tuberculosis oral

11 CHRISMED Journal of Health and Research /Vol 1/Issue 1/Jan-Apr 2014

INTRODUCTION

World Health Organization (WHO) estimates that the largest number of new tuberculosis (TB) cases in 2008 occurred in the South-east Asia region, which accounted for 34% of incident cases globally.[1] However, the estimated incidence rate in sub-Saharan Africa is nearly twice that of the South-east Asia region with over 350 cases per 100,000 population. Incidence of TB is increasing in developing as well as developed countries because of migrant population.[2] Increasing incidence of HIV infection, lack of public health efforts to control TB after its elimination, poverty, and emergence of multidrug-resistant (MDR) TB are the reasons of increase in TB incidence in developed countries.

TB is still among the most life-threatening infectious diseases, resulting in high mortality in adults. With an incidence of 139 per 100,000 (in 2007) active Mycobacterium TB infections globally, it is estimated that two billion people (i.e. one-third of the world’s population) have been in contact with the TB bacillus. A significant

proportion of patients (15-25%) exist in whom the active TB infection is manifested in an extrapulmonary site. Moreover, the emergence of drug-resistant TB has recently raised serious concerns. TB is a frequent cause of missed or complicated diagnosis in general medical settings.[1,2]

Healthcare workers, including dentists, are at the frontline and can make an important contribution to the control of this infectious epidemic. Oral TB has been considered to account for 0.1-5% of all TB infections.[3] Nowadays, oral manifestations of TB are reappearing alongside many forgotten extrapulmonary infections as a consequence of the outbreak and emergence of drug-resistant TB and of the emergence of acquired immunodeficiency syndrome (AIDS), where oral TB is found to account for up to 1.33% of human immunodeficiency virus (HIV)-associated opportunistic infections, based on a cohort of 1,345 patients.[2,3] This review, therefore, seeks to assess the manifestations and symptoms of TB in the oral cavity as documented in the literature published in English to the present date. It is true that the dental identification of M. TB has the potential of serving as an important aid in the first line of control for this dangerous, and often fatal, disease.

Oral manifesta onTB oral lesions are a relatively rare occurrence. Studies vary, but the incidence has usually been reported as less than 1% of the TB population. Saliva is believed to have a protective effect, which may explain the

Corresponding Author: Dr. Shekhar Kapoor, Department of Oral Medicine and Radiology, Christian Dental College and Hospital, Ludhiana - 141 008, Punjab, India. E-mail: [email protected]

REVIEW ARTICLE

Oral manifestations of tuberculosisShekhar Kapoor, Sumir Gandhi1, Nitasha Gandhi2, Inderjot Singh1

Departments of Oral Medicine and Radiology, 1Oral and Maxillofacial Surgery, 2Prosthetic Dentistry,Christian Dental College and Hospital, Ludhiana, Punjab, India

A B S T R A C T

Tuberculosis (TB) is still among the most life-threatening infectious diseases, resulting in high mortality in adults. A significant proportion of patients (15-25%) exist in whom the active TB infection is manifested in an extrapulmonary site. Healthcare workers, including dentists, are at the frontline and can make an important contribution to the control of this infectious epidemic. Oral TB has been considered to account for 0.1-5% of all TB infections. Nowadays, oral manifestations of TB are re-appearing alongside many forgotten extrapulmonary infections as a consequence of the outbreak and emergence of drug-resistant TB and of the emergence of acquired immune-deficiency syndrome.

Keywords: Drug-resistant, extrapulmonary, tuberculosis

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DOI: 10.4103/2348-3334.126772

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Kapoor, et al.: Oral tuberculosis


paucity of TB oral lesions, despite the large numbers of bacilli contacting the oral cavity mucosa in a typical case of pulmonary tuberculosis. Other factors that attribute to relative resistance of oral cavity for TB are presence of saprophytes, resistance of striated muscles to bacterial invasion, and thickness of protective epithelial covering. It is believed that the organisms enter the mucosa through a small break in the surface. Local factor that may facilitate the invasion of oral mucosa includes poor oral hygiene, leukoplakia, local trauma, and irritation by clove chewing, and so on. Self-inoculation by the patient usually results from infected sputum or by hematogenous or lymphatic dissemination.[3-5]

Oral TB lesions may be either primary or secondary in occurrence. Primary lesions are uncommon, seen in younger patients, and present as single painless ulcer with regional lymph node enlargement. The secondary lesions are common, often associated with pulmonary disease, usually present as single, indurated, irregular, painful ulcer covered by inflammatory exudates in patients of any age group but relatively more common in middle-aged and elderly patients.[2,3,6]

Oral TB may occur at any location on the oral mucous membrane, but the tongue is most commonly affected. Other sites include the palate, lips, buccal mucosa, gingiva, palatine tonsil, and floor of the mouth. Salivary glands, tonsils, and uvula are also frequently involved. The retromolar region is rarely involved. Secondary lesions of the mandibular ridge (alveolar mucosa) are extremely rare. Primary oral TB can present with painless ulceration of long duration and enlargement of the regional lymph nodes.[3,6,7]

