The dentist’s role in syphilis prevention and control

Dear Editor:

Syphilis remains a public health concern globally, and in Brazil, the disease has been presenting a significant increase in incidence since 2010. This infection affects more than 10 million people worldwide per year¹, with 60% or more incident cases occurring in men who have sex with men (MSM), mostly associated with human immunodeficiency virus (HIV) co-infection and high-risk sexual behavior².

The disease presents in four distinct stages that are characterized by particular symptoms, clinical manifestations, and levels of infectivity: primary, secondary, tertiary, and latent syphilis³. The clinical differentiation between the oral lesions in primary and secondary syphilis is based on the presence of painful symptoms and the number of lesions⁴.

Oral chancres in primary syphilis are characterized as painless ulcers, measuring 1 to 2 centimeters, with a firm and rolled border⁵. They manifest as a single ulcer, usually on the lip or more rarely on the tongue³. Oral chancres are observed in approximately 4% to 12% of patients with primary syphilis, located where the bacteria penetrate the mucosa⁶.

Secondary syphilis presents multiple and generally symptomatic ulcerations⁴. Oral ulcers are observed in 30% of cases of secondary syphilis, usually associated with other clinical manifestations. In these cases, the lesions are maculopapular, affecting the hard palate and, sometimes, the soft palate³.

Gumma-associated bony destruction and a possible predisposition to oral squamous cell carcinoma are associated with tertiary syphilis. A gumma manifests initially as one or more painless swellings, especially on the hard palate⁷.

Previous studies demonstrated that patients with syphilis present a higher risk of being infected by other sexually transmitted diseases (STDs), especially HIV, since syphilitic lesions are vulnerable sites for virus penetration⁸.

The clinical diagnosis of syphilis is challenging for the dentist due to the variety of clinical characteristics of oral lesions, which may be similar to other ulcerative injuries⁶. The differential diagnosis of oral lesions of secondary syphilis includes erythematous lupus, multiform erythema, stomatitis, pemphigus, idiopathic leukoplakia, lichen planus, and candidiasis, among others⁹.

Laboratory diagnosis confirmation of syphilis is performed using serological tests. Nevertheless, the diagnosis also needs a high index of clinical suspicion during anamnesis⁴, since clinical and histological findings may be subtle and imprecise, especially considering other more common diagnoses¹⁰. Therefore, dentists should include questions on a patient’s recent sexual history in the anamnesis and be prepared to recognize and diagnose oral and systemic manifestations of STDs, especially syphilis³.

Dentists undergo academic training that makes their participation in multi-professional teams important for diagnosis and treatment of STDs¹¹. Dental staff play a fundamental role in public health systems by guiding patients, performing accurate and early diagnosis, and referring patients to adequate treatment^1,12. Since oral lesions are highly contagious, the reliability of correct diagnosis aids adequate management, reduces the infection chain, and reduces the risk of transmission to health professionals.

REFERENCES

• ¹
  Sukumaran A. Resurgence of syphilis: Challenges for dental care providers. J Dent Res Rev 2016;3:115-6
• ²
  Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2016. Atlanta: U.S. Department of Health and Human Services; 2017.
• ³
  Minicucci EM, Vieira RA, Oliveira DT, Marques SA. Oral manifestations of secondary syphilis in the elderly -a timely reminder for dentists. Aust Dent J. 2013;58(3):368-70.
• ⁴
  Lim JHL, Chio MTW. Watch the Tongue. Annals Academy of Medicine. 2015; 44(12):575-6.
• ⁵
  Lu DJ, Zbar A. Atypical presentation of syphilis as an aphthous ulcer. CMAJ. 2017;189:E748.
• ⁶
  Fregnani ER, Perez-de-Oliveira ME, Parahyba CF, Perez DEC. Primary syphilis: an uncommon manifestation in the oral cavity. J Formos Med Assoc. 2017;116(4):326-7.
• ⁷
  Leão JC, Gueiros LA, Porter SR. Oral manifestations of syphilis. Clinics. 2006;61(2):161-6.
• ⁸
  Seibt CE, Munerato MC. Secondary syphilis in the oral cavity and the role of the dental surgeon in STD prevention, diagnosis and treatment: a case series study Braz J Infect Dis. 2016;20(4):393-8.
• ⁹
  Santos IS, Bastos DB, Valente VB, D’Vila SP, Tjioe KC, Biasoli ER, et al. Reemerging syphilis: diagnosis from oral lesions. J Oral Diag. 2017;2(1).
• ¹⁰
  Carbone PN, Capra GG, Nelson BL. Oral Secondary Syphilis. Head Neck Pathol. 2016;10(2):206-8.
• ¹¹
  Moleri AB, Lobo CB, Santos FR, Silva EJ, Gouvêas CVD, Moreira LC. Differential diagnosis of manifestations of syphilis and aids with lichen planus in mouth: case report. J Bras Doenças Sex Transm. 2012;24(2):113-7.
• ¹²
  Strieder LR, León JE, Carvalho YR, Kaminagakura E. Oral syphilis: report of three cases and characterization of the inflammatory cells. Ann Diagn Pathol. 2015;19(2):76-80.

Publication Dates

• Publication in this collection
  14 Feb 2019
• Date of issue
  2019

History

• Received
  13 June 2018
• Accepted
  12 Nov 2018