Various painful oral adverse reactions following COVID-19 vaccination: a case series

Drug-associated gingival disorders: a retrospective pharmacovigilance assessment using disproportionality analysis

BACKGROUND

Drug-associated gingival disorders can negatively impact on oral health. This study aimed to utilize the United States Food and Drug Administration Adverse Event Reporting System (USFDA AERS) to comprehensively assess the associations between medications and specific gingival disorders.

METHODS

Data were extracted from the USFDA AERS from 2004-2024 using Preferred Terms for eight gingival disorders. Reports were deduplicated and disproportionality analysis was conducted using frequentist and Bayesian approaches to detect potential signals. Volcano plots were generated for each gum disorder to identify the drugs with the strongest signals based on the statistical significance and magnitude of association.

RESULTS

A total of 11,465 reports were included. Several anti-osteoporotic drugs, anti-thrombotics, calcium channel blockers and immunosuppressants showed significant associations with multiple gingival disorders. Phenytoin was linked to hypertrophy and bleeding. Stomatological preparations were associated with discoloration and bleeding. Emergent signals were identified with finasteride, COVID-19 vaccine, and levothyroxine with gum disorders.

CONCLUSION

This study highlights the need for increased awareness of oral side effects amongst healthcare providers. Future research should explore the mechanisms of drug-induced gingival disorders and develop interdisciplinary management strategies to enhance oral health in patients on long-term medications.

Effects of post-COVID-19 vaccination in oral cavity: a systematic review

OBJECTIVES

SARS-CoV-2 virus and its variants continue to be on a rampage worldwide. Several vaccines are being marketed to control their spread and reduce severity of symptoms in the affected. Various adverse events are being reported following the vaccine administration and therefore this systematic review investigated the oral adverse events post-COVID-19 vaccination.

MATERIALS AND METHODS

A systematic search of five databases was conducted. Case reports, case series and observational studies describing oral lesions/oral adverse effects (outcome) following anti-SARS-CoV-2 vaccination (exposure) in humans were included. Quality assessment of the studies was done using Joanna Briggs Institute Critical Appraisal tools. A working classification was developed from reported final diagnosis.

RESULTS

The systematic review included 18 individual cases. Majority of oral lesions occurred following BNT162b2 vaccination with average age of occurrence at 59.94 years. 67% of the affected individuals were female, with hypertension being the most common comorbidity.

DISCUSSION

Immune-mediated oral events have a propensity of occurrence following COVID-19 vaccination. mRNA-based vaccinations may have an affinity for causing oral adverse effects. It might be due to the immune dysregulation caused by these vaccinations.

CONCLUSION

The female, geriatric population and older individuals with co-morbidities might have an increased affinity to develop oral lesions post-COVID-19 vaccination.

Pathophysiology of oral lesions subsequent to SARS-CoV-2 vaccination: A systematic review

Amidst worldwide reports of adverse oral lesions subsequent to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, the current systematic review planned to determine the prevalence of adverse oral events in adult individuals (≥18 years) after SARS-CoV-2 vaccination, emphasizing upon the type and dose of vaccine, time of onset, and underlying pathophysiology. The registered protocol (PROSPERO CRD42023421307), conforming with PRISMA guidelines, included an all-inclusive literature search through online databases, consisting of Scopus, PubMed/MEDLINE, Web of Science, Lilacs, Livivo, and PROSPERO, completed on 2 May 2023, followed by assessment of risk of bias by Joana Briggs Institute Evaluation Checklist. Due to the paucity of literature, case reports and case series were included. Self-reported lesions were excluded. Qualitative synthesis employing Microsoft Excel software 2019 revealed low prevalence (43 subjects) from 26 case reports and two case series. There were multiple erosive oral ulcers on gingiva, palate, burning pain in the mouth, xerostomia, tongue fissuring and glossitis, palatal petechiae, diffuse erythematous lesions and loss of smell (16.2%), primary herpetic gingivostomatitis (21%), oral lichen planus (16.2%), Stevens-Johnson syndrome (6.9%), Bell's palsy in four cases where two cases were Guillain-Barré syndrome (9.3%), erythema multiforme (11.6%), pemphigus (4.6%), idiopathic thrombocytopenic purpura (6.9%), unilateral hypoglossal nerve palsy (4.6%), and trigeminal neuralgia (2.3%). Maximum cases (22 subjects) presented oral lesions after Pfizer (BNT162b2) SARS-CoV-2 vaccine. No association was found between the vaccine type and dose with oral side effects. Dentists must be aware of the oral adverse effects after coronavirus disease 2019 vaccination to better understand the pathogenesis and the risk factors associated with such reactions.

