Introduction:
According to global statistics and documented case reports across the world, there appears to be a significant rise in the cases of scarlet fever in recent times. This has also observed that the rise has been seen mainly in Europe countries during the COVID-19 post-pandemic period as per current medical research. It is in fact currently held responsible for more than 500,000 deaths annually throughout the globe. Scarlet fever is a disease that is primarily caused because of pyrogenic or exotoxin-producing bacteria. The streptococcus species or the streptococcus pyogenes bacteria is the main causative organism behind it. The unique and deadly manifestations of scarlet fever are because of the superantigens (SAgs) secreted by the group A streptococcus (GAS).
What Is the Prevalence of Scarlet Fever?
Though scarlet fever would possibly affect individuals in any age group, the most common age group affected by this disorder belongs to the first and second decades of life. The school-going children as well as young adults between five to fifteen years have an increased prevalence of this Infection. The prevalence is specifically observed during the winter and spring seasons globally.
The disease of scarlet fever is primarily characterized by a sore throat with an erythematous or edematous oral manifestation in the mouth. Cervical lymphadenopathy would be a common finding by the oral and maxillofacial surgeon upon extra oral inspection. Patients can also complain of abdominal pain, vomiting, and tender or painful cervical lymph nodes. Such systemic symptoms are features of infection by these highly contagious streptococcus pyogenes organisms.
What Is the Mode of Transmission?
Transmission of scarlet fever would usually occur either by close contact with the infected individuals or even possibly through droplet spread via either cough or sneezing. The infection can also spread to healthy individuals by direct salivary contact with an infected person, through nasal fluids, or by skin-to-skin contact with the infected lesions. Current research also suggests that direct contact with either objects or surfaces contaminated by the GAS organisms can prove to be a common route for the spread of infection.
Foodborne transmission though uncommon, can be associated also with the transmission of scarlet fever (for example the outbreak of infections at a community level).
The nature of this disease is that it is quite acute in symptoms, initially presenting only with sore throat and fever, however when these GAS colonize the upper respiratory tract, then oropharyngeal infections are quite common as well in infected individuals.
Medical literature states that approximately 12 percent of all children globally infected by GAS would be silent carriers of the organism. In the asymptomatic forms of scarlet fever, the child or young adult may only show signs of streptococcal pharyngitis infections.
What Is the Nature of Infection?
These GAS /Group A streptococcus secrete superantigens. These have a deadly or pathogenic mechanism of action in the infected host and hold the potency to overstimulate the immune reactions. This causes an amplification in the individual hypersensitivity reactions as well as altered immunity and reactions. This manifests more either on the skin in and around the mouth or even in the throat. The initial clinical symptoms of scarlet fever are known to be pyrexia in affected patients (high fever of acute origin), sore throat, and skin rashes that have a sandpaper-like texture or consistency. Dental or maxillofacial surgeons can usually come across or encounter such clinical cases with the common oral manifestations known as the “strawberry tongue” or the raspberry tongue. It's essential that oral health professionals detect this initial or classic form of scarlet fever in affected individuals that can help them in timely interdisciplinary management and long-term recovery from the disease. Based on culture and sensitivity tests, the antibiotics would be decided by the oral surgeon or the physician. It is important hence that dental practitioners are aware of the first signs or early symptoms of scarlet fever such as the strawberry or raspberry tongue for the detection of infections so they can refer the case immediately to the physician.
What Is Strawberry Tongue?
One of the unique and pathognomonic signs of this infection is that the patient's face may appear to be flushed or have very light skin only around the mouth region (known as circumoral pallor). This can give the appearance of an erythematous skin rash on the face in the infected individual with scarlet fever Intraorally, the most common observation by a dentist would be that of a yellowish-white colored coating over the taste buds or the red papillae covering the tongue. While the coating appears yellow-white, the subsequent fading of it would lead the remaining area or a patch of the tongue to retain a residual bright reddish coating. This is the terminology behind the strawberry tongue or raspberry tongue of the filiform and fungiform papillae in scarlet fever. Furthermore, these tongue papillae would be inflamed or swollen leading to more redness or erythematous appearance worsening the clinical symptoms or appearance of the tongue.
It's also not uncommon to observe fissured lips or enlarged and edematous tonsils that may be presenting with pus or exudate. These are common oral signs of GAS (Group A Streptococcus) induced scarlet fever infection.
What Are the Differential Diagnoses?
It is important for the dentist to establish a confirmative diagnosis of this disease by looking at the lesions of differential diagnosis.
Viral infections, for instance, measles or rubella may present with oral and skin rashes as well as areas of skin or tongue papilla desquamation which are similar in clinical features. The main way to differentiate the viral lesions from these GAS lesions is by the presence of pastia lines. These lines appear as persistent erythematous spots that do not disappear even upon the compression of the infected skin on the neck, trunk, or groin. In viral lesions such as measles and rubella, pastia lines even if present will disappear upon compressing the infected spot or area.
Also, one more major way of differentiation is that there are absolutely no signs of any upper respiratory tract infections or inflammation as such in patients suffering from scarlet fever. A tonsillar swab for culture sensitivity can be highly beneficial for establishing a confirmative diagnosis of scarlet fever. Though, rapid antigen tests or bacterial culture of the lesions with the presence of GAS can confirm the diagnosis.
How to Manage Scarlet Fever?
Management of scarlet fever is mainly aimed at the reduction of clinical symptoms. This is done by preventing undue systemic complications. Extreme care should be taken by the parents of the ward or the physician or the dentist in controlling the risks of transmission of infections from the child to the young adult to others (till Infection subsides completely).
The oral and maxillofacial surgeon or the physician usually prefers the Penicillin group drugs as the main drug of choice for antibiotic therapy. However other drugs like Cephalexin, Cefadroxil, or broad-spectrum antibiotics like Clarithromycin can also be alternative medications for Penicillin-allergic patients (as recommended by the professional health-care provider).
Steps should be taken by the parents of the individuals affected by scarlet fever post-diagnosis and through the management of lesions as well as isolating properly. This helps to maintain good hand and oral hygiene. Following the instructions of the dentist or the physician for respiratory etiquette is crucial in reducing the transmission of scarlet fever Infection.
Conclusion:
Early diagnosis and treatment are extremely important for managing the general and oral manifestations of this life-threatening disease. It is also important for the interdisciplinary team of the dentist and physician to prevent local complications. Suppurative or nonsuppurative sequelae such as cervical lymphadenitis, invasive GAS infections, peritonsillar abscesses, retropharyngeal abscesses, hepatitis, gallbladder hydrops, and splenomegaly should be diagnosed properly and treated accordingly. Early diagnosis and prevention are important for preventing life-threatening local or systemic conditions as well as complications like acute rheumatic fever, endocarditis, and glomerulonephritis.
