PCR)<\/td>Atypical Sweet syndrome<\/td>AZTHCHOseltamivirTocilizomabFavipiravir<\/td>Increased levels of CRP, ESR, D\u2010dimerLeukocytosis<\/td><\/tr>
Ta\u015fl\u0131dere 24<\/a><\/td>51Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Swollen lipFissured tongue<\/td>\u2013<\/td>LipTongue<\/td>\u2013<\/td>MalaiseUnilateral Facial paralysisFacial edema<\/td>Coincident<\/td>\u2013<\/td>MRS<\/td>HCHAZTCS<\/td>Increased levels of CRPNegative Serology for HSV, CMV,EBV, coxsackieGround glass opacity in CT scan<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>28Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Aphthous\u2010likeAgeusia<\/td>\u2013<\/td>LipTongue<\/td>6<\/td>FeverCoughHeadacheMyalgiaChillsAnosmia<\/td>8<\/td>+(PCR)<\/td>\u2013<\/td>Mouthwash<\/td>\u2013<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>29Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Aphthous\u2010likeAgeusia<\/td>Painful<\/td>Tongue<\/td>5<\/td>CoughDyspneaFeverMalaiseHeadacheAnosmia<\/td>8<\/td>+(PCR)<\/td>\u2013<\/td>Ipratropium bromideFenoterol hydrochloride<\/td>\u2013<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>35Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Aphthous\u2010like<\/td>\u2013<\/td>Tonsil<\/td>8<\/td>FeverMalaiseSore throatCoughHyposmiaAgeusiaOdynophagia<\/td>6<\/td>+(PCR)<\/td>\u2013<\/td>\u2013<\/td>\u2013<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>32Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Aphthous \u2010like<\/td>\u2013<\/td>Tongue<\/td>5<\/td>DysgeusiaFeverCoughHeadacheAnosmia<\/td>10<\/td>+(PCR)<\/td>\u2013<\/td>Dipyrone<\/td>\u2013<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>72Y<\/td>M<\/td>HTNDM<\/td>\u2013<\/td>Aphthous\u2010likeNecrosisHemorrhagic ulcer<\/td>painful<\/td>Lip<\/td>7<\/td>FeverDyspnea<\/td>5<\/td>+(PCR)<\/td>\u2013<\/td>P\/TAZTCeftriaxoneAcyclovirPBM<\/td>Increased levels of CRPLymphocytopeniaPositive PCR for HSV<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>83Y<\/td>F<\/td>HTNCOPDObesityParkinsonPancreatitis<\/td>\u2013<\/td>Aphthous\u2010likePetechiaeNecrosis<\/td>painful<\/td>TongueHard palate<\/td>5<\/td>\u2013<\/td>2<\/td>+(PCR)<\/td>\u2013<\/td>CeftriaxonePBMTP\/T<\/td>Negative PCR for HSVLymphocytopenia<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>71Y<\/td>F<\/td>HTNDMCRFObesity<\/td>\u2013<\/td>Aphthous\u2010likeHemorrhagic necrosisUlcer<\/td>painful<\/td>TongueLip<\/td>15<\/td>FeverCoughDyspnea<\/td>4<\/td>+(PCR<\/td>\u2013<\/td>AZTCeftriaxoneAcyclovirPBMT<\/td>Positive PCR for HSV<\/td><\/tr>
Brand\u00e3o 7<\/a><\/td>81Y<\/td>M<\/td>HTNCOPD<\/td>\u2013<\/td>Aphthous\u2010likeNecrosisHemorrhagic ulcer<\/td>painful<\/td>LipTongue<\/td>11<\/td>Dry CoughDyspneaFeverChillsDysgeusia<\/td>5<\/td>+(PCR)<\/td>\u2013<\/td>AZTCeftriaxoneAcyclovirPBMT<\/td>Increased levels of CRPGround glass opacity in CT scanPositive PCR for HSV<\/td><\/tr>
Malih 8<\/a><\/td>38Y<\/td>M<\/td>\u2013<\/td>MP<\/td>Erythema Aphthous\u2010like<\/td>Painful<\/td>tonsil<\/td>\u2013<\/td>FeverFatigueMyalgiaLoss of taste and smell<\/td>3<\/td>+(PCR)<\/td>\u2013<\/td>Acetaminophen<\/td>\u2013<\/td><\/tr>
