Principal findings compared to literature
The present study focused on assessing the knowledge of dentists regarding COVID-19 related oral lesions. Overall, the dentists demonstrated a satisfactory level of knowledge, which is consistent with prior research about MERS-CoV [
17‐
19]. The findings indicate that certain deficiencies exist in understanding the SARSCoV-2 virus with respect to accurate symptomatology and pharmacological interventions. However, research found that dentists highlighted a deficiency in readiness to address a highly contagious respiratory illness like COVID-19. The study posits a need for enhanced protective measures in the dental operatory and efficient operational management and guidelines [
20].
In terms of the oral lesion’s symptoms, sites, types, timing and prognosis, the level of knowledge was average to excellent among more than half of the respondents. Although the study identified a gap in dentists’ understanding of oral lesions specifically related to COVID-19, limiting comparisons to the existing literature. Nevertheless, compared to other studies on the level of knowledge about oral lesions, this study found that the awareness level among dentists was better [
21‐
23]. According to literature, the symptoms of COVID-19-associated oral lesions can vary depending on the type of lesion, can occur on any part of the oral mucosa and can occur at any time during the course of the disease. However, they are most common in the early stages of infection [
24,
25]. The prognosis of COVID-19 associated oral lesions is generally favorable, with most lesions resolving spontaneously within a few weeks without requiring specific treatment. However, the duration of these lesions can vary depending on the type of lesion and the severity of the underlying COVID-19 infection [
26].
The management of COVID-19 associated oral lesions primarily focuses on symptom relief and maintaining oral hygiene. For more severe lesions, systemic medications such as corticosteroids or immunosuppressants may be considered [
27]. Estimates of the prevalence of COVID-19 associated oral lesions vary widely due to differences in study methodologies and patient populations. However, studies suggest that oral lesions may affect a significant proportion of COVID-19 patients, with some reports indicating a prevalence of up to 30% [
24,
28].
However, due to the non-specific nature of oral lesions, it is essential to consider other potential causes in the differential diagnosis. These include herpes simplex virus (HSV), aphthous stomatitis, hand, foot, and mouth disease (HFMD), candidiasis, lichen planus, trauma, allergic reactions, nutritional deficiencies, and other medical conditions. A thorough medical history, physical examination, and appropriate laboratory tests are crucial for establishing an accurate diagnosis and guiding appropriate management [
24,
26,
29].
A study conducted in Istanbul, Turkey in 2009 revealed that a significant proportion of dentists faced challenges in accurately diagnosing oral mucosal lesions, with approximately 85% experiencing difficulties in this regard. Furthermore, approximately 62% of the dentists surveyed did not actively seek to update their knowledge through literature sources. Additionally, a substantial majority of dentists, approximately 93%, did not engage in the practice of conducting biopsies or seeking consultation from other healthcare professionals when faced with such lesions. Thus, most dentists had trouble diagnosing oral mucosal lesions [
22].
On a positive note, recent research conducted at Princess Nourah University in Riyadh, Saudi Arabia, revealed that healthcare providers there were informed about oral squamous cell carcinoma, a type of oral cancer. The practitioners demonstrated an understanding of risk indicators for the disease. However, the study also highlighted that a lack of training was the main obstacle preventing a comprehensive oral examination for early identification of oral squamous cell carcinoma. This suggests that while there is some awareness and knowledge of this type of oral cancer among healthcare providers, there is still room for improvement in terms of training and conducting thorough examinations. It is essential for healthcare providers to receive adequate training and education to ensure early identification and appropriate management of such conditions to provide optimal patient care [
23].
Our research encountered no disparity between genders in oral mucosal lesion knowledge, but freshly graduated dentists answered more questions correctly than students which is consistent with another study conducted in KSA to evaluate the general knowledge of students and interns regarding oral lesions’ knowledge [
21]. A study at Ajman University found that dental interns (52.5%), final year students (44.1%) and general dentists (51.9%) had the highest rate of correct answers. There were no gender differences in their ability to classify and distinguish correct answers. These results may be attributed to the fact that freshly graduates care for patients more comprehensively and their dedicated efforts in studying for licensure examinations. These results reinforce continuous education [
30].