The oral lesions may present in a variety of forms, such as ulcers, nodules, tuberculomas, and periapical granulomas.[3,7,8] The identification of a TB lesion in any location in the mouth is an unusual finding and its discovery is usually indicative of underlying pulmonary disease. Therefore, in all cases of oral cavity TB, search for primary site of the disease should always be considered even in the absence of any signs and symptoms. The oral manifestations of TB can also be in the form of superficial ulcers, patches, indurated soft tissue lesions, or even lesions within the jaw that may be in the form of TB osteomyelitis or simple bony radiolucency.[8,9] Of all these oral lesions, the ulcerative form is the most common.[3,6,10] It is often painful, with no caseation of the dependant lymph nodes. Oral lesions of TB are nonspecific in their clinical

presentation and often are not considered in differential diagnosis, especially when oral lesions are present before systemic symptoms become apparent. Primary gingival involvement is more common in children and adolescents than adults.[3,7,11] It usually presents as a single painless indolent ulcer, which progressively extends from the gingival margin to the depths of the adjacent vestibule and is often associated with enlarged cervical lymph nodes. They may be single or multiple, painful or painless and usually appear as irregular, well-circumscribed ulcer with surrounding erythema without induration and satellite lesions are commonly found.[4,9,12]

When oral TB occurs as a primary lesion, an ulcer is the most common manifestation usually developing along the lateral margins of the tongue which rest against rough, sharp, or broken teeth or at the site of other irritants. Patients with oral tubercular lesions often have a history of preexisting trauma. Any area of chronic irritation or inflammation may favor localization of the Mycobacterium associated with the disease.[13,14] Deep tubercular ulcers of the tongue are typical in appearance with a thick mucous material at the base. These tongue lesions are characterized by severe unremitting and progressive pain that profoundly interferes with proper nutrition and rest. Classically, tubercular ulcers of the tongue may involve the tip, lateral margins, dorsum, the midline, and base of the tongue. They are irregular, pale, and indolent with inverted margins and granulations on the floor with sloughing tissue.[3,14,15]

Oral cavity TB is difficult to differentiate from other conditions on the basis of clinical signs and symptoms alone. While evaluating a chronic, indurated ulcer, clinicians should consider both infectious process such as primary syphilis and deep fungal diseases and noninfectious processes such as chronic traumatic ulcer and squamous cell carcinoma in the list of differential diagnosis. If there is no systemic involvement, one should go for excisional biopsy for tissue diagnosis and bacteriologic examination with culture for a definitive diagnosis. The efficiency of demonstration of acid fast bacilli in histological specimens is low, as there is relative scarcity of tubercle bacilli in oral biopsies.[3,15]

According to various studies only a small percentage (7.8%) of histopathology specimens stain positive for acid fast bacilli.[11,16] Therefore, a negative result does not rule out completely the possibility of TB . Another




concern is the occurrence of mycobacterial infection as a part of AIDS. Histologically, an immunocompromised patient may not show granuloma or caseation. This poses a potential problem in diagnosing TB. HIV-1-associated TB is reaching epidemic proportions in many African countries. The prevalence and incidence of TB is similar in both HIV-positive and HIV-negative individuals, but the risk of active TB was elevated only for seropositive subjects. Increasing problems with TB may well continue because of the continuing emergence of MDR strains of M. TB, which is a major threat, particularly with HIV- and AIDS-infected patients, among whom, mortality rates are high.[8,11,17]

With the increasing number of TB cases, unusual forms of the disease in the oral cavity are more likely to occur and be misdiagnosed. Although rare, doctors and dentists should be aware of the oral lesions of TB and consider them in the differential diagnosis of suspicious oral ulcers [Figure 1-3]. TB of the oral cavity frequently simulates cancerous lesions and others like traumatic ulcers, aphthous ulcers, actinomycosis, syphilitic ulcer, or Wegener’s granuloma. The traumatic ulcer, which occurs in areas of chronic irritation from either sharp cusps or prosthesis, is acute in presentation and exquisitely tender. Also, the source of irritation is usually evident on examination. The chronic indurated ulcer has to be carefully distinguished from a carcinoma, as with other TB lesions of head and neck, they can resemble each other and frequently coexist.[3,4,15,18,19]

The history reported by the patient and the clinical and radiological examination play an important part in the diagnosis of TB. However, laboratory confirmation is most essential for the diagnosis, with culture of microorganisms taken as the absolute proof of the disease. A biopsy of an oral lesion is confirmatory but in majority of the cases, a single biopsy may not suffice because the granulomatous changes may not be evident in early lesions. The lesion is eventually disclosed by repeat biopsies. The differential diagnosis is made with the identification of a caseating granuloma with associated epitheloid cells and giant cells of the Langerhans type during histological evaluation of biopsied tissue. Deeper biopsies are always advocated for ulcers of the tongue; a superficial biopsy may not reveal the etiology due to epithelial hyperplasia. A chest x-ray and a Mantoux skin test are mandatory to rule out systemic TB. Most often complete remission of tubercular ulceration of the tongue takes place after standard antitubercular chemotherapy using antibiotics

Figure 3: Gingival enlargement

Figure 2: Ulcer in buccal vestibule

Figure 1: Tuberculous ulcer on tongue

such as isoniazide, rifampicin, pyrazinamide, and ethambutol for 6 months.[3,19,20]

TB and den stTB is a recognized occupational risk for dentists, as we work in close proximity to the nasal and oral cavities of patients, with generation of potentially infectious sprays during routine operative procedures. A history of TB should prompt the clinician to distinguish whether the




person is an active case under treatment, active case without treatment or previously infected but currently disease free. The nontreated active cases pose maximum risk to the dental personnel.

