FACT SHEET: Mpox (also known as “monkeypox” and “MPX”, caused by mpox virus1)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- Yes, during the period of communicability (see below).
Is medical consult advised?
- Yes, if the patient/client is not already under medical care.2
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Yes, during the period of communicability (see below) and when there is significant morbidity.
Is medical consult advised?
- See above.
Is medical clearance required?
- No.
Is antibiotic prophylaxis required?
- No.
Is postponing treatment advised?
Yes, all non-essential (elective) dental/dental hygiene appointments/procedures (e.g., cleanings) should be postponed during the period of communicability (see below).
Oral management implications
- Mpox is a re-emerging infectious disease that has relevance to oral health professionals due to risks of cross-infection and occupational exposure. Oral health professionals also play a role in initial detection of the disease.
- Mode of transmission in the Canadian context is mainly person-to-person spread through direct contact with the rash/lesions or bodily fluids (including fluid or pus from skin lesions, as well as saliva, blood, and semen) of an infected person. Scabs are particularly infectious, and they may be found on the skin and mucosal surfaces (including the mouth and oropharynx). People can also contract mpox virus from contaminated objects (“fomites”) such as clothing, linen and eating utensils/dishes; through needle stick injuries in healthcare settings; or in community settings such as tattoo parlours.3 The virus can additionally spread through airborne droplets (from coughing, sneezing, talking, or breathing), although current evidence suggests respiratory transmission is likely limited and usually requires prolonged close proximity.
- The signs/symptoms of mpox develop 3 to 21 (usually 7 to 10) days after exposure to the virus (i.e., the incubation period) and last 14 to 28 days. Mpox is considered contagious to others once signs/symptoms begin.4 Communicability is considered over once there are no signs/symptoms and the rash or sores have scabbed over and fallen off with a fresh layer of skin formed underneath.
- The main risk of virus transmission in the dental/dental hygiene office setting is likely through direct contact with skin lesions or clothing that has been in contact with lesions. However, although the airborne route is not the main route of transmission, it is an important consideration in dental/dental hygiene settings given that certain procedures may generate infected droplets and aerosols. Also, increased risk accrues from close and extended contact with infected patients/clients.
- Suspected mpox cases should be reported as soon as possible to local public health authorities (i.e., local public units in Ontario) by designated parties (see below). At the time of writing this fact sheet, the Greater Toronto and Ottawa areas are regions of heightened concern.
- Standard precautions are likely to be effective to control the risk posed by mpox in dental/dental hygiene settings. However, if a person with known, probable, or suspected mpox presents in a healthcare setting, isolation precautions should be implemented. This includes wearing of masks by healthcare providers (ideally at least N-95 equivalent) and by the person with suspected, probable, or confirmed mpox (typically at least a surgical mask). Any exposed skin lesions should be covered. More information on infection, prevention, and control procedures (including environmental cleaning and disinfection) related to healthcare worker interaction with persons with suspect, probable, or confirmed mpox can be found at https://www.publichealthontario.ca/-/media/Documents/M/2020/monkeypox-ipac-recommendations-healthcare-settings.pdf?sc_lang=en.
- A fallow time between patients/clients is not required for mpox.
- In Ontario, a 2-dose primary series with Imvamune®5 vaccine is publicly funded and recommended for people at high risk of mpox.6 Additionally, immunization is funded and recommended following high-risk exposure to a probable or confirmed case of mpox or within a setting where transmission is happening.7 Currently, pre-exposure immunization is not routinely recommended for healthcare professionals.
- Healthcare workers who contract mpox should refrain from working during the period of communicability (i.e., from the start of signs/symptoms, including prodromal symptoms, and until the rash/lesions have scabbed and fallen off and new skin is present underneath).
- Persons who are contacts of a person with mpox are not considered contagious during their incubation period (i.e., prior to sign/symptom onset, typically 3 to 21 days post-exposure).
- Contacts (including healthcare workers and patients/clients) of a confirmed, probable, or suspect mpox case should self-monitor for signs/symptoms of mpox and self-isolate if these develop, pending further direction from public health.
