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

Sexually Transmitted Diseases• Chlamydia*• Gonorrhea* • Syphilis*• Genital herpes*• Condyloma

acuminatum (genital warts)* HPV

• Chancroid

• Infectious Mononucleosis**

• HIV – AIDS• Trichomoniasis • Granuloma inquinale • Hepatitis B, C, D• Others

Chlamydia Infections • Genital infections caused by

Chlamydia trachomatis represent the most common bacterial sexually transmitted disease in the United States

Chlamydia Infections• Incidence and prevalence • About 4 million cases occur each year• Peak incidence is in the late teens and early

twenties• Prevalence 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 InfectionsMen Women Nongonococcal urethritis Postgonococcal urethritis (develops 2 to 3 weeks after single drug Rx for gonococcal urethritis) Epididymitis Proctitis Conjunctivitis Reiter’s syndrome (consists of conjunctivitis, urethritis and mucocutaneous lesions)

Acute urethral syndromeBartholinitis Cervicitis Proctitis Endometritis Salpingitis Conjunctivitis Perihepatitis Reiter’s syndrome (consists of conjunctivitis, cervicitis and mucocutaneous lesions)

Gonorrhea• Gonorrhea 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

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STDs• Gonorrhea 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 rare

• Vertical transmission during parturition

Mandell GL; Atlas of Infectious Diseases, Vol. V, Churchill Livingstone, p 1.5, 1996

Gonorrhea • Signs and

symptoms• 1 to 3 % of men are

asymptomatic • In men symptoms usually

occur after incubation period of 2 to 5 days

• Mucopurulent urethral discharge

• Pain on urination• Urgency and increased

frequency of urination• Pharyngeal infection in up

to 50% of cases

• Signs and symptoms• About 50% of women are

asymptomatic • Tenderness and swelling of

the meatus can occur • Vaginal or urethral discharge• Pain on urination• Urgency and increased

frequency of urination• Anal canal infection common

in both males and females

Gonorrhea• Gonococcal

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 weeks

Mandell GL; Atlas of Infectious Diseases, Vol. V, Churchill Livingstone, p 1.10, 1996

Gonorrhea• Disseminated

gonococcemia (dermatitis)

• Most common signs of dissemination are myalgia, arthralgia, polyarthritis and dermatitis

Harrison’s Online, hppt://www.harrisonsonline.com, plate 11D-60, 2002

Gonorrhea• Risk factors• Adolescence • Multiple sexual partners• Nonbarrier contraception • Low socioeconomic status• Use of IV drugs or crack cocaine• Previous history of gonorrhea

Syphilis• Syphilis is the fourth-most-

frequently reported sexually transmitted disease surpassed only by chlamydia, gonorrhea, and AIDS

Syphilis•Etiology • Etiologic agent is Treponema pallidum • It is a slender, fragile, anaerobic

spirochete• T. pallidum is easily killed by heat,

drying, disinfectants, and soap and water• The organism is difficult to stain, except

for certain silver impregnation methods

Syphilis• Pathophysiology • T. pallidum does not invade intact skin• It can gain entry via minute abrasions or hair follicles • It can invade intact mucosal epithelium• Within hours after invasion it spreads to the

lymphatics and blood stream• Early 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 Syphilis

Mandell 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 - Primary• Classic manifestation of

primary syphilis is the chancre

• It consists of a solitary granulomatous lesion at the site of contact with the infectious organism

• The chancre occurs usually within 2 to 3 weeks after exposure

• Patient is infectious before the appearance of the chancre

• Lesion begins as a small papule and enlarges to form a surface erosion or ulceration

• Associated with the chancre are enlarged, painless, hard regional lymph nodes

• The chancre subsides in 3 to 6 weeks

• The genitalia, lips, tongue, fingers, nipples, and anus are common sites for chancres

Syphilis• Chancre of

primary syphilis• Ulceration of

tongue on left dorsal surface

Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p168, 2002

Syphilis – Secondary• Maculopapular

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 - Secondary• Distribution of skin

lesions of secondary syphilis

• Macular lesions most often found in pink colored areas

• Papular lesions in light blue areas

• Pustular lesions in the purple areas


Syphilis• Secondary

syphilis• Erythematous

rash affecting the palm of the hand


Syphilis• Mucous patch of

secondary syphilis(lips)

• Whitish zone of exocytosis and spongiosis of lower labial mucosa


Syphilis – Tertiary • Tertiary (late) stage of

syphilis occurs in up to 40% of untreated patients

• Patients are noninfectious• Is the destructive stage of

the disease• Any organ of the body can

be involved• Classic 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 aorta• Neurosyphilis can consist

of altered tendon reflexes, meningitis, general paresis, or tabes dorsalis

• Oral lesions are a diffuse interstitial glossitis and the gumma

Syphilis • Tertiary syphilis• Palatal gumma

Regezi JA: Atlas of Oral and Maxillofacial Pathology, W.B. Saunders, p 6, 2000

Syphilis• Congenital

syphilis• Hutchinson’s

incisors (greatest mesiodistal width in the middle third of the crown)


