Oral Syphilis Management
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Direct answer
Syphilis, "the great imitator", resurfaces in Indian oral medicine clinics and imitates everything from an aphthous ulcer to leukoplakia. Treponema pallidum produces the painless indurated chancre of primary disease (lip or tongue, appearing roughly three weeks after contact), the mucous patches and "snail-track" erosions of secondary disease, the palatal gumma and atrophic luetic glossitis of tertiary disease, and the Hutchinson triad — notched incisors, interstitial keratitis, eighth-nerve deafness — of congenital infection. Diagnosis pairs a non-treponemal test (VDRL or RPR, whose titre falls with cure) with a treponemal test (FTA-ABS or TPHA, which stays positive for life), and treatment is benzathine penicillin G 2.4 million units intramuscularly as a single dose for early disease, with the Jarisch-Herxheimer reaction explained beforehand.
What you must remember
- Stage timelines: chancre at about 10-90 days (average three weeks) after contact, healing in three to six weeks; secondary stage weeks to months later; tertiary (gummatous, cardiovascular, neurosyphilis) after years of latency.
- Primary chancre features: painless, indurated, clean-based ulcer with rubbery regional lymphadenopathy — lip, tongue tip and tonsillar area are the oral favourites.
- Secondary stage mucosa: highly infectious mucous patches — grey-white sloughed erosions — coalescing into the "snail-track" ulcer; split papules at the commissure; rash of palms and soles; generalised lymphadenopathy.
- Tertiary oral disease: gumma of the hard palate (chronic granulomatous ulceration that may perforate into the nose) and luetic glossitis — the atrophic, fissured, leukoplakia-like tongue carrying malignant potential.
- Congenital markers: Hutchinson's triad of notched, screwdriver-shaped permanent central incisors, interstitial keratitis and sensorineural deafness, with mulberry (Moon's) molars, saddle nose and rhagades.
- Serology logic: VDRL/RPR for screening and follow-up (titre falls with treatment; false positives in pregnancy, malaria, leprosy); FTA-ABS/TPHA to confirm — it remains positive for life.
- Treatment: benzathine penicillin G 2.4 million units IM single dose for primary, secondary and early latent disease; three weekly doses for late disease; doxycycline for the penicillin-allergic; expect the Jarisch-Herxheimer reaction — fever and chills within hours from cytokine release, harmless but frightening.
One patient through the stages
A 32-year-old man presents with a three-week painless ulcer on the lower lip and a firm, non-tender submental node. Dark-field microscopy from an oral lesion is unreliable because commensal oral treponemes confuse the field, so serology is drawn: RPR positive at 1:32, TPHA positive — primary syphilis. He receives benzathine penicillin 2.4 million units intramuscularly once, is warned about the flu-like reaction that evening, and is tested for HIV and other sexually transmitted infections, with partner notification arranged. Six weeks later he returns with shallow grey erosions on both buccal mucosae — mucous patches in the secondary stage; the same treatment dose is repeated and follow-up titres planned at six and twelve months, expecting a fourfold fall. The teaching thread: the ulcer that looked traumatic, the "candidal patch" that was not, and the palate perforation years later all belong to one spirochaete on one timeline — and the oral physician who recognises any single stage can interrupt all the rest.
Where students slip
The serology pairing is the perennial trap: answering "FTA-ABS to monitor treatment" inverts the logic, because treponemal tests persist for life while VDRL and RPR titres track cure — screening with one, confirming with the other is the phrase to reproduce. The second slip is the snail-track mix-up with pyostomatitis vegetans: syphilitic patches are sloughed erosions with serological proof, while pyostomatitis is pustular and points to the bowel. The third is the painless-versus-painful switch: the chancre and gumma are classically painless, unlike tuberculous or aphthous ulcers, and tertiary luetic glossitis masquerades as leukoplakia with malignant potential — a favourite "which of these is premalignant" foil. Finally, forgetting the Jarisch-Herxheimer reaction turns a routine treatment evening into an emergency-department visit.
Frequently asked questions
What is the treatment of primary and secondary syphilis?
Benzathine penicillin G 2.4 million units intramuscularly in a single dose, with doxycycline as the alternative in penicillin allergy.
Distinguish VDRL and FTA-ABS in diagnosis and follow-up.
VDRL/RPR are non-treponemal screening tests whose titres fall with cure and guide follow-up; FTA-ABS/TPHA are treponemal confirmatory tests that remain positive for life.
What are mucous patches and the snail-track ulcer?
Grey-white, highly infectious erosions of secondary syphilis that coalesce into serpiginous "snail-track" ulcers on the mucosa.
Name the components of Hutchinson's triad.
Notched, screwdriver-shaped Hutchinson's incisors, interstitial keratitis and eighth-nerve sensorineural deafness — the stigmata of late congenital syphilis.
What is the Jarisch-Herxheimer reaction?
Fever, chills and malaise within hours of the first penicillin dose, caused by cytokine release from killed spirochaetes — self-limiting, and the patient is warned rather than hospitalised.