2018 Oregon Dental Conference Course Handout Denis Lynch, DDS, PhD

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1 2018 Oregon Dental Conference Course Handout Denis Lynch, DDS, PhD Course 9121: Infectious Hazards in Dentistry or What You Never Thought You'd Have to Worry about after You Passed National Boards Thursday, April 5 1:30-4:30 pm

2 Infectious Hazards in Dentistry Oregon Dental Conference Portland, Oregon April 5-7, 2018 Denis P. Lynch, DDS, PhD Outline STDs Tuberculosis Candidiasis Human herpes virus Human papilloma virus 1

3 Synopsis Major clinical signs and symptoms Diagnostic criteria and tests Currently accepted therapeutic modalities Acquired Syphilis Etiology and Epidemiology Treponema pallidum >100,000 cases annually Males > females (3:1) 35% of MSMs 30% of sex partners 20% asymptomatic 2

4 Clinical Features Primary Chancre at site of infection 2-4 weeks following exposure Indurated, painless ulcer Non-tender lymphadenopathy Resolution in 2-4 weeks Clinical Features Secondary 6 week incubation Flu-like symptoms Non-specific rash (80%) Non-tender lymphadenopathy Resolution in 4 weeks Occasional exacerbations Clinical Features Secondary Mucous patch Painless, non-adherent plaque Eroded base Erythematous border 3

5 Clinical Features Tertiary Non-infectious 1/3 rd seronegative 1/3 rd seropositive with no disease 1/3 rd seropositive with disease Cardiovascular and neurologic (10%) Palatal and lingual gummas Atrophic glossitis Differential Diagnosis Aphthous ulcer Traumatic ulcer Squamous cell carcinoma Candidiasis Stomatitis areata migrans Diagnosis Darkfield microscopy Inappropriate for oral use Serology VDRL and RPR FTA-Abs (gold standard) Biopsy 4

6 Treatment and Prognosis Medical referral Most cases respond to common antibiotics Excellent prognosis if treated early Increased risk of tongue carcinoma in long-term, untreated syphilitic glossitis Gonorrhea Etiology and Epidemiology Nisseria gonorrhea #1 reportable infectious disease >1,000,000 cases reported annually >1,000,000 estimated unreported cases annually Increasing incidence of oral disease 5

7 Clinical Features Frequently asymptomatic >50% of women and <10% of men Pseudomembranous ulcers Regional lymphadenopathy Non-specific pharyngitis Non-specific stomatitis Necrotic gingivitis Differential Diagnosis Recurrent aphthous ulcers Primary herpetic gingivostomatitis Necrotizing ulcerative gingivitis Viral parotitis Bacterial pharyngitis Viral pharyngitis Diagnosis Smear Culture Immunofluorescent antibody 6

8 Treatment and Prognosis Medical referral Most cases respond to common antibiotics Excellent prognosis if treated early Sterility if left untreated Tuberculosis Etiology and Epidemiology Mycobacterium tuberculosis 1 billion infections #1 cause of infectious deaths 25% of preventable deaths 20 million active cases 8 million new cases annually 3 million deaths annually 7

9 Epidemiology United States million infected persons 100,000 are also HIV positive Multiple Drug Resistant (MDR) tuberculosis 277 cases 16 cases in health care workers 5 deaths Clinical Features - Systemic Fever Malaise Anorexia Weight loss Night sweats Productive, painful cough Hemoptysis Clinical Features Oral 1% with oral lesions Tongue, palate and lips Indurated nodules Often ulcerated 8

10 Differential Diagnosis Squamous cell carcinoma Deep fungal infection Diagnosis PPD Only indicates exposure Culture Biopsy Treatment Isoniazid Rifampin Pyrazinamide Ethambutol Streptomycin 9

11 Prognosis Fair prognosis Poor medication compliance Relapses common Candidiasis Etiology and Epidemiology Candida albicans Most common fungal infection 35% of healthy adults 90% of denture wearers Females > males 10

12 Predisposing Factors Antibiotics Xerostomia Immunodeficiency Infancy Antimetabolites Acquired Malnutrition Endocrine dysfunction Diabetes mellitus Pregnancy Oral contraceptives Corticosteroids Pseudomembranous Candidiasis Infants and debilitated adults White, non-adherent plaques Erythematous base Stomatopyrosis stomatodynia Differential Diagnosis Chemical burn Allergy Hypersensitivity Mucous patch Morsicatio buccarum / lingualis / labialis 11

13 Erythematous candidiasis Most common form Diffuse erythema Variable symptoms denture sore mouth Limited to denture bearing mucosa Frequently painless Perlèche Angular cheilitis Moist, macerated, cracked Variable symptoms (?) role of decreased vertical dimension (?) role of vitamin B complex deficiency Median Rhomboid Glossitis Not a congenital defect Posterior dorsal tongue Red, depapillated area Frequently painless Unknown significance 12

