Oral lesions in human monkeypox disease and their management

Abstract Objective: The current outbreak of human monekypox (MPX) in several endemic and non‐endemic regions in 2022 has generated significant international attention. Despite the early classification as zoonotic, MPXV has demonstrated the potential for human‐to‐human transmission through close contact with lesions, body fluids, respiratory droplets, and contaminated materials. Therefore, our objective was to elaborate on the oral lesions in human MPX and their management.Materials and Method: Articles published up to August, 2022, were screened to identify relevant studies in humans that reported oral lesions in MPX.Results: Oral lesions have been found to manifest differently and transform from vesicles to pustules, accompanied by umbilication and crusting within four weeks. Along with fever and lymphadenopathy, these lesions may develop in the oral cavity and then spread to the skin surrounding the extremities in a centrifugal pattern. In some patients, the oropharyngeal and perioral lesions were the initial presentations.Conclusions: The oral lesions of MPX infection and its management strategies are relevant for dentists. Dental practitioners may be the first to detect the initial lesions of MPX. Therefore, high alertness should be there, especially while examining patients with fever and lymphadenopathy. It is also essential to thoroughly examine the oral cavity for macular and papular lesions in oral mucosa, tongue, gingiva, and epiglottis. Symptomatic and supportive care of oral lesions is recommended.

confirmed cases of MPX spreading in 93 nonendemic counties (WHO, 2022). Despite the early classification as zoonotic, the MPXV has demonstrated the potential for human-to-human transmission through close contact with lesions, body fluids, respiratory droplets, and contaminated materials. In addition, its sexual transmission would be a cause for concern. The MPXV was also detected in the patients' seminal fluid, genital and rectal lesions, and feces (Adler et al., 2022;Jang et al., 2022).
The clinical diagnosis of MPX requires laboratory confirmation, and a swab is collected from the lesion exudate or crust to isolate viral nucleic acids for diagnosis (Thornhill et al., 2022;WHO, 2022).
The MPXV genome-specific polymerase chain reaction (reverse transcription-polymerase chain reaction) using the viral DNA is used to confirm the diagnosis (WHO, 2022). The differential diagnosis of MPX, including smallpox, measles, chickenpox, syphilis, and others, depends on the local epidemiology, such as Peruvian warts in various places in Latin America or Buruli ulcer in Africa.
The clinical manifestations of MPX include nonspecific symptoms such as fever, chills, myalgia, headache, lethargy, and lymphadenopathy, followed by a vesiculo-pustular rash with an incubation period ranging from 5 to 21 days (Thornhill et al., 2022). Ulcers in the oral cavity or oropharynx can be the primary lesions (Ajmera et al., 2022;Tarín-Vicente et al., 2022) and then spread to the face and extremities, including the palms and soles. Each lesion begins as a macule and then progresses to papules, vesicles, pustules, and scabs (WHO, 2022). In the current outbreak, perioral papules have been reported that blistered and ulcerated (Ajmera et al., 2022).

| ORAL LESIONS
The oral ulcerations and management of the cases reported recently are outlined in Table 1. It was discovered that nearly a quarter (23.5%) of the people with MPXV had mouth ulcers. Oral lesions have been found to manifest differently and transform from vesicles to pustules, accompanied by umbilication and crusting within 4 weeks (Ajmera et al., 2022;Thornhill et al., 2022). Along with fever and lymphadenopathy, these lesions may develop in the oral cavity and then spread to the skin surrounding the extremities in a centrifugal pattern. In some patients, the oropharyngeal and perioral lesions were the initial presentations (Thornhill et al., 2022). Oral Candidiasis was also presented in cases (Ajmera et al., 2022). Even in the absence of skin lesions in the prodromal stage, viral DNA particles were detected in patients with oral lesions' oral and pharyngeal passages. be limited due to the concern of developing hemorrhagic lesions.

Regardless
"Magic mouthwash," along with intravenous fluconazole for oral candidiasis and an intramuscular dose of penicillin, demonstrated symptomatic relief in patients (Ajmera et al., 2022).
Oral acyclovir may be prescribed at a prophylactic dose of 50 mg/kg given twice daily. Many oropharyngeal lesions, such as tonsillar edema and odynophagia, can be relieved within 5 days when tecovirimat is administered for skin lesions (Matias et al., 2022).
Cidofovir, Brincidofovir, and Tecovirimat are the antivirals used in MPX and as a postexposure prophylactic (PEP) agent in exposed immunocompromised individuals who are contraindicated to receiving the smallpox vaccine as a PEP measure (Matias et al., 2022).
Patients with oral lesions should be monitored for dehydration and malnutrition and maintain good nutrition and hydration. Complications of illness include low mood, and emotional lability may expose the patients to poor oral health practices (Adler et al., 2022).
The oral lesions of MPX infection and its management strategies are relevant for dentists. Dental practitioners may be the first to detect the initial lesions of MPX. Therefore, high alertness should be there, especially while examining patients with fever and lymphadenopathy. It is also essential to thoroughly examine the oral cavity for macular and papular lesions in the oral mucosa, tongue, gingiva, and epiglottis. Symptomatic and supportive care of oral lesions is recommended.

ACKNOWLEDGMENT
Open Access funding provided by Qatar National Library.