COURSE SUMMARY

AUTHOR: Louis G. DePaola, DDS

AUDIENCE: Dentists; Dental Hygienists; Dental Assistants
ABSTRACT: The transmission of infection within the
dental office is one of the biggest concerns in the oral health
profession. This course, in particular, focuses on some of
the most prevalent diseases in the U.S. todayknown
as sexually transmitted infections (or STIs)which have
oral manifestations that can be detected by dental
professionals. It reviews the most common types of STIs, as
well as some of the newer infections (such as human
papillomavirus [HPV]) that have emerged within the past
decade, in addition to how they manifest in the oral cavity.
OBJECTIVES:
1. Review current statistics on the prevalence of STIs/STDs in the U.S. today.
2. Learn what oral manifestations are connected to the most common STIs/STDs.
3. Identify additional symptoms of STIs that dental professionals should be able to detect.
4. Understand how oral manifestations can indicate various stages of a STI/STD.
5. Recognize patients that need a referral if showing symptoms in the oral cavity.
CLINICAL CATEGORY: Infection Control
CE ACTIVITY: Online/Self-Instructional
NUMBER OF CREDITS: 2 Credits
TOTAL COST: $20.00
PUBLISH DATE: April 17, 2013
EXPIRATION DATE: April 17, 2016
SPONSORED BY:

COURSE CONTENT: The information and opinions contained in this CE course are those of the author, and do not
necessarily reflect the views of The Richmond Institute for Continuing Dental Education, or its affiliates. Any brand or
product name mentioned throughout this course should not be inferred as an endorsement of any kind by the
aforementioned parties. In addition, The Richmond Institute does not warrant or make any representations concerning
the accuracy or reliability of the materials on this website, or any site(s) that are linked to richmondinstitute.com.
CONFLICT OF INTEREST: Dr. DePaola has received research support from Colgate and serves as a consultant for
Biotrol, Colgate, Dentsply, Johnson and Johnson, and The Richmond Institute. The Richmond Institute for
Continuing Dental Education is a division of Young Innovations, Inc. It is dedicated to ensuring that its continuing
dental education programs are intended for the sole purpose of education and do not serve as an endorsement for any
product(s) or service(s), including those of the sponsoring company.
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author, or need technical assistance please email support@richmondinstitute.com.
SCORING: To earn credit for a course from The Richmond Institute for Continuing Dental Education, participants
must earn an overall score of 80 percent or above on the associated exam before receiving a certificate that confirms CE
accreditation. (*NOTE: There is no limit to the number of times a participant may re-take the exam in order to obtain
this passing score). All courses that are published on this site are categorized as self-instructionalwhich means
participants must complete the course on their own time and submit the accurate payment in order to earn CE credit.
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responsible for the participants use or misuse of the techniques and procedures discussed in this course.
LIMITED KNOWLEDGE RISK: The information provided in this course may not be comprehensive enough for
implementation into professional dental practice. It is highly recommended that additional information be attained
once the course is completed to establish greater proficiency on the topic at hand.

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INTRODUCTION
Disease transmission has been a significant concern in oral
healthcare for as long as the dental profession has been around.
With so many infectious diseases that can spread from one patient
to another, the need for dental practitioners to comply with the
latest infection control protocols cannot be stressed enough.
Moreover, the ability to identify these diseases is just as important
since patients may not even be aware that they have an infection.
Coincidentally, over 90% of systemic conditions have oral manifestations, so this gives dental
professionals a unique opportunity to diagnose and prevent those conditions from spreading to
other individuals. This course highlights this transmission in the dental office, with a special focus
on the oral implications of sexually transmitted infections, which are some of the most prevalent
diseases in the world today.
Overall, diseases can be transmitted a number of different ways both inside and out of the dental
operatory; typically, they are spread from one person to the next through the following forms of
contact:

direct contact with a pathogen OR indirect contact with a contaminated object/surface

