Oral Manifestations PDF Draft 1 Apr 16 2013

8/19/2019 Oral Manifestations PDF Draft 1 Apr 16 2013

1/16

COURSE SUMMARY

AUTHOR: Louis G. DePaola, DDS

AUDIENCE: Dentists; Dental Hygienists; Dental Assistants

ABSTRACT: The transmission of infection within thdental office is one of the biggest concerns in the oral healt

profession. This course, in particular, focuses on some

the most prevalent diseases in the U.S. today —know

as sexually transmitted infections (or STIs)— which hav

oral manifestations that can be detected by dent

professionals. It reviews the most common types of STIs, a

well as some of the newer infections (such as huma

papillomavirus [HPV]) that have emerged within the pa

decade, in addition to how they manifest in the oral cavity.

OBJECTIVES:

1. Review current statistics on the prevalence of STIs/STDs in the U.S. today.

2.

Learn what oral manifestations are connected to the most common STIs/STDs.

3.

Identify additional symptoms of STIs that dental professionals should be able to detect.

4. Understand how oral manifestations can indicate various stages of a STI/STD.

5.

Recognize patients that need a referral if showing symptoms in the oral cavity.

CLINICAL CATEGORY: Infection Control

CE ACTIVITY: Online/Self-Instructional

NUMBER OF CREDITS: 2 Credits

TOTAL COST: $20.00

PUBLISH DATE: April 17, 2013

EXPIRATION DATE: April 17, 2016

SPONSORED BY

http://www.richmondinstitute.com/dr-louis-g-depaola-dds-mshttp://www.biotrol.com/http://www.richmondinstitute.com/dr-louis-g-depaola-dds-ms


2/16

COURSE CONTENT: The information and opinions contained in this CE course are those of the author, and do n

necessarily reflect the views of The Richmond Institute for Continuing Dental Education, or its affiliates. Any brand o

product name mentioned throughout this course should not be inferred as an endorsement of any kind by th

aforementioned parties. In addition, The Richmond Institute does not warrant or make any representations concernin

the accuracy or reliability of the materials on this website, or any site(s) that are linked to richmondinstitute.com.

CONFLICT OF INTEREST: Dr. DePaola has received research support from Colgate® and serves as a consultant f

Biotrol™, Colgate®, Dentsply, Johnson and Johnson, and The Richmond Institute. The Richmond Institute fo

Continuing Dental Education is a division of Young Innovations, Inc. It is dedicated to ensuring that its continuin

dental education programs are intended for the sole purpose of education and do not serve as an endorsement for an

product(s) or service(s), including those of the sponsoring company.

FEEDBACK AND QUESTIONS: After the course has been completed, an evaluation form will be emailed to the us

to provide valuable feedback on the information just presented. If you have additional feedback, questions for th

author, or need technical assistance please email [email protected].

SCORING: To earn credit for a course from The Richmond Institute for Continuing Dental Education, participan

must earn an overall score of 80 percent or above on the associated exam before receiving a certificate that confirms C

accreditation. (*NOTE: There is no limit to the number of times a participant may re-take the exam in order to obtaithis passing score). All courses that are published on this site are categorized as self-instructional— which mea

participants must complete the course on their own time and submit the accurate payment in order to earn CE credit.

PAYMENT POLICY: As of October 1, 2011, participants must pay online before taking the exam for any course liste

on this website to receive verification of CE credit. No other form of payment will be accepted. Expenses must be pa

with a valid credit card; acceptable forms include: Visa, MasterCard, Discover, or American Express. The Richmon

Institute can only accept payments from individuals who live and/or practice in the United States or select U.

Territories. Course material may not be resold or republished for any commercial purposes acknowledgement from Th

Richmond Institute.

CANCELLATION/REFUND POLICY: All courses purchased from this website are final and non-refundable.

STATE DENTAL PRACTICE ACT: It is the responsibility of the participant to adhere to all laws and regulation

proposed by the state that he or she is licensed to practice in. The Richmond Institute and its authors are no

responsible for the participants’ use or misuse of the techniques and procedures discussed in this course.

LIMITED KNOWLEDGE RISK: The information provided in this course may not be comprehensive enough f

implementation into professional dental practice. It is highly recommended that additional information be attaine

once the course is completed to establish greater proficiency on the topic at hand.

