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									Sexually Transmitted Diseases
• Chlamydia*             • Infectious
                           Mononucleosis**
• Gonorrhea*
• Syphilis*              • HIV – AIDS
• Genital herpes*        • Trichomoniasis
• Condyloma acuminatum   • Granuloma inquinale
  (genital warts)* HPV   • Hepatitis B, C, D
• Chancroid              • 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 Infections
Men                              Women
Nongonococcal urethritis         Acute urethral syndrome
Postgonococcal urethritis        Bartholinitis
(develops 2 to 3 weeks after     Cervicitis
single drug Rx for gonococcal    Proctitis
urethritis)
                                 Endometritis
Epididymitis
                                 Salpingitis
Proctitis
                                 Conjunctivitis
Conjunctivitis
                                 Perihepatitis
Reiter’s syndrome (consists of
conjunctivitis, urethritis and   Reiter’s syndrome (consists of
mucocutaneous lesions)           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              • Signs and symptoms
• 1 to 3 % of men are             • About 50% of women are
  asymptomatic                      asymptomatic
• In men symptoms usually
                                  • Tenderness and swelling of
  occur after incubation period
  of 2 to 5 days                    the meatus can occur
• Mucopurulent urethral           • Vaginal or urethral discharge
  discharge                       • Pain on urination
• Pain on urination               • Urgency and increased
• Urgency and increased             frequency of urination
  frequency of urination          • Anal canal infection common
• Pharyngeal infection in up to     in both males and females
  50% of cases
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
                             Mandell GL; Atlas of Infectious Diseases, Vol. V,
                             Churchill Livingstone, p 1.10, 1996

• Left untreated it will
  resolve within 6 weeks
Gonorrhea
• Disseminated
  gonococcemia
  (dermatitis)
• Most common signs
  of dissemination are
  myalgia, arthralgia,
  polyarthritis and    Harrison’s Online, hppt://www.harrisonsonline.com, plate 11D-60, 2002

  dermatitis
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
       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


Course of Untreated Syphilis
Syphilis - Primary
• Classic manifestation of       • Lesion begins as a small
  primary syphilis is the          papule and enlarges to form
  chancre                          a surface erosion or
• It consists of a solitary        ulceration
  granulomatous lesion at the    • Associated with the chancre
  site of contact with the         are enlarged, painless, hard
  infectious organism              regional lymph nodes
• The chancre occurs usually     • The chancre subsides in 3 to
  within 2 to 3 weeks after        6 weeks
  exposure                       • The genitalia, lips, tongue,
• Patient is infectious before     fingers, nipples, and anus
  the appearance of the            are common sites for
  chancre                          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

                             Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually
                             Transmitted Diseases, Churchill Livingstone, p 9.10, 1996
Syphilis
• Secondary syphilis
• Erythematous rash
  affecting the palm of
  the hand



                   Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p169, 2002
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
Syphilis – Tertiary
• Tertiary (late) stage of         • All other manifestations of
  syphilis occurs in up to 40%       tertiary syphilis are vascular
  of untreated patients              in nature and result from an
• Patients are noninfectious         obliterative endarteritis
• Is the destructive stage of      • Aneurysm of the aorta
  the disease                      • Neurosyphilis can consist of
• Any organ of the body can          altered tendon reflexes,
  be involved                        meningitis, general paresis,
• Classic lesion is the gumma,       or tabes dorsalis
  thought to be the end result     • Oral lesions are a diffuse
  of a hypersensitivity reaction     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)



                     Neville BW: Oral & Maxillofacial Pathology, 2nd edition, Mosby, p170, 2002
Syphilis
• Congenital syphilis
• Mulberry molar
  (maxillary molar
  demonstrating
  occlusal surface with
  numerous globular
  projections         Neville BW: Oral & Maxillofacial Pathology, 2   nd   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 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                 • A prodrome of localized
• 60% are asymptomatic               itching, tingling, pain, and
                                     burning precedes vesicular
• Incubation period 2-7 days
                                     eruption
• Lesions appear – papules,
  vesicles, ulcers, crusts, and    • Healing of recurrent lesions
  fissures                           occurs in 10 to 14 days
• Lesions in moist areas           • Constitutional symptoms are
  ulcerate early and are             generally absent
  painful                          • Between recurrences
• Painful lymphadenopathy,           infected persons shed virus
  fever, malaise, myalgia occur      intermittently in the genital
• Recurrent lesions usually less     tract
  severe
Genital Herpes
• HSV keratitis
• A nonhealing
  corneal ulcer of the
  right eye in a 15-
  year old girl with
  AIDS
• Culture showed         Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually

  HSV-1 infection        Transmitted Diseases, Churchill Livingstone, p 15.13, 1996
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
                           Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually
                           Transmitted Diseases, Churchill Livingstone, p 15.10, 1996
  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
                        Mandell GL; Atlas of Infectious Diseases, Vol. V, Sexually
                        Transmitted Diseases, Churchill Livingstone, p 15.13, 1996
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

								
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