droplet or splatter contact from an infected person through coughing, sneezing
inhalation of airborne microorganisms (able to remain in the air for long periods of time)
In addition, sexual activity is another way that diseases can be transmitted from one individual to
the next. This activity puts both partners at risk for coming in direct contact with infected
pathogenic microorganisms. Unfortunately, sexually transmitted diseases (STDs) are as old as
mankind. They were reported in considerable numbers in ancient civilizations, and were referred to
as venereal diseases (VD) derived from the Latin Veneris (Venus)the Roman goddess of
love. Social disease has evolved to be a more polite euphemism for an STD. However, new diseases
such as HIV and HPV have emerged, which are efficiently transmitted through sexual contact. Once
infected, a person can spread the infection to his/her sexual contacts without having any overt signs
of the disease, since the signs and symptoms may not be detectable for weeks, months, years or even
decades.
Therefore, the term sexually transmitted infection (STI) has become the accepted term for any
disease/infection transmitted human-to-human through various forms of sexual activity. The
diseases that are transmitted almost exclusively from sexual activity include: HIV, syphilis,
gonorrhea, chlamydia, human papillomavirus (HPV), human herpes viruses, and numerous other
infections. Many other infectious diseasesincluding the common cold, influenza, pneumonia, and
other viral/bacterial infectionsare sometimes inadvertently transmitted during sexual contact as
well. However, since they are also transmitted through nonsexual contact, these types of infections
are not considered STIs.

STIs IN THE UNITED STATES

According to data reported from every state and territory
(including the District of Columbia), the CDC estimates that
there are about 20 million new diagnoses of STIs in the USA
each yearcosting the American healthcare system nearly
$16 billion in direct medical costs.1-5 It is estimated that over
110 million men and women are currently infected with an
STI in the US today, although this figure does not include
the 50,000 new infections of HIV that are also diagnosed in
this country every year.4-7
Young adults shoulder the most responsibility for the spread of these infections in the United States.
The CDC estimates that half of all new STIs in the country occur among young men and women
between the ages of 15 and 24, with an almost equal dispersion of these diagnoses among men and
women (49% and 51%, respectively).4-7 To further complicate the issue, a single person can beand
often isinfected with multiple STIs at one time. Each infection presents a potential threat to both
the immediate and long-term health and well-being of the infected individual. More importantly, if
STIs are not diagnosed and treated in a duly timeframe, the STIs can easily spread to uninfected sex
partners.4-7
STIs are transmitted in a number of ways. Whenever there is unprotected sexual contact and/or an
exchange of body fluids (regardless of the type of sexual activity the individual engages in), there is a
risk he/she will transmit an STI to the other partner. This risk increases if a break or tear occurs
within the mucous membrane of the oral, vaginal or peri-anal tissues, which readily facilitates the
disease to be passed from the infected person to the next.
Table 1 illustrates the U.S. incidence rate and age distribution for these diseases:
hepatitis B virus (HBV)
human immunodeficiency virus (HIV)
syphilis
herpes simplex virus type 2 (HSV-2)
gonorrhea
trichomoniasis
chlamydia
human papillomavirus (HPV).

(see Table 1 on following page)

ORAL MANIFESTATIONS OF STIs

While the mucous membranes of the oral cavity, the peri-anal area, and the genitalia of both sexes
perform different functions, they are also very similar in many ways. Mucous membranes are linings
of mostly endodermal origin, and are covered in epithelium, which assist in the process of
absorption and secretion; moreover, they line cavities that are exposed to the both the external
environment, and internal organs.
The glans clitoridis, glans penis, and the inside of the foreskin, as well as the clitoral hood, are all
mucous membranes. Urethral, endometrium (or uterine) mucosa, oral/buccal mucosa, and the nasal
mucosa are also all considered mucous membranes. Because of the similarities between the genital,
oral and peri-anal mucous membranes, many STIs have oral manifestations.

SYPHILIS
Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum.8 The
history of syphilis goes as far back as medieval times, when the disease was also known
as Pox or Lues. The bacterium, T. pallidum, was first identified by Schaudinn and Hoffmann in
1905; a year later, August von Wassermann devised the first serum reaction test for syphilis. With
this test, a diagnosis for syphilis could be made, but unfortunately there was no effective treatment
until the discovery of sulfonamides and penicillin in the late 1930s. 8 The prevalence of syphilis in