The Richmond Institute for Continuing Dental Education is an ADA CERP Recognized Provider. ADA CERP is a

service of the American Dental Association to assist dental professionals in identifying quality providers of continuing

dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply

acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the

provider or to ADA CERP at www.ada.org/goto/cerp.

http://www.richmondinstitute.com/http://www.richmondinstitute.com/http://www.richmondinstitute.com/http://www.zoomerang.com/Survey/WEB22DW584TA6Shttp://www.zoomerang.com/Survey/WEB22DW584TA6Smailto:[email protected]:[email protected]:[email protected]://www.ada.org/goto/cerphttp://www.ada.org/goto/cerphttp://www.ada.org/goto/cerphttp://www.ada.org/goto/cerpmailto:[email protected]://www.zoomerang.com/Survey/WEB22DW584TA6Shttp://www.richmondinstitute.com/


3/16

INTRODUCTION

Disease transmission has been a significant concern in oral

healthcare for as long as the dental profession has been around.

With so many infectious diseases that can spread from one patient

to another, the need for dental practitioners to comply with the

latest infection control protocols cannot be stressed enough.

Moreover, the ability to identify these diseases is just as important

since patients may not even be aware that they have an infection.

Coincidentally, over 90% of systemic conditions have oral manifestations, so this gives dent

professionals a unique opportunity to diagnose and prevent those conditions from spreading t

other individuals. This course highlights this transmission in the dental office, with a special focu

on the oral implications of sexually transmitted infections, which are some of the most prevalen

diseases in the world today.

Overall, diseases can be transmitted a number of different ways both inside and out of the denta

operatory; typically, they are spread from one person to the next through the following forms o

contact:

direct contact with a pathogen OR indirect contact with a contaminated object/surface

droplet or splatter contact from an infected person through coughing, sneezing

inhalation of airborne microorganisms (able to remain in the air for long periods of time)

In addition, sexual activity is another way that diseases can be transmitted from one individual t

the next. This activity puts both partners at risk for coming in direct contact with infectepathogenic microorganisms. Unfortunately, sexually transmitted diseases (STDs) are as old a

mankind. They were reported in considerable numbers in ancient civilizations, and were referred t

as venereal diseases (VD) derived from the Latin Veneris (Venus)—the Roman goddess o

love. Social disease has evolved to be a more polite euphemism for an STD. However, new disease

such as HIV and HPV have emerged, which are efficiently transmitted through sexual contact. Onc

infected, a person can spread the infection to his/her sexual contacts without having any overt sign

of the disease, since the signs and symptoms may not be detectable for weeks, months, years or eve

decades.

Therefore, the term sexually transmitted infection (STI) has become the accepted term for andisease/infection transmitted human-to-human through various forms of sexual activity. Th

diseases that are transmitted almost exclusively from sexual activity include: HIV, syphili

gonorrhea, chlamydia, human papillomavirus (HPV), human herpes viruses, and numerous othe

infections. Many other infectious diseases—including the common cold, influenza, pneumonia, an

other viral/bacterial infections—are sometimes inadvertently transmitted during sexual contact a

well. However, since they are also transmitted through nonsexual contact, these types of infection

are not considered STIs.


4/16

STIs IN THE UNITED STATES

According to data reported from every state and territor

(including the District of Columbia), the CDC estimates tha

there are about 20 million new diagnoses of STIs in the US

each year—costing the American healthcare system near

$16 billion in direct medical costs.1-5 It is estimated that ove

110 million men and women are currently infected with aSTI in the US today, although this figure does not includ

the 50,000 new infections of HIV that are also diagnosed i

this country every year.4-7

Young adults shoulder the most responsibility for the spread of these infections in the United State

The CDC estimates that half of all new STIs in the country occur among young men and wome

between the ages of 15 and 24, with an almost equal dispersion of these diagnoses among men an

women (49% and 51%, respectively).4-7 To further complicate the issue, a single person can be—an

often is—infected with multiple STIs at one time. Each infection presents a potential threat to bot

the immediate and long-term health and well-being of the infected individual. More importantly,

STIs are not diagnosed and treated in a duly timeframe, the STIs can easily spread to uninfected se

partners.4-7

STIs are transmitted in a number of ways. Whenever there is unprotected sexual contact and/or a

exchange of body fluids (regardless of the type of sexual activity the individual engages in), there is

risk he/she will transmit an STI to the other partner. This risk increases if a break or tear occur

within the mucous membrane of the oral, vaginal or peri-anal tissues, which readily facilitates th

disease to be passed from the infected person to the next.