Lab\u00e9 22<\/a><\/td>3Y<\/td>M<\/td>\u2013<\/td>ExanthemaPalmar edema<\/td>CheilitisGlossitisStomatitis<\/td>\u2013<\/td>LipTongueOral cavity<\/td>\u2013<\/td>FeverAstheniaCervical LAP<\/td>\u2013<\/td>\u2013<\/td>Kawasaki\u2010like<\/td>IVIG<\/td>Increased levels of CRPLeukocytosisGround glass opacity in CT scan<\/td><\/tr>
Lab\u00e9 22<\/a><\/td>6Y<\/td>M<\/td>\u2013<\/td>Target lesions<\/td>Erosion CheilitisHemorrhagic crust<\/td>painful<\/td>LipGingiva<\/td>21<\/td>Loss of appetite<\/td>7<\/td>+(PCR)<\/td>EM like<\/td>\u2013<\/td>Negative serology for mycoplasma Negative PCR for HSV<\/td><\/tr>
Aghazadeh 9<\/a><\/td>9Y<\/td>F<\/td>\u2013<\/td>Papule Plaque<\/td>VesiclesErosions<\/td>\u2013<\/td>LipTongueBuccal<\/td>7<\/td>FeverWeaknessLoss of appetiteAbdominal painDiarrhea<\/td>Coincident<\/td>+(PCR)<\/td>Herpetiform<\/td>Acetaminophen<\/td>Bilateral ground glass opacity<\/td><\/tr>
K\u00e4mmerer 10<\/a><\/td>46Y<\/td>M<\/td>HLPCAD<\/td>\u2013<\/td>Multiple ulceration covered by yellow gray membrane<\/td>Painful<\/td>Oral cavityGingiva<\/td>\u2013<\/td>FeverFatigueDry coughRespiratory distressLAP submandibular<\/td>5\u2009days after intubation<\/td>+(PCR)<\/td>Secondary herpetic Gingivostomatitis<\/td>AZTMeropenemAcyclovir<\/td>Increased levels of CRP, IL6,EosinopeniaPositive PCR for HSVPositive serology for HSV(IgM)Bilateral ground glass opacity in CT scan<\/td><\/tr>
Cruz Tapia 23<\/a><\/td>42Y<\/td>M<\/td>_<\/td>_<\/td>Macules<\/td>Burning<\/td>Hard palate<\/td>7<\/td>FeverMalaiseDysgeusiaHeadache<\/td>14<\/td>+(PCR)<\/td>Mucositis due to vasculitis and thrombosis<\/td>AcetaminophenMouthwashCS<\/td>_<\/td><\/tr>
Cruz Tapia 23<\/a><\/td>55Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Tongue enlargementPurple blister<\/td>\u2013<\/td>Tongue<\/td>5<\/td>FeverHeadacheNasal congestion<\/td>2<\/td>+(PCR)<\/td>Angina bullosa\u2010like<\/td>Acetaminophen<\/td>\u2013<\/td><\/tr>
Cruz Tapia 23<\/a><\/td>51Y<\/td>F<\/td>HTN<\/td>_<\/td>Vascular\u2010like purple macule nonbleeding Purple plaque<\/td>\u2013<\/td>Palate<\/td>\u2013<\/td>FeverMalaiseDysgeusiaArthralgia<\/td>\u2013<\/td>+(PCR)<\/td>Vascular disorder<\/td>CSAZTNSAID<\/td>\u2013<\/td><\/tr>
Cruz Tapia 23<\/a><\/td>41Y<\/td>F<\/td>_<\/td>_<\/td>Erythematous blister<\/td>\u2013<\/td>Hard palate<\/td>\u2013<\/td>FeverMalaiseDysgeusia<\/em>Hyposmia<\/td>\u2013<\/td>+(PCR)<\/td>Angina\u2010bullosa\u2010like<\/td>AcetaminophenFexofenadine<\/td>\u2013<\/td><\/tr>
D\u00edaz Rodr\u00edguez 6<\/a><\/td>78Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Dry mouthAtrophy of surface of tongueWhite & red patchesFissured tongue<\/td><\/td>Tongue Hard PalateSoft palateLip<\/td>15<\/td>\u2013<\/td>\u2013<\/td>+(PCR)<\/td>Pseudomembranous candidiasis Angular cheilitis due to StressImmunosuppression<\/td>Artificial salivaNystatinNeomycinCS<\/td>\u2013<\/td><\/tr>
D\u00edaz Rodr\u00edguez 6<\/a><\/td>53Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Angular cheilitis<\/td>Burning<\/td>Lip<\/td>10<\/td>DysgeusiaAnosmia<\/td>Few days after discharge<\/td>+(PCR)<\/td>Cheilitis due to stress and immunosuppression<\/td>NystatinCSNeomycin,Mouthwash<\/td>\u2013<\/td><\/tr>
