| Highlights |
• Monkeypox is a re-emerging viral infectious disease that may be of relevance to dental professionals due to the risk of cross-infection or occupational exposure. • The characteristic eruption seen is usually widespread, but frequently affects the oral cavity and perioral structures. Cervical lymphadenopathy is a common feature. • It is important to conduct further research to understand the risks of emerging and re-emerging viral infectious diseases in dental settings. |
Monkeypox is a re-emerging zoonotic infectious disease caused by monkeypox virus (MPXV), which is a member of the genus Orthopoxvirus in the family Poxviridae. Small rodents and other mammals, endemic to Central Africa, are believed to be the natural reservoirs of MPXV.
On 6 May 2022, a case of monkeypox was reported in the United Kingdom and several records were identified shortly afterwards. On July 23, 2022, the WHO declared the monkeypox outbreak a public health emergency of international concern.
| Transmission routes |
Zoonotic transmission of MPXV occurs from infected animals through bites, scratches, and close contact.
The 2022 outbreak is characterized by person-to-person transmission and sexual contact has been documented in 91.7% of cases. However, it is still unclear whether the virus spreads directly through the genitals or if transmission is due to close contact with an infected person during sexual activity.
| Clinical presentation |
Monkeypox has a relatively long incubation period that can range from 5 to 21 days. The disease is characterized by two well-differentiated phases. Symptoms begin with an initial prodromal illness that includes: fever, lymphadenopathy, myalgia, fatigue, headache, and back pain.
The initial illness is usually followed by a rash within a few days of the appearance of preliminary symptoms. Individual lesions progress through the following appearances: macules (flat-based lesions), papules (firm, raised lesions), vesicles (lesions with clear fluid), pustules (lesions with yellowish fluid), and crusted lesions.
Anogenital lesions and rectal pain have also been frequently reported during the current outbreak, and as it progresses, more clinical symptoms may be added to the case definition. The extremities, genitals and face are the most commonly affected sites and although most cases are self-limiting, complications can include pneumonitis, encephalitis and secondary bacterial infections.
Patients are considered no longer infectious when the scabs have fallen off and new skin or mucosa has developed, which can take up to four weeks.
| Risk for healthcare workers |
Healthcare professionals may be at increased risk of contracting the infection through close and prolonged contact with infected patients.
Dentists may be at additional risk due to the production of droplets and aerosols during dental procedures and prolonged close contact with patients. Fluid from MPXV-containing skin or oral lesions, or from blood and saliva, can be dispersed into the environment through droplets and aerosols, or by direct contact with patients.
| Knowledge and management of a possible or probable case |
Overall, monkeypox causes little risk to dental professionals; the number of cases is low compared to the millions of patients seen each year.
During periods of increased community transmission, some monkeypox patients may seek dental care. Therefore, it is important for dentists to understand the disease and its clinical presentation. Patients who present with an unexplained rash anywhere on the body and one or more typical symptoms should ask dental professionals to consider MPXV as a possible cause.
In the case of a suspected case, the patient should be provided with a surgical mask and asked to return home to isolate. Any elective dental treatment in patients with possible, probable, or confirmed monkeypox should be delayed until monkeypox is ruled out or the patient is no longer infectious.
| Infection prevention and control measures |
The use of gloves, aprons, fluid-resistant surgical masks, and eye protection where appropriate would provide protection against contact transmission. There is not yet enough data to confirm or refute airborne transmission as a primary route of transmission.
| Vaccination |
The cessation of smallpox vaccination since the eradication of the disease has probably reduced population immunity.
Vaccination in the UK is currently considered for pre-exposure prophylaxis in high-risk groups and for healthcare and laboratory workers likely to be exposed to monkeypox patients or working with MPXV samples.
| Primary presentation and differential diagnosis |
Although patients with acute discomfort, or those with a generalized smallpox-like rash, are likely to present to medical colleagues, patients with more limited disease affecting the head and neck may present first to medical colleagues. dental professionals.
For example, a common symptom of monkeypox is lymphadenopathy, as well as oral and perioral lesions. Differential diagnoses may include lesions caused by varicella-zoster virus or molluscum contagiosum.
| Future implications |
The current monkeypox outbreak has some similarities to the emergence of HIV, including the fact that it is primarily due to sexual contact between men.
Unlike HIV, monkeypox appears to resolve in about a month and people are no longer infectious beyond this point. Therefore, the risks of transmitting monkeypox during healthcare procedures would only occur during the prodromal or acute phases of the infection, dramatically reducing the likelihood of dentists coming into contact with infectious cases.
| Conclusions |
Monkeypox is transmitted through direct contact and respiratory droplets, although airborne transmission cannot be excluded.
It is important that dentists are aware of the typical symptoms of monkeypox in the unlikely event that they are presented with an infected patient, as well as the need to use respiratory and ocular barriers.
Continued research is necessary to ensure we are well prepared for future challenges.