Table 1 illustrates the U.S. incidence rate and age distribution for these diseases:

hepatitis B virus (HBV)

human immunodeficiency virus (HIV)

syphilis

herpes simplex virus type 2 (HSV-2)

gonorrhea

trichomoniasis

chlamydia

human papillomavirus (HPV).

(see Table 1 on following page)


5/16

ORAL MANIFESTATIONS OF STIs

While the mucous membranes of the oral cavity, the peri-anal area, and the genitalia of both sexe

perform different functions, they are also very similar in many ways. Mucous membranes are lining

of mostly endodermal origin, and are covered in epithelium, which assist in the process o

absorption and secretion; moreover, they line cavities that are exposed to the both the extern

environment, and internal organs.

The glans clitoridis, glans penis, and the inside of the foreskin, as well as the clitoral hood, are a

mucous membranes. Urethral, endometrium (or uterine) mucosa, oral/buccal mucosa, and the nas

mucosa are also all considered mucous membranes. Because of the similarities between the genita

oral and peri-anal mucous membranes, many STIs have oral manifestations.

SYPHILIS

Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum.8 Th

history of syphilis goes as far back as medieval times, when the disease was also know

as Pox or Lues. The bacterium, T. pallidum, was first identified by Schaudinn and Hoffmann i

1905; a year later, August von Wassermann devised the first serum reaction test for syphilis. Wit

this test, a diagnosis for syphilis could be made, but unfortunately there was no effective treatmen

until the discovery of sulfonamides and penicillin in the late 1930’s. 8 The prevalence of syphilis i

http://www.richmondinstitute.com/wp-content/uploads/2013/04/Table-1.png


6/16

the U.S. at that time was estimated from 5% to 10% of the entire public, with rates up to 25% amon

lower socioeconomic groups.8

Prior to the discovery of penicillin, syphilis was a major global public health problem — analogou

with the human immunodeficiency virus (HIV) of today. If undiagnosed and untreated, syphil

could cause long-term complications and/or death, and was associated as the major cause o

neurologic, cardiovascular, and perinatal morbidity and mortality at that time.8 While the rates o

syphilis have significantly reduced in the post-antibiotic era, it is still a commonly occurring STamong the population today. The CDC estimates that about 55,400 new syphilis infections occur i

the USA every year. 8 However, in 2011, there were only 46,042 reported new cases, 13,970 of whic

were primary and secondary (P&S) syphilis— which constitute the earliest and most transmissib

stages of syphilis.8

During the 1990s, syphilis most often occurred among heterosexual men and women of racial an

ethnic minority groups.8 Within 10 years, cases increased among men who have sex with me

(MSM), and by 2002, the rates of P&S syphilis were highest among men 30 to 39 years

old.8 However, by 2011, P&S syphilis were highest among men 20 to 29 years of age, with

noticeable increase in disease acquisition among young MSM, who accounted for 72% of all P&syphilis cases in 2011.8 The average time between infection with syphilis and the onset of the fir

symptom is 21 days, but can range from anywhere between 10 and 90 days.8,9

Syphilis has been divided into primary, secondary and latent (previously referred to as tertiary

stages.8,9 The organism is transmitted from the primary lesion (known as the chancre), whic

initiates the primary stage of syphilis after T. pallidum has entered the body.8,9 The chancre usual

presents itself as a firm, round, small, yet painless ulceration that appears at the site of the infection

This lesion is usually singular, but considering the fact that syphilis often referred to as the grea

mimic, it can present itself with many different appearances, so multiple lesions may occur. Thchancre can occur anywhere on the external genitals, vagina, anus, or in the rectum.8,9 Chancres als

appear in the peri-oral area (most commonly on the lips, tongue and oral mucosa); see Figure 1.

http://www.richmondinstitute.com/wp-content/uploads/2013/04/Figure-1.png


7/16

The primary stage of syphilis usually lasts three to six weeks, while the chancre can hea

spontaneously with or without antibiotic therapy.8,9 However, if no treatment is administered, th

infection will progress to the secondary stage, prompting the widespread dissemination of T

pallidum to initiate systemic manifestations. This stage of syphilis (sometimes referred to a

the mucous patch stage) is heralded by the development of skin rashes and/or mucous membran

lesions on the face, genitalia, anus, or inside the mouth. Lesions can occur on one or multiple sites o

the body, including the oral and peri-oral areas (Figures 2 & 3 below).8,9

These rashes may appear as the chancre is healing, or may be delayed several weeks after the healin

process has completed. The characteristic rash of secondary syphilis is maculo-papular (flat an

slightly bumpy).8,9 It may appear as being rough, red, or having reddish-brown spots on either th

palms of the hands and/or the bottoms of the feet, which is a unique characteristic of this diseas

and several others (Figure 2).8,9 However, a rash is still a common symptom of many oth

diseases, which can make the diagnosis difficult. Sometimes rashes associated with secondar

syphilis are so faint that they are not noticeable.