the U.S. at that time was estimated from 5% to 10% of the entire public, with rates up to 25% among
lower socioeconomic groups.8
Prior to the discovery of penicillin, syphilis was a major global public health problem analogous
with the human immunodeficiency virus (HIV) of today. If undiagnosed and untreated, syphilis
could cause long-term complications and/or death, and was associated as the major cause of
neurologic, cardiovascular, and perinatal morbidity and mortality at that time.8 While the rates of
syphilis have significantly reduced in the post-antibiotic era, it is still a commonly occurring STI
among the population today. The CDC estimates that about 55,400 new syphilis infections occur in
the USA every year. 8 However, in 2011, there were only 46,042 reported new cases, 13,970 of which
were primary and secondary (P&S) syphiliswhich constitute the earliest and most transmissible
stages of syphilis.8
During the 1990s, syphilis most often occurred among heterosexual men and women of racial and
ethnic minority groups.8 Within 10 years, cases increased among men who have sex with men
(MSM), and by 2002, the rates of P&S syphilis were highest among men 30 to 39 yearsold.8 However, by 2011, P&S syphilis were highest among men 20 to 29 years of age, with a
noticeable increase in disease acquisition among young MSM, who accounted for 72% of all P&S
syphilis cases in 2011.8 The average time between infection with syphilis and the onset of the first
symptom is 21 days, but can range from anywhere between 10 and 90 days.8,9
Syphilis has been divided into primary, secondary and latent (previously referred to as tertiary)
stages.8,9 The organism is transmitted from the primary lesion (known as the chancre), which
initiates the primary stage of syphilis after T. pallidum has entered the body.8,9 The chancre usually
presents itself as a firm, round, small, yet painless ulceration that appears at the site of the infection.
This lesion is usually singular, but considering the fact that syphilis often referred to as the great
mimic, it can present itself with many different appearances, so multiple lesions may occur. The
chancre can occur anywhere on the external genitals, vagina, anus, or in the rectum. 8,9 Chancres also
appear in the peri-oral area (most commonly on the lips, tongue and oral mucosa); see Figure 1.

The primary stage of syphilis usually lasts three to six weeks, while the chancre can heal
spontaneously with or without antibiotic therapy.8,9 However, if no treatment is administered, the
infection will progress to the secondary stage, prompting the widespread dissemination of T.
pallidum to initiate systemic manifestations. This stage of syphilis (sometimes referred to as
the mucous patch stage) is heralded by the development of skin rashes and/or mucous membrane
lesions on the face, genitalia, anus, or inside the mouth. Lesions can occur on one or multiple sites of
the body, including the oral and peri-oral areas (Figures 2 & 3 below).8,9
These rashes may appear as the chancre is healing, or may be delayed several weeks after the healing
process has completed. The characteristic rash of secondary syphilis is maculo-papular (flat and
slightly bumpy).8,9 It may appear as being rough, red, or having reddish-brown spots on either the
palms of the hands and/or the bottoms of the feet, which is a unique characteristic of this disease
and several others (Figure 2).8,9 However, a rash is still a common symptom of many other
diseases, which can make the diagnosis difficult. Sometimes rashes associated with secondary
syphilis are so faint that they are not noticeable.

Other symptoms of secondary syphilis may include:8-9

fever
swollen lymph glands
sore throat
patchy hair loss
headaches
weight loss
muscle aches
fatigue
As with the primary stage, the symptoms of secondary syphilis can resolve with or without
treatment, although the lesions themselves are considered infectious, and may be transmitted to
anyone who has direct contact with a person in these first or second stages of the disease. If that
person still does not seek treatment after those symptoms have subsided, the infection will then
progress to the latent stages of the disease. Latent syphilis can appear 10 to 20 years after the
infection was first acquired, and can cause serious damage to the internal organs, including the
brain, nerves, eyes, heart, blood vessels, liver, bones, and joints.8,9 If left untreated at this stage,
death could surely ensue.8

GONORRHEA
Another bacterial STI of concern is Gonorrhea, which is caused by the infection known as Neisseria
gonorrhoeae. This organism infects the mucous membranes of the reproductive tract, including the
cervix, uterus, and fallopian tubes in women, and the urethra in women and men. It can also infect
the mucous membranes of the mouth, throat, eyes, and anus. In the USA, 820,000 people are
infected with new gonorrheal infections every year; globally there are 88 million new cases per year.
There is great concern over the fact that more than half of these infections reported to CDC occur
mostly in young people 15 to 24 years-of-age. Gonorrhea is transmitted through sexual contact with
the penis, vagina, mouth, or anus of an infected partner, and may also be spread prenatally from
mother to baby during childbirth.
When symptomatic, signs of urethral infection in males will include dysuria, or a white, yellow, or
green urethral discharge that usually appears 1 to 14 days after infection. Most women with
gonorrhea are asymptomatic, and an increasing number of men are as well, which increases the risk
of secondary transmission, and the development of serious complications that can result in
significant morbidity and mortality. Additionally, untreated gonorrhea infections can increase the
risk of acquiring or transmitting HIV disease. From an oral health standpoint, gonorrhea may infect
the pharynx; although it is usually asymptomatic, it can cause symptoms of a sore throat and/or
dysphagia. Unfortunately, these lesions are rare, and when presented, often go unrecognized.

