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.