Only dental emergencies should be undertaken for treatment under controlled environment for active cases of TB, such as the one described here. The constant risk of contracting the disease should encourage the dental clinicians to follow basic precautions of using face masks, protective eye gear, and gloves. Also, high standards of operatory disinfection and instrument sterilization should be maintained.[7,20-22]

CONCLUSION

Though rare, TB should be included in the differential diagnosis of chronic ulcers of the tongue. The dentist should realize the importance of his role in detection of TB in patients who have asymptomatic oral lesions and are unaware of the disease. However, the mere diagnosis of such lesions is not sufficient and a persistent follow-up is of equal, if not more, importance. Identification of TB is of significance not only to the patient himself, but also to the dental team that comes in contact and the community at large, where the patient can be a potential source for spread of infection.

REFERENCES

1. Mignogna FV, Garay KF, Spiegel R. Tuberculosis of the head and neck and oral cavity. In: Rom WN, Garay SM, editors. Tuberculosis. Boston: Little Brown and Company; 1996. p. 567-76.

2. Shafer WG, Hine MK, Levy MB. A Textbook of Oral Pathology. Philadelphia: WB Saunders; 1983. p. 340-440.

3. Chisholm DM, Ferguson MM, Jones JH. Introduction to Oral Medicine. Philadelphia: WB Saunders; 1978. p. 59-60.

4. Emmanuelli JL. Infective granulomatous diseases of head and neck. Am J Otolaryngol 1993;14:155-67.

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6. Mignogna MD, Muzio LL, Favia G, Ruoppo E, Sammartino G, Zarrelli C. Oral tuberculosis: A clinical evaluation of 42 cases. Oral Dis 2000;6:25-30.

7. Eng HL, Lu SY, Yang CH, Chen WJ. Oral tuberculosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:415-20.

8. Sierra C, Fortún J, Barros C, Melcon E, Condes E, Cobo J, et al. Extra-laryngeal head and neck tuberculosis. Clin Microbiol Infect 2000;6:644-8.

9. Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med 1985;79:467-78.

10. Iype EM, Ramdas K, Pandey M, Jayasree K, Thomas G, Sebastian P, et al. Primary tuberculosis of the tongue: Report of three cases. Br J Oral Maxillofac Surg 2001;39:402-3.

11. Thilander H, Wennestrom A. Tuberculosis of mouth and the surrounding tissues. Oral Surg Oral Med Oral Pathol 1956;9:858-70.

12. Gupta N, Nuwal P, Gupta ML, Gupta RC, Dixit RK. Primary tuberculosis of soft palate. Indian J Chest Dis Allied Sci 2001;43:119-21.

13. Dimitrakupoulos I, Zouloumis L, Lazaridis N, Karakasis D, Trigonidis G, Sichletidis L. Primary tuberculosis of the oral cavity. Oral Surg Oral Med Oral Pathol 1991;72:712-5.

14. Regezi JA, Sciubba JJ. Oral pathology: Clinical- pathological correlations. Philadelphia: WB Saunders; 1989. p. 38 -9.

15. Haddad NM, Zaytoun GM, Hadi U. Tuberculosis of the soft palate: An unusual presentation of oral tuberculosis. Otolaryngol Head Neck Surg 1987;97:91-9.

16. Mani NJ. Tuberculosis initially diagnosed by symptomatic oral lesion. Report of three cases. J Oral Med 1985;40:39-42.

17. Rauch MD, Friedman E. Systemic tuberculosis initially seen as an oral ulceration: Report of a case. J Oral Surg 1978;36:387-9.

18. Prabhu SR, Daftary DK, Dholakia HM. Tuberculous ulcer of the tongue: Report of a case. J Oral Surg 1978;36:384-6.

19. Brennan TF, Vrabec DP. Tuberculosis of the oral mucosa. Report of a case. Ann Otol Rhinol Laryngol 1970;79:601-5.

20. Turbiner S, Giunta J, Maloney PL. Orofacial tuberculosis of the lip. J Oral Surg 1975;33:343-7.

21. Waal V, Kwast V. Oral Pathology. Chicago: Quintessence; 1988. p. 342-3.22. Worsaae N, Reibel J, Rechnitzer C. Tuberculous osteomyelitis of the

mandible. Br J Oral Maxillofac Surg 1984;22:93-8.22.

Cite this article as: Kapoor S, Gandhi S, Gandhi N, Singh I. Oral manifestations of tuberculosis. CHRISMED J Health Res 2014;1:11-4.

Source of Support: Nil. Confl ict of Interest: No.


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