Syphilis

DR NIKITHA SREE K
MALABAR DENTAL COLLEGE

1. INFECTIOUS DISEASES- SYPHILIS Dr. Nikitha Sree . K Lecturer Malabar Dental College and Research Centre

2. CONTENTS SYPHILIS AQUIRED SYPHILIS -PRIMARY -SECONDARY -TERTIARY EARLY,LATE AND LATENT SYPHILIS DIAGNOSIS CONGENITAL SYPHILIS TREATMENT DENTAL TREATMENT FOR PATIENT WITH SYPHILIS

3. SYPHILIS Syphilis is a chronic infectious systemic disease with a number of stages and with intervening periods of clinical remission, and is caused by Treponema pallidum . It occurs almost by venereal contact. In over crowded living infection also occurs by non-venereal routes.

4. There are two types of syphilis -Acquired syphilis -Congenital syphilis

5. AQUIRED SYPHILIS Acquired by sexual contact in adult life. Classified according to the type of lesion and course of the disease- - primary - secondary - tertiary Atypical and malignant progression of tertiary neuro syphilis in HIV infected individuals are sometimes referred to as ‘ quaternary syphilis ’.

6. CLINICAL FEATURES PRIMARY SYPHILIS Initial manifestation is the chancre,a slightly raised, ulcerated,firm plaque,which is usually round and indurated with rolled raised edges. Begin as papule and then ulcerates. Size vary from 5mm to cm in diameter. Painless unless super infected. Chancre may occur with in 3-4 weeks after exposure and disappears without therapy after about 10 days.

7. Indurated ulcer and enlarged nontender regional lymph glands -classic sign of primary syphilis. ORAL MANIFESTATION Chancre on the lips, oralmucosa , tongue, softpalate , tonsilar area, pharyngeal region. Intra oral chancres are usualy slightly painful and covered with a grayish white film. Extra oral portions of lip chancres are more typical brown crusted appearance.

8. SECONDARY SYPHILIS Organism proliferare and spread from primary focus through blood stream. Appear within 3-6 weeks after the primary lesion. Lesion appears on skin as fine macular or papular rash,sometimes accompanied by alopecia. Mucous patch,split papule and condyloma latum are the three possible lesions on moist skin areas and on mucous membranes.

9. Mucous patches - small, smooth , erythematous areas or superficial grayish white erosions found on the mucous membranes. Found on vulva,penis or oral cavity. On the palate and tonsil it described as “snail-track ulcers” .

10. Condyloma latum describes grayish,moist , flat-topped, extra large papules, sometimes coalescing into plaques, found on vulva, anus, scrotum, thighs, axilla , and other intertriginous areas. Papules on skin folds appear as double and called as split papule .

11. Secondary syphilis with papular eruptions

12. ORAL MANIFESTATIONS Mucous patches - found on tongue,buccal mucosa,tonsilar , pharyngeal regions, lips and gingiva . -Most highly infectious. -On tongue it appear as raised in the early lesion with partial loss of lingual papilla. -Often painless. Painful when they develop on movable tissue or on exposed surface -Trauma results in raw bleeding surface.

13. Papules- split papules are raised papular lesions Develop on dorsum of tongue, commissures of the lips And develop a fissure that seperates upper lip portion of papule from lower lip.

14. Condylomata lata - occur on skin as well as on the mucosa. Flat, silver gray, wart like Painless papules Sometimes with ulcerated surface.

15. TERTIARY SYPHILIS Occur at any age from the third year up to the patient’s life. One third develop benign or gummatous form, one third cardiovascular form and one third neurosyphilis

16. Gumma - is due to a chronic destructive granulomatous process which occurs. It is the result of hypersensitivity reaction between host and treponema . Cerebral gumma may produce symptoms suggestive of brain tumor .

17. NEUROSYPHILIS - Occurs due to obliteration of small vessel arteries involving vasa vasorum of aorta and other large vessels of the central nervous system. Manifested as tabes dorsalis and geneal paresis. TABES DORSALIS- Syphilitic involvement dorsal column of spinal code and dorsal root ganglion.