- In Ontario, mpox 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 (and other designated parties) are obligated to report this disease to the local Medical Officer of Health8 so the local public health unit can take measures to limit spread to susceptible persons. Immunization of exposed susceptible contacts can limit the spread of disease.
- To reduce acquisition of, and spread from, sexually transmissible infections (including mpox) in the oral cavity, condoms or dental dams should be used for all oral-genital and oral-anal contact.
- Occasionally, oral ulcers can impair a patient/client’s ability to eat and drink, causing dehydration and malnutrition. Saltwater rinses can be useful in the management of sores in the mouth.
Oral manifestations
- The characteristic rash/lesions (see below) frequently affect the oral cavity and perioral structures9, and mucosal lesions in the mouth often precede skin lesions on the face and extremities.
- Perioral mucocutaneous lesions may present as papules, which evolve into blisters and ulcers around the lips, chin, and nose.
- Oral lesions predominately occur in the pharynx/oropharynx, tonsils, buccal mucosa, and tongue. Similar to skin lesions, oral lesions typically progress through maculopapular, vesicular, pustular, and erosive (ulceration) phases over a period of 14 to 21 days, potentially resulting in depigmented scars.
- While the primary oral presentation of mpox is likely to be pink macules or papules on the oral mucosa, papules (and vesicles) are infrequently seen intraorally, because they soon burst due to tongue movements and chewing, leaving a residual crateriform red lesion. Thus, the dental hygienist (or dentist) may be the first to note the eruptions during routine examination of the oral mucosa, particularly because the patient/client may be unaware of their existence given that the lesions are not painful in the early maculopapular phase.
- Sore throat is a common symptom. Less frequent manifestations include petechiae, white spots on the tonsils, hyperemia, erythema, a pseudomembranous appearance10, tonsillar pain, limited mouth opening, muffled speech, dysphagia, and odynophagia (painful swallowing).
- Cervical and submandibular lymphadenopathy (swollen lymph nodes) are common.
Related signs and symptoms
- While non-travel related mpox was not found in Canada prior to 202211, person-to-person transmission is currently ongoing. Most cases thus far are in persons who self-identify as gbMSM (gay, bisexual and other men who have sex with men), especially those with multiple sexual partners. This is consistent with international trends in countries where mpox did not occur before the ongoing global outbreak. However, the risk of exposure to the mpox virus is not exclusive to any group or setting. 234 confirmed cases occurred in Ontario from January 1 to October 19, 2024 versus only 33 in all of 2023. The ongoing global outbreak of clade IIb mpox has caused more than 100,000 cases in 122 countries, including 115 countries where mpox was not previously reported.
- Mpox illness typically presents with prodromal symptoms (e.g., fever, chills, headache, myalgia [muscle pain], arthralgia [joint pain], fatigue, headache, backache) followed by a progressively developing rash/lesions 1 to 4 days later that usually start on the face and then spread elsewhere on the body. In some instances, the first signs of mpox illness are oral, genital, or perianal lesions prior to the onset of the usual prodromal signs/symptoms.
- The rash/lesions of mpox are usually concentrated on the face, palms of the hands, and soles of the feet, although they may be more widespread. While the rash often begins on the face, it can also start on other parts of the body where contact was made, such as the genitals. Individual lesions generally progress through the following appearances: macules (flat, discoloured areas of skin), papules (raised firm lesions), vesicles (lesions with clear fluid), umbilicated pustules (lesions with yellowish fluid), and finally crusted lesions. The often blackish crusts eventually fall off. The rash may be painful.
- Mucosal involvement and generalized lymphadenopathy are common.
- Respiratory symptoms such as nasal congestion and cough may occur.
- In the 2022 global outbreak, proctitis (inflammation of the rectal lining) was the predominant gastrointestinal manifestation in patients/clients with mpox. Other gastrointestinal manifestations included abdominal pain, diarrhea, nausea, rectal bleeding and pain, tenesmus12, and vomiting.
