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Oral Symptoms of Measles

Today, measles is on the rise. As of April 11, 2019, 555 new cases of measles have been reported.

Today, measles is on the rise. As of April 11, 2019, 555 new cases of measles have been reported. States with active cases are California, Colorado, Connecticut, Georgia, Illinois, New Jersey, New York, Oregon, Texas, and Washington. Outbreaks have been linked with travel to areas where the disease is still endemic such as Europe, Asia/Pacific, and Africa. Other reasons for the increase include vaccination hesitancy and vaccine refusal. Oral health professionals may not be familiar with the signs and symptoms of active measles. With the recent rise in incidence, they should be able to recognize measles and understand the related oral health considerations.

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Risk Factors

Measles virus is transmitted through the respiratory route via coughing and sneezing or direct contact with secretions. Once an individual is infected, clinical signs will appear within 9 days and 19 days. Measles can affect individuals of all ages. Risk factors for measles virus include children with immunodeficiency such as human immunodeficiency virus, leukemia, or taking corticosteroid’s, travel to areas where measles is endemic, children whose parents declined immunization, and infants who lose passive antibody before the age of routine immunization. Malnutrition, pregnancy, and vitamin A deficiency are also risk factors for measles.

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Presentation of Measles

Measles typically begin with a high fever as high as 104°F or more that lasts for 4 day to 7 days. The prodromal phase is also characterized by the classic triad of cough, coryza (head cold, fever, sneezing), and conjunctivitis (red eyes), known as the “3C’s.” Other symptoms may include malaise, anorexia, photophobia, periorbital edema, myalgias, and diarrhea. Adults may experience a transient hepatitis. Clinical measles begins with small Koplik’s spots on the buccal mucosa. The lesions can be numerous small, blue-white macules, also referred to as “grains of salt,” surrounded by erythema. Koplik’s spots occur 1 day to 2 days prior to the characteristic maculopapular skin rash; they may occur on the labial mucosa and soft palate in addition to the buccal mucosa, and in some cases, do not occur at all. Other oral manifestations associated with measles include candidiasis, necrotizing ulcerative gingivitis, and necrotizing stomatitis if the individual is suffering from severe malnutrition. Pitted enamel hypoplasia of developing permanent teeth may occur in severe cases of measles in early childhood. Enlargement of lingual and pharyngeal tonsils may be found during the course of illness.

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Diagnosis

The diagnosis of measles is often made through the classic clinical presentation. However, laboratory confirmation can be made through serologic testing using measles specific IgM or IgG titers or viral culture using throat or nasal swabs. Prior to the presentation of the rash, measles can mimic other diseases and conditions including influenza, croup, other viral illnesses, and pneumonia. Once the rash develops, other differential diagnoses may include: allergic drug reactions, Epstein-Barr Virus (EBV), infectious mononucleosis, Kawasaki disease, Rocky Mountain spotted fever, toxic shock syndrome, scarlet fever, fifth disease, rubella (German measles), and varicella (chickenpox).

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Treatment

Because measles is caused by a virus, there is no known cure. Treatment mainly consists of good hydration with fluids, rest, antipyretics, and vitamin A supplementation. In some cases when an individual is markedly febrile, dehydration occurs and intravenous rehydration is required. Most cases of measles are uncomplicated and resolve in 7 days to 10 days after the onset of illness. Secondary bacterial infections, such as otitis media or pneumonia, will need to be treated with antibiotics. On rare occasions, the virus infects the central nervous system causing encephalitis-related complications.

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Prevention

Oral health professionals are well suited to support primary prevention. A main line of defense against spreading infectious diseases is assessment of the patient’s medical history. As such, all patients should have a full medical history taken and reviewed at each appointment. Collecting immunization information is also important, as it provides the opportunity to encourage vaccination for prevention of infectious diseases. Patient masks should be available in the reception area along with a hand sanitizer dispenser. Furthermore, one of the first presenting symptoms for measles is hyperpyrexia (high fever). Therefore, collecting and assessing vital signs, including temperature, for a symptomatic patient is a critical factor in preventing further transmission of the virus.

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Infection Control Protocol

Most important, if a patient is displaying signs and symptoms of measles infection, precautions must be implemented. First, oral health care treatment should be deferred, and the patient should be referred immediately to his or her primary physician for diagnosis and treatment. Second, as measles is a nationally notifiable disease, oral health professionals need to be well versed in the procedures and protocols used to notify the state Department of Health. The dental office is required to contact the state Department of Health to document the case and to ensure notification is rendered to other potentially exposed patients as measles is a notifiable infectious disease. Finally, safeguard the dental team by confirming that dental staff members have updated immunizations to prevent spreading the virus to potentially unvaccinated family members and other patients.

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