Table 3. Tabular representation of the studies used for this systematic review.

Author and year of study	Sample size and mean age	Study design	Study description	Study inference
Benslama et al (2022) 12	A 34 year old man	Case report	The patient had a 2-day history of fever and a mouth rash when they arrived. He also recorded mouth pain, swallowing issues, and headaches. He had a personal history of sexually transmitted diseases, particularly gonorrhoea and chlamydia genital infections.	Clinical examination revealed several mouth sores on the floor of the mouth and the top of the tongue, as well as bilateral laterocervical lymphadenopathy (figure). These oral lesions have a "cockade-like" pattern, with a white halo surrounding a central red ulcer. He didn't have any skin lesions when he arrived. Monkeypox was detected in swabs taken from lesions on the tongue using polymerase-chain reaction tests. Notably, the patient had not received a smallpox vaccination.
Girometti et al (2022) 13	54 (all males); mean age 41 years	Observational study	Of the 54 people, 30 (55%) had lymphadenopathy, while 4 (7%) had oropharyngeal lesions.	In this study, oral mucosal enanthema were more frequently recorded among unvaccinated individuals than among those who had received vaccinations. This condition can occur in more than 70% of cases.
Iamaroon et al (2022) 14	-	Literature review	At the time this study was being written, the monkeypox outbreak in non-endemic areas had spread to at least 47 nations and more than 4,100 new cases. In contrast to central and western Africa, the clinical characteristics in non-endemic locations are unusual. Monkeypox is mostly diagnosed based on clinical manifestations and laboratory tests.	Before the rash appears on the face and other areas of the body, it may first present as mouth lesions since the oral mucosa is frequently affected by this condition. It is possible for oral symptoms to appear before skin eruptions, indicating that dental professionals should be well-versed in the disease's characteristics.
Martins-Filho et al (2022) 15	3 (2 females); the females were 28 and 12 years respectively, with the male being 24 years old	Epidemiological case report	In a low-income area of Brazil, all 3 instances were identified between August 22 and August 26, 2022. Using real-time polymerase chain reaction, samples from skin lesions all tested positive for monkeypox DNA (RT-PCR).	Only the first of the three cases—involving a 28-year-old woman who saw the doctor 15 days after developing fever, asthenia, headache, and sore throat—was found to have early lesions in her oral mucosa. This case also had several pruritic, papulovesicular lesions on the limbs and trunk.
Noe et al (2022) 16	2 males	Observational study	In order to emphasise the significance of recent advances for medical experts around the world and to share further observations regarding human-to-human transmission in these cases, this paper details the first two cases of monkeypox (MPX) infections in Germany.	One patient described having trouble swallowing and having white patches on his tonsils. These oral sores on the tonsils were supposedly the patient's first outward sign of MPX. Such oral lesions have been previously identified for MPX in animal models as a component of the lymphatic tissue's involvement. These oral symptoms were absent in the second patient.
Patel et al (2022) 17	197 (all males); median age 38 years	Descriptive case series	Twenty seven participants presented with oral mucocutaneous manifestations without systemic symptoms.	Oral mucocutaneous lesions and systemic features were found to have a varied temporal relationship, which raises the possibility of a new clinical path for the illness.
Peters et al (2022) 18	2 (both males); 38 and 30 year old respectively	Case report	One of the patients noticed a sore, sensitive, "pimple-like" nodule on the tip of his tongue that grew larger before he went to the emergency room. A well-defined, tan-grey ulceration of the front tongue that was around 1.0 cm in size was found. However, the second person did not have any reported oral lesions.	The differential diagnosis for monkeypox oral symptoms frequently includes more prevalent inflammatory and viral diseases. If the lesion appears as a tan-grey ulceration involving the anterior tongue, traumatised ulcerations from biting may be taken into consideration.
Piero-Mestres et al (2022) 19	12 (all men); mean age 38.5 years	Clinical observation study	Real-time PCR was used to gather and evaluate 147 clinical samples from 12 individuals at various times. All instances had monkeypox DNA in their saliva, sometimes with high virus levels.	11 out of 12 patients reported experiencing a generalised systemic syndrome, including fever, myalgia, general malaise, and mouth ulcers. Oral lesions were found in at least one area of the oral cavity in half of the individuals.
Samaranayake et al (2022) 20	-	Case review	The information was gleaned from the most recent literature, primarily from the databases of the World Health Organization and the Centres for Disease Control and Prevention, and covered the aetiology, modes of transmission, signs and symptoms, diagnosis, and management, as well as the risk of occupational transmission in dental settings.	Clinicians should be aware that the disease typically manifests as macules and ulcers on the oral mucosa before the characteristic skin lesions. Patients should be isolated and referred when necessary, especially when a local outbreak is present. Standard, contact, and droplet infection control measures should also be implemented.
Sukhdeo et al (2022) 21	8 (all males); age range from 25-56 years	Observational study	In this study, clinical photos are provided to demonstrate the range of cutaneous and mucocutaneous lesions that eight patients with HMPX (whose diagnosis was supported by real-time polymerase chain reaction) presented with while receiving therapy in Toronto, Canada, between May and July 2022.	A primary tongue lesion was present in one patient. The 5 mm ulcer on the right tip of the tongue was painful, covered in purulence, and encircled by oedema. There was a localised swelling surrounding another ulcer on the left posterior part of the dorsal tongue, which is not visible in this image. The patient's initial clinical presentation consisted of these ulcers, which were a primary crop of lesions. On another patient's right upper lip, there was an ulcer. The 12 mm peripheral erythematous ulcer was not painful or pruritic.
Tarín-Vicent et al (2022) 22	181 (all males); median age 37 years	Observational cohort study	Demographics, smallpox vaccination, HIV status, exposure to monkeypox, travel, mass gathering attendance, risk factors for STIs, sexual behaviour, signs and symptoms at initial presentation, virological results at multiple body sites, co-infection with other STIs, and clinical outcomes 14 days later were all outcomes assessed in all participants with a confirmed diagnosis.	Lesions in the oral and perioral area were present in 78 people (or 43%). 70 (39%) of the patients experienced difficulties that required medical attention, including 19 (10%) tonsillitis, 6 (3%) abscesses, and 8 (4%) exanthems.
Thornhill et al (2022) 23	528 (all males)	International descriptive case series	26 people reported that their first symptoms were oropharyngeal, including pharyngitis, odynophagia, epiglottitis, and oral or tonsillar lesions.	A variety of dermatologic and systemic clinical symptoms were present in monkeypox manifestations. The oral route (in the form of droplets), close or direct contact with skin lesions are the routes by which the monkeypox virus is spread.
Yadav et al (2022) 24	2 (both males); 35 years and 31 years old respectively	Case report	One of the patients experienced several vesicular rashes in the lips and oral cavity, which led to an oedematous upper lip. None of the significant mouth lesions were visible to the other patient.	Oral lesions are an important diagnostic marker in cases of monkeypox.
Yinka-Ogunleye et al (2017) 25	122 (84 males); median age 29 years	Epidemiological and clinical study	A form of oral vesicular rash appeared in all 122 confirmed or probable cases, and 45 (58%) of the 77 confirmed patients also experienced sore throats.	A rash on the tongue and mucous membranes, as well as any sores or lesions on the tongue, in the oral cavity, or on the corners of the mouth, are common early signs of monkeypox.