1. Pathogens and the Oral Cavity Wilkins CH 4 Concorde Career College Preclinical Sciences DH101 Lisa Mayo, RDH, BSDH Virginia Carrillo, RDH, BSDH

2. Pathogens Transmissible by the Oral Cavity Wilkins CH4  Tuberculosis p.44-45  Viral hepatitis p.45-50  HIV p.54-58  Herpetic infections p.50-54

3. Tuberculosis  Tuberculosis: special consideration when sterilization and disinfection methods are selected and administered  Types of TB: drug-resistant, multidrug resistant TB, extensively drug-resistant  Transmission: Inhalation of fresh droplets containing tubercle bacilli disseminated from sputum & saliva of infected individual by coughing, sneezing, or breathing heavily  Factors affecting transmission  Degree to which infected individual produces infectious droplets & amount and duration of exposure and susceptibility of the recipient  Maximum communicability is just before the disease is diagnosed

4. Tuberculosis  Areas of infection: lungs (most common), lymph nodes, meninges, kidneys, bone, skin, & oral cavity.  Clinical management: official 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 7.A separate reception area for suspected or confirmed TB patients is preferred, and appointment scheduling should be arranged to prevent a waiting period.

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

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

7. 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.

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

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

10. HEPATITIS B

11. Hepatitis B  HBV is a 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 Percutaneous (intravenous, intramuscular, & subcutaneous) & Perimucosal exposure Accidents with needle stick & other sharps Exchanging contaminated needles, syringes, & other IV drug paraphernalia 1.) Sexual exposure 2.) Infection from blood transfusion & blood products

12. Hepatitis B  Transmission (cont’d)  Perinatal transmission During fetal stage, at birth Infected infant at high risk for chronic infection, which can lead to chronic liver disease or cancer later in life  Carrier state or chronic hepatitis B All HBsAg-positive persons are potentially infective chronic carrier is defined as individual with the HBsAg marker found in the blood on @ least 2 occasions at least 6mo apart

13. 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 of infants & children; immunization of adolescents & adults (especially those at high risk)  Enforce blood bank control measures (screening of donors, strict testing for all donated blood)  Enforce use of disposable syringes & needles  Education of public  Active immunization: the vaccines, available since 1982 for pre-exposure & post exposure prophylaxis; stimulate antibodies & convey immunity.

14. Hepatitis C  General facts: Serologic test for antibody to HCV was developed in 1991, and routine blood screening was implemented in 1992.  Transmission: primarily parenteral; rarely occurs from mucous membrane exposures to blood  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 are essential  Standards precautions in dental office

15. Hepatitis D  Delta hepatitis virus, also called the delta agent, causes infection ONLY in the presence of HBV infection (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, by direct exposure to contaminated blood and serous body fluids, contaminated needles and syringes, sexual contacts, and perinatal transfer  Prevention: all measures used to prevent HBV prevent HDV since delta is dependent on presence of HBV.  Immunization with HBV vaccine also protects the recipient from delta hepatitis infection (NBQ)

16. (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.

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

18. Herpes Virus Diseases Description  Endemic worldwide, each virus causing many disease entities that are highly infectious  Public health problem due to lack of effective therapeutics & vaccines  8 strains are known to infect humans  Herpes viruses produce diseases with latent, recurrent, and sometimes 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, the virus has the ability to remain latent in the individual and only become reactivated to produce recurrent infection Certain stimuli Immune response lowered/altered

19. Herpes Virus Description  Relation to periodontal disease  Human herpes viruses occur in periodontitis, found in pocket flora with relatively high prevalence  Infection with herpes viruses can suppress a patient’s immunity, and as a result, subgingival overgrowth of opportunistic periodontal pathogens can occur, making periodontal disease symptoms more severe

20. Herpes Virus Description  HSV-1: primary infection usually occurs in children, but may occur at any age  Antibodies (anti-HSV) are produced, but do not guarantee immunity to recurrent herpes or other herpes virus infections  Sulcular epithelium can serve as reservoir for the viruses, Anti-HSV is present in gingival sulcus fluid  The possibility exists that trauma to oral tissues during dental or DH appointment may bring about herpetic recurrence

21. Herpes Virus Diseases Primary Herpetic Gingivostomatitis  Primary infection with HSV-1  Full-blown case presents with 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”

22. 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

24. 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: contagiousness, may spread around their oral cavity  Irritation to the lesion(s) can prolong the course and increase severity of the infection  Prodromal state MOST contagious!!

25. 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

26. 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

27. 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

28. 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  Antiviral therapy can suppress HSV-2 lesions, but the latency of the virus can never be eradicated

29. Herpes Virus HSV3 Varicella-Zoster Virus  Varicella-zoster virus 1.Chicken pox caused by varicella virus: 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 caused by herpes zoster virus: chickenpox leaves lasting immunity, but the VZV remains latent in the dorsal root ganglia. Secondary infection.

31. 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

32. Infectious Mononucleosis

33. Oral Hairy Leukoplakia

34. Herpes Virus HSV5 Cytomegalovirus  Cytomegalovirus (CMV)  Common in HIV/AIDS  Most severe form developing in infants affected in utero  Transmission Virus from mother’s primary or recurrent infection may affect infant in utero, in the birth canal, or through breast milk. CMV in the fetus can lead to premature birth, anemia, mental retardation, microcephaly, motor disabilities, deafness, and chronic liver disease Blood transfusion, post-transplant infection, sexual, respiratory droplet (daycare rate high)  Prevention Standard precautions, handwashing

35. HSV8  Kaposi’s sarcoma-related herpes virus in immunocompromised host, a major cofactor in production of Kaposi sarcoma, an AIDS-defining lesion.

36. HIV

37. HIV-1 Infection General facts Severe pandemic disease caused by HIV infection First recognized in 1981 as cluster of diseases characterized by loss of cellular immunity Major types: HIV-1 (more prevalent in U.S. & Europe) & HIV-2 Slow, progressive, & often lethal Can persist within cells such as macrophages for long periods  Transmission: semen, vaginal secretions, breast milk, blood  Serological tests: 1985 (EIA/ELISA)  Confirmation with Western blot or IFA test  T-helper cell % marker for progression

38. 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

39. 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.

40. 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

41. Clinical Course of HIV-1  Early symptomatic HIV disease  CD4+ T lymphocytes 200-500 cells; continued increase in viremia; systemic symptoms: night sweats, weight loss, diarrhea, fever, malaise, general weakness; opportunistic infections begin; oral lesions become more common  Late-stage disease: AIDS  CD4+ count below 200; pneumonia is presenting feature with other AIDS- defining diseases; presentation of full-blown AIDS is highly variable & affected by host’s prior exposure to chronic infections & treatment.  Symptoms: AIDS-indicating conditions  CD4+ numbers decline, Opportunistic infections become more frequent, extensive, & severe AIDS-dementia complex, Tuberculosis infection, Constitutional disease, Neoplasms Death in 1 to 3 years (if untreated)

42. 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

43. Prevention of HIV Infection  Community education  Attitudinal, behavioral changes: increase awareness, modes of transmission, prevention methods  Goals  Primary prevention: lower rate at which new cases of HIV-1 appear. HIV testing is 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. Counsel HIV-infected individuals to practice safe sex, cooperate with screening programs, and counsel their sexual contacts and families

44.  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