The oral cavity can be involved in a gonococcal infection,

either directly or indirectly. Both types of involvement are dangerous

to the patient so affected and to the other patients who follow the one
so affected, as well as to the dental practitioner himself.
Because we are presently in the midst of a gonorrheal epidemic,
an awareness of this infectious process is definitely indicated.
The clinical features, oral manifestations, diagnosis, treatm ent, and
prevention are described in detail to assist the practitioner
in the proper management of this disease.

Gonorrhea— its natural history, oral

manifestations, diagnosis, treatment,
and prevention

Natural history of gonorrhea

P. W. Y. Chue, DDS, MD, Edwardsville, III

G onorrhea is an infectious disease caused by a

During the past 14 years there has been a signif­
icant, steady increase in the incidence of gonor­
rhea in the United States. In 1961, the total num­
ber of reported cases of gonorrhea was 265,665
or 147.8 per 100,000 population.1 In 1972, the
total figure jumped to 718,401 or 349.7 per 100,-
000 population.1 The sharpest increase took
place in the past five years, and the current rate
of growth is estimated at about 15% per year.2
It was expected that in 1974 the number of people
affected would total more than 900,000. This fig­
ure only refers to the reported cases. Since a
much higher percentage of cases goes unreport­
ed, the actual total number of gonorrhea cases
in the United States, therefore, is estimated at
more than 2,500,000.2 Because of the alarming
incidence of this dreadful infectious disease,
many authorities in public health believe that we
are currently in the midst of a true epidemic of
gonorrhea.3,4
As this highly contagious disease is not solely
confined to the urogenital tract, it is the purpose
of this article to draw attention to the other pri­
mary and secondary sites of infection—partic­
ularly the oral cavity in the interest of the dental
profession.
gram-negative intracellular diplococcus, N eis­
seria gonorrhoeae. The infection usually starts
in the mucous membranes of the genitourinary
tract and is most frequently contracted by sex­
ual intercourse.5'6 In rare cases it also may occur
by contact with contaminated articles such as
instruments, washcloths, and toilet seats.7 The
microorganism is quickly destroyed on drying
or at temperatures over 106 F (41.1 C), but it may
remain viable in a moist environment for many
hours.7 The incubation period of infection is be­
tween three and ten days.
In males, the infection usually starts in the an­
terior part of the urethra and tends to spread to
involve the posterior urethra, prostate, seminal
vesicles, epididymis, and urinary bladder.8
In females, the primary sites of involvement
are the urethra and cervix uteri.9 If untreated,
extension of the infection along the urogenital
tract may lead to skenitis, bartholinitis, cystitis,
parametritis, salpingitis, oophoritis, as well as
peritonitis.
Whereas dysuria and white or yellow urethral
discharge are common initial symptoms appear­
ing in the man, the entire clinical picture is much
less florid in the infected woman. It has been es­
timated that 75% to 80% of the uncomplicated
JADA, Vol. 90, June 1975 ■ 1297
cases o f gonorrhea in women are o f the asymp­
tomatic variety, in contrast to 15% to 20% sim­
ilar cases involving infected m en.10
In either sex, hematogenous dissemination o f
the gonorrheal infection can lead to arthritis,
tenosynovitis, bursitis, periostitis, meningitis,
endocarditis, myocarditis, and pericarditis as
w ell as various types of skin3 and mucous-mem-
brane lesions.
Although genital union is the usual mode of
sexual intercourse, orogenital and anogenital
contacts are also common practices between
members o f the opposite sexes as well as mem­
bers o f the same sex. Consequently, primary
extragenital gonococcal lesions such as gono­
coccal tonsillitis and gonococcal proctitis are not
rare.
H ypersensitivity reactions caused by gonor­
rheal infection and appearing in the forms o f gen­
eralized erythema, erythema multiforme, and
urticaria have been recognized.11
Oral gonorrheal lesions
T he tissues of the oral cavity can be affected by
the gonorrheal process either directly or indi­
rectly. In the former, the primary lesion in the
oral cavity is caused by direct contact o f the oral
cavity with the infecting microorganisms; in the
latter situation, the oral tissue involvement is
secondary to the primary site o f infection else­
where in the body such as the genital tract or the
anal canal.
Primary oral gonococcal lesions seem to be
more common, and various tissues of the oral
cavity may be affected. The lips may show acute
ulcerative inflammation, which is intensely pain­
ful12'15 and therefore renders mouth-opening dif­
ficult. The gingiva may becom e erythematous,
spongy, and tender, either with or without ne­