http://www.richmondinstitute.com/wp-content/uploads/2013/04/Figure-3.pnghttp://www.richmondinstitute.com/wp-content/uploads/2013/04/Figure-2.png


8/16

Other symptoms of secondary syphilis may include:8-9

fever

swollen lymph glands

sore throat

patchy hair loss

headaches

weight loss

muscle aches

fatigue

As with the primary stage, the symptoms of secondary syphilis can resolve with or withou

treatment, although the lesions themselves are considered infectious, and may be transmitted t

anyone who has direct contact with a person in these first or second stages of the disease. If thperson still does not seek treatment after those symptoms have subsided, the infection will the

progress to the latent stages of the disease. Latent syphilis can appear 10 to 20 years after th

infection was first acquired, and can cause serious damage to the internal organs, including th

brain, nerves, eyes, heart, blood vessels, liver, bones, and joints.8,9 If left untreated at this stag

death could surely ensue.8

GONORRHEA

Another bacterial STI of concern is Gonorrhea, which is caused by the infection known as Neissergonorrhoeae. This organism infects the mucous membranes of the reproductive tract, including th

cervix, uterus, and fallopian tubes in women, and the urethra in women and men. It can also infec

the mucous membranes of the mouth, throat, eyes, and anus. In the USA, 820,000 people ar

infected with new gonorrheal infections every year; globally there are 88 million new cases per yea

There is great concern over the fact that more than half of these infections reported to CDC occu

mostly in young people 15 to 24 years-of-age. Gonorrhea is transmitted through sexual contact wit

the penis, vagina, mouth, or anus of an infected partner, and may also be spread prenatally from

mother to baby during childbirth.

When symptomatic, signs of urethral infection in males will include dysuria, or a white, yellow, ogreen urethral discharge that usually appears 1 to 14 days after infection. Most women wit

gonorrhea are asymptomatic, and an increasing number of men are as well, which increases the ris

of secondary transmission, and the development of serious complications that can result i

significant morbidity and mortality. Additionally, untreated gonorrhea infections can increase th

risk of acquiring or transmitting HIV disease. From an oral health standpoint, gonorrhea may infe

the pharynx; although it is usually asymptomatic, it can cause symptoms of a sore throat and/o

dysphagia. Unfortunately, these lesions are rare, and when presented, often go unrecognized.


9/16

HIV DISEASE

Since the first reports of this new infection in 1981, every country in the world has reported cases of

HIV/AIDS.

By the end of 2011, the following statistics were reported about this disease:

Around the world, 34 million people have been diagnosed with HIV.

30 million deaths have been reported worldwide by this disease.

1.7 million people died from AIDS-related illnesses in 2011 alone.7

In the USA, the CDC estimates that 1,148,200 persons aged 13 years and older are living

with the HIV infection, including 207,600 (18.1%) who are unaware of their infection.11

The CDC estimates that approximately 50,000 people are newly infected with HIV each

year.11

In 2010, there were an estimated 47,500 new HIV infections.11 Nearly two thirds of these

new infections occurred in MSM.

African American men and women were estimated to have an HIV incidence rate that was

almost eight times higher than the incidence rate among whites.11

An estimated 15,529 people with an AIDS diagnosis died in 2010.

Altogether, approximately 636,000 people in the USA with an AIDS diagnosis have died

since the beginning of the epidemic.11

The routes of transmission of HIV are well documented and include the following:

Unprotected sexual contact (regardless of sexual preference).

Sharing needles, syringes, rinse water, or other equipment to prepare illicit drugs for

injection. Although very rare, HIV may also be transmitted through unsafe or unsanitary

injections or other medical or dental practices.

Having parenteral, mucous membrane, or non-intact skin contact with HIV-infected blood

blood components, or blood products.

Receiving transplants of HIV-infected organs and tissues, including bone, or transfusions o

HIV-infected blood.