D\u00edaz Rodr\u00edguez 6<\/a><\/td>43Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Multiple ulcer covered by yellow\u2010gray membraneLingual depapillation<\/td>Burning<\/td>Tongue<\/td>10<\/td>FeverMalaiseDysgeusiaAnosmiaDiarrheaPneumonia<\/td>14<\/td>+(PCR)<\/td>Aphthous\u2010like due to stress and immunosuppression<\/td>MouthwashCS<\/td>\u2013<\/td><\/tr>
Ch\u00e9rif 27<\/a><\/td>35Y<\/td>F<\/td>\u2013<\/td>Macule<\/td>Chapped lipsUlcerHypogeusia<\/em><\/td>\u2013<\/td>TongueLip<\/td>10<\/td>FeverMyalgiaDyspneaDry coughV<\/em>omitingDiarrhea<\/td>\u2013<\/td>+(PCR)<\/td>Kawasaki\u2010like<\/td>HCHAZTCefuroxime<\/td>Thrombocytopenia AnemiaNeutrophiliaLymphopeniaIncreased levels of liver and cardiac markersIncreased levels of CRP,LDH,ferritin<\/td><\/tr>
Ansari 18<\/a><\/td>75Y<\/td>M<\/td>HTN<\/td>\u2013<\/td>Irregular ulcer in erythematous background<\/td>Painful<\/td>Tongue(anterior)<\/td>7<\/td>Hypoxia<\/td>7<\/td>+(PCR)<\/td>Mucosal ulcer due to COVID\u201019<\/td>AZT,Mouthwash<\/td>Negative Serology for HSV 1\u20102<\/td><\/tr>
Ansari 18<\/a><\/td>56Y<\/td>F<\/td>DM<\/td>\u2013<\/td>Irregular ulcer in erythematous background<\/td>Painful<\/td>Hard palate<\/td>7<\/td>FeverDyspnea<\/td>4<\/td>+(PCR)<\/td>Mucosal ulcer due to COVID\u201019<\/td>RemidisivirAZT<\/td>Negative Serology for HSV 1\u20132<\/td><\/tr>
Biadsee 3<\/a><\/td>36.25Y<\/td>NS<\/td>HTNDMHypothyroidismAsthma<\/td>\u2013<\/td>Plaque bleedingSwelling Xerostomia Dysgeusia<\/td>\u2013<\/td>TonguePalateGingiva<\/td><\/td>FeverCoughMyalgiaSore throatAnosmiaGI symptoms<\/td>\u2013<\/td>+(PCR)<\/td>\u2013<\/td>\u2013<\/td>\u2013<\/td><\/tr>
Olisova 11<\/a><\/td>12Y<\/td>F<\/td>\u2013<\/td>PurpuraMacule<\/td>Swollen,IrritatedPronounced lingual papilla<\/td>\u2013<\/td>Tongue<\/td>3<\/td>FeverFatigueHeadache<\/td>3<\/td>+(PCR)<\/td>\u2013<\/td>Paracetamol<\/td>Increased levels of ESR CRP<\/td><\/tr>
Tomo 36<\/a><\/td>37Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Erythema Depapillation of tongue<\/td>Painful<\/td>Tongue(border)<\/td>14<\/td>FeverAstheniaDysgeusiaAnosmia<\/td>9<\/td>+(PCR)<\/td>Mucositis due to hypersensitivity to SARS\u2010CoV\u20102<\/td>CSDipyroneMouthwash<\/td>\u2013<\/td><\/tr>
Ciccarese 17<\/a><\/td>19Y<\/td>F<\/td>\u2013<\/td>MaculesPapulesPetechiae<\/td>ErosionUlcerHemorrhagic crustPetechial<\/td>\u2013<\/td>LipPalatalGingivalOropharynx<\/td>5<\/td>FeverFatigueHyposmiaSore throat<\/td>7<\/td>+(PCR)<\/td>Thrombocytopenia due to COVIDS\u201019 and cefixime<\/td>IVIGCS<\/td>ThrombocytopeniaLeukocytosisIncreased levels of liver markers and LDH<\/td><\/tr>
Sakaida 16<\/a><\/td>52Y<\/td>F<\/td>\u2013<\/td>MPPetechiae<\/td>Erosion<\/td>\u2013<\/td>LipBuccal<\/td>\u2013<\/td>FeverDyspneaDry cough<\/td>\u22123<\/td>+(PCR)<\/td>Drug eruption<\/td>NSAIDClarithromycinSAMLevofloxacinCs<\/td>LeukocytosisLymphopeniaNeutrophiliaIncreased level of CRP<\/td><\/tr>