crosis o f the interdental papillae.1214,16 The
tongue may be red and dry with ulcerations,12,14
or swollen as well as glazed with eroded areas,
which are exceedingly painful to touch.12 M ove­
ments o f this organ also may be restricted.12 The
buccal mucosa may show diffuse inflammation
or reveal ulcerative areas that tend to bleed eas­
ily on manipulation.1214 The soft palate and
uvula may be intensely reddened and edema­
tous, together with many areas denuded o f epi­
thelium .12,16,17 In addition, the oropharynx may
be covered with vesicles.17 In all these areas,
pseudomembranes—white, yellow, or grey in
1298 ■ JADA, Vol. 90, June 1975
color—are frequently present.12,13 They are
nonadherent in character, and bleeding surfaces
usually result on their removal.
In som e persons, the whole mouth seem s to
be involved in the infectious p rocess.12,15 The
lips are inflamed and swollen. The entire oral
mucous membrane becom es fiery red. Ulcera­
tions and pseudomembranes are scattered all
over the oral tissues. Speaking becom es exceed­
ingly difficult and eating almost impossible. In
other individuals, the inflammation seem s to be
less acute. Bronson12 cited a case in which the
whole mucous membrane was wine red in color
and was as smooth as if it had been varnished,
because o f gonococcal infection.
Parotid glands also can be involved in gono­
coccal infection. Diefenbach18 reported one case
o f acute gonococcal infection o f the right parotid
gland in a passive homosexual practicing fella­
tio. The affected gland was inflamed, swollen,
and exceedingly tender to touch. The opening of
the parotid duct was reddened and edematous.
A whitish purulent exudate could readily be ex­
pressed from the affected duct. Pronounced dif­
ficulty in moving the jaw s was experienced.
Although almost any soft tissue in the oral cav­
ity can be affected in gonococcal infection, most
observers seem to agree that the tonsils and oro­
pharynx are the most frequent sites of involve­
ment. The tonsillar tissues may be infected uni­
laterally or bilaterally.17,19 The intensity o f in­
flammation may be mild without regional lym-
phadenopathy or severe with mucopurulent dis­
charge as well as cervical lymphadenitis.12,17
The same clinical picture has been observed with
respect to pharyngeal gonorrhea. H olm es20 re­
ported that 19% o f gonococcal pharyngitis that
he discovered were so mild that the patients
never even complained o f any discomfort in the
throat. Ratnatunga21 reported two cases in which
N gonorrhoeae were cultured from pharyngeal
areas that appeared almost normal. Similar ob­
servations have been reported by others.22'24
However, Fiumara and Metzger, as well as my­
self, have seen the fiercely inflamed pharynx to­
gether with pyrexia that was proven to be gono­
coccal in causation.
Often, when the oral cavity is involved in an
acute gonorrheal process, the first symptom the
patient experiences usually is a burning or itchy
sensation, or a feeling o f dryness and heat in the
mouth.12 Then within 24 hours to a few days,
acute pain follows. Salivary secretion may be in­
creased or decreased.12,13 Its viscosity is fre­
quently elevated, and it may have a horrible
taste.12 In some instances, the saliva consists
principally o f pus cells with epithelial debris with
a large number o f N goriorrhoeae.12 The breath
is usually repulsively fetid.
Depending on the oral tissue affected, enun­
ciation, chewing, or swallowing can be quite dif­
ficult. When the anterior part is involved in the
acute gonorrheal process, introduction o f sour
or hot food into the mouth can intensify greatly
the discomfort. Submaxillary lymph nodes are
almost always swollen and painful in acute gono­
coccal infection. Sublingual lymph nodes also
can be involved, but this is less common. The
degree o f fever tends to be parallel with the acute­
ness o f the whole infectious process. In asymp­
tomatic individuals, there is generally no eleva­
tion o f body temperature.19,23 In individuals in
whom the symptoms are fulminant, pyrexia can
be as high as 102.4 F or higher.12
Secondary gonorrheal involvements o f the
oral tissues can be divided into two groups: sep­
tic embolization in which erythematous, pur­
puric, vesiculopustular, hemorrhagic, ulcera­
tive, or keratotic lesions are present; and hyper­
sensitivity reactions in which the erythema mul­
tiforme types o f lesions are found. Both groups
o f oral lesions appear to be rather uncommon.
H ow ever, Bronson12 cited one case in which el­
evated erythematous maculas were found on the
gingiva. Later, in the same patient, the whole
left side o f the oral cavity was ulcerated and cov­
ered with pseudomembranes. There was abun­
dant salivation, and the submaxillary glands
were swollen. Cowan25 reported one case o f ul­
ceration o f the tongue that was believed to be
metastatic in origin with the primary focus in the
genital tract. Bruusgaard and Thjotta26 found
