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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 2  |  Page : 87-90
Tuberculous ulcer of tongue with oral complications of oral antituberculosis therapy


Department of Oral Medicine and Radiology, Yenepoya Dental College Hospital, Unit of Yenepoya Institute of Medical Sciences and Research, Nithyanand Nagar Post, Deralakatte, Mangalore 575 018, India

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   Abstract 

Tuberculosis (TB) is an infectious disease affecting humans of all ages in all parts of the world. The dentist plays an important role in the identification and control of this condition by early recognition of oral lesions that may precede the detection of the pulmonary form. Occurrence of increased incidence of mycobacterial infections as a part of the spectrum of AIDS only emphasizes the importance of early diagnosis. A case of a tuberculous ulcer on the tongue along with oral ulcerations, which occurred as a consequence of oral antituberculosis therapy (ATT), is presented. Such complications have rarely been reported in the literature and the management of these is described herein. The tuberculous ulcer healed uneventfully in five weeks after institution of ATT and the other ATT-induced ulcers healed after a week of topical anesthetic application. The clinical presentations, differential diagnoses to be considered, and management of such oral manifestations is discussed. The occupational risk posed by TB to the dentist and appropriate precautions to be observed have been highlighted.

Keywords: Tuberculosis, tongue, chronic ulcer, antituberculosis therapy oral complications

How to cite this article:
Ajay G N, Laxmikanth C, Prashanth S K. Tuberculous ulcer of tongue with oral complications of oral antituberculosis therapy. Indian J Dent Res 2006;17:87-90

How to cite this URL:
Ajay G N, Laxmikanth C, Prashanth S K. Tuberculous ulcer of tongue with oral complications of oral antituberculosis therapy. Indian J Dent Res [serial online] 2006 [cited 2014 Sep 30];17:87-90. Available from: http://www.ijdr.in/text.asp?2006/17/2/87/29884

   Introduction Top


Tuberculosis (TB) is a systemic, infectious disease of global health concern. TB manifests in a variety of clinical forms in humans [1]. Most of the TB cases occurring in the oral cavity are secondary to pulmonary infections, though primary lesions are not rodcnown. The secondary lesions are thought to be a result of contact of oral mucosa with the infected sputum or hematogenous dissemination from pulmonary TB [2]. Although oral TB affects persons of all age groups, middle aged males who smoke tobacco are most commonly affected [1]. The AIDS epidemic due to HIV infection has led to strong re­emergence of TB in industrialized countries where TB had been on the decline in the past [2].

A case of secondary tuberculosis manifesting as a chronic ulcer on the dorsum of the tongue is described here to emphasize the role of the dental clinician in early diagnosis of such lesions. Also the oral complications of antituberculosis therapy (ATT) are described which have not been commonly reported in the literature.


   Case report Top


A thirty-year-old south Indian male patient complained of an ulcer on his tongue of one and half month duration. The patient gave history that this ulcer started as a small sized one and enlarged gradually. It was painless and did not cause him any difficulty. He did not recollect any previous occurrence of such ulcers or any associated traumatic episode.

The patient's medical history was significant for he reported suffering from chronic productive cough and fever for the preceding two months. The fever peaked in the evenings upto 102° F with normal body temperature in the mornings. He reported losing about twelve kilograms weight in the past ten months. The patient's family history and past dental history were non-contributory. The patient was a habitual smoker and had a history of smoking upto ten cigarettes a day for about fifteen years.

On general physical examination, lymphadenopathy was noted in the right and left axillary regions. These nodes were multiple, non-tender and firm in consistency. On extra oral examination, multiple lymph nodes were palpable at all levels on the right side of the neck with the same characteristics as those in the axialle. However, none ofthe nodes on the left side of the neck were palpable.

