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Oral manifestations of sexually transmitted illnesses

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Contrary to popular belief, there is actually more to sexually transmitted illnesses than their effects on reproductive areas. The purpose of this article is to raise some much needed awareness on the little known effects of STIs with regards to the inside of the mouth.Infective agents range from viruses such as Herpes, HPV and HIV; bacteria, including but not limited to gonorrhoea and syphilis; and fungi, an example of which would be candida.

Herpes Simplex

There are two types of this virus: Type 1 and Type 2. The Type 1 virus causes sores on the mouth and sometimes nose, which are known as cold sores. On the other hand, Type 2 causes sores in the genital and anal area. However both types can affect all areas, through spread by oral sex. The small fluid-filled blisters tend to be itchy, leaving a painful sore when they burst. Transmission is via direct contact with the infected person, which apart from kissing and penetrative sex, includes also oral sex. Blisters and sores in particular, are highly infectious.

Human Papilloma Virus (HPV)

Genital Human Papilloma Virus (also called HPV) is the most common sexually transmitted infection (STI). There are more than 40 HPV types that can infect the genital areas both of males and females. These HPV types can also infect the mouth and throat. Most people who become infected with HPV are unaware.  Certain types of HPV viruses may cause warts to grow in the throat, known as recurrent respiratory papillomatosis (RRP).

Human Immunodeficiency Virus (HIV)

HIV presents orally in several ways, but unfortunately these manifestations are not specific.  The effects of HIV are mostly due to the compromised immune system, meaning that the patient’s defence mechanism will not resist infections, which would normally be warded off by a healthy individual.

Oral candidiasis (as seen on the picture on the left) is often the first presenting sign of HIV infection. This is a fungal infection, pseudomembranous candidiasis being the most common presentation. This is characterized by white or whitish-yellow papules that can be wiped from the inner lining of the mouth to reveal erosions on the mucosa itself. Any surface may be involved but these often affect the buccal sides (insides of the cheeks) and the palate (roof of the mouth).

Decreased immunity may also reactivate any dormant viruses, such as Herpes Simplex, in the body. Several small vesicles appear, generally on the lips. These small vesicles sometimes coalesce into larger vesicles. The vesicles then rupture, resulting in painful ulcerations. The ulcerations are highly infectious until they crust over. This type of infection is more aggressive and prolonged in HIV patients than in normal patients. Lesions in the mouth also occur, most commonly on the tongue, gums and roof of the mouth, but in HIV patients the infection may also reach other areas, such as the tonsils and oesophagus.

Hairy leukoplakia is a very common oral manifestation of HIV. White patches appear, most commonly on the sides of the tongue due to an Ebstein-Barr Virus (EBV) infection.

Gonorrhoea

This is also known as the clap, strain or drip. It may be transmitted orally via orogenital contact or by selfinoculation via the fingers (i.e after touching first the infected area then the oral region). Initially round, greyish white elevated spots appear, which then become eroded, leading to a burning and itching sensation. This infection is communicable for years if untreated.

Syphilis

Syphilis is due to a bacterium known as Treponema pallidum. Its effects occur in three stages: primary, secondary and tertiary.

In the primary stage, the lesion appears 2-6 weeks after infection. It presents as a small bump that erodes to form a generally painless ulcer. The ulcer heals in about a month even if untreated, but the person is still highly infectious. The most common extragenital site affected is the lip followed by the tongue and tonsillar area.

The secondary stage (1-4 weeks later) consists of a number of grey-white patches. These are painless and highly infectious, and may last from a week to a year.  Even if untreated, most people will not suffer from a recurrence.

In 1/3rd of the untreated people, the tertiary stage kicks in after 3 or more years. Orally, this stage presents as leukoplakia (white patches) of the tongue and ulcers which may perforate, especially if present on the roof of the mouth (palate). During this stage the person is no longer infectious.

In a country where more than 40% of the population claim to have casual sex and only 8% claiming to use a condom constantly (Genitourinary report 2007), it is absurd to say that contracting a Sexually transmitted Infection is not possible. So if you are having sex, whatever your sexual orientation, remember that STIs do not discriminate, always use protection.

If you have any concerns, contact the GU clinic in Boffa Hospital on 22987115 or 21227981 for an appointment.

Cher Farrugia is the Health Officer of Malta Association of Dental Students (MADS)

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