Al-Kharj researchers found that males had somewhat more knowledge than females, although the difference was minor. Contrary to our results, they observed no significant influence of graduation time on knowledge. Most dentists were ignorant of frequent etiologic variables, high-risk areas, and what to assess during a normal visit [
31]. This research demonstrated that clinicians might miss clinical symptoms for all oral lesions.
About 43.9% of subjects stated that COVID-19 causes oral symptoms. The logical link between oral lesions and COVID-19 has been testified in the literature [
32‐
35]. The inflammation triggered by the virus can induce tissue damage directly and indirectly, facilitating the emergence of other complications, such as heightened hypersensitivity. Furthermore, the identification of ACE2 receptors in the oral mucosa [
36] and the presence of viral particles in saliva [
37] may provide evidence or at least suggest the plausibility of authentic oral manifestations of COVID-19 [
19,
20]. Several studies have documented the incidence of oral lesions at an early stage of the disease [
33,
34] or their manifestation in the absence of typical systemic symptoms [
32].
The most commonly reported oral symptom related to COVID-19 was dry mouth. Other symptoms included oral ulcers, Candida infections, hyperpigmentation, tongue coating, atrophy, petechiae, herpes, white lesions, gingivitis, and periodontitis [
32,
38]. Interestingly, a significant proportion of patients (41.0%) were unaware of COVID-19’s oral manifestations, and a similar percentage (37.7%) did not know which locations in the mouth were most affected.
The World Health Organization (WHO) has recently included gustatory impairment, in addition to olfactory changes, as a recognized symptom of COVID-19. Patients diagnosed with COVID-19 may exhibit various types of oral lesions, including but not limited to ulcerative, erosive, vesicobullous, and plaque-like presentations [
6,
39].
Oral mucosal inflammation may manifest concomitantly with typical manifestations of COVID-19 or supplementary skin presentations. The appearance of lesions is observed concomitantly with or preceding systemic manifestations of COVID-19 [
6]. The correlation amongst COVID-19 and oral lesions remains uncertain and requires further investigation. Several publications have reported that taste impairment is the sole oral symptom associated with COVID-19. In contrast, other oral lesions may arise due to factors such as decreased immunity resulting from a viral infection, opportunistic or recurrent infection, or medical management for COVID-19 [
29,
40]. It has also been observed that these oral mucosal lesions tend to exhibit disappearing symptoms or a reduction in size over time, usually within 6 to 14 days It is still uncertain whether there is a direct correlation between these oral lesions and COVID-19, or if they may be caused by other factors such as decreased immunity or medical management for the disease [
8,
41].
Strengths and limitations
Strengths: This study is one of the few that have explored the dentists’ knowledge of oral lesions associated with COVID-19 pandemic and emphasized the importance of their role in oral health during such crises. The sample size was adequate and the questionnaire was validated which would help researchers for future research.
This study was subject to a number of limitations. The introduction of a novel questionnaire was accompanied by a predominantly undergraduate and recent graduate participant pool, necessitating consideration of this demographic when analyzing the results. It is recommended that a subsequent survey be conducted, which should comprise of more comprehensive questionnaires and a larger sample size of institutions and participants, with a particular focus on recently graduated dentists, to authenticate the findings of the current study. Also, this study does not include data on the subjects’ practice or knowledge regarding management options, and medications’ doses.
Implications and future studies
Additional investigation is required to validate a potential association between documented mucosal lesions and COVID-19, as these lesions may serve as an initial indication of the disease or may be a result of various factors such as medication usage, compromised immunity, localized or widespread inflammation, vascular impairment, and inadequate oral hygiene. It is imperative for dental practitioners to possess knowledge regarding oral symptoms, influencing factors, and fundamental mechanisms prior to conducting patient examinations and commencing treatment.
Further studies are required to comprehend better the prevalence and causal relationships between oral lesions and COVID-19. Also, it is important to recognize the pathogenesis of oral manifestations in COVID-19 patients and increase dentists’ knowledge to enhance their ability to pandemic challenges associated with oral lesions.