HIV DISEASE
Since the first reports of this new infection in 1981, every country in the world has reported cases of
HIV/AIDS.
By the end of 2011, the following statistics were reported about this disease:

Around the world, 34 million people have been diagnosed with HIV.
30 million deaths have been reported worldwide by this disease.
1.7 million people died from AIDS-related illnesses in 2011 alone.7
In the USA, the CDC estimates that 1,148,200 persons aged 13 years and older are living
with the HIV infection, including 207,600 (18.1%) who are unaware of their infection.11

The CDC estimates that approximately 50,000 people are newly infected with HIV each
year.11

In 2010, there were an estimated 47,500 new HIV infections.11 Nearly two thirds of these
new infections occurred in MSM.

African American men and women were estimated to have an HIV incidence rate that was
almost eight times higher than the incidence rate among whites.11

An estimated 15,529 people with an AIDS diagnosis died in 2010.

Altogether, approximately 636,000 people in the USA with an AIDS diagnosis have died
since the beginning of the epidemic.11
The routes of transmission of HIV are well documented and include the following:

Unprotected sexual contact (regardless of sexual preference).

Sharing needles, syringes, rinse water, or other equipment to prepare illicit drugs for
injection. Although very rare, HIV may also be transmitted through unsafe or unsanitary
injections or other medical or dental practices.

Having parenteral, mucous membrane, or non-intact skin contact with HIV-infected blood,
blood components, or blood products.

Receiving transplants of HIV-infected organs and tissues, including bone, or transfusions of

HIV-infected blood.

Perinatal transmission from mother to child around the time of birth; HIV can also be
transmitted from mother to child during pregnancy, birth, or breast-feeding.
Although HIV can be transmitted by any of the above, sexual transmission accounts for the majority
of cases on a global basis. HIV selectively infects and reproduces in critical immune cells known as
CD4 cells.12 In this complex process, the CD4 cell is killedwhich releases new virions of HIV that

infect more cellsand allow the virus to propagate throughout the body. The killing of CD4 cells
directly translates to a gradual decline in overall immune functionality.12 The diagnosis of AIDS is
made when the CD4 count falls below 200, and/or the individual shows one or more symptoms on
the AIDS Defining Illness checklist.12
With a declining immune system, other infections will soon develop, and eventually the patient will
succumb from one or more of them.12 If antiretroviral therapy is not implemented, the amount of
time between the onset of infection and death is approximately 10 years. 12 However, considerable
progress has been made in the medical management of HIV disease, so when a patient is compliant
with the appropriate antiretroviral regimens, he or she has a life expectancy similar to that of a nonHIV infected individual.12 While there are numerous oral manifestations of HIV disease, this
discussion will focus on the most frequent fungal and viral infections.

ORAL CANDIDIASIS
Oral candidiasis (OC) is the most common lesion among patients with HIV. The most common
organism causing this infection isCandida albicans; however, other species such as C. glabrata, C.
tropicalis, C. krusei, C. kefyr, and C. dubliniensis have been reported to cause it as well.12-16 OC can
occur in four different forms of an HIV infection: pseudomembranous, erythematous, hyperplastic
and angular cheilitis.12-16 Pseudomembranous candidiasis presents itself as white or yellowish spots
or plaques on the palate, tongue, or oral mucosa that can be wiped off and leave a raw, bleeding
surface (Figure 4).12-16
Erythematous candidiasis presents itself as red, atrophic areas, usually on the palate or dorsum of
the tongue (Figure 5).12-16Angular cheilitis presents itself as cracking, fissuring and ulcerating
angles in the mouth, while hyperplastic candidiasis presents itself as a thick white plaque that does
not rub off.12-16

