Pathogens and the Oral Cavity Wilkins CH 4 Concorde Career College Preclinical Sciences DH101 Lisa Mayo, RDH, BSDH Staci Janous, RDH, BS

Pathogens Transmissible by the Oral Cavity Wilkins CH4  Tuberculosis p  Viral hepatitis p  HIV p  Herpetic infections p.50-54

Tuberculosis  Tuberculosis: special consideration when sterilization and disinfection methods are selected and administered  Transmission: Inhalation of fresh droplets containing tubercle bacilli disseminated from sputum & saliva of infected individual by coughing, sneezing, or breathing heavily  Areas of infection: lungs (most common), lymph nodes, meninges, kidneys, bone, skin, & oral cavity  Factors affecting transmission  Maximum communicability is just before the disease is diagnosed

Tuberculosis Clinical management: CDC recommendations 1.Annual risk assessment 2.Screening of all newly employed DHCP 3.Taking and updating medical history 4.Referral of patients with suggestive TB history or symptoms 5.Deferral of elective dental treatment 6.Urgent dental care be provided in a facility that can offer isolation

(Source: McInnes ME. Essentials of communicable disease. 2nd ed. St. Louis: The C.V. Mosby Co.; 1975).

Review Tuberculosis infection occurs most commonly in which area? A) Lymph nodes B) Lungs C) Kidneys D) Liver

Answer B) Lungs is the correct answer. Tuberculosis infection occurs most commonly in the lungs, although it can occur in lymph nodes, kidneys, bone, skin, & the oral cavity.

Viral Hepatitis  Inflammation of the liver  Causes  Viral & bacterial infections  Toxins & certain medications  Heavy alcohol use

Viral Hepatitis  Categories  A & E: Oral-fecal route. Unsanitary food & water  B, C, & D: Blood-borne route. Impacts DH  F & G: New, transfusion-transmitted

HEPATITIS B

Hepatitis B (HBV)  Serious, endemic, worldwide disease  Use of strict sterilization of equipment & materials, aseptic techniques, & self-protection measures is mandatory  Transmission (cont’d next slide) Blood & other body fluids Childbirth (mom to child) Accidental needle stick Exchanging contaminated needles, syringes, & other IV drug paraphernalia 1.) Sexual exposure 2.) Infection from blood transfusion & blood products

Hepatitis B  Prevention: critical occupational hazard for DH due to close association with potentially infected body fluids of patients  Preventive measures  Prenatal testing of all pregnant women for HBsAg  Universal immunization: available since 1982  Blood bank control measures (screening of donors, strict testing for all donated blood)  Public education

Hepatitis C  General facts: Serologic test for antibody to HCV was developed in 1991, routine blood screening was implemented in  Transmission: primarily parenteral  No documentation of transmission from intact or non-intact skin exposures to blood  Sexual contact with infected partner most common  Prevention & control: No vaccine is available for HCV  Education & behavior modification  Standards precautions in dental office

Hepatitis D  Delta hepatitis virus causes infection ONLY in the presence of HBV infection (Memory trick: ‘B’ BEFORE ‘D’)  Transmission  Delta infection is superimposed on HBsAg carriers  Multiple exposures to HBV, especially those with hemophilia and IV drug use  Transmission similar to that of HBV  Prevention: same measures used to prevent HBV  Immunization with HBV vaccine also protects the recipient from delta hepatitis infection (NBQ)

(Source: Hoofnagle JH. Type D hepatitis and the hepatitis delta virus. In: Thomas HC, Jones EA, editors. Recent advances in hepatology. Edinburgh: Churchill Livingstone; 1986). Diagram shows the delta antigen surrounded by HBsAg.

Herpes 1.Description 2.HSV1 & 2: Primary Herpetic Gingivostomatitis, Herpes Labialis, Herpetic Whitlow, Ocular/Ophthalmic Herpes, Genital herpes 3.HSV3: Varicella-Zoster Virus 4.HSV4: Epstein-Barr Virus 5.HSV5 Cytomegalovirus 6.HSV8 Kaposi’s Sarcoma

Herpes Virus Diseases Description  Endemic worldwide  Public health problem  8 strains known to infect humans  Herpes viruses produce diseases with latent, recurrent, malignant tendencies  HS type 2 has been implicated in cervical cancer  HS type 1 in oral cancer  Epstein-Barr virus with various types of cancer  After infection: virus can remain latent & cause recurrent infections

Herpes Virus Description  Relation to periodontal disease  Human herpes viruses occur in periodontitis, found in pocket flora with relatively high prevalence  Viruses can suppress a patient’s immunity – allows for opportunistic pathogens – makes perio more severe

Herpes Virus Description  HSV-1: primary infection usually occurs in children  Antibodies (anti-HSV) are produced – does NOT guarantee immunity to recurrent herpes or other herpes virus infections  Sulcular epithelium: reservoir for the viruses  Trauma from dental procedures can reactivate virus

Herpes Virus Diseases Primary Herpetic Gingivostomatitis  Primary infection of HSV-1  Widespread oral ulcers that may involve pharyngeal areas  Fever, malaise, inability to eat, swollen lymph nodes  Reactivation may also lead to herpetic ulcerations of the lip, the typical “cold sore”

Herpes Virus Diseases: Labialis  Herpes labialis (cold sore, fever blister)  HSV-1 & HSV-2 cause genital & oral-facial infections (cannot distinguish between the 2)  Reactivation of oral-facial HSV-1 infections are more frequent than oral-facial HSV-2  Recurrent triggers: stress, sunlight, illness, trauma (dental appts)  Prodromal: prior lesion appearance, burning, stinging, tingling sensations with slight swelling may appear  Clinical characteristics  Group of vesicles form and eventually ruptures & may coalesces  Crusting follows and healing may take up to 10 days  The lesions are infectious, with viral shedding  Care must be taken by the patient because autoinfection (to eye, nose, or genitals) is possible, as is infection of other people  Laser dentistry

Herpes Virus Diseases Labialis  Clinical management: Use patient-friendly terms such as “cold sore” or “fever blister” or “ulcer” NEVER SAY HERPES LESION!!  POSTPONE appointment for patient with active lesion  Explain problems that can occur  Irritation to the lesion can prolong the course & increase severity of the infection  Prodromal state MOST contagious!!

