Sexually Transmitted Diseases

GONORRHEA Oral gonococcal infection with Neisseria gonorrhoeae is not uncommon. The most frequent mode of transmission is fellatio. Consequently, it is seen more commonly in females and homosexual males. A stomatitis may occur with fiery red and inflammed oral mucosa. More commonly, a pharyngitis involving the uvula and tonsils occurs. Gonococcal pharyngitis may present with or without pustules or exudate. In the carrier state, a normal pharyngeal appearance may be present. Treatment is the same as with genital involvement.1 54

SYPHILIS The primary chancre of syphillis can occur orally and may affect the lips, gingiva, hard and soft palates, buccal mucosa, pharynx, and tongue. Chancre of the lip is the most common oral site involved. Tongue involvement is next in frequency, followed closely by the tonsils. An oral chancre is similar in appearance to the genital counterpart. Initially, the lesion may be an erythematous papule that erodes into the classic painless, punched-out ulcer that becomes firm and indurated. 1 54

Secondary syphilis follows the onset of the primary lesion by 9 to 90 days. Systemic symptoms such as fever, malaise, generalized lymphadenopathy, weight loss, and arthralgia are common during the secondary stage. Oral lesions are common and frequently accompany cutaneous lesions but may occur alone. They are usually multiple, oval-shaped, slightly raised ulcers or erosions covered with a gray membrane. They occur most commonly on the tip and sides of the tongue. Condyloma lata rarely occur intraorally.1 54

Tertiary syphilis can occur many years after the initial infection. Intraorally, the tongue is enlarged in a lobulated or irregular pattern with atrophic and hypertrophic areas. A single gumma is unusual. Chronic interstitial glossitis may result in fissuring of the tongue. In late syphilis, the tongue atrophies secondary to ischemia associated with chronic interstitial glossitis, resulting in balding of the tongue with thinning and wrinkling of the mucosal surface. Gummatous infiltration of the hard palate also may occur.1 54

Congenital syphilis affects the formation of both the anterior and posterior teeth. The permanent maxillary incisors are most affected. These Hutchinson incisors are usually shorter than the lateral incisors and barrel-shaped, resembling a screwdriver. The central portion of the incisal edge may be notched. The posterior molars, or mulberry molars, are narrower at the oclussal surface, and the normally occurring four cusps are replaced by many more, resulting in the characteristic mulberry appearance.111,9,54

Diagnosis of syphilis is with serology or dark-field examination of the primary and secondary lesions. Benzathine penicillin G 2.4 million units intramuscularly is used to treat primary, secondary, and latent syphilis of less than 1 year duration. VDRL at 3, 6, 12, and 24 months is necessary. Weekly injections for 3 weeks are necessary for the treatment of infections of greater than 1 year duration. Daily ceftriaxone injections for 10 days in the penicillin-allergic patient are an alternative. 1 54

HERPES TYPE 2 Ninety percent of all herpes type 2 occurs in the anogenital region, but with oral-genital contact, oral lesions may occur. Oral herpes type 1 and type 2 infections are clinically indistinguishable, with primary infection frequently causing a gingivostomatitis and associated fever and malaise. Lesions may last up to 2 weeks. Secondary or recurrent lesions occur as a result of the same predisposing factors as type 1. Definitive diagnosis is made in the laboratory by viral cultures or DNA probe. Treatment of primary genital lesions with acyclovir 400 mg PO tid or Valtrex 1g PO/bid for 10 days is recommended. Acyclovir 400 mg PO tid or valacyclovir 500 mg PO bid for 5 days shortens the course of disease, and prophylactic therapy reduces recurrences and subclinical shedding of herpes simplex type

HUMAN PAPILLOMAVIRUS Human papillomavirus is probably the most common sexually transmitted disease today. HPV-6, -11, and -45 are most commonly associated with condyloma acuminatum, or venereal warts. Although most commonly affecting the anogenital region, oral lesions can occur. Intraorally, the labial and buccal mucosa, palate, tongue, and gingiva are most commonly affected, although any site can be involved. Lesions many be solitary or multiple and are sessile or pedunculated nodules. Treatment is with electrosurgical or laser therapy.1154

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