asthma

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For Information See Chapter 14 of Dental
Management of the Medically Compromised Patient
TextFor more information see http//www.nlm.nih.
gov/medlineplus/tutorials/sexuallytransmitteddisea
ses/htm/lesson.htm
Sexually Transmitted Disease
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Causes STDs (4 categories)

• Bacteria (N. gonorrhea, T. pallidum)
• Viruses
• HIV, hepatitis B
• Human papillomavirus (HPV)
• Human herpesviruses (8 types)
• Fungal
• Parasites

For dentistry, our focus is on the first 2
categories.
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There are more than 20 Sexually Transmitted
Diseases Disease Organism Acquired
immune deficiency syndrome (AIDS)
HIV Amebiasis Entamoeba histolytica
Bacterial vaginosis Bacteroides
spp., Mobiluncus spp. Chancroid
Haemophilus ducreyi Condyloma acuminatum
(genital warts)
HPV-6,HPV-11 Cytomegalovirus infection
Cytomegalovirus Enterobiasis
Enterobius vermicularis Epididymitis,
mucopurulent cervicitis,
Chlamydia trachomatis lymphogranuloma
venereum, nongonococal urethritis, pelvic
inflammatory disease, Reiter's syndrome
Epididymitis, gonorrhea, mucopurulent cervicitis,
Neiseria gonorrhoeae pelvic
inflammatory disease Genital herpes
HSV-1, HSV-2
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TABLE 14-1 Sexually Transmitted Diseases
(continued) Disease Organism Giardiasis
Giardia lamblia Granuloma inguinale
Calymmatobacterium granulomatis Hepatitis
B Hepatitis B virus (HBV) Human
immunodeficiency virus (HIV) infection/AIDS
HIV Molluscum contagiosum
Poxvirus Nongonococcal urethritis, nonspecific
vaginitis Trichomoniasis
vaginalis Nongonococcal urethritis Ureaplasma
urealyticum Pediculosis Pediculus
pubis Salmonellosis Salmonella
spp. Shigellosis Shigella
spp. Streptococcal infections
Streptococcal group B spp. Syphilis
Treponema pallidum Vulvovaginal
candidiasis Candida spp.,
Torulopsis spp.
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STDs People in the News
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Epidemiology STDs - in U.S.A.

• HSV Over 45 million Americans infected and
  400,000 new cases annually (1 in 5 adults
  infected)
• Chlamydia 4 million new infections annually
• Syphilis The number of cases of primary and
  secondary syphilis dropped to 20,627 in 1994, and
  has fluctuated between 6,800 and 8,000 between
  1999 and 2004. This represents a rate of declined
  of 86, from 20.3 cases/100,000 population to
  2.7/100,000 during the past decade.
• Gonorrhea 700,000 cases/yr, 358,366 cases of
  reported in U.S. in 2006 (159.2 persons per
  100,000). Drug resistant cases increased from
  11,000 (1986) to 35,000 (1990)

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Who is at Risk?

• First sexual experience at a young age, multiple
  sexual partners (sexually active persons), men
  who have sex with men, low education, low
  socioeconomic standing, and being an urban
  dweller (thus higher risk in racial and ethnic
  populations).
• Incarceration women in jail 35 have syphilis,
  27 chlamydia, 8 gonorrhea (MMWR 47(21)429,
  1998)
• Diagnosis can be complicated by simultaneous
  infections
• Infections (ie., chlamydia, HSV-2, syphilis,
  gonorrhea) can be asymptomatic
• However, most can be cured with no ill effect if
  detected early

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Bacterial

• STDs caused by bacteria include syphilis,
  gonorrhea, chlamydia, and chancroid

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Neiserria Gonorrhea

• Gram negative diplococcus, aerobe
• 600,000 new infections in USA annually
• strict requirement moisture and pH, easily killed
  by drying
• not transmitted by fomites
• Men- urethral infection- most symptomatic
• Women- most asymptomatic

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Gonorrhea Rates United States, 19702004 and
the Healthy People 2010 target
Note The Healthy People 2010 target for
gonorrhea is 19.0 cases per 100,000 population.
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Gonorrhea Rates by county United States, 2004
In 2006, the rate was highest in the southern USA
with 159 cases per 100,000. Note The Healthy
People 2010 target for gonorrhea is 19.0 cases
per 100,000 population.
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Gonorrhea Rates by sex United States,
19812004 and the Healthy People 2010 target. In
1996, rate in women exceeds that in men.
Note The Healthy People 2010 target for
gonorrhea is 19.0 cases per 100,000 population.
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Gonorrhea Rates by race and ethnicity United
States, 19812004 and the Healthy People 2010
target
18X higher in blacks than whites
Note The Healthy People 2010 target for
gonorrhea is 19.0 cases per 100,000 population.
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Gonorrhea Age- and sex-specific rates United
States, 2004
Highest rates found in 15-30 year olds
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Gonorrhea
Men Women