Perinatal transmission from mother to child around the time of birth; HIV can also be

transmitted from mother to child during pregnancy, birth, or breast-feeding.

Although HIV can be transmitted by any of the above, sexual transmission accounts for the majorit

of cases on a global basis. HIV selectively infects and reproduces in critical immune cells known a

CD4 cells.12 In this complex process, the CD4 cell is killed— which releases new virions of HIV tha


10/16

infect more cells—and allow the virus to propagate throughout the body. The killing of CD4 cell

directly translates to a gradual decline in overall immune functionality.12 The diagnosis of AIDS

made when the CD4 count falls below 200, and/or the individual shows one or more symptoms o

the AIDS Defining Illness checklist.12

With a declining immune system, other infections will soon develop, and eventually the patient wi

succumb from one or more of them.12 If antiretroviral therapy is not implemented, the amount o

time between the onset of infection and death is approximately 10 years.12

However, considerabprogress has been made in the medical management of HIV disease, so when a patient is complian

with the appropriate antiretroviral regimens, he or she has a life expectancy similar to that of a non

HIV infected individual.12 While there are numerous oral manifestations of HIV disease, th

discussion will focus on the most frequent fungal and viral infections.

ORAL CANDIDIASIS

Oral candidiasis (OC) is the most common lesion among patients with HIV. The most commo

organism causing this infection isCandida albicans; however, other species such as C. glabrata, C

tropicalis, C. krusei, C. kefyr, and C. dubliniensis have been reported to cause it as well. 12-16 OC ca

occur in four different forms of an HIV infection: pseudomembranous, erythematous, hyperplast

and angular cheilitis.12-16 Pseudomembranous candidiasis presents itself as white or yellowish spo

or plaques on the palate, tongue, or oral mucosa that can be wiped off and leave a raw, bleedin

surface (Figure 4).12-16

Erythematous candidiasis presents itself as red, atrophic areas, usually on the palate or dorsum o

the tongue (Figure 5).12-16 Angular cheilitis presents itself as cracking, fissuring and ulceratin

angles in the mouth, while hyperplastic candidiasis presents itself as a thick white plaque that doe

not rub off.12-16



11/16

In the presence of HIV infection, numerous viral infections cause oral manifestations. Herpe

simplex virus infection is commonly encountered in either the oral cavity, genitalia, o

both.17 Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruse

type 1 (HSV-1)—commonly referred as oral herpes—or type 2 (HSV-2), which is commonly referre

to as genital herpes.17 Approximately 776,000 people in the USA get new herpes infections eac

year, and about 16.2% of people aged 14 to 49 years have the HSV-2 infection.17

Infection is more easily transmitted from men to women than from women to men, which probabl

accounts for a higher rate of HSV-2 infections among women than men. 17 HSV-1 and HSV-

infections are transmitted through contact with lesions, mucosal surfaces, genital secretions, or ora

secretions, although asymptomatic shedding can also occur. 17 HSV-1 and HSV-2 lesions loo

identical, and cannot be distinguished based on clinical presentation or location; moreover,

eithecan appear in the oral cavity or on the genitalia.17

Most cases are asymptomatic, or have very mild symptoms that go unnoticed, which results in 81.1%

of infected individuals being unaware of their infection.17 Symptomatic lesions typically appear a

one or more vesicles on or around the genitals, rectum or mouth.17 The vesicles then ruptur

creating painful ulcers that form a crust (scab), but heal in two to four weeks without leaving

scar (Figure 6 & 7).17 Recurrent outbreaks of oral and/or genital herpes are common.



12/16


13/16

Kaposi’s sarcoma (KS) is a malignant neoplasm of the blood vessels, and is strongly associated wi t

human herpesvirus-8 (HHV-8)— which is also referred to as Kaposi’s Sarcoma-Associate

Herpesvirus (KSAH).12-16 A gene of HHV-8 promotes spindle cell proliferation and angiogenesi

and it is thought that this may eventually lead to neoplasia. The virus is shed in virtually all bod

fluids, and is associated with sexual contact and the overall number of partners.12-16 An unknown co

factor may be involved in transmission, however, immunosuppression (HIV disease) must b

present to cause KS.12-16

Prior to the introduction of effective antiretroviral regimens, KS was a common neoplasm, occurrin

in approximately 15% to 20% of the patients with AIDS.12-16 Although appearing less frequently, K

does still often present itself in the oral cavity and/or the peri-oral areas.12-16 Lesions initial

present themselves as blue, red, or purple macules on the palate, gingival, and/or tongue. 12-16 Thes

lesions may be very subtle and difficult to see, especially in patients with significant racia

pigmentation.12-16 The lesions may become raised and nodular, with extensive ulceration, bleedin

and pain (Figure 8).12-16 Any suspicious lesions should be referred for a biopsy to provide

definitive diagnosis.