Intraorally, soft tissue examination revealed the presence of a large, solitary shallow ulcer [Figure - 1] in the midline of the dorsal surface of the anterior two third region of the tongue. It measured approximately 15 nun in diameter with irregular margins and a surrounding zone of erythernatous, depapillated mucosa The floor contained yellowish granular tissue, which obscured inspection of the edge of the ulcer. On palpation, the ulcer was non-tender, indurated and with an undermined edge. Based on the history reported by the patient and clinical examination findings, a provisional diagnosis of tuberculous ulcer of the tongue was arrived at. The other differential diagnoses that were considered included traumatic ulcer and major aphthous ulcer. Smears made from the floor of the ulcer stained positive for acid-fast bacilli [Figure - 2]. The patient's hematologic workup did not show any abnormality other than a highly elevated ESR of 120 mm/hour by the Westergren method (normal 10-20 mm/hour). The patient was found to be HTV­ negative as indicated by a non-reactive T?LTSA. A chest radiograph [Figure - 3] showed non-homogenous opacification of both lungs in patches with pronounced opacity and cavitation in the upper lobe of the right lung. The trachea was shifted to the right and minimal fibrotic bands were apparent radiographically. The patient was then admitted as an inpatient by the department of General Medicine of our institute Mantoux test was performed, which exhibited a positive result. The patient's sputum from three successive mornings was also sent to the district tuberculosis control society, Mangalore for examination. The sputum examination yielded positive results for the mycobacterium tuberculosis bacilli. Thus the diagnosis of pulmonary tuberculosis was confirmed both microscopically and radiographically and the ulcer on the tongue was therefore concluded as a tuberculous ulcer secondary to pulmonary tuberculosis. The patient was then prescribed antituberculosis therapy (ATT) consisting of isoniazid (300mg), ethambutol (1000mg), pyrazinamide (1500mg) and rifampicin (600mg).

When reviewed after three days, the tuberculous ulcer [Figure - 4] showed yellow slough on the floor and slight creeping of the margins towards the centre. However, the patient now complained of multiple small ulcers on the ventral surface of the tongue [Figure - 5] and on the soft palate and uvula [Figure - 6]. These ulcers were extremely painful to the patient and caused him difficulty in eating, swallowing and speech. When questioned, the patient reported placing all the AFT tablets in the lingual vestibule initially and then swallowing them with water. These smaller ulcers were seen to be present only in those areas, which would come in contact with the AFT medication. Therefore these ulcers were concluded to be drug-induced ulcers secondary to ALL The patient was prescribed a topical anaesthetic gel (Mucopain gel) as symptomatic treatment for these drug-induced ulcers and a 0.12% chlorhexidinemouthwash.

When reviewed after five more days, the Tuberculous ulcer [Figure - 7] showed creeping of the margins towards the centre decreasing the size of the visible floor. Also, the smaller drug-induced ulcers on the soft palate had healed completely without scars [Figure - 8]. The drug-induced ulcers on the ventral surface of the tongue had enlarged, desquamated and become confluent [Figure - 9]. However they were non-tender on palpation. The patient also reported no difficulty in swallowing solid and liquid food.

When examined a week later, the Tuberculous ulcer showed definite signs of healing as evidenced by the decrease in its size and well-defined margins [Figure - 10]. The drug-induced ulcers on the ventral surface of the tongue had healed completely without scarring [Figure - 11]. The patient was then discharged by the physician and was advised continuation ofATT for a period of six months.

The patient was then evaluated ten days after discharge from the hospital (25 days after initial presentation). The Tuberculous ulcer [Figure - 12] showed significant decrease in size, measuring less than 5 nun in diameter. The induration of the ulcer was not present. The ulcer showed complete resolution [Figure - 13] with normal mucosal appearance when evaluated ten days later (35 days after initial presentation). At the end of course of AFT (6 months) the patient showed no evidence of any oral mucosal lesions.


   Discussion Top


Tuberculosis (TB) is most commonly caused by the microorganism, mycobacterium tuberculosis, which is aerobic, non-motile, non-capsulated, non-spore forming and rod shaped. However, mycobacterium bovis Scientific Name Search  and atypical mycobacteria can also cause TB. Although TB affects the lungs in majority of the cases, it can also affect any other body part, including the oral cavity [1],[3]. TB affects about 8 million people annually worldwide [4]. The regions with high incidence rates are the Indian subcontinent, southeast Asia and Africa [2].Incidence of oral tubercular infections are quite rare, occurring in 0.05%- 5% of all cases [5]. Oral lesions maybe primary or secondary to TB elsewhere in the body [4]. The integrity of the oral epithelium and inhibitory effect of saliva are considered to be the reason for relative resistance to infection by the bacilli [6]. However a break in the epithelial continuity in the form of scratches or abrasions facilitates inoculation by the bacilli present in sputum, which is brought in intimate contact during coughing or speech. Both local and systemic predisposing factors exist for the occurrence of oral lesions [1]. Local factors include poor oral hygiene, local trauma presence of preexisting lesions such as leukoplakia periapical granulomas, cysts, abscesses and periodontitis [1],[2]. Lowered host resistance due to primary or secondary irmauno suppression and nutritional deficiencies form the spectrum of systemic predisposing factors. The most vulnerable areas include gingiva extraction sockets, buccal folds and tongue [1],[2],[6],[7]. In the tongue, the lateral borders are more at risk for minor trauma from the cusps of teeth, which may be unnoticed. However the dorsrmi is also known to be affected, particularly in the posterior third along the midline [1]. In the case described, however, the lesion manifested in an unusual anterior location. Other areas of the oral mucosa that may be affected are palate, lips, alveolar mucosa and jaw bones [1].