Dominguez\u2010Santas 37<\/a><\/td>19Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Minor aphthous<\/td>\u2013<\/td>Lip<\/td>\u2013<\/td>FeverHeadachAnosmiaMalaisedyspnea<\/td>0<\/td>+(PCR)<\/td>Cytokine storm due to COVID\u201019<\/td>\u2013<\/td>LymphocytopeniaNegative PCR for HSVNegative serology for syphilis,HIV, EBV,CMV, HBV,HCV<\/td><\/tr>
Dominguez\u2010Santas 37<\/a><\/td>37Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Minor aphthous<\/td>\u2013<\/td>Tongue<\/td>\u2013<\/td>\u2013<\/td>5<\/td>+(PCR)<\/td>Cytokine storm due to COVID\u201019<\/td>\u2013<\/td>LymphocytopeniaNegative PCR for HSVNegative serology for syphilis,HIV, EBV,CMV, HBV,HCV<\/td><\/tr>
Dominguez\u2010Santas 37<\/a><\/td>33Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Minor aphthous<\/td>\u2013<\/td>Mucogingivljunction<\/td>\u2013<\/td>PneumoniaFeverMalaise<\/td>3<\/td>+(PCR)<\/td>Cytokine storm due to COVID\u201019<\/td>\u2013<\/td>LymphocytopeniaNegative PCR for HSVNegative serology for syphilis,HIV, EBV,CMV, HBV,HCV<\/td><\/tr>
Dominguez\u2010Santas 37<\/a><\/td>43Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>Minor aphthous<\/td>\u2013<\/td>Buccal<\/td>\u2013<\/td>Bilateral pneumonia FeverMalaise<\/td>4<\/td>+(PCR)<\/td>Cytokine storm due to COVID\u201019<\/td>\u2013<\/td>LymphocytopeniaNegative PCR for HSVNegative serology for syphilis,HIV, EBV,CMV, HBV,HCV<\/td><\/tr>
Putra 5<\/a><\/td>29Y<\/td>M<\/td>_<\/td>Papule<\/td>Aphthous Stomatitis<\/td>\u2013<\/td>\u2013<\/td>\u2013<\/td>FeverMyalgiasore throatDry cough<\/td>6<\/td>+(PCR)<\/td>Enanthema due to COVID\u201019<\/td>ParacetamolAZTHCHOseltamivirVitamin CVitamin D<\/td>Increase level of CRP<\/td><\/tr>
Mart\u00edn Carreras\u2010Presas 12<\/a><\/td>65Y<\/td>F<\/td>HTNObesity<\/td>Rash<\/td>Desquamative gingivitis<\/td>Painful<\/td>TongueGingiva<\/td>28<\/td>FeverDiarrhea<\/td>25<\/td>+(serology)<\/td>EM\u2010like<\/td>AntibioticCSHCHHAL\/R<\/td>\u2013<\/td><\/tr>
Mart\u00edn Carreras\u2010Presas 12<\/a><\/td>58Y<\/td>M<\/td>DMHTN<\/td>\u2013<\/td>Unilateral multiple small ulcers<\/td>Painful<\/td>Palate<\/td>7<\/td>\u2013<\/td>\u2013<\/td>\u2013<\/td>Herpetiform<\/td>Mouthwash<\/td>\u2013<\/td><\/tr>
Mart\u00edn Carreras\u2010Presas 12<\/a><\/td>56Y<\/td>M<\/td>\u2013<\/td>\u2013<\/td>Dysgeusia, Herpetiform Stomatitis<\/td>Painful<\/td>Hard Palate<\/td>10<\/td>Fever AstheniaLAP<\/td>2<\/td>NP<\/td>Herpetiform<\/td>Val acyclovirMouthwashHA<\/td>\u2013<\/td><\/tr>
Jimenez\u2010Cauhe 21<\/a><\/td>60Y<\/td>M = 2F = 4<\/td>\u2013<\/td>EM\u2010like<\/td>Macule Petechiae<\/td>\u2013<\/td>Palate<\/td>\u2013<\/td>\u2013<\/td>19<\/td><\/td>Enanthema due to COVID\u201019<\/td>AZTHCHL\/R<\/td><\/td><\/tr>
Jimenez\u2010Cauhe 21<\/a><\/td>40Y<\/td><\/td><\/td>PurpuraEM\u2010like<\/td>PetechiaeMacule Petechiae<\/td>\u2013<\/td>PalatePalate<\/td>\u2013<\/td>\u2013<\/td>224<\/td>\u2013<\/td>Enanthema due to COVID\u201019Enanthema due to COVID\u201019<\/td>L\/RHCHAZTTCSL\/RHCHAZTTocilizomabCS<\/td>ThrombocytopeniaHighD\u2010dimerHigh D\u2010dimer<\/td><\/tr>
Jimenez\u2010Cauhe 21<\/a><\/td>50Y<\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/td><\/tr>