• Up to 80 asymptomatic
• similar to men
• intramenstrual bleeding
• results in pelvic inflammatory disease in 1
  million women / yr

• up to 40 are asymptomatic
• purulent urethral discharge
• pain on urination
• urgency of urination
• frequency of urination

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N. Gonorrhoea replicates in transitional
epithelium (urethra) better than squamous
epithelium. Thus, location is helpful in
formulating the differential diagnosis.It is
rare for N. gornorrhea to infect the oral cavity,
but when present more often it occurs in
oropharyngeal transition region.
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Gonoccoal pharyngitis is uncommon. 0.7 up to
22 of infected patients have oral infections -
most common in men who have sex with men (MSM),
frequently asymptomatic, transmission is
infrequent.
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Laboratory Dx Smear and gram stain for
presumptive diagnosis culture for definitive
diagnosis, EIA, PCR . Normal oral cavity harbors
Neisseria spp.
This is a Gram stained smear of a purulent
urethral discharge. Large numbers of
polymorphonucleocytes (PMNs) are present with a
few squamous cells. In the cytoplasm of the PMNs
can be seen phagocytosed Gram negative diplococci
which are indicative of gonorrheal infection.
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Treatment of Gonorrhea 4-20 penicillin resistant

• Cefixime 400 mg orally 1 dose, or
• Ceftriaxone 125 mg IM 1 dose
• Quinolones due to increased drug resistance are
  no longer recommended by CDC for any gonorrhea
  case. See next 2 slides.
• Alternativve if cant take a cephalosporin
  spectinomycin (2 g IM) is recommended
• Note Infectiousness is reversed within a matter
  of hrs of antibiotic treament.

All single dose regimens
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Gonococcal Isolate Surveillance Project (GISP)
Percent of Neisseria gonorrhoeae isolates with
resistance or intermediate resistance to
ciprofloxacin, 19902004
Note Resistant isolates have ciprofloxacin MICs
1 µg/ml. Isolates with intermediate resistance
have ciprofloxacin MICs of 0.125 - 0.5 µg/ml.
Susceptibility to ciprofloxacin was first
measured in GISP in 1990.
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Gonococcal Isolate Surveillance Project (GISP)
Percent of Neisseria gonorrhoeae isolates with
resistance to ciprofloxacin by sexual behavior,
20012004
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Complications of Untreated Gonorrhea

• Increased risk of pelvic inflammatory disease
  that can contribute to infertility or ectopic
  pregnancy
• Increased risk of HIV if s/he exposed
• Vertical transmission during childbirth

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Dental patient with history of gonorrhea and no
signs of infection - poses little threat to the
dental health care worker (DHCW). However,
clinical examination should always include
assessment for signs of active infection with
appropriate referral made if signs are present.
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Syphilis

• a STD caused by the bacterium Treponema pallidum.
  It has often been called the great imitator
  because so many of the signs and symptoms are
  indistinguishable from those of other diseases.
• There are 4 stages of infection.
• primary, secondary, latent, tertiary
• Congenital infection is the result vertical
  transmission

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Syphilis

• Anaerobe
• Fragile spirochete
• Easily killed by heat, drying, oxygen, soap and
  water
• Transmission almost exclusively via sexual
  contact (genital, anal, oral)
• by fomites extremely rare
• Risk groups 15-25 yrs age, multiple sex
  contacts, lower SES, urban dweller, males 31
  females

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Epidemiology
over 32,000 cases of syphilis (all stages)
reported in USA in 2002, with about 9,756 cases
(1o and 2o) reported in 2006.
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Primary and secondary syphilis Rates United
States, 19702004 and the Healthy People 2010
target
Rate has been rising 2002-2006
Note The Healthy People 2010 target for PS
syphilis is 0.2 case per 100,000 population.
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Primary and secondary syphilis Rates by county
United States, 2004
Note The Healthy People 2010 target for PS
syphilis is 0.2 case per 100,000 population. In
2004, 2,488 (79.3) of 3,139 counties in the U.S.
reported no cases of PS syphilis.
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Primary and secondary syphilis Rates by race
and ethnicity United States,19812004 and the
Healthy People 2010 target
Note The Healthy People 2010 target for PS
syphilis is 0.2 case per 100,000 population.
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Primary and secondary syphilis Age- and
sex-specific rates United States, 2004
Rate in males is 5X than females
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Clinical Presentation and Stages

