Chapter 13: Sexually Transmitted Diseases

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1

What are STDs?

sexually transmitted diseases

2

What are the four most prevalent reportable bacterial STDs?

  1. chlamydia
  2. gonorrhea
  3. trichomoniasis
  4. syphilis
3

What are the four most prevalent viral STDs?

  1. human papillomavirus (HPV)
  2. herpes simplex virus (HSV)
  3. hepatitis B virus (HBV)
  4. human immunodeficiency virus (HIV)
4

What is the causative agent of gonorrhea?

Neisseria gonorrhoeae

5

What is the primary mode of transmission of Neisseria gonorrhoeae?

sexual contact

6

What are the primary sites of infection in gonorrhea? (4)

  1. urethra
  2. cervix
  3. rectum
  4. oropharynx
7

How does risk for gonorrhea vary between men and women?

More cases are reported in men.

8

What type of bacteria is Neisseria gonorrhoeae?

It is an aerobic gram-negative diplococci.

9

How do different types of epithelium vary in their susceptibility to N. gonorrhoeae?

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Both columnar (urethra and cervix) and transitional (pharynx and rectum) epithelium are highly susceptible; stratified squamous epithelium (skin and oral cavity) is relatively resistant.

10

What is the incubation period for urethral gonorrhea infection in men?

2 to 5 days

11

What are the symptoms of acute urethral gonorrhea infection in men? (3)

  1. urethritis
  2. purulent discharge
  3. dysuria
12

What is the incubation period for gonorrhea infection in women?

5 to 10 days

13

What are the symptoms of urethral gonorrhea infection in women?

Most cases are asymptomatic.

14

What complication of urethral gonorrhea infection in women may contribute to tubal scarring, leading to infertility or ectopic pregnancy?

pelvic inflammatory disease (PID)

15
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A patient presents with:

  1. erythematous oropharynx
  2. enlarged palatine tonsils
  3. yellowish exudate
  4. cervical lymphadenopathy

What is a possible diagnosis?

oropharngeal gonorrhea

16

What three diagnostic methods are used for gonorrhea testing?

  1. Gram stain
  2. culture
  3. nucleic acid amplification testing (NAAT)
17

What is an appropriate test for N. gonorrhoeae in symptomatic patients with purulent discharge?

card image

gram stain

18

What is an appropriate test for N. gonorrhoeae, for both symptomatic and asymptomatic patients?

nucleic acid amplification testing (NAAT)

19

What organism is often tested for along with N. gonorrhoeae due to its high likelihood for co-infection?

Chlamydia trachomatis

20

What is an appropriate test for N. gonorrhoeae in patients who have received an antimicrobial regimen and yet have a persistent NAAT-positive result?

culture

21

Why is dual therapy recommended for gonorrhea?

Due to antibiotic resistance of N. gonorrhoeae.

22

What is the recommended treatment for gonococcal infection of the cervix, urethra, pharynx, or rectum in adults? (2)

  1. ceftriaxone 250 mg IM, and;
  2. azithromycin 1 g PO
23

What is the recommended treatment for uncomplicated gonococcal infection when ceftriaxone is unavailable? (2)

  1. cefixime 400 mg PO, and;
  2. azithromycin 1 g PO
24

What is the recommended treatment for uncomplicated gonococcal infection for patients with a cephalosporin allergy? (2)

  1. gemifloxacin 320 mg PO, and;
  2. azithromycin 2 g PO, or;
  3. gentamicin 240 mg IM, and;
  4. azithromycin 2 g PO
25

What is the risk of disease transmission in a patient with a recent gonorrhea infection that has been treated with antibiotic therapy?

The risk is low; patients in this category can receive dental care within days of antibiotic treatment.

26

What is the causative agent in syphilis?

Treponema pallidum

27

What are the four stages of syphilis?

  1. primary
  2. secondary
  3. latent
  4. tertiary
28

What is the primary site of syphilitic infection?

genitalia

29

Why is syphilis a particularly important STD?

Because of the morbidity it can cause.

30

How does risk for syphilis vary between men and women?

It affects more than ten times more men.

31

What type of bacteria is Treponema pallidum?

It is a fragile microaerophilic spirochete.