14 Differential Diagnosis Erosive / atrophic lichen planus Chemical burn Allergy / hypersensitivity Impetigo Geographic tongue Diagnosis Smear Culture Biopsy Latex agglutination Therapeutic diagnosis Treatment Topical antifungals Systemic antifungals Topical antimicrobials 13

15 Topical Antifungals Nystatin (Mycostatin ) Oral suspension Pastilles Vaginal suppositories Cremes and ointments Clotrimazole (Mycelex ) Troche Cremes and ointments Systemic Antifungals Ketoconazole (Nizoral ) Fluconazole (Diflucan ) Itraconazole (Sporanox ) Topical antimicrobials Gentian violet Chlorhexidine Peridex Periogard GUM (alcohol-free) 14

16 Prognosis Excellent prognosis Frequent recurrences Treat predisposing factors Recurrent Herpes Simplex Etiology and Epidemiology Human Herpes Virus 1 (HHV-1) #2 most common viral disease Majority of individuals in USA exposed 50% of individuals give history of contact 15% asymptomatic shedders 15

17 Clinical Features Prodrome Burning Itching Tingling Recurrences due to stress Trauma Emotion Endocrine Clinical Features Herpetiform cluster of vesicles Vermilion border Attached gingiva Hard palate Infectious for 5-7 days Heal in 14 days Differential Diagnosis Impetigo Recurrent aphthous ulcers Traumatic ulcers Other viral stomatitis 16

18 Diagnosis History Clinical signs and symptoms Serology Viral culture Tzanck test Treatment Non-prescription topical antiviral drugs Abreva Prescription topical antiviral drugs Denavir Prescription systemic antiviral drugs Zovirax Famvir Valtrex Treatment OTC remedies Iontophoresis Do not use corticosteroids 17

19 Occupational Hazards Herpetic whitlow Herpetic conjunctivitis 18

20 Prognosis Excellent prognosis Variable recurrence pattern Human Papillomavirus Viral Warts Verucca vulgaris (common wart) Squamous papilloma Condyloma acuminatum (venereal wart) 19

21 Etiology and Epidemiology Human papilloma viruses Relatively common Clinical Features Verucca vulgaris More common in children Auto-innoculation common Lips, tongue and labial gingiva affected Painless, clustered, sessile papule(s) Rough (verrucoid), white surface Slow growing Clinical Features Squamous papilloma Adults Unclear transmission (fomite(?)) Tongue and soft palate common Solitary, soft, painless, pedunculated Exophytic, finger-like projections Pink -> red -> white Slowly enlarging 20

22 Clinical Features Condyloma acuminatum Transmitted by sexual contact 20% of lesions seen in STD clinics Auto-innoculation possible More common in young adults Presumptive of sexual abuse in kids Lips, lingual frenum, soft palate Large, sessile, pink mucosal masses Differential Diagnosis Verucca vulgaris Squamous papilloma Condyloma acuminatum Focal epithelial hyperplasia (Heck s dz) Acanthosis nigricans Focal dermal hypoplasia Diagnosis Clinical signs and symptoms Microscopic features Routine H&E staining Immunohistochemistry 21

23 Treatment Conservative excision Cryotherapy Fulguration Immunotherapy (interferon) Podophyllum resin (Podofin ) condyloma Prognosis Excellent Variable recurrence rate Spontaneous remission of verucca vulgaris (?) premaligant potential HPV and Oral Cancer 22

24 HPV Infection Most infections cleared by the immune system % of high-risk HPV infections cleared in 18 months Persistent infection may lead to cancer HPV-related Cancers SITE ANNUAL HPV HPV 16/18 Cervix 12,000 11,500 9,100 Vulvar 3,100 1,600 1,400 Vagina Penis 1, Anus 4,700 4,500 4,200 Oropharynx 11,700 7,400 7,000 TOTAL 33,400 25,900 22,600 What does the data show? HPV is an independent risk factor for oral and oropharyngeal squamous carcinoma Multiple studies; multiple institutions ~30% prevalence rate of HPV detection in H&N cancer surgical specimens Higher prevalence in oropharyngeal lesions (~35%) than laryngeal (~25%) or oral (<25%) lesions 23

25 Which HPV is responsible? HPV % of oropharyngeal lesions 68.2% of oral lesions 69.2% of laryngeal lesions Sex & Oropharyngeal Cancer Sexual behavior is associated with oropharyngeal carcinoma Related to lifetime # of sex partners Vaginal sex and oral sex Open-mouth kissing HPV exposure precedes oropharyngeal cancer by at least 10 years Nagging Questions Do we treat HPV-positive premalignant, i.e., dysplastic, oropharyngeal lesions differently? Not currently Do we treat HPV-positive malignant oropharyngeal lesions differently? Identical treatment but better outcomes Would some oropharyngeal cancers be prevented by HPV vaccination? Yes 24