Oral lesions have a non-specific presentation varying from ulcers to granulomas and fissures and may be overlooked [1],[2],[4]. The lesions on the tongue, usually ulcers, may be single or multiple, are usually painful, grayish-yellow, with irregular margins, firm and slightly indurated [1],[6]. In this case, the ulcer was completely painless, which was in contrast to the usually reported finding. The differential diagnosis of such ulcers with variable clinical characteristics should include traumatic ulcer, malignant ulcer, aphthous stornatitis, syphilitic ulcer, actinomycosis and Wegener's granuloma [1],[8]. The traumatic ulcer, which occur in areas of chronic irritation from either sharp cusps or prosthesis, are 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 Tuberculous lesions of head and neck, they can resemble each other and frequently coexist [7].

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 [1]. 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 [1].

Once the diagnosis of TB is confirmed, the patient should be referred to a specialist competent in handling TB cases for systemmic Antituberculosis therapy (AFT). The first line Drugs most commonly used are rifampicin, isoniazid, ethambutol, pyrazinamide and streptomycin [2]. Our patient was on ATT, as a result of which he had developed multiple ulcerations on his soft palate, uvula and ventral surface of the tongue. These lesions resembled typical ulcers induced by contact with other drugs and were reported to have started only after the onset of ATT. The high potency and toxicity of the antitubercular drugs may have caused an immediate reaction in the oral mucosa. A conservative approach consisting of a topical anesthetic (Mucopain gel) application accorded relief in this case and the ulcers healed uneventfully within 10 days.

TB 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 [2],[4]. 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 non-treated active cases pose maximum risk to the dental personnel [4].

Only dental emergencies should be undertaken for treatment under controlled environment for active cases of TB, such as the one described here [2],[4]. 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 [1].

In 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 asymptornatic 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 apotential source for spread of infection.

 
   References Top

1.Prabhu SR, Sengupta SK: Bacterial infections due to mycobacteria, In Prabhu SR, Wilson DF, Daftary DK, Johnson NW, editors oral Diseases in the Tropics, (1st ed), Delhi Oxford university press, p.195-202,1993.  Back to cited text no. 1    
2.Rinaggio J: Tuberculosis, Dent Clin North Am, 47[3]:449-65,2003.  Back to cited text no. 2    
3.deAguiarMC,ArraisMJ,MatoMJ,deAraujoVC: Tuberculosis of the oral cavity: a case report, Quintessence, 28:745-747,1997.  Back to cited text no. 3    
4.Yepes JF, Sullivan J, Pinto A: Tuberculosis: medical management update oral Surg Oral Med Oral Pathol Oral Radiol Endod, 98[3]: 267-73, 2004.  Back to cited text no. 4    
5.Mignogna MD, Muzio LLO, Favia G, Ruoppo E, Sammartino G, Zarrelli C et al . Oral tuberculosis: a clinical evaluation of 42 cases oral Dis, 6:25-30, 2000.  Back to cited text no. 5    
6.Eng HL, Lu SY, Yang CH, Chen WJ: Oral tuberculosis oral Surg Oral Med Oral Pathol Oral Radiol Endod, 81: 415-420,1996.  Back to cited text no. 6    
7.type 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, 39[5]: 402-3, 2001.  Back to cited text no. 7    
8.Bhat P, MehndirattaA, D'Costa L, Mesquita AM, Nadkarni N: Tuberculosis of tongue: a case report, Indian J Tub, 44: 31-3,1997.  Back to cited text no. 8    

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Correspondence Address:
G N Ajay
Department of Oral Medicine and Radiology, Yenepoya Dental College Hospital, Unit of Yenepoya Institute of Medical Sciences and Research, Nithyanand Nagar Post, Deralakatte, Mangalore 575 018
India
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DOI: 10.4103/0970-9290.29884

PMID: 17051875

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13]

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