Primary syphilis remains a cause of oral ulceration

The Mucosal Manifestations of Syphilis in the Head and Neck

Objectives: Syphilis is a resurging disease which can present itself in many ways, including lesions within the head and neck mucosa. Some of these lesions may clinically mimic oral malignancies. This literature review aims to better characterize the mucosal presentations of syphilis. Methods: PubMed, EMBASE, and clinicaltrials.gov were searched for full-text, English articles published from 1950 to 2022 that reported patients with head and neck mucosal manifestations of syphilis. Articles were screened according to PRISMA guidelines. Results: One hundred forty-three manuscripts documenting 236 individual patients were included in the review. Patients with secondary syphilis accounted for 62% of patients presenting with head and neck mucosal lesions. The most common lesions found in primary and secondary syphilis were ulcerations, primarily found on the tongue, lips, and palate. While serologic studies are the gold standard for diagnosing syphilis, biopsy of these lesions have characteristic syphilitic changes. Conclusions: Syphilis' nickname of "The great imitator" remains to be true, and the head and neck mucosal manifestations of this disease can resemble commonly seen malignancies. Awareness of this disease and its lesions is prudent given the rising incidence of syphilis within the United States.

Syphilitic Chancre of the Lip

Syphilis is a sexually transmitted disease caused by Treponema pallidum. The primary stage of the disease (the chancre) mainly involves the genital areas. Extragenital areas are involved in 5%-14% of cases, many of which occur in the oral cavity. Among the extragenital locations, the lip is the most frequent; however, despite this, published cases of the chancre of the lip are few. We present a case of a chancre presenting on the lip of a nonimmunocompromised 55-year-old male patient with immunohistochemical confirmation.

Sonographic appearance of syphilitic induration mimicking squamous cell carcinoma in the lower lip: a case report

Background

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. Recently, its incidence has been increasing worldwide. We encountered a young woman who presented with induration mimicking squamous cell carcinoma in the lower lip, without major medical conditions.

Case presentation

A 25-year-old Japanese woman presented with a 1-month history of a painless induration in her lower lip. Because squamous cell carcinoma was suspected, a preoperation work up was performed, including laboratory tests, an ultrasonographic examination, and a biopsy. The ultrasonography findings showed an oval-shaped 17 × 11 × 12 mm tumor-like lesion with heterogeneous internal echo and an indistinct border. A pressure test and color Doppler sonography revealed that the lesion was soft with a very abundant blood flow. These findings suggested the possibility of underlying inflammatory causes rather than a neoplastic tumor. Serology tests for syphilis, including the anti-Treponema pallidum antibody and reactive rapid plasma reagin tests, were positive. The biopsy revealed no malignancy. Finally, she was diagnosed as having primary syphilis and treated with amoxicillin for 28 days. The rapid plasma reagin value gradually decreased and the initial induration in her lower lip disappeared.

Conclusion

This case highlights the need for prompt examinations for possible underlying infective causes, such as syphilis, when seeing a painless induration with ulcer in the lip. Ultrasonography was helpful in the differential diagnosis of a tumor-like lesion and should be included in addition to syphilis serology tests, such as anti-Treponema pallidum antibody and rapid plasma reagin tests.

The challenging diagnosis of overlapping oral primary/secondary syphilis with nonreactive serology

The prevalence of oral syphilis, known as "the great imitator" because of its diagnostic complexity and varied clinical manifestations, is increasing worldwide, particularly in people living with HIV (PLWH), who could present false-negative serological results. Although some studies have described the variable presentation of oral syphilis in the context of HIV infection, the difficulty in distinguishing between the primary and secondary stages, clinically and histopathologically, underscores the need to describe atypical cases. We report the case of a 28-year-old HIV-positive man presenting with a 3-month history of painless white/red ulcerated lesion on the soft palate. Physical examination revealed an ulcerated lesion with local signs of inflammation. Initial biopsy revealed a nonspecific inflammatory process and immunohistochemistry (IHC) using anti-Treponema pallidum antibodies showed negative results. The results of serological tests for syphilis (Venereal Disease Research Laboratory and fluorescent treponemal antibody-absorption test) were negative on repeated occasions. Nonetheless, polymerase chain reaction (PCR) assay and subsequent IHC for T. pallidum showed positive results, confirming the diagnosis of oral syphilis. This case illustrates that the diagnosis of oral syphilis is challenging in the absence of serological evidence, and specific tests such as PCR and IHC are useful complementary diagnostic tools.

