• Skin lesions are the main presentation of patients infected with monkeypox.
  • Perioral, oral, and oropharyngeal lesions are reported in up to 43% of patients. They are often confused with other viral infections, particularly herpes labialis and stomatitis.
  • Perioral, oral and oropharyngeal lesions can be the only presentation of monkeypox, depending on the mode of transmission.
  • Patients may present to oral health care clinicians due to the pain and unusual nature of the perioral, oral and oropharyngeal lesions.
Last updated: 28 September 2022
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What is monkeypox

  • Monkeypox is a viral infection that usually causes a rash. Most people recover within a few weeks.
  • The outbreak of monkeypox in NSW is predominantly occurring in gay, bisexual and other men who have sex with men (MSM).
  • Transmission occurs with prolonged direct close contact with someone who has monkeypox, or intimate contact of infected lesions of the skin including the genitals, lips, as well as the oral mucosa and oropharynx, which occurs with sexual activity.
  • Monkeypox can also be spread by contaminated materials, such as bedding and clothes, or more rarely, by inhaling large respiratory droplets, exhaled by someone who has monkeypox.
  • Skin lesions are a common symptom of monkeypox, presenting in 95% of documented cases. Perioral, oral, and oropharyngeal lesions occur in over 40% of cases. The pharyngeal lesions can be more infectious than the skin lesions.
  • Perioral, oral and oropharyngeal lesions can be the only presentation of monkeypox.

What is the monkeypox situation in NSW?

Since May 2022, there has been a global increase in monkeypox cases reported from multiple countries where monkeypox is not usually seen.

The World Health Organisation declared the monkeypox outbreak to be a Public Health Emergency of International Concern and it was declared a Communicable Disease of National Significance in Australia in July 2022.

The situation with monkeypox in NSW is changing rapidly. While most cases have been acquired overseas, a small number may have acquired their infections in Australia. Most cases in NSW are in gay, bisexual and other men who have sex with men.

The Public Health Laboratory Network (PHLN) and the Communicable Diseases Network of Australia have released guidelines around monkeypox testing and clinical management.

Presentation of monkeypox

  • Symptoms usually begin 7-14 days after exposure. This can be as short as a few days or as long as 21 days.
  • Monkeypox symptoms include:
    • rashes, pimple-like lesions, or sores, particularly in areas that are hard to see such as the genitals, anus or buttocks, and on the face, arms and legs.
    • ulcers, lesions, or sores in the mouth.
    • fever, headache, muscle aches, backache, swollen lymph nodes, chills and/or exhaustion prior to the rash or lesions developing.
    • the lesions start as a localised flat red macule that develops into pustules, which then form crusts or scabs and fall off.
  • Head and neck regional lymphadenopathy may be evident (with oral/perioral lesions).
  • The lesions of the perioral skin tend to be raised and single or of small number, with a pustular or pseudo-pustular centre. If untreated, the lesions can grow in size, then breakdown into an ulcer.
  • The lesions of the lips, oral and oropharyngeal mucosa tend to be ulcerative, of an irregular shape, and painful. A differential diagnosis includes trauma. However, the clinical features, pain, and lymphadenopathy warrants consideration of herpes labialis, herpes stomatitis (from herpes simplex virus, types 1 or 2) infection and recurrence.

Management of monkeypox

  • A patient who is experiencing concurrent malaise and flu-like symptoms and/or skin lesions should be referred to a NSW Sexual Health Clinic so an assessment for monkeypox can be arranged.
  • A swab from the base of the perioral/oral or oropharyngeal lesions should be taken and placed in a dry tube or viral transport media for PCR testing.
  • For guidance and advice, including the process for patient referral and collecting of samples, please contact an oral medicine specialist (see contact details at the end of this fact sheet).

Clinical presentations of monkeypox

Clinical presentation of monkeypox - Primary inoculation site with large pustule of the skin of the right lower faceClinical presentation of monkeypox - B. A pustular lesion with a crusted centre on the right lower lip.
Clinial presentation of monkeypox - C. Three confluent lesions of the left dorsal tongueClinical presentation of monkeypox - D. Ulcerative lesion of the right palatine tonsil.

A. Primary inoculation site with large pustule of the skin of the right lower face.

B. A pustular lesion with a crusted centre on the right lower lip.

C. Three confluent lesions of the left dorsal tongue.

D. Ulcerative lesion of the right palatine tonsil.

Attribution: Eloy José Tarín-Vicente EJ, Alemany A, Agud-DiosM, et al. Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. Lancet.

Articles in Press: Corrected Proof. Published: August 08, 2022, DOI  and The Lancet.
 

Infection control

  • Personal protective equipment (PPE) should be used for monkeypox and is the same PPE used for COVID-19.
  • Contact and droplet precautions are considered the minimum level of PPE:
    • protective eyewear/face shield
    • surgical mask or P2/N95 Respirator (fit checked) for prolonged care; aerosol generating activities
    • use of disposable impervious gown/gloves for patient and environment contact.
  • Linen or disposable materials that contact the patient’s lesions or oral secretions must be carefully placed in specified waste containers and disposed of immediately. Minimise shaking or flicking.
  • Donning: PPE should be donned before entering the patient’s room and used for all patient contact.
  • Doffing: Gown and gloves should be disposed of prior to leaving the self-isolation room, anteroom or designated doffing area where the patient is admitted (as per COVID-19 guidelines).

Environmental cleaning and disinfection

  • Cleaning should be done wearing the above PPE and using Therapeutic Goods Administration (TGA) approved cleaning and disinfection products that demonstrate efficacy against the vaccinia virus (for example, 0.1 % sodium hypochlorite or similar).
  • Attention should be paid to toilets and frequently touched surfaces, including in outpatient settings.

Oral medicine specialists – contact details

Westmead

  • Dr Ben Karim
  • Dr Sumar Sukumar
  • A/Prof Mark Schifter

Office hours: (02) 8890 8716

After hours: (02) 8890 5555

Sydney Dental Hospital

  • Dr Kenelm Kwong - Phone: (02) 9293 3333

Nepean Centre for Oral Health

  • A/Prof MD Iqbal Firoz - Phone 1300 769 221

Newcastle Community Dental

  • Dr Michelle Kang - Phone 1300 651 625
Current as at: Wednesday 28 September 2022
Contact page owner: Communicable Diseases