# Oral Lesions in Pediatric Subjects: SARS-CoV-2 Infection and COVID-19 Vaccination
## 3 Results
### Study Characteristics and Qualitative Synthesis
#### 3.2.1 Oral Lesions in Pediatric SARS-CoV-2 Positive Subjects
In 4 studies, the data were missing [15; 17; 18; 20], and in 1 study, the patient had no comorbidities [22]. Of the 35 study participants, 17 were hospitalized [15; 16; 18; 19; 21; 22; 23] due to COVID-19, and 2 subsequently died [15; 19]. In 1 study [20] reporting 15 cases, data on COVID-19 severity were missing. COVID-19 treatment, not specified in 1 record [20], was reported in 8 studies [15; 16; 17; 18; 19; 21; 22; 23]. Specifically, patients had undergone the following: IVIG in 7 studies [15; 17; 18; 19; 21; 22; 23]; plasma therapy in 1 study [22]; artificial ventilation in 3 studies [15; 19; 22]; vitamin D supplementation in 1 study [21]; antibiotics in 4 studies [15; 19; 21; 22]; antivirals in 3 studies [15; 19; 22]; antiprotozoals in 1 study [1]; antieincents in 1 study [19]; monoclonal antibodies in 3 studies [15; 19; 22]; FAS in 5 studies [15; 16; 19; 22; 23]; isotropic therapy in 2 studies [15; 22]; anticoagulants in 3 studies [17; 19; 22]; antiaggregrants in 1 study [22]; phosphodiesterase-III inhibitors in 1 study [19]; sympathomimetics in 1 study [19]; stem cell treatment in 1 study [15]; normal saline bolus in 1 study [19]; par-enteral nutrition in 1 study [21]; VV-ECMO in 1 study [15]; unspecified creams for topical use in 1 study [21]; eye drops in 1 study [21]. In all 9 studies included in this systematic review, data on time to oral lesion onset were missing. The primary oral lesions, categorized as per a previously proposed classification [13], and accounting for 18.61% of all oral lesions described (Figure 3), were as follows: nonspecific erosions and ulcers in 6.98% (n = 3) [15; 16; 18]; maculae and petechiae in 11.63% (n = 5), particularly in the form of erythema in 4.65% (n = 2) [15; 19], pur purura in 2.33% (n = 1) [23], ecchymosis in 2.33% (n = 1) [23] and petechiae in 2.33% (n = 1) [23]. Other oral lesions, detailed in Figure 4, were reported in 81.4% (n = 35) of cases (Figure 3), particularly in the form of: fissures in 4.65% (n = 2) [17; 19]; hypertrophic papillae in 2.33% (n = 1) [17]; oral candidiasis in 11.63% (n = 5) [20; 21]; geographic tongue in 2.33% (n = 1) [20]; coated tongue in 4.65% (n = 2) [20]; hyperemic pharynx in 23.26% (n = 10) [20]; crusts in 2.33% (n = 1) [18]; swollen in 2.33% (n = 1) [16]; nonspecific oral mucosal changes were reported in 27.91% (n = 12) of cases [15; 18; 22]. Oral lesions affected in descending order of occurrence the lips [19; 22; 23], pharynx [20], tongue [17; 18; 20], and the gingiva [18]; affected site was not better defined for 17 [15; 18; 22; 23] and missing for 6 oral lesions reported [16; 20; 21]. No cytological nor histological investigations were recorded in any of the 9 studies included in this systematic review. The following were reported definitive diagnoses: Kawasaki disease in 12 cases [15; 17; 18; 22], incomplete Kawasaki disease in 1 case [15], oral candidiasis in 5 cases [20; 21], ulcer in 1 case [16], erythema multiforme in 1 case [18], immune thrombocytopic purura in 1 case [23]. In 15 cases, the final diagnosis was not specified and the reported lesions were: coated tongue  
Figure 3: Frequency of reported oral lesions in pediatric SARS-CoV-2 positive subjects: primary oral lesions and other lesions [13]. (2 cases) [20], swollen tongue (1 case) [16], geographic tongue (1 case) [20], hyperemia of the pharynx (10 cases) [20], erythemata cracked lips (1 case) [19]. Diagnostic procedures, not reported in 1 study [16], were described in 8 studies: RT-PCR for SARS-CoV-2 detection in 7 studies [15; 17; 18; 19; 21; 22; 23]; serological tests in 7 studies [15; 17; 18; 19; 21; 22; 23]; Computed Tomography; in 4 studies [15; 18; 19; 22]; ultrasound investigations in 4 studies [15; 17; 19; 23]; measurements of vital parameters in 5 studies [17; 19; 20; 21; 23]; in X-rays in 4 studies [17; 19; 21; 23]; microbiological examinations in 4 studies [17; 18; 19; 23].