| Abstract|| |
There is a well-known phrase that states, "The more things change, the more they stay the same." This expression continues to apply to tuberculosis (TB), a widespread infectious disease traced back to the earliest of centuries. TB has claimed its victims throughout much of known human history. Mycobacterium tuberculosis may have killed more persons than any other microbial pathogen and is one of the major causes of ill health and death worldwide. Although the overall incidence of TB has decreased, recently, the incidence of this disease appears to be increasing. Oral lesions of TB though uncommon are seen in both the primary and secondary stages of the disease. In secondary TB, the oral manifestations may be accompanied by lesions in the lungs, lymph nodes, or in any other part of the body and can be detected by a systemic examination. Most of the cases are secondary to pulmonary disease and the primary form is uncommon. Here, we present a case of primary oral TB, affecting the gingiva and hard palate in a 40-year-old Indian female patient.
Keywords: Epitheloid cells, oral tuberculosis, oral ulcers, tuberculosis
|How to cite this article:|
Kamala R, Sinha A, Srivastava A, Srivastava S. Primary tuberculosis of the oral cavity. Indian J Dent Res 2011;22:835-8
Tuberculosis (TB) is a chronic infectious granulomatous disease caused mainly by Mycobacterium tuberculosis, an acid-fast bacillus that is transmitted primarily through the respiratory route through inhalation of infected airborne droplets containing the bacillus, M. tuberculosis. Less commonly, TB is caused by exposure to Mycobacterium bovis through ingestion of unpasteurized, infected cow's milk or other atypical mycobacteria. 
|How to cite this URL:|
Kamala R, Sinha A, Srivastava A, Srivastava S. Primary tuberculosis of the oral cavity. Indian J Dent Res [serial online] 2011 [cited 2015 Jan 30];22:835-8. Available from: http://www.ijdr.in/text.asp?2011/22/6/835/94680
Oral lesions are seen in 0.05 to 5% of the patients with TB and may be either primary or secondary. Primary forms generally are uncommon and occur in younger patients with frequently associated caseation of the draining lymph nodes. Secondary lesions are more common and are seen mostly in older persons. 
Pulmonary TB is the most common form of disease. However, TB can also occur in the lymph nodes, meninges, kidneys, bone, skin, and in the oral cavity. , Oral lesions of TB are nonspecific in their clinical presentation and are present before systemic symptoms became apparent. In dental clinics, oral health workers are at high risk for M. tuberculosis infection because of close contact with patients and aerosol spread during the dental treatment process. The purpose of this article is to report a case of primary TB and to emphasize the importance of early diagnosis to reduce the risk of exposure to the patient's contacts. 
| Case Report|| |
A 45-year-old woman presented to the department of oral medicine and radiology with a complaint of ulcer in the gum since 4 months, which was persistent, gradually progressing painless lesion. She was also suffering from gradual loss of weight and generalized weakness.
The medical history was not significant for any serious illness. There was no history of difficulty in swallowing or breathing, cough, fever, blood mixed sputum, or evening rise of temperature. She was a housewife and chronic bidi smoker for past 20 years. Her husband was suffering from TB and was undergoing treatment. General physical examination revealed that patient was of normal gait and built and poorly nourished. Right submandibular and multiple cervical lymph nodes were enlarged, mobile, matted, and nontender on palpation [Figure 1].
Intraoral soft tissue examination revealed two ulcers. First, a large irregular ulcer present on the right maxillary gingiva involving the labial aspect in relation to 16, 15, 13, 12, 11 and extending to the alveolar mucosa and measuring approximately 2 × 4 cm. The ulcer was bordered by well-defined margins. Floor covered by necrotic slough surrounded by erythematous area. On palpation, the ulcer was nontender. Purulent exudates in the affected area were also present [Figure 2].
The other mucosal surface involved was the palatal mucosa with single oval ulcer, measuring 1 × 1 cm, present in the anterior mid palate with undermined margins. The surface of ulcer was granular [Figure 3].
Correlating the patient's age of presentation, chronic ulcer of four-month duration with an associated habit of smoking, palpable submandibular and cervical lymph nodes which were matted, and a positive family history of infectious disease, a provisional diagnosis of tuberculous ulcer was made.
A differential diagnosis of periodontal abscess, syphilitic ulcer, mycotic ulcer, and herpetic ulcer were included.
Chest radiograph did not reveal any abnormality [Figure 4]. Laboratory investigation which included routine hematologic examination showed a raised erythrocyte sedimentation rate (ESR) (55 mm/1 st hr Wintrobe). Analysis for Human Immunodeficiency Virus (HIV) and Venereal Disease Research Laboratory were negative. Mantoux test was positive ≥12 mm in 72 hours and Ziehl-Neelsen staining for acid fast bacilli was positive in biopsy. An incisional biopsy was done and the specimen was sent for histopathological examination, section revealed groups of Langhans type of giant cells with peripherally arranged nuclei. Epitheloid cells are distributed throughout the stroma with lymphocytic infiltration [Figure 5] and [Figure 6].