32

What is the primary mode of transmission of Treponema pallidum?

sexual contact

33

How does the risk of transmission vary based on the stage of syphilis?

Transmission can occur during the primary, secondary, and early latent stages, but not in late stages.

34

When are patients with syphilis most infectious?

During the first 2 years.

35

What is the characteristic manifestation of primary syphilis?

chancre

36
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A patient presents with a painless ulceration covered by a yellowish crust. What is a possible diagnosis?

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This is a chancre of primary syphilis.

37

How soon after exposure to Treponema pallidum does the chancre appear in syphilis?

2 to 3 weeks

38

How long does it take for the chancre of primary syphilis subside without treatment?

3 to 6 weeks

39

How long after initial exposure to Treponema pallidum do the manifestations of secondary syphilis appear?

6 to 8 weeks

40

What is the most common extragenital site for chancres in primary syphilis?

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oral cavity

41
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A patient presents with:

  1. fever, malaise, headache
  2. lymphadenopathy
  3. patchy hair loss
  4. maculopapular rash
  5. warty oral lesions

What is a possible diagnosis?

secondary syphilis

42

What are the warty lesions that may affect the genitalia or oral cavity in secondary syphilis called?

condyloma lata

43

What is a rare and severe manifestation of secondary syphilis in immunocompromised patients?

lues maligna

44

Why are the lesions of the skin and mucous membranes in secondary syphilis of particular concern?

Because they are highly infectious.

45

What are the manifestations of latent syphilis?

Patients in this stage are seroreactive but asymptomatic.

46

What are the two stages of latent syphilis?

  1. early latent syphilis (infected <1 year ago)
  2. late latent syphilis (infected >1 year ago)
47

Are patients with latent stage syphilis infectious?

During the first 4 years of latent syphilis, patients may have relapses and are infectious; after 4 years, relapses are rare, and patients are noninfectious.

48

What are the two possible outcomes of latent stage syphilis?

It may last for many years (up to the remainder of the person's life) or it may progress to tertiary syphilis.

49

What percentage of cases of latent syphilis progress to tertiary (late) stage?

10% to 40%

50

What are the three subtypes of tertiary syphilis?

  1. neurosyphilis
  2. cardiovascular
  3. gummatous disease
51

A patient with tertiary syphilis presents with:

  1. meningitis-like syndrome
  2. altered tendon reflexes
  3. general paresis
  4. impaired coordination
  5. insanity

What subtype of tertiary syphilis is this?

neurosyphilis

52

What are Argyll Robertson pupils?

Pupils that react to accommodation but not to light; associated with neurosyphilis.

53

What is tabes dorsalis?

Degeneration of dorsal columns of the spinal cord and sensory nerve trunks; associated with neurosyphilis.

54

A patient with tertiary syphilis presents with:

  1. obliterative endarteritis
  2. aortic stenosis
  3. aortic aneurysm

What subtype of tertiary syphilis is this?

cardiovascular syphilis

55

What is the classic localized lesion of tertiary syphilis?

gumma

56

What is a gumma?

A noninfectious, inflammatory granulomatous lesion with a central zone of necrosis, though to be the result of a hypersensitivity reaction.

57

Which subtype of tertiary syphilis is characterized by the gumma?

gummatous disease

58

Where do gummas occur in tertiary syphilis? (4)

  1. skin
  2. mucous membranes
  3. bone
  4. organs
59

What is can result if a mother is infected with Treponema pallidum while pregnant?

congenital syphilis

60

A 1-year old baby presents with the following:

  1. hepatomegaly
  2. hematologic abnormalities
  3. maculopapular rash
  4. condylomata lata
  5. osteochondritis

What is a possible diagnosis?

early stage congenital syphilis

61

What is Hutchinson's triad?

  1. interstitial keratitis of the cornea
  2. eighth nerve deafness
  3. dental abnormalities

Associated with late stage congenital syphilis.

62

What is the traditional two-step testing algorithm used to diagnose syphilis?

  1. nontreponemal “screening” test
  2. confirmatory specific treponemal test
63

What are the nontreponemal tests used for detecting syphilis? (2)

  1. Venereal Disease Research Laboratory (VDRL) test
  2. rapid plasma reagin (RPR) test
64

What is the basis for the nontreponemal tests for syphilis?