Jimenez\u2010Cauhe 21<\/a><\/td>60Y<\/td><\/td>\u2013<\/td>EM\u2010like<\/td>Macule Petechiae<\/td>\u2013<\/td>Palate<\/td>\u2013<\/td>\u2013<\/td>19<\/td>+(PCR)<\/td>Enanthema due to COVID\u201019<\/td>L\/RHCHAZT<\/td>High D\u2010dimer<\/td><\/tr>
Jimenez\u2010Cauhe 21<\/a><\/td>60Y<\/td><\/td>\u2013<\/td>PapuleVesicle<\/td>Petechiae<\/td>\u2013<\/td>Palate<\/td>\u2013<\/td>\u2013<\/td>\u22122<\/td>+(PCR)<\/td>Enanthema due to COVID\u201019<\/td>L\/RHCHAZT<\/td>High D\u2010dimer<\/td><\/tr>
Jimenez\u2010Cauhe 21<\/a><\/td>40Y<\/td><\/td>\u2013<\/td>purpura<\/td>Macule<\/td>\u2013<\/td>Palate<\/td>\u2013<\/td>\u2013<\/td>12<\/td>+(PCR)<\/td>Enanthema due to COVID\u201019<\/td>L\/RHCH<\/td>ThrombocytopeniaHighD\u2010dimer<\/td><\/tr>
Patel 33<\/a><\/td>35Y<\/td>F<\/td>_<\/td>_<\/td>BleedingHalitosisGeneralized edematous erythematous gingivaNecrosis<\/td>Painful<\/td>Gingiva<\/td>5<\/td>FeverLAP submandibular<\/td>3<\/td>NP<\/td>Bacterial co\u2010infection<\/td>MetronidazoleMouthwash<\/td>_<\/td><\/tr>
Chaux\u2010Bodard 14<\/a><\/td>45 Y<\/td>F<\/td>\u2010<\/td>Patch<\/td>Ulcer<\/td>Painful<\/td>Tongue(dorsal)<\/td>10<\/td>Asthenia<\/td>\u2013<\/td>+(PCR)<\/td>Vasculitis<\/td>\u2013<\/td>\u2013<\/td><\/tr>
Soares 15<\/a><\/td>42Y<\/td>M<\/td>DMHTN<\/td>PetechiaeVesicleBlister<\/td>UlcerMacules<\/td>Painful<\/td>BuccalTongueLipHard Palate<\/td>21<\/td>FeverCoughDyspnea<\/td>\u2013<\/td>+(PCR)<\/td>Thrombotic vasculopathy due to SARS \u2013CoV\u20102<\/td>CSDipyrone<\/td>IHC: negative for other viral and trepnema palladium<\/td><\/tr>
dos Santos 4<\/a><\/td>67Y<\/td>M<\/td>CADHTNPCKRT<\/td>\u2013<\/td>White plaque Multiple yellowish ulcer Geographic tongueErythema Hypogeusia<\/td>\u2013<\/td>TonguePalateTonsil<\/td>14<\/td>FeverDiarrheaDyspnea<\/td>24<\/td>+(PCR)<\/td>Herpetiform lesions secondary to determination of systemic health and treatment<\/td>MouthwashFluconazoleNystatinAZTCeftriaxoneHCHMeropenemT\/S<\/td>Positive Culture for +Saccharomyces cerevisiae<\/em><\/td><\/tr>
Corchuelo 20<\/a><\/td>40Y<\/td>F<\/td>\u2013<\/td>\u2013<\/td>PetechiaeWhitish areaBrown pigmentation<\/td>Painful<\/td>TongueLipGingiva<\/td>20<\/td>LAP of neck<\/td>\u2013<\/td>+(IgG)<\/td>CandidiasisThrombocytopenia due to ibuprofenPIH<\/td>IbuprofenVitamin DAZTMouthwashNystatin<\/td>\u2013<\/td><\/tr>
Jimenez\u2010Cauhe 35<\/a><\/td>66.7(58\u201077)Y<\/td>F = 3<\/td>_<\/td>EM\u2010like<\/td>PetechiaeMacule<\/td>\u2013<\/td>Palate<\/td>14\u201021<\/td>_<\/td>19.5(16\u201024)<\/td>_<\/td>EM\u2010Like<\/td>AZTCeftriaxoneCsHCHL\/R<\/td>Increase levels of CRPHighD\u2010dimerLymphocytopeniaNegative serology for syphilis, M. Pneumonia and other viral<\/td><\/tr>
Cebeci Kahraman 34<\/a><\/td>51Y<\/td>M<\/td>_<\/td>_<\/td>Large erythematousPetechiaePustules<\/td>Painful<\/td>Hard palateOropharynxSoft palateAgeusia<\/td>A few days<\/td>FeverFatigueDry coughSore throatAnosmia<\/td>10<\/td>+(IgM)<\/td>Enanthema due to COVID\u201019<\/td>Clarithromycin<\/td>\u2013<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Open in a separate window<\/a><\/p>\n\n\n\n