• Primary Stage usually marked by the appearance
  of a single sore (called a chancre), but there
  may be multiple sores. The time between infection
  with syphilis and the start of the first symptom
  averages 21 days. If adequate treatment is not
  administered, the infection progresses to the
  secondary stage after about 6 weeks.
• Secondary Stage characterized by skin rash and
  mucous membrane lesions. The rash develops on one
  or more areas of the body and usually does not
  cause itching.
• Latent Stage (asymptomatic but seroreactive, no
  clinical presentation)
• Tertiary (Late) Stage The latent (hidden) stage
  of syphilis begins when secondary symptoms
  disappear. Without treatment, the infected person
  will continue to have syphilis even though there
  are no signs or symptoms infection remains in
  the body. In the late stages of syphilis, it may
  subsequently damage the internal organs,
  including the brain, nerves, eyes, heart, blood
  vessels, liver, bones, and joints. This internal
  damage may show up many years later.

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Primary Syphilis
The chancre is usually firm, round, small, and
painless. It appears at the spot where syphilis
entered the body. The chancre lasts 3 to 6 weeks,
and it heals without treatment.
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Chancre of Primary Syphilis
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Secondary syphilis

• Rashes associated with secondary syphilis can
  appear as the chancre is healing or several weeks
  after the chancre has healed.
• Characteristic appearance of rash rough, red, or
  reddish brown spots both on the palms of the
  hands and the bottoms of the feet. However,
  rashes with a different appearance may occur on
  other parts of the body, sometimes resembling
  rashes caused by other diseases.
• Symptoms of secondary syphilis may include fever,
  swollen lymph glands, sore throat, patchy hair
  loss, headaches, weight loss, muscle aches, and
  fatigue.
• Signs and symptoms of secondary syphilis will
  resolve with or without treatment, but without
  treatment, the infection will progress to the
  latent and late stages of disease.

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Latent Syphilis

• Period after the primary and secondary infection
  with T. pallidum when patients are seroreactive,
  but demonstrate no other evidence of disease. 1 yr Early latent syphilis 1 yr Late
  Latent syphilis

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Tertiary (Late) Syphilis
Infection on the back of a man with late-stage
syphilis. (from http//www.scienceclarified.com/im
ages/uesc
Signs and symptoms of the late stage of syphilis
include difficulty coordinating muscle movements,
paralysis, numbness, gradual blindness, and
dementia. This damage may be serious enough to
cause death.
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Tertiary syphilis non-infectious, yrs after
initial infection, destruction by obliterative
endarteritis of epithelium, bone, nervous system
and vascular system (aortic aneurysms)
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LABORATORY FINDINGS - Syphilis

• T. pallidum never been cultured successfully
• Definitive diagnosis of syphilis is made from a
  positive dark- field microscopic examination
  ordirect fluorescent antibody tests on fresh
  lesion exudate.
• Dark-field examination is consistently positive
  only during 1o and early 2o stages.
• Other Treponema species are indigenous to the
  oral cavity.
• Nontreponemal serologic tests for syphilis (VDRL
  and RPR)
• detect the presence of an AB-like substance
  called reagin that is produced when T. pallidum
  reacts with various body tissues.
• Venereal Disease Research Laboratory (VDRL)
  slide test and the Rapid Plasma Reagin (RPR) test
  are examples of these. They are equally valid.
  The Stat RPR provides results within 15 minutes
  using venipuncture blood. A disadvantage of
  reaginic tests is the occasional biologic
  false-positive result that can occur.
• The Serologic test for syphilis (STS) i.e., more
  specific, less sensitive than RPR, MHA-TP, TPI,
  FTA

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Syphilis Treatment

• Benzathine penicillin G (BPG) 2.4 million U IM
• Test for HIV and retest after 3 months
• Penicillin Allergy
• Doxycycline 100 mg orally 2 x d for 2 weeks
• Erythromycin 500 mg orally 4 x d for 2 weeks
• If compliance is a problem with the above
  consider use of ceftriazone 1 g for 8-10 days
• Reverses infectiousness within hours

