FACT SHEET: Dengue (also known as “dengue fever” [“DF”] and “break-bone fever”, and, in its most severe forms, “dengue hemorrhagic fever” [“DHF”] and “dengue shock syndrome” [“DSS”]; caused by one of four dengue virus [DENV] serotypes)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- Yes, if the patient/client is febrile and/or has significant morbidity.
Is medical consult advised?
- Yes, if the diagnosis is uncertain and/or the patient/client is not already under medical care. If the patient/client has signs that may indicate progression to severe dengue (particularly persistent vomiting, severe abdominal pain, bleeding [especially mucosal], difficulty breathing, and hypotension), refer immediately for medical attention (i.e., hospital emergency department).
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Yes, if the patient/client is febrile and/or has significant morbidity.
Is medical consult advised?
- See above.
Is medical clearance required?
- Yes, particularly if severe dengue (such as dengue hemorrhagic fever [which involves a severe bleeding disorder] or dengue shock syndrome), is suspected.
Is antibiotic prophylaxis required?
Is postponing treatment advised?
- Yes, while patient/client is acutely ill. Patients/clients suspected of having dengue hemorrhagic fever or dengue shock syndrome should be referred for immediate medical attention.
Oral management implications
- Mode of transmission is primarily by bite of an infected mosquito (principally day-biting types that also transmit chikungunya virus, which are found in tropical and subtropical locales and are infected by biting persons with viremia1). Vertical maternal-fetal transmission in infected pregnant women also occurs. The incubation period in humans (i.e., time from mosquito bite to clinical signs/symptoms) is 3 to 14 days, and usually 4 to 7 days. Because of the approximately 7-day viremia in infected persons (from shortly before until the end of the febrile period), transmission can occur through exposure to infected blood, organs, or other tissues. While blood-borne transmission is possible (including, rarely, via needle stick injury), such transmission is highly unlikely in the dental hygiene setting with appropriate application of standard infection control precautions. This is particularly the case for dengue fever, which, unlike less common dengue hemorrhagic fever, does not involve life-threatening bleeding. Otherwise, direct person-to-person transmission of dengue does not occur.
- In Ontario, dengue hemorrhagic fever, a viral hemorrhagic fever, is a specified Reportable Communicable Disease (as per Ontario Regs 559/91 and amendments under the Health Protection and Promotion Act). Thus, physicians and laboratories are obligated to report this form of dengue disease to the local Medical Officer of Health so the local public health unit can ensure affected persons are appropriately managed and risk of transmission to others is minimized.
- Case-fatality rate of patients/clients with very severe dengue (i.e., DHF and dengue shock syndrome) can be reduced from ~10% to <0.1% by the timeliness and quality of clinical care received; hence, prompt medical referral is important.
- Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen and naproxen) should be avoided in all forms of dengue. Acetaminophen is the antipyretic and pain reliever of choice.
- The oral mucosa is affected in up to 30% of patients/clients with dengue viral infection, and more often in those with DHF than DF. Hemorrhagic bullae on the mucous membranes, brown plaques on the buccal mucosa, petechiae2, purpura, and ecchymoses (bruises) may be found.
- Gingival bleeding (sometimes spontaneous) is the most common oral finding. Other manifestations include erythema and crusting/coating of lips and tongue, spontaneous bleeding of the tongue, tonsillar inflammation, as well as small vesicles on the palate.
- In addition to oropharyngeal erythema, facial erythema may occur during the first 24 to 48 hours of dengue onset.
- Dysgeusia (altered taste) has been uncommonly reported with dengue infection.
- Enlarged tonsils, submandibular lymphadenopathy, and xerostomia may occur in patients/clients with dengue hemorrhagic fever.
Related signs and symptoms
- Dengue is the most common mosquito-borne viral disease globally, with 40% of the world’s population living in areas with dengue virus transmission (i.e., virtually all tropical and subtropical regions of Asia, the Americas, the Caribbean, Oceania, and Africa). Severe dengue affects most Asian and Latin American countries, and it has become a leading cause of hospitalization among children and adults in these regions. Areas that border dengue endemic regions (e.g., USA-Mexico border) may experience DenV introductions and epidemics. About 400 million infections and 100 million clinical (i.e., symptomatic) cases occur annually, and reported incidence is increasing.3
- Canadian travellers are at risk of contracting dengue in affected regions, especially in urban and suburban areas. The principal dengue mosquito vector Aedes aegypti is very common in the Caribbean basin, and Aedes albopictus is a secondary dengue vector in Asia. Depending on the timing of the bite of an infected mosquito, signs/symptoms may not manifest until the traveller has returned home. Currently, the Aedes mosquitoes that transmit DENV are not established in Canada.4
- Only a small proportion of dengue cases progress to severe dengue. 1 in 2,000 to 1 in 4,000 cases results in death, equating to about 22,000 deaths from severe dengue globally each year.