Abbreviations: AZT, azithromycin; CAD, chronic arterial disease; COPD, chronic obstructive pulmonary disease; CRF, chronic renal failure; DM, diabetes mellitus; HCH, hydroxychloroquine; HLP, hyperlipidemia; HTN, hypertension; L\/EX, lower extremity; M, month; MP, maculopapular; MRS, Melkersson\u2010Rosenthal syndrome; P\/T, piperacillin\/tazobactam; PCK, poly cystic kidney; PIH, postinflammatory hyperpigmentation; RT, renal transplantation; SAM, ampicillin sulbactam; T\/S, trimethoprim\/sulfamethoxazole; Y, year.<\/p>\n\n\n\n

4.\u2003DISCUSSION<\/h2>\n\n\n\n

Enanthema can develop in various types of viral diseases including dengue fever disease, Ebola virus disease, herpangina, human herpes virus (HHV) infections, measles, and roseola infantum. Infectious diseases, especially of viral etiology, constitute approximately 88% of causes of enanthema. Different types of enanthema such as aphthous\u2010like ulcers, Koplik’s spots, Nagayama’s spot, petechiae, papulovesicular, or maculopapular lesions, white or red patches, gingival and lip swelling have been reported with various viral infections. Both keratinized (hard palate, gingiva, and dorsum of tongue) and nonkeratinized (labial and buccal) mucosae can be involved. 38 <\/a>Biadsee and colleagues demonstrated that 7% of the patients with RT\u2010PCR positive test had plaque\u2010like changes on the dorsum of tongue. Also, swelling of oral cavity (including palatal, lingual, and gum) was reported by 8% of the patients. Furthermore, appearance of oral lesions was simultaneously found with loss of taste and smell in the patients and more severe and disseminated oral lesions were reported in older patients and in severe COVID\u201019. 3 <\/a>In another study, enanthema was reported in 29% of cases with confirmed COVID\u201019 and cutaneous exanthema. 35<\/a><\/p>\n\n\n\n

4.1. Aphthous\u2010like lesions<\/h3>\n\n\n\n

Aphthous\u2010like lesions appeared as multiple shallow ulcers with erythematous halos and yellow\u2010white pseudomemberanes on the both keratinized and nonkeratinized mucosae. In one patient, oral lesions appeared simultaneously with systemic symptoms and in other patients, latency time was between 2 and 10\u2009days. One patient had positive history of recurrent aphthous stomatitis (RAS) and two patients had positive PCR for herpes simplex virus (HSV). 4 <\/a>, 5 <\/a>, 6 <\/a>, 7 <\/a>, 8 <\/a>, 37 <\/a>Aphthous\u2010like lesions without necrosis were observed in younger patients with mild infection, whilst aphthous\u2010like lesions with necrosis and hemorrhagic crusts were observed more frequently in older patients with immunosuppression and severe infection. Lesions healed after 5 to 15\u2009days. 7 <\/a>Regression of oral lesions was in parallel association with improvement of systemic disease. Increased level of tumor necrosis factor (TNF)\u2010\u03b1 in COVID\u201019 patients can lead to chemotaxis of neutrophils to oral mucosa and development of aphthous\u2010like lesions. Stress and immunosuppression secondary to COVID\u201019 infection could be other possible reasons for appearance of such lesions in COVID\u201019 patients. 4<\/a><\/p>\n\n\n\n

4.2. Herpetiform\/zosteriform lesions<\/h3>\n\n\n\n

Herpetiform lesions presented as multiple painful, unilateral, round yellowish\u2010gray ulcers with an erythematous rim on the both keratinized and nonkeratinized mucosae. Manifestations of these lesions preceded, coincided with, or followed systemic symptoms. In one case, geographic tongue appeared after recovery of herpetiform lesions. Stress and immunosuppression associated with COVID\u201019 was the suggested cause for appearance of secondary herpetic gingivostomatitis. 4 <\/a>, 9 <\/a>, 10 <\/a>, 12 <\/a>, 13<\/a><\/p>\n\n\n\n