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Congenital Syphilis
T. pallidum transmitted from mother with syphilis
to fetus. , usually after the 16th week of
pregnancy. Rate declining since last epidemic
late 1980s-1992 (95/100,000) to 20.6/100,000
live births (1998) to 8.5 cases per 100,000
live births (2006) African-American
87/100,000 Hispanics 28/100,000 American
Indian 14/100,000 Asian 5/100,000 Non-Hispa
nic white 2.9/100,000
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Congenital syphilis Rates for infants of age United States, 19812004 and the Healthy
People 2010 target
Note The Healthy People 2010 target for
congenital syphilis is 1.0 case per 100,000
live births. The surveillance case definition for
congenital syphilis changed in 1988.
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Features of Congenital Syphilis
Most infants born with congenital syphilis have
no signs of the disease at birth Within 3 months
anemia, skin rash, hepatosplenomegaly, nasal
discharge Multiorgan infection neurological
manifestations (MR) musculoskeletal handicap
(rhagades, saddle nose), or death
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Human herpesviruses
ETIOLOGY HSV belongs to a family of eight human
herpesviruses that includes cytomegalovirus,
Epstein-Barr virus, varicella-zoster virus, human
herpesvirus type 6 (HHV-6), human herpesvirus
type 7 (HHV-7), and Kaposi's sarcoma associated
herpesvirus (HHV-8). HSV-1 is the causative
agent of most herpetic infections that occur
above the waist, especially on the mucosa of the
mouth (herpetic gingivostomatitis, herpes
labialis), nose, eyes, brain, and skin.
Infection with HSV-1 is extremely common most
adults demonstrate antibodies to this virus. It
is thought that many primary infections with
HSV-1 are subclinical and thus are never known to
the infected person. Transmission is usually by
close contact, such as touching or kissing.
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After the primary infection HSV-1 (or HSV-2)
enters nerve termini and travels to the sensory
ganglia where the virus enters latency in
neurons. The virus reactivates periodically after
stress to induce recurrent lesions at sites near
the original infection.
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HSV Shedding at Partuition

• Reactivation of virus from the neuron can result
  in either
• Shedding of virus in secretions (potentially
  infectious) Cone et al. JAMA 1994 detected HSV
  DNA in the genital region of 9 of 100
  consecutively sampled asymptomatic seropositive
  women at delivery indicating that HSV-2
  reactivates near the time of delivery more
  frequently than was previously appreciated.
  Kaufman and Hill detected HSV-1 DNA in the oral
  swabs of 92 patients during daily monitoring.
• 2. Recurrent lesions (cold sores, fever blisters)

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Not wearing gloves can result in transmission of
HSV-1 to dental health care workers fingers or
exposed surfaces and to patients.
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STD Prevention Guidelines CDC Recommends

• Education of patient
• Detection of asymptomatic infected persons
• Effective diagnosis and treatment of infected
  persons
• Evaluation, treatment and counseling of sex
  partners of those infected
• Preexposure vaccination of persons at risk (no
  vaccine for HSV yet)

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• CDC Recommended Regimens
• Primary Herpes Simplex Infection

7-10 days
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• CDC Recommended Regimens
• Recurrent Herpes Simplex Infections

5 days
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• CDC Recommended Regimens
• Daily Suppression Herpes Simplex Infections

daily
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Infectious mononucleosis

• Caused, in at least 90 of cases, by the
  Epstein-Barr virus (EBV), a lymphotropic
  herpesvirus. Other viruses can also cause acute
  infectious mononucleosis features.
• EBV infects the lymphocytes
• Classic clinical triad of fever, pharyngitis and
  lymphadenopathy.
• Transmission of virus is primarily by way of the
  oropharyngeal route during close personal contact
  (i.e., intimate kissing).
• Children, adolescents and young adults are most
  commonly affected.
• About 40 of asymptomatic, herpesvirus
  seropositive adults carry EBV in their saliva .

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Head, neck and oral manifestations

• Fever, severe sore throat, palatal petechiae, and
  cervical lymphadenopathy.
• Treatment is palliative.
• Post-recovery, EBV is associated with the benign
  entity, oral hairy leukoplakia, as well as
  Hodgkin and non-Hodgkin lymphomas.

lymphadenopathy
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Human papillomaviruses (HPVs)

• Small, double-stranded, nonenveloped DNA viruses
• Infect and replicate in epithelial cells
• Over 100 HPV genotypes more than 30 types are
  transmitted sexually
• Virus has anatomic site predilection propensity
  for altering epithelial growth and replication.
• Low-risk HPVs (HPV-6, HPV-11) cause benign
  proliferative lesions of mucocutaneous
  structures.
• High-risk HPV types (HPV-16, HPV-18, HPV-31,
  HPV-33, HPV-35) are strongly associated with
  dysplasia and carcinoma of the
• Uterine tract 90 are HPV-associated and other
  mucosal sites 20-30 of oral squamous cell
  carcinomas