- Most dengue is a mild to moderately severe illness characterized by a high fever (typically lasting 2 to 7 days), sometimes accompanied by one or more of intense headache, retro-orbital eye pain, myalgia (muscle pain), arthralgia (joint pain), bone pain, anorexia, rash (flat or maculopapular), and mild bleeding (e.g., petechiae, purpura, tendency to bruise, and nose bleeds).
- Young children5 and those with their first dengue infection generally have milder signs/symptoms than older persons or those with repeat infections. Despite the name “break-bone fever”, fewer than half of infected persons exhibit classic muscle or bone pain. While lifelong immunity usually accrues to the specific DENV serotype causing infection, patients/clients remain susceptible to illness from other serotypes with which they have not yet been infected.
- Depending on severity of infection, dengue is associated with thrombocytopenia (low platelet count) and leukopenia (low white blood cell count).
- Dengue hemorrhagic fever is characterized by signs/symptoms initially consistent with dengue fever. However, when the fever declines, other sign/symptoms may develop, including vomiting, severe abdominal pain, and difficulty breathing. This marks the start of a 24- to 48-hour period when capillaries become excessively permeable, resulting in ascites (i.e., fluid in the peritoneal, or abdominal, cavity) and pleural effusions (i.e., fluid in the pleural cavities around the lungs). This can lead to failure of the circulatory system, shock, and followed by death if circulatory failure is not addressed. In addition, the patient/client with DHF has pronounced hemorrhagic manifestations, which include easy bruising, bleeding of the nose and gums, hematochezia (blood in stool), melena (black tarry stools due to upper gastrointestinal bleeding), hematemesis (vomiting of blood), hematuria (blood in urine), menorrhagia (heavy menstrual bleeding), and possibly internal bleeding.
- Clinically, patients/clients with severe dengue may present with hepatitis, myocarditis, pancreatitis, and encephalitis.
- While dengue’s signs/symptoms overlap with those of chikungunya, persons infected with DENV tend to have more bone and muscle pain, neutropenia, thrombocytopenia, and hemorrhagic manifestations. Persons infected with CHIKV are more likely to have high fever, pronounced joint pain, arthritis, rash, and lymphopenia. Compared with chikungunya, dengue is much more likely to become life threatening. The risk of severe dengue illness increases if one develops dengue fever a second, third, or fourth time.
References and sources of more detailed information
- Anekar J, Baipadavu J, Chirakara RA, Nappalli D, Kumar KS, John IE. Oral lesions associated with Dengue fever. J Indian Acad Oral Med Radiol. 2019;31:307-10.
- Roopashri G, Vaishali MR, David MP, Baig M, Navneetham A and Venkataraghavan K. Clinical and Oral Implications of Dengue Fever: A Review. J Int Oral Health. 2015 Feb;7(2):69–73.
- Mithra R, Baskaran P and Sathyakumar M. Oral presentation in dengue hemorrhagic fever: A rare entity. J Nat Sci Biol Med. 2013 Jan-Jun;4(1):264–267.
- Mobeen, N. Oral Manifestation of Chikungunya and Dengue Fever. J Pharm Sci & Res. 2015;7(9):769–771.
- Simcoe Muskoka District Health Unit
- Centers for Disease Control and Prevention (Division of Vector-Borne Diseases)
https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section10.html (includes Dengue Fact Sheet)
- Mayo Clinic
- World Health Organization
- Heymann DL (ed.). Control of Communicable Diseases Manual (20th edition). Baltimore: American Public Health Association; 2015.
1 In Africa, the virus is also maintained in a sylvatic cycle involving non-human primates and forest dwelling mosquitoes.
2 Petechiae and purpura are red or purple spots on the mucosa or skin, which do not blanch to applied pressure, caused by extravasation of blood (i.e., hemorrhages). Petechiae are pinpoint to pinhead in size (i.e., 1 to < 3 mm in diameter), whereas purpura lesions range from 3 to 10 mm in diameter.
3 While a dengue vaccine exists, its use is targeted for persons aged 9 to 45 years living in endemic areas who have had at least one documented dengue virus infection previously.
4 By contrast, Aedes albopictus has spread to more than 32 states in the USA, and more than 25 countries in Europe, largely due to the international trade in used tires (a breeding habitat) and other goods (e.g., lucky bamboo). This mosquito is highly adaptive.
5 Vertical transmission of dengue during pregnancy or around the time of birth can cause death of the fetus, low birth weight, and premature birth.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.