Latent infection of herpes simplex virus. Path of the virus traced from point of viral penetration on lip to establishment of latent infection in the trigeminal ganglion

Herpes Virus Diseases: Whitlow  Herpetic whitlow  HSV-1 infection of the fingers that results from viral entry through minor skin abrasions  Most frequently found around a fingernail  Prevention is with use of protective gloves during dental procedures  Extinct in dentistry with standard precautions

Herpes Virus Diseases Ocular/Ophthalmic Herpes  Can be primary or recurrent infection in the eye from HSV-1 or HSV-2  Transmission from splashing saliva or fluid from a vesicular lesion directly into an UNPROTECTED eye  Prevention: PPE

Herpes Virus Diseases HSV2  Herpes simplex virus type 2 (HSV-2)  Commonly known as genital herpes, but can also occur as an oral and ocular infections

Herpes Virus HSV3 Varicella-Zoster Virus  Varicella-zoster virus 1.Chicken pox: highly contagious, may be transmitted by direct contact, droplet (possibly air-borne), or indirect contact with articles soiled by discharge from vesicles and the respiratory tract. 2.Shingles: chickenpox leaves lasting immunity, but the VZV remains latent in the dorsal root ganglia. Secondary infection.

Herpes Virus HSV4: Epstein-Barr Virus  EBV virus causes: 1.Infectious mononucleosis Prevention: minimize contact with saliva by frequent handwashing, avoiding drinking from a common container, follow standard precautions 2.Oral hairy leukoplakia High incidence in HIV/AIDS patients Tongue lesions appear as white linear lesions along the lateral borders

Infectious Mononucleosis

Oral Hairy Leukoplakia

Herpes Virus HSV5 Cytomegalovirus  Cytomegalovirus (CMV)  Common in HIV/AIDS  Most severe form developing in infants affected in utero  Transmission Virus from mother may affect infant in utero, in birth canal, through breast milk Blood transfusion, post-transplant infection, sexual, respiratory droplet (daycare rate high)  Prevention Standard precautions, handwashing

HSV8  Kaposi’s sarcoma-related herpes virus in immunocompromised host  Major cofactor in production of Kaposi sarcoma  “AIDS-defining” lesion

HSV TYPEVIRUSDISEASE HSV 1Ulcers eyes, fingers, mouth, genitals HSV 2Ulcers genitals HSV 3Varicella-zosterChicken-pox Shingles HSV 4Epstein BarrMono Oral hairy leukoplakia HSV 5Cytomegalovirus HSV 8Kaposi Sarcoma

HIV

HIV-1 Infection General facts First recognized in 1981 as cluster of diseases characterized by loss of cellular immunity Major types 1.HIV-1 (more prevalent in U.S. & Europe) 2.HIV-2 Can persist within cells such as macrophages (WBC) for long periods  Transmission: semen, vaginal secretions, breast milk, blood  Serological tests:  Diagnosis: ELISA, confirmed with Western blot or IFA test  T-helper cell % marker for progression

Review Which of the following tests determines the progression of HIV? a.IFA b.T-cell % c.Western blot d.ELISA

Review Which of the following tests determines the progression of HIV? a.IFA b.T-cell % c.Western blot d.ELISA

Review The majority of cases of transmission of HIV in adults is due to which of the following? A) Blood transfusion B) Needle sharing C) Sexual contact D) Contact with saliva

Answer C) Sexual contact is the correct answer. Sexual contact is the most common way HIV is transmitted among adults. Transmission via blood transfusions is rare, especially in developed countries. Needle sharing is a method of transmission, but not as common. No cases of transmission via saliva are known.

Clinical Course of HIV-1  Seroconversion = when antibody can be detected  6wks-6mo after exposure  Incubation period: Range from time infection → AIDS symptoms  Could be 15+yrs

Clinical Course of HIV-1  Early symptomatic HIV disease  CD4+ T lymphocytes cells; continued increase in viremia;  Many systemic symptoms  Late-stage disease: AIDS  CD4+ count below 200  Pneumonia common cause of death Death in 1 to 3 years (if untreated)

Oral Manifestations of HIV-1  Extraoral examination: Lymphadenopathy, Skin lesions  Intraoral examination  Fungal infections: Candidiasis  Viral infections: Kaposi Sarcoma, Herpes, Oral Hairy Leukoplakia, Chickenpox, Verrucca vulgaris, HPV, Cytomegalovirus  Bacterial infections: Linear Gingival Erythema, NUG/NUP  Dental hygiene management: Refer symptomatic patients, help maintain quality of life, educated on home care

Prevention of HIV Infection  Community education  Goals  Primary prevention: lower incidence rate  HIV testing required for all pregnant women, all newborns  Secondary prevention: For seropositive individuals to reduce the rate of transmission and introduce treatment early.  Early intervention may postpone severe clinical manifestations of advanced illness

 Postpone visit due to herpes infection  Don’t touch/scratch lesion  Avoid transferring virus to objects  Keeping medical history up-to-date  Maintaining oral health Factors to Teach the Patient