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Home , Herpetic whitlow, Whitlow

Special Report

Herpetic Tayfun Günhay"^ / Sevtap Günbay*'" /Servet Kandemir***

This paper describes a case of transmission of to the index finger of a dental student from a patient with . The recognition of intraoral vira! in patients is important because these have serious implications for heaith care providers. Rubber gloves must be worn when patients with primary or secondary herpetic are treated. Asymptomatic permanent herpes virus carriers must also be treated with appropriate precautions. (Quintessence Int }993;24:363-364:)

Introduction contact with virus-containing saliva. is usually a mild disease that presents as a single The human body is the only natural host for the or cluster of lesions adjacent to the vertnilion borders herpes virus.' " Herpes virus infections are acquired by of the lips,"^ contact with infected secretions, such as saliva or the Herpes simplex of the fingers is a danger exúdate from active lesions, or from individuals shed- for medical, dental, and nursing personnel. Dentists, ding virus in secretions in the absence of elinieal le- who come in frequent contact with oral secretions and sions,' The herpes viruses include lesions, are at the most risk for contracting herpetic I, herpes simplex virus II, varicella-zoster virus, Ep- whitlow,' Herpes simplex virus 1 is the usual eause of stein-Barr virus, and cytomegaiovirus,"' Antibodies to herpetic whitlow in health care providers, whereas herpes simplex virus (HSV) may be found in most HSV II is the more frequent cause of finger infections people in the blood serum. Humans may carry the in the general population,''' virus without clinical signs of disease."^*' The virus, be- Lesions occur most often in the distal phalanx of the tween the primary and secondary attacks of herpes, is index finger and are often found around the finger- located in the gasserian ganglion. The virus may de- , where breaks in the epithelial integrity allow the scend to the lip through the trigeminal nerve, which virus to gain access to underlying basal cells. If the le- might explain why the location of the on the lip sions extend under the nail, intense pain develops. is usually the same,'" The incidence of the recurrence of herpetic whitlow Oral primary infeetion with HSV, if symptomatic, has not been established, but there will be loss of sen- most often presents as herpetic gingivostomatitis. The sation in the affected finger,-'' disease may range from mild to severe,''' Oral lesions initially appear as vesicles; then they ulcerate and develop through the oral cavity. The lesions frequently Case report occur in buccal mueosa, tongue, gingival tissues, hard A 20-year-old dental student had a eomplaint of a and soft palates, and paratonsillar pillars,^ Lesions painless lesion in her index finger. Seven days previ- may extend extraorally and are readily spread via ously the student had a microtrauma caused by an amalgam matrix when she was restoring a tooth. She did not take proper precautions and just washed her hands with an ordinary soap. After 1 day she pre- • Assistant Professor, Department of Oral Surgery, Aegi;ar sented with itching, swelling, and pain in her index University, Faculty of Dentistry, 35100 Bornova, Izmir, Tur- key, finger. The lesion was localized on distal phalanx (Fig \). ** Associate Professor. Department of Orai Surgery. Aegean but she demonstrated axillary . She University. '** Assistant Professor, Department of Oral Diagnosis attd was prescribed dindamycin, to be taken four times daily Radiology. Aegean University. for 'S days. After 5 days there was no sign of healing

Ouinlessence International Volume 24, Number 5/1993 363 speciai Report

cautions. The lesion in this patient was located on the distal phalanx of the index finger, as reported in the literature,'' The prevalence of herpes simplex viruses makes it impossible to completely avoid this disease. Special care must be taken when patients with herpes simplen infection are examined, because virus is present in saliva and on the lips and can easily be transmitted to other sites. For dental staff, infection can spread into the subcutaneous tissue ofthe hands through minimal skin abrasions, A thorough medical history must be obtained from the patient, and if any herpes virus infection occurred Herpetic whitlow on the right index tinger. in the past, the dental staff should take precautions. Even in the absence of symptoms, the patient will have and vésicules were seen in her finger. Her medical his- the herpes virus in his or her oral secrefions.'' Each tory revealed that she had a herpes zoster virus infection infected individual who is intcrmittantly infectious 4 years previously. The lesion was diagnosed as herpelic serves as a permanent carrier of the virus. whitlow and the patient was told to take acyelovir Dentists must use protective barriers such as gloves, {200-mg tablets four times daily for 5 days). The vesi- masks, and eyewear when treating all dental patients cles ruptured, became dry, and crusted. In 2 weeks to prevent transmission of virus from the oral cavity of they had resolved, and the patient's subjective com- a patient to the practitioner's hand or mucous mem- plaints also disappeared. branes of the oral cavity, nose, or eyes,^ Transfer of herpes simplex virus may be direct or through contact with contaminated materials Ot sur- Discussion faces. The dental professional is at risk, and infection Epidemiologie studies have estimated that 80% to occasionally occurs on the hand or finger. Ruhber 90% of the population has antibodies to HSV I. gloves must be worn when patients present with a pri- Nevertheless, only a portion of infected individuals mary or secondary hetpetic lesion. The ability of a develop disease in Ihe form of herpetic stomafitis,'' In dentist with herpetic whitlow to treat patients is limited many people, the infection is therefore latent or sub- not only by pain but also by the risk of spread of infec- chnical. About 40% of those who have primary infec- tion to other patients. tion manifest a clinical reaction to the virus, charac- terized by herpes labialis,'' Between attacks, HSV I lies latent in the trigeminal ganghon. Reactivation is References triggered by numerous factors, ranging fiom trauma to 1. Nolte WA. Oral Microbiology with Basic Microbiology and sunlight to emotional stress.''''' Immunolügy, ed 3, St Louis: Mosby, 1977:401-404, Herpes simplex viral infection of the finger is most 2, Nally FF, JatDcs JD, Primary herpes simplex. Oral Surg Oral frequently found in health care providers, especially Med Oral Pathol t970;29:6S0-688, those who come in contact with oral secretions. 3, Schuster GS, Oral Microbiology ot lnfeetious Disease, cd 3, Philadelphia: Decker, 1990,356-365, Herpes simplex infections of the dentist's fingers can 4. Latney PJ, Lewis MAO. Oral triedicine in practice: Viral infec- result from treating patients with recurrent herpes le- tion. Br Dertt J t989; 167:269-274. sions of the lips or from treating patients who have 5. Sigfrid AM, Rochester MD, Viral intections of the skir and herpes simplex virus latently or subelinically in their mouth: A selected review. Oral Surg Oral Med Oral Pathol oral secretions. The virus enters a break in the skin iy71:32:752-759, 6. Daniel AG, Irving BS, Ma^ AL, Periodontics, eii 6, St Louis: caused by trauma and causes a localized infection.^ Mosby, 1988:413^ IS, In this case, the patient probably came in contact 7, Spouge JD. Oral Pathology, ed 1, St Louis: Mosby, t973; with the herpes simplex virus during the treatment of 217-222, a dental patient who was asymptomatically shedding 8, Robirti M, Longston D, Longston M, Herpetie infection in adults. Oral Surg Oral Med Oral Pattiol t970;30:41-47, the virus in his or her oral secretions. The dental stu- y. Main DMG. Acute heipetic gingivostomalitis: Referrals to Leeds dent therefore did not feel the need to take atiy pre- Dental Hospital 1978-1987. Br Dent J 1989;166:14-16, D

364 Quintessence International Volume 24, Nutnber 5/1993