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

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 in general medial settings is 3% to 5%
Prevalence of chlamydia cervical infection for asymptomatic college students and prenatal patients is 5%

4. Chlamydia Infections Men 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 syndrome
Bartholinitis
Cervicitis
Endometritis
Salpingitis
Perihepatitis
Reiter’s syndrome (consists of conjunctivitis, cervicitis and mucocutaneous lesions)

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
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( ) > 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. Gonorrhea Signs and symptoms 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

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

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

19. 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

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. 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

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. 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

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 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

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 with EBV
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 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

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

51. Infectious Mononucleosis
Numerous petechiae of the soft palate in a patient with infectious mononucleosis
Petechiae are found in up to 25% of the patients

52. 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)

53. 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)

54. 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