diseases of major concern to the dental assistant

Herpes Simplex

Herpes (HER-peez) simplex is a common and troublesome viral disease (Figure 10-12). Herpes simplex virus type 1 (HSV1) is usually associated with infections of the lips, mouth, and face; and herpes simplex virus type II (HSV2) is normally associated with the genital area. Type II, however, can appear in the oral cavity. Both viruses are extremely contagious and spread by either direct contact with a fluid-filled lesion, called a vesicle, or the fluid from such a lesion.

Figure 10-12

Herpetic labialis lesion.

Herpetic labialis lesion.

Courtesy of Joseph L. Konzelman, Jr., DDS

Most adults have been infected by herpes simplex virus type I. Initially, the infection may cause flu-like symptoms and a blister or sore in the mouth. It remains in the nerve cells within that area for life. HSV1 reactions often result from fever, prolonged exposure to the sun, stress, or ingestion of certain high-acid foods. These herpes simplex viruses (cold sores or aphthous ulcers) can reactivate and appear in the same general areas. The virus may infect the fingers if open sores are present; but this virus on the finger ( play audio herpetic whitlow) is rare, and was a greater concern to dental personnel prior to the usage of treatment gloves. The virus can be transferred to the eye and cause conjunctivitis or a play audio corneal ulcer, which could result in blindness.

Treatment of HSV1 depends on type, site, and severity. Dental teams may suggest rescheduling the patient if the sores are apparent. This is primarily for the comfort of the patient, but it also may be office policy not to provide treatment when vesicles are present in the oral cavity. A number of topical treatments are available for patient comfort. Some people take L-Lysen, an amino acid, when they feel the symptoms coming on. Antiviral drugs such as acyclovir, the generic for Zovirax, are sometimes helpful.

HSV2 is sexually transmitted genital herpes. It displays the same vesicles, erupting on the sex organs, and may erupt orally as well. As with type 1, type 2 can recur.

Bloodborne Diseases

Bloodborne diseases, or bloodborne pathogens (disease-producing microorganisms), are of great concern. The Occupational Safety and Health Administration (OSHA) addresses this problem in the Bloodborne Pathogen Standard (see Chapter 11). Bloodborne diseases of concern to the dental assistant are viral hepatitis (HBV) and human immunodeficiency virus (HIV), which later develops into acquired immunodeficiency syndrome (AIDS). These diseases are transmitted directly through contaminated blood and other body fluids.

High-Risk Behavior for Acquiring Hepatitis B, HIV, and AIDS

• Injuries or sticks with sharp objects contaminated with blood or body fluid

• Multiple sexual partners, unprotected sex (homosexual, bisexual, or heterosexual)

• Sharing contaminated needles

• Exposure to non-intact skin or open wound with contaminated blood or body fluid

“Hepatitis” means inflammation of the liver and viral hepatitis means that it is transferred by means of a virus. Other things can cause hepatitis such as heavy alcohol use, some drugs, toxins, and bacteria. There are five primary types of hepatitis (Table 10-1). Hepatitis A and E are transmitted by person-to-person contact or by ingestion of contaminated water or food. The symptoms, which appear from 15 to 40 days after contact, range from flu-like symptoms to acute liver damage.

Hepatitis A.

Hepatitis A (often called infectious hepatitis) is in the news when a food provider has a number of customers who become ill and the virus is identified. No long-term immunization has been available until recently. People who have possible contact with contaminated food or water are given an injection of gamma globulin within 14 days of exposure, which provides short-term immunization. In 1995, a vaccine called Havrix was licensed by the U.S. Food and Drug Administration (FDA). A paper by the Centers for Disease Control and Prevention (CDC) stated the benefits of Havrix and, in 1997, Havrix was awarded the pediatric vaccine contract. Children in areas with a high rate of hepatitis A will be given the initial and booster dose of Havrix between the ages of 2 and 18 years.

Hepatitis B.

Hepatitis B is of major concern to dental personnel. This disease (commonly called serum hepatitis) has been recognized only since the early 1950s. Primarily transmitted through contaminated needles and syringes, the incubation period is from 50 to 180 days. Only one-third of infected people have symptoms that can be easily identified, one-third have only slight symptoms, and one-third have no symptoms at all. The symptoms include loss of appetite, digestive upset, upper abdominal pain and tenderness, fever, weakness, muscle pain, and jaundice (yellowing of the skin). According to the CDC, about 300,000 people are infected each year; of that number, 300 will die from the disease, 10,000 will be hospitalized, and 20,000 will become chronic carriers. The CDC estimates that there are over a million carriers in the United States today. The FDA approved Hepsera (adefovir dipivoxil) tablets in 2002 for treatment of chronic hepatitis B in adults. Hepsera slows the progression of chronic hepatitis B.

