Sexually Transmitted Diseases Chlamydia* Gonorrhea* Syphilis* Genital herpes* Condyloma acuminatum (genital warts)* HPV Chancroid Infectious Mononucleosis**

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  • Sexually Transmitted DiseasesChlamydia*Gonorrhea* Syphilis*Genital herpes*Condyloma acuminatum (genital warts)* HPVChancroid

    Infectious Mononucleosis** HIV AIDSTrichomoniasis Granuloma inquinale Hepatitis B, C, DOthers

  • Chlamydia Infections Genital infections caused by Chlamydia trachomatis represent the most common bacterial sexually transmitted disease in the United States

  • Chlamydia InfectionsIncidence and prevalence About 4 million cases occur each yearPeak incidence is in the late teens and early twentiesPrevalence of chlamydia urethral infection among young men seen in general medial settings is 3% to 5%Prevalence of chlamydia cervical infection for asymptomatic college students and prenatal patients is 5%

  • Chlamydia Infections

  • GonorrheaGonorrhea is the second-most-common reported infectious disease in the United States behind chlamydia Neiseria gonorrhoeae gram-negative diplococcus

  • Gonorrhea - Incidence (reported) 1979 1,000,000 cases 1990 - 900,000 cases 1998 - 355,642 cases

    During the last 3 years the reported incidence has been increasing among adolescents, gay and bisexual men and African Americans

  • STDsGonorrhea and syphilis in just 2 years( 2002-2004) > 45 % increase in selected U.S. cities ( e.g. Detroit and St. Louis)

  • Transmission of Gonorrhea Transmission is almost exclusively by sexual contact Disseminated gonococcal infection (DGI) may occur Transmission by inanimate objects is very rareVertical transmission during parturition Mandell GL; Atlas of Infectious Diseases, Vol. V, Churchill Livingstone, p 1.5, 1996

  • Gonorrhea Signs and symptoms1 to 3 % of men are asymptomatic In men symptoms usually occur after incubation period of 2 to 5 daysMucopurulent urethral dischargePain on urinationUrgency and increased frequency of urinationPharyngeal infection in up to 50% of cases Signs and symptomsAbout 50% of women are asymptomatic Tenderness and swelling of the meatus can occur Vaginal or urethral dischargePain on urinationUrgency and increased frequency of urinationAnal canal infection common in both males and females

  • GonorrheaGonococcal pharyngitis Is seen in both men and women who have had oral sexual exposure Impossible clinically to differentiate from pharyngitis caused by other bacteria must culture Left untreated it will resolve within 6 weeksMandell GL; Atlas of Infectious Diseases, Vol. V, Churchill Livingstone, p 1.10, 1996

  • GonorrheaDisseminated gonococcemia (dermatitis) Most common signs of dissemination are myalgia, arthralgia, polyarthritis and dermatitis Harrisons Online, hppt://www.harrisonsonline.com, plate 11D-60, 2002

  • GonorrheaRisk factorsAdolescence Multiple sexual partnersNonbarrier contraception Low socioeconomic statusUse of IV drugs or crack cocainePrevious history of gonorrhea

  • SyphilisSyphilis is the fourth-most-frequently reported sexually transmitted disease surpassed only by chlamydia, gonorrhea, and AIDS

  • SyphilisEtiology Etiologic agent is Treponema pallidum It is a slender, fragile, anaerobic spirocheteT. pallidum is easily killed by heat, drying, disinfectants, and soap and waterThe organism is difficult to stain, except for certain silver impregnation methods

  • SyphilisPathophysiology T. pallidum does not invade intact skinIt can gain entry via minute abrasions or hair follicles It can invade intact mucosal epitheliumWithin hours after invasion it spreads to the lymphatics and blood streamEarly response to the bacterial invasion is endarteritis and periarteritis Risk of transmission occurs during primary, secondary, and early latent stages of the disease but not in late syphilis

  • Course of Untreated SyphilisMandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p10.2, 1996

  • Course of Untreated Syphilis Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p10.2, 1996

  • Syphilis - PrimaryClassic manifestation of primary syphilis is the chancreIt consists of a solitary granulomatous lesion at the site of contact with the infectious organismThe chancre occurs usually within 2 to 3 weeks after exposurePatient is infectious before the appearance of the chancre

    Lesion begins as a small papule and enlarges to form a surface erosion or ulcerationAssociated with the chancre are enlarged, painless, hard regional lymph nodesThe chancre subsides in 3 to 6 weeksThe genitalia, lips, tongue, fingers, nipples, and anus are common sites for chancres

