23 April 2023

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Increased incidence of scarlet fever, implications for dentistry

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A significant increase in the incidence of scarlet fever, mainly in Europe, has been noted during the COVID-19 postpandemic period. Scarlet fever is caused by a pyrogenic exotoxin-producing streptococcus—Streptococcus pyogenes—responsible for more than 500,000 deaths annually worldwide. 

This concise review, published online April 14 in the International Dental Journal, outlines the prevalence, pathogenicity, oral and systemic manifestations, as well as the dental implications of scarlet fever.

Historically, scarlet fever was considered a benign infection of early childhood, but its status changed in the early 19th century, when case-fatality rates dramatically started to surpass 15%. A more recent upsurge of scarlet fever and invasive Group A streptococcus (GAS) infection amongst children younger than 10 years in a number of European countries, including France, the Netherlands, Sweden, Ireland and the UK, particularly since September 2022, has rekindled the attention given to this disease.

Superantigens (SAgs) secreted by this GAS usually overstimulate the human immune system, causing an amplified hypersensitivity reaction leading to initial symptoms such as sore throat, high fever, and a sandpaper-like skin rash. There could be concurrent oral manifestations known as “strawberry tongue” or “raspberry tongue,” which may be first noted by oral health professionals.

The early diagnosis and treatment of this disease is critical to obviate the development of local and systemic sequelae such as acute rheumatic fever, endocarditis, and glomerulonephritis. Antibiotics should be prescribed early to mitigate its duration, sequelae, and community spread.

Dental practitioners should be aware of the early symptoms of scarlet fever for infection detection, emergency patient management, and appropriate referral. Patients with suspected cases should be advised on the importance of infection control including wearing of face masks so as to minimize the spread of the infection.

As dental professionals currently adhere to standard infection control measures coupled with transmission-based precautions, particularly due to the COVID-19 endemicity, there should be no additional risk of scarlet fever transmission of the disease in dental clinics. Nevertheless, it is salutary to have a strategic plan to manage scarlet fever amongst patients, some features of which are annotated below:

• The dental team should be alert to peaks and occurrence of scarlet fever outbreaks in the region and maintain an appropriate index of suspicion.
• A management plan for patients with suspected cases should be available and displayed prominently in the clinic, particularly during periods of outbreaks.
• Such a plan should include immediate management and referral data to the appropriate local medical centre dealing with such infectious diseases.
• All elective surgical procedures should be deferred until the patient fully recovers from scarlet fever.
• The local public health protection team and/or the patient's general medical practitioner should be approached for advice on the immediate management aspects of patients with acute cases.
• Additional droplet precautions such as wearing FFP3 respiratory masks may be necessary when acute patients are treated.
• In addition, the patient should be treated at the end of a clinical session, if possible, and a thorough disinfectant of the surgery undertaken thereafter.
• Equipment within the surgery should be kept to a minimum as much as possible during the surgical procedure.

Victor Haruo Matsubara, Janina Christoforou, Lakshman Samaranayake, "Recrudescence of Scarlet Fever and Its Implications for Dental Professionals," International Dental Journal, 2023, ISSN 0020-6539, https://doi.org/10.1016/j.identj.2023.03.009.