Spike in Syphilis Cases Keeps Dentists on Alert

Symptoms of the disease – making a comeback due to opioid abuse – often seen in the mouth and on tongue and lips

hruti Kashikar was startled to see the results of a biopsy sent to her lab for diagnosis a few years ago. The patient had syphilis, which many assume was nearly eradicated by the 1950s after penicillin was found to be a successful treatment.

“It was kind of rare to see it,’’ said Kashikar, an assistant professor in the Division of Oral and Maxillofacial Pathology at Rutgers School of Dental Medicine.

A recent spike in syphilis cases, linked to the opioid epidemic, means dentists and other oral health care providers should be ready to spot signs of the disease, which often appear in the mouth, Kashikar says.

Although syphilis rates declined after 1943, when penicillin was discovered as a cure, cases began to increase in the early 2000s. Today, rates are at their highest since 1993. Within the past year, there has been an increase of 18 percent of reported cases, totaling nearly 9 cases per 100,000 population, according to the Centers for Disease Control (CDC).The disease is transmitted through sexual contact and needle sharing. As the rate of opioid addiction increases, more users are injecting the drugs intravenously.

“Syphilis is back and it is more important than ever to catch this disease early,” says Kashikar, who helped treat two cases of the syphilis during her residency at New Presbyterian Hospital in New York. “Oral manifestations can be seen at all stages of syphilis in men, women and children. It is up to us, as oral health care providers, to diagnose and treat these patients before it’s too late.”

Untreated syphilis can lead to systemic manifestations including heart complications, neurological symptoms, problems with the eyes, bones and skin and, in some cases, death. Before penicillin was used to treat it, patients were often severely disfigured and stigmatized by the disease.

At a recent lecture, sponsored by the dental school’s Office of Research, Kashikar showed slides of syphilis symptoms that can appear in the mouth, including nonspecific ulcers and white mucosal patches on the tongue and lips. Ulcerated lesions that increase in size and firmness, perforations of the palate and nodular growths on the tongue are other symptoms.

Congenital syphilis, which is transmitted from mother to child during pregnancy, can also present with oral symptoms, including “Hutchinson’s Teeth,” notched incisors and “mulberry molars,” which have many small bumps, like the mulberry fruit, Kashikar says. About 40 percent of fetuses and newborns with congenital syphilis don’t survive, according to CDC statistics. Children with congenital syphilis can go deaf or blind. Others have severe anemia and bone deformities.

At RSDM, suspected cases of syphilis can be biopsied and those confirmed must be reported to the CDC, which tracks syphilis cases.  Syphilis is most prevalent among gay men and coinfection with HIV can contribute to quicker progression, although in recent years, the disease has spread among intravenous drug users.

As she sought more information about the disease, Kashikar delved into the history of syphilis and the misconceptions that have surrounded it over time. In 1494, the first European case was reported in Naples, Italy, and many believe that Christopher Columbus’ sailors introduced syphilis in Spain after their voyage from the Americas. It wasn’t until later that Europeans realized the disease was sexually transmitted. Early on, they thought it was caused by astrological forces.

The disease is also associated with a shameful chapter in American medical history: the Tuskogee syphilis experiment, which lasted 40 years. Beginning in 1932, black subjects were told they were being treated for “bad blood” but were left untreated to measure the progression of the disease, even after the advent of penicillin as a cure.

Throughout history, attitudes toward syphilis have changed significantly, with blame for the spread of the disease assigned to various people and nationalities. Women, especially prostitutes, were scapegoated for the endemic transmission of syphilis, particularly during the Victorian era.

“This stigmatization of female sexuality is clearly depicted in art by various artists throughout 18th and 19th century,” Kashikar says. “With time, however, attitudes have changed, along with the demographics of the disease.”