  • SyphilisChancre of primary syphilisUlceration of tongue on left dorsal surface Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p168, 2002

  • Syphilis SecondaryMaculopapular rash of secondary syphilis on the trunk The symptoms of secondary syphilis appear about one month after the onset of primary syphilis Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 9.10, 1996

  • Syphilis - SecondaryDistribution of skin lesions of secondary syphilis Macular lesions most often found in pink colored areasPapular lesions in light blue areasPustular lesions in the purple areas Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 9.10, 1996

  • SyphilisSecondary syphilisErythematous rash affecting the palm of the hand Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p169, 2002

  • SyphilisMucous patch of secondary syphilis(lips)Whitish zone of exocytosis and spongiosis of lower labial mucosa Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p169, 2002

  • Syphilis Tertiary Tertiary (late) stage of syphilis occurs in up to 40% of untreated patientsPatients are noninfectiousIs the destructive stage of the diseaseAny organ of the body can be involvedClassic lesion is the gumma, thought to be the end result of a hypersensitivity reaction All other manifestations of tertiary syphilis are vascular in nature and result from an obliterative endarteritis Aneurysm of the aortaNeurosyphilis can consist of altered tendon reflexes, meningitis, general paresis, or tabes dorsalis Oral lesions are a diffuse interstitial glossitis and the gumma

  • Syphilis Tertiary syphilisPalatal gumma Regezi JA: Atlas of Oral and Maxillofacial Pathology, W.B. Saunders, p 6, 2000

  • SyphilisCongenital syphilisHutchinsons incisors (greatest mesiodistal width in the middle third of the crown)Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p170, 2002

  • SyphilisCongenital syphilisMulberry molar (maxillary molar demonstrating occlusal surface with numerous globular projections

    Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p170, 2002

  • Syphilis Treatment Primary, secondary, early latent Single injection of long-acting benzathine penicillin (penicillin G, 2.4 million units)Allergic to penicillin Oral doxycycline (100 mg bid for two weeks) Oral erythromycin (500 mg, qid for two weeks) IM ceftriazone sodium Screen for HIV infectionCongenital syphilisTest all pregnant women for syphilis by serologyIf Positive treat expectant mother with penicillin

  • SyphilisPrimary syphilisChancre of the tongue

  • Syphilis Dental TransmissionLesions of untreated primary and secondary syphilis are infectious as are the patients blood and salivaPatients being treated or have a positive serology test for syphilis should be viewed as potentially infectious Necessary dental care may be provided unless oral lesions are present Once the oral lesions have cleared the patient can commence dental treatment

  • Genital HerpesGenital herpes is a recurrent, incurable viral infection of the genitalia caused by one of two closely related types of herpes simplex virus (HSV) types 1 & 2 Most genital infections are caused by HSV type 2

  • Genital HerpesIncidence and prevalenceNot a reportable diseaseMany cases are mild or asymptomatic45 million in USA are infectedMore than 750,000 seroconvert/year70% to 90% of first case infections caused by HSV-2Prevalence is 45% in African Americans and 18% in whitesPrevalence has increased by 30% since the late 1970s

  • Genital Herpes Signs and SymptomsHSV-2 infections60% are asymptomatic Incubation period 2-7 daysLesions appear papules, vesicles, ulcers, crusts, and fissuresLesions in moist areas ulcerate early and are painfulPainful lymphadenopathy, fever, malaise, myalgia occurRecurrent lesions usually less severe A prodrome of localized itching, tingling, pain, and burning precedes vesicular eruption Healing of recurrent lesions occurs in 10 to 14 daysConstitutional symptoms are generally absent Between recurrences infected persons shed virus intermittently in the genital tract

  • Genital HerpesHSV keratitis A nonhealing corneal ulcer of the right eye in a 15-year old girl with AIDSCulture showed HSV-1 infection Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 15.13, 1996

  • Genital HerpesAutoinoculation of the thumb (herpetic whitlow) after primary genital herpes Autoinoculation of distant sites is often seen during primary HSV infection Once latency is established periodic reactivation can occur Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 15.10, 1996

  • Genital Herpes - TreatmentFirst Clinical episode Antiviral therapy acyclovir 400 mg orally 3 times daily for 7 to 10 days Counseling regarding natural history of genital herpes, sexual and perinatal transmission, and how to reduce transmission Frequent recurrences (6 or more/year)Daily suppressive antiviral therapy can be usedAcyclovir 400 mg orally 2 times daily