They detect an antibody-like substance called reagin, which is a surrogate for the immunologic response to a syphilis infection.

65

The initial test nontreponemal test for syphilis qualitative. What is performed if it is positive?

A quantitative step that generates “titers” values reported as serologic dilutions (e.g., 1 : 2, 1 : 4, 1 : 8).

66

When do patient with syphilis yield the highest titers?

Between 3 and 8 weeks after the appearance of the primary chancre.

67

What type of change in titers signifies a clinically meaningful change in serial test results for syphilis?

A fourfold change (e.g. 1 : 4 to 1 : 16 or 1 : 32 to 1 : 8).

68

What long does it take for nontreponemal test results to revert to negative following successful treatment of primary syphilis?

within 12 months

69

What long does it take for nontreponemal test results to revert to negative following successful treatment of secondary syphilis?

up to 24 months

70

What long does it take for nontreponemal test results to revert to negative following successful treatment of tertiary syphilis?

Many patients remain seropositive for life.

71

What are the treponemal tests used for detecting syphilis? (3)

  1. fluorescent treponemal antibody absorption test (FTA-ABS)
  2. T. pallidum particle agglutination assay (TPPA)
  3. T. pallidum hemagglutination assay (TPHA)
72

What is the advantage of treponemal tests for syphilis?

They are highly specific.

73

What is the disadvantage of treponemal tests for syphilis

They cannot differentiate between current and past infection because antibodies remain positive in most patients.

74

What is the recommended treatment for primary, secondary, or early latent syphilis in adults?

penicillin G 2.4 million IU IM

75

What is the recommended treatment for primary, secondary, or early latent syphilis in children or infants?

penicillin G 50,000 IU/kg IM

76

What is the recommended treatment for late latent or tertiary syphilis in adults?

penicillin G 2.4 million IU IM once a week for 3 weeks

77

What is the recommended treatment for neurosyphilis or ocular syphilis?

  1. penicillin G 18 to 24 million IU IV, or;
  2. penicillin G 2.4 million IU IM sid x 10-14 d, and;
  3. probenecid 500 mg PO qid x 10-14d
78

What is the recommended treatment for syphilis in patients allergic to penicillin?

  1. doxycycline 100 mg PO bid x 2 weeks, or;
  2. tetracycline 500 mg PO qid x 2 weeks
79

What is the Jarisch-Herxheimer reaction?

An acute febrile reaction accompanied by chills, myalgias, and headache that may occur within 24 hours after initiation of antibiotic therapy for syphilis.

80

What is the risk of disease transmission in a patients with untreated primary and secondary syphilis?

These patients are infectous; lesions, blood, and saliva are all possible means of transmission.

81

What is the risk of disease transmission in a patients who are currently being treated or who have been treated and remain seropositive?

These patients are potentially infectious; necessary dental care may be provided with standard precautions.

82

What are the oral manifstations of syphilis? (3)

  1. oral chancres
  2. grayish mucous patches
  3. oral gumma (rare)
83

What is a potential concern of palatal gummas in syphilis?

They may erode bone and perforate into the nasal cavity or maxillary sinus, creating a fistula.

84

What are the oral manifstations of congenital syphilis? (3)

  1. Hutchinson's incisors
  2. mulberry molars
  3. skin fissures
85

What are Hutchinson's incisors?

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Peg-shaped permanent central incisors with notching of the incisal edge, associated with congenital syphilis.

86

What are mulberry molars?

Defective molars with multiple supernumerary cusps, associated with congenital syphilis.

87

Why is syphilis referred to as the “great imitator”?

Many of its manifestations can mimic malignant neoplasms.

88

What is the causative agent in genital herpes?

herpes simplex virus (HSV-1 or HSV-2)

89

Which type of HSV infection is associated with three times the risk for acquiring HIV infection?

HSV-2

90

Which type of HSV infection is the causative agent of most herpetic infections that occur above the waist?

HSV-1

91

Which type of HSV infection is transmitted predominantly by sexual contact?

HSV-2

92

What are the three characteristic stages of lesions result from the cellular destruction caused by HSV infection?

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Formation of papules that progress to fluid-filled vesicles, which rupture, leaving an ulcer.