In the presence of HIV infection, numerous viral infections cause oral manifestations. Herpes
simplex virus infection is commonly encountered in either the oral cavity, genitalia, or
both.17 Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses
type 1 (HSV-1)commonly referred as oral herpesor type 2 (HSV-2), which is commonly referred
to as genital herpes.17 Approximately 776,000 people in the USA get new herpes infections each
year, and about 16.2% of people aged 14 to 49 years have the HSV-2 infection.17
Infection is more easily transmitted from men to women than from women to men, which probably
accounts for a higher rate of HSV-2 infections among women than men.17 HSV-1 and HSV-2
infections are transmitted through contact with lesions, mucosal surfaces, genital secretions, or oral
secretions, although asymptomatic shedding can also occur. 17 HSV-1 and HSV-2 lesions look
identical, and cannot be distinguished based on clinical presentation or location; moreover, either
can appear in the oral cavity or on the genitalia.17
Most cases are asymptomatic, or have very mild symptoms that go unnoticed, which results in 81.1%
of infected individuals being unaware of their infection.17 Symptomatic lesions typically appear as
one or more vesicles on or around the genitals, rectum or mouth.17 The vesicles then rupture,
creating painful ulcers that form a crust (scab), but heal in two to four weeks without leaving a
scar (Figure 6 & 7).17 Recurrent outbreaks of oral and/or genital herpes are common.

Kaposis sarcoma (KS) is a malignant neoplasm of the blood vessels, and is strongly associated with
human herpesvirus-8 (HHV-8)which is also referred to as Kaposis Sarcoma-Associated
Herpesvirus (KSAH).12-16 A gene of HHV-8 promotes spindle cell proliferation and angiogenesis,
and it is thought that this may eventually lead to neoplasia. The virus is shed in virtually all body
fluids, and is associated with sexual contact and the overall number of partners. 12-16 An unknown cofactor may be involved in transmission, however, immunosuppression (HIV disease) must be
present to cause KS.12-16
Prior to the introduction of effective antiretroviral regimens, KS was a common neoplasm, occurring
in approximately 15% to 20% of the patients with AIDS.12-16 Although appearing less frequently, KS
does still often present itself in the oral cavity and/or the peri-oral areas.12-16 Lesions initially
present themselves as blue, red, or purple macules on the palate, gingival, and/or tongue.12-16 These
lesions may be very subtle and difficult to see, especially in patients with significant racial
pigmentation.12-16 The lesions may become raised and nodular, with extensive ulceration, bleeding,
and pain (Figure 8).12-16 Any suspicious lesions should be referred for a biopsy to provide a
definitive diagnosis.

HUMAN PAPILLOMAVIRUS (HPV)

Human Papillomavirus (HPV) is the most common STI in the world. 18,19 So far, over 60 strains have
been identified, and at least 50% of sexually active people are at one time or another infected with at

least one strain of HPV.18,19 Although the virus infects men and women equally, women are more
likely to present symptoms of this disease.18 HPV is the causal agent of cervical cancer, which is the
second leading cause of death among women worldwide.18,19 Although most women are infected
upon the initiation of sexual activity, only 1% to 5% of women infected with HPV will develop
malignancies.18,19 Virtually, all cervical cancers are caused by the HPV infection, with HPV types 16
and 18 causing about 70% of all casesas well as close to half of vaginal, vulvar, and penile
cancers.18,19
Most recently, HPV infections have been found to cause cancer of the oropharynxwhich includes
the soft palate, the base of the tongue, and the tonsils.18,19 In the US, more than half of the cancers
diagnosed in the oropharynx are linked to HPV-16, and the incidence of HPV-associated
oropharyngeal cancers has increased during the past 20 years, especially among men. 18,19 It has been
estimated that by 2020, HPV will cause more oropharyngeal cancers than cervical cancers in the
US.19 Other strains of HPV are responsible for condyloma accuminatum (venereal warts), and a
variety of other warty lesions, which are especially common in the oral and genital mucosa of HIVinfected persons.18,19 At least 17 different HPV DNA types have been detected in oral mucosal
lesions; the most common of which included HPV DNA subtypes: 2, 6, 11, 13, 32 and 57.15,18,19 Oral
HPV presents itself as one or more soft, pink pedunculated, or sessile, masses that have a
cauliflower-like surface (Figure 9).15 The lip, gingival, palate, and tongue are the most preferred
sites, overall.15

Treatment is conducted by surgery, laser surgery, cryotherapy, or the use of topical agents, such as
podophyllin.15 Lesions may be very difficult to treat and have a strong tendency to reoccur. 15 The
best protection from an HPV infection may be vaccination. Gardasil (Merck & Co) is a
quadrivalent vaccine developed to prevent cervical cancer, precancerous genital lesions and genital
warts from HPV types 6, 11, 16 and 18. A second vaccine Cervarix (GlaxoSmithKline) is bivalent,
targeting two HPV types: 16 and 18. Both vaccines are approved for males and females ages 9 to 26
years of age, and are most effective when they are administered before the onset of sexual activity.