4.3. Ulcer and erosion<\/h3>\n\n\n\n

Ulcerative or erosive lesions appeared as painful lesions with irregular borders on the tongue, hard palate, and labial mucosa. Lesions appeared after a latency time of 4 to 7\u2009days and in one case, lesions appeared 3\u2009days before the onset of systemic symptoms and recovered after 5 to 21\u2009days. In two cases, PCR for HSV\u20101 and HSV\u20102 was performed and was negative. Different factors including drug eruption (to NSAID in one case), vasculitis, or thrombotic vasculopathy secondary to COVID\u201019 were suggested as causes for development of ulcerative and erosive lesions. 14 <\/a>, 15 <\/a>, 16 <\/a>, 17 <\/a>, 18 <\/a>, 19<\/a><\/p>\n\n\n\n

4.4. White\/red plaques<\/h3>\n\n\n\n

White and red patches or plaques were reported on dorsum of tongue, gingiva, and palate of patients with confirmed or suspected COVID\u201019. Candidiasis due to long\u2010term antibiotic therapy, deterioration of general status, and decline in oral hygiene can be the cause of white or red patches or plaques. 4 <\/a>, 6 <\/a>, 20<\/a><\/p>\n\n\n\n

4.5. EM\u2010like lesions<\/h3>\n\n\n\n

EM\u2010like lesions appeared as blisters, desquamative gingivitis, erythematous macules, erosions, and painful cheilitis with hemorrhagic crust in patients with cutaneous target lesions in the extremities. Lesions appeared between 7 and 24\u2009days after the onset of systemic symptoms and recovered after 2 to 4\u2009weeks. 12 <\/a>, 21 <\/a>, 22<\/a><\/p>\n\n\n\n

4.6. Angina bullosa\u2010like lesions<\/h3>\n\n\n\n

Angina bullosa\u2010like lesions presented as asymptomatic erythematous\u2010purple blisters without spontaneous bleeding on the tongue and hard palate in two confirmed cases of COVID\u201019. 23<\/a><\/p>\n\n\n\n

4.7. Melkerson\u2010Rosenthal syndrome<\/h3>\n\n\n\n

There was a report of a 51\u2010year\u2010old woman presenting with complaint of malaise and unilateral lip swelling, fissured tongue and right facial paralysis. She had past history of Melkersson\u2010Rosenthal syndrome since 4\u2009years ago that was spontaneously cured with no relapse. Laboratory data demonstrated an increased level of CRP and computed tomography (CT) scan showed ground\u2010glass opacities in both lungs. The patient cured completely after treatment of COVID\u201019 disease. 24<\/a><\/p>\n\n\n\n

4.8. Atypical sweet syndrome<\/h3>\n\n\n\n

There was a report of 61\u2010year\u2010old female who presented complaining of fever, fatigue, arthralgia, myalgia, several erythematous nodules on the scalp, trunk and extremities, and minor aphthous ulcers on the hard palate and buccal mucosa. RT\u2010PCR for COVID\u201019 was positive. Skin biopsy showed diffuse neutrophilic infiltration in the upper dermis with granulomatous infiltration in the lower dermis and subcutaneous area that was compatible with erythema nodosum\u2010like Sweet syndrome. 25<\/a><\/p>\n\n\n\n

4.9. Kawasaki\u2010like disease<\/h3>\n\n\n\n

Oral lesions including cheilitis, glossitis, and erythematous and swollen tongue (red strawberry tongue) appeared in COVID\u201019 patients with Kawasaki\u2010like disease (Kawa\u2010COVID). The long duration of latency between appearance of systemic symptoms (respiratory or gastrointestinal) and onset of oral or cutaneous symptoms could be due to a delayed hyperactivation response of the immune system and secondary release of acute inflammatory cytokines rather than direct effects of virus on the skin and oral mucosa. 22 <\/a>, 26 <\/a>, 27 <\/a>, 28 <\/a>, 29 <\/a>, 30 <\/a>, 31 <\/a>, 32<\/a><\/p>\n\n\n\n

4.10. Necrotizing periodontal disease<\/h3>\n\n\n\n

There was a report of a 35\u2010year\u2010old female suspicious for COVID\u201019 who presented with fever, submandibular lymphadenopathy, halitosis, and oral lesions. Oral lesions included a painful, diffuse erythematous and edematous gingiva with necrosis of inter\u2010papillary areas. The suggested diagnosis was necrotizing periodontal disease due to bacterial coinfections (especially prevotella intermedia) along with COVID\u201019. The lesions recovered after 5\u2009days. 33<\/a><\/p>\n\n\n\n