The oral manifestations of syphilitic disease: a case report

Background

Syphilis is a sexually transmitted bacterial infection of the spirochete, Treponema pallidum. While primary syphilis often involves genitalia, oral manifestations are observed in a subset of patients. These lesions are often associated with submandibular and cervical lymphadenopathy. This is a case report of a primary syphilitic lesion located on the hard palate of the oral cavity, with only a very few cases described previously.

Case presentation

We describe a rare case of syphilis in a 59-year-old African American man presenting with subjective fevers, chills, marked submental lymphadenopathy, a diffuse skin rash, and an ulcer of the hard palate.

Conclusions

This case report demonstrates the importance of maintaining a high index of suspicion for syphilitic infection when a patient presents with nonspecific symptoms, a diffuse rash, and an oral lesion.

Ulcerated Lesions of the Oral Mucosa: Clinical and Histologic Review

Ulcerated lesions of the oral cavity have many underlying etiologic factors, most commonly infection, immune related, traumatic, or neoplastic. A detailed patient history is critical in assessing ulcerative oral lesions and should include a complete medical and medication history; whether an inciting or triggering trauma, condition, or medication can be identified; the length of time the lesion has been present; the frequency of episodes in recurrent cases; the presence or absence of pain; and the growth of the lesion over time. For multiple or recurrent lesions the presence or history of ulcers on the skin, genital areas, or eyes should be evaluated along with any accompanying systemic symptoms such as fever, arthritis, or other signs of underlying systemic disease. Biopsy may be indicated in many ulcerative lesions of the oral cavity although some are more suitable for clinical diagnosis. Neoplastic ulcerated lesions are notorious in the oral cavity for their ability to mimic benign ulcerative lesions, highlighting the essential nature of biopsy to establish a diagnosis in cases that are not clinically identifiable or do not respond as expected to treatment. Adjunctive tests may be required for final diagnosis of some ulcerated lesions especially autoimmune lesions. Laboratory tests or evaluation to rule out systemic disease may be also required for recurrent or severe ulcerations especially when accompanied by other symptoms. This discussion will describe the clinical and histopathologic characteristics of a variety of ulcerated lesions found in the oral cavity.

Forty cases of acquired oral syphilis and a review of the literature

The aim of this study was to describe 40 cases of acquired oral syphilis (AOS) and to discuss the distribution of demographic characteristics, clinical features, and differential diagnosis of the disease. A retrospective study was conducted covering a 17-year period at a single institution in southern Brazil. Moreover, a literature review was performed through a search of the PubMed database for articles on AOS published between 1955 and March 2018. Data were analyzed descriptively. The predominant group within the case series was male patients in their twenties. The vast majority of cases (92.5%) were in the secondary stage of the disease. The lips were the most commonly affected site, with greyish-white mucous patches and reddish ulcers. In the literature review, the largest number of reported cases came from North America. Male patients in the third and fourth decades of life were most affected. AOS occurred more commonly as mucous patches and ulcers on the tongue and palate. Similarities regarding the distribution by sex, age, and anatomical location were found in the present study when compared to cases reported elsewhere. Clinicians, oral pathologists, and maxillofacial surgeons should familiarize themselves with the variable spectrum of signs and symptoms of AOS in their clinical practice to improve diagnosis and management.

Return of the Great Pox

Syphilis is on the increase globally. While recognized more frequently in patients with, HIV/AIDS, it is not unusual among immune competent individuals sometimes presenting with unusual manifestations and/or behaviour. This paper reviews the history and clinical features of syphilis and draws attention to the oral manifestations. CPD/Clinical Relevance: Syphilis should be in the differential diagnosis of oral ulcers or unusual oral lesions.

Syphilitic Chancre of the Lips Transmitted by Kissing: A Case Report and Review of the Literature

Primary syphilic chancre most often involved genitalia, with 12% to 14% extragenital lesions. This article describes a rare case of a female patient with labial ulcer and diagnosed as oral syphilis (OS), an uncommon presentation of primary syphilis. OS is transmitted through orogenital contact.This study is case report and literature review.We report a 27-year-old woman with painless, ulcerative, and indurated lesion on her lower lip and a 7-day history of symmetrically distributed nonpruritic macules. OS was diagnosed based on clinical presentations and serologic test and patient's oral ulcer was cured with intramuscular penicillin G benzathine. However, both the patient and her husband denied any orogenital sexual history before. In addition, her husband was also diagnosed as syphilis later in our clinic. He reported having orogenital contact with other people.Therefore, this is a rare case of OS transmitted through kissing.

