Sexually Transmitted Diseases

1. Chlamydia* Gonorrhea* Syphilis* Genital herpes* Condyloma acuminatum (genital warts)* HPV Chancroid Infectious Mononucleosis** HIV – AIDS Trichomoniasis Granuloma inquinale Hepatitis B, C, D Others Sexually Transmitted Diseases

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

3. 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 ingeneral medial settings is 3% to 5% • Prevalence of chlamydia cervical infection for asymptomatic college students and prenatal patients is 5%

4. Chlamydia Infections

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

6. 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

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

9. 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

10. 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

11. 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

12. 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

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

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

15. 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

16. 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

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

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

19. 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 - Primary

20. Syphilis • Chancre of primary syphilis • Ulceration of tongue on left dorsal surface Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p168, 2002

21. 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

22. 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 Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 9.10, 1996

23. Syphilis • Secondary syphilis • Erythematous rash affecting the palm of the hand Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p169, 2002

24. Syphilis • Mucous 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

25. 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

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

27. Syphilis • Congenital syphilis • Hutchinson’s incisors (greatest mesiodistal width in the middle third of the crown) Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p170, 2002

28. Syphilis • Congenital syphilis • Mulberry molar (maxillary molar demonstrating occlusal surface with numerous globular projections Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p170, 2002

29. 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

30. Syphilis • Primary syphilis • Chancre of the tongue

31. 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

32. 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

33. 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

34. 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 – Signs and Symptoms

35. 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 Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 15.13, 1996

36. 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 Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually Transmitted Diseases, Churchill Livingstone, p 15.10, 1996

37. 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

38. Genital Herpes

39. Genital Herpes • Recurrent 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

40. HPV Infection • Condyloma acuminatum

41. 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 betransmitted 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

42. 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

43. HPV Infection • Oral condyloma acuminatum • Microscopic appearance of lesion shown above

44. 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)

45. 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)

46. 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 withEBV • 10% to 20% of asymptomatic, seropositive adults (antibodies to EBV) carry the virus in their oropharyngeal region

47. 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

48. 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 thesymptomatic 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

49. Infectious Mononucleosis • Oral manifestations • Fever • Severe sore throat • Palatal and lip petechiae • Enlarged, tender anterior and posterior cervical lymph nodes

50. 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