On April 9^th at 11:44 pm the patient’s mother contacted the pediatric dentist through WhatsApp asking for help and sending a few pictures and a video of her child’s mouth and tongue. The mother reported that his son’s tongue had been hurting and stinging for the past two days and his body temperature increased to 37.5 °C. An anamnesis interview was conducted via WhatsApp: there were no history of burns on his tongue nor of exanthema on his body. The mother reported that the lesions on the tongue became less uniform and more painful throughout the last two days. The child’s tongue pain could be relieved by drinking cold water. In addition, he experienced mild neck pain. From the digital examination by the pictures a normotrophic mucosa in the genial, vestibular, palatal and lingual area of the mouth was noticed with the exception of the area of the tongue’s apex which presented an inhomogeneous aspect with erythematous areas and the absence of papillae interspersed with areas with hypertrophic papillae with pearly white characterizations.

On the basis of these elements it was possible to formulate some diagnostic hypotheses, but none perfectly fitted this case. The pictures may suggest: a burn but the latter cannot explain neck pain and fever; a strawberry tongue but there wasn’t exanthema, throat pain and an high body temperature that could be framed as an early stage of scarlet fever; a Kawasaki syndrome, that during COVID-19 pandemic could be associated to the Sars-CoV 2 virus in children [7,8], but there wasn’t a sign/symptoms of the infection and the mother assured that the child did not experience any social contact outside his family during COVID-19 lockdown. Since no certain diagnosis could be made, a “watch and wait” approach was adopted.

On April 10^th at 08:05 am, the mother sent a new picture and referred to the pediatric dentist that her son had trouble sleeping because of pain. He had to sleep with his mouth open and he could relieve his pain slightly only by keeping his tongue out of the mouth. However, his body temperature dropped to normal, no exanthema was present and no new systemic signs/symptoms appeared.

An oral spray rich in Vitamin E (Vea Oris Oral Spray - HULKA s.r.l. - Rovigo, Italy) was prescribed to the patient, suggesting four local applications per day.

On April 11^th at 10:53 am, the mother sent a new picture and reported that pain and burn decreased and the child woke up with a white patina on the tongue.

On the basis of the new picture, a diagnostic hypothesis was finally formulated: oral candidiasis. Oral candidiasis in children could be associated with fever and loco-regional lymphadenopathy, explaining the child’s neck pain. According to this hypothesis, throughout the initial manifestations of pain and stinging, the formation of pseudomembranes was partially hindered by the patient’s self-removal using lips and teeth. After the application of the oral spray rich in Vitamin E, which allowed the creation of a protective layer, the absence of friction allowed the development of the pseudomembranes and the attenuation of the painful symptoms. Miconazol Nitrate 2g (Daktarin 20mg/g, Janssen-Cilag S.p.A.) oral gel, 3 applications per day for ten days, was prescribed by Whatsapp.

On April 14th at 10:27 am the mother updated the pediatric dentist with a new picture that shows an improvement of the patient’s tongue.

On April 21st at 12:12 am, last day of drug medication treatment, the mother sent a picture that shows the healed tongue of her son.

On May 11th at 14:31 am, the mother updated the pediatric dentist with two pictures that show, at 1-month follow-up, the complete healing of the tongue with the papillae regrowth.