Primary syphilis of the oropharynx: an unusual location of a chancre

A 33-year-old man presented with a two-week history of an asymptomatic ulcer of the oropharynx and submandibular lymph nodes swelling. Laboratory examinations were normal, but serological tests revealed positivity for rapid plasma reagin, Treponema pallidum haemagglutination assay and anti- T. pallidum IgM antibodies. Since the patient denied any homosexual relationship, a biopsy of the lesion was performed, which confirmed primary syphilis. The patient received an intramuscular injection of Benzathine Penicillin G (2.4 MU) with complete resolution of the lesion. Extragenital chancres occur in at least 5% of patients with primary syphilis, and the oral mucosa is the most frequent location as a consequence of orogenital/oroanal contact with an infectious lesion. Because of their transient nature, these oral ulcerations are often underestimated by the patient or by any unsuspecting clinician. Health professionals should consider the recent sexual history of their patients and should be prepared to recognise oral and systemic manifestations of sexually transmitted infections.

Oral syphilis: a series of 5 cases

Syphilis is an infectious, usually sexually transmitted, disease caused by Treponema pallidum, subspecies pallidum. Because of the increasing prevalence in Europe during the past few years, dentists could be confronted with patients with oral manifestations of syphilis. Because oral lesions are highly contagious, it is vital to make the correct diagnosis quickly to initiate the proper therapy and to interrupt the chain of infection. We present the cases of 5 patients with syphilis-related oral lesions. These cases are representative because of their clinical presentation, age, and gender distribution and the diagnostic approach. The aim of the present report is to emphasize the importance of the dentist knowing and identifying syphilis in different stages to diagnose the disease and institute treatment at an early stage.

Oral Syphilis: a retrospective analysis of 12 cases and a review of the literature

OBJECTIVE

To present a retrospective analysis of multicentre case series of oral syphilis and a review of relevant literature.

SUBJECTS AND METHODS

A PUBMED search was carried out from 1950 to 2011. Clinical records of patients with exclusive/prevalent oral manifestations of syphilis were collected and examined in three independent hospitals.

RESULTS

Of 23 reports describing 34 patients were detected through the review (35% primary, 56% secondary, and 9% tertiary disease), describing unspecific ulcers (59%), mucosal patches (23%), keratosis (6%), pseudomembranes (3%), and gumma (9%). Multicentre case series revealed 12 patients with oral syphilis, of which 17%, 58%, and 25% with, respectively, primary, secondary, and tertiary lesions. Clinically, patients showed white patches (17%), blistering mucositis (8%), chronic unspecific ulcers with/without skin lesions (50%), gumma (17%), and necrosis of the dorsum of the tongue (8%). Oral bullae and tongue necrosis are never described in the current review.

CONCLUSIONS

Diagnosis of syphilis remains a challenge because of the multiform and polymorphous clinical pattern at onset and its ability to imitate different diseases. It is mandatory to include syphilis in the differential diagnosis of unusual oral lesions. Diagnosis of oral lesions of syphilis is often difficult, and biopsy is required in controversial cases.

Angiomatoid fibrous histiocytoma on the hard palate: case report

BACKGROUND

Angiomatoid fibrous histiocytoma (AFH) is a rare, soft tissue sarcoma, which is slow growing with low metastatic potential. We recently had a patient present with AFH, which had a palatal perforation and it looked like a cyst in the occlusal view. Therefore, the radiological and histological features of AFH are reported herein. In addition, the differential diagnosis for this lesion is also discussed with a review of the literature.

CASE REPORT

A 23-year-old woman presented with a spontaneous perforation of the palate. Clinically, a painless and ulcerative lesion was shown on the mid-palate area. Radiological findings revealed a well-demarcated, homogeneous, oval-shaped radiolucent lesion in the occlusal view. Histological examination with incisional biopsy, showed a relatively well-defined cystic-like mass including tumor cells. Taking into consideration the histological and immunohistochemical findings, the presented lesion was diagnosed as AFH. Under general anesthesia, the patient underwent a modified cylindrical partial maxillectomy including safety margins.

