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Sexually Transmitted Diseases
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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 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
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)
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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
Harrison’s Online, hppt://www.harrisonsonline.com, plate 11D-60, 2002
dermatitis
Gonorrhea
• Risk factors
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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
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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
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
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
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)
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
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Oral doxycycline (100 mg bid for two weeks)
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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
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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 15year 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
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
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 HPVassociated oral lesions
HPV Infection
• Oral condyloma
acuminatum
• Microscopic
appearance of lesion
shown above
STDs
• Dental management
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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
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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 EBVantigen 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