Syphilis

• Caused by Treponema pallidum

• It is transmitted by direct contact with a clinically-detectable lesion and forms a variety of wide-spread lesions.

• The syphilis organism is motile, can pass through minute skin/mucosal abrasions, and probably can pass through intact skin/ mucous membrane.

• While it is theoretically possible for a• dentist or dental hygienist to contract the

disease from contact with an active oral lesion, this rarely happens.

• Now proper barrier techniques are used in dental practice (asepsis, gloves, masks, and gowns), transmission to dental personnel should never occur.

Pathogenesis

• Within days the spirochetes have multiplied dramatically (spirochetemia).

• In spite of the widespread infection, the patient has no fever and otherwise feels just fine.

• The spirochetemia persists for months to years; the reason for this wide variation is unknown.

Patterns of Infection• There are two basic forms of syphilis: 1)

syphilis “acquired” after birth—acquired syphilis

• and 2) syphilis present at birth— congenital syphilis.

• The disease passes through two distinctive phases and, if not treated, may enter a third fatal stage.

• Penicillin will kill T. pallidum.

Clinical features

• The lesions of syphilis vary in location and appearance.

• Four stages are recognized: 1, 2, latent, and 3.

• Not all of those infected develop the final stage

Primary Acquired Syphilis

• “primary chancre.”• Genitalia. In the mouth, it may be located

on the lips, the tongue, the palate or, for that matter, anywhere else.

• Spirochetes are present in these lesions— they are potentially infective.

Primary syphilis. A, Chancre on tongue seen in

primary syphilis. B, Extragenital

chancre of the lip

• The chancre starts as a raised hard, firm elevation which soon becomes necrotic and ulcerated.

• The classic lesion is cratered lesion surrounded by an elevated rim measuring about 1.0 cm in diameter

• When occurring in the mouth, it most closely resembles the appearance of an invasive squamous cell carcinoma.

• Lymphadenopathy without fever.

Secondary Acquired Syphilis

• In one to three months after, lesions of secondary syphilis appear. • The locations of these new lesions are not related to the type or

location of original contact—they may appear anywhere.• Most prominent is a widespread itchless rash that may appear on

the face, the trunk, and/or the extremities. In addition, circular lesions may appear around the genitalia and anus; these are called “condyloma latum.”

• Finally, white lesions may appear in the mouth: on the tongue, the lips, the floor of the mouth, or elsewhere—they are known as “mucous patches.”

• Since spirochetes abound in all these lesions, they, like the primary chancres, are infective.

Lesions of secondary syphilis. A, Profuse

papular rash. B, Mucous patch of the

lower lip (A from Habif TP,

Campbell JI Jr, Chapman MS, et al. Skin Disease: Diagnosis and Treatment, 2nd ed.

St. Louis, Mosby, 2005.)

Latent Acquired Syphilis

• Symptom and sign-free stage • Last months, years, or decades. Most still

harbor the spirochete and all still test positive for nontreponemal and treponema antibodies.

Tertiary Acquired Syphilis“gummas”.

the stage in which disabilities, psychoses, and deaths occur

• About 80% develop a destructive process in the thoracic aorta causing its expansion and rupture (thoracic aortic aneurysm).

• Ten percent (10%) experience severe central nervous system lesions.

Congenital Syphilis• Hutchinson’s Incisors Screwdriver-

shaped central incisors seen in congenital syphilis.

• Mulberry Molars Berry-like molars seen in congenital syphilis.

Diagnosis

• VDRL. This antibody not only rises with syphilis but also may rise in other conditions (e.g., SLE and infectious mononucleosis)

• The fluorescent treponemal antibody test (FTA)

• Dark Field Examination

Oral Manifestations of SYPHILISPrimary syphilisChancre—painless ulceration with indurated borders

on the lip, tongue, buccal mucosa, or oropharynx withlymphadenopathy

Secondarysyphilis

Mucous patches—oval plaques on the tongue with awhite or gray pseudomembrane. Split papules, macer-

ated, flat-topped papules at the oral commissures)condyloma lata .(chronic oral ulcerations

Tertiary syphilisInterstitial glossitis with atrophy of filiformand fungiform papillae and fissuring of the tongue, Pre-malignant leukoplakia, gummas involve palate

Congenitalsyphilis

Hutchinson teeth in 50%—peg shaped with crescenticnotches along incisal edge of incisors. Mulberry or

Moon’s molars—rounded or crenated occlusal cusps of first molars

Psoriasis• Psoriasis is an inflammatory and hyperplastic disease of

the skin, characterised by erythema and scale. • Affects about 0.5% to 3% of different population groups. • It is strongly familial. • The presentation is variable and the course frequently

difficult to predict. • The clinical manifestations are numerous and from minor

inflammation at 1 or 2 sites on the skin to total skin involvement with pustulation and constitutional symptoms.

• There is an associated arthritis in up to 7% of patients.

Etiology• The primary defect may be an abnormally

activated immune response in the skin.• The psoriatic process seems to be a complex

interaction between keratinocytes and T-lymphocytes. Cytokines and epidermal growth factors cause proliferation and inflammation.

• Common trigger factors are infections (streptococcal, viral including human immunodeficiency virus), trauma to the skin , psychological stress and drugs.

There may be an association between certain types of psoriasis

)especially pustular psoriasis (and geographic tongue

Treatment

• In a mild case, emollients or a weak topical corticosteroid may suffice, but disabling or disfiguring psoriasis may warrant the use of systemic drugs such as immunosuppressants