DISCUSSION

In the present case, clinically differential diagnosis can be made with various diseases that have palatal perforations such as trauma, infection, neoplasia, collagen vascular disease, and idiopathic conditions. The treatment recommended in the literature has been radial excision. The prognosis of the tumor has been favorable.

Transmission of Nonviral Sexually Transmitted Infections and Oral Sex

Introduction

Oral sex is usually considered a lower-risk sexual activity when compared with sex, but it is frequently the cause of sexually transmitted infections (STI). In particular, STI transferred through oral sex might have no visible symptoms, depending on the type of infection.

Aims

The aim of this study is to review the literature about the role of oral sex in the transmission of nonviral STI.

Main Outcome Measures

State-of-the-art information in the area of STI in relation to sexual function and self–care, this last important for development of STI prevention products such as vaginal microbicides. Sexual behaviors assessed focusing on receiving oral sex and giving oral sex.

Methods

A search of the main electronic databases including registers of clinical controlled trials was performed in addition to a hand search of the most relevant Journals. The following electronic databases were searched: PubMed, Embase, Google Scholar, literature review of research articles, and public health department Internet Web sites, for the period of 1945–2011. In addition to searching the Clinical Trials Registry at the US National Institutes of Health, we also used the meta Register of Controlled Trials and the Cochrane Central Register of Controlled Trials.

Results

STI affect the mucous membranes both directly and indirectly producing characteristic diagnostic signs and lesions. Daily dental clinical activity needs an appropriate knowledge of any kind of oral lesions-related STI. The reader is offered a practical approach with clinically relevant recommendations that may prove useful in his/her daily practice when dealing with STI.

Conclusions

These data provide a foundation for understanding diverse STI. We advise physicians to be receptive to discuss sexuality issues and provide patients with adequate therapy.

The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity

Syphilis has plagued mankind for centuries and is currently resurgent in the Western hemisphere. Although there has been a significant reduction of tertiary disease and recognition of facilitative interactions with human immunodeficiency virus infection, the natural history of syphilis has remained largely unchanged; thus, new strategies are required to more effectively combat this pathogen. The immunopathologic features of experimental syphilis in the rabbit; the course, stages, and pathology of human syphilis; and a comparison of human syphilis with leprosy suggest that the clinical course of syphilis and its tissue manifestations are determined by the balance between delayed-type hypersensitivity (DTH) and humoral immunity to the causative agent, Treponema pallidum. A strong DTH response is associated with clearance of the infecting organisms in a well-developed chancre, whereas a cytotoxic T-cell response or strong humoral antibody response is associated with prolonged infection and progression to tertiary disease. Many of the protean symptoms/appearances of secondary and tertiary human syphilis are manifestations of immune reactions that fail to clear the organism, due to a lack of recruitment and, more importantly, activation of macrophages by sensitized CD4 T cells. The Bacillus Calmette-Guerin vaccination can enhance DTH and has been shown to produce a low, but measurable, beneficial effect in the prevention of leprosy, a disease that shows a disease spectrum with characteristics in common with syphilis. In the prevention of syphilis, a potential vaccine protective against syphilis should be designed to augment the DTH response.

Nodules on the tongue in an HIV-positive patient

Syphilis is a sexually transmitted disease caused by Treponema pallidum. Epidemiological studies show that rates have increased dramatically in recent y, especially in human immunodeficiency virus (HIV)-seropositive patients. Although lesions most frequently develop on the genital area, they are presently frequently detected in the oral cavity. We present an HIV-positive patient without antiretroviral treatment and immunologically stable, with firm nodules on the tongue. Following serological tests, clinical symptoms and histopathological findings, lesions were diagnosed as secondary syphilis. A spectacular improvement was achieved with specific treatment. To our knowledge this is the first case described in the literature of secondary syphilis presenting as nodular, painless lesions on the lingual mucosa.

Multiple aphthoid syphilitic chancres of the oral cavity

Summary

We describe the case of a 31-year-old man who was affected by three asymptomatic, aphthoid, syphilitic chancres of the oral cavity. These lesions were accompanied by right latero-cervical and chin lymphadenopathy. The infection was previously diagnosed as aphthous stomatitis. The search for Treponema pallidum by means of darkfield microscope examination was positive. The patient was successfully treated with oral erythromycin ethylsuccinate. To our knowledge, this is the first case of multiple aphthoid syphilitic chancres of the oral cavity reported in the literature. We suggest that all patients with a recent history of painless ulcers in the oral cavity, accompanied by regional lymphadenopathy in which the clinical diagnosis has not been confirmed, should undergo a darkfield microscope examination.