Correlating the patient's history, clinical examination, laboratory investigation, and histopathological examination, a final diagnosis of tuberculous granuloma of oral cavity was given. The patient was then referred to the Department of General Medicine where an anti-TB regimen consisting of rifampicin 600 mg/day, isoniazid 300 mg/day, and pyrazinamide 1 500 mg/day, ethambutol 1 200 mg/day for two months followed by isoniazid 300 mg/day and rifampicin 600 mg/day for next four months was instituted and the patient is still under medication and observation.
| Discussion|| |
TB is a chronic granulomatous disease caused by M. tuberculosis. The target organ of M. tuberculosis is the bronchopulmonary apparatus, and the head and neck are usually secondary. In industrialized countries, TB is nearly always caused by the human type of bacillus, as a result of person to person spread through airborne droplets from a patient with active disease. Oral mucosa has rarely been reported to be the site of the first invasion by Mycobacteria. 
Oral manifestation are uncommon, observed only in 0.05 to 5% of patients with TB and most of these cases represent lesions secondary to pulmonary TB. However, the primary form is uncommon in the oral cavity. A notable feature in this case was the location in the maxillary gingiva and palate. Involvement of these areas by primary oral TB previously reported, is rare. 
Oral lesions are seldom primary, but rather are secondary to a pulmonary disease. It appears most likely that the organisms are carried in the sputum and enter the mucosal tissue through a break in the surface. It is also possible that they are carried through the hematogenous route, deposited in the submucosa, and subsequently to proliferate and ulcerate the overlying mucosa.  In the case that we presented, no evidence of lung or other systemic involvement was found; TB on the upper airway generally has the symptomatology of a cough, weight loss, and dysphagia. The present case was not suffering from above manifestation supporting the diagnosis of primary oral TB. 
Primary form of tuberculous oral lesions usually affects the gingiva and mucobuccal folds. An inflammatory focus adjacent to teeth or teeth extraction sites has also been reported. In addition, primary lesions are often associated with enlarged cervical lymph nodes. The secondary form is more frequent in middle-aged and older persons and involves mainly the tongue and hard palate. 
Although the clinical picture is variable, the typical lesion of oral TB is an irregular, superficial, or deep, painful ulcer which tends to increase slowly in size. It is frequently found in areas of trauma and may be mistaken clinically for a simple traumatic ulcer or even carcinoma.  Tongue is most often affected. Lesions are found less often on the floor of the mouth, gingiva, palate, and lips. Oral lesions typically consist of a stellate ulcer with undermined edges and a granulating floor. Nodules, fissures, tuberculomas, or granulomas can be found. Lesions may be single or multiple, painful or painless. Ulcers are usually characterized by undermined edges with minimal induration affecting the tongue and hard palate. Skin, cervical lymph nodes, and salivary glands are also frequently involved.
Clinical diagnosis can be difficult because TB can mimic a variety of other conditions, including malignancy, HIV, Cicatricial pemphigoid, syphilis, and deep mycotic infection such as histoplasmosis, Wegener granulomatosis, and sarcoidosis. 
For confirmation and differential diagnosis, positive tuberculin skin test indicates previous exposure to the M. tuberculosis. Mantoux reaction was scored as positive if the induration was ≥10 mm in diameter or ≥5 mm in BCG-vaccinated subjects, in patients who had contact with someone with infectious TB and in those who have a chest X ray with fibrotic changes consistent with pulmonary TB. Biopsy for histologic examination, Ziehl-Neelsen staining with demonstration of acid and alcohol fast bacilli, and culture should be obtained.
Antitubercular regime given regularly is effective but must be given for long periods. Agents most commonly used in triple therapy include rifampicin in combination with isoniazid and pyrazinamide, usually for the first 2 months of treatment. Ethambutol can be added as a fourth drug when isoniazid resistance is considered likely. Continuation therapy with the two drugs rifampicin and isoniazid is usually given for the further 4 months, so that a total of 6-month therapy is given.
In conclusion, although TB of the oral cavity is relatively rare, the unusual forms of the disease in the oral cavity are more likely to be misdiagnosed; with the increasing incidence of TB, it must be considered in the differential diagnosis of atypical ulcerative lesions of the mouth. Oral lesions and concurrent pulmonary lesions should also alert the oral physician to consider systemic disease so that confirmatory diagnostic studies can be performed.
| Acknowledgement|| |
We would like to thank Department of Oral and Maxillofacial pathology for their contribution for preparing the slide.
| References|| |
|1.||Kolokotronis A, Antoniadis D, Trigonidis G, Papanagiotou P. Oral tuberculosis: Oral Dis 1996;2:242-3. |
|2.||Goel MM, Ranjan V, Dhole TN, Srivastava AN, Mehrotra A, Kushwaha MR, et al. Polymerase chain reaction vs. conventional diagnosis in fine needle aspirates of tuberculous lymph nodes. Acta Cytol 2001;45:333-40. |
|3.||Eng HL, Lu SY, Yang CH, Chen WJ. Oral tuberculosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:415-20. |
|4.||Prabhu SR, Daftary DK, Dholakia HM. Tuberculosis ulcer of the tongue: Report of case. J Oral Surg 1978;36:384-6. |
|5.||Rivera H, Correa MF, Castillo-Castillo S, Nikitakis NG. Primary oral tuberculosis: A report of a case diagnosed by polymerase chain reaction. Oral Dis 2003;9:46-8. |
|6.||Erbaycu AE, Taymaz Z, Tuksavul F, Afrashi A, Güçlü SZ. "What happens when oral tuberculosis is not treated?". Monaldi Arch Chest Dis 2007;67:116-8. |
|7.||Eguchi J, Ishihara K, Watanabe A, Fukumoto Y, Okuda K. PCR M method essential for detecting Mycobacterium tuberculosis in oral cavity. Oral microbiol Immunol 2003;18:156-9. |
Department of Oral Medicine and Radiology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]