Introduction:
Syphilis, a sexually transmitted disease (STD), was identified in Europe around the end of the fifteenth century. In 1943, with the introduction of penicillin, the incidence of the disease considerably decreased. However, during the past decades, the incidence of syphilis has increased, and research now shows epidemiologic links between syphilis and human immunodeficiency virus disease. Syphilis is also the fourth most commonly reported infectious disease in the United States, leading in incidence apart from other STDs like gonorrhea, varicellae, and AIDS (acquired immunodeficiency disease).
How Is Syphilis Linked With HIV?
The genital ulcerations in syphilis represent a major risk factor for acquiring HIV through sexual transmission because it may act as a reservoir for further entry of viral particles. HIV infection may also definitively affect the course of syphilis, and this virus can also be responsible partially for syphilis-oriented treatment.
In HIV patients, however, who have contracted syphilis, the disease may follow a more serious way ahead; in HIV patients suffering from syphilis, the mortality risk is much higher because it is associated with serious neurological complications, even after conventional therapy and frequent relapse of infection are possible.
How Is Syphilis Classified?
Syphilis can be majorly classified based on etiology:
- Congenital.
- Acquired -
- Primary.
- Secondary.
- Tertiary or late syphilis.
Primary syphilis and secondary syphilis are almost defined for one year or less post the initial infection; however, the symptoms of tertiary syphilis usually manifest when it is untreated for more than one year. Congenital syphilis is characterized by the transmission of infection to the fetus in utero.
What Causes Syphilis?
The etiological agent of syphilis is the spirochete bacterium Treponema pallidum. Humans are the only known vectors for the life cycle of this bacterium. Transmission mainly occurs through these modes:
- Oral-genital.
- Oral-anal.
- Sexual contact.
- Transfusion of contaminated blood.
- Direct contact with any contaminated material.
- Intra-uterine transmission.
What Are the Systemic and Oral Manifestations of the Primary Stage Syphilis?
The initial lesions in primary syphilis are called a chancre. The syphilis oral manifestations appear one to two weeks after exposure to the Treponema pallidum, wherein the preliminary stage occurs at the inoculation site. The period of bacterial incubation can be extended up to 40 days. The lesions manifested are Erosive or ulcerated edges or appearance, singular and rather painless, with observable infiltration and hardened high margins. These lesions occur more commonly in the anogenital or even the oral cavity.
After the initial appearance of the chancre, it is accompanied by regional lymphadenopathy in the patient. Though these lesions undergo spontaneous healing within three to six weeks in most cases without any scar formation at the site of lesions, still certain indurate ulcerations can be observed orally on the tongue dorsum (alongside hyperplasic foliate papillae). Other oral manifestations include:
- Erythema or reddening at the site of lesions, swelling or edema, and petechial bleeding or hemorrhage may be seen in the region of the soft palate, which may be accompanied with or without the chancre.
- Asymmetry of the uvula or tonsillar pillars is also reported in some cases.
- The intra-oral ulcerations are often seen as a crateriform appearance along with a yellowish-colored transudate.
- If regional lymphadenopathy is present, then the lymph nodes on physical examination, especially if non-tender, should be noticed by the physician, dentist, or healthcare provider as a clinical means or symptom in the primary identification of patients at risk for acquiring sexually transmitted diseases.
What Is the Differential Diagnosis of Oral Syphilis?
- Squamous cell carcinoma: It is a common variety of skin cancer that develops into the squamous cells that produce the middle and outer layers of the skin.
- Orofacial tuberculosis: The lymph nodes are involved initially in this condition and present as a non-painful, or slow-growing swelling. In the later phases of the infection, pain, abscess, puss, and involvement of the nerves can be witnessed along with general symptoms like fever, cough, weight loss, etc.
- Herpetic or fungal infections: Infections caused by fungus.
- Generalized tuberculosis: It emerges when a tuberculous lesion gets into a blood vessel, dispersing millions of tubercle bacilli into the bloodstream and then throughout the body.
- Histoplasmosis: Histoplasmosis is an infection caused by a fungus called Histoplasma.
- Maxillofacial trauma: Trauma caused to the maxillofacial area.
What Are the Clinical Manifestations of Secondary Syphilis?
Secondary syphilis manifests a general systemic impact of this severe disease, with the lesions being highly contagious. The manifestation of secondary syphilis begins approximately four to eight weeks after chancre emergence when primary syphilis is left untreated. Initially, the lesions manifested are symmetrical, coppery-red or they may appear either rounded or oval spots (also termed roseolar rashes). Later, it may show papular cutaneous rash with palm and sole involvement. In this stage, there may be mucous patches and generalized micro-lymphadenopathy.
As opposed to first-stage syphilis, secondary lesions manifested orally are not only painful but often multiple lesions are observable with the onset of cutaneous eruptions. The patient may also suffer from fever, severe migraine headaches, and sore throat. Syphilis oral lesions in secondary syphilis are a pivotal finding if they can be reported by the dentist to the physician. The oral lesions are of either two types: macular or papular eruption accompanied by mucous patches. These lesions appear more oval or serpiginous, with slightly raised erosive borders, or may appear as shallow ulcers with erythematous borders. The overlying exudate opposed to primary syphilis, is now gray or silver white. Differential diagnosis of secondary syphilis includes a list of several infectious and non-infectious diseases.
What Are the Clinical Manifestations of Tertiary Syphilis?
Tertiary syphilis occurs in individuals with untreated primary or secondary syphilis post one year of viral contagion and spread. The destructive lesions of this phase are termed gumma. These lesions signify a chronic hypersensitivity reaction due to the systemic infiltration of the spirochete bacterium.
Oral manifestations include:
- Gumma is seen on the hard palate. These can be chronic and progressive and granulomatous.
- The lesions can perforate through the palatal bone into the nasal septum.
- The tongue may frequently resemble the appearance of being atrophic, fissured, or lobulated.
- In some cases, leukoplakic plaque is also present on the dorsal surface of the tongue.
Therefore, a follow-up of every three to six months by the physician and dental surgeon post-diagnosis of tertiary syphilis is mandatory. Also, a biopsy is recommendable by most surgeons because these lesions need to be observed for possible malignant transformation.
How Is Syphilis Diagnosed and Treated?
The most specific and sensitive serologic tests for syphilis advocated by the physician are:
- The fluorescent treponemal antibody absorption test.
- Micro-hemagglutination test; Both these tests are capable of detecting antibodies that are produced against treponemal antigens.
The treatment is a time-dependent phenomenon as per the strategy adopted by the physician based on the extent of the infection. The choice of drug for both primary and secondary syphilis includes two doses of Benzathine penicillin G (approximately around 2.4 million units injected intramuscularly). These dosage regimens are given one week apart; for tertiary syphilis, it may be even three to four dosing regimens. Patients allergic to Penicillin can be administered with alternative drugs of choice; either Tetracyclines or Ceftriaxone.
Conclusion:
Hence to conclude, the management of syphilis depends on the extent of infectious spread. In addition, the disease is highly contagious during the later stages due to systemic infiltration by infectious bacteria. Therefore, the treatment and prognosis are mainly dependent on early diagnosis.
