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FACT SHEET: Fifth Disease and Parvovirus B19 Infection (fifth disease is also known as “erythema infectiosum” and “slapped cheek disease”; caused by human parvovirus B19, which is also known as erythrovirus B19; the virus targets rapidly growing erythroid progenitor cells; the virus may also manifest as “papular-purpuric gloves and-socks syndrome” and other conditions)

Date of Publication: May 7, 2014
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Fifth disease received its name because it was fifth in a list of historical classifications of common skin rash illnesses in children.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • Yes, if the patient/client is contagious and/or has significant morbidity. Limiting exposure to a potentially infectious patient/client is particularly important if you, the dental hygienist, may be pregnant and not immune to parvovirus B19. 

Is medical consult advised? 

  • Yes, if the diagnosis is uncertain (including differentiation from rubella, scarlet fever, and erythema multiforme) and/or the patient/client is not already under medical care. If it is necessary to see a physician, the patient/client should call first to minimize exposure to others.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes, if the patient/client is contagious and/or has significant morbidity, including significant immunosuppression (including significant neutropenia), thrombocytopenia, anemia, or an aplastic crisis. An aplastic crisis is a medical emergency, which necessitates immediate referral and transfer to an appropriate facility for management.

Is medical consult advised? 

  • See above. 

Is medical clearance required? 

  • No, not typically.
  • Yes, if the patient/client has significant immunosuppression (including significant neutropenia), thrombocytopenia, or anemia.

Is antibiotic prophylaxis required? 

  • No, not typically.
  • Possibly, if there is significant immunosuppression (including significant neutropenia).

Is postponing treatment advised?

  • Yes, during the period of communicability, particularly if you, the dental hygienist, are pregnant (see below).
  • Yes, until patient/client is medically cleared if that person has significant immunosuppression, thrombocytopenia, or anemia.

Oral management implications

  • Mode of transmission is primarily through personal contact, via aerosols, respiratory secretions (including sputum and nasal mucus), or saliva droplets when an infected person sneezes or coughs. Transmission can also occur transplacentally from mother to fetus, and parenterally through transfusion of blood and blood products (for which risk is reduced in Canada, because of risk mitigation measures).
  • More common in children than in adults, fifth disease occurs sporadically or in epidemics. In persons with rash illness alone, the period of communicability is greatest before the onset of rash (i.e., when there was just “a cold”), with transmission less likely thereafter. However, children with the disease should be considered infectious from a few days before the onset of rash until the rash has faded, usually a span of one week to 10 days. For some persons, it may be safe to be around others and return to work once the rash appears. However, persons with aplastic crisis may be infectious for longer, and immunosuppressed people with chronic infection and severe anemia can be infectious for months to years.
  • It takes from 4 to 20 days after exposure to a person with fifth disease for a non-immune individual to develop a rash or, in susceptible persons (i.e., those with hemolytic anemia, such as sickle cell disease), symptoms of an aplastic crisis. Rash is often atypical or absent in adults. 20% to 25% of children and adults newly infected with parvovirus B19 do not have any symptoms.
  • Once recovery occurs from fifth disease, life-long immunity is generally conferred.
  • If you, the dental hygienist, are pregnant (or are immunosuppressed or have sickle cell disease or thalassemia or leukemia) and have never had fifth disease or other parvovirus B19 infection, you should avoid contact with persons with contagious erythema infectiosum. If you are exposed to parvovirus B19 virus and are non-immune, contact your physician. Exposed pregnant women can be offered parvovirus B19 antibody testing to determine susceptibility and to assist with counseling with regard to risk to their fetuses.
  • There is no vaccine or medicine that can prevent parvovirus B19 infection.1
  • All health care providers and patients/clients should follow strict infection control practices to prevent parvovirus B19 from spreading in the workplace.

Oral manifestations

  • Intra-oral manifestations of fifth disease are uncommon, although sore throat may occur along with other mild constitutional symptoms.
  • Stomatitis and/or petechiae2 on the lips and palatal/buccal mucosa may be seen in papular-purpuric gloves-and-socks syndrome, as well as other severe cases of parvovirus B19 infection, particularly in adults.
  • Mucosal bleeding can result from thrombocytopenia.
  • Peri-oral pallor often accompanies the “slapped cheek” rash.
  • Dental pulp can harbour some DNA viruses, including parvovirus B19, and be an anatomical site of virus tropism. However, research at this time points to viral persistence of parvovirus B19 rather than direct pathogenic activity.