Immunogenicity and Safety of Half-Dose Heterologous mRNA-1273 Booster Vaccination for Adults Primed with the CoronaVac® and ChAdOx1-S Vaccines for SARS-CoV-2

Coronavirus disease 2019 (COVID-19) has been extensively researched, particularly with regard to COVID-19 vaccines. However, issues with logistics and availability might cause delays in vaccination programs. Thus, the efficacy and safety of half-dose heterologous mRNA should be explored. This was an open-label observational study to evaluate the immunogenicity and safety of half-dose mRNA-1273 as a booster vaccine among adults aged >18 years who underwent a complete primary SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) vaccination regimen with CoronaVac® and ChAdOx1-S. Adverse events (AEs), seropositivity rate, seroconversion, geometric mean titer (GMT) of SARS-CoV-2 antibodies, neutralizing antibodies, and T cells (CD4+ and CD8+) specific for SARS-CoV-2 were analyzed. Two hundred subjects were included in the final analysis, with 100 subjects in each priming vaccine group. Most of the AEs were mild, with systemic manifestations occurring between 1 and 7 days following vaccination. A significant difference was observed in the GMT and seropositivity rate following booster dose administration between the two groups. CD8+/CD3+, IFN (interferon)-producing CD8+, and TNF (tumor necrosis factor)-producing CD8+ cells showed significant increases in both groups. The administration of the half-dose mRNA-1273 booster is safe and effective in increasing protection against SARS-CoV-2 infection.

A comprehensive review of oral microenvironment changes and orofacial adverse reactions after COVID-19 vaccination: The good, the bad, and the ugly

BACKGROUND AND AIMS

Anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines have the potential to alter several biological systems concurrently with remolding the immune system, most of which are related to immunization, while some others are known as adverse effects. This review aims to explore the potential effects of vaccination on the oral microenvironment and classifies them as good, bad, or ugly, with a brief review of facial diseases following coronavirus disease 2019 (COVID-19) vaccination.

METHODS

This study was a comprehensive review conducted through searching related articles in Medline, Scopus, and Google Scholar databases.

RESULTS

On one side, the "Good" impacts of vaccination on the oro-nasal mucosa are explained as if the mucosal immune responses followed by SARS-CoV-2 vaccines are enough to provide immunity. On the other side, the possible "Bad" and "Ugly" effects of the vaccine, which manifest as orofacial adverse events and autoimmune reactivations, respectively, should be noted. Exacerbation of pre-existing autoimmune conditions such as lichen planus, pemphigus vulgaris, bullous pemphigoid, and Stevens-Johnson syndrome have been reported.

CONCLUSION

COVID-19 vaccines could affect different biological systems alongside stimulating the immune system, and some of these effects are referred to as adverse effects. Nonetheless, these adverse effects are treatable, and healthcare professionals should not prevent patients from taking the first available vaccination.

Neurological complications following mRNA COVID-19 vaccination: Oral and lower limb paresthesia. A case discussion and literature review

Vaccines used in the coronavirus pandemic have reported some minor side effects such as pain at the injection site, headache, myalgia and fever. Also major neurological side effects have been experienced by some patients. We present the clinical case of a healthy woman who two weeks after being vaccinated with the third dose of Moderna COVID-19 Vaccine, began to feel numbness in mouth, both feet, legs, interscapular space, and hands. She was diagnosed with distal sensory polyneuropathy caused by the vaccine. Progressive improvement was seen. The patient did not require corticosteroid medication. We reviewed the literature to assess the frequency of this type of complication. Key words:COVID-19, SARS-CoV-2, vaccine, vaccination, peripheral axonal neuropathy, transverse myelitis, oral manifestations.

Oral adverse events following COVID-19 and influenza vaccination in Australia

Vaccine hesitancy, spurred by misinterpretation of Adverse Events (AEs), threatens public health. Despite sporadic reports of oral AEs post-COVID-19 vaccination, systematic analysis is scarce. This study evaluates these AEs using the Australian Database of Adverse Event Notifications (DAEN). A secondary analysis of DAEN data was conducted, with the analysis period commencing from the start of the COVID-19 vaccination rollout in February 2021 and the inception of the influenza vaccine database in 1971, both through until December 2022. The focus of the analysis was on oral AEs related to COVID-19 and influenza vaccines. Reports were extracted according to a predefined schema and then stratified by vaccine type, sex, and age. Oral paresthesia was the most common oral AE after COVID-19 vaccination (75.28 per 10,000 reports), followed by dysgeusia (73.96), swollen tongue (51.55), lip swelling (49.43), taste disorder (27.32), ageusia (25.85), dry mouth (24.75), mouth ulceration (18.97), oral hypoaesthesia (15.60), and oral herpes (12.74). While COVID-19 and influenza vaccines shared most oral AEs, taste-related AEs, dry mouth, and oral herpes were significantly more common after COVID-19 vaccination. mRNA vaccines yielded more oral AEs than other types. Females had higher oral AE incidence. Most oral AEs did not differ significantly between COVID-19 and influenza vaccination. However, specific oral AEs, particularly taste-related, dry mouth, and oral herpes, were more prevalent after COVID-19 vaccination compared with seasonal influenza, especially in females and mRNA vaccine recipients.

