Diabetes & Dental Managment

This brief summary is meant only as a quick reference to provide dental practitioners with an overview of sexually transmitted diseases and dental management. It is not intended to be an inclusive discussion of this topic and should, therefore, be supplemented by more in-depth reading on the subject.

Sexually transmitted diseases (STDs) are a major health problem in the US, varying in their manifestations from minor inconvenience or irritation to severe disability and death. Included among this group of diseases are AIDS, gonorrhea, syphilis, chlamydia, genital herpes, hepatitis B, trichomoniasis, lymphogranuloma venereum, chancroid, genital warts, and pediculosis pubis.

Although most STDs have the potential for oral infection and transmission, this discussion will be limited to (1) gonorrhea, (2) syphilis, and (3) genital herpes. Please refer to a separate discussion of AIDS and to "Liver Diseases" for a discussion of hepatitis B.

Since some persons provide no history and demonstrate no significant sign or symptoms suggestive of disease, it is not possible to identify potentially infectious patients. It is thus necessary to manage all patients as though they were infectious. Recommendations published by the US Public Health Service for controlling infection in dentistry have become the standard for preventing cross-infection. Strict adherence to these recommendations will eliminate the danger of disease transmission between dentist and patients.

Drug Interactions. There are no adverse interactions between the usual antibiotics or drugs used to treat STDs and the drugs commonly used in dentistry. No drugs are contraindicated.

General description and epidemiology. Gonorrhea is the most commonly reported infectious disease in the US, with over 690,000 cases recorded in 1990.¹ Its transmission is almost exclusively via sexual contact, the primary sites of infection are the genitalia, anal canal, and pharynx. Though gonorrhea is seen more commonly in 15-19 year-old and 20-24 year old age groups, it can occur at any age.¹ Single, black, urban dwellers with multiple sexual partners are at high risk. Other risk factors include low educational level and socioeconomic status.

Etiology and clinical presentation. Gonorrhea is caused by Neisseria gonorrhoeae, which is a gram-negative diplococcus commonly found within polymorphonuclear leukocytes. N. gonorrhoeae is an aerobe that requires high humidity and specific temperature and pH for optimum growth, and is readily killed by drying. It develops resistance to antibiotics rather easily, and many strains have become resistant to penicillin and tetracycline, as well as to other antibiotics.

In men, the most common symptoms include a mucopurulent urethral discharge, pain on urination, urgency, and frequency, In women, a significant percentage (50%) of cases may be asymptomatic or only minimally symptomatic. Women who are symptomatic may demonstrate vaginal or urethral discharge and dysuria with frequency and urgency. Backache and abdominal pain may also be present. Within the oral cavity the pharynx is most commonly affected. It is usually seen as an asymptomatic infection with diffuse, nonspecific inflammation or as a mild sore throat.

Treatment. Infectiousness diminishes rapidly following antibiotic therapy with ceftriaxone and doxycycline.

Medical considerations. Due to the specific requirements for disease transmission and to the disease's rapid response to antibiotics, gonorrhea poses little threat of disease transmission to the dentist. Whatever care is necessary should thus be provided.

Oral Complications. The rare presentation of oral gonorrhea is nonspecific and varied and may range from slight erythema to severe ulceration with a pseudomembranous coating. The patient may be either asymptomatic or incapacitated with limitations of oral function. Definitive diagnosis of oral lesions should be attempted, and the patient should be under the care of a physician. Treatment of the oral lesions is then symptomatic.

General description and epidemiology. Syphilis is the third most frequently reported infectious disease in the US, surpassed only by gonorrhea and chickenpox. It is most common in ages 20-40; its reported incidence is greater in males than females, by more than 2:1.¹ Its transmission is predominantly sexual; however, it can occur via non-sexual means such as kissing, blood transfusion, or accidental inoculation with a contaminated needle. Congenital syphilis occurs when the fetus is infected in utero by an infected mother. The primary site of syphilitic infection is usually the genitalia, although primary lesions also occur on the lips, tongue, finger, nipples, and anus.

Etiology and clinical presentation. The etiologic agent of syphilis is Treponema pallidum, which is a slender fragile anaerobic spirochete. It is easily killed by heat, drying, disinfectants, and soap and water.

The manifestations of syphilis are classically divided into 5 stages of occurrence (primary, secondary, latent, tertiary, and congenital), with each stage having its own distinct signs and symptoms that are related to time and antigen-antibody responses.

Treatment. Syphilis is treated with parenteral long-acting benzathine penicillins. When allergy to penicillin is present, oral doxycycline, and oral tetracycline are used.² As with gonorrhea proper treatment rapidly reverses infectiousness.

Medical considerations. The lesions of untreated primary and secondary syphilis are infectious, as is the patient's blood and saliva. Even after treatment has begun, the effectiveness of therapy cannot be determined except by conversion of the positive serologic test to negative; this may take a few months to over a year. Although patients with syphilis should be viewed as potentially infectious, any necessary dental care may be provided safely.

Oral complications. Syphilitic chancres and mucous patches are usually painless unless they become secondarily infected. These lesions are highly infectious, but regress spontaneously with or without antibiotic therapy. As with gonorrhea, oral treatment is essentially symptomatic.

General description and epidemiology. The herpes simplex virus (HSV) is transmitted by direct contact, usually kissing (transfer of infective saliva) or sexual contact. Since it is not a reportable disease, its incidence is unknown. However, the Centers for Disease Control estimate that the number of patient consultations for genital herpes increased from 26,000 in 1966 to 423,000 in 1983. As with other STDs, this estimate is probably understated.

Etiology and clinical presentation. HSV is classified into two closely related types, HSV-1 and HSV-2, HSV-1 is extremely common, and is the causative agent of most herpetic infections that occur above the waist. Most adults demonstrate antibodies to this virus. HSV-2 is the causative agent of most herpes infections that occur below the waist. While it is transmitted mainly by sexual contact, it may also be passed on to a newborn from an infected mother. Although the primary site of occurrence of HSV-1 is above the waist and of HSV-2 is below the waist, each infection may occur in either site and can be inoculated from one site to the other.

Lesions of primary genital herpes (and moist areas) in both men and women tend to ulcerate early. Lesions on exposed dry areas tend to remain pustular or vesicular and then crust over. Painful regional lymphadenopathy accompanies the infection, along with headache, malaise, and symptoms of fever. These subside in about 2 weeks, with healing in 3-5 weeks³. All herpetic lesions are highly infectious, regardless of the state they are in.

Treatment. In that no definitive treatment or cure exists, treatment is of a symptomatic and palliative nature. Acyclovir (zovirax) is the only drug that has been shown to be effective in decreasing viral shedding, duration of lesion, and symptoms.

Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed St. Louis, MO: Mosby Year Book; 1993: 276-288.