Related signs and symptoms

  • Fifth disease usually presents in children as a mild illness with red rash. Mild constitutional symptoms — such as low-grade fever, runny nose, headache, and nausea — often precede onset of rash by several days. A striking redness of the face (“slapped cheek” appearance) is the most recognized feature of the illness; this is more common in children than adults. Some people may additionally develop a lace-like rash on the trunk or extremities several days later. This second rash may be itchy, especially on the soles of the feet and palms of the hands. This rash can vary in intensity and may come and go for several weeks, particularly upon exposure to sunlight or heat (e.g., bathing). As the second rash fades, it may look particularly lacy.
  • In adults, rash is often atypical or absent. While 25% or more of parvovirus B19 infections may be asymptomatic, arthralgias or arthritis (polyarthropathy syndrome) lasting days to even years may occur. Hands, feet, and knees are most commonly affected, with joint pain and swelling usually resolving in 1 to 3 weeks. In North America, 50% to 80% of adults have serological evidence of past infection, depending on age and location.
  • In young adults or children, parvovirus B19 infection may uncommonly present as symmetric, painful erythema and edema of the feet and hands known as papular-purpuric gloves-and-socks syndrome (PPGSS). There is a sharp demarcation of the papular, purpuric rash at the wrists and ankles, although other areas may also be involved. Patients/clients may experience fever, arthralgia, or both. Signs and symptoms usually resolve within 1 to 3 weeks.
  • While severe complications of parvovirus B19 infection are unusual, the body may temporarily stop making new red blood cells. This can lead to transient aplastic crisis in persons with anemia that requires increased red blood cell production (e.g., sickle cell disease and thalassemia). Persons who are immunosuppressed may develop severe, chronic anemia.
  • Immunocompromised persons may not develop the typical symptoms of erythema infectiosum, including rash or joint symptoms (which are likely immune-mediated). Due to an inadequate immune response, these patients/clients may instead experience chronic parvovirus B19 infection, which can lead to neutropenia (low neutrophil white blood cell count), thrombocytopenia (low platelet count), or complete bone marrow suppression.
  • Most pregnant women who are not immune do not have serious complications after they are exposed to others with fifth disease. They usually have only mild illness, and their fetuses usually do not have any problems. However, sometimes a fetus will develop severe anemia, which may be accompanied by thrombocytopenia (low platelet count). Infection in the first trimester may result in fetal loss or miscarriage. Infection in the second and third trimesters may result in fetal anemia, myocarditis, high output cardiac failure, hydrops fetalis (severe edema), and stillbirth. Fetal death occurs in up to 10% of infected fetuses. However, miscarriage happens in fewer than 5% of all pregnant women with parvovirus B19 infection, and this is usually confined to the first half of pregnancy.
  • Rarely, parvovirus B19 infection manifests as systemic vasculitis, autoimmune hepatitis, glomerulonephritis (a form of kidney inflammation), or myocarditis (which may lead to dilated cardiomyopathy, a form of heart muscle disease). Neurologically, seizures, meningitis, encephalitis, and encephalopathy, are other rare complications of parvovirus B19 infection.
  • Rheumatoid arthritis may be exacerbated by parvovirus B19 infection. In addition, emerging evidence suggests that the virus may trigger or exacerbate other chronic autoimmune diseases.

References and sources of more detailed information


Date: February 12, 2014
Revised: January 3, 2020; January 8, 2026


FOOTNOTES

1 The disease process typically resolves without intervention, and symptom control and supportive care form the basis of treatment. Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage fever, arthralgias, and headache. IV immune globulin may be of some benefit in patients/clients who are immunocompromised. In the event of aplastic crisis, red blood cell transfusions must be given as needed during the course of infection.
2 Palatal petechiae are tiny red or purple spots caused by bleeding underneath the palatal mucosa.


* 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.