hemorrhagic spots on the soft palate in a patient
with gonococcem ia and gonococcal meningitis.
In one case o f gonococcal dermatitis reported
by K eil,27 a few small vesicles surrounded by an
erythematous halo were observed on the soft
palate. In the same patient, gonococci were
grown from the blood. Keratotic lesions o f kera-
toderma blennorrhagica, though usually associ­
ated with Reiter’s disease, have been found in
the mouth in the course o f gonorrheal infec­
tion.5,28 Although evidence o f gonococci is dif­
ficult to demonstrate in these lesions, this has
been done on several occasion s.28 T hese lesions
are believed to be the result o f hematogenous
dissemination o f the gonococcal infection from
a primary focus elsewhere in the body.
In the tissues adjacent to the oral cavity, met­
astatic gonococcal lesions have also been re­
ported. Vesiculopustular gonorrheal lesions on
the chin and eyelids have been encountered by
Abu-Nassar and co-workers29 and on the face by
Ackerman, Miller, and Shapiro.30
Pindborg31 has seen an individual in whom
erythematous lesions on the palate, buccal mu­
cosa, and part o f the gingiva were found, and
they were suspected to be gonorrheal hyper­
sensitive in nature. Zachariae32 reported a case
in which multiple erythematous and ulcerated
lesions, interpreted as an allergy to gonococcal
infections, were seen on the individual’s gingiva,
inner cheeks, and soft and hard palates. Eryth­
ema multiforme syndrome is believed to be
caused by a hypersensitive-type vasculitis in
response to a wide variety o f underlying diseases
or conditions including bacterial, viral, m ycotic,
and protozoan infections.33 This condition fre­
quently involves the mucous membranes o f the
eyes, nose, and anogenital areas, as well as the
mouth.33 Erythema multiforme o f the skin,
caused by gonorrheal infection, has been re­
ported,11 and it is quite conceivable that it also
can cause similar lesions in the oral cavity.
Infection in relation to dentistry
With the drastic change in the moral standards
in our society and liberalization o f attitudes
toward sexual practices, venereal disease has
becom e increasingly widespread and has
achieved major significance in the public health
field in our country at the present time. Because
of the 15% rate o f increase in the incidence o f
the disease each year,2 we are bound to see more
and more patients afflicted with gonorrheal in­
fection in the mouth.
A s mentioned earlier in this article, gonococ­
cal infection in the oral cavity is not infrequently
asymptomatic. The patients have neither local
pain nor fever nor other symptoms system ic in
nature. Therefore, patients often fail to seek
medical attention until the condition has becom e
more serious, and more contacts have becom e
infected. T he importance o f the problem is com ­
pounded further by the fact that simple treat­
ment o f anogenital gonococcal infection fre­
quently fails to cure concomitant gonococcal
oral infection.23 H olm es20 pointed out that pha­
ryngeal gonococcal infection poses three dan­
gers: first as a reservoir o f N gonorrhoeae in the
transmission o f this infectious disease; second
Chue: GONORRHEA ■ 1299
as a potential source o f gonococcem ia, giving
rise to arthritis, perihepatitis, meningitis, and
carditis as well as other focal septic embolization
lesions in the various tissues o f the body; and
third as a possible cause o f acute severe local
discomfort caused by fulminating infection.
I may add that any primary gonococcal infec­
tion in the oral cavity carries with it the same
categories o f danger. Dental practitioners are
constantly exposed to this area o f the human
body, where potentially dangerous infection
may exist, in the practice o f their profession.
T he gonorrheal process can be transmitted from
one patient to another by way o f the instruments
that the dentists use. Furthermore, dentists can
infect them selves by operating on an infected pa­
tient. Though it is rare, infection o f a physician’s
finger by contact with a gonorrheal patient, lead­
ing to subsequent development o f a severe sys­
tem ic infection and gonococcal arthritis, has
been reported.29
Mechanical dissemination o f the infection to
other tissues in the oral cavity o f an infected pa­
tient is also an ever-present possibility. Thus,
gonococcal osteitis resulting from a dental ex­
traction in a patient with oral gonorrhea is defi­
nitely a constant danger.
Diagnosis of oral gonorrhea
Because o f the multiplicity o f clinical manifes­
tations o f this infectious process that one may
encounter in the oral cavity, diagnosis o f this
condition is naturally by no means easy and a
high index o f suspicion is a prime prerequisite.
It is a known fact that gonorrhea occurs more
frequently among the low socioeconom ic
groups, but this is not always so. Primary oral
gonorrhea is more common in homosexuals, but
