by Nancy W. Burkhart, RDH, EdD
Reports of measles outbreaks continue to increase in locations such as France, Africa, Southeast Asia, and other European countries reporting thousands of measles cases. Cases have been reported from 38 countries, including Serbia, Macedonia, and Turkey. Most cases reported have been in individuals who had not been vaccinated, and the contraction is often from individuals who are from other countries visiting the United States or from U.S. residents visiting other countries.
Figure 1: Dr. James Sciubba: From DeLong L. and Burkhart N.W., General and Oral Pathology for the Dental Hygienist, Wolters Kluwer: Lippincott Williams & Wilkins, 2008.
As of June 10, 2011, the Centers for Disease Control and Prevention reported 152 cases of measles occurring in 23 states in the United States. Of this number, 53 patients needed to be hospitalized. Most of the reported cases occurred in Minnesota, New York, California, Massachusetts, Utah, Pennsylvania, Florida, Kansas, Texas, and Virginia.
Reports of measles in homeless shelters, day care, and areas where children are in close proximity with other children have recently been reported. Recent numbers have also increased with regard to mumps and whooping cough. Again, these vaccine-preventable diseases are showing resurgence in strength. Worldwide, the CDC reports that there are 20 million cases with 197,000 deaths each year. Almost half of the measles cases occur in India.
Measles (rubeola) is caused by the Paramyxoviridae virus infection. The virus normally grows in the cells that line the back of the throat and the lungs.
Measles cases usually arise in the winter/spring months and the incubation period is 10 to 12 days. Measles symptoms typically begin with common cold symptoms such as drainage from nose, eyes, cough, and fever. A rash occurs beginning on the face and ultimately extending to the whole body.
Of particular interest to dental personnel is the fact that one of the early signs of measles is what is called Koplik spots that are found on the buccal and labial mucosa (see Figure 1). The spots usually precede the external rash that is classically found in measles.
Since measles outbreaks have been rather rare for the past decades, many practitioners have never seen Koplik spots clinically, and they may have a vague recollection of an image in a textbook. Therefore, recognition may not occur readily and confusion with other oral conditions may be a factor for the clinician.
Rubella (German measles) is caused by a virus from the Togaviridae family and is especially detrimental to pregnant women when contracted in the first trimester of pregnancy and can cause spontaneous abortion or birth defects in the unborn. Exposure to either type of measles may make pregnant women miscarry or become very ill, causing problems for the unborn child.
Measles is usually a self-limiting entity. But, in some cases, hospitalization may be needed, and pneumonia can occur. Some victims suffer neurological problems, deafness, brain damage, encephalitis, seizures, and death. Worldwide, many deaths continue to occur from measles. Additionally, those who are especially vulnerable such as the very old, the very sick such as cancer patients or those taking immune suppression medications, and the very young are placed at risk and are susceptible to this disease. Sometimes those who develop measles never know the origin or carrier of the disease.
Normally, children have been vaccinated with the MMR (measles, mumps, and rubella) early in childhood. However, during the past decades, there has been a decline in parents who select to vaccinate their children. This has been primarily because of noted controversy regarding some ill effects of the vaccines. There has been controversy related to autism in particular and the effects of all vaccines in relation to autism. Proponents of vaccines for measles say that their children are being placed at high risk by those who select to forgo vaccination.
It is advised that babies can be immunized at six months before traveling to other countries and will need their regular MMR shots at 12 to 15 months and the second one at the start of school at age four to six years old.
A combination of MMRV is also available, which includes the varicella immunization. Some reported ill effects have been documented in some patients with this vaccine, and it is suggested that normally the separate vaccines be used.
It is also advised that adults who travel abroad have the vaccine if they had a single dose as a child. If adults were born before 1957 when measles was more prevalent, the adult is usually resistant and also if the person had measles previously, since measles does not usually recur.
In cases reported and documented with the CDC, it is very possible to expose a child by just being in a room with another child who has measles. Sometimes this occurs in an office, such as a doctor’s office before any diagnosis has even occurred.
This is especially relevant to dental offices where many aerosols are produced, making infection of others much more likely.
Early signs such as infection of the nose, eyes, coughing, etc., and the presence of Koplik spots should alert the clinician that the patient may be infected with measles. Postponing the appointment and rescheduling for a few weeks later is optimal. In such a case, it is also wise to alert the parent to watch closely and also to report back any subsequent confirmation of measles.
Additionally, careful cleaning of the unit, airing out the room, and addressing the waiting area that has been contaminated is also very important. Patients should be notified if they had an appointment during this time period or shortly afterwards that they may have been exposed to measles.
Measles has been almost dormant in the United States for so many years, but there is new movement with regard to this virus. Careful attention to young patients and thorough oral exams can assist in the early detection of measles and possibly keep the disease from needlessly spreading. This is particularly relevant to pediatric practices or large clinics that treat many pediatric patients daily. Many clinics are structurally open and not confined by walls as individual operatories tend to be. This makes the aerosol very disbursed and the spread of measles more likely. Aerosols have been documented to travel considerable distances, and this is more important in open clinical areas (Bentley et al. 1997). If any respiratory signs are present, careful evaluation of the patient and follow-up dialogue with the parent is strongly suggested.
As always: Keep asking good questions and always listen to your patients.
Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contaminations during dental procedures. J Am Dent Assoc 1994;125: 579-584.
DeLong L, Burkhart NW. General and Oral Pathology for the Dental Hygienist. Wolters Kluwer: Lippincott, Williams & Wilkins. Baltimore. 2008.
http://www.cdc.gov/vaccines/vpd-vac/measles/downloads/dis-measles-bw-office.pdf. Accessed 6/24/2011.
http://wwwnc.cdc.gov/travel/notices/in-the-news/measles.htm. Accessed on 6/27/2011.
http://phil.cdc.gov/phil_images/20030214/16/PHIL_3187.tif Accessed on 2/27/2011
http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.pdf Accessed on 6/27/2011.
http://www.cdc.gov/Features/Measles/ Accessed on 6/2/2011.
http://www.nacd.in/ijda/volume-02-issue-01/23-aerosols-a-concern-for-dentist Accessed on 7/2/2011.
Nancy W. Burkhart, BSDH, EdD, is an adjunct associate professor in the department of periodontics, Baylor College of Dentistry and the Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (http://bcdwp.web.tamhsc.edu/iolpdallas/) and co-author of General and Oral Pathology for the Dental Hygienist. She was a 2006 Crest/ADHA award winner. Her website for seminars is www.nancywburkhart.com.
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