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SCIENCE: Signs of measles may appear in oral cavity before other manifestations of disease

March 02, 2015

By Jean Williams

Measles
Clinical case: Koplik spots indicate measles inside a mouth. Because the disease shows up in the head and neck region and/or the mouth first, a patient may head to the dentist for care

 

Polio. Tuberculosis. Whooping cough.

In the 20th century, thanks to vaccines and drugs, these diseases were under control in the U.S. But the needle is moving again on infections worldwide among certain thought-to-be-contained diseases. One of them is measles.

The first signs of measles occur typically in the head and neck region and in the oral cavity. But some dentists may not have had the occasion to actually see these signs due to years of successful control of the disease.

Dr. Flaitz
Dr. Flaitz

“It’s been rare among oral diseases,” said Dr. Catherine Flaitz, a spokeswoman for American Academy of Pediatric Dentistry. “All of a sudden, this viral infection has resurfaced. In the past, we educated our students about this disease with the caveat that it is unlikely that they will diagnose a case among their patients. And now with this lack of universal vaccination, we’re beginning to see these oral manifestations present themselves again.”

Measles outbreaks have been reported in pockets around the country. Officials traced a California outbreak to a popular theme park. In a Jan. 23 health advisory on its website, the Centers for Disease Control and Prevention said of that incidence, “The United States is experiencing a large multi-state measles outbreak that started in California in December 2014 and has spread to six additional states and Mexico. The initial confirmed case-patients reported visiting Disneyland Resort Theme Parks in Orange County, CA, from December 17 through December 20, 2014.”

Later in February, five babies reportedly acquired the disease at a suburban Chicago daycare center. In the backdrop of the outbreaks, a national debate rages on between pro- and anti-vaccination components.

In the wake of the Disneyland outbreak, the California Dental Association began issuing advisories on its website to remind members to be vigilant, including information about reducing risk to aerosol transmissible diseases and sharing recommendations from the California Department of Public Health that health care workers get the measles, mumps and rubella combination vaccination, if they have not already been immunized.

Meanwhile, Dr. Flaitz advises dentists to be prepared in the event a patient shows up with certain signs and symptoms of the disease. Because the disease presents in the head and neck region and/or the mouth first, a parent may head to the dentist for care, Dr. Flaitz said.

“I’m a pediatric dentist and an oral and maxillofacial pathologist,” she said. “So I see a number of children who have viral infections, and you never know what gets them in the front door. It may be that the child’s running a fever, but it’s not so high. But then the parents look inside the mouth and they see these sores, so they assume that these sores are actually the cause for the fever. Sometimes they will go with a fever straight to their primary health care provider, such as a pediatrician, who notices the oral problems and makes the referral to the dentist. But other times, if there are sores or irritations that are present in the mouth, they may seek the advice of the dentist first.”

Dr. Flaitz described three main signs in the oral cavity indicative of measles: Koplik spots; atypical gingivitis with pustules and necrosis; and operculitis.

“Some of these signs and symptoms are subtle,” she said. “So it’s very important to do a thorough soft tissue examination along with the dental examination. Lots of times, a number of these oral lesions are the first indication that a person has either an infectious disease or an underlying systemic disease. Sometimes this is the very first sign besides maybe more nondescript findings, such as a fever.”

Other signs and symptoms can help dentists recognize patients with undiagnosed measles.

“They typically at this time, too, will have a high fever, often 104 or greater,” Dr. Flaitz said. “They also will have malaise; they don’t eat well; they are very fussy. Those are the primary, nondescript signs and symptoms that they may have.”

Dr. Flaitz said dentists should note, too, the three Cs in the head and neck region: conjunctivitis, coryza and cough. “Photophobia, periorbital swelling and myalgia may be concurrently seen,” she said. “This is followed by an itchy, red rash that starts on the face and then moves down the neck to the rest of the body.”

As outbreaks continue, dentists should brush up on all potential signs and symptoms for measles in the head and neck region and the oral cavity, Dr. Flaitz advises.

The ADA Center for Professional Success offers additional guidance on measles for dental professionals. See “Infectious Disease and Workplace Liability” at Success.ADA.org.