Ulcerative lesions of the mouth: an update for the general medical practitioner

Oral ulceration is a common complaint of patients attending out-patient clinics. Because of the diversity in causes of oral ulceration, patients presenting with oral mucosal disease can be challenging to diagnose and manage. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics; however, in most instances the ulcers do not result from gastrointestinal disease. The aim of the present article is to review aspects of the etiology, diagnosis and management of common ulcerative disorders of the oral mucosa. A search in the National Library of Medicine computerized bibliographic database MEDLINE was performed. Selection of publications, extraction of data, and validity assessment were then performed by the authors. Based upon the searched literature, it is concluded that there are several systemic disorders that can present with similar clinical signs and symptoms, and knowledge of each disease is necessary for the clinician to provide proper management.

Cutaneous manifestations of syphilis : recognition and management

After a marked decline in the number of syphilis cases in the context of AIDS prevention campaigns, a significant increase has been observed in states of the former Soviet Union since 1994. In recent years, outbreaks have also been reported in the US, Canada, and several European countries. The current epidemic in the US and in different parts of Europe has largely involved men who have sex with men, many of whom are infected with HIV. Since a misdiagnosis of syphilis can have serious consequences for the patient and also for pregnancies and newborns, clinicians should be aware of the many manifestations of syphilis and difficulties in the diagnosis and management of the disease. Younger clinicians in particular are no longer familiar with the diverse clinical symptoms and the complex diagnostics of syphilis. Patients co-infected with HIV may present with atypical clinical manifestations and laboratory test results. Furthermore, through its association with an increased risk of HIV infection, syphilis has acquired a new potential for morbidity and mortality, and the diagnosis of syphilis should be routinely considered in patients with uveitis, sudden deafness, aortic thoracic aneurysm, or pregnancy. Only a minority of syphilis infections are detected in the primary stage. This may be because of atypical locations and, occasionally, atypical morphology of the lesions; however, it may also be because of the difficulty of detecting the pathogen. In the secondary stage, which is clinically extremely diverse, the diagnosis is confirmed serologically. There is a need for increased awareness of the symptoms and signs of acute infections, together with a willingness to consider the diagnosis of syphilis in patients with vague symptoms. An increasing number of diagnostic tests (both specific and nonspecific) are now available. However, in the absence of clinical symptoms or in cases with a low titer or inconsistent test results, diagnosis of syphilis can be difficult or even impossible. Treatment and follow-up should follow current guidelines designed for the involved area. In this article, the cutaneous manifestations of syphilis and their diagnostic and therapeutic management are described in detail.

Syphilis and HIV Infection: an Update

Although once on decline in the United States and Europe, the incidence of syphilis has been on the rise since 2000. This increase is noteworthy because there is a high coinfection rate with HIV, especially among men who have sex with men. In light of high coinfection rates, all HIV-infected patients should be tested for syphilis and vice versa. HIV can alter the clinical manifestations of syphilis and, in turn, syphilis has the potential to change the course and transmission of HIV. This article addresses variations in clinical presentation, diagnosis, and management of individuals coinfected with HIV and syphilis.

Oral manifestations of syphilis

The past decade has shown a significant rise in the prevalence of infective syphilis in the developed world, and striking increases in its frequency have occurred in Eastern Europe, particularly the UK, and in the US. Although oral manifestations of syphilis are most likely to be observed during secondary disease, all stages of the disease can give rise to oral lesions. Significant oral lesions such as gumma-associated bony destruction and a possible predisposition to oral squamous cell carcinoma are associated with tertiary disease. Since the prevalence of infective syphilis in heterosexuals has been increasing, there has now been a gradual rise in the number of children born with congenital syphilis. Consequently, the congenital disease gives rise to dental anomalies as well as bone, skin, and neurological anomalies of the face. The aim of this report is to review syphilis-related oral lesions, as well as to summarize the relations between human immunodeficiency virus (HIV) and syphilis.

