Sexually Transmitted Diseases
Sexually transmitted diseases have been a part of human existence from ages. However, in the last couple of decades with changing sexual practices among heterosexual and homosexual individuals, the incidence of STDs have exponentially increased.
Moreover, with the emergence of various multidrug resistant strains of pathogens, newer spectra of diseases such as acquired immunodeficiency syndrome (AIDS) and the evidence of venereal spread of various pathogens, the need to prevent, recognize these diseases and manage them effectively is important.
According to the statistics of the Centers for Disease Control and Prevention (CDC), approximately 19 million STD cases are reported annually in the United States. Among these 19 million cases about 50% of these are seen in people in the age group of 15–24 years.
It is believed that there are more than 25 diseases that are transmitted through sexual activity. The most common STDs are HIV, chlamydia, gonorrhea, syphilis, genital herpes, human papillomavirus, hepatitis B, trichomoniasis and bacterial vaginosis.
As most of these venereal diseases have characteristic oral findings, the oral physician needs to keep abreast of the latest updates about the whole range of clinical manifestations of these diseases.
A good personal history will help in the diagnosis. However, other conditions that may mimic such lesions are frequent use of drinking straws, habit of sucking on candies (produces negative pressure), petechiae secondary to forceful sneezing, vomiting or coughing, upper respiratory tract infections, blood dyscrasias, infectious mononucleosis, nasopharyngeal tumors and anticoagulant or antithrombotic medications.
Lesions on the lingual frenum are usually seen in individuals who practice cunnilingus (tongue projected into the vaginal area). During such tongue thrusting, the ventral surface of the tongue and particularly the lingual frenum rubs against the incisal edges of the mandibular anterior teeth.
Patient may complain of pain and soreness in relation to the ventral surface of the tongue. On clinical examination, the ventral surface of the tongue and the lingual frenum may exhibit an ulcerative lesion usually covered by a fibrinous exudate. The ulcer is typically bounded by an erythematous halo. In chronic cases irritation fibroma may be evident on the lingual frenum.
The term ‘syphilis’ was coined by the Italian physician and poet Girolamo Fracastoro (1530). Other names which have been used in literature are French disease, Italian disease, Christian disease, British disease, lues venerea and Cupid’s disease. In the 16th century syphilis was recognized as ‘Great Pox’ in Europe.
The major source of transmission of syphilis is by sexual contact (acquired). The other modes of transmission include transplacental spread (congenital/neonatal) or accidental inoculation of the causative organism (non-sexual modes of transmission).
T. pallidum is a delicate fastidious spirochete whose only natural hosts are humans. It is of 10–15 μm in length and 0.2 μm in thickness, tapering ends and possesses 10–15 spirals. It has a graceful ‘to and fro’ and angulating movement under dark-field microscopy in a wet preparation. Organisms can be demonstrated in tissue/tissue fluids by silver staining and immunofluorescence. Pathogenic T. pallidum (Nicholas strain) has not yet been able to culture but organisms can be maintained in rabbit’s testicular tissue with retaining its pathogenicity. In refrigerated blood the organisms die within 5 days and can be easily killed with soap and water.
The organisms gain entry through mucous membrane or abraded skin during sexual contact. It is estimated that only about 50% of people who come in contact develop syphilis. It is believed to be due to the presence of local factors and ‘immobilins’ in the blood which immobilize T. pallidum. Incubation period varies from 9 to 90 days.
Natural immunity to syphilis does not occur in humans and vascular changes appear to be more significant, characterized by endarteritis and periarteritis. Fibroblastic proliferation leads to fibrosis and scar formation.
Primary syphilis is typically acquired via direct sexual contact with the infectious lesions of a person with syphilis. Approximately 10–90 days after the initial exposure (average 21 days), a skin lesion appears at the point of contact, which is usually the penis, vagina or rectum, but can occur anywhere on the body.
Lee et al (2006) reported a case of syphilitic chancre presenting as a solitary nodule of the nipple. Primary lesions on the fingers usually result from contact with genital lesions during sexual foreplay or as an occupational exposure in physicians and nurses as a result of direct contact with infectious ulcers in their patients. Little (2005) suggested that syphilis can be spread by direct contact with mucosal lesions of primary and secondary syphilis or blood and saliva from infected patients.
This lesion, called a chancre, is a firm, painless ulceration localized at the point of initial exposure to the spirochete. The chancre begins as a papule that subsequently ulcerates. The chancre may persist for 3–8 weeks and usually heals spontaneously. Localized lymphadenopathy may be evident.
The oral primary syphilitic lesion (chancre) like elsewhere in the body, is generally seen after about 3 weeks after the exposure at the site of inoculation of the virus. Initially a papule is formed which subsequently ruptures to form a painless ulcer. The ulcer is generally punched out and may be indurated. Regional lymphadenopathy is usually a characteristic feature. The chancre resolves in about 4 weeks leaving a scar.
Though it is often believed that the secondary lesion of syphilis appears about 2 months after the primary lesion has healed, an estimated 30% of the individuals may present a chancre along with the secondary lesion.
Skin rashes may be seen which may have varied presentations such as papules, macules and pustules. These lesions are typically copper colored and sometimes referred to as ‘raw-ham’ colored lesions. The palms and soles are commonly affected. These lesions are generally not pruritic.
Systemic signs and symptoms associated with secondary syphilis include malaise, prostration, cachexia, low-grade fever (seldom exceeding 100°F), headache, asymptomatic meningitis, cranial nerve palsies (nerves II to VIII), painless lymphadenopathy, vague bone pain, jaundice, syphilitic hepatitis, proteinuria, nephrotic syndrome, rapidly progressive glomerulonephritis, renal failure and ulcers affecting the antral and pyloric areas of the stomach.
It is estimated that about 30% of the patients with secondary syphilis present with oral mucosal involvement. Secondary syphilis in the oral mucosa can exhibit two characteristic features: mucous patches and maculopapular lesions. Occasionally nodular lesions may be seen.
A severe generalized form of secondary syphilis is referred to as ulceronodular disease (lues maligna). This form of syphilis is characterized by fever, headache and myalgia, followed by a papulopustular eruption that rapidly transforms into necrotic, sharply demarcated ulcers with hemorrhagic brown crusts on the face and scalp. The incidence of lues maligna in AIDS patients is high.