A case report published on June 19 in Cureus is drawing attention to an easily overlooked element of the dental visit: the extraoral examination.
Asymptomatic lesion with well-defined borders arouses a clinician’s suspicion
A 43-year-old man presented for a routine dental evaluation, and the clinician, conducting an extraoral exam, spotted a solitary ulcer measuring 2 cm in diameter on the man’s forehead. The lesion had an indurated base with well-defined borders and wasn’t tender when palpated. The man relayed the lesion had been present for several weeks, but he had not sought treatment for it, according to the report.
Figure 1: Extraoral clinical presentation of the lesion. (a) General view showing the lesion on the left frontal region. (b) Close-up view demonstrating a solitary, well-defined, indurated ulcerative lesion with a crusted surface. The lesion was asymptomatic and was incidentally identified during extraoral examination, leading to the diagnosis of primary syphilis.Images and captions courtesy of Farih et al.
The clinician ordered serological testing, which showed a venereal disease research laboratory test of 1:2 dilution and a positive Treponema pallidum hemagglutination result of 217.9, validating a diagnosis of primary syphilis, a sexually transmitted disease (STD), the report's authors state.
The report highlights the valuable role clinicians can play in safeguarding their patients’ health.
“This case underscores the value of comprehensive clinical assessment in dental practice and the role of oral health professionals in the early detection of systemic infections,” wrote the report’s lead author, Dr. Ziad Farih, a resident physician with the department of oral and maxillofacial surgery at Mohammed VI University of Health and Medical Sciences in Casablanca, Morocco.
Syphilis is making a resurgence
In the past 10 years, syphilis has reemerged as a significant global health concern. It’s estimated that 8 million new infections occur each year among adults ages 15 to 49. Increases have been reported across multiple populations, including men who have sex with men, but also in heterosexual individuals and women of reproductive age, contributing to a worrying rise in congenital syphilis cases.
Its resurgence is attributed to a few factors, including changes in sexual behavior, gaps in screening and prevention programs, and disruptions to diagnostic and sexual health services caused by COVID-19, and disparities in health surveillance systems in low- and middle-income countries, the authors wrote.
Syphilitic chancres increasingly may present as atypical
For clinicians, primary syphilis may produce painless, indurated ulcers on the lips, tongue, and buccal mucosa. In this case report, however, the lesion on the patient’s forehead is an unusual extragenital presentation that could easily be mistaken for a traumatic ulcer, cutaneous leishmaniasis, or a skin neoplasm, the authors wrote.
Dentists are uniquely positioned to catch systemic diseases
The report’s authors assert that most people visit their dentist more often than their physician, and for some, the dental setting may be their only contact with a healthcare professional. Therefore, clinicians can recognize signs of systemic disease.
“While dentists are primarily trained to focus on the oral cavity, their field of observation naturally extends to the facial and cervical areas. The extraoral examination, sometimes considered secondary, is in fact an essential step for identifying signs of systemic, infectious, metabolic, or neoplastic disease that may otherwise go unnoticed,” Farih and co-authors wrote.
The authors also relayed that gaps in knowledge about the oral and extraoral manifestations of syphilis remain concerning, which therefore highlights the need for continuous education and “clear referral pathways,” they wrote.
Follow-up and outcome
The patient in this case was referred to his general practitioner and treated with a single intramuscular dose of benzathine penicillin G. At a six-month follow-up, repeat serological testing was negative, and the lesion had completely resolved, the authors reported.
The takeaway for clinicians is to always conduct a thorough head-and-neck extraoral examination as part of your overall patient evaluation. If you encounter an atypical ulcerative lesion -- one that is painless and indurated -- include syphilis in the differential diagnosis, with a referral for serological testing that can make a significant difference in patient outcomes and public health.