18. Patient loses the positional sense of his lower extremities and -Walks with a characteristics slapping step -Accompanied by burning or pricking sensations of the extremities, - Paresthesias or actual anaesthesia of the part.

19. Neurosyphilis - spirochetes in neural tissue

20. Positive Romberg's sign- - person is unable to stand erect unaided with his eyes closed. Tabetic crises –short, shooting knife like pains may be experienced on abdominal region, which result from involvement dorsal root ganglion

21. Charcot’s joint- trophic changes consist of deep perforating ulcers and painless destruction of larger joints. GENERAL PARESIS- syphilitic involvement of cerebral tissue. Argyll Robertson pupil- involvement of cranial nerves results in pupils that react to accommodation but not to light.

22. Personality changes are often the first manifestation- -increased irritability -fatigue -mental sluggishness -carelessness in personal habits There is loss of fine muscular coordination indicated by inability to perform delicate task with the hands

23. CARDIOSYPHILIS- affects particularly the aorta or aortic valve. Obliteration of vasa vasorum of the aorta and its larger branches as the result of syphilis leads to medial necrosis and destruction of elastic tissues in the walls of the large blood vessels

24. Cardiovascular syphilis - narrowing of coronary ostia in aortus Aortitis,aortic regurgitation,anneurysm formation in the proximal aorta, or narrowing of the ostia of the coronary arteries may result from these changes

25. ORAL MANIFISTATIONS Oral lesions occurs most frequently on the palate and the tongue. Gummatous destruction of palatal bone results in perforation of palate. Even manifestate as solitary, deep, punched out oral mucosal ulceration with serious complication.

26. Numerous small healed gummata in the tongue resulted in a series of nodules or scars in the deeper areas of the organ,giving the tongue an ‘upholstered’ or tufted appearance. Diffuse luetic involvement of this organ results in complete atrophy papillary coating called bald tongue , also referred to as interstitial glossitis .

27. Leukoplakia was frequently associated with this luetic glossitis . Severe neuralgic pains of the head and neck may occur in tabes dorsalis and must be differentiated from neuralgic pain secondary to dental or pharyngeal disease. Loss of taste and spontaneous necrosis of the alveolar process .

28. Parasthesia may occur in lips, tongue, and the cheeks. Painless ulceration of the palate and the nasal septum . Spontaneous death of dental pulp in the absence of recognizable precipitating factors and altered pulp test responses. Patients with damaged aortic valve secondary to luetic involvement is still occasionally seen and should be given antibiotic prophylaxis before dental inorder to prevent bacterial endocarditis .

29. EARLY,LATE, AND LATENT SYPHILIS On the basis of infectivity related to time, syphilis is also classified into early and late stages. EARLY SYPHILIS defined as syphilis one year or less after infection. infectious stage. either symptomatic (with lesions)or latent.

30. LATE SYPHILIS syphilis of more than one year’s durations. It is not infectious and patient is probably immune to reinfection . It may be symptomatic –cardiovascular or neurosyphilis or gummatous lesion or asymptomatic. LATENT SYPHILIS It is also divided into early latent and late latent syphilis. Early latent syphilis – Defined by united State Public Health Services as less than one year after infection.

31. Clinically symptomless with a positive serologic reaction. And a history consistent with primary or secondary syphilis, or sexual contact with a partner with early syphilis and no history of treatment. Patient are potentially infective. Late latent syphilis- More than one year after infection. And future adverse consequences effect the patient but not the patient’s contact.

32. DIAGNOSIS OF SYPHILIS Dark field Microscopy VDRL, RPR FTA-ABS, MHA-TP Direct Fluorescent Antibody (DFA)

33. The Venereal Disease Research Laboratory test is positive in 50% to 70% of primary cases. The Fluorescent treponemal antibody absorption and microhemagglutination assay for T. pallidum (MHA-TP) tests are positive in 70% to 98% . Diagnosis of secondary syphilis should be suspected on the basis of symptpms or signs and may confirmed by blood test. 98% to 100% of both reagin and treponemal tests are positive during this stage.