HUMAN PAPILLOMAVIRUS (HPV)

Human Papillomavirus (HPV) is the most common STI in the world. 18,19 So far, over 60 strains hav

been identified, and at least 50% of sexually active people are at one time or another infected with



14/16

least one strain of HPV.18,19 Although the virus infects men and women equally, women are mor

likely to present symptoms of this disease.18 HPV is the causal agent of cervical cancer, which is th

second leading cause of death among women worldwide.18,19 Although most women are infecte

upon the initiation of sexual activity, only 1% to 5% of women infected with HPV will develo

malignancies.18,19 Virtually, all cervical cancers are caused by the HPV infection, with HPV types 1

and 18 causing about 70% of all cases—as well as close to half of vaginal, vulvar, and peni

cancers.18,19

Most recently, HPV infections have been found to cause cancer of the oropharynx— which include

the soft palate, the base of the tongue, and the tonsils. 18,19 In the US, more than half of the cance

diagnosed in the oropharynx are linked to HPV-16, and the incidence of HPV-associate

oropharyngeal cancers has increased during the past 20 years, especially among men.18,19 It has bee

estimated that by 2020, HPV will cause more oropharyngeal cancers than cervical cancers in th

US.19 Other strains of HPV are responsible for condyloma accuminatum (venereal warts), and

variety of other warty lesions, which are especially common in the oral and genital mucosa of HIV

infected persons.18,19 At least 17 different HPV DNA types have been detected in oral mucosa

lesions; the most common of which included HPV DNA subtypes: 2, 6, 11, 13, 32 and 57. 15,18,19 Or

HPV presents itself as one or more soft, pink pedunculated, or sessile, masses that have cauliflower-like surface (Figure 9).15 The lip, gingival, palate, and tongue are the most preferre

sites, overall.15



15/16


16/16

12. Bartlett JG, Gallant JE and Pham PA, Medical Management of HIV Infection, 2012 Edition, Knowledge SourceSolutions, Durham, North Carolina.

13. Silverman S, Eversole LR and Truelove EL. Essentials of Oral Medicine, 2002, BC Decker, Inc. Hamilton, Ontario.

14. Little JW, Falace DA, Miller CS and Rhosus NL. Dental Management of the Medically Compromised Patient,7th Edition, 2008, Mosby Elsevier, Saint Louis, Missouri.

15. DePaola L & Silva A: HIV infection/AIDS, Oral Care in Advanced Disease. Edited by Davies & Finlay, February,2008, Oxford University Press, UK.

16.

DePaola LG and Meeks VI. Human Immunodeficiency Virus, Acquired Immunodeficiency Syndrome, and RelatedInfections; Chapter 3, In Cottone’s Practical Infection Control in Dentistry, 3rd Edition, Lippincott Williams &

Wilkins, Philadelphia, 2008.

17. Centers for Disease Control and Prevention. Genital Herpes – CDC Fact Sheet. Updated February,2013.http://www.cdc.gov/std/Herpes/STDFact-herpes-detailed.htm.

18.

Centers for Disease Control and Prevention. Genital HPV Infection – Fact Sheet. Updated March, 2013.http://www.cdc.gov/std/HPV/STDFact-HPV.htm.

19. National Institutes of Health, National Cancer Institute. HPV and Cancer, Reviewed March,2012,http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
http://www.cdc.gov/std/Herpes/STDFact-herpes-detailed.htmhttp://www.cdc.gov/std/Herpes/STDFact-herpes-detailed.htmhttp://www.cdc.gov/std/Herpes/STDFact-herpes-detailed.htmhttp://www.cancer.gov/cancertopics/factsheet/Risk/HPVhttp://www.cancer.gov/cancertopics/factsheet/Risk/HPVhttp://www.cancer.gov/cancertopics/factsheet/Risk/HPVhttp://www.cancer.gov/cancertopics/factsheet/Risk/HPVhttp://www.cdc.gov/std/Herpes/STDFact-herpes-detailed.htm

Documents

Oral Manifestations PDF Draft 1 Apr 16 2013