Palatal perforations: past and present. Two case reports and a literature review

Syphilis and cocaine abuse are posing a growing public health problem on a global and national scale. Clinicians are increasingly likely to come across associated oral manifestations. We present two cases of palatal perforations caused by tertiary syphilis and cocaine abuse respectively. The literature review discusses issues specific to palatal perforations and those general to both conditions. The purpose of the report is to focus attention on syphilis and cocaine abuse as rising problems for the dental profession.

Study of the viral infections and cytokines associated with recurrent aphthous ulceration

Mouth ulcers are one of the most common oral complaints. However, the association between oral ulceration and viruses and cytokines is uncertain. We detected the presence of human papilloma virus (HPV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV)-1, HSV-2 and human herpesvirus (HHV)-8 DNA in oral tissues by polymerase chain reaction (PCR) and Southern hybridization techniques, and quantified the serum levels of cytokines including interleukin (IL)-2, IL-4, granulocyte-macrophage colony-stimulating factor (GM-CSF), soluble Fas (sFas) and the Fas ligand (FasL) by enzyme-linked immunosorbent assay (ELISA) for 67 recurrent aphthous ulcer (RAU) patients and 72 normal individuals. Seven patient specimens were excluded from the study due to the negative PCR results for the beta-globin used as the internal control. Among the 32 (53.3%) virus-positive results from 60 patients' samples, 8 (13.3%) HPV, 4 (6.7%) HSV-1, 11 (18.3%) CMV, 9 (15.0%) EBV, and 16 (26.7%) HHV-8 samples proved to be positive. No HSV-2-positive samples were found. The percentage of single-virus infection (56.3%) was significantly greater than that of double-virus co-infection (31.3%) and the percentage of double-virus co-infection was significantly greater than the percentage of triple-virus co-infection (12.5%) (P < 0.05). In the 72 normal oral-tissue specimens, no viral DNA was detected. The mean serum cytokine level for patients was significantly (P < 0.05) greater than for controls for most of the separate age groups. The mean serum cytokine concentrations for the patient group demonstrated a diffuse pattern covering a wide range of serum concentrations, a very different result from the compact serum concentration pattern and lower mean serum cytokine concentrations revealed by the normal group. Overall association between viruses and recurrent aphthous ulceration is HHV-8 > CMV > EBV > HPV > HSV-1, regarding the frequency of prevalence (P < 0.05).

Oral syphilis—re-emergence of an old disease with oral manifestations

Three representative cases of oral primary syphilis are presented. We wish to highlight the resurgence of this disease, which has occurred recently in the western world, particularly in Europe and the United States of America. Since the initial presentation may be oral, it is important to include syphilis in the differential diagnosis of patients presenting to oral diagnostic clinics with atypical oral ulceration. Recent developments in the serological diagnostic tests and treatment are reviewed. Early diagnosis and treatment has significant implications, not only for the patient, but also for previous and future transmission to contacts. Early syphilis is a highly infectious disease in which the lesions heal spontaneously, despite inappropriate treatment which may appear curative, and yet the patient remains infectious. It is therefore important that clinicians maintain a high clinical index of suspicion and crucial that an accurate diagnosis be made at presentation.

Oral fungal and bacterial infections in HIV-infected individuals: an overview in Africa

Oral opportunistic infections developing secondary to human immunodeficiency virus (HIV) infection have been reported from the early days of the epidemic and have been classified by both the EC-Clearinghouse and the World Health Organisation (WHO). Among the fungal infections, oral candidiasis, presenting in African HIV-infected patients has been sporadically documented. We review the literature with respect to candidal carriage, oral candidiasis prevalence and the predictive value of oral candidiasis for a diagnosis of underlying HIV disease in African HIV-infected patients. The use of oral candidiasis as a marker of disease progression, the species of yeasts isolated from the oral cavity in Africa and the resistance of the yeasts to antifungal agents and treatment regimens are discussed. Orofacial lesions as manifestations of the systemic mycoses are rarely seen in isolation and few cases are reported in the literature from Africa. In spite of the high incidence of noma, tuberculosis, chronic osteomyelitis and syphilis in Africa, surprisingly there have been very few reported cases of the oral manifestations of these diseases in HIV-positive individuals. Orofacial disease in HIV-infected patients is associated with marked morbidity, which is compounded by malnutrition. The authors indicate specific research areas, initially directed at the most effective management strategies, which would complete data in this important area.