In 1982, a plasma-derived Heptavax-B vaccine was introduced in the United States. Since that time, Recombivax HB and Engerix-B have been licensed for use in the United States and are shown to be effective against the hepatitis B virus. Both these vaccines are administered in a series of three injections. The schedule is initially, then a month later, and then 3 months from the first vaccine administration. The vaccine is administered in the form of an injection to the deltoid muscle in the arm. It has been found that administration in the buttocks did not yield the same seroconversion rate (i.e., vaccine causing the development of immunity).

It should be noted that, according to OSHA standards, the employer is responsible for offering the HBV 3 series vaccination to new employees in Categories I and II within 10 days of employment at no cost to the employee. The employee can refuse the vaccine by signing an informed refusal form that is to be kept in the employee file (see Chapter 12).

After completing the three series of HBV vaccines, a blood test is performed to ensure that immunity has developed. The employer is not responsible for the blood test, because it is not noted in the OSHA standard, but it is an important step for the dental assistant to take to ensure prevention of hepatitis B. If the dental assistant tests negative for seroconversion, the physician must make a determination about additional dosages of the HBV vaccine.

A booster dosage is not recommended by the CDC unless an exposure incident has occurred or a physician recommends it after testing negative for seroconversion.

Hepatitis C.

Hepatitis C, often called non-A and non-B, reacts somewhat like hepatitis B, but there is no vaccine available currently. About 50 percent of the people infected become chronic carriers.

Hepatitis D.

Hepatitis D, also known as the delta agent, cannot replicate on its own and requires the presence of hepatitis B. The vaccination for hepatitis B should also prevent hepatitis D.

Hepatitis E.

Hepatitis E is found in the feces of people and animals and is therefore spread through contaminated water and food. The symptoms are loss of appetite, dark urine, fatigue, and nausea. To prevent this disease an individual should wash hands carefully when preparing food and when traveling take special care in avoiding contaminated water.

Human Immunodeficiency Virus

Human immunodeficiency virus (HIV) belongs to the class of retroviruses and is the cause of acquired immunodeficiency syndrome AIDS. It gains access to the bloodstream via sexual intercourse, transfusions, and sticks with infected needles that break the skin. Also, a fetus can be infected by its mother. HIV attacks T-lymphocytes, part of the immune system, and then multiplies. People in this stage pose no threat to the health care worker if standard precautions are followed. People who have HIV but are unaware that they carry it are called asymptomatic carriers. Some have vague complaints, such as fever, weight loss, or unexplained diarrhea. These individuals are referred to as having AIDS-related complex (ARC).

In most cases, the disease progresses and the infected individual develops some brain damage in the form of dementia. If the individual is in this state for a long period of time, more severe brain damage may occur; normally, the infected individual most likely succumbs to AIDS before this happens.

Current treatment focuses on symptoms and not the disease itself. A great deal of research is being done currently to develop a vaccine to fight this retrovirus.

Acquired Immunodeficiency Syndrome.

Acquired immunodeficiency syndrome (AIDS) results from infection with HIV, but not all individuals infected with HIV develop AIDS. A syndrome is a group of symptoms that characterize a disease. In the United States, 100,000 cases of HIV were diagnosed in the 1980s. The first few cases were reported in 1981. The CDC was notified of a rare and unusual lung infection in young homosexual men. Also, a slow-growing skin tumor usually found in aging men, called Kaposi’s sarcoma, was found to be growing aggressively in this same group of young men (Figure 10-13). Individuals with these two symptoms reported with a number of opportunistic infections, such as pneumonia.

Figure 10-13

A Kaposi’s sarcoma lesion on the palate.

Courtesy of the Centers for Disease Control and Prevention/Sol Silverman, Jr., D.D.S., University of California, San Francisco

After much research, the virus was found to be transmitted via the semen and blood of infected individuals. “Casual” spreading of the disease does not seem to happen. For example, kissing does not spread the disease. A person with full-blown AIDS exhibits cancers, infections, diarrhea, or a number of other viral diseases. The prognosis is often fatal, but life may be sustained for a number of years with appropriate diet and health measures. Through December 2009, the cumulative number of AIDS cases reported to the CDC was 1,108,611. As of 2008, the total deaths of this same group were 617,025. The majority of these diagnosed cases are in the 30- to 40-year-old age group.

There is no cure for AIDS. The complications are treated accordingly. Several antiviral drugs are used, such as zidovudine (AZT) and acyclovir. AZT has a number of side effects but has been shown to slow progression of the disease. Research continues in an effort to find a vaccine for HIV, with several drugs showing promise.