34. CONGENITAL SYPHILIS It is related to transplacental infection . Time of development of lesion is after 18 weeks gestation. CLINICAL FEATURES Manifestation within first 2 years of life. Rhinitis and chronic nasal discharge with a maculopapular eruption,other mucocutaneous lesions,and loss of weight.

35. These lesions include - bullae , - vesicles , and - superficial desquamation with cracking and scaling of reddened soles and palms, - petechiae , and mucous patches and - condyloma latum . Osteitis , Anemia and number of disorder involving the visceral organs may also occur.

36. Late manifestation develop after 2 years of age and include - interstitial keratitis and - vascularization of the cornea , -8 th nerve deafness , - arthropathy , -signs of congenital neurosyphilis ,and - gummatous destructions of palate and nasal septum. Unexplained nerve deafness , and retinal and corneal damage noted later in life , in a child born to syphilitic mother

37. Congenital syphilis - perforation of palate

38. ORAL AND FACIAL MANIFESTATIONS It include postrhagadic scarring about the mouth ,changes in teeth and other dental abnormalities. Postrhagadic scarring and syphilitic rhagades : Linear lesion found around the oral and anal orifices Results from a diffuse luetic involvement of skin in these areas from the third to the seventh week after birth.

39. Congenital syphilis - mucous patches

40. Lesion first appear as red or copper coloured linear areas covered with a soft crust. Rhagades are frequent on lower lips because of thinness of the epithelium covering this structure and greater mobility. Frequently there is diminished colouring of the lip and the mucocutaneous border is indistinct.

41. Changes in dentition: Primary dentition is rarely effected,since fetal luetic infection occuring during the formation of these teeth usually results in abortion. Hutchinson’s triad – includes the characteristic defect hypoplasia of permanent incisors and first molars , -8 th nerve deafness , -interstitial keratitis Dental hypoplasia - effects permanent incisors , cuspids ,and first molar .

42. Congenital syphilis - - Hutchinson’s teeth

43. General constriction of the crown towards the incisal edge, which produce screw driver and pegshaped incisors and rounding of mesial and distal incisal line-angles. Mulberry molars -Molar lesions are characterised by cusp positioned towards central portion of the crown.

44. Characteristic notching of the incisal edge of the permanent incisors -demonstrated by means of a radiographic examination before the eruption of this tooth. Mesio -distal diameter and the size of this tooth are usually smaller than adjacent second molar

45. Dentofacial changes: (syphilitic stigmata) -malocclusion -open bite An abnormal facies : -frontal bossing -saddle nose - poorly developed premaxilla .

46. DIAGNOSIS OF CONGENITAL SYPHILIS Identification of T.pallidum by 1.microscopy 2. fluorescent antibody or other special stains in specimens of lesion 3. autopsy Detection of IgM antitreponemal antibody in cord serum –active infection

47. TREATMENT OF SYPHILIS Benzathine pencillin-2.4 million units IM Aqeous crystalline pencillin Tetracycline-500mg orally 4 times a day for 15 days. Erythromycin-500mg by mouth 4 times a day for 15 days. FOLLOW UP-followed with repeated physical examination and repeated VDRL test.

48. DENTAL TREATMENT FOR PATIENT WITH SYPHILIS Differentiate the oral iesions from solitary ulcers,nodules of lip,tongue&fauces , licheniod lesions &unexplained areas of mucositis Evaluation of lesion should always be done with gloves when performing examination&treatment

49. Reference Burket's Oral Medicine- Greenberg , Glick, Ship Textbook of Oral Medicine - Anil Govindrao Ghom Textbook of Oral Medicine,Oral diagnosis and Oral Radiology- Ravikiran Ongole, Praveen B N

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