Syphilis• Congenital

syphilis• Mulberry molar

(maxillary molar demonstrating occlusal surface with numerous globular projections


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 infection

• Congenital syphilis• Test all pregnant women for syphilis by serology• If Positive treat expectant mother with penicillin

Syphilis• Primary syphilis• Chancre of the

tongue

Syphilis – Dental Transmission• Lesions of untreated primary and

secondary syphilis are infectious as are the patient’s blood and saliva

• Patients 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 Herpes• Genital 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 Herpes• Incidence and prevalence• Not a reportable disease• Many cases are mild or asymptomatic• 45 million in USA are infected• More than 750,000 seroconvert/year• 70% to 90% of first case infections caused by

HSV-2• Prevalence is 45% in African Americans and

18% in whites• Prevalence has increased by 30% since the

late 1970s

Genital Herpes – Signs and Symptoms• HSV-2 infections• 60% are asymptomatic • Incubation period 2-7 days• Lesions appear – papules,

vesicles, ulcers, crusts, and fissures

• Lesions in moist areas ulcerate early and are painful

• Painful lymphadenopathy, fever, malaise, myalgia occur

• Recurrent 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 days

• Constitutional symptoms are generally absent

• Between recurrences infected persons shed virus intermittently in the genital tract

Genital Herpes• HSV keratitis • A nonhealing

corneal ulcer of the right eye in a 15-year old girl with AIDS

• Culture showed HSV-1 infection


Genital Herpes• Autoinoculation 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


Genital Herpes - Treatment• First 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 used• Acyclovir 400 mg orally 2 times daily

Genital Herpes

Genital Herpes• Recurrent

herpetic whitlow • HSV infection may

be acquired on the finger as sometimes is seen in dentists and medical personal


HPV Infection• Condyloma

acuminatum

HPV Infection• Incidence and prevalence • HPV infections are one of the three most common

sexually transmitted diseases in the United States• An estimated 20 million Americans have genital

HPV infections that can be transmitted by sexual contact

• About 18% of women and 8% of men carry genital HPV

• Highest 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 infectious• Universal precautions must be used• Presence of oral lesions necessitates

referral to rule out genital lesions• Excisional biopsy is recommended for

HPV-associated oral lesions

HPV Infection• Oral condyloma

acuminatum

• Microscopic appearance of lesion shown above

STDs • Dental management • Patients may come to the dentist because of oral signs and

symptoms• The dentist can screen the patient or refer to a physician for

diagnosis and Rx • Caution because of transmission to others• Be aware of other conditions• 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)

Infectious Mononucleosis • Not classically defined as a

sexually transmitted disease• However transmission is by

intimate personal contact• Most cases caused by Epstein-Barr

virus (a lymphotropic herpes virus)

Infectious Mononucleosis • Incidence and prevalence• More than 90% of adults worldwide have been

infected with EBV• In the United States 50% of 5 year old children

and 70% of College freshman show evidence

of prior infection with EBV

• 10% 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 products• Incubation period is 30 to 50 days• Infection of B lymphocytes induces large reactive

lymphocytes (T lymphocytes) which make up about 10% lymphocytes on blood smears

• Acute infection involves reactive lymphocytes, cytokines they produce and B-cell produced antibodies (heterophile) against EBV

• Enlargement of the spleen occurs in 40% to 50% of cases• Rupture of the spleen occurs in 0.1% to 0.2% of all cases

Infectious Mononucleosis• Signs and symptoms• Asymptomatic when found in children • In young adults about 50% will be symptomatic• Fever, sore throat, and lymphadenopathy occur in most

of the symptomatic patients• Other clinical features include malaise, fatigue, an

absolute lymphocytosis (more than 10% reactive lymphocytes) and a positive heterophil antibody test

• Palatal petechiae are found in about 33% of the patients during the first week of the illness

• About 30% of the symptomatic patients develop an exudative pharyngitis and 10% develop a skin rash and/or petechiae

Infectious Mononucleosis •Oral manifestations • Fever• Severe sore throat• Palatal and lip petechiae• Enlarged, tender anterior and

posterior cervical lymph nodes

Infectious Mononucleosis• Hyperplastic

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 Mononucleosis• Numerous

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 spleen• Short 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 symptoms• The 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 PID

Mandell GL; Atlas of Infectious Diseases, Vol. V,Churchill Livingstone, p 1.9, 1996

Documents

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