The Oral Manifestations of Infectious Syphilis

The Western Australia (WA) Department of Health has issued an alert due to the increase in syphilis notifications, and the state-wide rate of infectious syphilis doubled between 2018 and 2022. Syphilis can be challenging to diagnose because of its varied presentations and has often been described as the “great imitator.” Dental and health professionals involved in oral care need to be aware that syphilis can present in the oral cavity.

Communities at risk include:

• People experiencing homelessness

• People who use methamphetamine and/or inject drugs

• Aboriginal people

• Culturally and linguistically diverse (CaLD) people

• Women of reproductive age

• Men who have sex with men (MSM)

Clinical presentation of infectious syphilis

Clinically, syphilis may present at one of three stages: primary, secondary and tertiary syphilis. Each can have different clinical presentations and infectivity (Syphilis - STI Guidelines Australia). Oral lesions may occur at any of the three main stages of the clinical course.

Primary syphilis

The mouth can be the site of primary syphilis, particularly with the rise in oral sexual activity. A chancre, a painless, indurated ulcer at the site of inoculation, characteristically develops within one to four weeks of acquisition after an incubation period. There may be accompanying regional lymphadenopathy. Typical sites include the lips, buccal mucosa or the tongue (Figure 1). Chancres may resolve without treatment.

Secondary syphilis

The features of secondary syphilis reflect the hematogenous spread of T. pallidum, and typically appear four to six weeks after the primary event. The oral manifestations of secondary syphilis can be more extensive and/ or variable than those of the primary disease (Minicucci et al. 2013) and arise in at least 25-30% of patients with secondary syphilis (Carbone et al. 2015, Leao et al. 2006).

Systemic symptoms include malaise, fatigue, fever, headache and a hallmark rash, which is classically a maculopapular rash diffusely involving the trunk and extremities including the palms and soles (Figure 2; Carbone et al, 2015). Condyloma lata (white gray mucous patches) are mainly found in the genital or anal area in 5–22% of patients (Ficarra and Carlos 2009).

Multiple ulcerative lesions of the hard and soft palate have been observed (Minicucci et al. 2013) as well as the tongue, gingiva and lips (Porto Matias et al. 2020). Other oral cavity manifestations can include macular or papular lesions and mucous patches.

Tertiary syphilis

In about one third of patients with untreated syphilis, long-term complications develop (Ficarra and Carlos 2009). The oral complications of tertiary syphilis include gumma formation, and much more rarely, syphilitic leukoplakia. Gummas tend to arise on the hard palate and tongue, although very rarely they may occur on the soft palate, lower dental alveolus, and parotid gland (Minicucci et al. 2013).

Diagnosis

The diagnosis of syphilis may require a knowledge of the patient’s sexual history, physical examination, and an interpretation of serological and microbiological findings. A biopsy may not be required. The patient should promptly be referred to their medical practitioner for investigation and management or referred to a specimen collection centre for a syphilis polymerase chain reaction (PCR) swab and syphilis serology.

Testing for other pathogens may be warranted (e.g. herpes simplex virus; HSV). Ensure the patient’s medical practitioner or primary healthcare provider receives a copy of the results, as treatment and contact tracing will be required rapidly, if the result is positive. Re-infection can occur so contact tracing is essential and sexual partners need testing and treatment. Syphilis is a nationally notifiable disease, so the local public health unit (https://www.healthywa.wa.gov.au/ Articles/A_E/Contact-details-forpopulation-public-health-units) may provide the patient’s medical practitioner with support for contact tracing in certain circumstances.

Treatment

Management by a medical doctor usually requires a long-acting penicillin and may include desensitisation if the person has a penicillin allergy.

Infectious syphilis (infection within 2 years i.e. primary, secondary, early latent)

Benzathine benzylpenicillin (Bicillin® L-A) injection - 2.4 million units IM stat

Notes on medication

• Benzathine benzylpenicillin (Bicillin® L-A) is different from benzylpenicillin (BenPen®) and procaine penicillin (Cilicaine®). Must ensure correct formulation is given.

• Benzathine benzylpenicillin injection comes as 1.2 million units in a 2.3mL single use pre-filled syringe.

• Two vials are required for each dose.

• Benzathine benzylpenicillin (Bicillin® L-A) is available in the Doctor’s Bag. (https://www.pbs.gov.au/browse/doctorsbag)

*If allergic to penicillin or if tertiary syphilis is suspected, please refer to the Silver Book or obtain advice from a sexual health or infectious diseases specialist.

Dr Amanda Phoon Nguyen

Oral Medicine Specialist, amanda@pomds.com.au

Dr Suzanne McEvoy, MBBS (Hons), MAppEpid, PhD, FAFPHM

Public Health Physician, Metropolitan Communicable Disease Control, North Metropolitan Health Service, Perth WA, suzanne.mcevoy@health.wa.gov.au

Further Reading https://sti.guidelines.org.au/sexuallytransmissible-infections/syphilis/

Leão JC, Gueiros LA, Porter SR. Oral manifestations of syphilis. Clinics (Sao Paulo). 2006 Apr;61(2):161-6. doi: 10.1590/s180759322006000200012. Epub 2006 Apr 25. PMID: 16680334.

Leuci S, Martina S, Adamo D, Ruoppo E, Santarelli A, Sorrentino R, Favia G, Mignogna M. Oral Syphilis: a retrospective analysis of 12 cases and a review of the literature. Oral Dis. 2013 Nov;19(8):738-46. doi: 10.1111/odi.12058. Epub 2013 Jan 7. PMID: 23294141.

References on request

“AESTHETICS FORUM”

Extracted natural teeth, including Upper Molars, Lower Molars and especially Upper Anterior natural teeth are needed for the production of Student Endodontic models for 2023 and WA Dental CPD endodontic courses.

The teeth will need to be saved in saline or bleach and can be dropped off when attending events at ADA House or OHCWA (marked for OPTECH). Alternatively, arrangements can be made for their collection. For further details, please contact Christine Ludgwick | OHCWA christine.ludgwick@uwa.edu.au 08 6457 7679

Dr Jenny Ball | ADAWA jenny@adawa.com.au 0419 044 549