93

Where do the progeny of HSV reside in latent infection?

They enter local peripheral neurons and migrate up the axon to the regional ganglia.

94

Which neural ganglia are predominantly effected by HSV-1?

trigeminal

95

Which neural ganglia are predominantly effected by HSV-2?

sacral

96

What is a "nonprimary" HSV infection?

Infection by HSV in an individual who already has been infected with the other type.

97

What are the prominent features of primary HSV infection? (2)

  1. lymphadenopathy
  2. viremia
98

How long does the primary HSV infection last in immunocompetent individuals?

10 to 20 days

99

What is the incubation period of primary genital HSV infections before the herpes lesions appear?

2 to 10 days

100

Primary genital HSV infections may cause lymphadenopathy headache, malaise, myalgia, and fever. How long does it take for these symtomes to subside?

2 weeks

101

How long does it take for primary genital herpes lesions to heal?

3 to 5 weeks

102

How often do outbreaks of recurrent genital herpes typically occur?

2 to 6 times per year

103

Which type of HSV is more efficient in reactivating and associated with more frequent recurrences?

HSV-2

104

How long does it take for recurrent genital herpes lesions to heal?

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10 to 14 days

105

What is the risk of disease transmission in a patients with HSV lesions?

These lesions are highly infectious; one should assume that all lesions are infectious before crusting.

106

What two tests are used to confirm viral types in samples taken from active HSV genital lesions?

  1. nucleic acid amplification testing (NAAT)
  2. direct immunofluorescence (DIF)
107

What is the disadvantage of viral culture for HSV?

It is slow, expensive, and technique sensitive.

108

What is the advantage of real-time PCR assays (NAAT) for HSV?

They are accurate, rapid, provide quantitative results, and can be used to assess asymptomatic viral shedding.

109

What is limitation of DIF testing for HSV?

It can only be used on rich fresh samples; samples should be taken from the base of the vesicular lesions within 24 hours of the initial clinical manifestations.

110

What type of serology test can be used to detect past HSV infection?

HSV-1 or HSV-2 immunoglobulin G

111

What oral antiviral drugs are used to treat genital herpes? (3)

  1. acyclovir
  2. famciclovir
  3. valacyclovir
112

What is the mechanism of action of the oral antiviral drugs acyclovir, famciclovir, and valacyclovir?

They are nucleoside analogues that act as DNA chain terminators during virus replication.

113

What is the limitation of the use of oral antiviral drugs in the treatment of HSV infections?

They do not eliminate the virus from the latent state, nor do they affect subsequent risk, frequency, or severity of recurrence after drug use is discontinued.

114

What is the recommended treatment for patients with frequent HSV recurrences (more five per year)?

Daily suppressive antiviral therapy with periodical discontinuation to reassess the need for therapy.

115

What is the recommended treatment regimen for patients presenting with a primary episode of genital herpes? (4)

  1. acyclovir 400 mg po tid x 7–10 d, or
  2. acyclovir 200 mg po 5x/day x 7–10 d, or
  3. famciclovir 250 mg po tid x 7–10 d, or
  4. valacyclovir 1 g po bid x 7–10 d
116

What is the recommended treatment regimen for suppressive antiviral therapy in patients presenting with frequent HSV recurrences? (4)

  1. acyclovir 400 mg po tid x 5 d, or
  2. acyclovir 200 mg po 5x/day x 5 d, or
  3. acyclovir 800 mg po bid x 5 d, or
  4. famciclovir 125 mg po bid 5 d, or
  5. valacyclovir 500 mg po bid x 3-5 d
  6. valacyclovir 1 g po bid x 5 d
117

What is the recommended treatment regimen for patients presenting with a recurrent infection of genital herpes? (4)

  1. acyclovir 400 mg po bid
  2. famciclovir 250 mg po bid
  3. valacyclovir 500 mg po sid
  4. valacyclovir 1 g po sid
118

In what stages are the herpes simplex virus–induced lesions infectious?

They are infectious in all three stages (papular, vesicular, and ulcerative) and elective dental treatment should be delayed until they are completely healed.

119

When can a herpetic lesion be considered noninfectious?

After the lesion has crusted.