Systematic review of the oral manifestations produced by the SARS-CoV-2 vaccine

Background

To combat the coronavirus pandemic different vaccines have been developed. However, diverse adverse effects have been reported due to their use, including oral manifestations. Our objective is to review the existing bibliography to analyze what complications these vaccines have caused in the oral cavity.

Material and Methods

A bibliographic search was conducted by two independent reviewers (TS and CL), in parallel in 6 electronic databases (PubMed, Scopus, Cochrane, Google Scholar, LILACS, BioMed Central). A total of 22 articles were analyzed.

Results

The most frequent adverse effect was oral lichen planus, with a higher prevalence in women and after the Pfizer mRNA BNT162b2 vaccine.

Conclusions

These complications are minor and resolve with treatment, so the benefit of the use of vaccines outweigh the potential risks associated with these. Key words:Covid-19 vaccine, oral lesions, oral manifestations, SARS-CoV-2 vaccine, oral symptoms.

Oral side effects of COVID-19 vaccines in 32 European countries: Analysis of EudraVigilance reports

The recent reports of oral side effects (SEs) following COVID-19 vaccination warrant further investigation into their prevalence, severity, and aetiology. This study was conducted to synthesize the first-ever population-level evidence about oral SEs of COVID-19 vaccines in Europe. The European Union Drug Regulating Authorities Pharmacovigilance (EudraVigilance) database was accessed in August 2022 to extract summary data of all potential oral SEs reported after COVID-19 vaccination. The data were reported descriptively and cross-tabulated to facilitate sub-group analysis per vaccine type, sex, and age group. Dysgeusia was the most commonly reported oral SE (0.381 case per each 100 received reports), followed by oral paraesthesia (0.315%), ageusia (0.296%), lip swelling (0.243%), dry mouth (0.215%), oral hypoaesthesia (0.210%), swollen tongue (0.207%), and taste disorder (0.173%). Females had significantly (Sig. < 0.001) a higher prevalence of all most common (top 20) oral SEs, except for salivary hypersecretion, which was equally prevalent among females and males. The present study revealed a low prevalence of oral SEs, with taste-related, other sensory and anaphylactic SEs being the most common SEs in Europe, similar to what was found earlier among the US population. Future studies should explore the potential risk factors of oral sensory and anaphylactic SEs to verify whether they are causally linked to COVID-19 vaccines.

Vulval Aphthous Ulcers in Adolescents Following COVID-19 Vaccination - Analysis of an international case series

STUDY OBJECTIVE

To review and characterise reports of vulval aphthous ulcers (VAU) following COVID-19 vaccination in VigiBase, the World Health Organization global database of reported potential side effects of medicinal products, to demonstrate the importance and power of case reports for rare suspected adverse reactions and to investigate whether they suggest a potential for COVID-19 vaccination to be a trigger.

METHODS

Cases reporting the Medical Dictionary for Regulatory Activities' (MedDRA) Preferred Term (PT) "Vulvovaginal ulceration" and related PTs in adolescent patients aged 12 to 17 years in association with any COVID-19 vaccine were extracted from VigiBase. The cases were clinically reviewed, and causality was assessed by applying the Bradford Hill criteria to the obtained case series.

RESULTS

As of June 30^th, 2022, there were 444 reports for the selected MedDRA PTs following COVID-19 vaccination in VigiBase. Ninety-four de-duplicated reports concerned adolescent female patients. Thirty-seven cases were clinically consistent with the diagnosis of VAU. Upon causality assessment, the analysed case series fulfilled six of the nine Austen Bradford Hill criteria supporting a potential causal relationship.

CONCLUSION

VAU can be perceived as a traumatic experience, especially in adolescent patients. There is, furthermore, a risk that the ulcers will be misdiagnosed resulting in avoidable investigation and treatment burdens for patients. We communicate our findings to support the small number of published case reports and raise awareness of VAU occurring in a temporal association with COVID-19 vaccination. Furthermore, our analysis supports observations about the value of case reports for the recognition and assessment of rare adverse events.