SUMMARY
STIs often are associated with oral manifestations. Oral health providers should be familiar with the
signs and symptoms of STIs, and refer patients for evaluation by a medical professional whenever
suspicious lesions are detected.

References:
1. Satterwhite CL, et al. Sexually transmitted infections among U.S. women and men: Prevalence and incidence
estimates, 2008. Sex Transm Dis 2013; 40(3): pp. 187-193.
2. Owusu-Edusei K, et al. The estimated direct medical cost of selected sexually transmitted infections in the United
States, 2008. Sex Transm Dis 2013; 40(3): pp. 197-201.
3. Centers for Disease Control and Prevention. CDC Fact Sheet, Incidence, Prevalence, and Cost of Sexually
Transmitted Infections in the United States. February, 2013, http://www.cdc.gov/std/stats/STI-Estimates-FactSheet-Feb-2013.pdf
4. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S.
Department of Health and Human Services; 2012. http://www.cdc.gov/std/stats11/surv2011.pdf
5. Centers for Disease Control and Prevention. CDC Fact Sheet, STD Trends in the United States, March 2013.
http://www.cdc.gov/std/stats11/trends-2011.pdf
6. Centers for Disease Control and Prevention. CDC Fact Sheet, 2011 National Data for Chlamydia, Gonorrhea, and
Syphilis 2011. Atlanta: U.S. Department of Health and Human Services;
2012. http://www.cdc.gov/std/stats11/trends-2011.pdf.
7. Centers for Disease Control and Prevention. Diagnoses of HIV Infection in the United States and Dependent Areas,
2011, HIV Surveillance Report, Volume
23. http://www.cdc.gov/hiv/surveillance/resources/reports/2011report/index.htm.
8. Centers for Disease Control and Prevention. Syphilis CDC Fact Sheet, Updated February, 2013.
http://www.cdc.gov/std/syphilis/STDFact-Syphilis-detailed.htm.
9. Douglas, JM. Penicillin Treatment of Syphilis, JAMA. 2009; 301(7):769-771.
10. Centers for Disease Control and Prevention. Gonorrhea CDC Fact Sheet, Updated February,
2013,http://www.cdc.gov/std/gonorrhea/STDFact-gonorrhea-detailed.htm.
11. UNAIDS. UNAIDS Repot on the global AIDS epidemic
2012,http://unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/20121120_UNAI
DS_Global_Report_2012_en.pdf.

12. Bartlett JG, Gallant JE and Pham PA, Medical Management of HIV Infection, 2012 Edition, Knowledge Source
Solutions, Durham, North Carolina.
13. Silverman S, Eversole LR and Truelove EL. Essentials of Oral Medicine, 2002, BC Decker, Inc. Hamilton, Ontario.
14. Little JW, Falace DA, Miller CS and Rhosus NL. Dental Management of the Medically Compromised Patient,
7th Edition, 2008, Mosby Elsevier, Saint Louis, Missouri.
15. DePaola L & Silva A: HIV infection/AIDS, Oral Care in Advanced Disease. Edited by Davies & Finlay, February,
2008, Oxford University Press, UK.
16. DePaola LG and Meeks VI. Human Immunodeficiency Virus, Acquired Immunodeficiency Syndrome, and Related
Infections; Chapter 3, In Cottones Practical Infection Control in Dentistry, 3 rd Edition, Lippincott Williams &
Wilkins, Philadelphia, 2008.
17. Centers for Disease Control and Prevention. Genital Herpes CDC Fact Sheet. Updated February,
2013.http://www.cdc.gov/std/Herpes/STDFact-herpes-detailed.htm.
18. Centers for Disease Control and Prevention. Genital HPV Infection Fact Sheet. Updated March, 2013.
http://www.cdc.gov/std/HPV/STDFact-HPV.htm.
19. National Institutes of Health, National Cancer Institute. HPV and Cancer, Reviewed March,
2012,http://www.cancer.gov/cancertopics/factsheet/Risk/HPV