120
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What is the herpetic infection of the fingers or nail beds contracted by contact with an oral herpetic lesion?

herpetic whitlow

121

What is mucocutaneous eruption characterized by “target” papules and ulcers that can result from asymptomatic HSV shedding?

erythema multiforme

122

What is the primary causative agent of infectious mononucleosis?

Epstein-Barr virus (EBV)

123

What patients are most commonly affected by infectious mononucleosis?

Children, adolescents, and young adults.

124

What is the primary mode of transmission of infectious mononucleosis (IM)?

oropharyngeal (i.e. kissing)

125

What clinical triad characterizes IM?

  1. fever
  2. sore throat
  3. lymphadenopathy
126

What is the incubation period of EBV infection?

6 weeks

127

How long is the prodromal period preceding the clinical phase of IM ?

3 to 5 days

128

How long is the clinical phase of IM?

7 to 20 days

129

What cells does EBV infect during the prodromal phase of IM?

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It infects oropharyngeal epithelial cells and spreads to B lymphocytes in the tonsillar crypts.

130

What type of do T-lymphocytes EBV-infected B lymphocytes trigger?

CD8+ T-lymphocytes

131

How long after the acute infection does EBV remain latent in B lymphocytes?

For the lifetime of the host.

132

What are the most common symptoms of IM? (4)

  1. lymphadenopathy
  2. sore throat
  3. malaise
  4. fatigue
133

How long does it usually take for the symptoms of IM to dissipate?

3 weeks

134

What complication of IM is of particular concern in patients who play sports?

splenic rupture

135

What three conditions are strongly associated with EBV and a history of IM?

  1. multiple sclerosis
  2. lymphoma
  3. nasopharyngeal carcinoma
136

What diagnostic tests are used to detect IM? (4)

  1. CBC
  2. nonspecific heterophile antibody test
  3. specific enzyme immunoassay antibody tests
  4. PCR
137

What results on a CBC are suggestive of IM?

A white blood cell count demonstrating lymphocytosis (>50%) with blood smears revealing more than 10% atypical “reactive” lymphocytes.

138

What is basis for the Monospot test for IM?

It is based on heterophile antibodies, which are IgM antibodies that bind to nonhuman erythrocytes.

139

What is the disadvantage of the rapid latex agglutination test (Monospot test) for IM?

It can lead to false-negative results (up to 25%, particularly during early infection).

140

What three specific enzyme immunoassay antibody tests are available for IM?

  1. viral capsid antigen for IgM (VCA-IgM)
  2. viral capsid antigen for IgG (VCA-IgG)
  3. EBV nuclear antigen (EBNA)
141

What does a positive VCA-IgM result indicate?

primary infection

142

What does a positive VCA-IgG result indicate?

previous infection

143

What are the treatments for IM? (4)

  1. bedrest, fluids
  2. acetaminophen or NSAIDs
  3. gargling saline solution
  4. lidocaine to relieve sore throat

*IM is the result of the immune response to EBV, thus there are no pharmacotherapies for the disease.

144

Why must vigorous activity be avoided in patients with IM?

To reduce the risk of splenic rupture.

145

What co-infection is common in patients with IM?

β-hemolytic streptococcal pharyngotonsillitis

146

What is the treatment for streptococcal pharyngotonsillitis in patients with IM?

penicillin VK

147

Why should ampicillin not be used to treat streptococcal pharyngotonsillitis in patients with IM?

Because it can cause a hypersensitivity reaction and skin rash.

148

Can patients with oral signs and symptoms of IM recieve dental treatment?

No; they should be referred to a physician; routine treatment should be delayed for 4 weeks until the patient has recovered.

149

A 13-year old patient presents with the following:

  1. palatal petechiae
  2. enlarged tonsils
  3. pharyngitis with tonsillar exudate
  4. cervical lymphadenopathy
  5. temperature of 100.3 F

What is a possible diagnosis?

infectious mononucleosis

150

What is the causative agent of genital warts?

human papillomaviruses (HPV)

151

What type of virus is HPV?

It is a small, double-stranded, nonenveloped DNA virus.