26 Nagging Questions Is HPV transmitted by kissing? Yes Deep kissing? Yes How deep is deep? Not defined How do you test this? Difficult If HPV is transmitted by kissing, are you giving someone oral cancer? Legal argument Is there a risk of mother-child transmission? Yes, but uncommon Nagging questions If a latent infection reappears, how does your spouse know it s not a new infection? S/he doesn t Should everybody be tested? No Is HPV positivity in an adolescent a marker for sexual activity? No When do you recheck an HPV+ patient? At every normally scheduled recall How about the rest of the family? No 25

27 Infectious Hazards Post-Test Which of the following statements is not characteristic of chancres? 1. Chancres occur at the site of infection. 2. Chancres are soft, painful nodules. 3. Chancres are associated with regional lymphadenopathy. 4. Untreated chancres will spontaneously resolve. Which of the following statements is not characteristic of secondary syphilis? 1. Secondary syphilis manifests as a non-specific skin rash. 2. Affected patients have flu-like symptoms. 3. Affected patients have non-tender lymphadenopathy. 4. Oral lesions (mucous patches) present as painless, non-adherent plaques. 5. All of the above are characteristic of secondary syphilis. Which of the following statements is not characteristic of tertiary syphilis? 1. Cardiovascular disease 2. Neurologic disease 3. Granulomatous disease 4. Atrophic glossitis 5. All of the above are characteristic of tertiary syphilis. Which of the following diagnostic procedures is inappropriate for use in oral lesions of syphilis? 1. VDRL 2. RPR 3. FTA-Abs 4. Darkfield microscopy 5. Biopsy What is the most significant potential complication of long-term untreated gonorrhea in women? 1. Cervical cancer 2. Uterine cancer 3. Sterility

28 Which of the following is not a common site for oral lesions of tuberculosis? 1. Dorsal tongue 2. Palate 3. Lips 4. Retromolar pad Which of the following statements regarding oral Candida albicans infections is incorrect? 1. Candida albicans is found in the mouth in one-third of healthy dentate patients. 2. Oral Candida albicans infections are common in immunodeficient patients. 3. The most common presenting clinical symptom is stomatopyrosis. 4. Erythematous candidiasis in denture wearers is frequently painless. 5. All of the above statements are correct. Which of the following statements regarding median rhomboid glossitis is incorrect? 1. Median rhomboid glossitis is common in infants and children. 2. Median rhomboid glossitis is frequently painless. 3. Median rhomboid glossitis is characterized by depapillation of the tongue. 4. Median rhomboid glossitis is caused by Candida albicans. Which of the following statements regarding recurrent Human Herpesvirus Type I (Herpes simplex) is incorrect? 1. Lesions are often preceded by a prodrome. 2. Intraoral lesions are limited to non-keratinized mucosa. 3. Recurrent oral Human Herpesvirus Type I lesions are indistinguishable from recurrent oral Human Herpesvirus Type II (Herpes progenitalis) lesions. 4. Occasional, otherwise uncomplicated lesions are best treated symptomatically rather than pharmacologically.

29 Which of the following statements regarding verruca vulgaris is incorrect? 1. Oral lesions are more common in children. 2. Oral auto-inoculation is common. 3. Floor of mouth and buccal mucosa are common sites of infection. 4. Oral lesions present as painless, clustered, sessile papules. Which of the following statements regarding squamous papilloma is incorrect? 1. Oral lesions are more common in children. 2. Oral mucosal inoculation most likely involves fomites. 3. Tongue and soft palate are common sites. 4. The mucosal surface exhibits exophytic, finger-like projections. 5. All of the above statements are correct. Which of the following statements regarding condyloma acuminatum is incorrect? 1. Oral lesions are more common in young adults. 2. Oral lesions are usually due to oral-genital contact. 3. Lips, lingual frenum and soft palate are common sites of involvement. 4. Detection of oral lesions in children is presumptive evidence of sexual abuse 5. All of the above statements are correct. Which human papilloma viruses are considered high-risk for the development of oral-pharyngeal squamous cell carcinoma? 1. HPV 2 and 7 2. HPV 3, 8, and HPV 6 and HPV 13 and HPV 16 and 18

30 Which of the following statements regarding human papilloma virus is incorrect? 1. One-half of sexually active adults will become HPV-positive at some point in their life. 2. Most HPV-positive individuals will clear their infection and be virus-free within. 3. Persistent HPV infection is associated with increase genital cancer risk. 4. Persistent HPV infection is associated with increase oral-pharyngeal cancer risk. 5. All of the above statements are correct.