  • Genital Herpes

  • Genital HerpesRecurrent herpetic whitlow HSV infection may be acquired on the finger as sometimes is seen in dentists and medical personal Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 15.13, 1996

  • HPV InfectionCondyloma acuminatum

  • HPV InfectionIncidence and prevalence HPV infections are one of the three most common sexually transmitted diseases in the United StatesAn estimated 20 million Americans have genital HPV infections that can be transmitted by sexual contactAbout 18% of women and 8% of men carry genital HPVHighest infection rate is found in 19 to 26 year old individuals

  • HPV Infection Dental management Genital condylomata acuminatum do not affect dental management Oral lesions are infectiousUniversal precautions must be usedPresence of oral lesions necessitates referral to rule out genital lesionsExcisional biopsy is recommended for HPV-associated oral lesions

  • HPV InfectionOral condyloma acuminatum

    Microscopic appearance of lesion shown above

  • STDs Dental management Patients may come to the dentist because of oral signs and symptomsThe dentist can screen the patient or refer to a physician for diagnosis and Rx Caution because of transmission to othersBe aware of other conditionsIf the dentist screens the patient a complete blood count, heterophil antibody test (Monospot), and EBV-antigen testing are indicated Delay routine dental treatment until patient has recovered (3 to 6 weeks)

  • Infectious Mononucleosis Not classically defined as a sexually transmitted diseaseHowever transmission is by intimate personal contactMost cases caused by Epstein-Barr virus (a lymphotropic herpes virus)

  • Infectious Mononucleosis Incidence and prevalenceMore than 90% of adults worldwide have been infected with EBVIn the United States 50% of 5 year old children and 70% of College freshman show evidence of prior infection with EBV10% to 20% of asymptomatic, seropositive adults (antibodies to EBV) carry the virus in their oropharyngeal region

  • Infectious Mononucleosis Pathophysiology Transmitted through exposure to oropharyngeal secretions and on occasion by infected blood productsIncubation period is 30 to 50 daysInfection of B lymphocytes induces large reactive lymphocytes (T lymphocytes) which make up about 10% lymphocytes on blood smearsAcute infection involves reactive lymphocytes, cytokines they produce and B-cell produced antibodies (heterophile) against EBVEnlargement of the spleen occurs in 40% to 50% of casesRupture of the spleen occurs in 0.1% to 0.2% of all cases

  • Infectious MononucleosisSigns and symptomsAsymptomatic when found in children In young adults about 50% will be symptomaticFever, sore throat, and lymphadenopathy occur in most of the symptomatic patientsOther clinical features include malaise, fatigue, an absolute lymphocytosis (more than 10% reactive lymphocytes) and a positive heterophil antibody testPalatal petechiae are found in about 33% of the patients during the first week of the illnessAbout 30% of the symptomatic patients develop an exudative pharyngitis and 10% develop a skin rash and/or petechiae

  • Infectious Mononucleosis Oral manifestations FeverSevere sore throatPalatal and lip petechiaeEnlarged, tender anterior and posterior cervical lymph nodes

  • Infectious MononucleosisHyperplastic pharyngeal tonsils with yellowish crypt exudates in a patient with infectious mononucleosis Neville BW; Oral & Maxillofacial Pathology, 2 ed, W.B. Saunders Co.p 225, 2002

  • Infectious MononucleosisNumerous petechiae of the soft palate in a patient with infectious mononucleosis Petechiae are found in up to 25% of the patients

  • Infectious Mononucleosis Medical management Symptomatic treatment consisting of bed rest, acetaminophen or NSAIDs for pain control, and gargling and irrigation with saline solution Avoid vigorous activities to avoid rupture of spleenShort course of prednisone for patients with exudative pharyngotonsillitis, pharyngeal edema, and upper airway obstruction 20% of symptomatic patients develop streptococcal infection and need to be treated with penicillin V if they are not allergic to it (avoid ampicillin as more than 90% of these patients will develop an allergic skin rash to the drug)

  • Infectious Mononucleosis Dental management Patients may come to the dentist because of oral signs and symptomsThe dentist can screen the patient or refer to a physician for diagnosis and Rx If the dentist screens the patient a complete blood count, heterophil antibody test (Monospot), and EBV-antigen testing are indicated Delay routine dental treatment until patient has recovered (3 to 6 weeks)

  • Gonorrhea Pelvic inflammatory disease (PID) PID occurs in about 30% of women who have untreated gonococcal infection Complications are infertility (10%) incidence for each episode of PIDMandell GL; Atlas of Infectious Diseases, Vol. V,Churchill Livingstone, p 1.9, 1996

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