it also can occur in heterosexuals. Promiscuity
is definitely o f major importance in the acqui­
sition o f this disease, but w e must remember that
transient laxity in the moral behavior o f the well
disciplined can be followed by the same infec­
tious process. Though gonorrhea is predom­
inantly a disease o f those between 15 and 29 years
of age,2 no age group is actually exempt from
this condition. Therefore, w e must be on our
guard at all times, and whenever the suspicion
o f gonorrhea arises, a culture should be done
with a Thayer-Martin or Transgrow medium.
The oral cavity harbors many N e isse ria micro­
organisms that appear morphologically similar
1300 ■ JADA, Vol. 90, June 1975
to N g o n orrh oeae on a smear. H ence, as far as
gonococcal infection o f the oral cavity is con­
cerned, smear examination by gram stain is not
advisable. Thayer-Martin and Transgrow media
contain antibiotics and carbon dioxide that se­
lectively permit the growth o f N gon orrh oea and
N m en in gitidis but not other N e isse ria organ­
ism s.34 T o differentiate N gon orrh oeae from N
m en in gitidis, a sugar fermentation test can be
done. N gon orrh oeae can ferment dextrose but
not m altose and sucrose, whereas N m eningitidis
can ferment both dextrose and maltose but not
sucrose.35
Recently, the fluorescent antibody test has
been introduced in the diagnosis o f gonorrheal
infection. It is a useful method, but special train­
ing is needed to achieve proficiency in this pro­
cedure.
Treatm en t of gonorrhea
With the discovery o f antibiotics, treatment o f
gonorrheal infection has become relatively sim­
ple.
If the patient has no history of hypersensitivity
to penicillin, aqueous procaine penicillin in a
dose of 4.8 million units given intramuscularly
and preceded by oral administration o f 1 gm of
probenecid half an hour before the injection is
the preferred treatment for men and w om en.36
Long-acting benzathine penicillin is not recom­
mended since it cannot reach the blood level high
enough to be effective against gonococci.
Probenecid is used in this instance to ensure
a high blood level of antibiotic by decreasing its
loss through urinary excretion.
Should an oral antibiotic be chosen, ampicil-
lin, in a dose o f 3.5 gm, may be administered si­
multaneously with 1 gm of probenecid.36
H ow ever, if the patient is known to be allergic
to penicillin or if penicillin fails to eradicate the
infection, tetracycline, administered orally, may
be used. The dosage is 1.5 gm initially, followed
by 0.5 gm four times daily for four days until 9 gm
has been used. Spectinomycin does not appear
to be effective against pharyngeal gonococcal
infection.19
Prevention of spread of oral gonorrhea
Since oral gonorrhea is not only dangerous to the
infected person himself but to the dental practi­
tioner and also to the patients following the in­
fected individual, proper precautionary mea­
sures should be taken if the possibility o f gonor­
rheal infection cannot be ruled out. The prac­
titioner should not examine the suspected lesion
without surgical gloves, especially if there is a
lacerated area on his finger. Only an emergency
dental service should be rendered. Dental ex­
traction or any traumatizing procedure involving
the soft tissues should be postponed. T he patient
should be told, in a tactful manner, that urgent
medical service is needed, and he should be re­
ferred to a physician without delay. T he gloves
used in the examination should be discarded,
and all instruments contaminated should be ster­
ilized properly.
Conclusion
Gonorrhea is a serious venereal disease that
does not confine itself to the primary site o f the
infection but can spread by way o f the hema­
togenous route to involve distant, important or­
gans o f the body. Although urogenital gonorrhea
has been recognized for centuries, extragenital
gonorrheal lesions, either primary or secondary
in nature, have only becom e the center o f atten­
tion recently. With an annual increase rate of
15% in incidence o f this dreadful disease, extra­
genital lesions will assume greater and greater
significance in the control o f this condition.
Members o f the medical profession such as
the ophthalmologists, dermatologists, and in­
ternists have becom e more aware o f the natural
history o f this highly infectious disease; I believe
that the time has com e for the members o f the
dental profession to be more cognizant o f the
problem. A s control o f any disease process can
only be possible if one has sufficient knowledge
o f the natural behavior o f the disease in question,
it is hoped that this article, in some small way,
can contribute a little to this end.
Dr. C hue is associate professor and chairm an, departm ent of
m edicine, School o f Dental M edicine, Southern Illin o is U niver­
sity, Edwardsville, 62025.
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Chue: GONORRHEA ■ 1301