4.11. Vesicles and pustules<\/h3>\n\n\n\n

We found a report of a 9\u2010year\u2010old female presenting with fever, weakness, abdominal pain, and diarrhea that coincided with oral and acral erythematous papular exanthema. Oral lesions included vesicular eruptions and erosions on the tongue and buccal mucosa. PCR test for COVID\u201019 was positive. Lesions cured after 1 week. 9<\/a><\/p>\n\n\n\n

There was also another report on a 51\u2010year\u2010old male presented with fever, fatigue, dry cough, dysgeusia, anosmia, and a positive serology for COVID\u201019. After 10\u2009days, widespread erythema appeared on hard palate and oropharynx with petechiae and pustules on soft palate border. The suggested diagnosis was enanthema due to COVID\u201019 and the lesions cured after a few days. 34<\/a><\/p>\n\n\n\n

4.12. Petechiae<\/h3>\n\n\n\n

In a few studies, Petechiae were reported on the lower lip, palate, and oropharynx mucosa. Latency time for patients with petechiae was shorter compared to the patients with both petechiae and macular lesions. Thrombocytopenia due to COVID\u201019 infection or the prescribed drug were suggested as possible causes of petechiae. 20 <\/a>, 21 <\/a>, 34 <\/a>, 35<\/a><\/p>\n\n\n\n

4.13. Nonspecific lesions (mucositis)<\/h3>\n\n\n\n

Erythematous\u2010violaceous macules, patches, papules and plaques on the tongue, lip mucosa, hard palate, and oropharynx were reported in several studies. Thrombotic vasculopathy, vasculitis, hypersensitivity associated to COVID\u201019 could be the causes of mucositis in patients with COVID\u201019. Mucosal hypersensitivity secondary to COVID\u201019, thrombotic vasculopathy, and vasculitis might be the possible causes of mucositis in COVID\u201019. 8 <\/a>, 15 <\/a>, 21 <\/a>, 23 <\/a>, 34 <\/a>, 35 <\/a>, 36<\/a><\/p>\n\n\n\n

4.14. Postinflammatory pigmentation<\/h3>\n\n\n\n

There was one report of pigmentation in the attached and interpapillary gingiva in a 40\u2010year\u2010old female. Increased levels of inflammatory cytokines (including interleukin\u20101 [IL\u20101], tumor necrosis factor [TNF]\u2010\u03b1) and arachidonic acid metabolites (prostaglandins) secondary to production of stem cell factor (SCF) and basic\u2010fibroblast growth factor (bFGF) from keratinocytes of basal layer lead to postinflammatory pigmentations.\u00a020<\/a><\/p>\n\n\n\n

5.\u2003CONCLUSION<\/h2>\n\n\n\n

Aphthous\u2010like lesions, herpetiform lesions, candidiasis, and oral lesions of Kawasaki\u2010like disease are the most common oral manifestations of COVID\u201019 disease. An older age and severity of COVID\u201019 disease seem to be the most common factors that predict severity of oral lesions in these patients. Lack of oral hygiene, opportunistic infections, stress, underling diseases (diabetes mellitus, immunosuppression), trauma (secondary to intubation), vascular compromise, and hyper\u2010inflammatory response secondary to COVID\u201019 might be are the most important predisposing factors for the development of oral lesions in COVID\u201019 patients.<\/p>\n\n\n\n

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Authors: Behzad Iranmanesh,\u00a0Maryam Khalili,\u00a0 et. al. Dermatol Ther.\u00a02021 Jan-Feb; 34(1): e14578.\u00a0Published online 2020 Dec 13.\u00a0doi:\u00a010.1111\/dth.14578PMCID:\u00a0PMC7744903PMID:\u00a033236823 Abstract Dysgeusia is the first recognized oral symptom of novel coronavirus disease (COVID\u201019). In this […]<\/p>\n","protected":false},"author":2,"featured_media":9085,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[790,335,390,586],"tags":[],"class_list":["post-5922","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-dysgeusia","category-mouth","category-oral-ulcers","category-tongue"],"_links":{"self":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts\/5922","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=5922"}],"version-history":[{"count":1,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts\/5922\/revisions"}],"predecessor-version":[{"id":9086,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/posts\/5922\/revisions\/9086"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=\/wp\/v2\/media\/9085"}],"wp:attachment":[{"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=5922"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=5922"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/cov19longhaulfoundation.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=5922"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}