- Dysuria (painful urination) can occur if the urethral mucosa is involved.
- Mpox tends to be a self-limiting infection, and most persons recover on their own after a few weeks. However, complications such as secondary infection, encephalitis, pneumonia, and keratitis (inflammation of the cornea of the eye) can arise.13
- For the clade II type of virus currently circulating in Ontario, the risk is low for severe illness that requires hospitalization. More than 99% of people survive clade II infection. This is in contradistinction to the clade I type circulating in parts of Africa, which historically had a case fatality rate of 10%, although recent outbreaks have seen lower death rates in the 1 to 3.3% range.
References and sources of more detailed information
- Issa AW, Alkhofash NF, Gopinath D, Varma SR. Oral Manifestations in Monkeypox: A Scoping Review on Implications for Oral Health. Dent J (Basel). 2023 May 12;11(5):132. doi: 10.3390/dj11050132. PMID: 37232783; PMCID: PMC10217612.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10217612/# - Halani S, Mishra S, Bogoch II. The monkeypox virus. CMAJ. 2022 June 20;194:E844. doi:10.1503/cmaj.220795.
https://www.cmaj.ca/content/194/24/E844 - Amato M, Di Spirito F, Boccia G, Fornino D, D’Ambrosio F, De Caro F. Human Monkeypox: Oral Implications and Recommendations for Oral Screening and Infection Control in Dental Practice. J Pers Med. 2022 Dec 2;12(12):2000. doi: 10.3390/jpm12122000. PMID: 36556221; PMCID: PMC9788482.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9788482/ - Zemouri, C, Beltrán, E, Holliday, R et al.Monkeypox: what do dental professionals need to know?. Br Dent J. 2022;233:569–574.
https://www.nature.com/articles/s41415-022-5079-8 - Allan-Blitz LT, Klausner JD. Current Evidence Demonstrates That Monkeypox Is a Sexually Transmitted Infection. Sex Transm Dis. 2023 Feb 1;50(2):63-65. doi: 10.1097/OLQ.0000000000001705. Epub 2022 Oct 28. PMID: 36098576; PMCID: PMC9855745.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9855745/ - Lakshman S, Sukumaran A. The Monkeypox Outbreak and Implications for Dental Practice. International Dental Journal. 2022;72(5): 589-596.
https://doi.org/10.1016/j.identj.2022.07.006 - City of Toronto
https://www.toronto.ca/community-people/health-wellness-care/information-for-healthcare-professionals/communicable-disease-info-for-health-professionals/mpox-information-for-health-professionals/ - Public Health Matters for Health Professionals, York Region Public Health
https://mailchi.mp/york/public-health-matters-sept2024-13866606?e=905937d42d - Public Health Ontario
https://www.publichealthontario.ca/-/media/Documents/M/24/mpox-ontario-enhanced-episummary.pdf?rev=96972e9466764977a8d4f10b37ae756e&sc_lang=en
https://www.publichealthontario.ca/-/media/Documents/M/2020/monkeypox-ipac-recommendations-healthcare-settings.pdf?sc_lang=en - Government of Canada
https://www.canada.ca/en/public-health/services/diseases/mpox/risks.html
https://www.canada.ca/en/public-health/services/diseases/mpox/outbreak-update.html - Centers for Disease Control and Prevention (CDC)
https://www.cdc.gov/mpox/index.html
https://www.cdc.gov/mpox/situation-summary/index.html - Indiana Department of Health
https://indental.wpenginepowered.com/wp-content/uploads/22_Monkeypox-flyer-oral-health.pdf - Decisions in Dentistry
https://decisionsindentistry.com/article/presentation-monkeypox-dental-setting/ - Pan American Health Organization (PAHO)
https://www.paho.org/en/mpoxdisease# - FDI World Dental Federation
https://www.fdiworlddental.org/what-are-implications-monkeypox-outbreak-dental-practice-discover-now - Heymann DL (ed.). Control of Communicable Diseases Manual (21st edition). Washington, DC: American Public Health Association; 2022.
