Byline: Anil. Sukumaran
Syphilis has plagued humankind for over 500 years. After the first reported outbreaks that struck Europe in 1495, the disease spread rapidly to other continents and gushed to become a global pandemic. The infection rate dramatically decreased by the mid-20[sup]th century with the advent of antibiotic therapy. However, in the last decade, the infection with the bacteria Treponema pallidum has been re-emerging globally and more than 10 million cases are reported annually. Yet, the reason for the resurgence of this sexually transmitted infection remains poorly understood. The current data show 5 times more cases in London, 118% surge in Ireland, an increase of 163% more cases in America in a single year, 50% more cases in Australia, almost double the numbers in China and Russia than previous couple of years. Interestingly, 90% of all the cases aforementioned are among homosexual men and are strongly associated with human immunodeficiency virus (HIV) coinfection and high-risk sexual behavior.[sup],
This recent resurgence points at high-risk sexual activity, especially among men. Social media and networking play an important role in bringing a particular section of community together. Media apps and websites with hook up-driven themes among homosexuals or drug drove “chemsex” parties wherein they choose sexual partners depending on their HIV status along with use of drugs such as methamphetamines contribute to the increasing pattern in certain sections of society. This has been supported by the fact; when an infection is seen in a particular community or social network, a corresponding increase in incidence is seen in that group.[sup] With AIDS being a faint memory in the recent future, improper sexual habits are on rise especially with reduced use of condoms in certain parts of Europe and Canada. Factors that trended in the early 1990's still hold true for the current emergence, especially in developing countries such as China, India, and Brazil. These include globalization coupled with economic growth causing internal and external migration, increased traveling leading to increased sex trade and influences of various sexual ideologies, and wider socioeconomic inequality implications mainly affecting high-risk groups such as homosexuals, drug users, and sex traders.[sup]
Majority of cases are transmitted sexually although it may also be transmitted vertically from an infected woman to her newborn child. Transmission of syphilis occurs mostly through sexual intercourse and sites of inoculations are usually genital but can also be extragenital. The popularity of oral sex has been increasing in recent years in part because it is supposed to be a safer sex practice.[sup] Consequently, extragenital lesions, of which oral manifestations are the most frequent, have become more common. Since the oral lesions are highly contagious, reliability on correct diagnosis not only helps in proper management and nipping the chain of infection but also reduces the risk of transmission to the health care personnel.[sup],
Syphilis evolves through a series of four overlapping stages commonly known as primary syphilis, secondary syphilis, latent syphilis, and tertiary syphilis. Each stage has distinct clinical characteristics and degree of infectivity. Oral chancres are observed in about 4%–12% of patients with primary syphilis and occur at the site of penetration of the organism into the mucosa. The most common site is the tongue, gingiva, soft palate, and lips. Lesions appear as painless indurated ulcers associated with enlargement of the submandibular and cervical lymph nodes. In secondary syphilis, the oral manifestations are quite variable with no specific features. The most well-recognized and characteristic lesions are multiple mucous patches that are slightly raised and covered by grayish-white pseudomembranous lesion surrounded by erythema. The typical sites are the soft palate and pillars, tongue, and vestibular mucosa. Oral lesions are often painful and snail track ulcers result when multiple mucous patches become confluent. Tertiary syphilis manifests itself in the oral cavity as gumma localized mainly in the hard palate. Other sites may be the tongue, lips, and soft palate. Gumma starts as small ulcers that enlarge and may involve adjacent structures, if left untreated.[sup]
The health care providers should be more vigilant about the current situation and shoulder the role in early diagnosis, prevention, and management. The dentists in this era are less familiar with the oral lesions of syphilis and should be alert to suggestive oral lesions and include them in the list of differential diagnoses. The oral and systemic clinical manifestations of syphilis may resemble other similar entities, and both the clinical manifestations and the habitual diagnosis may be masked by the presence of coinfection with other pathogens such as the HIV. Stringent infection control measures in the clinic should be observed. Personal protective equipment should be worn at all times. Maintaining optimum hand hygiene especially before and after patient contact by the clinician and use of preprocedural mouthwash can go a long way in obliterating nosocomial infection.
In summary, an epidemic uptrend in syphilis is observed particularly in homosexual groups and this trend may continue in future. Syphilis has some important implications for the dental team. First, syphilis can result in oral manifestations, the first and second stages of which are highly contagious. Second, the disease can be transmitted by direct contact with oral lesions, saliva, and blood. Third, additional sexually transmitted diseases could be co-present and the risk of HIV infection could be greater. Finally, the dental team can play a role in making an accurate and early diagnosis and referring the patient for adequate treatment.
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