152

Which subtypes of HPV are classified as "low-risk," associated with benign lesions? (2)

HPV-6 and HPV-11

153

Which subtypes of HPV are classified as "high-risk," associated with malignant lesions? (2)

HPV-16 and HPV-18

154

Which HPV subtype is strongly associated with oropharyngeal cancer at the base of tongue and tonsils?

HPV-16

155

What are the most common STDs globally?

genital warts (HPV)

156

What is the most important risk factor for the development of genital warts?

The lifetime number of sexual partners.

157

How is genital HPV transmitted?

sexual contact

158

What are the genital lesions caused by HPV called?

condyloma acuminatum

159

How soon after HPV infection do condyloma acuminatum appear?

3 weeks to 8 months

160

Which two HPV subtypes are the most commonly detected in human cancers?

HPV-16 and HPV-18

161
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A patient presents with multiple pink cauliflower-like lesions on her vagina and flat-topped lesion of her labial mucosa. What is the diagnosis?

HPV infection

162
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A patient presents with multiple pink to dusky grey oral warts. What is the diagnosis?

HPV infection

163

What is the only definitive test to confirm condyloma acuminatum of HPV infection?

biopsy

164
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A tissue sample shows the following:

  1. sessile base with raised epithelial borders
  2. thick spinous spinosum layer (acanthosis)
  3. hyperkeratosis with koilocytes
  4. In situ hybridization shows purple stains

What is the diagnosis?

HPV infection

165

What are the two categories of treatments used for genital warts?

  1. surgical and ablative techniques
  2. antiproliferative or immunomodulatory agents
166

What are the surgical or surgical and ablative techniques for genital warts? (5)

  1. scalpel excision
  2. electrosurgery
  3. laser removal
  4. cryotherapy
  5. chemical destruction
167

What are the two agents commonly used for chemical destruction of genital warts?

  1. trichloroacetic acid (TCA)
  2. bichloracetic acid (BCA)
168

What are the antiproliferative or immunomodulatory agents commonly used for genital warts? (3)

  1. podophyllin
  2. imiquimod
  3. sinecatechins
169

What is the only type of genital warts that can be treated by the patient alone?

external anogenital warts

170

What are the patient administered treatment options for external anogenital warts? (3)

  1. imiquimod 3.75% or 5% cream, or
  2. podofilox 0.5% solution or gel, or
  3. sinecatechins 15% ointment
171

What are the provider administered treatment options for external anogenital warts? (3)

  1. cryotherapy, or
  2. surgical removal, or
  3. TCA or BCA 80%–90% solution
172

What are the treatment options for urethral meatus warts? (2)

  1. cryotherapy, or
  2. surgical removal
173

What are the treatment options for vaginal warts? (3)

  1. cryotherapy, or
  2. surgical removal, or
  3. TCA or BCA 80%–90% solution

*The use of a cryoprobe is not recommended because of the risk for vaginal perforation and fistula formation.

174

What are the treatment options for cervical warts? (3)

  1. cyotherapy, or
  2. surgical removal, or
  3. TCA or BCA 80%–90% solution

*Management of cervical warts should include consultation with a specialist.

175

What are the treatment options for intraanal warts? (2)

  1. cyotherapy, or
  2. surgical removal, or
  3. TCA or BCA 80%–90% solution

*Management of intraanal warts should include consultation with a specialist.

176

What is Gardasil?

A quadrivalent HPV vaccine.

177

What four HPV subtypes are included in the quadrivalent HPV vaccine (Gardasil)?

  1. HPV-6
  2. HPV-11
  3. HPV-16
  4. HPV-18
178

What five additional HPV subtypes are included in the nonavalent HPV vaccine (Gardasil 9)?

  1. HPV-31
  2. HPV-33
  3. HPV-45
  4. HPV-52
  5. HPV-58
179

What are the oral manifestations of HPV infection?

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  1. oral condylomata acuminatum
  2. oral warts
180

Why might identification of oral condylomata in children be reason for concern?

It raises the suspicion of sexual abuse, particularly when autoinoculation was been rules out.

181

You may suspect a patient has an STD, but you don't have to do anything about it unless you know for sure. True or false?

False; failure to report signs of an STD to state health officials is a legal offense in some states.

182

Can patients with oral warts recieve dental treatment?

Yes; oral warts typically present little risk for transmission to the oral health care team.