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HPV-Associated Oral Mucosal Lesions

• Lesion Most common HPV type
• Condyloma acuminatum 6, 11
• Epithelial dysplasia, carcinoma in situ,
  SCCa 2, 16, 18
• Focal epithelial hyperplasia 13, 32
• Lichen planus 11, 16
• Oral bowenoid papulosis 6, 11, 16
• Squamous papilloma 6, 11
• Verruca plana 3, 10
• Verruca vulgaris 2, 4, 6, 11, 16
• Verrucous carcinoma 2, 6, 11, 16/18

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Venereal (Genital) Warts

• HPV warts on genital organs or rectum. Usually
  go undetected until they cause mild irritation or
  itching. Growths are seen in sexually active
  individuals in warm, moist, intertriginous areas
  such as the anogenital skin and mouth.
• Appear as small, soft papillomatous growths
• Exact incidence of HPV infection is unknown,
  because it is not a reportable STD, it is
  estimated that condylomata acuminatum affect 1
  million new persons each year in U.S., and 10 to
  33 of sexually active individuals are infected
  with the virus.1

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HPV Infection Warts Treatments

• Surgical, cryotherapy
• Laser with hi speed evacuation
• Topical
• Podofilox 0.5 solution or gel 2x day for 3 days
  then 4 days of no therapy. Repeat for up to 4
  cycles. Do not exceed 0.5 ml/d
• Imiquimod (Aldara) 5 cream h.s. 3 x week for up
  to 16 weeks
• Podophyllin resin 10-25 in tincture of benzoin.
  Apply
• Trichloroacetic Acid (TCA) or BCA 80-90 apply
  weekly
• Intron A (interferon alpha-2B recombinant) newly
  indicated. Need to treat sexual partners
  simultaneously

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Dental Management of the Patient with a Sexually
Transmitted Disease

• PATIENTS WITH HISTORY OF A STD
• Evaluated carefully. They are at higher risk
  for additional STDs and recurrent infections.
• Clinician should ensure that adequate
  treatment of a previous infection was provided
  and new infections have not developed.
• Special attention should be given to
  unexplained lesions of the oral, pharyngeal, or
  perioral tissues. Review of systems may reveal
  urogenital symptoms.
• Patients with a history of gonorrhea or
  syphilis should give a history of antibiotic
  therapy. Patients treated for syphilis should
  receive a periodic STS test for 1 year to monitor
  conversions from positive to negative. Adequate
  medical follow-up care should have been provided,
  if not consultation and referral to a physician
  should be considered.

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Dental Management of the Patient with a Sexually
Transmitted Disease

• PATIENTS WITH SIGNS, SYMPTOMS, OR ORAL LESIONS
  SUGGESTIVE OF A STD
• Approached with caution.
• The index of suspicion should be higher if the
  patient is between 15 and 29 years of age and has
  risk factors such as being an urban dweller,
  single, and from a lower socioeconomic group.
• Any patient who has these unexplained lesions
  should be questioned about possible relationships
  of the lesions with past sexual activity and
  advised to seek medical care.
• Herpetic lesions in or around the oral cavity,
  combined with a history of past involvement,
  should be recognizable. Patients with acute oral
  herpes lesions should not receive routine dental
  care but be given palliative treatment only.
• For a severe primary oral infection or infectious
  mononucleosis, the patient may require specific
  therapy and referral to a physician.

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Dental Management of the Patient with a Sexually
Transmitted Disease

• Gonorrhea - little threat of transmission to
  dentist oral lesions are possible. Provide
  dental treatment after lesions heal.
• Syphilis - untreated primary and secondary
  lesions infectious blood also is potentially
  infectious.
• Genital herpes - little threat of transmission
  to dentist oral lesions are possible from
  autoinoculation. Provide dental treatment after
  lesions heal.
• HPV infection - little threat of transmission to
  dentist oral lesions are possible. Potential
  risk for oral cancer with high risk genotypes.
• Persons with STDs are at 2-5X increased risk for
  HIV infection.
• Also, persons infected with gonorrhea and HIV are
  more likely to shed HIV in genital secretions and
  at higher copy number.
• New cases of syphilis, gonorrhea, and AIDS should
  be reported to the local/state health department.