FOOTNOTES
1 Mpox virus causes a disease similar to, but less severe than, variola virus, which causes smallpox. Mpox is a zoonotic disease (i.e., a disease that can spread from animals to humans) that is endemic to parts of Central and West Africa where its natural reservoir is thought to involve small mammals and non-human primates. There are two types (clades) of mpox virus. Clade I (“Central African”) was responsible for the 2024 outbreak in Africa. Clade II (“West African”) was responsible for the 2022 multi-country mpox outbreak beyond areas of endemicity, and ongoing localized transmission continues to result in infections in Ontario, including the uptick in cases in 2024. On August 14, 2024, the World Health Organization (WHO) declared mpox a Public Health Emergency of International Concern due to the spread of the more severe clade Ib strain of the virus in countries in West and Central Africa. At the time of writing this fact sheet, no cases of mpox clade Ib have been reported in Ontario, and the overall risk of mpox to people in Canada remains low. A previous Public Health Emergency of International Concern for mpox was in place from June 23, 2022 until May 10, 2023. This was due to the multi-country outbreak of mpox caused by clade IIb mpox virus in previously non-endemic countries, including Canada.
2 In addition to being diagnosed clinically, mpox viral infection can be confirmed in the laboratory by polymerase chain reaction (PCR) testing of specimens taken directly from the rash – skin, fluid, or crusts – that are collected by vigorous swabbing. In the absence of skin lesions, testing can be done using swabs of the throat or anus. Treatment of mpox mainly consists of supportive care, including good hydration with fluids, rest, skin care, and antipyretic (anti-fever) medications. Antiviral therapy may be a consideration in severe or complicated cases. When other persons are present, the lesions should be covered and the affected person should wear a mask.
3 Additionally, the virus can be acquired transplacentally, during or after birth, or via physical contact with an infected animal (which historically was the main mode of transmission in Africa until the more recent rise in human-to-human transmission). Animals do not currently play a role in the spread of mpox in Canada.
4 Some experts (although not Public Health Ontario nor the Centers for Disease Control and Prevention) suggest that an infected person may be contagious to others up to 4 days before the onset of signs/symptoms. However, at the time of writing this fact sheet, there is no robust evidence demonstrating that asymptomatic people have spread the virus to someone else.
5 Imvamune® is a non-replicating orthopoxvirus vaccine. In addition to offering protection against mpox, it also protects against smallpox (which was globally eradicated in 1980).
6 Persons considered at high risk of mpox in Ontario include:
- men who have sex with men and:
- have more than 1 partner or are in a relationship where at least 1 of the partners has other sexual partners
- have had a confirmed sexually transmitted infection in the past year, or
- engage in sexual contact in sex-on-premises venues
- persons who have a sex partner who meets the criteria above
- sex workers
- persons who work or volunteer at sex-on-premises venues and have contact with contaminated objects or materials without using personal protective equipment
- persons who engage in sex tourism
- persons who expect to experience any of the above scenarios.
7 In post-exposure vaccination, the first dose should be ideally offered within 4 days (up to 14 days) from the date of the last exposure to individuals who are a high-risk contact of a confirmed or probable case of mpox. The second dose should be offered at least 28 days after the first dose if mpox infection did not develop.
8 It is also a requirement for Ontario-licensed dentists to report a suspected or confirmed case of a reportable communicable disease (including mpox) to their local Medical Officer of Health.
9 Depending on the citation, the oral mucosa is affected in about 70% of mpox cases, and oral ulcers occur in 25% or more of cases.
10 Pseudomembranous lesions may resemble those of oral candidiasis.
11 Prior to 2022, essentially all mpox cases outside of Africa were related to travel to endemic areas.
12 Tenesmus is the physical sensation of incomplete defecation, which may occur even if the rectum is empty.
13 Persons more likely to develop severe illness may include those with severely weakened immune systems, children younger than one year of age, people with a history of eczema, and people who are pregnant.
* 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.