# Oral Lesions in Pediatric Subjects: SARS-CoV-2 Infection and COVID-19 Vaccination
## 4 Discussion
### Oral Lesions in Pediatric SARS-CoV-2 Positive Subjects  
The overall prevalence of cases diagnosed with oral lesions following SARS-CoV-2 infection among pediatric subjects accounted for 35 patients. Although this might seem low, it should actually be considered in line with the low number of infected pediatric subjects, especially in the early stages of the COVID-19 pandemic [1]. Subsequently, the number of reported cases among pediatric SARS-CoV-2 positive subjects spiked, especially during the spread of the Omicron viral variant and the concomitant generalized reduction in public health and social preventive measures. By 24 July 2022, pediatric SARS-CoV-2 positive subjects constituted 26.82% of all cases and 1.38% of deaths worldwide [7]. However, such epidemiologic data may be biased by the frequent asymptomatic presentations and milder symptoms characterizing SARS-CoV-2 infection in pediatric subjects [4], potentially causing underreporting. For the same reason, it may be hypothesized that the presently computed prevalence of oral lesions in SARS-CoV-2 positive pediatric subjects might have been mainly affected by the fact that most of them were a-/oligo-symptomatic [4;5] under domiciliary or self-care, so oral lesions may have been under-acknowledged. As a counterpart, oral lesions in pediatric subjects with severe forms of COVID-19, potentially showing oral and multi-systemic involvement, may have been underdiagnosed, given patients' life-threatening conditions. Indeed, the attention to the impact of the SARS-CoV-2 infection on children has dramatically increased upon the observation of a hyperinflammatory syndrome, albeit rare, complicating recovery from COVID-19, and known as \"Multisystem Inflammatory Syndrome in Children\" (MIS-C) or \"Peadiatric Inflammatory Multisystem Syndrome Temporally Associated with COVID-19\" (PIMS-TM) [6]. Furthermore, such a low prevalence of oral lesions in pediatric SARS-CoV-2 positive subjects may also be due to the exclusion of normal variation of the oral mucosa, such as geographic tongue, which is considered the most frequent oral mucosal condition in children [26; 27], from the present analysis. Similarly, also self-diagnosed mucosal alterations and pre-existing conditions were not currently considered, in the attempt to point out those lesions likely attributable to either viral direct cytotoxic effect or COVID-19 pathogenesis, complications, and therapies [28]. The higher incidence of oral lesions following viral infection in young males (M:F = 20:15), also observed in adult subjects (M:F = 3156:1769) [13], may be due to the higher prevalence of the severe forms of COVID-19 requiring hospitalization registered in pediatric males. Indeed, according to the study by [PERSON] et al. [29], involving 3.111.714 cases worldwide, although male and female pediatric subjects have an equivalent risk of becoming infected, males develop severe forms of the disease, requiring hospitalization or, unfortunately, leading to death, more frequently compared to females. Thus, it may be assumed that oral lesions have been diagnosed most in male pediatric subjects compared to female ones due to hospitalization; in fact, oral cavity inspection is hardly conducted in domiciliary and self-care settings. Alternatively, it may be proposed that such oral lesions may occur in the severe forms of the disease, most frequently developing in males. However, given the low number of pediatric cases diagnosed with oral lesions following SARS-CoV-2 infection, their overall prevalence remains under study. Similarly, since data concerning COVID-19 severity were missing in 15 out of 35 cases, albeit 17 males were hospitalized and 2 of them subsequently died, so the degree of association of oral lesions with SARS-CoV-2 infection, as previously performed for HIV infection [30], could not be computed. The time between SARS-CoV-2 positivity and the appearance of oral lesions, previously described by [PERSON] et al. in an adult population [31], has not been reported in any study concerning pediatric subjects.