Oral lesions after COVID-19 vaccination: Immune mechanisms and clinical approach

COVID-19 vaccination, although is a promising tool to overcome the pandemic, has side effects. There are increasing reports of oral lesions after COVID-19 vaccination. The aim of this review is to identify the occurrence of some oral lesions after COVID-19 vaccination, and highlight the underlying immune mechanisms involved. A narrative literature review was performed by searching electronic databases including PubMed, Scopus and Web of Science to investigate the oral lesions after COVID-19 vaccination. The inclusion criteria were original studies, including the case reports, case series, letter to the editor, and cross-sectional studies. The exclusion criteria included the studies which examined the oral lesions caused by COVID-19 infection. The information, including the number of participant(s) receiving vaccine, type of vaccine, dose number, side effect(s), time of onset following vaccination, healing time, treatment strategies for the existing lesions, and related mechanisms were then summarized in a data extraction sheet. The results of this review showed that some vaccines had side effects with oral involvement such as pemphigus vulgaris, bullous pemphigoid, herpes zoster, lichen planus, Stevens-Johnson syndrome and Behçet's disease. Future research needs to elucidate the physiopathology of oral manifestations after the COVID-19 vaccination, and better understand the risk factors associated with such responses. Sometimes vaccine's side effects may be due to the nocebo effect, which means that the person expects some adverse events to occur following the vaccine administration.

Rare Heterogeneous Adverse Events Associated with mRNA-Based COVID-19 Vaccines: A Systematic Review

Background: Since the successful development, approval, and administration of vaccines against SARS-CoV-2, the causative agent of COVID-19, there have been reports in the published literature, passive surveillance systems, and other pharmacovigilance platforms of a broad spectrum of adverse events following COVID-19 vaccination. A comprehensive review of the more serious adverse events associated with the Pfizer-BioNTech and Moderna mRNA vaccines is warranted, given the massive number of vaccine doses administered worldwide and the novel mechanism of action of these mRNA vaccines in the healthcare industry. Methods: A systematic review of the literature was conducted to identify relevant studies that have reported mRNA COVID-19 vaccine-related adverse events. Results: Serious and severe adverse events following mRNA COVID-19 vaccinations are rare. While a definitive causal relationship was not established in most cases, important adverse events associated with post-vaccination included rare and non-fatal myocarditis and pericarditis in younger vaccine recipients, thrombocytopenia, neurological effects such as seizures and orofacial events, skin reactions, and allergic hypersensitivities. Conclusions: As a relatively new set of vaccines already administered to billions of people, COVID-19 mRNA-based vaccines are generally safe and efficacious. Further studies on long-term adverse events and other unpredictable reactions in close proximity to mRNA vaccination are required.

Oral Adverse Events Following COVID-19 Vaccination: Analysis of VAERS Reports

Background

Oral adverse events (AEs) following COVID-19 vaccination have been sporadically reported during the previous months, warranting further investigation for their prevalence and suspected relationship with vaccine-elicited immune response.

Methods

A retrospective analysis using the Vaccine Adverse Event Reporting System (VAERS) data was conducted to evaluate AEs within the oral cavity (mucosa, tongue, lips, palate, dentition, salivary glands) and AEs involving taste and other sensations. Oral AEs reported after receiving COVID-19 vaccination (test group) and seasonal influenza vaccination (control group) were extracted and cross-tabulated to assess their relative prevalence.

Results

Among the 128 solicited (suspected) oral AEs, oral paresthesia (0.872%) was most reported after receiving COVID-19 vaccines, followed by the swelling of lips (0.844%), ageusia (0.722%), oral hypoesthesia (0.648%), swollen tongue (0.628%), and dysgeusia (0.617%). The reported prevalence of oral AEs was higher in the COVID-19 vaccine group than in the seasonal influenza group. The distribution pattern of the most reported oral AEs was similar for both COVID-19 and seasonal influenza vaccines. Female sex, older age (>39 years old), primer doses, and mRNA-based COVID-19 vaccines exhibited a higher reported prevalence of oral AEs.

Conclusion

Within the limitations of this study, COVID-19 vaccines were found to be associated with rare oral AEs that are predominantly similar to those emerging following seasonal influenza vaccines. The most commonly reported oral AEs were oral paraesthesia (mouth-tingling), lip swelling, and ageusia, representing various pathophysiologic pathways that remain unclear. Taste-related AEs should be acknowledged in the context of the COVID-19 pandemic and the public should be adequately informed about a potential taste dysfunction after receiving the COVID-19 vaccination. Dentists and dental teams need to be aware of the prevalence, severity, and prognosis of oral AEs to inform their patients and increase public confidence in vaccines.